Mind the Gap

Mind the gap warning beside railtrackDoctors are members of one of the most ancient professions. Such membership brings the expectation of professional attitudes and behaviour. But what does it mean to be professional?

Dictionary definitions include references to expertise, competence and skill. It is about maintaining a standard well beyond that of the amateur.  Further exploration of the general use of the term uncovers comments of appropriate appearance, demeanour, etiquette and of ethics. So far so good. However, the term ‘professionalism’ also has some different connotations for some people.

Problematic ‘Professionals’ and trust.

Autonomous. Self-regulating. Exclusive. Privileged. Elitist. These are a few of the less desirable behaviours that you come across. Some people use the badge of professionalism as a mask for protectionism. They are easily stung by criticism and are resistant to ‘interference’ from ‘others’. They feel threatened by managers, politicians or those jumped-up-healthcare-professionals-who-are-not-doctors encroaching on their territory.

True professionalism is a cornerstone of trust. Yet, over the past decade there has been an implosion of trust in our society. It’s most evident in the world of politics. We’ve seen that as trust declines, anti-establishment resistance grows. Many doctors feel threatened by a similar distrust and associated attitudes.  Some look back to the days when patients simply did what they were told with misty eyed nostalgia.  But medical practice has changed considerably over the years and so has the concept of true professionalism.

The gap.

There is increasingly a gap between what doctors are trained to do and the realities of modern practice.

That’s the headline of Advancing Medical Professionalism – a publication developed in consultation with healthcare professionals, patients and other stakeholders.  In-depth knowledge of the natural sciences combined with technical skill and manual dexterity are essential characteristics for being a good doctor. However, true excellence requires much more.

The report proposes seven key aspects of professional medical practice:

  • healer
  • patient partner
  • team worker
  • manager and leader
  • learner and teacher
  • advocate
  • innovator

It argues that such professionalism brings benefits for patients, teams, organisations and for doctors themselves.  Achieving true mastery of all seven aspects is a lifelong endeavour, so there is always room for improvement.  That aligns directly with our ideals at Oxford Medical Training.

What steps are you taking to advance your professionalism?

Stephen McGuire – Director of Development

An alternative to negative feedback?

Someone giving negative feedbackWe all take on many roles in our working lives. Our success is often dependent on an apparently straightforward but essential skill: giving quality feedback.

As proactive team members, we must interact with our peers and members of other teams. We also have to be able to raise issues with people in more senior positions. How else would they know what is causing us difficulties? And if they don’t know, then why should we expect them to do anything about it?

When we are leading or teaching others, we have to let people know if they are doing the right thing or not. How else would they know whether they are on track and making progress? And if they don’t know, then how does that make them feel?

So, an important skill. Yet many delegates on our courses are open about the fact that they really struggle with sharing feedback. This has been confirmed by our peer-reviewed research, based on self-assessment by over 200 doctors. 45% indicated that they were not effectively challenging or giving corrective feedback to fellow team members. Our ongoing follow-up study is suggesting this is an even greater issue for doctors when working in a leadership context.

Does it matter?

Well we could consider it to be just a cultural thing. People aren’t perfect. There’s only ever so much time available, so we have to prioritise. Patients are more important, so doctors just have to get on with it.

But – and it’s a big but – not speaking up about things which aren’t going well or causing problems leads to major questions of professionalism. Not speaking up allows behaviours which are causing difficulties to ourselves or others to persist. Stress, disconnection and burnout are waiting just along the line. And what about the Duty of Candour? Where does this start? Speaking up about things which aren’t right must be the frontline of action. Waiting to be open and honest with a patient when something has gone wrong is surely at odds with the true spirit of this ethical position.

So, what holds you back?

Many doctors have fallen into the thinking that ‘feedback’ is an annual event. There’s a reliance on anonymous comments via digital portals. But this can never replace face-to-face conversation about what is going well and what is not.

There can be many reasons for not speaking up and saying what needs to be said. Some people have a fear of repercussions or upsetting others. There’s also a culture of staying quiet and many doctors don’t actually know how to go about giving feedback. A good number of our course delegates say they feel comfortable with the idea of giving ‘positive’ feedback. However, this can often be the surprising driver of inhibition.

What’s the opposite to ‘positive’ feedback? ‘Negative’ feedback obviously. And who wants to be negative?

An alternative mindset

Rather than thinking of polar opposites, it helps to go back and consider the reasons for giving feedback. Sometimes we want to recognise effort, achievement or progress. Our aim is to reinforce what we want, encouraging the other person to continue in this direction. At other times we want them to change something and to initiate some improvement. So, how about this:

  • Rather than ‘positive’ think Recognition or Reinforcement Feedback
  • Rather than ‘negative’ think Change or Improvement Feedback

The feedback still needs to be delivered in a constructive manner that the receiver can take on board and use. So, a structured approach is still important. However, altering mindset and intent can significantly change the delivery and outcome.

What do you recognise as the most constructive aspects of your attitude to giving feedback.  How can you change and improve?

Stephen McGuire – Director of Development

Looking beyond Unconscious-Competence

In a recent blog post I used driving a car as an analogy. Sometimes we arrive at our destination but can’t actually remember navigating that major junction. Our internal autopilot, based on a combination of familiarity, habitual decision making and muscle memory, has ensured that we get there safely. It’s an example of what is commonly referred to as ‘unconscious competence’. Many use this term to indicate the highest level in the development of comprehension or of a skill. But is this really the highest level? If we believe in the idea that we can always improve then this would suggest there must be something more. But what? Well, let’s go back to the beginning.

A simple model of progression

You may have encountered the conscious/competence model on our Teach the Teacher Course for Doctors or elsewhere in your training. Here’s a diagram to illustrate the four clear steps:

Conscious competence pyramid

1: Unconscious-incompetence

This is where we don’t know what we don’t know. Ignorance is bliss – but unconscious-incompetents can pose a serious risk in many ways. When people are unaware of what could go wrong then disaster lurks just around the corner. Doctors working in teaching or leadership capacities who know the dangers are the ones who feel the pressure at this point. They are typically well versed in watching out for and managing such risks. We must choose the right time and right method to bring the issue to the learner’s attention, moving them to the next phase in a constructive manner.

2: Conscious-incompetence

Conscious-incompetence is often considered the most uncomfortable stage of the learner’s experience. Being aware that you don’t understand, can’t remember or are incapable of doing something that you want or need to do can be very stressful. Again, doctors who are teaching or leading others need to be aware of the multiple reactions to such stress and become skilled at guiding those in their charge to the next level.

3: Conscious-competence

This feels good for all concerned. It’s a safe and rewarding place to be. We get satisfaction from awareness of progress and confidence grows all round. But being conscious of absolutely everything that we are doing beyond the fleeting moment would be overwhelming. We need to concentrate and focus on the most demanding matters, so, as mentioned earlier, we have an internal autopilot which is designed to help us. It kicks in through repeated practise and experience as we progress to the in the fourth stage.

4: Unconscious-competence

Unconscious-competence would seem like the place to be – at the pinnacle of the pyramid. We can just get on with complicated matters with minimal effort. But what’s next?

What’s the next stage?

There have been numerous efforts to propose a fifth stage of development.  Here’s the one that I find simplest and most useful which is based on a different diagrammatic representation of the model. To explain it, let’s return to the driving analogy.

Conscious-competence cycle

On the day we sit our driving test we are definitely functioning in conscious-competence mode. We’re hyper-aware of everything we are doing. Once we get the good news that we’ve passed and gain our full licence we increasingly function in the unconscious-competence mode. We learn to listen to the music and chat to friends as we drive. The more familiar we become with the task, the more smoothly we drive and manoeuver the car. And what happens next?

Many of us start to go over the speed limit on a regular basis. We forget what some of those road-signs that we knew for the test mean. We start to function by expecting other drivers to do what we expect them to do. We’re less likely to notice that we cut across another driver as we change lanes. BANG!

The longer we spend in unconscious-competence the more likely we are to develop bad habits; to forget less commonly used facts and information; to fail to adopt and adapt new concepts into our practise. All too often, the next stage is actually a return to unconscious-incompetence.

An alternative?

An alternative approach is to regularly and deliberately return to conscious-competence. To revisit, remind, refresh and reset. This is one of the key reasons for ongoing CPD activity. The frequency of new discoveries and advancements in the technical aspects of a doctor’s knowledge far outstrips advancements in the social scientific matters: teaching; leadership; management; patient or team communication. Yet it is essential to regularly return to these topics to stimulate conscious-competence.

How effectively do you revisit, remind, refresh and reset yourself?

Stephen McGuire – Director of Development

Compliance or Utilisation: Where are you?

A big tick to indicate complianceIt’s now 10 years since the WHO surgical checklist was introduced to the NHS. Ara Darzi was one of the doctors involved in the implementation. He should be proud of the countless lives saved and impairments prevented through the use of such a simple tool. Similar checklists are now widespread across healthcare. Their associated actions are very familiar to countless doctors and other clinicians. So familiar, in fact, that they are often just part of the routine. It’s a bit like getting in the car or walking to get to work.  It’s easy to go through the steps without really thinking. When we arrive at work we often can’t remember negotiating that busy junction. But we know we’re safe, don’t we? We know this because, thankfully, nothing happened and everyone is OK. Yet, unfortunately, NHS Improvement’s data shows that so-called ‘never events’ still happen every single day across the UK.

Ticking boxes

Lord Darzi recently described how,

“Some surgeons scoffed at the idea that such basic checks could make a difference. Some objected that it was a box-ticking exercise. Staff complained it was poorly worded, time-consuming, inappropriate or redundant.”

‘Ticking the box’ is a common human behaviour. We’re most guilty when we become over-familiar with a routine, where we don’t understand the reasons or when we don’t really believe in a task. There are plenty of other examples of where tick-box attitudes have become common for some doctors. One is with the appraisal/revalidation process. Another is the practice of shift-handovers.

A shift in handovers?

A few years back, the discussions at our Advanced Team Communication Skills Courses suggested shift handovers no longer needed attention. The problem had been identified. Royal Colleges had published guidance and toolkits. Organisations had created and launched processes. Sorted. Time to focus attention on other matters then.

In recent times, though, there are indications that this simple process is slipping in some quarters. I’m meeting course delegates who openly admit that they don’t turn up to handover meetings. Some are locums and some are not. No one challenges them about this. So it’s become acceptable that they are not there. Others admit that they don’t listen. They are there when the meeting happens – it’s the routine afterall – but their mind is elsewhere. They’re ticking the box. One doctor told me that, to his bemusement, the department he had just joined now conduct the process via recorded voice messages.  A good solution to short attention spans and big time pressures? Or are these indications that the handover is at risk of losing its way? There was no way for him to ask questions about anything that was unclear. The risks should be obvious…

Compliance or Utilisation?

Let’s go back to Lord Darzi. Here are his thoughts on the purpose for the checklist processes which were derived from the approach taken in aviation.

“The object of the checklist is not to eliminate thought but to stimulate it, by assisting professionals with the myriad routine tasks they must carry out, freeing them to do what they are trained to do – deliver skilled care”.

During our Healthy Teams in Healthcare Study, we asked doctors how they communicated with others regarding team processes. We asked, “How clearly can you describe the reasons for working this way?” 28.7% of the 202 doctors who participated responded either “Not enough” or “Not at all”.  Even more notable was the fact that 36.6% stated that they didn’t discuss improvement of team processes either enough or at all. Were they avoiding the processes, ignoring them or mechanically going through the motions?

There aren’t enough hours in the day to waste time on doing things that serve little or no purpose. So doctors should, indeed must, challenge any activities which waste time and effort. Such challenge, when done well, should lead directly to systems improvements. This may be due to the generation of new and fresh ideas. At other times, however, the improvement arises because the doctor raising the challenge discovers the true thinking behind the system. In doing so, they may realise that there is true value. They are then likely to move from the mechanical compliance of a tick-box mentality into genuine utilisation. The improvements arise because they take ownership for the system.

Where are the mechanical compliance and tick-box moments in your current practice? What are you doing about it?

Stephen McGuire – Director of Development

Perception or reality: the best driver of change?

Do you want to change something? Well, start with ‘why’. People will follow you because they believe.  So, if you can explain ‘why’ you want to change something and people believe your message then you’re more likely to get them on board. That’s the message shared by Simon Sinek in one of TED’s most popular talks of all time.  We need to meet people where they are and start from there.  Working with beliefs boosts motivation and motivation kick-starts change.  It also helps to sustain efforts when the going gets tough.  We regularly explore these concepts during our Essentials of Medical Leadership & Management course.

Our perceptions are closely related to our beliefs. But how do we know if our perceptions match up with reality?  Well, if they are such a key driver for change, does it really matter?

A Case Study in Reality

A recent NHS case study from Brighton’s Seven Dials Medical Practice is worth considering. The GP’s who worked there were considering the number of ‘inappropriate’ appointments made by patients. These were the cases where the service could have been provided by another healthcare professional, such as a practice nurse or pharmacist. Their estimate was that these probably represented around 20% of their appointments. However, their analysis revealed the true figure to be closer to just 8%.

It would have been easy for the disparity between initial perception and significantly lower reality to have dulled their motivation. However, putting the reality into context created a new perception. The 8% represented 31 appointments. That is the equivalent of two full GP sessions a week being spent on inappropriate appointments for the practice. Resolving this inefficiency then became the focus of their attention.

Through a combination of staff training, a better system to promote consistency and improved communication, the practice successfully converted the equivalent of two full GP sessions a week from inappropriate to appropriate appointments. This meant more availability for patients with shorter waiting times. At the same time, there was an increase in patient awareness of the services available to them from other healthcare professionals plus an increase in the consistency of approach by the reception team.

Perception AND Reality

This is a great example of the initial perception being far removed from the reality. Our gut feel and hunches are useful indicators for telling us where to look, but they can be misleading. There was every chance that, rather than the inappropriate appointments being lower than the GP’s believed, the numbers could have turned out higher once measured. Establishing reality can confirm a hunch, dispel a myth or even reveal a new truth. This is an important element of any well conducted review or good audit process.

Clarifying reality should reveal what has gone well and where things have or are going wrong. All too often we jump directly from here to deciding what to do differently.  But first we must establish the reasons behind the issues and define how we will know that we’ve made a worthwhile, sustainable change. These are the skills that we focus on during our Practical Leadership & Management Course for Doctors. We also explore how to take such information, put it in context and present it in a motivational manner. After all, if the people you are trying to lead don’t believe in ‘why’ or that the change is unachievable, then you are likely to fall at the very first hurdle.

So which is the best driver of change?

Perception and reality are both relevant.  They need to match up and this is the basis of what we at Oxford Medical call Evidence Based Medical Leadership.

Stephen McGuire – Director of Development


What can you see in the NHS crystal ball?

Gazing a the crystal ballCast your mind back 10 years to January 2009. How accurately would you have been able to predict the world as it is today?

Who could have thought that Michael Jackson would leave the planet within six months? Or we would then lose David Bowie, Prince and George Michael during a single year in 2016? That this annus horribilis of celebrity deaths would occur just a few months after Queen Elizabeth became the longest reigning monarch in UK history and still going strong? Could you have entertained the idea of Dr Who being a woman? In January 2009 Gareth Southgate was really struggling as manager of Middlesborough football. He was heading for relegation and the sack. Would you have predicted that by 2019 he would be the most successful England manager of recent times? How many people would have laughed at the thought of Donald Trump as President of the USA – even though this was foreseen by Bart Simpson? Could you have imagined your worried patient making an appointment to discuss their smartwatch data? And what else has changed in your life over the past 10 years?

We can’t predict the future. Today, the current political events related to Brexit mean we find it hard to predict what our situation will be this time next week, never mind in January 2029.

So, why bother with a 10 year plan?

The new long term plan for the NHS in England has now been published. Yet it hardly seems like any time since the turmoil of the major restructure driven by the Health as Social Care Act began. This act passed through parliament in March 2012. Implementation began April the next year with the final changes being as recent as 2015. One of it’s cornerstones was that every NHS Trust would achieve Foundation status by 2014.  That never happened.

And haven’t we just started working with the Five Year Forward View? Well that was published in 2014. Today, we find ourselves in a situation where the intended integration between health and social care looks very different in one part of the country to another. Just another journey started but never completed?

Think closer to home and to your own hospital, department or team.  Think of all those change-projects that have taken place. What proportion of them actually achieved anything worthwhile? How many have made a lasting impression? Multiply this across the country and now think how much these failed local initiatives have all cost in total? And for what?

With all these projects, changes of structure and direction, are things today any better now than they were in 2009? If we can’t even tell what the world will be like 6-months from now, then what’s the point in a 10 year plan? You might well be hearing some colleagues say, “Just let doctors get on with their jobs!”

So what makes a good plan?

The best plans do make a difference. Before they even start there is clarity of overall purpose. They are focused to the future and keep this purpose in mind. Though informed by the past, they go beyond simply identifying what’s gone wrong. They have identified why it’s gone wrong. Simultaneously, they pay equal attention to what is going right and why. This helps set a long term direction with clear but general ambitions. From this, projects are defined which are aligned to this direction. These projects are managed by people who have taken the time and effort to develop the skills required. We are then all in a good place to be able to work with actions at a monthly, weekly and daily level which are aligned to the direction and purpose.

To quote Nelson Mandela:

Vision without action is just a dream. Action without vision just passes the time. And vision with action can change the world.

Though we can’t always tell what the change will look like in the end, paying attention to progress and events means that direction is maintained. The greater the number of people who are working with awareness, who are informed of the plans, know the system and paying attention to progress being made, the greater the chance of achieving the purpose.

What steps are you taking to improve your ability to participate in the change?

Stephen McGuire – Director of Development

Should we work on insignificant improvements?

Doctors hate their computers. Well, that’s according to Atul Gawande. The influential doctor and writer recently dedicated almost 9,000 words to outline his thoughts on the matter in The New Yorker’s Annals of Medicine.  So many initiatives intended to make things faster and better actually result in the opposite. His main focus of his frustration is on computerised patient record systems. They slow down consultations and increase workload. The vast majority of ‘improvements’ made seem to result in demand for more hours working away from patients.  He goes on to suggest a direct link between software and bureaucracy. As prevalence and complexity of the former grows, so too does the latter.  In addition:

“I began to see the insidious ways that the software changed how people work together. They’d become more disconnected; less likely to see and help one another, and often less able to.”

Impact on patients

Atul Gawande is not alone in throwing the spotlight onto computer systems which are intended to help. To quote Helen Salisbury, writing in The BMJ:

“..if I’m not careful, technology can take over the consultation so that (it takes) more time than the listening and the talking. Worse still is when I try to do both at once—listening a bit but not enough, hands already typing, eyes on the screen. There’s nothing like not listening to encourage not talking.”

It’s so easy to see how, in hindsight, all the little things add up to being something much bigger. Mountains are made up of countless grains of sand – some fused together as solid, impenetrable rock. All the extra little tasks and delays add up to hours of our time. But do we think about all the little things that could help in the same way?

Do we think about improvements in the same way?

If you are reading this, then you are reading the first blog entry on our newly redeveloped website. It’s much, much faster than the old version. Didn’t you notice? No? But then, why should you? We don’t usually notice how quickly or efficiently something works. We just expect it. If we do notice an improvement, it doesn’t take long for us to get used to it and forget the way things were. But we do notice when things are slow and get in the way.

To quote Tom Peters:

“There’s no such thing as an insignificant improvement.”

Such thinking feeds into the concept known as the ‘aggregation of marginal gains’. This principle was utilised by Sir David Brailsford as he coached the British Cycling team and Team Sky to unparalleled success. Yes, all the little inefficiencies add up to major problems. Equally, multiple little improvements add up to something well worth the effort.

Making a worthwhile difference

Our research, published in BMJ Leader, revealed major shortfalls in doctors discussing things that matter. Of over 200 doctors, some 40% said they were not discussing progress toward goals either enough or at all with their colleagues. 37% said they were not involved with discussions about improving processes. Learning how to have such discussions with team members would be one small improvement. Actually having the discussions would create the possibility of many more. Learning how and improving the ability to channel ideas into worthwhile change helps make these little changes real. All too often, we wait for the big idea or the big initiative. Worse still is waiting for someone else to do something. Meanwhile, the problematic little things continue to tighten their grip.

What small yet significant improvements will you make next?

Stephen McGuire – Head of Development

Is patient-doctor communication needing to evolve?

Financial limitations create many challenges for the NHS. Across the country, the four home nations of the UK are each embarking on programmes designed to ensure high-quality, sustainable systems for the future. Let’s start with a look at NHS Wales’ Prudent Healthcare approach which is based on a set of four guiding principles;

  • Achieving health and well-being with the public, patients and professionals as equal partners through co-production.
  • Care for those with the greatest health needs first, making effective use of all skills and resources.
  • Do only what is needed, no more, no less; and do no harm.
  • And Reduce inappropriate variation using evidence-based practices consistently and transparently.

Similar ideas are included in the strategic plans of England, Scotland and Northern Ireland. A few examples of the activities resulting from Prudent Healthcare include:

  • A drive to reallocate finances from high-cost/low-effect activities toward high-effect strategies, such as shifting the spend for the treatment of COPD from providing steroid inhalers toward support for smoking cessation.
  • Reducing unnecessary procedures and use of medications, in particular anti-microbials, anti-psychotics and opioids.
  • And Transparency of the costs of prescriptions.

The ‘Transparency’ challenge

Transparency of costs requires striking a delicate balance for clinicians in communication with patients.  In Scotland, an elderly relative of mine had a discussion with their Consultant about care options and was informed of the cost of treatment.  “I can’t expect the NHS to pay that for me”.  A conclusion reached without any awareness of the costs of any other treatment they or any others currently receive.

The ‘crackdown’

On the day of writing this piece, the BMJ reports, ‘NHS England has launched a fresh crackdown on GPs’ prescribing of “low priority” items in a bid to save £70m a year to reinvest in other areas.‘ This will undoubtedly lead to some difficult conversations with patients and family members who have previously received such prescriptions.  News media reporting of NHS England’s consultation activity is risking alarming patients.  There are suggestions that supplying needles and blood glucose testing strips for diabetics will be halted as part of the same initiative that stops provision of silk garments to people with skin conditions.  GP’s are no doubt bracing themselves for an avalanche of queries.

Further changes

These changes are taking place at the same time as the drive for social prescribing and the shift away from old-style patriarchal medical-practice into concordance and informed consent. In combination, these changes and progressions create significant challenges for healthcare professionals – not least in relation to patient communication. There can only ever be true informed consent when doctor and patient are speaking the same language.  Yet patients speak a number of different languages – and I don’t mean based on their geographic heritage. I mean in relation to their attitude to their care.

Different languages

Groopman and Hartzband proposed thinking of patients in terms of:

  • Minimalists resist and want to avoid interventions, treatment or contact with healthcare professionals
  • Maximalists want and even demand attention and action for every ailment – real or imagined
  • Naturalists trust mother earth or spirituality to provide the best solution
  • Technologists believe that the very latest man-made inventions, drugs and techniques must be the answer.

Evolution of language

This approach to categorisation was based on a framework of two distinct dichotomies.  Yet all languages continually evolve. The changes towards prudence, consistency and transparency introduce new dimensions to complicate the model. These include:

  • the patient’s attitudes toward fairness, in terms of person rights and entitlement versus collective social responsibility
  • the patient’s perception of what constitutes good value for money versus what is expensive
  • the patient’s desire for having personal control versus patriarchal care

Change is essential if we are to ensure we have a sustainable healthcare system to meet the challenges of the UK in 21st Century.  The skill requirements for doctors to truly speak to patients in their own language has never been higher. If patient languages are evolving then so too must doctors.

What steps are you taking to ensure you develop and maintain your skills as a multi-linguist in terms of patient communication?

Stephen McGuire – Head of Development




Not all superheroes wear capes

Sad news this week about the passing of Stan Lee, creator of the Marvel Universe.  His unique imagination gave us a world of superheroes with special powers, many of them dedicated to helping ordinary people deal with situations beyond their control.

The best superhero stories go well beyond simple “POW”, “CRASH”, “BANG” and “WALLOP” of early fun-time Batman movies.  Many of the greatest tales are parables for everyday life.  In these comics and movies we often we witness “ordinary” people doing extraordinary things.  They take a stand and make a real difference.  When we see such acts in real life we often refer to these people as superheroes-without-capes.

Now many gifted superheroes go to great lengths to conceal their actions, challenges and achievements even from those closest to them.  Sometimes it’s because it can seem too big or too much.  Sometimes they want to protect their loved ones from worry or concern.  This often backfires with spectacular results.  In one popular movie, Will Smith played Hancock: a superhero who had become an empty shell of himself, bitter and twisted, feeling unappreciated for his talents and efforts.

To the general public, doctors do extraordinary things.  They are often considered in the superhero-without-capes category.  But back in the real world, and it’s anti-bullying week (11-16th November).  Sadly it seems that every other week there is another notable case of bullying related to doctors and the NHS.

Does it need a superhero to take a stand?

Here’s a link to a video from our new NHS & UK Medical Regulation Video Tutorials.


How effectively are you supporting the superheroes-without-capes who work around you in your team?

Stephen McGuire – Head of Development

Is openness in healthcare under threat?

Mask being held ready for disguiseLately, the subject of Care Quality Commission inspections has been prevalent in the healthcare news.   It’s been claimed the ‘CQC cannot be relied upon to enforce the duty of candour‘.  Their ‘tick box mentality‘ has also been criticised as ineffectual.  A government funded study has concluded ‘evidence is elusive’ to support the idea that ‘the regulator’s regime of intensive inspection has been beneficial’.  In addition, any real evidence that the general public pays any attention to the CQC’s ratings is also lacking.  A potentially greater problem is that some new online GP services are reported to be actively evading inspection.

So are inspections necessary?

Well, let’s consider the new online GP services as an example.  There are undoubtedly some great benefits for all concerned if new systems can be developed which get things right.  Unfortunately, there are also great risks: misdiagnosis, fragmentation of care, over-prescribing and even the reinforcement of health inequalities.  Add in the aspect of ensuring appropriate financial management as new organisations disrupt the status quo and the case for proactive regulation is obvious.  It’s easy to see the relevance in this case. So, why should it be any different for established providers?  Let’s consider events as wide ranging as the scandal of Stafford Hospital from the last decade through to the recent problems stemming from ‘toxic bickering‘ at St George’s Hospital, London.  Things can and do go very wrong.

Waiting for things to go wrong?

The principles of clinical governance are designed to provide a systematic approach for maintaining and improving quality of care by measuring performance against a recognisable standard and promoting accountability.  Inspections by regulators should form an important element of this.  It would be unacceptable for them to simply wait for things to go wrong, relying on others bringing issues to their attention.  But clinical governance cannot stop with the regulators if its full benefits are to be realised.  It’s an essential discipline for all levels of healthcare practice – national, regional and local; within organisations, departments and teams.  Clinical governance should also be central to the personal standards of practice of each and every individual doctor.

Auditing and openness

Audit is one of the main seven pillars of clinical governance.  Organisations, departments and teams must participate in auditing themselves – and each other.  They must be aware of standards, pay attention to performance, compare it to the expected standard and take action where necessary.  This can happen formally or informally by simply sharing feedback.  Again, individual doctors must do the same.  People can and should audit themselves, as well as each other.

Openness is another of the seven pillars.  Good governance requires honesty and candour over what is being observed.  It also requires honesty and candour over personal performance.  But true openness goes beyond transmission of information.  It also includes receiving information from others: the good, the bad and the ugly.  But here lies a problem.

Our research has revealed significant shortfalls in the willingness of doctors to give and receive feedback.  This conclusion results from information gathered through self-audit of over 200 participants.  We also identified a notable reluctance to ask for help when required.  Reasons for this lack of openness vary from arrogance to fear to simply falling in line with the prevalent culture.

Moving forward

Without doubt, the CQC and other regulators must find ways to ensure their inspection processes and reports lead to real differences.  Likewise, all doctors must ensure that they and their colleagues develop the practical skill and discipline required for meaningful performance management.  They must also develop the ability to communicate effectively within teams.  Audit and feedback must be raised above the level of simplistic tick-box exercises.  Otherwise true openness, honesty and candour really does come under serious threat.

What are you doing to improve audit and openness?

Stephen McGuire – Head of Development