Happy Birthday NHS

Much is being written about the NHS this week as we pass the 70th anniversary of the creation of it.
Here is my contribution. This maybe cathartic, maybe therapeutic, and chances are that the published version won't be as eloquent as others, and will have been edited and self-censored.

I've been alive for just over half of the time that the NHS has been around, and yet my memories of initial interactions are all a bit blurred - the GP who gave you a smartie as you left after an appointment, an Xray of my hands to check my growth was within normal range, dental checkups with Garfield on the ceiling.

And yet other memories are really quite vivid - 15th December 1996 in particular. Just after my 15th birthday. But to put it in context I need to explain some background.

I am the 3rd of 4 kids, the oldest died at 4 hours old back in the days when 'special care' was in big central hospitals, not in small hospitals. The second, my older brother Adam, was born just over a year later. At 6 months old he was noticed not to be developing 'normally' and was eventually diagnosed with a rare autosomal recessive disorder, Canavan's disease. When I came along 2 years later it was apparently a relief.

Even now trying to place it into medical terminology and describe his condition feels strange because he was Adam, his condition was part of him. In summary the condition affects nerve signal transmission, and thus he had a large head, and very limited muscle mass, with some scoliosis and contractures. Thus he was dependent. He could 'chew' minced up food, and swallow it but not a great deal more. However he had a wicked sense of humour, and any telling off that my sister or I received would set him off laughing.

It was only at school really that I discovered that this wasn't 'normal' - having suction machines under the bed to clear secretions; passing an NG when he was unwell, doing the litmus paper test, then pouring dilute dioralyte into a 50ml syringe barrel and watching it drain into him; even getting calpol from a 5ml syringe (in the days before they packed one in the box).

So Adam was 'given' a life expectancy of 5 but either he hadn't heard properly or the stubborn gene lives strong in the family, and with the help of the kindly Consultant neurologist, whose waiting room my sister and I sat and squabbled in on several occasions and the GP who was happy to be called day or night and did extra house calls on his way home from the surgery if mum had 'sounded worried on the phone', and who told his junior colleagues to ring him if they were concerned, Adam had done well. Without making it sound like a utopia, the NHS provided this back up, the drugs, the physios, the health visitors etc and at no point presented a bill, at no point suggested that Adam's condition wouldn't be treated and at no point asked my parents to pay for his care. It truly was free at the point of delivery, according to need not ability to pay.

In saying this, I have to pay tribute to my mum. carrying a teenager, even one who 'only weighs' 3-4stones, up and down stairs, in and out the car and into and out of various wheelchairs and buggies, and being a 24/7 carer, along with dragging up my sister and I and supporting Dad and running home was no small task.

So anyway, 15th December 1996, Adam was 17and 3 months - we had been out to family friends for lunch and were coming home at around 5.30pm. As we got home, Adam seemed to be making a funny noise in his car seat. Mum got him out the seat and took him into the house then upstairs to the room he and I shared. The next bit is a blur in my head but I vividly recall the ambulance arriving, and the crew bringing bags of stuff into the house and upstairs. There was calm tones but urgent from upstairs, the front door was wide open and the winter weather was blowing into the hallway.

After 20 minutes or so, they and mum carried Adam out and into the ambulance, calmly, and set off without the blue lights on. Dad took my sister and I up to the hospital in the car and we sat in the waiting room for what felt like hours. Eventually Mum came and got Dad and walked through a set of doors, telling us they'd be back soon. She hadn't looked that upset, so maybe things weren't as bad as I think I thought.

My next image is of being in a relatives room and a nurse explaining to us that Adam had died. She may have used nicer language but the meaning was clear. We all got up and walked into the resus area where Adam was. The lights over the other bays were off, leaving him in the middle of a room, lit up with darkness all around.  I don't remember what he looked like at that stage though from what I found at home that night, at least 2 of his teeth had been broken. The whole scene felt like something from Holby City or Casualty - the rest of the room fading to darkness, the bed illuminated - harsh bright unforgiving fluorescent tube light.

Since then there have been many family interactions with the NHS - my nieces being born, grandparents being unwell and receiving end of life care, my own visit to ED when a tree branch landed on my head, and of course my exposure to it when training and now practicing medicine.

I'm not sure what role it played in my deciding to do Medicine - I knew I wasn't going to hit the high flyer exam results at 16 or 18, and so I ended up doing Biology at Uni, completing my Medicine as a postgrad. But I didn't really think much about this episode that December evening until I was a CT1 doing my Emergency Medicine and had to walk into Resus with the lights mostly off and only one set of harsh fluoresecent tubes on, above one bed. I didn't like it and still don't - resus when it is busy, noisy, full of activity is great, but when it is empty and still......

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.