One week on from Agents for Change

A week is, so they say, a long time in politics, and at the moment in medical politics, even 24hrs seems to bring new developments. So it seems like a month since the #agents4change conference in London, but actually only 6 days. 

This weekend I'm on night shift so have had a rest day today, after working days earlier in the week. Whilst still enthused by what I heard,asteroids weekend, I am challenged tonight by the thought' what have you done about it?'. In reality, nothing. 

This initially sounds negative, but sometimes the mountain seems huge and needs breaking down a bit. What I have done is started to read, again, Better by Atul Gawande, one in his series of books. Whilst not finished it yet, one theme has struck me repeatedly thus far, and it's not new to me, to anyone. It is the concept that you need to measure something before you can improve it.

This seems initially obvious, and thereafter a complication. Obvious because if course we all love bar charts showing a huge leap in compliance with a checklist or reduction in central catheter infections after our intervention, and simultaneous complicated because some things, some of the really important things in healthcare, don't fit nicely into any medical scale. Does me taking time to introduce myself and my colleague to the patient alter their care in a way we can assign a numerical value to? Possibly not, but it matters, at least as much as the reduced central line infection rate, sometimes even more. 

So it could be said that I have been biding my time.  I have also been reading the blog of my current health board. This has been very interesting. Some posts are people talking about their current initiatives, some and guest posts from senior medical and nursing staff in NHS Scotland, clearly syndicated to many similar blogs.  But the ones which have struck home the most have been the reflective, personal, even self critical and painful blog posts by staff who are involved in complaints management and demonstrate a keen desire to improve the quality of the care we provide to our patients, not just in terms of accurate diagnosis, rapid treatment and symptoms management, but also in terms of communication with patients and families, recognition of deteriorating patients, and good handovers between teams. 

This has given me much to think about, and some names of people to contact to look at using the remaining 3 months of this rotation to look at some areas and see what quality improvement intervention I could work on which could have a meaningful, measurable and lasting impact in the care of patients here.  

Initial thoughts on the #agents4c conference today

So back on the train again, this time heading through Buckinghamshire. Having seem the scrum for the standard class end of the train, I've paid for the weekend first upgrade for some space, quiet and free drinks. The fact the car is waiting in Glasgow means these will be tea coffee or juice but even so it beats the alternative. 

So how was it you may ask.  Well agents for change, #agents4c to use its Twitter hashtag, was potentially one of those days that you remember for a long time.  Alongside my first day in anaesthetics and a medical student, or my first day in resist when suddenly everything clicked. This was what I'd been missing, or at least it filled the Part that had been empty.  

Inspiring speakers aplenty, including the two first up in the morning, who made the greatest impression on me I think. 

• the measured tones of Sir Bruce Keogh and his challenge to be the intellectual capital of the NHS and to take best practice with us as we rotate between different hospitals during our training. He exhorted us to maintain our professionalism, no matter what may happen because that professionalism gives us the authority to lead change and to change for the benefit of patients. 
• the moving story of the Morcambe Bay scandal told by James Titcombe, reporting on the greater role now given to patient safety in NHS trusts, the duty of candour and the need to learn from adverse events, both personally and on a systems basis.  To offer staff incentives for reporting 'near misses' and to challenge the cultures of fear and compliance and instead strive for safety and improvement. 

That is not to suggest the other speakers were poor, merely that these two struck home, perhaps due to personal experiences which they shared. Both emphasised the courage required to challenge seniors and managers when we feel things are not right. 

Other speakers focuses on the more practical aspects of simulation and situational awareness, the role of leadership and quality improvement within postgraduate medical education and how to make QI a part of everyday working life. In the words of Emma Vaux, quoting  Bruce Keogh, we have two jobs A) our day job and B) how to do that job better. 

Peter Lees, from FMLM talking about how we should be killing ourselves to be the leaders of the future spoke of the volatile, uncertain, complex and ambiguous world we face, and that this is unlikely to change, we should be upskilling ourselves to have the skills for this world.  We should aim that we are developing skills for the next role, and the next challenge, no matter what level we are at. Thus when we enter that role we need some fear keen be to grow into and thus carry ourselves with a maturity that befits the role we hope to move into. 

So in summary, a stimulating and inspiring day, a bargain in terms of the cost of the day vs the benefit I can take from it. And the chance to put some faces and real personalities to their Twitter names. Sometimes just meeting enthusiastic fellow trainees is all you need to give you back the fire for your career.  

Take home summary for me:

Health is about people  delivering care to other people. We should be able to explain all that we are doing, and we should be honest & transparent with families, team players with our colleagues and positive in the face of adversity, overcoming our own fears in all that we do. 

Peter Lees left us at the end of his talk with the following thought (I paraphrase)

'The future is created, not found, or chosen from a range of alternatives.' 

Where's he going at this time of the morning?

So it's 4.20 and I'm sitting on a train in Glasgow. It's Saturday morning. I got up at 3am, and drive through the nighttime fog mist and rain to Glasgow, weaved through the east end passed the sections of motorway closed for maintenance, having minor worry about whether I'd make it on time, and parked in the multi-storey car park. Then a quick walk through the rain passed the crowds of people waiting for a taxi after their night out in the city centre.  As I walked passed one, into the station, I heard him comment to his friend words to the effect of 'I wonder where he's off at at this time of the morning, it's bed time'. And so it is.

Whether it is my lack of sleep, the fact it's a melancholic time of night, or whether it's just a stage of life that I have reached, I'm feeling in reflective mood this morning. Some may even argue that I shouldn't be here, now, today and they may have a point. Two and a bit years into my anaesthetic training, having been unsuccessful at the Primary FRCA MCQ exam twice, with the third attempt just over 3 weeks away; with the application window open for LAT jobs for February and a half edited CV for that application sitting on my computer at home; and more prosaically, with a list of household tasks as long as my arm.

So in summary I am left reflecting upon why I am here. Why am I on this train at this time.. Well I'd booked for this conference 'Agents 4 change' before the latest furore over junior doctor contracts blew up, before the junior doctor workforce was again energised to stand up and defend their current working conditions and raise longstanding issues regarding the state of medical training in the UK.

Now as a trainee based in Scotland, the contract issue doesn't directly affect me, since Shona Robison the SNP Cabinet Secretary for Health in the Scottish Parliament has stated that any contract changes in Scotland will be negotiated. So it's not a case of no changes, it's none now, and no imposition of changes. Many other things are a bit different up here as well - the most noticeable being our integrated structure between primary and secondary care and lack of commissioning and relative lack of competition between hospitals.

With initiatives such as Scottish Patient Safety Programme, we have also as a health service used our size (5 million population, so equivalent to one of the English regions, to organise coordinated patient improvement initiatives across various work streams. With relatively ambitious but attainable targets and a culture of collaboration and sharing of initiatives and practice between health boards, clinicians, managers, patients and government the process has seen the incorporation of quality improvement into everyday clinical practice.

For trainees, quality improvement projects has joined audit in the list of things looked for by ARCP panels in the annual paperwork blizzard, many conferences and academic seminars ask for posters on quality improvement, service changes or innovative ways of working.

So against this background, I'm heading down with a degree of uncertainty about what to expect. The programme looks interesting with several experienced and high-profile speakers. I'm left wondering about the other delegates - will they all have CVs full of management activity and quality improvement projects which have changed services, saved thousands or improved the lives of many patients. In the workshops will they talk knowledgeably about CQUINs, tariffs, stakeholders and how they engaged with managers? I guess in summary I am a bit worried that I  will feel like a fraud, someone there more for the experience than with something meaningful to share.

However, my cohort, my generation, will, within 5-10years be the 'new consultants' with ideas, experiences and skills to bring to the workforce. We are used to a 24/7 shopping society, used to be able to manage banking, shopping, utilities and even e-learning at weekends, evenings, and even the middle of the night. We have grown up with computers, from early MSDOS computers in primary school with a networked printer, through windows, then mobile phones, text messages, email and the Internet to iPod, tablets, connected appliances, instant connectivity round the world, then social media, Facebook and Twitter. The ability to interact with others in similar, or very different circumstances. The chance to question senior professors directly about journal articles, newspaper comments and their own tweets. The chance to build campaigns, collaborate and work together across distance, and in some cases time zones.

In short, now is a critical time in medicine. Now is the change to start the processes of change, to develop systems with work together for the benefit of patients, clinicians, health systems and society as a whole.  The only way that these systems will happen in a way that works effectively and efficiently is by clinicians being involved from the start, leading, managing and working constructively.

Much work has been done over recent years by our past and current seniors. The change in specialties like endocrinology to be largely outpatient with newly diagnosed diabetics often seen in clinics, and with daily urgent appointments for those having problems with self management of their condition rather than their being referred via acute admissions and potentially being admitted for assessment. Likewise the embracing of day case surgery by surgeons, with fit patients for elective  hernias, laparoscopic cholecystectomies, etc all being discharged same day, and often being in the hospital for less than 6 hours altogether.

However these changes are not yet universal, some hospitals still admit all patients the night before, even fit healthy people for afternoon procedures.  This can lead to duplicated paperwork, inconvenience for patients, a higher risk of 'adverse events' and a greater cost to the health board, through bed occupancy, staffing etc.

So whilst we need to see innovation in all areas of health, we also need to adopt best practice from other professionals and other healthcare systems and systems and reduce the variations in cost, and outcome across the health service. There will always be exceptions - patients who lives 2hrs from the hospital, those with multiple comorbidities and those with complex social circumstances.

One of the other reasons I'm heading to London today is for encouragement. At present, based in a DGH almost a hundred miles from home, and commuting down there at the start of each run if shifts, and back after them, I feel slightly dislocated from something. But from what - from the buzz of big cities, from the challenges that tertiary centres bring, or just being in a smaller pool of trainees, so that you inevitably compare yourself, and if you view yourself as less successful, and with less interesting quality improvement projects, with less exam success you can become demoralised, and losing motivation. 3 or 6 month rotations can mean that you never feel part of a team, and are rarely anywhere long enough to complete a full audit cycle of an intervention, or you end up trying to coordinate its supervisors in other hospitals to achieve ethics approval, study design, data collection, presentations, and interventions, all the time while working somewhere else.

It's funny but this can make the 'long days' in work the more enjoyable ones - the ones where you spend the evenings 'fire fighting' using your knowledge and skills to help patients - facilitating surgery or stabilising the critically unwell. But after a ten hour day trying to find the motivation for another 4hrs in the library isn't easy. Especially when you feel like you've been studying for this exam for a year, and studying towards one exam or assessment for 15 years since you left high school.  In summary, is there an end, to this, to the seeming endless hurdles of assessments, examinations, audits, conferences, teaching sessions, training courses, quality improvement projects and suchlike which we are expected to have attended or completed.

So in summary I guess, as I head south through Lanarkshire, I'm heading to this conference hoping to be enthused, motivated, given back my mojo and maybe, just maybe, inspired to my next quality improvement projects, to not only embrace change, but maybe even to develop the change in my hospital.