Sunday, 15 December 2013

It's more than 7 day working we need to change

7 day working is back on the agenda. It's been cropping up now at regular intervals - it keeps cropping up because it is something we haven't yet solved.

It sounds like a good idea to have consultant presence on the wards 7 days a week, and it reflects a reality of modern day health care: consultants are the means through which investigation and treatment plans are currently achieved. Another solution might be to have teams that function effectively even in the absence of the consultant, but this does not seem to be a solution on the wider agenda. Consultants are the de facto clinical leaders, and they should be the experts. More junior doctors may be expert as well, and in many cases they offer leadership - but there is too much variation. The difference in expertise between a first year registrar and a final year registrar can be huge. The best way for the system to guarantee the best expertise is to focus on the provision of those people who have successfully navigated the training, and demonstrated the ability deliver the level of care required to be a consultant.

How well our training system does this is the topic of another conversation. But I can see why the currency of expertise in the current health service is measured in terms of consultant numbers.

Consultants are useful tools around which a health service can be shaped. But they are also the most expensive tools. We have to ensure that consultant time is used to the greatest possible utility.

If we look at how we might offer greater presence of consultants on the wards at weekends, there are a number of solutions that we might choose.

  1. Employ more consultants - costs more money, and requires more consultants to be trained. 
  2. Pay current consultants more money to work more hours - costs more money, risks burn out, risks deterring young doctors from entering specialties that require 7 day working
  3. Focus 7 day provision on acute services, and cut elective services to create the capacity for more acute work - this will lengthen waiting times, and perhaps create a perverse incentive for more people to use acute services for chronic problems: we might arrive at a situation where the best way for patients to receive timely, expert care is through the acute services. 
Something has to give, and it is not simply an issue of giving the problem money: even with unlimited resources, we would not currently be able to staff 7 days services across the country, for the want of appropriately trained consultants to take up the work. Within geriatrics at the moment, within current service provision models, many trusts across the country are struggling to recruit suitably trained doctors. 

Therefore, we need to decide how important this is, compared to the work that consultants already do. 

And this, I suspect is where the possibility for change lies. Implicit in the attention being focused on 7 day working is the knowledge that the acute pathways are struggling with demand, and the evidence that emergency outcomes, and surgical outcomes are worse at the weekends. 

Now this really is a complicated issue, but I've had a simple thought about it: the acute services experience high levels of demand, not just because we have high levels of sick people, but because they are the only services that mirror the preferred usage patterns, and expectations of the patients. They are the only services that respond to patient's needs when they have them; they are the only services which provide patients with answers in the time-scales that they feel they need, or they expect.

And let's remember, many of the people who use A&E are not really patients: 40% of them are sent home with only advice. This is telling us something. 

I know there has been a whole heap of work done around how people use health services, and how we can provide better out of hours care for non-urgent problems. But perhaps it tells us something else as well, and perhaps one of the areas that needs real scrutiny is how we provide routine, elective and non-urgent care.

If we accept that acute services respond to individual's needs in the time-frame that patients expect them to be, then what does that say about the way we deliver out-patient and elective care. 

If you take the kinds of out-patient services I have worked in, then it is evident that the nature of care provided to patients is significantly organised around the capacity and structure of the service. The ability of a clinic to review new patients is often a function of clinic capacity, not of patient need; and the frequency and time between follow-up appointments is not always dependent on clinical need, but on the nature of the service. 

Too much out-patient care is based on an old-fashioned and historical structure which bears little resemblance to the health care habits of the modern day. The time of need is not weeks or months after the referral was made, but on the day that they went to their GP with the problem in the first place, or the day that the ailment started. 

Too much out-patient care is delivered too late, too infrequently, and is influenced too much by the limitations of the service. 

This is the area of care that we need to deliver differently. This is the area of our system that we could revolutionise to provide more rapid diagnostics, assessments and treatment plans, and the area of our system that could share more of the burden currently borne by the acute services.

So let's figure out how we can use consultant time more effectively for the benefit of our patients, but while we have the chance, let's also figure out, at the same time, how we can adapt the way we work, to help consultants help patients better. 

Monday, 25 November 2013

0800 4 70 80 90

When I first started at prep school, the only way I could communicate with my parents was by letter - something we were made to do every Sunday after Church. These letters were screened by the teachers, to make sure we were gave them appropriate care. Aged 8, I barely wondered whether it was acceptable to have my missives home checked by someone who worked at the school that I might well have cause to complain about.

I never felt like I needed a more immediate, less monitored means of reaching my parents - I was too busy having fun, larking around in the woods with my mates, planning raids on enemy bases, to be too concerned by such matters. I was too busy being happy.

But boarding school is a relentless place to be sad, or lonely or scared. And someone realised this.

When Child Line was introduced in the late 80s, the school was fitted out with a pay phone that took those old school phone cards, that you could renew with the judicious use of some Tippex. It was all just a game to me - one term, when I was off games with a broken arm, I once phoned up Child Line and asked them for help with my Latin homework. To their credit, they gave it a go. I guess it all seemed like a bit of fun to me.

But under other circumstances, it might not have been fun - it might have been my only window to the outside world. Not all kids had the fun I had at school, and not all kids at my boarding school had the fun I had. For some, the chance to phone home, to phone Child Line might have been a Big Deal indeed.

The launch of the Silver Line reminded me of all of this. I have written before about loneliness being a big illness in the elderly. I have watched it, seen it, touched it, but I have never found a way to do anything about it.

That embarrasses me. But my embarrassment means nothing - it is not important. It is, important, however, that someone has found the energy to do something about it.

I don't really know what it feels like to experience the kind of aching loneliness that many of our elderly must feel. I do know that I don't want the people in my life to experience it, and I do know that I don't want our elderly folk to experience it.

Silver Line may just be a phone line, but to some people, it may just be a very Big Deal too. And perhaps, more than that, it might serve as a reminder to all of us, that while we are out there exploring the world, for some people, that is no longer possible.

For them, the challenge is to bring the world to them. Perhaps Silver Line is the start of something, just as Child Line was the start of something.

I hope so. I hope that Silver Line has the kind of impact that Child Line had, and I hope that its reach is broader, and that from this simple, important intervention, something bigger in our society can spring up.

Thursday, 21 November 2013

The right intention, but the wrong idea?

Here at the British Geriatric Society Conference, much of the conversation so far has been based around the challenge of meeting the needs of residents in care homes.

At face value, it seems like a good idea: care homes are where the frail elderly often go to live. It makes sense, therefore, to organise care around these units, as they are good ways of selecting out the people most in need of comprehensive geriatric care.

But I have a number of concerns about this shift in organisation. Let me explain:

1) A great many frail and elderly patients live in care homes, but a great many do not. By organising care around care homes, the risk is that we create differential levels of care for those inside care homes compared to those outside them. Perversely, this may create a driver to admit patients to care homes, so that they receive the kind of long term care that they need. Our challenge, however, is to create a system that meets all need, not just those of an artificially selected care home population.

2) By organising services around care homes, we are doing very little to influence the use of care homes in the first place. As a strategy, it does not change the game enough: it is a response to a situation we find ourselves in, and not an attempt to modify that situation to something more acceptable, and more effective. By organising services around care homes, are we acknowledging that there is nothing we can do to support the frail elderly in their own homes? Could we not, with differently organised, and better managed services, respond to the needs of the frail elderly at home, and forestall or delay the need for them to enter care homes altogether.

3) A care home is simply where someone lives. It is perhaps a marker of their needs, but it also represents more: it could be a function of the choices that individual has made, the nature of their family and social support networks, and a whole range of other factors. A good system responds to the needs of individuals wherever they live, and adapts around that person. A system that organises around care homes is using the admission to the care home as its surrogate marker for frailty. This may well be fairly accurate, but it is not comprehensive, and it encapsulates a fatalistic view of our ability to influence the need for individuals to enter long term care.

The current use of care homes is currently unsustainable, and it is impersonal. Stories abound about patients admitted to hospital in a crisis, and then without ever having the chance to visit their own homes again, are admitted to long term care. Life sometimes falls off a cliff, but perhaps, with better and more intelligent organisation, we could slow down that falling trajectory.

My fear is that, as we enter a period of great change in how we look after our frail, elderly patients, we resort to type, and continue to organise care around physical units (acute hospitals, community hospitals, and care homes) and not around the individuals. The care we give, and how we give it should be influenced by the needs of the patients. The organisation of services should adapt to those needs. Historically, and currently, the care we offer our patients is significantly influenced not by their actual needs, but by the resources and set-ups available. We approximate the needs of the patients to the needs we can meet.

This is classic cart before the horse stuff, and I think we ought to put it right. Perhaps more importantly, I think we can put it right.

Thursday, 14 November 2013

Time and Health

When I sat down to watch the analysis of the Wales-South Africa match on Scrum V the other night, I did not expect to have a moving experience. But one interview changed all that.

Wales had lost - they had never looked like winning. Some things never change. Throughout the 1990s, they were ruthlessly put to the sword by successive Springbok sides. These days the results are the same, but the matches are close. In those days, there was barely a contest.

One man often stood out for the Springboks. Joost van der Westhuizen. You wanted to hate him, but, boy, he was good. There are some athletes who remind you why you watch sport - he was one of them. Tall, powerful, fast, quick-thinking, and utterly ruthless. He was a giant of rugby.

Today, aged 42, he has motor neurone disease. He is a shadow of the man he once was. But he is also a different kind of hero. He is a man laid low by devastating, progressive and incurable illness. His voice is stuttered by the weakness of his nerves. He has months to live.

But he has something important to say about life. He tells us that we all think we have time, and health. He has neither, and he has something to tell us.

Do one thing for me today - listen to him speak. That's it. That's all. Good night.

Saturday, 19 October 2013

Loneliness - a simple problem with complex answers.

Jeremy Hunt has been talking about the national shame of loneliness of the elderly in the UK ( . I feel like I have been harking on about this to anyone who will listen to me for ages. Perhaps even you, dear reader, is getting bored of my fixation with this issue.

But bear with me. Companionship is not just a nicety of civilised living. Loneliness is recognised risk factor for ill health, and it is a bell-weather for how society functions. The way we treat the elderly is a symptom of how fast, and how much, the functioning of modern society has changed. The pattern of our lives has altered so much that we have not yet adapted to deal with an issue that has not troubled previous generations in the way that it currently troubles us.

There are a number of truths that we need to consider: that individuals are living longer, that elderly individuals are often living not just longer lives, but significant periods of their lives in poor health; that families are now smaller and more dispersed. I would encourage you to absorb the impact of those three factors, to get away from the idea that somehow the elderly in our society are lonely because their families and communities have stopped caring about them. It is unhelpful to blame the attitude of families, and communities, in the way they care for the elderly, because it fails to acknowledge that the issue we have with the elderly is not just the result of a change in the way we care, but also of some profound changes in the way we live.

Perhaps your view on the issue is shaped by your direct experience. Perhaps you know of children who travel hundreds of miles each week to check in on their parents who live in a different town. Perhaps you have seen the worry, the stress and the anxiety caused by wanting to help, but not being able to, due to the insurmountable obstacles of the need to work, and the impossibility of moving cities.

Perhaps you know people who take no interest in their parents or grandparents. These people undoubtedly exist, but is theirs an attitude borne out of a habit of our age, or is it more complex than that?

Jeremy Hunt suggests that the start of an answer is simple: take a lesson from Asian families who tend to care for their elderly relatives at home. It might be that easy, but I doubt it.

The issue is underpinned by the impact of social mobility. Where I live, my neighbour was born in the house she still lives in. Her  brother lives across the road, and her son lives three doors away. In this context, it would be possible to take on a care burden. But she is relative rarity. For children growing up in Dorset today, the majority of them will have to move away to further their education, and to seek employment opportunities. In a world of heightened opportunities (recent recessions notwithstanding) the price we have had to pay for greater autonomy and choice in our life patterns has been the requirement to relocate. This won't change.

Add to this the rising reality of prolonged old age, and prolonged dependency in old age, on a scale never previously seen before, and one can really start to question to validity of any assertion that the main solution to loneliness in old age starts and ends at home with the family. That is not to say that it wouldn't be ideal - it is surely preferable to the elderly to be surround by their kin. The issue is that it is not practicable.

Where do we start in the search for practicable solutions? Any approached needs to be many pronged: it starts with consideration of how the frail elderly among us can be afforded the opportunity to interact with the people near us. This perhaps starts with some concept of surrogacy: if you are not supporting your own parents and grandparents, then perhaps there is something that you can do to support the parents or grandparents of someone else, who live near you. With small beginnings, the impact of paying this kind of volunteering forward could really begin to tell.

But the future for modern society needs to consider the impact it can have on stemming the tide of elderly disability: socially engage, mentally stimulated, and physically active elderly men and women accumulate illness and frailty less quickly than those who are not. Embedding not just a role, but a reciprocal obligation of society to accommodate the elderly, and the elderly to take part, heralds a future in which the elderly not just have a role, but a community network that enjoys their input, and then supportively wraps them up, as they become less able to take an active part.

What does that look like? It could be anything, but it to me, it looks like the elderly reading with primary school children, running workshops to teach children about the past, and the skills they developed over time. It involves cross-generational community projects, play schemes, sharing of hobbies, interests and sports through  local clubs. It looks like whatever you want it to look like, because it looks like whatever you make it.

Wednesday, 16 October 2013

A short thought about the way we think

How many people in the UK have mental health problems? What makes the burden of mental illness tangible? How can we make it seem relevant to our lives?

About 10% of the population will suffer from depression during their lives. About 4% have bipolar disorder, just under 1% have schizophrenia. Add in insomnia, addiction, eating disorders and the behavioural problems associated with dementia , and mental illness starts to become the norm - not the exception.

The statistics rarely capture the reality. Throughout our communities there are pockets of expertise, borne not out of education or learning, but out of experience. The sharpest understanding of what it means to suffer, live and cope with mental illness comes from suffering, living and coping with it. The profoundest empathy of the struggles of others suffering, living and coping with mental illness comes from supporting someone you love with their own troubles.

Mental illness in all its forms is so common that these pockets of lived expertise must be everywhere. And yet we live in a society where the perception is that mental illness is the poor relative of physical health problems. Anyone whose life has been touched by these problems knows how profound, disruptive and real mental illness can be; and they also perhaps know how joyful it can be to emerge, for however long, from the shadow cast by psychiatric relapse.

The truths of mental illness are self-evident to all those who live with it. The succour of clinical expertise, loving families and good social support are the cornerstones of happy outcomes. And yet, a great many of the worst sufferers exist in social isolation, without friends, money or families, in communities that pretend they don't exist.

Marcus Trescothick was an international cricketer, whose depression undermined his ability to continue. When he left the England Cricket team during their tour of India in 2006, the team management told the press that he had left on account of personal problems. This wasn't entirely accurate. He left because of depression. He found the obfuscation unhelpful. When he found the strength to be open with people, he discovered a whole world of support, and understanding, both from people he worked with, and people he had never met.

No one wants to have to be an example to others when they are at their lowest ebb, but sometimes, some people find the strength to drive progress. In his own little way, Marcus achieved that: he enabled the people around him to learn about his problems, and to let them demonstrate to him that they care.

And this is the Catch 22 of mental illness. I imagine the majority of people would want to help, to be supportive if someone that they knew was going through a mental health crisis. But we do not know how to broach it. And for the person with the problem, being open about the issue is hard to do, when they are at their most vulnerable, and when they might feel some shame about their problems. You probably wouldn't hesitate to tell me if you'd had pneumonia, but you probably would if you'd been off work with depression.

Society cannot take a lead on changing the nature of its mental health dialogue - it just doesn't work like that. And we cannot place the burden of openness on the people suffering the most.

But perhaps, we can all through our language, and our approach, make it clear that life is tough, and sometimes, the manifestation of illness is psychiatric, and that we get that. Perhaps we can be the people who by being mindful of mental health problems in other people, are mindful and open about our own problems. We may not suffer in the same way as others, but we may also suffer worse. Openness is easier to start when you are feeling strong. Don't wait for your moment of weakness to wish that we were better at talking about mental health. 

Thursday, 3 October 2013

Empiricism in context

In my new role as a community geriatrician, I am exploring how to deliver what I think to be good geriatric care in a new environment. The challenge suits me: I work in nice hospitals, with caring staff, in nice part of the world. It feels like I am doing what geriatrics is all about: doing the right medicine for people who need a lot of care and attention. It is all about balance, judgement, and respect for the individual. 

I have spoken before about the limits of practising geriatrics within an acute hospital setting, and how it is the wrong environment for confused, vulnerable men and women. Increasingly, acute hospitals are factories for technological care. They are busy, fast-moving and bewildering environments. The men and women I deal with often need the best technical care we can offer, but they also need to be in an environment that helps them find their feet again, and helps us decide what issues are really at the centre of their problems: the pattern of symptoms might be easy to discern, but determining their underlying cause takes a bit more nouce.

I said that I like my new job because it gives me the chance to deliver what I think to be good care. This element of subjectivity, of what I think is the best approach, is both the strength and weakness of modern geriatrics. 

However confident we might be that we are acting in our patients' best interests, there is a need for circumspection. The rise of empiricism in medicine is unquestionably a good thing; but it is not without its flaws, and it is not without its areas of poor coverage. Geriatrics is one of these low signal areas: the elderly are often excluded from the big trials, and the application of the evidence base to even common conditions in the elderly is through extrapolation of data sets from younger patients. It might surprise you, but it wasn't until the HYVET trial in 2008 that we could say with any confidence that there was a benefit to treating high blood pressure in the elderly. And even then, the need for circumspection remains, as many of the trial participants were Chinese, and therefore of questionable equivalence to the patients that we deal with.

But let's not get stuck on this. The point I wish to make is that empiricism is an important aspect of modern medical practice. But where geriatrics is concerned, it is only one aspect. Of course, we need to know that the treatments and therapies we use on patients are effective, and not unduly harmful (that is always a question of risk vs benefit). But the care of elderly patients goes beyond the technical questions of the best treatments - it is more complex than that. Of course it is. 

It is these non-empirical aspects of my job that I really love. The variety of approach, and the broadness of it. What I do may not be cutting edge, but I get the chance, as part of a team, to make a difference to the lives of our patients. Go fast, go slow, do nothing at all. Do the test, start the treatment, or hold off entirely. Tackle the physical problem, the mental health problem, or stand back and let the therapists focus on empowering the patient by improving their function and independence. Often, my patients teach me a thing or two about life, from the secret to a successful marriage, to dealing with loss, or what is was like making a dress for the Queen. It's all there if you give it time.

Geriatrics requires knowledge, skill, experience, team play, humility, and usually a clear articulation of what you are trying to achieve - all skills that you can never quite tick off as completed. We might aim to help someone get back to playing golf, or we might try to give someone some peace and dignity in their dying days. Geriatrics normalises normal stuff, and it highlights the unusual. There are themes and trends; there are frustrations and depressing realities. There are disappointments and regrets.

But above all, there is the knowledge that even if we cannot heal the patient, we can help them and their families cope with the reality. 

Sometimes, perhaps quite often, there is the reality that we don't do things terribly well, but we can change that. We have to. 

Moving to community hospitals has helped me to realise that there is a lot we can do to deliver care more suited to the needs of my elderly patients if we are prepared to work differently.  But not everyone shares my view: the question I often get asked is what is the evidence for community-based care. The sub-text is always that they know there isn't really much, and that it is therefore not worth investing in. I smile, I nod, and I acknowledge their point. But I also tell them that we are not really trying to do things differently - we are trying to do the same things better. 

What matters to my patients is not so much about mortality, or length of stay. It is much more about having the right care, the right expertise, good communication, and the best possible quality of life. And we will be content to be held to that account. 

Monday, 23 September 2013

Empowerment of endings

Last week, just before he was cut short by the intractable problems that the Today programme has with its telephonics, David Attenborough said that 'old age is not for sissies.'

Rather than be affronted that an interview that was supposed to centre on his new show was inelegantly redirected towards euthanasia and quality of life in old, he expressed great temperance and dignity in beginning to address the issue. The phone line dropped before he could make his full point, but it was ramping up to be considered and eloquent.

His qualification for questioning on the issue was predicated on the fact that he is old. But he did not pretend to be an expert. In fact, he seemed a little bemused. He is after all in very good health, and sustaining an enviable professional output. For him, the issue of frail old age may well be as distant to him as it is to us, as it is simply not his experience of the world.

It can be difficult to empathise with something of which you have no direct experience, and what he did so well was to illustrate the need for circumspection. There is no right or wrong answer in the issue of euthanasia in old age (for that is what Justin Webb was rather insensitively asking him about). In fact, most of the headline cases of people seeking assisted suicide involve younger individuals with predictable progressive neurological illnesses, for whom the manner and timing of their own deaths is the last defiant act they can take, towards a disease that has robbed them of so much.

By asserting that old age is not for sissies, David Attenborough made exactly this point. Your individual reaction to the aches and limitations of old age is not predetermined, and it is not universal. There can be no universal answer to the problem of what we should do with or for our frail and elderly.

He is a good example of what good old age looks like. He is also an example of how well the elderly can do when they have purpose, respect and opportunities. Often the discussion around euthanasia and the elderly takes place in a climate of negative assumptions about the role that they have in society. The question of whether the elderly should have access to assisted suicide, or the right to die, is perhaps underlined by the implication that they have no broader role in society, and the implication that the best that we can offer them is the choice of when they die.

The question will always remain, and it will always remain a matter of collective judgement and value. I repeat, there is no right answer. But there is a sense in which we are still not ready to progress the debate: the risk of allowing assisted suicide or euthanasia is the risk that individuals will be coerced, in a variety of ways, both well-meant and sinister, to end their lives when they would not have otherwise done so.

This risk would be tempered if the role of the elderly in the day to day functioning of society was more embedded. David Attenborough may be in his late 80s, but we all respect the work he has done, and continues to do. But is his success the product of some rare talent that he has, or is he simply the rare individual who has continued to have opportunities, where other elderly folk do not.

Until we can satisfy ourselves that the role of the elderly in society is better embedded, and that their participation in the communities and the work place is limited only by their ability or willingness to take part, then I would rather see the discussion centre on how we can involve them more, not on how we can help them end their existences.

The issue here is one of empowerment. Euthanasia and assisted suicide are issues that have at their heart the empowerment of an individual who is losing, or has lost, their reason to live. A discussion around its application to our elders can only meaningfully take place in a society that has done all it can to empower those individuals who are experiencing the waning of their physical and cognitive abilities. Until we can satisfy ourselves that this is something that we do well, then further discussion is premature. I worry that the repeated emergence of the euthanasia debate in the media portrays our collective ambivalence to the role of the elderly in the smooth functioning of society.

I have no doubt that the kindest action we can take right now for our frail elders is to involve them better in the decisions around their medical care, while at the same time working tirelessly to involve them better in the daily functioning of our communities. There must be a great many David Attenborough's out there who are not given the chance to shine.

Old age is not for sissies, partly because it can be tough, but also because we make it tough.

Monday, 16 September 2013

Induction with a difference

I trudged along to the induction at my new Trust. This was the 12th organisational induction I have attended, a number which says more about the nature of my training than it does about me.

It's difficult to get too excited about hearing a new version of fire training, or information governance. But this induction was different.

After coffee in the morning, and the session about the organisational values and aims, there was a session labelled something like 'The perspective of the service user.' An inauspicious title perhaps, but one which had a huge impact on me, and made me ask why out of all 12 Trusts I have worked in, this was the first one to place the perspective of the patients and their carers on centre-stage.

It was a powerful experience. Watching the nervousness of the man who told us about his journey through the system, dealing with treatment-resistant depression made it clear, that we were not just being offered an insight, we were being given a privilege. Mental health will only lose its stigma when we learn to talk about it openly, but it takes some brave individuals to lead that charge.

He was followed by another man, who told us of his experiences of looking after his wife, who suffered from bipolar disorder, with all of its incumbent challenges. The problem for them was that it took her years to be diagnosed with bipolar: every doctor she saw told her she had depression, because she only presented when she was low, and they refused to include her husband in the consultation.

Both of them had reason to be upset: they had both at times been disappointed by the response of the service, by the response of individuals. But they had both seen it all improve, and they both had met people who did little things that made a big difference.

They wanted us to know that what we do makes a difference to the lives of ordinary people, and that what we do is important. They wanted us to know that they way we do our jobs makes a difference to the lives of people who are suffering. We all have the power to make a difference in a job like ours, and I think that they simply wanted to remind us of that.

I asked them whether they had any advice on what we should do to help ourselves and those around us be as good as we could be; to avoid being the people who lacked empathy, or made them feel that they didn't matter.

I was struck by what they said. They said that we need to remember that what we do isn't just a job, it is more than that.

They also said that patients need to remember that we are people too, and that we can also have bad days.

It's a simple message, but it's a good one.

There aren't many induction sessions that I remember clearly, but I think I'll remember this one. 12th time lucky, I suppose. And at least it's for a Trust that I hope to be working in for a long time.

Monday, 9 September 2013

Sharing the load

It's amazing what you can learn from a different perspective. My new job has me working in the community, where I sit at the interface between the acute hospitals, and the GPs. Put alongside my role within the organisation, it is a fascinating mix.

The challenges that face healthcare delivery in the future can be hampered by giving too much air time to one's own particular challenges. For example, the pressures being faced by the acute sector can be managed in a number of ways. The solution chosen really depends on where you are viewing the problem from. For example, if you choose to view the issue purely from the operational perspective of the acute hospital, then your solutions will be directed towards capacity, efficiency and crisis management.

If however, a more system-based view is taken, then your solutions may well centre around how the rest of the system can take some of the strain for the acute hospitals.

The reality of healthcare at the moment is that Emergency Departments and acute pathways are under pressure. There are no doubt a host of reasons for this. But we can boil it down. More people go to A&E, where they perhaps present late in their disease process. They are seen by junior doctors, working in departments that are struggling to manage the throughput of patients, often functioning without a full complement of consultants (many departments have struggled to appoint and retain A&E consultants). The fallout is that the decision to admit or refer is influenced by the late presentation of the patient and the need to ensure that clinical risks are not taken. This is understandable. And, I suspect, inevitable. When you place a health system under strain, staff will take actions that reduce the strain on them, but will also try to minimise the risk to patients.

Under different circumstances, things could be different. If the staffing levels were higher, or if the patient numbers were lower, then doctors could take the time to ensure that they have assessed patients as thoroughly as their presentation allows. Take out the pressure of time, and staff have the breathing space to apply their best thinking to the patient. If there were more consultants, then junior doctors would benefit from easy access to expert opinions, and a better training experience.

But can we imagine significant changes in staffing levels, patient numbers, or consultant presence? Of those factors, the issue that seems to be most remediable is patient load: by ramping up the system in other places to take on some of the work currently done by Emergency Departments, we might start to make headway.

The solution to acute sector strain may well therefore reside in the ability of the rest of the system to improve pick up patients earlier in their illness, and closer to home, or to implement successful policies to maintain wellness.

Viewed in this way, the stress on the acute sector should be viewed as a symptom of the illness, not the illness itself.

Our actions to treat the illness must involve some symptom relief, but they must also treat the underlying illness. This involves understanding the mechanism of disease, and understanding what aspects of the process can be modified.

I never meant to make a medical allusion, but it seems to fit. We need Emergency Departments that provide excellent care, and we need nurses and doctors to be happy working there. Without their job satisfaction, maintaining safe and expert level of staffing will always be a challenge.

The whole health sector needs to think about what it can do to help out its ailing colleague. The involvement of the whole health service needs to be committed and meaningful, or we risk running a system with great care in lots of place, except at the front door, where it often matters the most.

Friday, 30 August 2013

We never really start from scratch

Next week I start a new job in Dorset. My excitement at the prospect extends beyond the reality of living in a beautiful part of the world, with more space, and the prospect of better primary schools for our daughter. It is more than that, because the job I will be starting seems to hold the promise of really examining what geriatrics can do for a widely dispersed population of frail elderly people.

I have long anguished over the reality of geriatric practice, of admitting patients to hospital when life at home becomes untenable due to social isolation, insufficient care arrangements, and the impossibility of overseeing complex matrices of chronic conditions with anything like the kind of attention required. Much of my time in the acute hospitals of North West London seemed to involve inheriting patients admitted out of hours for the want of proper care in the community, managing their hospital acquired infections, dealing with the pitfalls of iatrogenesis, and trying to return them to a point at which they could be looked after at home. Often that point was below the level of function that they had previously held, but the dynamic of the acute sector is to minimise length of stay.

The pressure on length of stay is not just a financial imperative. It is also underpinned by the understanding that for elderly patients, being in hospital is a risk factor for delirium, infections, and a long list of other possible harmful outcomes. For the physician in the acute hospital, often the best outcome is achieved by getting patients fit enough, quickly enough for them to avoid the risk of harm in their own homes. This can be a difficult message to make sympathetically, and too often patients feel like they are being forced out of hospital. And who can blame them? They expect hospitals to provide them with good care, while they take the time to recover.

We have not yet worked out how to do this. One wonders whether we ever will. But is there another way?

For some time, my frustration at my own practice has been the feeling that while I am looking after patients, I get to know them, and their illnesses well. I learn about what works, how they respond, and what to avoid. I learn about the idiosyncrasies of the person, and their body, that can only come with spending time with them. One can observe the evidence-base carefully, but that never tells you how the individual in front of you will actually respond. Patients often don't want to know the percentages, they want to know what they as an individual can reasonably expect. Sometimes the only way to answer their queries truthfully is to give them, and yourself, the time to see how they respond.

Achieving this kind of insight can be done. It takes time, but not just time during the days they are with you. It also takes an investment of time over the course of their lives, through their wellness as well as their illness. If you only ever see patients when they are sick, then you have no clear idea of what they are like when they are well. This is important, and only partially resolved by the emphasis we place on observer narrative. However the description you get from someone else about what your patient is normally like, it is never as good as the impression you get from seeing that patient back to their best yourself.

The practice of the hospital physician has moved away from the long term care of patients. Commissioning arrangements encourage us to discharge our patients back to their GPs. Consequently, we only ever see our patients again when they become sick enough to be admitted to hospital again.

And this creates a peculiar skew to the view of wellness we get. The patients we see are generally sick, and that view is no longer offset by seeing them well again. I do not know for certain what impact this has on my practice, but at its most basic level, it means that in order for patients to benefit from the input of the hospital physician, they have to get sick. They do not benefit from that expertise when they are well.

This gap in service provision creates for me the sense that our pattern of working is mis-aligned. Can it be right to spend most of your time responding to crises, and not working to stop the crises happening in the first place.

What would your practice look like if you designed it from scratch again? There might be similarities, but there would almost certainly be big differences as well. The way that we work is as much a function of history and circumstances, as it is of clinical need.

What would you change? That is the easy bit of the challenge? The hard bit is figuring out going from where you are to where you want to be.

It is that kind of challenge that I now face in a job which is specifically looking to care for elderly patients closer to home, and trying to avoid their admission to acute hospitals, by being more proactive earlier in their acute illnesses.

There is clearly much for me to learn, but it seems that the most important thing is to understand the set-up of the services I am moving to, listen to the ideas floating round, and most crucially, listen to the patients. My idea of what I think they want, and what they actually want may overlap considerably, but there will almost certainly be areas where it is easy to make the wrong assumptions.

So as I embark on this new challenge, it is with excitement, and also a little nervousness. It seems like a very big deal from where I am sitting.

I will let you know how I get on.

Sunday, 18 August 2013

Spirituality for the modern times

I hear that Rowan Williams never wanted to be Archbishop of Canterbury, but at the time he was appointed, it wasn't really offered to him as a choice. He comes across as an articulate, cerebral man, but for whom the challenges of matching daily realities of life with the considered thesis of his religious beliefs held a responsibility and a demand for compromise that he was never really comfortable with.

That he has weighed and considered views is clear. But perhaps they are not worldly, and he has always appreciated that about himself. His strengths lie in the philosophical appraisal of the issues that surround modern religion, but not in the translation of his theses into a political reality.

It is interesting to contrast the approach that he took as Archbishop with the approach being taken by the new incumbent, where the emphasis is shifting from the doctrine of Anglican Christianity, to the practical role of the Anglican Church in modern life. Justin Welby seems to be taking the view that while faith is waning, there is still a considerable role for the Anglican Church as a force for good in social cohesion, and the relief of poverty and suffering. This is still an approach clearly underlined by Christian thinking, but which accepts that there is little to be done to persuade people back to belief, as that is not how religious faith works. A Christian way of life is partly defined by the beliefs you hold, but perhaps as important as that, is the manner in which your beliefs encourage you to behave.

There is something implicit in much of the teaching of Christianity, and perhaps other world religions, that makes sense. They were forged in eras of different social standards, and different world views, but encapsulate much that remains true of society that functions largely outside the purview of formal religious practice. Much of what Christianity preaches to its followers equally valued and agreed by those without formal religion, or without faith at all.

It is therefore refreshing to see the Church trying to act as a force for non-denominational good (although one wonders whether payday loans were the best place to start) and it is refreshing to hear a former Archbishop talk with reference to his own beliefs, but with application to anyone at all, about the meaning of spirituality. (

Ignore the reductionist title of the article. Rowan Williams it seems was arguing for perspective in the face of adversity. He seems to reason that life has never been entirely easy, and nor should we expect it to be. He also seems to argue that he has benefitted from his own reflections on both what spirituality means for him, and what it means for others. In particular, I applaud his suggestion that we should seek to avoid too much self-congratulation for our perceptions of our own spiritual awareness and practice.

In particular, Williams argues that spirituality is not just about nurturing the way that you feel in yourself, but about nurturing how you interact with each other.

That is perhaps a salient message for the times. Is it perception or reality that the zeitgeist is defined by what we can achieve for ourselves, rather than what we can achieve as part of our communities? If you agree, then you perhaps will also agree that the sensitive and considered suggestion that a challenge for all of us is to foster a greater sensibility to the impact we have on others, and the emphasis on turning our influence in to positive experiences for those around us.

Rowan Williams is self-deprecating in his understanding of how others view him. But he also runs the risk of being inspirational. 'Spiritual care mean[s]....filling out as much as possible the human experience."

I read the linked article the day after I wrote my last blog, and there was a resonance. There is something meaningful about understanding that there should be importance placed on magnifying our spiritual impact. I mean spiritual in a totally agnostic fashion. There can be the appreciation that our impact on the world could be measured meaningfully through our impact on all the people around us.

For those who work in healthcare for example, this includes, but is not limited to our patients. It also includes our colleagues, our families and our friends.

And therein lies the theme. The quality of care we offer in our hospitals and GP surgeries is significantly influenced by the training of the staff, and the systems in place, but it is also surely influenced by the ability of the staff, and perhaps also the patients, to be spiritually tended.

Perhaps 'spiritual' is the wrong word - it has the wrong overtones. But what is a better one to suggest that we are most effective if we are aware that it is not just with our patients that we have the opportunity to offer good, but with the other people that the successful discharge of our jobs involves?

This requirement is not emphasised enough, and it is not formalised enough. We should make time to develop it better.

Wednesday, 14 August 2013

Our greatest asset

The news that Whipps Cross has fared poorly in a recent CQC assessment triggers some consideration of how many other Trusts across the country are struggling in a similar vein. (

Some friends of mine have worked at the hospital, and their stories about working there have often been notable by the amount of graft that they have to put in. It seems like a busy place to work. 'Busy' in medical speak can be something of a euphemism. It encapsulates a lot of implied truths. That the numbers of patients are high, that staffing levels can seem insufficient, that the types of patient they deal with are often very sick. There is no precise definition, but there is the suggestion that a 'busy' job is one in which it can be difficult to provide the level of care that you would like to. Working in a busy job can seem like it is a job that asks a lot of you as a person, physically, intellectually, and emotionally. It is draining. It is disheartening. It is unsustainable.

It has been a feature of our assessment of the NHS in the wake of the Francis report to be shocked at some of the stories that have come out. But how shocked are the doctors and nurses who work in the system when they read about the failings at another hospital. Nothing takes away from the disappointment of hearing that patients across the country are failing to be offered the kind of care that all patients deserve. Nothing excuses it. But how many clinical staff read the stories and wonder how different their own wards or services how. How many of them think, "There but for the grace of God go I."

We live in a world where basic human compassion should be the fundamental principle underpinning our health services, and it is on top of this absolute requirement that all other quality measures should be built. There is no reason why the care we offer patients should not be compassionate, high quality and timely.

Except there are lots of reasons why it isn't.

Chief among these, perhaps, is the failure to understand that the delivery of healthcare is entirely about people. Not just the people it serves, but also the people it employs. Compassion is delivered by people who are able to feel compassion. It cannot be rushed, it cannot be contracted out, and it cannot be put on a protocol.

Compassionate care is the inevitable result of staff who are supported to perform at their best; by managers who understand the strain they are under, who take the time to understand the strain they are under, and help them manage it. Compassionate care is given by staff who feel that they have the time to do their jobs properly, who have the training to learn how to manage the demands of their jobs, and for whom managing their own personal responses to their job becomes part of their routine.

Being expert at a job, particularly in healthcare is not just about technical excellence, it is also about learning to deal with the personal demands that the role makes of you. This does not happen by chance. With time, your experience guides you through, but before that time, it is about having the right kind of mentoring, the right kind of instruction, and the support to do it. It is about open communication, constructive feedback, and having dedicated time.

Highly functioning teams do this informally. But highly functioning teams do not occur often by chance. They need to be honed, tended and grown.

The stories about the care at Whipps Cross from the media coverage are alarming. They are disappointing, and they are sometimes shocking. But what strikes me through all of them, is that they are the result of a hospital running at full steam, and running out of drive. They are the result of staff members and teams who, under the constant and unrelenting strain to deliver, have unravelled.

There is no place for unkindness in our health system. But ask yourself whether the individuals who have been seen to be giving unacceptable care have always been like that, or whether they need always be like that.

In the urgency for quick solutions, one wonders how well the systemic issues that are affecting hospitals like Whipps Cross will be dealt with. But certainly part of that solution needs to involve a conversation with the staff not just about their responsibilities to patients, but the organisations responsibilities to them.

Ask the team leaders what they need, and how they can be helped, and slowly watch the culture shift. Support underperforming individuals to achieve more. Let people be fragile or scared or stressed, and help them manage the challenges. Then watch them blossom.

Is it fanciful to argue that the main asset the health service has is its staff, and that if we fail to look after them properly, we will be underselling how much good the NHS can do for its patients?

Tuesday, 21 May 2013

Vision in reality

I have recently being trying to write a book. I harboured romantic ideas of sitting down at my desk, and tapping out my ideas, sending it to a publisher and then watching the money roll in.

I did sit down, and I did tap out a first draft, and then realised that that is when the really hard work begins. The draft I currently have is already very different from the book I intended to write, and having reread it, I realise that it will have to change again if it is to be palatable for popular consumption. I say popular guardedly: a second realisation is that the work I have produced can at best be described as niche, but is probably more accurately described as obscure.

As is my way, this experience triggered some thinking.

Writing a book is something over which the writer should have total control: the words chosen to fill the blank page are wholly the choice of the writer. And yet writing can sometimes create the sense that you are being dragged along by another force - sometimes it feels as if other forces are acting through you. This is no doubt a feature of the writer's limitations: it feels foreign, because the words that result do not quite capture the true essence of what you are trying to say.

Great writers show total mastery: reading the work of a true word smith evokes awe. Sometimes it can be annoying: Martin Amis knows how to construct a beautiful sentence, and he knows it; he spends entire books wowing us with his linguistic flourishes, to the extent that he starts to come across as pompous and haughty. No one likes a show-off.

Writing words that are only ever an approximation of the true essence of what you are trying to say could be a motif for life: our actions and outcomes are only ever an approximation of what we are actually aiming for.

I have been thinking a lot recently about how the way that I practise medicine is only ever an approximation of the way that I think it should be practised. There are fundamental aspects to the way that we deliver care that I would change, if I had total control over the way the system is organised.

But perhaps, even if I had total control, the system that would result would be different from the perfect one I imagined, because translating vision into reality is difficult, and because my vision of perfection may not actually be the system that best serves patients.

And this is my message for the day: it is important to have clear visions of what perfection looks like, but it is also important to consider how, in the real world, we can begin to deliver that vision of perfection. In our own imaginations we are not hamstrung by the mechanics of every day life, and rules and limitations are easy to ignore. This can make solutions seem simpler than they actually are.

Tuesday, 8 January 2013

Elderly care and the lives we lead

John Ashton says we are betraying a generation ( He is right. But we don't need to appeal to the achievements of their generation to justify the assertions that he makes. Our commitment to the elderly does not really need to be qualified or inspired by their efforts in the Second World War, or their creation of the welfare state that we now take for granted. Those are all noble achievements. But our commitment to them should be implicit in the responsibilities of being members of a liberal, progressive and affluent society. We should offer them our commitment because we can, and because they need it. I don't know if we should be ashamed, but we should certainly be embarrassed at the care we offer the elderly at the moment.This embarrassment needs no context, or qualification - it stands alone as the reason for change.

The reality of the world that we create for our elderly and vulnerable needs addressing - care standards are often poor, and the elderly are socially isolated and achingly lonely. We offer them precious little succour, affection or worth, and we exclude them from our day to day lives. We are often blissfully unaware of how poorly looked after they are, and we are blissfully unaware that we are cementing a model of care for when we are ourselves elderly.

We never imagine that we will be the people who end up frail, alone and unloved. We find it difficult to foresee a future in which basic care needs are out of reach, and in which our own sense of self-worth is dependent on the actions that others take on our behalf. The disconnect between us now, and in our old age is completed by the disconnect between us today, and the legions of unnoticed, and uncared for elders, who sit quietly behind closed doors, hoping that something better might happen to them.

As we wander through the world, making choices about where to visit, who to see and what to buy, we cannot imagine that there will be a time when we do not have the fitness, the money or the ability to continue to do all of those things. We cannot understand that the world in which we swim so freely today will probably leave us behind, and that our habits and preferences will appear quirky and old-fashioned. We do not see that there is a cost for the opportunities we have as individuals. We are scattered on the winds, chasing adventure, fulfillment and wealth, and it feels rewarding. Yet the price can be high - our families are fractured and disparate, and our implicit support networks vulnerable. Perhaps we have higher levels of self-sufficiency these days, but perhaps we have overstretched the supply lines that keep us safe. Perhaps the knowledge that back home there is someone who loves us gives us strength, but perhaps it is illusory: perhaps love needs to be experienced, not assumed.

I have a baby girl. I think she is gorgeous (she is) and want to show her off. Quite often, I will show my patients a picture of her.  Sometimes it feels as if that action alone affords them more therapeutic gain that any of the medicine I offer them. Sometimes, I wonder what it would be like to do my ward round, carrying her with me. There is something visceral and spontaneous about the reaction a patient with dementia gives you when they see a picture of a beautiful baby.

I am often struck at how happy a picture can make them, and also at how detached it can make them seem. Pictures of babies are brief glimpses into a world from which they are excluded. And the flip side is also true: the elderly are a world with which children and grown ups are unfamiliar.
We are uncomfortable talking about dying, and we pretend it doesn't happen. We distance ourselves from reminders about dying. We don't spend enough time thinking about our own mortality and this is reflected in the way that we treat the elderly. Being elderly is often much more like being a child than an adult: it is a return to a phase on life when the support of others is crucial - they don't need isolation, they need company and support.

There is a complex interweaving of religion, community and individual identity in all of this, but there are some basic themes: familiarity creates comfort, practice makes perfect. We don't just need to spend more time with the elderly, we need to better understand their role in society.
That great sage of Northfields, @tobyhillman introduced me to some work done by a Franciscan monk, Richard Ruhr, who identified that throughout the world's varied and diverse initiation ceremonies, a few distinct home truths tended to be emphasised:
  1. Life is hard
  2. You are going to die
  3. You are not that important
  4. You are not in control
  5. Your life is not about you.
There is a bluntness to these themes that I don't like. But there is something in there for us: perhaps it is fair to frame it slightly differently: life is not about us, it is about the people around us, and the kind of impact we have on them. And life is more of a circle than a straight line: if we are lucky enough to live long lives, we are likely to end up near where we started out, and perhaps we should think about this when we make the big choices.