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“How effective are you as a catalyst for change?”

Whenever you are preparing for your medical interview it pays to consider as many potential questions as possible as this will help you to clarify your experience and opinions in advance of the event.  You will always impress most if you can illustrate your responses with real life examples, explaining yourself clearly and succinctly which can be a challenge when faced with a broad, open question like the one above.  It therefore helps if you can use some form of relevant framework or model to help structure your answer.

Having a clear model in mind can enable you to think of specific events when you have demonstrated positive behaviours and to identify your development needs.  There are numerous frameworks to consider, ranging from complex personality type profiles, through processes like the GROW model for coaching, to simple lists.

One such list format has come this week in the shape of the output of the first phase of the Challenge Top Down Change initiative.  This is a joint initiative by HSJ, Nursing Times and NHS Improving Quality which is trying to pave the way for bottom-up change by an empowered frontline, rather than continuing with the current top-down culture of imposed change.  They have produced two lists which collate the anonymous opinions of a large numbers of workers in the NHS.

The first is a list of the top 10 barriers to bottom-up change:

• Confusing strategies
• Over-controlling leadership
• One-way communication
• Poor workforce planning
• Stifling innovation
• Playing it safe
• Poor project management
• Undervaluing staff
• An inhibiting physical environment
• Perverse incentives

The second is a list of 11 fundamental building blocks that can support bottom up change:

• Inspiring and supportive leadership
• Collaborative working
• Flexibility and adaptability
• Smart use of resources
• Autonomy and trust
• Challenging the status quo
• A call to action – clearly articulating purpose and meaning
• Fostering an open culture
• Nurturing our people
• Seeing the bigger picture
• Thought diversity – valuing dissenting opinions as much as coherence and conformity

When, how and how often have you demonstrated the elements in the list of fundamental building blocks for change?

When, how and how often have you demonstrated the elements in the list of top 10 barriers to change?

What are you doing about this?

 So, how effective are you as a catalyst for change?

Given the apparently relentless negative press which has bombarded the NHS over the past year it would seem inevitable that the overwhelming mood is and should be one of despondency and pessimism.  How many doctors then were taken aback at the output of the British Social Attitudes 2014 survey results?

 – Overall Public satisfaction with the NHS at 65% – its second highest level since the survey began in 1983
– Dissatisfaction at 15% – the best result ever
– A&E satisfaction increased to 58, compared to 53% the previous year
– It is Dentistry which continues to have the lowest satisfaction ratings at 54%

Are these 1937 respondents confused?  Are they representative?  Are they just expecting less than they used to? Or does this suggest that the constant barrage of negative stories is the result of politicians scrabbling to score political points by knocking an institution that we all care deeply about?  Could the survey be telling us that some things are improving?  Would we be deluded to be so optimistic?

On our leadership and management courses we explore the importance of self-awareness from different points of view in order to understand the impact which we have upon others.  It is worth pausing to consider where you are on the optimism-pessimism scale in relation to the performance of both your own area of influence and the NHS as a whole.

There’s lots of evidence to suggest that being an optimist is a good thing.  They live longer and outperform pessimists.  That’s not to say that the optimists are always right.  In a study by Martin Seligman, he found that pessimists were generally more accurate in their short term predictions.  The difference was that the optimists were more likely to focus on the upside, to persevere and learn from what went wrong.

Clearly there is an issue with blind optimism – ignoring problems and relying on wishful thinking.  Such individuals are likely irritate others with over inflated opinions of their abilities, taking undue credit for success and likely to be heading toward disaster.  Pessimists will generally have a negative impact on the mood and belief of those around them, making sure you know that “it was inevitable that this was going to happen”.

The attentive optimist, on the other hand, will accept appropriate responsibility for events whatever the outcome, and see what good can be taken from the situation.  They will proactively seek out true facts – be they favourable or otherwise – and use them to make progress.

So considering both the past year of negativity and the British Social Attitudes Survey 2014, how optimistic are you feeling about the NHS?

“There is nothing permanent except change itself.”  We will all be familiar with these words attributed to Heraclitus, the ancient philosopher, so it’s hardly a new sentiment.

When we initiate change ourselves, as many will have through New Year resolutions, we can feel empowered, energised and committed.  However when change is imposed upon us, our feelings, level of engagement and actions can be significantly different.  Many doctors will have encountered the work of Elisabeth Kubler-Ross.  Although the stages of grief defined in her seminal work, On Death and Dying, were originally applied to improving support through advancing patient communication skills, the change curve has been widely adopted and applied to help us understand people’s reactions to unwanted developments for many years.  We refer to this model in a number of our career development courses.  Denial, anger, bargaining and depression should all be expected before acceptance.

It is no surprise then that the public face of the NHS front line is one of frustration and despondency in light of the continued use of a top-down management approach to drive essential change.

Positive news arrived this week in the shape of a campaign to “Challenge Top-Down Change”, launched by the Health Service Journal, Nursing Time and NHS Improving Quality who want to identify how to bring about the right type of change in the NHS.  They point out that “The most successful organisations in the world give all staff and stakeholders the licence to get involved in change both from the bottom-up and the top-down”.  They want the help of NHS workers to understand the barriers faced when trying to implement change and, importantly, “to give voice to solutions that work.”

While this is clearly an opportunity for doctors to contribute, it is also a useful prompt to consider your own leadership style. Do you rely more on the top-down or the bottom up approach?  This is a simplification of the topic which we explore during our leadership and management courses and there are pros and cons to both.  So what are the implications of your style to implementing change within your own sphere of influence?  Awareness, after all, is one of the first steps to making pro-active changes to improving your own style.

Over the past couple of weeks BBC News has been focusing attention on locum doctors, reporting information which they have gained based upon freedom of information requests which they submitted.  Here’s a quick bullet point summary of the key financial points raised by these reports:

– Almost one in four A&E departments in hospitals in England fill more than 25% of their senior staff vacancies with agency doctors or locums.

– The reliance on freelance staff to fill senior posts costs hospital trusts more than £120m a year.
– NHS Scotland spent a record £82m on locum doctors last year, an increase of £18m on the previous year
– Western Isles and Shetland spent a third of their entire medical staff budgets on locum doctors.

These issues are related to the challenge that bodies NHS are facing increasing difficulty in meeting their financial targets.

Concern is also raised about the direct impact that locum doctors can have upon patient safety, particularly when unknown to the organisation employing their services and working in an unfamiliar environment.  Prof Suzanne Mason, of the College of Emergency Medicine, is quoted: “They often will provide different levels of care and perhaps not such high-quality care as we would come to expect as a specialty. That may be due to a lack of knowledge of the local systems but it may also just be due to just a general lack of clinical experience.”

Most sectors of employment have the need for a quality flexible workforce and healthcare is no different.  Locum doctors are essential for continuity of care to cover vacancies, holidays, maternity cover, secondments and unplanned absence being the key drivers.  In keeping with the majority of other sectors there are always geographic areas or particular specialities where these challenges are greater than others.

Where the government estimates the vacancy rate for consultants is 7%, the BMA puts this figure at 11%.  The challenge for NHS management is to strike the right balance between flexible and permanent staff and to make their vacancies attractive to the appropriate doctors.

There are numerous reasons why a doctor might choose to undertake work in a locum capacity.  But what of the previously mentioned negatives and concern expressed, in particular the issue of patient safety.

So what should any doctor working, or planning to work as a locum should bear in mind?

I discussed the topic with ID Medical, the award winning supplier of locum doctors to over 90% of NHS hospitals and private medical sector organisations.  Their advice is that you need to take many factors into consideration when choosing to locum, but fundamentally these should all revolve around professionalism, from selecting the correct jobs to ensure your own safety and that of your patients, to selling yourself and showing all you have to offer.

You should select an agency which is on the national framework, regulated and audited on compliance documentation who will offer you the opportunity to build a strong relationship with a named agent.  When working as a locum the most important priority should be your safety and the safety of your patients, not your bank balance. This means that you should think very carefully about which jobs you volunteer for.  How can you care for patients if you don’t know the system for checking their blood results or ordering investigations?  You can make life easier by choosing sites at which you currently work or have worked previously, where you understand and have access to the systems.  Alternatively report early to your post to make time for the person you are taking over from to explain these systems to you.

In addition to the technical skills required the meet the requirements, the very best locums have excellent team communication and time management skills.  Such doctors can fit into the team effectively and efficiently, providing continuity of care, rather than being a hindrance or posing a risk, so attention should be given to the development of these skills.

Ultimately, with careful thought and planning, locuming can be one of the most enjoyable moves you will make in your career, offering variety, flexibility, and fun – as well as ensuring the essential continuity of care which patients require.

It is human nature to make associations which are based on our experiences, attitudes and beliefs, helping us to “fill in the blanks” and reach quick and intuitive assumptions.  However it is inevitable that not all of our associations with be helpful and that not all of our assumptions will be correct.

In the world of stereotypes for example doctors are clinical purists who focus upon individual patients.  Managers on the other hand are financial realists who consider wide patient groups and categories.  Although these statements are sweeping generalisations there is often a gulf between doctors and managers with clashes arising from differing challenges and points of view.  Another strong instinct of human behaviour is to develop tribes with clearly perceived groups of “them” and “us” further contributing to the divide.

At last week’s Scottish Medical Leadership Conference 2014 in Edinburgh it was very refreshing to listen to the presentation by the team from Birmingham Children’s Hospital.  Two doctors together with two managers from the trust delivered an engaging session titled “Paired Learning for Excellence”.

The principle is really simple.  Each doctor in the pilot was paired with someone from the trust’s management team and introduced to each other.  They were not told what to do with self-direction following an email introduction a key principle.  Initial meetings over a coffee progressed for some to regular discussion meetings to share experiences.  Some pairs spent time in shadowing activities, some doctors contributed to meetings and business cases which they would not previously have been involved with and some pairs set about developing service improvement projects.

Fundamentally the sharing of contextual knowledge along with the day to day understanding of “how things really work” has served to expand the area of shared knowledge, leading directly to improved teamwork and the breaking down of “them and us”

It was telling that in the course of this day, which was concentrated up the development of leadership and management in the NHS, that this short presentation resulted in a large number of questions.  There was a great deal of interest in the simple idea of networking to enhance cross-team communication using a method which, at its simplest level required no real financial budget.  Needless to say the idea is gaining weight and spreading to other NHS Trusts and organisations.

The report by Lord MacLean into the C. difficile outbreak at Dunbartonshire’s Vale of Leven Hospital between 2007 and 2008 makes for uncomfortable reading.  NHS Greater Glasgow and Clyde has apologised unreservedly for a “terrible failure”.  Of 143 patients who were identified as having contracted the infection C. diff was defined as a contributory factor in 34 deaths – a figure which is probably an underestimate according to Lord MacLean.

Processes for infection prevention and control before and during the outbreak are described as being dysfunction, with emphasis placed on the essential requirement for “an effective line of reporting, accountability and assurance”.  Poor leadership among NHS GGC managers is cited as contributing to the situation where inexperienced junior doctors had too much responsibility and consultants were stretched.  The report concludes with a broad range of 75 recommendations in total.

The Vale of Leven Enquiry is a hot topic which any doctor preparing for medical interview would do well to be familiar with.

It’s worth noting that the era in question overlaps with the events of the well-publicised Francis Report into the events at the Mid-Staffordshire Trust and that a great deal has been has been learned and changed since these events.  While these reports throw the spotlight on the NHS of 7 years ago, the topics raised must be kept front of mind in order to drive the maintenance and improvement of standards today.  Regressing to the issues of this era cannot be an option.

The point about inexperienced doctors with too much responsibility reminded me of discussions on the topic of effective delegation which took place last week during one of our medical leadership and management courses.

There are many reasons why delegation of a task should happen:  it allows us to achieve more than we could on our own; it saves us time or enables us to concentrate on other tasks; it enables patients to be attended to in the time required; it spreads workload; it can enable development and growth for the person we are delegating the task to.

When we have a tasks to be delegated the question: “Who will be the best person for the job?” should be balanced with “Who will the job be best for?”  The manner in which the delegation takes places should then be determined by the consideration of the person’s experience and confidence – the requirements of the discussion to pass a task to someone with good experience and confidence will be significantly different from passing the same job to someone with little experience or who may have low confidence.  In either case the task and the level of performance expected must be clear and follow up to review progress and achievement is essential – otherwise this would be an abdication of task which is quite different to delegation where accountability is retained.

Every doctor, regardless of seniority, must be able to delegate effectively.  The alternative is an unrealistic world where the doctor works in total isolation from anyone else and conducts even the most menial task on their own.

The doctor’s approach and management of delegation, like any other skill, should be regularly reviewed and refreshed.

“Ok, so what you need to do is reduce taking the tablets you have been taking down to once a day and take two of these new tablets three times a day, then come back and see me in two weeks from now.  Is that ok?”  “Yes, thank you doctor.”

If only life were so simple.  “The single biggest problem in communication is the illusion that it has taken place” is the well-used quip from George Bernard Shaw.  The words of the American journalist Sydney J Harris are also worth considering: “The two words information and communication are often used interchangeably, but they signify quite different things.  Information is giving out, communication is getting through.”

These two quotes help to highlight some of the biggest challenges for the doctor in practice.

“Communication, partnership and teamwork” and “Maintaining Trust” are the third and fourth domains of Good Medical Practice.  As a doctor, the ability to effectively interact with others – to ensure that all concerned hear what needs to be heard whilst you demonstrate respect, compassion and commitment to care – has a powerful impact upon patients, carers and colleagues.  It is essential for the doctor to “get through” to the patient.  It is equally vital for the patient to “get through” to the doctor.  A proactive approach to reviewing and enhancing the skills in these domains must therefore be treated as equally important as any other clinical skill.

In our Advanced Patient Communication Skills Course for Doctors we the explore the many factors which come into play to both prevent and distort the messages which are travelling in both directions between doctor and patient.  Some patients have lots to say on any subject, while others are reluctant or struggle to share any information.  Some are openly emotional and ask lots of questions, while others are reserved, factual and even detached.  The pressures of time can mean that the patient has been left waiting, ready to burst forth with descriptions by the time the consultation starts; the doctor on the back foot and trying to get to the crux of the matter while trying to get back on schedule.  Missing information, inherent associations and time pressures lead to assumptions being made by both parties – not all of which may be correct.

The good doctor must be capable of managing the patient consultation to ensure that all concerned hear what needs to be heard.  Inevitably this is easier in some circumstances than others.

What steps have you taken recently to review and develop your skills in this area?

“Health care in the UK faces a future of increasing constraints. Serious challenges exist that threaten the sustainability of services. To preserve the standards of care provided across the NHS, waste must be reduced.”  These are the open words of the Academy of Medical Royal Colleges reportProtecting Resources, Promoting Value which has been released today.  In his foreword to the document Professor Terence Stephenson states that “avoiding waste and promoting value are about the quality of care provided to patients – which is a doctor’s central concern.” and he points out that “Maintaining NHS services may depend on doctors engaging with this issue to an extent that has not previously been the case.”

The BBC news website runs with the headline: “UK doctors have “ethical duty” to prevent waste”

Is it about time?

The document highlights the fact that “most people think of waste in a product sense….However, most waste in the NHS lies within clinical practice and models of care.”

There are 86,400 seconds in each day.  Time is a finite resource, just like any other.

With ever increasing workloads, pressures and deadlines, the ability for doctors to effectively manage time is imperative.  During our Time Management and Personal Effectiveness Course for Doctors we regularly discuss how the demand for this skill increases as progress is made up the career ladder.  Otherwise the doctor finds their finite time being wasted on ineffective meetings, trapped by conflicting demands and overloaded, jumping from crisis to crisis.  To quote David Loxterkamp from his column in the BMJ this May, when time is scarce “Our mind slows and narrows.  We ultimately forfeit what our patients need most: patience, compassion, deep understanding, wider scope and the gift of human relationship.”

Resolving issues with time management requires deliberate action and the investment of time itself.  It is likely to have taken you less than two minutes to read this blog.  What steps will you take to ensure that your valuable time is wisely spent?

 

David Loxterkamp reference: BMJ 2014; 348:g2634

On the 17^th of October David Behan, Chief Executive of the Care Quality Commission, launched the independent regulator’s State of Care 2013/14 report for health and social care in England.  It provides some uncomfortable reading.  Five basic questions were asked of all the services which were inspected: Are they safe? Are they effective? Are they caring? Are they responsive to people’s needs? Are they well led?

The report leads on the “widespread unacceptable variation in the quality of care,” with “differences in quality from one trust to another, from hospital to hospital within trusts, and between different services within hospitals”.

Basic safety and leadership are identified as key issues.  “Variation in basic safety is a serious problem, particularly a lack of effective safety processes,” and “a lack of a culture that truly learns from mistakes and near misses.”  Of the first 82 NHS acute hospitals rated 10% were assessed as being “inadequate for safety” with 70% requiring improvement.  This means that only one in five were considered “good” against these criteria.  None were given the “outstanding” rating in terms of safety.

The CQC states that it is “calling time on unacceptable variation in the quality of care” insisting that providers must “act swiftly as one system to protect people from poor care.”  At the same time they encourage the public to use the “reports and ratings to make decisions about your care and the care of those close to you”.  The way forward for the providers and patients is clear.

What is the individual doctor’s role in addressing this safety issue?

The thought provoking quotation, “There is no more neutrality in the world. You either have to be part of the solution, or you’re going to be part of the problem.” is attributed to political activist Eldridge Cleaver and it could be argued that this sentiment applies here.

One of the key steps toward improving safety which we regularly discuss during ourAdvanced Team Communication Skills Course for Doctors is the successful implementation of and utilisation of Shift Handovers.  There are many challenges here: tired/hungry participants who are wanting to go home; immediate patient care needs to be maintained; physical space to be able to hold this handover; the sheer quantity of information transfer required.  These are all obstacles to success which cannot be ignored and there are many more.  However many treatments will not take true effect until mid-way through the following shift, a great deal of time can be lost in trying to comprehend what steps a previous doctor has taken and the following doctor may well be following an entirely different train of thought to yourself.  These are only a few points which illustrate the importance that the shift handover has to play in improving patient safety.

So how successful are the shift handovers related to your practise?  What actions are you taking to ensure that they are as effective and consistent as possible?

A report by the General Medical Council (GMC) published last week revealed that there has been a sharp increase in the number of doctors coming to work in the UK from southern Europe. The report, titled The State of Medical Education and Practice 2014, showed that in the past the largest source of overseas-educated doctors came from south Asia. Now, according to the GMC, the UK medical landscape sees, ‘more doctors than ever coming to work here from Europe’.

In an official release, the GMC suggests that the reason for this rise could be due in part to changes in immigration rules that have made it more difficult for doctors outside Europe to work in the UK. They also claimed that the economic downturn in southern Europe, and the expansion of the European Union in eastern Europe, is likely to be behind this increase in Europe-trained doctors moving to practice in the UK.

The report also noted a significant increase in the number of women becoming surgeons and specialists in emergency medicine.

Niall Dickson, chief executive of the GMC, said, ‘The face of medicine is changing and it is important that those responsible for workforce planning understand the implications. Of particular concern are the potential shortages in some specialist areas where there are diminishing numbers of doctors in postgraduate training and large numbers over the age of 50. Recruitment in some parts of the UK, especially deprived areas and more remote communities, is also a significant challenge.

“We hope that this data from the GMC will help inform future decision making. The challenge for governments, educators and those who commission services must be to work together to make sure we have a medical workforce with the right skills and one which is adequately resourced, trained and supported to meet those needs.”

How does working with Europe-trained doctors affect teamwork in your hospital?

Oxford Medical runs regular UK-wide courses on leadership, management and team communication skills.