Thursday, May 26, 2016

Airline NHS

29th February really started at a whim. Blogging. Sitting in a cafe in Paris...looking back,it was supposed to be sort of like a personal diary- reading that blog suggests there never was any great expectations that many would read it but over time, some have taken the time to read the rants, pontifications, lectures, it any which way you want- whoever you are- thank you for reading and passing on your thoughts- it has been much fun indeed...or at the very least, cathartic.

Time moves at pace..and when you are having fun, before you know, 4 years and a bit of blogging have whizzed by..and here today, I pen my 200th blog. And this one is dedicated to one of my pet bugbears (No, it's not the HSJ- behave yourself!) but the airline analogy the NHS uses when it comes to patient safety. And it's frustrating to no you ask why? It's because the airlines really do have much to teach us but unfortunately the lessons which we can learn are lost in vacuous sound bytes and tokenism towards patient safety.

To begin with, if you are going to use airlines as a barometer for safety, then one cannot pick and choose which bits are to be used and what not. The culture of learning from mistakes is one to be admired and learnt from but without forgetting the professional approach taken by the airline industry towards it.

Let's begin with training. There isn't a single airline in the world which allows its planes to be flown by those not trained. Imagine the sheer emotions if your pilot casually mentioned that he hadn't actually trained in flying the plane or indeed got a certificate to prove his or her training. There's a sheer belief as a passenger that the person flying the plane is trained. So let's turn to the NHS- are WE sure we follow this? Are YOU sure the person you are seeing is trained in the pathology you have presented with? Thereby lies the split and dichotomy.
Let's say you need your gall bladder surgery- you wouldn't expect anyone to "just do it"- in fact if it's not a surgeon, you would like to know that the person wielding the knife is would like to know and believe that the anaesthetist putting you to sleep and in charge of waking you up wasn't a Diabetologist who had wandered into the operating theatre. When we start extending that analogy to specialty areas such as Type 1 diabetes ( I know, sorry to bang on about it..but it's a safety thing- so bear with me) there is little to no quality control and very little of the rigour applied to let's say, a hip replacement.

Let's clarify myself here,this isn't just about the GP or practice nurse...if you think every single diabetes specialist is trained in insulin pumps, you must be having a laugh. But across the country, many do indeed have a go at it. Let's not point the finger at primary care regards rigour of training if we specialists ourselves haven't quite got our house in order or at the least aren't able to offer primary care the support they need. If you start using the airline as a comparator, then in many cases, clinics should be shut down till training is complete. It's another matter we can't do that in health- thus the analogy crumbles a bit.

The problem as ever is with sheer capacity- the response of the aviation industry with increased demand has not been to ask flight attendants to fly planes but also to increase number of planes and trained pilots- simply as that is key to safety. So what do we do? Do we simply brush aside examples of good practice from the aviation industry or do we have something to learn? My gut feeling is there is much to learn- but a genuine move away from sound bytes may need to be the first step. Patient safety champions are quick to point out errors, exhort learning from aviation yet slow to respond to what aviation teaches us. Human factors is an important issue for aviation- Martin Bromleys work on this is much to learn from- do we use that enough? Do we want to or do we simply want to use a cheaper workforce as part of cutting corners?

Challenging questions which need to be answered...need to be looked at genuinely. Till that happens, we will continue to have a system where a Type 1 diabetes patient, in 2016, in a first world country gets admitted to ITU because somebody didn't quite realise that insulin is what that patient needs to survive. Or forgot because it wasn't a priority. Or didn't ask someone who were trained. Or didn't have access to someone who was trained. Take your pick but either way you cut it..that patient is left wondering how someone who isn't trained to fly a plane is actually doing so.

Aviation has much to teach us- if only we are willing to look at it properly.  It will challenge not only politicians and policy makers but us as healthcare professionals as a whole. If patient safety is genuinely something important, then maybe worth opening up that can of worms. If that results in even 1 less error, even 1 less admission to ITU..then it's all worth it for sure.

Thursday, May 19, 2016

Time out

Thought would use this blog aimed at all the junior doctors- with a simple message. Take a Time out.
Social media has been a curious cocktail since the "Deal" was announced- and conjectures, theories,mischief has flown around in equal measure- with to be honest, most folks having no idea what actually consist of the detail.
So to all junior doctors, take a time out. Shut yourselves from all external opinions and wait for the actual details to come out. As a senior clinician in the NHS and some experience of the system, would ask for calm, time and patience.
This isn't about the BMA or the DH- this is purely about YOUR future- and it is up to you to take the time and understand the details when it comes out. History- and indeed science is littered with examples where the abstract of a paper hides many a fact of the actual paper- and what you have isn't even an abstract but a press release.

I am not a member of the BMA- but for a moment, pause and appreciate the effort put in by Johann. Throughout all this, his composure has been much to admire, he has been resolute- and then he has also gone back to the table. Whether he has achieved what you want- well, let time and the details inform your choice.

Mischief abounds on social media- the desire to rile junior doctors is there- if you counted the number of folks with chips on their shoulders, you could open a local chippie. You, as junior doctors, are clinicians, scientists- apply that to the details and see whether the new deal helps to achieve your perspective- whether that be patient safety, equality or indeed quality of life.

For me personally, the contract was about hours worked, safeguards and indeed equality for all- not a 2 tier system based on whether you took a break due to pregnancy- and if these are looked at, I am happy. I don't know whether I am yet- because I await the details.
Think about the initial contract, see where you have got to- and then decide whether the negotiation team has achieved what you wanted. Not everyone will be happy- but it is about the majority view.

This is not about "winning"- this is about working in a safe environment for both yourselves and the patients- so wait for the details and see whether this achieves it or not. Of course, politicians will spin what they want to- but thats their job. We all know what a 7 day service needs- it certainly isn't a junior doctor contract change.
To achieve a turn around from a government and get back to table- from a bunch of junior doctors, who -lets face it- most folks didn't give 2 hoots- is nothing short of remarkable. Forget the ones trying to rile you- a generation of NHS staff and many many patients are very grateful not only for the resilience shown but the ability to go back and negotiate.

So- to all of you folks- without whom our health system would stop functioning- and to whom I am always grateful for the help you provide, its Friday. Stay off the Facebook forums, the angsty twitter chats…..take a time out. Enjoy your weekend- wait for the details- then get a nice drink, sit down with it- and make your decision- as an adult, as a clinician, as someone who is reading a paper, not a press release.

You have all earned our respect. Enjoy that…bask in that for the moment- and then make the decision that feels right to you- not influenced by anger or being riled by someone.

Best of luck x

Wednesday, May 11, 2016


Was it ever thus? Or is it that the power of social media has just made it more apparent? The culture of silence that is. Or should I say contrived silence? It's very difficult to pinpoint but whichever topic you choose, the culture of silence pervades through the NHS.

Many reasons abound for it..whether it be the fate of whistleblowers, whether it be downright bullying, whether it be political expediency or even the blame culture we all live in. No blame, no shame? The cruel harsh world of social media offers no such clause, it's stark, it's brutal, it's in your face and sometimes, not too far from a lynch mob- and not just the NHS but pervades through all sectors of life now. Sometimes overt, sometimes with a wink and a nudge...either way, the personal finger pointing promotes further silence.

We seem to have created an atmosphere where silence is the easier way out, the one path without much I know the healthcare philosophers will have some glib quote to suggest how patient care and vocation should trump all...but let me put this to you..if being honest and breaking silence puts you in hot water, either via someone baying for your head or resulting in an end of career....none of those philosophers will actually stand by you, will they? It's YOU on your own, so the natural instinct is to say "Hush". Nothing wrong there, vocation doesn't pay the bills nor the mortgage.

There rarely if ever is a healthcare professional in the NHS who doesn't see poor care..the question is....does every single one of us flag it, raise it, take the cudgels up and improve that patients journey or the next one? The answer is possibly no. Let's take my area of specialty....there rarely is a diabetes specialist in any shape or form who isn't aware of what happens to patients with diabetes admitted to hospitals ( I am not even talking about weekends)...many of us have been part of reporting errors, highlighting poor care, simple basics being missed...hand on many of us have tried raising each of these errors and kept going? How many of us at some point haven't been asked to hush as there is no money/stop causing a racket/isn't a priority? Have we then colluded for poor care continuing? Have we chosen the easy way out? Have we decided due to one reason or another to not raising it anymore, to keep quiet? Tough questions aren't they?

There is a reason why journalists finding scoops bemuses me to no end. Because any doctor or nurse worth their salt could actually find you better scoops -except that in the present system, you do so and you are a whistleblower. Finding scoops is easy- just try putting FOI of errors and actions can criticise many an event. In the cold light of time and through the sharp focus of a retro spectroscope, judgement is easy to pass.Patient errors are not too uncommon- what we need to find out what stops us from raising them...what promotes the culture of hush. It's a fine line between accountability and a witch we as a society balance that divide well or does the freedom of social media offer us all opinions without control?

The present contract fiasco is another private, there are few who will admit it's a good thing- at last check, bar David Dalton and Chris Hopson , no one has associated themselves with a public statement. To be clear, I respect them for that- whatever your views on it, at least they have been clear about their views...the rest have either chosen to stay silent or make oblique vague references to working together, having group hugs and all sorts of waffle. So here's my question...if the top echelons of the NHS are adapting the Hush approach, what message does it send to the rest of the staff?

The sadness is that these errors are actually gold dust, complaints are important and we must, as a system, understand why keeping quiet doesn't help anyone...perhaps society also needs to give the NHS staff a break when errors happen- if there is willingness to put ones hand up, learn and improve care, that must be seen as a positive. I am keen to try and improve patient safety- especially for those with diabetes- in hospitals. And I would strongly encourage staff to not walk past the next error, not shrug their shoulder but to raise it, whatever be the due process. If that turns to be a dead end, go further up..if still that doesn't work, I would like to know. I would like to understand what stops a type 1 diabetes patient from being given their insulin in 2016 in a first world country. I don't want a fancy hashtag for that...I want folks to genuinely believe it's worth speaking up.

Hush isn't really an option and in a small way, if I could help to break that cycle, please- do bring it to my attention- if all other avenues seem exhausted. One can only promise to try.

Sunday, May 1, 2016


What next is pretty much the question on everyone's lips. Many theories, many conjectures, many thoughts…but to be honest, when you are in uncharted territories, all bets are off. So all guesses, including mine, are all, at best, guesses- some tinged with reality, some in hope, some in despair- and some as ever with an agenda lurking in the background. Many blogs have appeared where patients feel left out of the discussion- as far as the government is concerned, they did have a discussion- it was in their manifesto- to have 7 day services. That discussion went quite well actually- it was called the General Elections.

So what will happen next? The strikes have happened- the seniors moved things around, cancelled stuff, stood by their juniors and to, what appears, the utter incredulity of some, no major safety issues cropped up. The scaremongering was anyway a bit silly- most seniors on the ground knew it would be ok- and to be fair, as did most NHS managers. All it needed was a bit of planning, cancellation of some activity, teaching etc- and there were enough personnel around to cover what was needed. I have no idea what happens next- more strikes, more the mix of that the Euro referendum - all of that makes this all pretty unpredictable- who knows- maybe both sides may have an epiphany and decide to go have a beer…though to be honest, the chance of that happening and Lance Armstrong coming back to competitive cycling appears to be at par-at the moment.

But heck, everyone's having a go at conjecturing- so why not me! Trusts are not stupid- they know, beyond everything, they do need their staff to run things safely. Given a choice- most executives will choose patient safety above fiscal discipline (aka being tight with money)- the reason? They rarely do their job to balance books- they do want to make a difference. Want an example? Pretty simple- the reason the NHS is still running reasonably well in spite of all pressures is because its happened at the expense of the money side…the billion dollar question is how long that is sustainable.
Anyway. so Trusts won't be stupid- and they will find loopholes in the contract to ensure their juniors find it reasonably acceptable. Roy Lilley's suggestion of "local negotiations" will happen- but not publicly- and variations will emerge- but by using the new contract.
That will result in gaps- which will need filling. The locum caps will be breached- has to be - in fact there exists a clause of breaching it for patient safety- and it will continue to happen at pace. If Trust X decides to hold to the cap, a neighbouring one will breach it…all about who wants patient safety above the issue of money. Tricksy eh?

What will that do for 7 day service? Nothing to pretty much nothing- why? Because the whole 7/7 had nothing to do with juniors but heck, who cares about technicalities. All that aggro, fights will result in little for patient safety, the finances will continue to take a hammering - so we are stuck where we are. And then comes the most important bit…to keep the NHS going, what you do need is a lot of "extra"…"extra" bits that are not paid for, bits that come from vocation- and angry disgruntled people don't give you that. Thats not special for a  medic, but is the same for the chap seeing you drinks at a bar too…he will stay on a bit extra because his boss made an extra effort to make him feel valued

So how would that happen? Well- it will require the medical leaders to do so…the question is whether they have the trust to do so? Would the juniors trust those who have either stayed quiet or openly forced the contract? Would those seen as, rightly or wrongly, furthering their career be trusted to put an arm around their shoulders…or will it need a new generation of leaders to do that? Tricksy indeed. How would Dalton fare when he stands up to speak to juniors and regain their trust- who knows indeed?

So, in short, a forced contract, achievement of bits of government manifesto,more financial troubles, need for new leaders to rejuvenate the workforce…that's my prediction for next 6-12 months
Or I could be completely wrong- and it could all be sorted by that one single beer between Johann and Jeremy.  Or the next battle with consultants will erupt with further embitterment, angst…and all those attempts at "working together"? Take one further hit.

Imagine…all of this potentially avoided by an open honest discussion with the public…something along the lines of "We genuinely want to improve 7 day service- however, we don't have enough money for it- so lets discuss what needs to stop or reduce"

Now…THAT wasn't so tricksy..was it?