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. (http://www.theguardian.com/uk-news/2013/aug/15/rowan-williams-persecuted-christians-grow-up)

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. (http://www.theguardian.com/society/2013/aug/14/whipps-cross-hospital-systematic-failings)

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?