Thursday, 28 June 2012

Continuity and organisational memory

I've just finished reading Peter Ackroyd's excellent "Foundations of Britain: Volume 1'. I know I've banged on about narrative before, but this book underlines the importance of good narrative: he starts in prehistoric Britain, and creates an uninterrupted story that takes us to the death of Henry VIIth. It is compelling reading.

The history of Britain is a great yarn. It exemplifies the old adage that fact is stranger than fiction. Sometimes, the protagonists over-egged the pudding (I am thinking specifically of the Wars of the Roses, which were frankly a little silly), but it is really interesting to move from speculating about Anglo-Saxon kings that we know relatively little about, to mediaeval Kings, about whom we know a great deal more, although admittedly from often biased sources. Richard IIIrd was no more evil than his contemporaries - he just had the misfortune to lose, and ended up being an historical hostage to his conquerers' spin-doctoring.

The tendency is to partition history up into discrete eras and epochs -Stewarts, Platagenets, Tudors, and so on. But this creates some false effects: it forgets that one follows seamlessly in to the next, and that at the time, there was not the same sense of transition. It's a bit like the quiet shift on-call - much of the appreciation that it was quiet is retrospective: at the time, you spend at least some time thinking that it could kick off any moment. I imagine that this was how a great many usurpers to the throne have felt over the years.

It also over-emphasises the historical details about which we have information. If at an excavation, you find lots artefacts that have managed to survive the centuries to be discovered by future archeologists, the risk is that the role of the objects uncovered will be over-played. A stone tablet may encourage you to conclude that these people recorded their information on stone tablets, whereas the truth may be that they actually wrote on paper, but none of this has survived.

Our view of history is always partial, and always subject to the interpretation of people who did not live at the time, and therefore do not share the same cultural biases, preferences and values. All of these factors can have a profound impact on the conclusion that an historian comes to in trying to make sense of the past.

The mark of a good historian is one who acknowledges the degree of uncertainty that must exist in a post hoc explanation of past actions and events. Good historians are the ones offer you a circumspect view, rather than a rigid one, and offer you their understanding of how to frame  your own consideration, informed by their reading, research and experience. There can never be a right answer, and historians must become comfortable with that.

The role of uncertainty in history has real echoes of what it means to be a doctor. Good doctors acknowledge the uncertainty and build it in to their management plan.

But I didn't really want to talk to about uncertainty today. What I really wanted to address was the role of continuity.

The main theme of Peter Ackroyd's book is just that: continuity. He has the idea that if you concentrate hard enough you can follow a continuous history of Britain from the earliest findings and records all the way through to today. In this respect, Foundations of Britain Vol 1 is a stellar success. He does that annoying thing of making it look easy. One of the important issues that he highlights is that much of the history of Britain is told in aspects of continuity. For example, many villages and towns can trace their history back thousands of years. Churches were often built on the sights of ancient standing stones. Street plans, and field arrangements have survived for centuries. The story of the country can be traced and felt through the way that people have lived, and the way that modern life still has echoes and ghosts of the way that people used to live. There is a direct line from you, reading this blog on your computer or your phone, all the way back hundreds of years. Your own heritage may be complicated and difficult to unravel, but the collective history of Britain is etched over our daily experience, in the names we use, the places we visit, and in our cultural identity.

Around this idea of social continuity, there is resonance with the idea of organisational memory. The NHS today looks very different to the NHS of 1946, both in the the services it offers, the fabric of the buildings, and of course the people who work in it. One could argue that there should be nothing left over from the NHS of 1946, that the buildings should have been replaced, the practices modified and the management structures improved; perhaps if anything still persists, then that is a reflection of an underlying problem.

But let's not get off track - the organisational memory of the NHS is encapsulated by the way we provide health care, the way we divide labour, and the way that we organise the services. Some of these processes will have been designed from the ground up, but a great many will have been derived and adapted from the pre-existing structures and systems. The structure of the NHS today would have been impossible without the structures and systems of the past. With this in mind, ask yourself the question, what would the NHS look like if I designed it today, on a blank piece of paper.

There is no doubt that it would operate and look very different to what we currently have.

But the mistake we often make when thinking about the NHS is that there was a time zero, a day when it all started. And while this may be true in terms of enactment of the relevant Health Acts by Nye Bevan in the 1940s, we must always remember that the institution of the NHS was a triumph of politics in the midsts of some powerful political powers, significant doubts about its affordability and effectiveness, and even about its ideology. From its very beginning, the NHS was moulded to the health systems that had gone before, and these compromises still resonate in the way we operate today. The role of GPs, how they are funded and how they operate all hark back to the pre-NHS era, as does the distribution and provision of hospital care. North West London has a large number of hospitals, which date back to the days before the NHS, when the building of a hospitals had nothing to do with the health needs of the local population.

So many of the decisions that we have to make today, in the name of improving the health care we provide can be understood in terms of the historical nuances that led us to be where we are today. Such a realisation does not necessarily change the debate, but perhaps it can influence your ideas about how we get from where we are today, to where we would like to be tomorrow.

Sunday, 24 June 2012

The true meaning of efficiency

The £20 billion efficiency saving that the NHS is being asked to make by 2015 is going to be extended, so that we have to save £50 billion by 2019-20. If you don't believe me, check out this article by John Appleby, Chief Economist of the Kings Fund, doi: 10.1136/bmj.e2416, where he not only highlights the scope of the challenge, but also highlights how fanciful it all is.

One of the issues here is about disconnect. I find it difficult to actually imagine what a £1 billion is. In days gone by, in the UK at least, billions were very rarely dealt with because a billion was a million million (I think they used to say a million millions too, but this seems to have fallen out of fashion, which is why Gordon Brown kept doing it at all his budget speeches, no doubt). This meant that conversations about very large amounts of money were still carried out in millions. However, by going over to the American definition of a billion, we have managed to condense a thousand million into less space. I am sure that in many people's minds, a thousand million feels like a lot more money that one billion.

This perhaps is a useful way to consider the NHS productivity challenge. Does the challenge of saving £20,000 million by 2015 sound plausible to you? How does the prospect of doing this for the next 8 years, to save £50,000 million by 2020? It sounds exhausting.

And that's just first impressions. Delving further only deepens the scale of the task. 'Efficiency saving' is something of a throw-away term. We won't be handing back any cash to the treasury - instead we will be providing the health service we have always provided for a population of people for whom it is more expensive to provide health care for (because of rising age, rising expectations and rising technological costs) but with a health budget that will remain flat. Thus one way to manage the Nicholson Challenge might be to cap health provision at its current level, and pull some clever tricks that keep demand at the level it is today. It would be a work of fiction to imagine how one could achieve that.

Thus, by extending the efficiency challenge to the end of the foreseeable future, we are being told that we should expect health funding to remain flat, and that the challenge of the health service is to meet the needs of the patients with no more money.

Therefore, the actual number is meaningless: I don't think it is possible to have a good grasp, at a service provision level, of what £50 billion is. What £50 billion means to you and me is that there will be no extra funding for 8 years.

I think this underpins one of the problems surrounding the discussion of efficiency savings: for those of us who go to work every day to spend the money that the health service has, these numbers have been thrown around, but it has been very hard to make any real connection between the numbers, and what they mean for the job we actually do.

In particular, it becomes very difficult to see how one can become more efficient, when one is working as hard as possible. It may seem that so far efficiency has been approached mainly through reducing staff numbers. To some extent this is inevitable, given that staff costs account for two thirds of the health service costs. But one wonders how the same level of service can be supplied, if those staff cuts are not supported by systems and changes that support each individual to deliver, or to support the delivery of, more patient care.

The challenge of creating a more efficient health service that delivers the same amount of health utility for less money would seem to me to be a challenge of creativity and ingenuity. Too often it seems like the challenge of deciding which staff you can do without, or the challenge of how much extra work you can persuade staff to take on for no extra money.

That might work for a couple of years, but I am certain it won't see us through to 2020.

Thursday, 21 June 2012

The rocky road to expertise

In the BMJ this week, Daniel Sokol talks about the role of empathy and compares it with imperturbability ( ), suggesting that overt demonstrations of empathy can alienate patients, and that what they want and need from us is for us to be detached, professional and expert.

I can see his point: who wants a doctor who can't maintain their composure at your time of need? But I think the distinction between empathy and imperturbability creates a false dichotomy. They do not lie at either end of the same spectrum.

It is always nice to be the person who keeps their head when all those around are losing there's, but it can be really difficult to predict who that will be, and it is not always the same person.

Loss of control in stressful situations results from a number of different factors, not all of them directly related to the situation itself. The outcome of each challenge we launch ourselves into will be influenced by the state we are in when we set off. People seem to struggle the most with stressful situations at work when the particular situation itself is one that is unfamiliar to them.

It is easy to persuade yourself that at any one time, we have the competence to deal with challenges up to a certain level, and that it is with further experience and learning that we are able to take on the bigger ones. However, significant stress becomes much easier to manage when you are familiar with the type of stress on offer. And when the stress become familiar, you can stop worrying about how the situation is going to affect you, because you already know, and can start worrying about the other people involved.

For example, breaking bad news, or leading cardiac arrest calls are objectively stressful situations, but they are ones that I do not mind doing, because I am familiar with how the scenarios play out, and how I respond, having had the experience of doing them many times.

Of course, there is no shortcut to experience, and you cannot always know how you will perform in a new situation. The transition from knowledge to expertise is one we do variably well in medicine. That is, we sometimes tutor people brilliantly, and we often do it badly. But with a system of graded and supervised exposure, it is possible to help people learn how to apply their technical knowledge in what are often highly emotive circumstances. The old-fashioned way of doing this is to throw the trainee in, and let them do it badly, until they figure out how to do it well. But that hardly seems fair to the patient.

The more experience one has in medicine, the fewer episodes you face when you do not know what to do. Uncertainty of action, and uncertainty of the possibilities is a significant source of anxiety for junior doctors. However well prepared they are, they often worry about the emotional impact and responses that their words and actions will have on patients and their relatives.

When my junior colleagues ask me how to deal with emotional and stressful situations, I encourage them to be themselves, and to respond in their own style to the emotional needs that they identify in front of them. Being a good doctor does not involve mimicking some model of the perfect doctor, or being ice cool and aloof.

The mark of a good doctor is someone who has achieved expertise in the knowledge and techniques that their specialty requires, but manage to marry this successfully with being natural, being sincere, and responding in their own way to the needs of the patient in front of them.

Few things are more alienating to patients than false affect, and trying to be imperturbable all the time smacks of falsehood and fakery. The simple truth is that sometimes you will be the one who excels, and sometimes it will be someone else. It doesn't always have to be you.

The challenges of being a doctor are varied, and often demanding. To pretend that you can always operate on the same level is to deceive yourself. You will have good days and bad days, and what it is important is to recognise that this does not represent any great failing in you - it is the beauty of the human condition. Forgive yourself, and nurture an environment around you that allows others to take on strain when you are not up to it, and vice versa.

And if you can do that, then you will definitely have a happy and successful career.

Monday, 18 June 2012

Individual choices in public health

My wife and I safely navigated a local NCT course this weekend. I think she was rather looking forward to it. I approached it with rather more trepidation. I would recommend something like an NCT course to any couple expecting their first baby: among other things, it is a really good way of framing your personal discussions about how you as a couple would like your labour and early weeks of parenthood to run. It is of course, a really good way of meeting other couples in the area.

Where is it less recommended is as a source of good information. My fist is a little sore this morning from the moments I was obliged to chew on it, for fear of opening my mouth and starting an argument. Anyone who goes to an NCT class willingly signs up for a certain type of experience, and it would be unfair of me to accuse the class of failing to deliver on its promise. It was, in fact, unerringly on message with what I had been told to expect.

But as a case study in human and social behaviour, an NCT class provides some interesting insight. As a way of framing a discussion about patient-centred care, it is brilliant. I found it very difficult to hold my tongue during the discussion about vaccination.

it occurred to me during the discussion of the merits of single jabs over the MMR that this issue is a little like religion: people often have views that they are comfortable with, and from which they do not want to be budged. It is often futile to have exchanges of view about religion because the starting points of two people who disagree often have very little overlap. The same is perhaps true of people’s views on vaccination. It is perhaps true of my view on vaccination.

It still suprises me how the impact of Andrew Wakefield’s discredited work on 12 children with autism continues to trump the safety record of a vaccine that has been used hundreds of millions of times across Europe, protecting both children and populations from harmful infectious diseases. That statement no doubt speaks volumes about how we assess risk both as individuals, and as a population.

What however, took me by surprise (perhaps naively) was the clear assumption by some people in the room that medical intervention in pregnancy and labour was aimed at something other than the health of the mother and the baby. It was clear to me that the motives of hospital midwives and doctors were somehow distrusted.

However, there were a couple of issues that made me think. During labour and in the early days of a baby’s life, you are offered a couple of interventions that on an individual basis might be considered overkill. For example, babies are often given a vitamin K injection to offset the relatively rare risk of haemorrhagic disease of the newborn. The risk of bleeding complications is low, but the effects when they do happen can be high. Therefore, one’s perception of whether it is worth doing is influenced often by one’s perceptions of the risks of having the injection when compared to the benefits of having the vitamin K.

When judged purely on an individual basis, I imagine that many people come down on the side of not having it. However, the decision to offer all babies this medication is a decision that is also based on benefitting whole populations.

And this creates a tension that one does not often see acknowledged. The NHS is charged with offering a comprehensive health service for everyone. This means that some of the decisions regarding treatment, screening and vaccination are heavily influenced by the benefit at the population level, at the expense, perhaps of the individual experience.

If we know that vitamin K deficiency affects 1 in 100 births, by giving everyone the injection, we are subjecting 99 in 100 babies to an injection that they don’t need. But it is either too costly, or not possible to work out which baby in every hundred needs the injection. So do we as a society fall on the side of public health, or individual utility. There is inevitably some value judgement in this.

And I imagine that this sense of conflict is heightened in couple who are trying to decide how they want their pregancy to run. Particularly the kind of couples who go to NCT classes, and particularly couples who respond to the loss of control that that the imminent arrival of a baby represents by trying to wrestle control over as many aspects of the process as they possibly can.

There are times when the delivery of effective population based care is at conflict with the delivery of patient-centred care. And we need to be honest about that.

I used to deliver a talk to patient and carers about stroke care in London. As part of the rearrangement of stroke services in London, patients are now taken to one of a number of hyperacute stroke units, which offer 24 hours expert assessment and treatment. They will usually return to their local hospital after a couple of days, but the experience of going to a hospital that is not their local one can be both disorientating and inconvenient. But my experience suggests that taking the time to explain that organising services in this way means that we can offer a better level of care to everyone is something that most people get.

And so, perhaps, we need to be honest and emphasise that sometimes that we will be offered therapies which may not offer us any personal utility, but if effectively delivered to whole populations will render huge benefits for everyone. Vaccination is a good example of this. And is a good example of the reality that we are not just individuals, or family units, but rather members of a wider community, and sometimes, there are things that we can do to benefit the population that we belong to.

Tuesday, 12 June 2012

Jim Bob reminded me of ageism

When Digby Jones, former director of the CBI, appeared on Desert Island Discs, he rather touchingly dedicated his final song selection to his wife. Many, however, felt that his sentiment was rather undermined by his choice of ballad. No one can deny that Bryan Adams’ ‘Everything I do, I do it for you’ was a popular song, but some, perhaps many, were disheartened by the barefaced cheesiness of it. A bit like using glucose-fructose corn syrup instead of honey.

For a while, I have harboured a wishful ambition to one day appear the show. I know that it’s a long shot, but just in case I get the chance, I am keen to avoid a Digby, and try to keep a running list of my top songs to take a long. Most of the sure-fire choices are great songs that also have some personal salience for me. Stevie Wonder will definitely be there, but whether it will be ‘Superstition’ or ‘Master Blaster’ will largely depend on how important the individual memories they are each associated with stand the test of time.

Once in a while, however, I rediscover a tune that makes me consider taking the risk, and gives me a sense of the ‘Oh sod it’ moment that Digby must have had when he decided on the final make-up of his discs. I recently had one such experience, when I chanced across an old recording of a Carter USM album, that took me hurtling back to 1991, and reminded me of at least the suggestion of the development of a political sensibility. If you have never heard the band, take a look at them here:

I never forgave Jim Bob (the genius lead singer) for his haircut, but I was prepared to overlook it on account of some his lyrics. Much of the band’s stuff was in bad taste, but a lot of it referenced a true, perhaps mischievous, sense of anti-establishment, that is alluring to the 13 year old boy trying to make his way at a boy’s boarding school. But beyond that, Jim Bob reined in a rather florid way with words to highlight some issues that did mean something, and on listening it again, still mean something.

The song that I have posted a link to references inequality to healthcare, and pensioner poverty. It would be hackneyed to quote it directly. My particular favourite, Sheriff Fatman gives a nod to elderly abuse, mocks the faux sympathy given to society’s vulnerable, and highlights greed and selfishness as perennial issue, all through a great comic-book characterisation of Sheriff Fatman.

I have no idea what Jim Bob is doing now. I thought about finding out, but didn’t want to risk the disappointment of finding out that my hero is not the man I thought he was. I want to still believe that he is still ostentatiously down at heel despite the fortune that comes with having hit records living in a squat in early 90s Brixton. But I did think about what the Jim Bob of my youth would have said about the new government policy to ban patients being denied treatment purely on the basis of age.

No one should be denied treatment on the basis of their age. But I rarely find that the issue of appropriateness for treatment is a simple matter of age. The landscape is usually a lot more complex than that. For many elderly patients, who have other medical problems, who are frailer than younger counterparts, medical and surgical treatments are associated with higher risks of complications and side effects. As a doctor, you can only ever advise on the overall risk, and you never know whether the patient that you are talking to is going to be one of the 10, 20 or whatever per cent who will experience the bad outcome you need to warn them about.

In having conversations with patients about how to manage their care, one of the challenges is to get a feel for who the patient is, and what their style is. What is their attitude to risk, how do they feel about their overall quality of life, and so on. Approximating the overall style and attitude of a patient in the type of medical care they receive is one of the tricks of being a good geriatrician. It relies on empathy, and communication. It almost never hinges on age.

I also know that the elderly often get a poor deal. But this is not just in health care. They get a poorer deal from society in general. If you don’t believe me, then spend a month shadowing me, and count the number of patients I meet who live in loneliness, with no one to check in on them and chat to them.

Ageism in health care reflects society’s attitudes to the elderly in general. There are things that we can do in hospital to mitigate it, and there are many excellent geriatricians, GPs and nurses who spend an awful lot of time doing just that. But we don’t get it right all the time, and we’re not going to.

The spectre of punishment for being seen to deny elderly patients care may result in elderly patients getting care that they don’t actually want. The reality of caring for elderly patients is that we are not always in the business of saving their lives - sometimes we are in the business of allowing them a dignified death. Provoking anxiety in health care professionals on this issue may undermine their readiness to have the difficult conversations about the end of life,and opt instead for treatment which offers false hope and discomfort.  And for many patients, that would be a shame.

Jim Bob wouldn’t be afraid to make this point. And perhaps just to remind me, I’ll risk a Digby, and take one of his songs to my desert island.

Thursday, 7 June 2012

A phoney war

From the distance that holiday provides you, it is possible to reflect on events close to home with a degree of detachment that would otherwise be very difficult. Thus, it is with the benefit of distance that it has become possible to make some sense of what the decision by the BMA members to vote for strike actually means. And doctors don't come out of this terribly well unfortunately.

 The problem is one of perception. The prospect of paying more and working longer for a smaller pension is never going to be a good one. The sense of injustice within the medical profession is no doubt heightened by a couple of other factors. Firstly, many within the profession believed that pensions had been renegotiated for the next generation 5 years ago, and that for the government to renege on the agreement made then is unfair. Secondly, for many, the prospect of a good pension is one of the factors on the plus side when considering the pros and cons of going into the medical profession in the first place, and maintaining one's allegiance to the NHS in the long term. And all of those arguments have merit. But probably not enough.

 In electing to strike over this issue, admittedly, only on the provision of non-urgent care, the medical profession is making a public appeal for support. And this is the problem. Whatever the realities of life are for a lot of doctors, the public perception of the profession is that its members are comfortable and fortunate. And doctors may well find this impression difficult to argue against: it is after all, a job that comes with a decent wage, and when doctors consider the things that they are currently struggling to afford, I suspect that they will be things that many other people would consider to be more towards the finer side of life, than the essential side.

 Without public support, in striking against the pensions reforms, particularly when doctors failed to strike against the broader health reforms, the risk is that the profession portrays itself as rather spoiled and petulant. And this would be a shame. The profession is still awash with genuinely well-meaning men and women, who are doing their best to serve their patients. But perhaps, on this occasion there has been a disconnect between the way that doctors think that their patients feel about them, and the way that their patients actually feel about them.

 And perhaps it also belies another misunderstanding by doctors: the possibility exists, and it is something that I have written about before, that NHS pensions, post-reform, become a thing of the past: as services become increasingly tendered out to non-NHS organisations, the increasing likelihood becomes that all doctors end up with a collection of different pension funds, with slightly varied terms and conditions, that represent the different organisations that they have worked for over the course of their careers.

 And if this is true, then any battle fought over the terms and conditions of the NHS pension, when the broader war about the provision of NHS pensions for all healthcare employees has been lost, is a part of a phoney war.

 And a phoney war that the public doesn't support. Make of that what you will.