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Lately, 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

Artificial intelligence is developing at pace.  Our mobile phones are filled with an ever increasing plethora of apps.  We no longer need to turn dials, push buttons or remember numbers to get in touch with friends or associates that we’ve not spoken to for years.  Cortana, Alexa and Siri are fast becoming part of our everyday lives.  They bring things to our attention, listen to our needs and take action accordingly.  Driverless cars don’t appear to be that far away.  But, even before we get to that stage, technology in our rapidly developing vehicles can give us directions, control our speed, start emergency braking faster than we can react or even alert us that we may be falling asleep at the wheel.  We are continually learning how to help technology learn so that it can serve us well.

Countless clinical applications already exist and progress is accelerating rapidly.  For some time, apps and instruments have collected data, taken scans and created records.  In the majority of disciplines we now have technology which makes diagnostic recommendations based on comparison of individual results to big data.  There’s even evidence that, in some fields, quantity and quality of information is outstripping our human ability to interpret it.  The ‘machines’ are starting to do it better!  See, for example, the case of technology outperforming retinal specialists in ophthalmology.  As this trajectory continues, clinicians will need to answer a fundamental question:

What are the benefits of being human?

You may or may not be familiar with the activities of the Luddites.  They were a band of 19th century English workers who destroyed new machinery in the belief it enabled factory owners to circumvent accepted manufacturing methods which would lead directly to job losses.  Their focus was driven by fear and self-protection rather than improving efficiency and quality.  Nowadays, their name is used to label anyone resistant to the spread of technology.  Their behaviour also led to the idea of the Luddite Fallacy: technology doesn’t actually lead to job losses – it simply changes the nature of work and the mix of job roles in the economy.  Rather than constantly aiming to prove that humans are better than the machines it helps to be honest.  The machines will be better at some things.  Humans will be better at others.  Let’s ask the question again in a different way:

What can a human do that a machine can’t?

And the answer to that one has to be: less and less as each day passes!

So let’s switch things around and consider healthcare from our patient’s perspective rather than the clinician’s.

What do our patients want?

Access to information?  Yes.  Easy access to services?  Yes.  Accurate, speedy diagnosis?  Yes.  Effective treatment?  Yes.  And again, all these points and more will be increasingly well served through the development of technology.  So, is the patient’s need for a robot fast replacing the need for a doctor?  The Luddite Fallacy informs us that, rather than replacing people, technology changes roles.  Adaptation is essential and this may mean changing focus.

The large proportion of patients are experiencing stress of one type or another.  This stress may be physical, emotional, practical or any combination of the three.  Stress is a complex human reaction.  When added to our patient’s experiences and opinions it opens the door to a plethora of potential behaviours and choices.  Who is best placed to deal with that?  Who should be better at listening, understanding, encouraging disclosure, breaking bad news and helping the person overcome the difficulties they face?  Who should be better at helping people to face their challenges with empathy and compassion?  Computer or human?

The human should be better placed at adjusting to the individual and their unique circumstances than the computer.  They should be better at dealing with patients on a human level.  Sadly, not all doctors live up to this.  Some practice in a functional, automated, dissociated manner.  Some are responding to their own personal stress and deal with patients without the benefits of human connection.  In the long run, it’s quite possible that the machines will be better than them.

The machines are increasingly studying a very important topic:

What does it mean to be human and how can I communicate more effectively?

How much effort are you putting into studying this topic?

Stephen McGuire – Head of Development

People who deliver presentations or lectures for learning tend to favour one of two approaches: those who give handouts and those who don’t.  Those who regularly offer handouts may argue that it is important to ensure learners take away the correct information.  After all, note-taking errors and erroneous interpretations can lead to major problems.  Others point to the importance for learners to take personal responsibility.  Giving handouts, they argue, encourages them to be passive, rather than active participants.

As a doctor, the expectation is that you practice evidence based medicine.  But where is the evidence to indicate whether it is better to give learners handouts or encourage them to make their own notes?  The style chosen is often based on the presenter’s personal approach to learning.  So, who’s right and who’s wrong?

What do learners want?

When we talk to the learners we find an even broader preference.  Some have no interest in handouts and will leave them behind after the session.  Others write endless notes during a lecture or tutorial that they will never, ever read.  Some record short sharp bullet points in their prized notebook.  Others want printed notes to read in tandem with the session.  And some would like all of the notes beforehand so that they can devour them and reflect on them in advance.  So, again, where’s the evidence to support the best approach?

Well, unfortunately, a recent research round-up on the subject of note-taking suggests this is an area where the depth of empirical findings are low in comparison to the breadth of theory proposed.  Yet it still raises some useful points that have kick-started a number of discussion threads.

Back to basics

Let’s consider two very different purposes for note-taking by a learner.  The first is to act as an ‘external storage’ process.  In this case, the challenge is to record as much detail that was seen and heard as possible.  The notes are made so that true learning can happen at a later date.  The second is where the learner is making notes to help convert information to comprehension right here and now.  The former approach is about collecting fact, word for word, step-by-step.  There’s no interpretation at this stage.  The latter is all about interpretation, paraphrasing and recording personal meaning.  Both extremes require mental effort.  As we have a finite limit to our capacity, this effort can either help or hinder genuine learning – dependent on how the presentation is delivered.

How can we use this information?

In a presentation scenario, a good teacher will realise that their group of learners will most likely include both extremes of these note-taking approaches plus all variations in-between.  In addition, there will also be those who have no interest in taking notes who need constant stimulation to maintain concentration.  The good teacher will then use this knowledge to ensure their presentation is prepared and delivered with consideration for this entire broad spectrum of preferences and approaches.

Here are a few suggestions:

• Structuring and signposting makes it easier for everyone.  Clear direction is like the scaffolding of your presentation.  “I’m going to introduce you to the four main causes of problem X.”  “Cause number 1…”  “Cause number 2…”  “Cause number 3…”  “Cause number 4…” How often have you missed a key point simply because the presenter hasn’t made it clear that they have moved from one sub-topic to another?
• Images and diagrams have a positive impact on both attention and retention, so long as they are well-chosen and relevant, rather than distracting.  They keep the attention of the observer group and boost comprehension for all beyond mere words.
• Pace and quantity must be considered.  How often has the presenter moved on to the next slide while you were still copying that diagram or scribbling down point four out of five?  The point or detail is often lost.  As a presenter, you must consider the ability of people to be able to record what you are sharing.  This should inform the length of time that you spend on any sub-topic or display a slide.  This can also give you clues to the quantity of information that you are going to share.
• Note-taking and handouts are both relevant.  Taking everything into account, encouraging and facilitating quality note-taking is a positive action.  At the same time handouts are particularly helpful when there are larger quantities of factual information or complex diagrams, when correct detail is essential or when you want learners’ focus to be on processing new ideas.

The best guidance may be to bear in mind that the point of your session is to enable your audience to learn – rather than for you to present.  Which brings us to another question:

To lecture or not to lecture?

Stephen McGuire – Head of Development

Another week – another report highlighting NHS performance issues.  This time around it’s a report highlighting the high number of serious surgeries which are cancelled on the day they are scheduled.  A significant proportion of patients have had their operation cancelled more than once.  Stress for patients, frustration for doctors plus wasted time and resources.  You may already have been involved in discussions within your team about how to sort this out.  Reasons must be identified.  Solutions must be developed.  Actions must be put in place.

But this blog isn’t about cancelled operations.  It’s about the mindset that typically prevails when we are trying to improve something and the unintended negative impacts.

The negative downward spiral

We generally have a tendency to focus on what’s going wrong and what’s not working.  “This is failing”.  “We don’t have resources”.  “That’s not being done well enough”.  “They/we/you didn’t do what they/we/you were supposed to do”.  We then try to figure how to fix the problem or solve the puzzle.  The fixation on failure and under-performance breeds blame and negativity.  The more and more we look at the problems the more they multiply.  They multiply in both severity and in number.  The more problems we have and the bigger they are, the more stressed and negative we feel.  The more people who are discussing the problems, the more people who feel the same.  Morale heads in a downward spiral.  If this goes unchecked it feels like we’re circling the drain with no way back.

No wonder some simply dissociate or bury their head in the sand.  But we can’t ignore the problems.  We have to face up to them and deal with them.

Could there be another way to look at this?

If a negative approach leads to negativity then it would be logical that there must be a positive alternative.  But our instincts tell us we must ask the tough questions and face facts if we are to improve.  Surely anything else is simply naive?

The well-established approach of Appreciative Inquiry is driven by a number of psychological principles, including the idea that a positively asked question will lead to positive change.  The model is summarised very well in this short video.

 

I’ve painted a rather bleak picture of focusing on the problem.  You may find there are benefits to taking different approaches at different times.

Take a few moments to consider:

On balance, is my approach more ‘problem interrogation’ or ‘appreciative inquiry’?  What is the impact of that?

Stephen McGuire – Head of Development

The emphasis on provision of healthcare by a healthy workforce has been ramped up in recent years.  Goal #1 on the current Commission for Quality & Innovation list: ‘Improving staff health and wellbeing’.  There are benefits all round.  Reducing absence rates while avoiding presenteeism means staff are less stretched and under less pressure.  That in turn reduces costs, simultaneously increasing quality of patient care and experience.  In addition, members of the workforce are less likely to become patients themselves.  Win-win-win.  Popular methods being provided by organisations for tackling stress and preventing burnout include mindfulness classes with a focus on developing mental resilience; gym classes to promote physical health and stress release; and encouragement for all involved to strive for the elusive work/life balance.  All such initiatives should be rightfully applauded.

But is it enough?  And, maybe there is a more important question:

Is the effort being focused at the right point?

Let’s consider a basic medical approach to a patient problem:

• Recognise the symptoms
• Diagnose the cause
• Appropriate treatment

Stress and burnout are symptoms of deeper issues.  As a doctor, how happy would you be to simply deal with alleviation of symptoms?  Yes, it’s an important step.  But there is a difference between treatment and cure.  It generally best to tackle the cause.  Take it a step further and the ideal is to focus on prevention.  Switching efforts away from manning rescue teams at the bottom of a cliff and onto building safe paths at the top is a better way of dealing with a problem.  So let’s switch attention to the causes of stress.

Getting to the root cause

Just like a patient whose symptoms are exacerbated by multi-morbidity, the causes of stress are multi-factorial.  There are conflicting demands, time pressures, depersonalisation, breaking bad news and demands for improvement to name just a few.  Just like any other ailment, we are each personally more vulnerable to some of these and less affected by others.  True, ‘the system’ has a lot that it has to address, change and to put right.  There are many issues beyond the control of any one individual.  Equally, many aspects of these factors are within the control of the individual – through the development of appropriate skills.

When the symptoms are recognised the key to effective long-term relief is to identify the root cause and deal with it.

Treatment and prevention

Development of skills has an important part to play in both treatment and prevention of stress and burnout.  Consider a doctor who has learned how to communicate effectively with colleagues as well as patients, is organised, can delegate, tackle underperformance, is assertive and deal constructively with the conflicting demands of others.  They will, as a result, be more resilient than one who is their equal in terms of medical knowledge and technical dexterity but has spent little effort in honing these important abilities.  The doctor who has developed an understanding of the system and its challenges, along with their teaching, communication, leadership and management skills will also be an asset to bolster the overall resilience of their department.  They support their team to be more creative, consistent and to improve in all respects.  They become a positive contributor to progress rather than a helpless passenger on a ship which has been cut adrift.

Yes, alleviating symptoms is essential.  But the very best doctors get to the root of the issue and focus on the cause.

What’s at the root of your stress and what are you doing about it?

Stephen McGuire – Head of Development

Did you catch this alarming story which sneaked through the news over first weekend in August?   According to The Times, “Toxic bickering” between groups of doctors has led directly to an increased rate of patient deaths at a London Hospital.  The mortality rate for cardiac surgery at St George’s Hospital had been recorded as being almost twice the national average.  That’s 3.7% over recent years compared to 2%.  Though there may have been several reasonable reasons for this, the output of the review into the situation makes very uncomfortable reading.

The fact that dozens more people have lost their life than would be expected has been attributed to the “tribe-like activity” among surgeons who were divided between “two camps” within a unit that was “poorly led”.  In addition, there was “inadequate internal scrutiny of results” with a “defensive approach” to the data on deaths.  Apparently there was even “an unsuccessful attempt to solve the problem by bringing in professional mediators to patch up disputes between surgeons.”

The press appear to have been distracted by the Bawa-Garba case and the story seems to have slipped under the radar for many.

What’s gone wrong here?

• Failures in communication
• Failures in the leadership of people
• Failures in the management of reviews and processes

St George’s, which has been in special measures since November 2016, is one of the biggest teaching hospitals in the UK.  What are junior doctors learning?

The shortfalls here have been identifiable as they are concentrated with the extremes of a small group in one location.  Yet, what about the consequences of the lower level failures which are happening day-in, day-out across the UK.  How many poor outcomes and poor patient experiences are caused each day, week, month and year?  St George’s cardiac surgery mortality rate is simply the clearest and obvious example.

It’s a hard reality that shortfalls in so-called ‘soft-skills’ have tough consequences.

Here’s a question.

Is ‘Soft-Skills’ the correct term to use?

What does the word ‘soft’ suggest to you?  Comfortable? Easy? Vague? Fluffy? Mushy? Weak? Simple?  Maybe an opposite of being firm, clear, strict, robust or strong?  It hardly suggests something scientific or evidence based.  Why bother with the ‘soft’ stuff when you can concentrate on the hard and the tangible?  Is it just another box-ticking area for training programmes, appraisal and revalidation?

St George’s problems shine a bright light on the need for doctors to go beyond the natural sciences, physical sciences and physical dexterity in their development.  The so-called ‘soft-skills’ sit within the discipline of social science.

The instincts that lead to tribal behaviour along with its consequences are well understood by those who have taken the time to learn about psychology.  Doctors who have explored team development and the human reactions to being subject to review will also have a grasp on the reasons for warring factions adopting a common defensive mindset to criticism.  Those who have honed their team communication and leadership skills will be much better equipped to play a constructive role in addressing the issues.

To quote Amanda Stanford, Deputy Chief Inspector of Hospitals at the Care Quality Commission, there is “the need to create a culture where all staff are enable to challenge poor practice.”

A new ‘Them’ and ‘Us’ challenge?

Doctors are increasingly being expected to work with professionals who have a career based on the social sciences: social-care professionals.  If true integration between health and social care is to be achieved between health and social care then it will require all involved to manage the tribal instincts of ‘them’ and ‘us’ that run deep within all.

What steps are you taking to hone your social scientific skills as a doctor?

Stephen McGuire – Head of Development

Do you want to understand more about the healthcare system in the UK? Would you like to know more about the history of the NHS and the many challenges it faces? Do you want to know how to play a constructive part in being part of the way forward? Well we’ve just finalised our annual revisions to our popular book A Guide to Medical Leadership & The NHS for 2018-19.

Click here to find our more.

In his first major speech since taking over as Health Secretary, Matt Hancock said, “I love the NHS, I really mean it.” That’s the good part. He also expressed his horror over the levels of bullying within the service and described how NHS staff feeling “undervalued” is “heartbreaking.” Let’s add these words to those of Baroness Dido Harding, Chair of NHS Improvement. In a recent interview with the BMJ she is quoted to say:

“I am quite shocked at the lack of some of the basics of people management that I would expect to see… It’s awful. The percentage of staff saying that they have been a victim or have witnessed bullying is three, four, fivefold more than you would see in other organisations.”

A long standing problem

Sadly, the only surprise for many readers in these comments is that our new Health Secretary expresses feelings of love and that his heart is being broken. A politician with a heart? Bullying is a topic that we have covered before in blog posts such as Medical leadership or just bullying? Is this simply this season’s efforts of paying lip-service to keep the disgruntled ‘weaker’ members of the service happy?

Well, let’s be clear. Dido Harding is no shrinking violet from a sheltered upbringing. Her father was a British Army Field Marshall who commanded the Desert Rats in World War II. She rose through the ranks of the McKinsey consultancy group before holding senior management roles with Thomas Cook, Woolworths, Tesco and Sainsbury’s. She then worked as Chief Executive of telecoms giant TalkTalk. I’m certain the Baroness knows what bullying is and recognises it when she sees it. The problem is real and not going away.

Something has to change – but what and how?

The way forward

Thankfully, Dido Harding is wise enough to identify the way forward. In relation to the bullying culture, she says:

“I suspect it’s a real indication of an immaturity in the whole system in what good management looks like. Good management isn’t soft and fluffy – good management is about giving or having honest adult conversations. Bad management can often be interpreted as bullying.”

She goes on to emphasise the importance of “thinking about how we plan and develop talent at the most senior level.”

I would suggest that waiting to focus on doctors as they begin to approach senior levels is too late. Dedicated development of skills from the earliest stages of a career and on an ongoing basis will be the only way to truly change this problematic culture. One difficulty is that there are so many other skills for a doctor to learn. Back to Baroness Harding for a few more wise words:

“It’s much easier to teach doctors and nurses to be great managers and leaders than it is to teach me to be a doctor or a nurse. Nonetheless, it’s a skill that needs to be taught and honed and practised – we are never too good at it to not practise.”

And, for balance, she sees plenty potential. “That’s not to say there are not pockets of brilliance – of course there are. I’ve seen examples of some of the best people a management and leadership I’ve ever seen. But it’s unbelievably inconsistent.”

What steps are you taking to play a part in changing the culture of bullying?

Stephen McGuire – Head of Development

Please note: this offer has now ended.

Why are we offering our 1 hour CPD course free of charge?

‘August is here.  For the population at large attention is being directed towards holidays, enjoying longer hours of daylight and making the most of the great outdoors.  In sharp contrast to this season of relaxation, August presents a very different stage in the annual cycle for doctors working in hospital.’

These were the words that we used a few years ago to open our blog-post titled August: A challenging time for doctors. In that piece we considered the potential stress and drama that occurs each year at the beginning of this month. Hospital wards across the UK welcome a fresh cohort of inexperienced university leavers who are taking a major step in their development as a doctor. At the same time, many other junior doctors are beginning their next rotation.

“Unfamiliar surroundings; new people; abilities being tested and stretched.  What could be more exciting!” was the closing line from that blog-post.

Whether you are beginning your very first placement, are changing to a new team or you are an experienced team leader the resulting team transitions make August an excellent time for all involved to pause for thought. There are many questions to consider in relation to the function and development of the team and the role that you play.

• How can I best prepare?
• What do my colleagues need?
• How do I let them know what I need?
• How is the team developing?
• What can go wrong?
• How do we avoid the pitfalls and make ourselves stronger?

To do our bit to help we have decided to give free access to our popular 1-hour online CPD accredited course Healthy Teams in Healthcare to everyone until 12th August 2018.

Click here for your free access to Healthy Teams in Healthcare

About Healthy Teams in Healthcare

During this online course, which would normally cost £40, you will be introduced to various models related to the development, function and dysfunction of teams. You will explore various aspects of these models, clarifying both how issues arise and the solutions to help avoid or resolve these challenges. You will then complete the Healthy Team Member Self-Assessment which will support you to consider the various strengths and challenges within your own team. Once you have completed and submitted the reflective learning statement at the end of the course you will have identified where you need to focus your attention, along with actions to improve your involvement and/or strengthen your team for the benefit of all concerned.

At the end of the course you will be asked to complete a reflective learning statement, submitting this to Oxford Medical Training in order to receive your CPD certificate.

We’d also encourage you to share this link with your friends and colleagues. Sharing and discussing your results together could prove to be the first steps in making significant progress to your integration into the team, to your leadership, or to your team’s development.

Click here for your free access to Healthy Teams in Healthcare.

We are delighted to announce two new locations for selected Oxford Medical Training Courses: Bristol and Newcastle-Upon-Tyne. For a limited period only, we are offering you courses in Newcastle for 10% below the standard prices.  Offer ends soon. Places are limited so make your booking now to avoid disappointment.

Courses currently listed for Newcastle-Upon -Tyne include:

• Teach the Teacher Course for Doctors
• Practical Leadership & Management Course for Doctors

Courses currently listed for Bristol include:

• Teach the Teacher Course for Doctors
• Essentials of Medical Leadership & Management
• 2 day Advanced Communication Skills Course for Doctors
• Advanced Patient Communication Skills Course for Doctors
• Advanced Team Communication Skills Course for Doctors

More choice, more opportunity

Our ever-growing list of locations offers you more choice. You may find it easier to find the course which interests you closer to home. Alternatively, why not combine your learning experience to visit friends and family or even to explore a new city. From north to south, our full list of cities for regular courses now reads:

• Glasgow
• Newcastle-Upon-Tyne
• Leeds
• Manchester
• Nottingham
• Birmingham
• Oxford
• Bristol
• London

Which location is best for you?