Wednesday, 8 March 2017

Candour amidst all the obfuscation

All 3 diehard followers of my blog will know that I am a cycling fan. I was drawn to it during the ruthless reign of Lance Armstrong, yet even his egregious deceit wasn't enough to throw me off the sport entirely. In cycling, the winner of the race is only one part of a complex narrative - and it is this complexity that makes it such a compelling sport. Much of the enticing texture lies in the little stories that open and close throughout the race, in the shadows of the contenders, vying for the victory. 

While Lance painted a bloody great black mark on the sport, he also provided the chiaroscuro necessary for redemption. Restoration is only possible if there is a context for it. Lance provided the context, and in the absence of a truly great cyclist in recent years, the quest for redemption has become a significant part of the story - and this is where Team Sky came in. 

I liked a couple of things about Team Sky: I liked their disruptive influence on the sport: they clearly didn't mind not being liked, because it probably indicated to them that they were doing something right. I admired their commitment to clean racing. Their was something childishly optimistic about their insistence that cycle racing could be won cleanly if you were on top of every other aspect of performance. They asserted that if you planned every controllable detail and worked hard, then you could do well. It's not particularly artistic, but preparation creates the landscape in which compelling sport could happen. 

Lance Armstrong liked big gestures. There was something brutal and beautiful about the way he stared into the face of Jan Ullrich on the way up the Alpe D'Huez in 2001, before standing up on his pedals and buggering off into the distance. When we thought he was riding cleanly that felt like a big moment. It was also one of the moments that convinced many people that Lance wasn't clean at all. You don't leave someone like Jan Ullrich standing on an 8% gradient the way he did unless you have an unfair advantage. 

In the absence of systematic doping, cycling has become less explosive. The 'Big Bugger Offs' you used to see in racing, when one cyclist would disappear up the road, fueled by a high haematocrit and the Popeye-like influence of testosterone and growth hormone have all but disappeared. Cycling became something more granular, slower-burning, and in many ways more compelling. To understand a recent Grant Tour properly, you had to pay attention for the whole 3 weeks, as the battle played out in small margins over a longer period of time. 

And leading the way was Team Sky. Yet, recently, we have learned that perhaps they weren't leading the way - perhaps they were merely reinventing the way that cheating was done. I don't know if Team Sky has been racing clean or not. I don't know if Bradley Wiggins took delivery of something he shouldn't have in the 2011 Criterium, but I do know that for a team founded on the principles of riding cleanly and proving you could win without doping, they should understand the need for transparency, particularly in the context of a sport about which people still harbour doubts. 

Every time Chris Froome has won the Tour de France he has faced accusations of doping - he even went as far as releasing his training data, and with this in mind, one would have thought that Dave Brailsford would understand the need for good governance and a clear audit trail. Apparently, however, he did not, to the extent that he and his team are unable to account for the medications they ordered (including some rather high quantities of triamcinolone (used for treating allergies by no one except cyclists' doctors.....), and they are unable to say who they were ordered for. None of this proves doping, but it creates a fog of uncertainty. In a sport that has learned to treat fogs as evidence of cheating, Team Sky are guilty of either doping, or monumental incompetence. I hope it's that latter, but my head refused to let me make the assumption that it is. 

Transparency is something we understand well in the NHS. The duty of candour removes the need for discretion in transparency: when something goes wrong, you tell the person it affected. It's really simple. And yet, it continues to be misunderstood. Of course, there is complexity in its implementation, such as what defines 'serious harm' but it can be guided by the cognitive heuristic that asking yourself if you should tell a patient something usually means you should. 

Of course, the ability to be open about anything depends on a culture in which openness is not just encouraged but actively enabled. The trust of staff in their organisations to treat them well when they make mistakes is often low. The perception of scapegoating still exists, and will take time to shift. Even the slightest sense that they will not be supported when mistakes occur will discourage staff from being instinctively open; and the support for this needs to percolate all the way through the NHS, starting at the top. 

Yet what hope is there when one is constantly battling the sense that those at the top do not seem to really appreciate what candour is, and how it is done. Simon Stevens has started to do his bit, but Jeremy Hunt and Theresa May seem to have some form of aversion to it. We shouldn't be surprised  - in broad terms, while the past is no indication of the future, it gives you a sense of where their preferences and tendencies lie. So when Theresa May indicated that A&Es were being over-whelmed through the failure of GP practices to stay open long enough, one has to wonder firstly, where she is getting her information from, and secondly, who's next on her list of people to alienate. And when Jeremy Hunt talks about his frustrations that parts of the NHS are providing unacceptable care, and that he has provided the NHS with extra money, one has to wonder how many times he had to practice his comments in front of the mirror before he was able to say them convincingly. 

For people who work in the NHS, who have seen their work-loads ramp up over the last 5 years, (while their pay stagnates without any sign of inflation-indexing), the disconnect between what they know to be happening in the health service, and what those who run the health service say, is so wide, that truth seems to have been the main victim of the spending squeeze. Remaining candid with our patients in an environment in which too few people seem able to talk honestly about what is happening in the NHS is something which continues to take courage. 

And as with many things in the NHS at the moment, it is the courage and commitment of the staff in it that keep us aligned to the values that define the service. In too many places the NHS operates outside of the conditions necessary to optimise the performance of staff. It is galling to hear the problems of the NHS framed in ways that do not match our lived experience, but the problems go deeper than that. The culture I work in is at odds with the culture presented by our political leadership and my current definition of futility involves describing attempts to square that circle. Perhaps, though it was ever thus, and perhaps we are naive to imagine that the culture needed in our health service would percolate down. Perhaps the truth is that it needs to percolate up; perhaps we need to ensure that we support the transparency and candour of our staff in spite of what we hear on the political stage. 

I know that doesn't really help. It never really helps to be told, 'Keep going' in response to a problem you have outlined, but that is probably the best I can do. The reality is that things that shouldn't take courage (like telling our patients that things have gone wrong) require precisely that. This won't change quickly, it may not change at all, but of all the choices we have, the only one that is palatable to me is to keep plugging away in spite of the difficulties. And that is what I will be trying to do. 

Sunday, 5 March 2017

The Language of Healthcare

In this world of STPs, flat cash and level 4 alerts, there is a lot of planning about the shape of future healthcare services, and with it comes a string of new terms to learn. It reminds me of the 'language' that I used to share with my siblings: it made perfect sense to us, but to anyone else, it made us sound a little moronic. Indeed, it was the exclusivity of it that kept the 4 of us connected when we reconvened at home after term time at different boarding schools.
The language of families and siblings is a members-only club. Indeed, much of grown-up life is a members-only club, and one of the faux markers of success is which club one becomes a member of. It certainly used to be the case that medicine was a good club to be admitted to, but one has to wonder these days. It is perhaps more advanced that many in its craft-tradition, which is so complex, that one has to attend medical school for 5 years to get to grips with it. Indeed, given how hopelessly unprepared I felt in my first weeks on the wards as a doctor, I have to wonder whether those years at medical school were spent, not learning the knowledge one needs to be a doctor, but rather the language one needs to be a doctor.
Many times medicine has seemed to me to be an exercise in verbal fluency - from clinical exams, where the fluent do better than the knowledgeable, to talking with patients and families, where the key is the distillation of complexity into something more easily absorbed. Medicine often is not about the depth of thinking, but the clarity of it. Good medicine is often indicated by a parsimony of language and a decluttering of terms. The more experienced I become, the less I tend to say.
That, however, is not the case, when talking about the shape of future services, STPs and clinical service reviews. I credit myself with a good understanding of how the NHS works. I credit myself with a particularly strong understanding of how community services for frail, elderly patients work, and in particular, I like to outline the reasonable limits to our expectations and the boundaries beyond which the hopes for community services are fanciful, or even delusional.
I think I can create a clear narrative about a model of care for frail, elderly patients, based in the community, and starting in the patients' homes, with good coordination with GPs. I can share my learning until my voice is hoarse, but too often it seems that my messages gets lost.
And do you know where it gets lost? It is swamped in the language set of commissioning that uses different words, or non-words, to describe a tangentional vision of the healthcare services that has been sketched out by people who have visited services, but never worked in them.
I once remember walking along a tunnel in the Paris metro and hearing a busker sing a song. I knew I recognised the song, but I couldn't make out the words, and I just couldn't quite hang on to what it was, tantalisingly close though it was. A few minutes later, it struck me: it was November Rain by Guns and Roses; what had made it difficult to fathom was that the man singing it clearly did not speak English and had learned not the words of the song, but the sounds of the words. What came out of his mouth, therefore, was not the song November Rain, but an approximation of the noise of November Rain - and that is a very different thing entirely.
This is what meetings about the planning and commissioning of local health services sound like to me: they sound like November Rain sung by sound and not by words. And my response to this is to spend much of my time working out where the overlap between the language I use to describe services and the language I hear services described by is.
Spending time on the language of discourse is important. People from different backgrounds uses different languages to describe the same things. This creates the perception of difference, where the true difference is only one of lexicon. This would appear to boil down to semantics, but it is actually more than that, because it is also about parsimony, which is another personal preference of mine.
During my psychology degree, one of my favourite modules, after I had indulged my passing passion for the evolution of language and intelligence, was behavioural psychology. I do not know the state of psychology today, but at the time, behavioural psychology was the least fashionable area of the subject. Cognitive psychology was where all the interest was - but it didn't really speak to me. Cognitive psychology was all about box-and-arrow diagrams, with little adequate explanation of what happened in the boxes. Behavioural psychology, however, took the view that one couldn't know what was happening inside the box (or the brain for that matter) but one could make a decent stab at understanding what went into the brain, and what behaviours came out. Behavioural psyhcology is pared down, purposefully limited in its scope and wedded beautifully to the idea of parsimony: that is the most simple explanation for a phenomenom is likely to be the simplest explanation for it.
For half a term, I sat for a few hours in the week, listening to one lecturer (the only behavioural psychologist at UCL?) talk without interruption in a rather simple and engaging style about parsimony. And rather like his underlying thesis, everything about this man was  parsimonious - he never deviated from his uniform of blue jeans and off-white T-shirt. I never discovered whether it was the same pair of blue jeans and off-white T-shirt, or whether he had a wardrobe filled with mutliple copies. Behavioural psychology cannot explain all behaviour but it explains some very powerfully and very simply.
Throughout my medical training and practice, my mind has wondered back to my learning from behaviourism, as I have contemplated the possible explanations for a medical presentation. Ockham's Razor is something of a philosophical totem for some physicians and asserts that the explanation with the fewest assumptions or interpolations is likely to be the correct one. It is an argument of parsimony in medical practice that often holds true. In our office at work, a colleague of mine has mounted a 6 foot picture of a zebra, as a warning to the number of times he has ignored Ockham. He gets away with it, because in every way he is a brilliant doctor, and he never ignores the obvious - he just excitedly hopes for something a bit more exotic.
In my recent cognitive ramblings about health service commissioning and service transformation, I keep coming back to the concept of parsimony as a guiding principle  The complexity of the language we use to plan and design our service belies the fundamental simplicity of the concepts that should underpin them. The processes behind transformation are often difficult to navigate, but the principles guiding them are simple, and too often we turn our thoughts about the health service around, assuming that if the processes are complex, then so must be the concepts.
Yet there is something important about turning this habit on its head: too often, we find ourselves lost in service redesign when we lose sight of the destination. Too many conversations I have had about developing community services have happened in abstraction from the simple goal of everything we are trying to achieve. Not enough time is spent understanding where we are trying to get to, in language that is simple, easily recalled, and easily stated. This I take to be the goal of clinicians involved in service redesign: remember what we are trying to achieve, and frame it in a way that anyone can understand. Translate the language of complexity into the broad clinical goals, and repeat. And repeat. And repeat.
It is in that direction, i think, that success lies.