Tuesday, 20 September 2016

Stoicism and hard graft.

Who was not charmed by the sight of Alistair Brownlee giving up his own chance of victory in the World Series Triathlon in Mexico to help his brother Jonny cross the finish line? Jonny hit the kind of athletic wall that would have put you or me into some form of terminal cataplexy. These are tough men - they wonderfully understated, stoical and talented Yorkshire men. They chose to daily inflict on themselves the kind of physical pain that would render me couch-bound for a week, all in the name of sporting excellence.

Jonny Brownlee chose the physical state he found himself in by continuing to push himself when his body was screaming at him to stop. Alistair put it rather more prosaically when he called him a 'flippin idiot' for not pacing it correctly.  Yet, this was an afterthought- his first reaction, instinct, if you prefer, was to help him finish; but it was not instinct that made Alistair gruffly shove his brother over the line ahead of him, in second place. He'd had at least 500m to think about it. That was a choice, and it was borne out of love, and sporting respect. He was rewarding his brother for the race he had run, and the effort he had given.

That brotherly shove encapsulated a great deal: it was a practical solution to the problem of negotiating a limp body over a finish line; it ensured his brother finished by himself (kind of) and ahead of him. It was also a payback for a finishing 500m that Alistair hadn't counted out: presumably he had held enough to get himself over the line but hadn't counted on having to do it for two. He was also making sure they weren't overtaken by the man behind them. It was practical, unfussy and unceremonious. I found it all rather tender. And inspiring. When Alistair Brownlee says that he would have done it for anyone, I believe him.


I have something of a soft spot for understated excellence. I am inspired by success through endeavour, and it often makes me rather emotional to see someone succeed on the back of hours of graft, pain and commitment. I outrageously interpolate unjustifiable conclusions about the type of person a sportsman or woman is from their performance. It's why the outing of Lance Armstrong was so bitter for me. Today, when the provenance of sporting performance is so murky, it is the Brownlees who help me keep my faith.


I want to think that they must have been terrible at school, such was the challenge of persuading them to sit still for long enough to learn something, but that might be my desperation to find a chink in these otherwise amazing athletes. These are not lime-lighters. Every interview with them seems to have the forebearance of someone under obligation. They were recently in an episode of Top Gear, but they seemed to use the challenge as a training exercise.

I suppose we find inspiration in different places. I find mine in sport, and in particular, I find it in sportsmen and women who practice, and train for the chance to win, but without the fear of failure.

I need that inspiration at the moment to counter-balance the clagging tribulations of being a doctor in the NHS right now. Today, it has been announced that the Consultants are to be expected to publish their private earnings (£0 for me - job done) which is one thing. Quite another is the manner of portrayal, as Nick Triggle on the BBC website reports that it is 'certainly not uncommon' for consultants to earn 'in excess of £500,000': this 'fact' can only be explained in 3 ways: it is either a loose representation of reality, a lie, or it is true -in which case my wife will probably tell me to pull my thumb out. Yet it taps into something important: many non-medical acquaintances of mine assume I work short hours for lots of money, with loads of lovely leisure opportunities at a golf course, which I drive to in an expensive car.

In itself, this is a small moment, but death by 1000 paper cuts appears to be looming, as the drip-drip of undermining reporting about doctors eventually makes you ask yourself whether you really are the earnest, hard-working person you try to be. I was bowled so far over by Theresa May suggesting that junior doctors were 'playing politics' that I did wonder whether I'd Rip van Winkled it and woken up in another world. The endless repetition of £10billion of extra investment in the NHS, with the highest number of doctors and nurses in the health services history, and the need for the NHS to be more efficient has been a prevalent, endlessly repeated riposte from the DoH at every marker of NHS crisis, syncophantically repeated by every news outlet that reports on it.

Yet every day, we doctors, nurses, therapists, managers and social workers go to work and know the realities of those pressures. We know that we are not so inefficient that savings will make up the shortfall. We know that we work flat out so much of the time that there is never any time to think about how to do things differently. And we know that no one is really listening, or think we are exaggerating.

Frustrating, isn't it.

So ask yourself this: what would the Brownlees do? Tapping into my habit of detailed character profiling from minimal robust psychological information, I have decided they would:


  1. Keep working as hard as ever, to do the best with what they have. 
  2. Not complain, but plough on
  3. Wait until someone asks them for help sorting the mess out
  4. When they do get asked, they would have a list of practical, sensible measures ready to implement.
So, from watching a brother help his hobbling brother finish a race, I have decided that I can finish this race by continuing to work on the things I do best (being a doctor) and spending time with my teams working on how we can continue to provide good care for our patients with what we have. We will be honest about what we can't do, and then just get on with it. Right now, no one wants to hear anything different, so we'll have to wait for someone that does.

If, in the meantime, you need cheering up, then perhaps you can watch the clip of Alistair and Jonny. Or perhaps you could watch this one, or this one, or even this one. 

Tuesday, 6 September 2016

Timeline melancholy

My Twitter time line is a forlorn place right now. The dominant theme is the Junior Doctor's strike, and there are three prevalent themes:


  1. Junior doctors are striking because of their concerns about patient safety
  2. Junior doctors are striking and are threatening patient safety.
  3. This person says Junior Doctors shouldn't strike, and this is why they are wrong. 
In the last couple of weeks, David Oliver (@mancunianmedic) has been asking doctors close to CCT how they will behave when they are consultants (#whenimaconsultant), and he sparked my current train of thought. 

I struggled emotionally through registrar training, and my overall synopsis of those 5 years could be presented in the motif  'I was a happy geriatrics registrar and miserable med reg.' Too much of my time was spent worrying about why I was finding the role difficult. I spent way too little time articulating to myself and others what made the role unnecessarily hard, and what could be done to improve it. I spent a lot of time feeling bad about feeling bad. I felt guilty that it mattered to me that I felt unsupported, over-worked and stressed. 

I would go to talks about leadership and hear platitudes about embracing the leadership potential of junior doctors, and about improving training. In the end, there were two things that made all the difference to me. The first was taking a year out to do a leadership programme that taught me all about reflective practice, and the habits of personal sustainability. The second was working for a consultant who offered all of his registrars the opportunity to help him develop his service and develop beyond the delivery of clinical services. He was fun, energetic, kind and restored my faith. 

A great many consultants I worked with over my junior doctor career were guided by the ethos of 'telling not asking', and 'bollocking not understanding,' and for them it was easy pickings: the entire focus of my junior doctor training, until I wrestled some control back, was entirely focused on clinical skills. None of the other essential skills of stress management, team working, team building, reflection, or understanding behaviours featured on my curriculum. 


Junior doctors now, as then, find out their rotas the day they start a job. Contracts never appear, pay not confirmed until you are actually paid. I once presented myself at induction, only to be told to go home as I was starting nights that evening. One hospital tried to be organised, and demanded that I take a day off work before I started there to visit their HR department. I refused. The consultant I was working for told me not to make trouble and to go along. 

There is something very akin to bad schooling about how we treat junior doctors. Publicly, we encourage them to question, to enquire, to be open about mistakes and feedback, but in private, our behaviours scream the exact opposite: we expect them to do as instructed, to mask their independence and intelligence until they are consultants, because until then, they are someone else's responsibility, and cannot be trusted to use all of their clinical skills, common sense and social skills effectively. I found it infuriating then - it still is now. 

Too little trust and autonomy is placed in these capable, effective men and women who staff our wards and clinics. Too little time is spent on helping them develop the habits and skills that will help them navigate stressful and demanding jobs with happiness and satisfaction. 

Twitter is currently reminding me of how toxic this kind of culture can be. The GMC has escalated the rhetoric about the risks junior doctors run by striking; the Association of Medical Royal Colleges has decided to discount the value judgement behind the decision to strike. Everyone seems to have an opinion about the justification of strike action, or the risk to patients, but with each comment we mark ourselves as dissociated and out of touch with the very doctors we are supposed to be mentoring. The debate around the strikes has turned into conversations with them, advice given to them, instruction given to them. No one would know we are all part of the same professional family. 

Imagine you are part of a rugby team, and you are planning a foreign tour somewhere, but your forwards don't want to go because of the poor human rights record of the country you are planning to visit. Do you tell them not to be silly, that they are putting in jeopardy the whole tour, upsetting the sponsors, and anyway, all the tickets have been booked? Would you go without them and try to beat a 15 man team with your 7 man team? Or would you listen to them?

In Bowling for Columbine, Marilyn Manson was asked what he would say to the children from the school, and marking himself out as something of a sage for our times, he replied 'I wouldn't say a word to them. I would listen to them.' Who knew that occasionally you need to consult a Shock Rocker to get any sense of a situation? What he realised about Columbine is that rock music wasn't the problem, it was a symptom, and that when kids feel like they're shouting and no one is listening, the shout louder, and more violently. 

Our junior doctors are shouting loudly, and instead of listening to them, we keep bollocking them. They are shouting loudly because no one seems to be listening properly, and those that do come up with childish put-downs which clearly misunderstand the point being made. Junior doctors are people who articulate complex problems for a living. They interpret a raft of symptoms into neat, precise sentences. They have analytical skills, deductive and inductive insights, and they have the verbal fluency. They are telling us there is a problem. That means there is a problem. 

Remember, junior doctors all learn when to ask for help. Good ones take the problem they are dealing with as far as they can, then call their consultant. These juniors have called their consultants, and now it our job to help them find a solution. It is our duty because they are part of our professional family, because they are crying out for support, and because they clearly recognise that they cannot fix this current impasse by themselves. They are doing all the things we have taught them to do. 

Perhaps with this round of industrial action we can do more than either support them or criticise them. Perhaps we can engage with the discussion both at our own trusts and more broadly about how we move forwards. Perhaps we can demonstrate to our junior colleagues that times have changed, and not only do we trust them, but we also believe them, and we value them. 

That was what I promised to do when I became a consultant. 


Tuesday, 16 August 2016

Tilting: the absence of effective team functioning.

I suffer from recurrent earworms. It's an affliction I've had for a long time. I once had to watch Adele's performance of Someone Like You on Jools Holland about 100 times before I could move on. The problem has flared up again recently with Christine and the Queens' 'Tilted'. The traditional management strategy is either to feed it relentlessly until it burns out, or pass it on to someone else. Usually, I have resorted to the former, but more recently, I have tried to share it with my 4 year old daughter. She loves music videos - her favourite is Michael Jackson's 'Beat It'. I don't think she is entirely convinced by Michael's ability to heal gangland rifts through the power of dance, but she does find it terribly amusing. 

For the last week, therefore, I have been exposing her to repeated viewings of Christine and the Queens' 'Tilted', both in video and live performance versions; she particularly enjoys two aspects: the man who walks on his hands and the line 'I am doing my face with magic marker.' 'That's silly, Daddy', she says. She is right, which only leads me to wonder whether a magic marker is the same as a permanent marker, and how worried I should be that she will become a music-lyric-copycat, and be left with ink stains on her face that remain until she grows new skin. She's due to start school in a few weeks - it's a real concern.....

Tilted is a song that first appeared in French. Heloise Letisser (Christine is her alter ego) speaks English with the kind of thought and consideration that allowed Nabokov and Conrad to write beautiful English prose in non-native languages. Tilted in English, is, I suspect, purposefully ambiguous, and contains the delicious line 'I am actually good, I can't help it if we're tilted.'

You make of that what you will, but to me, it invited comparisons with what it is like to work in healthcare. Over my career, there have been moments when I was unable to be the conscientious, well-meaning young man that decided to be a doctor. There have been moments when I found it impossible to be as compassionate as I wanted to be, to be a considerate as I needed to be, or as patient as my patients needed me to be. 

I am not alone in having set out in medicine to be expert, caring and good under pressure. I am not alone in having failed to live up to these objections. I am not alone in having felt the shame of having fallen short. Today, I wonder sometimes how I made it through my time as a medical registrar. 

Feelings of inadequacy in a hospital can be insidious, and undermining. You look around at all the people who manage to be nice all the time, who seem to breeze through the day, while you wrestle with the anguish of feeling inadequate. You exhort yourself to try harder, to be better, because, well, that is how you manage problems in the NHS. 

We have been fostered in an environment that talks about 'no-blame cultures', but which, through every action it actually takes, cements the perception that you are OK as long as you don't mess up. Targets are met through constant cajoling, pushing and exertion. Each day is a full throttle effort to keep up, leaving no time for colleagues to sit down and ask of each other 'Are you OK?'. There is no space to reflect, to learn, to plan different ways of working, or simply to make sense of what has happened. 

It is in this environment of working that staff start to wonder whether they have the stamina to survive. Each day in an acute hospital is run as if it is a crisis. Yet a crisis response is only sustainable if you know that the crisis will end; that one day soon, you will be able to take your foot of the peddle, slow down, catch up, tidy up and recover. 

The recovery time in medicine has disappeared. Recovery used to take place in the mess, in the pub, in the quiet moments of the day. The old way of team building through having the whole firm working together all the time wasn't ideal - machismo and practising on patients are no way to do healthcare, but at least there was solidarity. Now the hours have changed, but nothing has replaced the team structure. Modern working schedules do not allow firm team structures to exist in the way they used to. Without them, however, junior doctors have lost the support networks they used to have, and they have not been replaced with anything. One would have thought that with doctors switching teams so often, that the NHS would be the world leaders in team development strategies. Perhaps we might be, except that the current culture of healthcare seems to view team-building as non-essential. For confirmation, look at the number of junior doctors who started posts this August who still don't have contracts, know what they will earn and didn't get their rotas until a few days before starting. 


I have been musing over this, to the tune of Christine, and various online articles that have caught my eye (here and here, for example). The comments section of the 2nd article is illuminating, including the remark 'You're already a good doctor, and you'll get better.' A revealing insight into the perception that you learn by doing, and by coping. I would hope for more than that. 

The moment of expressed crisis in a colleague is not the moment to reflect deeply on what they are doing wrong. It is the moment to reflect on what you as a team are doing wrong. The moment a colleague makes a mistake is not the moment to enquire only on whether they are competent to do their job, but to enquire whether your team is functioning as effectively as it could be. Crises and mistakes are the moments when teams should huddle together in collective responsibility and openly outline the problems, and earnestly offer the solutions they can try. 

Fostering a team environment in which mistakes and crises are taken as opportunities to reflect genuinely on how they can operate better need not be hard. It requires only two commitments: to treat mistakes and crises as the whole team's responsibility, and commit to open, safe discussion of the causes and solutions as a group. 

I am glad I survived registrar training, because I have ended up working in with teams with whom I think I could take on the world. More importantly, I have ended up with teams with whom I feel I can be fragile and vulnerable. I know they will help me, and I wouldn't swap them for anyone. We may be out in West Dorset, but together we are working really hard to offer our patients services that we are proud of; and we are doing this by making sure we have time in our schedules to discuss what is going well, what isn't and what we want to try next. 

Next time someone looks like they're struggling, or they make a mistake, sing yourself the song, and remember, 'They're actually good, but can't help it if they're tilted'. 

Monday, 1 August 2016

Domiciliary admissions

On Friday, a GP phoned the integrated care hub in the community hospital I work in to request an admission for a lady bed bound at home, and in need of medical attention. We took her details, made sure the ward was ready for her and organised transport to bring her in.

Ordinarily, a team would wait for her to arrive and assess her when she was in her bed. Ordinarily, she would be brought on to the ward, sometimes after an interminable delay waiting for transport, and then be assessed by a nurse, then a doctor, and then acclimatise herself to the unfamiliar environment she found herself in.

Ordinary is boring. I wanted to do something a little different. Instead of waiting for her to arrive, I picked up my computer, my bag, and a drug chart, and I drove round to her house. I clerked her in her bedroom. I assessed her medical needs, I had a quick look around her house, and I met her husband. The ambulance arrived while I was still there, and I was able to talk to the crew about her needs. I spoke with her about what I thought was going on, and outlined to her how we would try to help when she arrived in hospital.

After I finished at her house, I popped round to a couple of other patients at home, and by the time I arrived back at the hospital, she was there, at her bed, looking both relaxed and relieved.

Seeing her at home might seem like a small thing. It might seem like a massively inconvenient thing, But it was also very useful. For some time already, I have given up out-patients clinics and only see patients at home. I find it is more relaxing for them, and useful for me. When you see someone in their own home, you instantly get a feel for how they are actually managing. In the same way, by assessing this lady at home, I could instantly get a feel for what she needed from me. It was also, surprising and reassuring for her to meet one of the doctors who would be looking after her in hospital, before she arrived.

I'm not saying that all patients could be assessed at home prior to admission, but I am saying that introducing  new ways of working that are designed around the needs of the patients you are trying to help can have a big impact on their experience and comfort with health services. I also suspect that it allows us to help them more effectively.

Monday, 11 July 2016

What CGA means to me

It worries me when someone talks about 'doing a CGA.' I shy away from CGA evangelism, but comprehensive geriatric assessment is the cornerstone of geriatric practice. Put as simply as I can manage, CGA is the holistic assessment of a patient, to capture all the issues that may be affecting a patient. Done well, it should cover medical, psychological, social and functional domains, creating a detailed picture which helps to explain the presentation of the patient at that moment.

Simple to understand, difficult to implement.

One of the tricks of geriatric medicine is to make sensible treatment decisions for the patient you are dealing. Achieving 'sensible' relies on having a clear picture of what that person is like when they are not ill, and not in hospital.

Admission to hospital is a cognitive stress-test, which usually takes place in the context of the physiological stress-test of acute illness. Often, the patient in front of you is far from the person they usually are. Imagining your way to that person in their routine is like foraging through a thick forest, looking for clues. The risk is significant: underestimate their usual level of function and deny them treatment that might be effective because we think they are too frail; overestimate them, and subject them to futile, disorientating care that offers them little utility.

I wrestle with the challenge of knowing my patients. I also wrestle with the concept of a CGA done in an acute crisis. It yields important information, but it yields it too late, and often incompletely. Too often it tells me too little about the recent narrative of that patient's life, the trajectory they have been on, and if offers them too little opportunity to take part in planning their care.

Serving a frail, elderly patient well asks that you involve them in their care, that your practice is influenced by their preferences, their style and their goals. These all vary hugely, and practicing geriatrics only one way means expecting your patients to all fit in with your judgments, preferences and biases. This is a certain way of ensuring that you partially serve most of your patients.

In the world of community geriatrics that I circulate in, we have been building services that aim to manage patients holistically, gently and responsively over time. The cornerstone of our adapted services has been the recognition that almost all of our frail, elderly patients are known well to at least one community service. Over time, these services, and key people within them understand in some detail what that patient deals with, what they are looking to achieve, and what they want to achieve from future care as they become more frail.

We base our conversations about how we help patients through periods of crisis or deterioration on the information provided by the person who knows them best. We develop our input around what we have learned about them from their previous care. It is an approach that requires carefully nurtured team cultures that encourage participation from staff of all roles, and it is an approach that demands significant investment of time, to allow for conversations that often swirl and circulate before you are able to focus in on the key issues that have been identified.

What we have yet to achieve is a system in which every routine assessment contributes to a centrally collated CGA, built up over time, and from every healthcare interaction, to which any relevant health professional can refer when they meet a patient. Some people call these care plans - I like to think of it in the narrative sense.

I am working towards a world in which CGAs are not done, but continuously honed. I look forward to a world in which every interaction with an elderly patient is treated as an opportunity to contribute to care when they get sicker or frailer; in which a crisis is just another chapter in the process of caring for frail, elderly patients. We should be able to leverage the opportunity offered by electronic records to collate this information automatically.

The goal is this: whenever a patient presents with an acute illness or crisis, their admission should be underpinned by an holistic care plan, built up over time, honed at every opportunity and able to support critical decision-making at any time.

My great frustration with acute geriatrics before I moved to the community was that I would spend time helping patients recover from their illnesses, understand how their diseases responded to treatment, and then have nothing to do with them until they became sick again.

After three years working in the community, I am much closer to understanding how holistic geriatric care could work effectively in the modern health system. And it's not as far away as you might think it is. 

Tuesday, 5 July 2016

Modern rituals.

Life has a lot of rituals. From the way we organise child-birth, to the day we die, our lives are marked in the stage-posts of periodic rituals. My little girl is due to start school in September, and even that has the hallmarks of a ritual. From the care-free playful days of her first four years, she will embark on a routine that starts to embed in her an understanding of the way that our world works. She will make friends (hopefully), she will learn to read and write. She will take exams - one of my favourite rituals of all.

Perhaps I am being too liberal with the word 'ritual'. Our lives are not governed in the way they once were by religion. That is not true everywhere, but here in the UK, religious practice is a matter of personal choice, rather than compulsory observation. Ritual has become secularised, which is not without its pitfalls.

I see evidence of secular ritualism all over the place, from humanist naming ceremonies, to football matches, summer festivals, graduation, even Christmas. Who can still argue that Christmas remains a primarily religious celebration?

I like rituals. They give us context, grounding and perspective. But primarily, they must have purpose. A good ritual allows us to appreciate where we stand in the world, where we have come from, and where we are going. It is a piece of community history, that encapsulates the learning of the past for the benefit of future generations.

Baptisms introduce a new child into their families and communities. Weddings celebrate the bonding of a couple. Funerals organise the grief over a lost friend or relative. It is always good to forge one's own path, but it is also important to understand from whence you came.

Yet, the ebbing away of religious practice from wider communities has left a big gap in how we deal with death. Today, over half of people die in hospital, yet only 8% want to. The majority would prefer to die at home.

At first glance this appears to be a fundamental failure of the health service to adapt appropriately to the needs of the people it serves; but hold your counsel for just a moment. How many of those people who were asked were actively dying at the time they were asked? I suspect not many.

I have supported a great many people in their final days, and done well, it can be a serene and valuable experience. Many of my patients were ready to die, and tired of life. Yet many were understandably scared and lonely. I try to advise families not to keep vigil, but to keep loving in those final days and hours. To talk, to hold hands, to give space and quiet. I have encouraged them to enjoy final lucid moments, to look out for signs of distress that we can help with, but more importantly to talk openly, honestly and candidly about what is happening, and to take a final chance to say the things they won't ever have a chance to say again.

And sometimes, to me, it feels a little absurd that it is I, a physician in his 30s, who is giving advice to families about how to deal with the process of seeing a loved one die. I never really thought I would become an expert in dying, even as a geriatrician, but then again, who else has the chance to become expert?

Patients often come into one of my community hospitals for palliative care, and we are glad to have them. We are pleased to be able to help. The nurses I work with offer the kind of care I wish everyone could have. With a calm, compassionate simplicity, they tend these patients compassionately, and allow the patients and their families to focus on the things that are important to them.

Many of these patients arrive having had a fraught time at home. Often they are desperate to be at home, and their relatives are desperate to support them. But the challenge of meeting the care needs of some very frail relative, often in pain, or with other symptoms can be overwhelming and incredibly stressful. It is also entirely unfamiliar. What is normal when someone is dying? How do you know what to expect?

Many of us, I suspect have never seen someone die, or even seen a dead person. I remember clearly the first time I was present at the very moment of death. You can tell instantly, and you start to understand why we used to believe in a spirit leaving a body, because that is exactly what it looks like.

It used to be the case that many people died young, or the elderly died at home. It used to happen all the time. Within communities, it was something that most people had experienced.
Vestiges of the past still live on through our hospital chaplains, who minister our patients with grace, calm and compassion. It is through our local vicars that some of this community expertise lives on. The double-edge of the success of modern medicine is that these routine occurrences have passed out of the collective experience. End of life care has been outsourced to hospitals, which means that when it does happen at home, it can be a scary experience for all involved, because there is too little access to people who know how it all works.

Much of the comfort that patients and relatives get from dying in one of my community hospitals is from being surrounded by staff who can help them know what to expect; people who will tend to routine care that is important, so that they can enjoy some tender last moments, without the pressure of attending to basic needs.

Perhaps this was a ritual that we used to have the community expertise to do at home. Perhaps it's something that we still have the expertise to do at home. What I know is that for some patients, being cared for in a calm, expert environment that isn't their home, is often the right thing to do.

Sunday, 22 May 2016

Calm under fire.

I'm a little baffled by the new contract proposal. I don't understand how you can mentor someone who has been on maternity leave to make up the time spent as a mother and not a doctor: equality doesn't mean that to me. Only women can deliver babies - they shouldn't be disadvantaged by that reality. I also don't understand why night shifts that start at 7.30pm don't attract the same pay uplift as shifts that start at 8pm (it is entirely possible I have missed something), and I don't understand why the same contract discussion is still taking place when it has been well demonstrated that not only does this contract not solve the problem the government is trying to fix, but that the problem itself is not a problem. Surely, we do not still linger on the misconception that radical working changes are required to improve survival expectations of patients admitted at the weekends.

Guessing what lies beneath the contract chicanery is a fool's game: we can tell you what the evidence suggests to us - that the NHS is being teed up for greater private provider involvement, but the current political oversight of the NHS is something of an evidence-free zone. Who can reason out the illogical reasoning behind our current situation?

And this is the knuckle-gnawingly frustrating thing about the whole situation. Logic doesn't prevail. Evidence doesn't talk. It reminds me of what it is like trying to explain to my three year old why she can't have more ice cream, while she is having a hissy-fit about not having more ice cream. Nothing gets through.

I can't count the number of people who have shaken their heads patronisingly at me, and said that junior doctors are being naive, that this is politics. The implication is that politics goes by different rules, and we should be OK with that. We should be OK with a world in which reason, evidence and grown-up dialogue are usurped by the diaphanous concept of 'winning'.

Where the sad reality leaves us that is that there is no clean way out of this. Jeremy Hunt talked, the morning after a proposed contract was agreed, about this not being about who won, but how long will that last. Can junior doctors trust him not to go crowing about winning the day after they agree what has been proposed? Could they stomach what would come after if they rejected the new contract?

The Department of Health keeps reminding us that this is about providing a 7 day service to patients. I suspect many are not convinced about their real understanding of what this means. But we do. We all know the areas of our service that we want to improve, we all understand the limitations to achieving what it is that we want to achieve; yet I imagine many of us still have plans for what we are going to do next.

In this crazy world of doctors having to play politics, understand the nuances of PR and social media, we are all still going to work, delivering the best we can for our patients today, and thinking about making our future services better still. There are elements of the service we work in that we have no control over. We can't predict what the current Health secretary wants to do next, and we can't predict how the next one will want to make his or her impact. What we do know is that they will want to do something, because when was the last time a Health Secretary trusted the people who run and deliver healthcare services to know what the best thing to do next might be?

And it was ever thus. We have been tinkered with, reorganised, and in some cases catastrophically buggered around with, all in the name of improving what we do now, since the NHS began. And yet we have continued to deliver better healthcare. The care we deliver now is not perfect, but our outcomes are better now than they ever have been.

There is also a silver lining. When was the last time that consultants and junior doctors felt so connected? The sense of solidarity pervades the NHS. Consultants now have a better grasp not only on what the problems of being trainee are, but what the day to day frustrations they experience are. They may only have walked a few days in the shoes of their juniors, but it has been enough to erase the rose tint from their own memories of being a junior, and focus on the reality of that life today, in the current NHS.

So we have solidarity, but we still have the threat of imposed change. Of course we do - and it won't go away. But in reality, it doesn't change very much. We always operate within the limitations of our current framework, yet great change is always possible.

The system may be telling junior doctors that they aren't appreciated, but we don't need to toe that line. Consultants, nurses and therapists are all capable of creating teams that any junior doctor would want to work in, and of delivering better services together.

It's not much, I know, but perhaps we would do well to remember that any framework creates opportunities, and however down-trodden we feel right now, we can still hang on to the prospect of creating something better for our patients.

While the metaphorical mortar shells are flying overhead, we must keep calm under fire, and do what it is that we have always sought to do: put the patient first. 

Saturday, 14 May 2016

On a raft without a paddle

Werner Herzog's cult movie 'Aguirre, the Wrath of God' opens with a shot of a Spanish baggage train weaving it's way down some steps cut into an Amazonian mountainside. As the shot zooms back, the scale of this path carved into the hillside becomes apparent - they start at the sky, and seem to weave their way into the bowels of the earth.

Aguirre is a notable movie with for a number of reasons- it is dark, weird, beautiful and atmospheric; Klaus Kinski is terrifying - up there with the Child Catcher from Chitty Chitty Bang Bang (you know I'm right). He doesn't do or say very much, but there is always menace, and an ominous verbal tick punctuating the movie foretells all manner of darkness. But what has always grabbed me is the story of its making: I was told (who knows how reliably) that Herzog wanted to recreate the reality of the conquistador's progress through the Amazon rain forest by undertaking a conquistador's progress through the Amazon rain forest. Let's call it Method Directing. Those steps on the mountain in the opening scene weren't there before the movie was made: Herzog got the cast and crew to carve them. They weren't very happy about it, but what could they do? They were marooned in the jungle with a maniacal director and a scary actor fully absorbed in a scary role. 

There's a moment in the film when the group needs to make its way down the Orinoco on rafts. There's no CGI here, and from I can work out, he put the cast on one wooden raft, the cameramen and crew on another, and pushed them down the river. He clearly didn't get much footage from it (he repeats certain shots), but the picture of fear on the actors faces is not faked: they were being pushed down some rapids in full 16th Century attire on hand-made wooden rafts. 

I thought of this scene recently at the British Geriatric Society conference, during a conversation about leadership. Herzog displayed the form of leadership that involves putting your team on a raft and sending them over the white water, while waving at them from the bank. This reminded me of some of the leadership behaviours I have witnessed in the NHS over the last 10 years. It seems to be particularly prevalent at the moment at the top of the health tree. 

I wonder if Herzog was angry that he got so little footage from this escapade, and gave his crew a bollocking. Let's imagine he did. Perhaps his crew could have pointed out that on a wooden raft, they didn't have appropriate camera rigging to get steady shots, that they couldn't capture decent sound while being on a different raft to the people they were filming. Perhaps, they argued that they spent so long worrying about their personal safety, whether they would be OK without life-jackets, that their minds weren't entirely focused on the job at hand. In fact, one could argue it's a miracle they captured any footage at all.

Sound familiar?  Ever get the feeling that we've been put on a raft, pushed down the river, while people shout from the safety of the river bank that we need to work harder and be better? Look after an ageing population with increasing complexity? You can have some more money, but we want you to save even more through being more efficient. Provide elective and emergency care across 7 days? You can't have any more money for this, but we will magically pay you more, while keeping the overall salary budget the same. 

The NHS is currently Herzog's crew on the raft. The major problem with this whole situation is that the patients are the cast on the other raft, and they too haven't had much say in how the whole process works. It's not hard for them to act the role of scared explorers on a raft, because the only difference is that they didn't know they were explorers.

The scenario I describe relates to a still prevalent leadership style within the NHS that is counter-productive. You can push people down a river, but usually, you only to do it once. Next time you go near water with them, they will keep you between the river and them. Perhaps you can argue that the end justified the means, but you'll have to make your own assessment of the price of art (or happy healthcare workers).

Sunday, 24 April 2016

Everyday crises

Death and taxes - the great unavoidables in life. Except, perhaps, if you have the phone number for a lawyer in Panama. Yet even the rich have yet to cheat death - it remains the great equaliser.

If 2016 is a bad year for celebrities, think for a moment about what it is that grabs us when one of them dies. The death of a celebrity prompts a bout of intoxicating nostalgia, that is not possible when they are alive. The loss of someone we feel we know (but haven't met) triggers some intangible emotions related to the fact that we have lost someone who didn't know they were important to us. Perhaps some of the grief is wrapped up in the realisation that they will never have the chance to know how important they were to us. Celebrities must have some abstract sense of the role they have played in other people's lives, but I doubt that they really grasp how resonant their song, book, film or art was to all their fans. Perhaps the sense of loss is more selfish - that the death of a celebrity reminds us of a bit our past that has gone for ever: reminds us that we are relentlessly marching in the same direction. I tie myself in knots thinking about it.

The manner of dying also has resonance: Bowie orchestrated a most stylish exit. Alan Rickman and Victoria Wood seem to have died privately, with friends and family around them. Prince was found in a lift. Marvin Gaye was shot by his father on his 45th birthday. Sean McGrotty died trying to rescue his family from a sinking car, after he had taken his 4 month old baby safely to the surface. The moment of dying is not just an ending, it is an epilogue to a life. It is the last thing you read in the book of someone's life, and it can colour or enhance everything that went before. 

I thought about this recently, when I heard that the body of Rose Polge had been found. All I know about her is that she was a junior doctor in Devon, and had last been seen in February; a note was found in her car. Who knows if being a doctor had anything to do with her death, but it sits there in the biography of her life as an emblem.

One's first years of practising medicine are an intoxicating mixture of pride, exhilaration, fear and exhaustion. While experiencing the thrill of diagnosing, prescribing and helping, there is also the worry, pressure and intensity. People always say that medicine is a tough job, but nothing prepares you for the reality of it. It is an odd and overwhelming feeling to be a doctor after the years spent chasing it. However, I found myself, for a time, hating parts of the job, and feeling wretched about it. It eased with time, but whenever I thought I had it sussed, something came along to unsettle me. Even now, I'm not quite sure how I made it through five years of being a medical registrar.

As I experienced self-doubt, and negative thoughts, I would look around me. All around me, I would see my peers seemingly sailing through with charm and style.  For a while as a house office, I went through some particularly hopeless periods. I wondered how I could feel so bitter about the people I was helping. I started to wonder if I cared enough about people to be a doctor. Interestingly, I started to find some perspective when I read 'House of God'. Samuel Shem's dark satire portrays a world so fancifully unrealistic, it is easy to dismiss it simply as black humour. But every hospital has a Fat Man,, who boils the world of medicine down to 13 simple rules. I had mine, and it was through him, I started to realise that I wasn't a bad doctor, I was simply a young doctor being asked to find his way through medicine without enough help. I wanted to be a Fat Man when I grew up. I guess we all do in a way: he is the one who makes it look easy. Yet even he went through his black periods, and perhaps the one thing that teaches us is never to trust the person who has never found it difficult.


There is nothing wrong with medicine being a challenging job. It is probably the lure of the challenge that draws so many in. It is therefore, unsurprising that many find it hard along the way: if we all found it easy, it would mean that it isn't that hard. What troubles me when I see it, is the failure to recognise and deal with stress and anxiety when we come across it at work. Who of us can truthfully say that we always help a struggling colleague whenever we find them? I often think about a house officer of mine who found the going tough when I was a registrar. I wanted to help her, but was barely keeping my head above water myself. I worked for a consultant who expected me to cope with everything that came my way. I often wonder what happened to her, and whether she made it through.

The challenge of supporting junior doctors gets confused because of how we think about junior doctors. The fact that we call them junior doctors illustrates the point. We treat them as students, and trainees, rather than fully functioning professionals. I prefer to think of them as colleagues. I prefer to think of them exactly as I think of other consultants, nurses and therapists. Of course, there are differences, but we shouldn't use these as an excuse for unjustified differences in how we treat them.

The hardest thing about dealing with junior doctors is their transience: they spend a few months with a team before moving on. There is little time to develop deep and trusting relationships. By the time you have understood how they are doing and what help they need, they are moving on. And this is the problem: we work with colleagues on the understanding that normally everything works well, but sometimes, we have to deal with problems.

The reality is that there are problems all the time. Dealing with challenges and stress is a daily part of the job, and should therefore be a daily part of the way we work.

From experiencing deep personal crises, I have learned that one of the most useless things to say to someone is 'You can ask me for help anytime.' One of the hallmarks of a crisis is not knowing how to ask for help, or how to approach a problem. The most helpful thing you can do for someone, is well, something helpful. You may not be able to solve the problem, but you can take away other things unrelated to the problem and increase their capacity for meeting the challenges ahead of them. I remember my Mum helping a neighbour who had lost her husband by doing her ironing. I thought it odd, but later realised, instead of offering sympathetic platitudes, she was doing something useful.

The most helpful thing that teams can do for junior doctors is to function in a way that allows the open contribution and discussion of problems and aspirations as part of the routine.

Personal sustainability in medicine is all about having the routines and habits that make a difficult job easier to bear, and teams who share the load. None of these skills is currently taught to junior doctors - they are expected to learn from people who themselves have never learned the good habits of personal sustainability. Is it any wonder then, that nothing seems to get better?

My goal is to ensure that the teams I work in communicate openly and honestly all the time; that we talk regularly about what is going well and what isn't; that we discuss what we want to do next, and we do it all together. I think, if we can do this, then any new member of staff, be it a junior doctor, healthcare assistant or nurse will join a team in which they know that they can learn, and struggle, and that all they support that they might ever need will not just be there when they ask for it, but given to them freely from the start.


Monday, 18 April 2016

Crowd-sourced trust

I have a snippet of a memory from many years ago. Aged 3 or 4, I am sitting in the back of a car - my parents are up front. There are novelties for all of us: it smells different, it is beige, it runs on diesel, it is Montego hire car. Remember the Montego? Outside it is foggy, snowing even, and it is bitterly cold. I hear my parents whisper to each other about it being too cold for a diesel car, that the fuel will freeze and we may well end up stranded on the side of the road.

For the rest of the journey, I am petrified. I give myself a pep-talk, telling myself how brave I am going to be if we break down and have to walk home. It never occurred to me to ask my parents if we were going to be OK - I had heard enough. And I dealt with my own fear by myself, because the last thing my worried parents needed was to have to deal with my own, small, child worries. Surely aged 3 or 4, I should be able to manage those for myself?

In the end, there was no crisis - the Montego defied expectations and carried on going, and we returned home without further incident.

I was thinking about that memory recently, as I drove to work on a cold, cold morning. And two things struck me: firstly, was it even a thing that diesel cars in the 80s would freeze if the ambient temperature dropped too low? I never saw it, I never see it now. Or was it that my parents had enough experience of British Leyland cars to know that if conditions fell off optimal then you could never be sure what the car would do. It's like the memory that in the 80s, whenever someone had a new car and you asked them how it was, they would always say 'It's too soon to tell.' You had to give them a couple of months to find out where all the gremlins were, which panels weren't properly fitted, which electrical components had been botched, and which bits of paint were going to flake off first.

I still see this in lots of my patients: the tacit acceptance that something brand new won't necessarily work well straight away. I think it might be why they take so much better care of their cars. They have the hard won knowledge from years of suffering well-designed, but terribly-made British cars, which unless they were cherished, polished, waxed and oiled, would seize up. They would look at the tide-mark of Dorset mud on the side of my car and shiver, I'm sure.

The second thing that this memory triggered was the realisation that my parents at that time had no idea how worried I was, and if I had mentioned it to them, they would have talked me through it, reassured me, and let me know that it would all be all right.

I often wonder how much I understand about what is worrying my patients. Sometimes I get a sense of what they aren't telling me, when one of them asks me a question, or does something so ordinary but unusual, that I begin to wonder whether a lot of their concerns never get asked, or aired. A man the other day interrupted my ward round review of him because he needed the loo. He was clearly desperate, but couldn't stop apologising afterwards. I couldn't reassure him enough that it was OK, that nobody should have to have an important conversation while bursting for a wee.

Another lady shyly asked me how her recent injury would affect some deeply personal aspect of her life. I was happy to advise her, but she was clearly mortified to have to ask, but still determined enough to do so.

This all begs the question, how do we give patients the confidence to ask, the time to be heard, and the confidence that they will be treated with compassion? I notice that so much emphasis is placed on my ward rounds by the patients that they get performance anxiety, and forget some of the things that they meant to ask. I encourage them to write their questions down when they occur, so that they don't slip their minds. But more than that, the thing I try to do now is to be present less formally. A ward round is quite a formal time: I go round the ward and see each patient in turn. They see me walk into the bay, and they wait their turn. Sometimes it must have the sense of an inspection, or progress report.

I have previously commented that my most fruitful relationships with patients are when we have a relationship on equal terms. They are them, and I am me, rather than a patient and a doctor. Honesty, to some extent, thrives on informality and familiarity; these are aspects of relationships that take time to build. and time is the one thing that we are not given enough of. I have 80 in-patients. If I spend just ten minutes with each of them, that is 13 hours a week.

Over time, I have learned that although my own relationship with my patients is important, it is not the only important relationship they have. They have close friends, and families; they have strong relationships with district nurses, therapists, their GPs. There are many people who have spent time with my patients over the years, and they are often well ahead in the trust-stakes with them.

Each moment I spend with them counts, but they are not the only moments that count. There are countless other opportunities to learn and understand. Effective team working enables this learning, and flat team hierarchies mean that it doesn't matter whether important conversations take place with a doctor, a nurse or a healthcare assistant - they can all be brought to bear for the patients' benefit as long as you have the trust in all the people you work with.


Tuesday, 12 April 2016

Crafting Care Plans

Legend has it that Voltaire wrote Candide in three days. Academic enquiry suggests it took a great deal longer. The idea that talent and perfection is innate has a peculiar traction, but it is perhaps lucky for most of us, that great works are more often the function of graft than inspiration. It is something that can give us all hope.

Novels take time to appear. I like to apply the Michelangelo idea to a book: the idea that a book starts as a solid block of paper, and the novel is chiseled out of the block in a process of rough outlining, correction and laborious polishing. It starts with the idea of what book is contained within, and the application of labour and skill to reveal the story concealed within. Reading Steinbeck or Nabokov or Conrad, one can certainly appreciate the process of refinement, and sense the bloody determination and brain-aching effort taken to phrase each sentence just so. 

Perfect prose has some of the hallmarks of a wonderful goal, or a breathtaking try. Before it happens you have the hope that it will work out the way you want. Afterwards, on the replays, it has the aura of something that always was, and was in some way always meant to be. 

My friend Charlie has written a wonderful (and beautiful) book (http://charliemaclean.co.uk/). It is actually more than just a good story, it is wonderful to hold and flick through. In the hand, there is the suggestion that it could only ever have been the way it turned out. But to know Charlie is to know the hours and the years that he put into crafting his first novel. It was a sacrifice to write, and a true labour. 

I know something of the commitment required: I have 70,000 words of almost complete twaddle sitting on my hard drive, waiting for me to find the courage to erase, and start again. Such is the experience of writing: one can go for miles and miles down one path before realising that it's the wrong one, and you need to go all the way back and start again. 

I thought of the creative process this afternoon, while engaged in a lively twitter discussion with David Oliver (@mancunianmedic) and Claire Solomon (@geridoclondon) about the wisdom of screening for frailty, without a clear plan of what to do with the knowledge that someone is frail. 

Within the world of geriatrics, it seems to be de rigeur to set up projects that screen patient groups for frailty. At a couple of events recently, I have listened to project after project describe how they are screening; but I have heard very little about what they do with that information. In many instances the process of screening is conflated for an actual comprehensive assessment, and what results from the whole process is a care plan, produced in one day, that is never updated, and almost certainly, rarely referred to again. 

Geriatricians deal with advanced frailty, and as David Oliver told me this afternoon, mild frail is about self-care and prevention, while  moderate frailty is about good primary care coordination. 

The question this poses me, as a community geriatrician, is what my role in all of this frailty management is. In reality, this question answers itself when I reflect on the patients that my capable and excellent local GPs ask me to see. Their referrals to me can be divided into three groups: those in whom they can't quite figure out what is going on (diagnostic uncertainty), those with complex symptoms in the context of multiple medical problems and those for whom the limits of medical intervention and treatment need to be considered (ie ceilings of care). 

The rest they mostly manage themselves. However, I have found that there is a useful role for me in this routine work, through the time I spend with GPs and MDTs, contributing to the discussions about patients and how we can best support them. 

Over the last two and a half years, I have learned a couple of important things about helping frail and vulnerable patients at home. 

The first is that success is defined by what the patient wants to achieve, and this can vary hugely. Some want to be pain free, others want to be able to breathe a bit easier. Some want to live long enough to go to their grand-daughters wedding or celebrate their ruby wedding anniversary. Others want never to have to see a doctor or go to hospital. And some simply want to die in comfort. There is no standard definition of success for these patients, and we can only know if we have done our jobs properly if we understand what it is that they wanted to achieve in the first place. 

Understanding patients to this kind of details takes time, and can't be achieved in one assessment or home visit. It takes patience, and commitment. 

And it takes something else: it requires you to listen, not just to the patient, but also to all the nurse, therapists and carers who have spent time with the patients, and formed a deep understanding of their issues and needs. 

Community MDTs need to function in a way that allows all team members who know the patients to be heard and to have the confidence to contribute; and care plans for these patients need to capture this information, and to evolve over time, as our understanding of individual patients grows and deepens. 

Care plans are not works of literature, but some of the same principles apply. Start at the beginning with a guiding concept, and over time, rework it, hone it and polish it. Make it a living document that everyone can refer to, contribute to and refer again to. 

Of course, behind every good book is a good editor, and perhaps the same is true of care plans. 

There is something of the chicken and egg about care plans: health professionals won't rely on them until they are readily accessible and contain useful information. GPs can be reluctant to spend much time on something that people can't access and don't use. 

Where I work, we have gone a long way to solving the accessibility issue. We just need to commit to both producing them, and using them. Of course, there are still barriers, but we won't get anywhere if we let that put us off. 

Thursday, 31 March 2016

Frailty is not a diagnosis, it is a question.

A little while ago, I decided to give Henry James a go. I sat down, in some rented cottage on a week off, curled up on a sofa and settled down with my new copy of The Turn of the Screw. It's rare I buy physical books these days - just my favourites (The Gormenghast Trilogy, The Catcher in the Rye, or The Meaning of Liff), or the ones I think will make me look erudite if seen on my bookshelf......I clearly, therefore, had big hopes for Henry James.

How wrong I was. I rarely hate a writer, but boy, did I hate Henry James. He made me angry. I felt misled, cheated even. How could a writer like him enjoy such a strong reputation after so many years? Surely, we should have worked out by now how sanctimonious and unnecessary his style of prose is. I don't know where the book is now. I may have used it for kindling.

Rarely have I been has my experience of reading a new writer been so divergent from my expectations. I was almost affronted. I was certainly miffed that I had given over good holiday time to him. Some writers grab you, others enthrall you; some flourish language like a paint brush. James clubs you with it, and then filibusters you. His sentences go on for ever. I seem to recall that he does rather like a semi-colon; who doesn't? He seems to use them, however, to link interminable independent clauses, until you forget what he was originally going on about. He approaches meaning tangentially, but never bloody spits out what he actually means. He doesn't seem to tell stories, he seems to mock your linguistic simplicity, while writing his curlicues of sentences, and bamboozling you with his grammatical purity.

If, as I do, the only thing you know about Henry James is the writing of his you have read, then, like me, you may well imagine him to have been some pompous man, who would stand by his mantelpiece telling you why he is forever right, and everyone else is forever wrong. I imagine he didn't have opinions, he had facts, polished out of the granite of his own intellect - unyielding and forever set.

It troubles me that I am so troubled by my experience of Henry James. It's not, I suppose, his fault that I hated reading his work so much: I'm the fool who carried on, when I could have stopped and switched over to something more personally edifying. Yet, I carried on. And I know why I did.

Henry James is part of the lexicon of good writers, and his reputation has persisted over the years, and generations. Writers continue to be read for two main reasons: they wrote something really good, or they wrote something that was loved enough by sufficient people at one time to be included in the teaching syllabus, and never be removed, even when tastes changed. Sometimes it seems as if particular literature continues to be admired in the fashion of some intellectual shibboleth, whereby those who know why it should be admired can seek each other out, and find comfort with each other.

How many writers have been over-read, over-analysed, and under-appreciated by virtue of being included as compulsory texts in English literature courses? If I had been made to read Henry James at school, I might even have given up reading.

You are probably thinking that I need to let this go, and you are right. Indeed, I thought I had done, until I was reminded of my thoughts about Henry James at a recent conference about frailty. Throughout the day, I heard lots of different people tell me stories about how they had adapted their services to better identify their patients with frailty. A lot of work had gone into to what they had done, and to be fair, their services were better aligned now than they had ever been to meet the needs of their patients. Except that I kept thinking 'So what?'

What was happening with this knowledge that they had frail patients? There was some care planning, there were some advanced decisions about what they would do in the event of a crisis, but fundamentally, the services that were available to these frail patients were the same, unadapted services that had been available to them all along. The actual delivery of medical care, and associated services was unchanged. They were still admitted to hospital, they were still expected to go to clinic appointments, they were still subjected to the various and varied inputs of multiple, unaligned specialists services.

Yet throughout the day, we were asked to celebrate the identification of frailty, while people were still unsure as to what they were going to do with that new knowledge, or what difference it makes to patients.

The identification of frailty is important, but only when it makes a difference to how that patient will be cared for. While we have moved a long way in understanding that frailty is an important concept, it seems as if that is as far as we have got. The concept has entered the modern medical lexicon but we are still some way off having a clear understanding of what to do with it. Frailty is not-curable, and only modestly modifiable.

However, knowing that patients are frail gives you the opportunity to frame differently your approach to patients. It is the flag that triggers the question, 'What are we trying to achieve with this patient?', or 'What is important to this person, and how can we help them most to achieve what it is that they want to achieve?' The answers to these questions are as varied as the patients themselves: for some the goal is to improve breathlessness, or to be free of pain. For others, it is to go to their grand-daughter's wedding, or finish the book they are writing. Success might also be not having to see a doctor or go to a hospital.

Knowing what to do with frail patients, therefore, is framed by knowing what that individual wants to achieve, and how you can help them do it. It is underpinned by having an approach to individuals that allows you to be as flexible as their varied ambitions. Identifying that someone is frail is the moment that you can realise that that person's goals probably aren't, or can't, be restoration to full health. And being able to act upon that knowledge is only possible if you and your teams operate in a way that allows them to be flexible in how they help.

The fundamental difference that this requires is a team-based approach centred on problem-solving on behalf of the patient, and doing what it is they need, regardless of what it is that they need. I am not saying that community health teams need to be able to do whatever it is that patients ask, but they should be open to the idea of helping them achieve their goals. We once had a patient whose dog died, and the absence of this beloved dog was having a huge impact on their sense of well-being. We put them in touch with a charity that could help them get another dog. It can be that simple.

So what's this got to do with Henry James? The connection is perhaps loose, but I read Henry James because I had heard that he was a good writer, but I never asked anyone why he was thought to be a good writer. In just the same way, I saw lots of people enthusiastically nodding at the suggestion that identifying frailty is a good idea, but I saw very few people ask why.

When trying anything new, it is important to have a clear sense of what you are doing, and why you are doing it. Without that kind of face validity, you are scrabbling round in the dark, hoping beyond hope, to land on the right answer.


Tuesday, 1 March 2016

This Crazy World

In popular film culture, the character that spends their entire time being mean to people ALWAYS gets their comeuppance. Think Darth Vadar, Hans Gruber (Die Hard), Gordon Gecko (Wall St), Ivan Drago (Rocky IV) Alex DeLarge (A Clockwork Orange). Crickey, even Tony DeVito got found out for being too bad in a world of bad men in Goodfellas.

Not all of life is represented in popular movies, but there is a sense of natural justice, even benign schadenfreude when these bad guys get taken down. Who didn't enjoy it when Biff finally got punched in the face in Back to the Future? There is almost a narrative imperative that their misdemeanours come home to roost - it just wouldn't be right for them to get away with it. How did you feel when Kevin Spacey posted Gwyneth Paltrow's head to Brad Pitt in Seven? It was dramatic, but it wasn't right.

This fantasy of movie justice has played over in my mind over the last week, as I have witnessed numerous counts of meanness in the popular press. From the imposition of the junior doctor contract, to the shameful hectoring at PMQs (http://www.bbc.co.uk/programmes/b071xc9z) and onwards to swapping of personal insults instead of open debate about the EU referendum. It is in this crazy, mean world that Donald Trump looks like he will get the Republican nomination. Who was the last person to be elected on the mandate to build a bloody great wall, on a ticket of isolationism? Where's the narrative justice?

Was it ever thus, or are we stuck in a rut, unable to remember the benefits of being polite to each other? Is it arrogance, certainty or chutzpah that leads our political leaders to focus discussion around personal inadequacy rather than principle, ideology or ethics? You've got to be pretty confident about yourself when you make a point predicated on the failings of your opposition.

There is the sense that it will get worse before it gets better. Who knows how the refugee situation will play out. Yet in the world of faux-ideology, those leading the charge will try to persuade you that they are on an ideological mission: the 7 day NHS, the recession-proof economy, the elimination of poverty, and the enhancement of social mobility.

I have no doubt that there is ideology involved, and that I can live with. What I find increasingly difficult to stomach is the sense that we are seeing the implementation of an ideology that many people did not know they were voting for.

Is this culture of austerity, ruthless budgetary restraint, European entrenchment what we wanted? Do we feel it is OK to wring as much 'productivity' from hard-working staff as long as it isn't us who is being wrung?

I can't help the feeling that I might be up next. As the terms of the new proposed consultant contract become public, I start to imagine a different future. I don't yet know all the details, but my initial feeling is that it asks a lot of doctors to accept a less bright future, and to start to wonder whether they might be better off working somewhere else, or putting discretionary efforts they currently put into their own services into something else, which allows them to bring home a little extra cash.

Of course, this may be one of the ideological drivers behind the contract: by undermining the motivation of those who work in the NHS to continue working in the NHS, alternative forms of healthcare provision become unavoidable. Increasingly it is difficult to ignore the emerging narrative that the general direction of travel is to take the comprehensive out of the comprehensive health care provided by the NHS.

As someone who has spent the last two and a half years working to provide comprehensive, integrated care to elderly patients at home, this is something of a blow. And I don't know yet whether I am supposed to rage against it, or simply get on with making the best of a bad situation.

I might be prepared to go along with it if I felt that the plan had been implemented on the back of good communication, respectful collaboration and expertise, but I can't see any of those things anywhere I look. I keep hoping for my narrative justice, but suspect this isn't Back to the Future - it's Seven, and I'm just going to have to find my peace with it, or find something else to get my teeth into.


Sunday, 21 February 2016

Niceness in a time of crisis

Is it me, or is there a bit of meanness percolating around the world of healthcare?

Where has your mind taken you to with that sentence? The imposition of the new junior doctor contract, all that talk of healthcare privatisation, the state of NHS finances? All would be suitable examples, but let's think more locally.

Whether you are a user or provider of healthcare, have you noticed rushed, harassed or over-worked professionals wandering around?

I have. Everywhere I go, I see colleagues grinding away at a daily slog of providing good services, and doing their best to make sure that their patients get the care they need. Talking to them, it's not the fact that they are busy that bothers them - it's the feeling that they are swimming against the tide. The feeling that they are being asked and expected to do ever more, with ever less.


Every service I know talks of vacancies: GPs can't replace retiring colleagues; nursing vacancies are high, and junior doctors seem to be wandering off to places where people are nice to them. The remaining staff have to work longer and more often to make up the short fall, yet the message they keep hearing is that we have to do more with less. I bet they go home and wonder how long it will be until they too are broken or simply cannot find the motivation to keep grinding on. It's like a professional depression: you keep going, you keep grinding, pretending that it will get better by itself, until one day you can't get out of bed, get dressed or even stand up.

I worry all the time about my colleagues; I wonder how I can protect them and myself from this funk we're stuck in. Speaking to a management colleague I was disappointed at how unsurprised I was at what she told me: during her hospital's recent rather profound bed crisis, her boss required her to check in every hour to tell her what she had done to find more beds for patients waiting to be admitted. Sounds reasonable? Perhaps, until you learn that these hourly check-ins amounted to little more than a bit of a dressing-down for not doing more to solve the systemic crisis that was none of her doing in the first place.

It doesn't sound like her boss took much time to thank her for her efforts, or remind her how grateful the hospital was for her efforts, or even to empathise about what a difficult time they were experiencing.

And this for me is the rub: every where you look, you will find health and social care professionals working flat out for the benefit of the people they serve. They are driven by compassion and dedication to their jobs. Yet within the workforce, the message they keep hearing is that they must try harder, be better, be more efficient, that they are not doing a good enough job. It simply doesn't ring true. They are working hard, all the time. They go home knackered, they return to work still knackered, and they put in the extra hours to try to get everything sorted. But the same message keeps being repeated: more, better, faster - all the time.

In the midst of this culture, we have forgotten that the starting point for compassionate care is to show compassion to each other. The pugilistic attitude from the top pervades its way throughout the organisation, and becomes normal. We forget to be nice to each other, and succeed in only being a bit mean to each other. It's crazy.

Yet, it needn't be like this, and in lots of places it isn't. I was reminded of how good it feels to work with compassionate colleagues this week. Sometimes, the care we offer patients falls short of our own expectations, and this week, we have been dealing with one such episode.

This week was the culmination of our internal review, in which we presented our findings to our medical director and nursing director, and I was gratified at how useful the experience was. It was allowed to be useful, because we treated it as the opportunity to learn as a team what went wrong, rather than blame particular individuals. Throughout the process, I noticed colleagues being very mindful of their colleagues emotional well-being, and allowing people to learn usefully without feeling like they were exposing themselves to excess blame. As a team, we were prepared to be open, and our senior managers allowed us to be. This allowed us to be open with the family, with whom we have spent time talking things through.

In dealing with this learning process, I have experienced from colleagues sympathy, empathy and support that I didn't even know I needed. I came out of a review of our care failings feeling that I had been part of a team learning exercise that emphasised the compassion of my teams not just to our patients, but also to each other. This week, instead of wondering where the strength to continue comes from, I know that it comes from colleagues like mine.

I have no idea what is going to happen to the NHS over the next few years, and I am still worried about it. The one thing I do know, though, is that I work with the kind of people, in the kind of organisation that you want to face a time of uncertainty with.

So perhaps, individually, we all need to take a leap of faith: be nice to the person next to you, and perhaps they will pay it forward. And who knows, in time, perhaps there will be a cultural reset, and niceness will percolate in the way that meanness currently does.