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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.

There is a clear expectation and requirement for doctors to actively engage in teaching, supporting the learning and development of others.  The fundamental principles of teaching adults are generic, regardless of the sector of employment, whether this is academia, sales, industry, physician or surgeon.  It is imperative however that these principles are adapted address the needs and environment of doctors.  As such, it is useful to step outside of the world of healthcare to see what can be learned from other sectors.

The Education and Training Foundation is a body which sets professional standards and codes of behaviour for teachers and trainers in further education in England.  Earlier this year, they defined the professional standards for this group which makes for interesting reading.  They are explained clearly and succinctly in this short three minute video.

It can be useful to benchmark yourself against the standards of a different peer group who will have used different words to express themselves to see what can be learned.  There is close alignment here between the expectation of the further education teachers and those of doctors, especially in relation to the development of others.  The question is always how to maintain these standards.  This is particularly relevant to the comments on keeping up to date and refreshing knowledge.

During our regular Teach the Teacher Courses for Doctors, we explore the fact that it is not enough for a doctor to have great understanding and expertise of their chosen speciality when considering the development of others.  Being able to effectively support the growth in knowledge, skills and attitude implies that there has to be dedicated effort on the part of the doctor taking on the role of teacher to maintain, review and refresh their own knowledge, skills and understanding of that specific role.

I hope you enjoy and find the Education and Training Foundation’s video useful.

Haven’t we been here before?

That’s exactly the scenario I experienced recently when I ran a full day meeting with the medically qualified NHS Consultants who are our tutors for our medical interview courses.  We had set aside the time to learn from each other, develop fresh approaches and to ensure that we continue to improve our work.  This is an example of the Communities of Practice approach which we advocate in our Teach the Teacher courses where integration of individuals into a professional community accelerates learning for all involved.  In such an environment, everyone uses their own knowledge and experience as a basis for learning, with the “teacher” playing the role of facilitator.

In this facilitator role, I had created a plan for the day where first of all we would revisit theories of adult education, followed by a session with some thought provoking fresh input from one of my colleagues.  One key principle which we focused upon is the idea that it is more important for the learner to learn than for the teacher to teach.  It’s all about enabling the learner.  So far, so good.  I was delighted that my carefully thought out plan was working so well, creating many light bulb moments and we happily went off to lunch together.

As the afternoon session began, I reminded everyone of the plan which had been circulated in advance.

“I know that’s what we agreed, but, after our ideas from this morning, I don’t think it’s what we need to move forward,” responded one of the doctors.

“I agree,” said another, “I’d much rather concentrate upon………..” putting forward an alternative topic and approach for the afternoon.  The others nodded in agreement.

My gut reaction was to stick to the plan and started to push for that to happen.  As the short negotiation process developed, I found myself having a challenging “practice what you preach” moment.  I’ve been here before and the message which we had focused on for the morning came very clearly into view:

It’s more important for the learners to learn than for the teacher to teach.

Taking a fresh approach, we discussed what we really needed and agreed how this could be achieved in the next couple of hours.

It’s essential for a facilitator to arrive at any planned event with a framework and method clearly defined.  It’s also essential that the facilitator listens carefully and responds positively to the needs of the group.

We went on to have an excellent afternoon where I learned at least as much as everyone else.  It is indeed far more important for the learners to learn than for the teacher to teach.

On the 4^th September, the independent Barker Commission on the Future of Health and Social Care in England published its final report and focused attention on the topic of integrated care.  The messages are clear and simply presented on the King’s Funds illustrated summary.

In short, the line between healthcare and social care is becoming increasingly blurred as we live longer and develop multiple, parallel issues.  The system as it stands us unfair meaning people with dementia may have to pay for their own care whereas those with cancer do not.  The separate sources of funding, where spending on health comes from national taxation yet any publicly funded social care is paid by local authorities, means that spending varies across the country, with decisions over who pays for what being a constant bone of contention.  The fact that the system is not co-ordinated results in inefficiency at both a financial and human level.  The Commission therefore calls for radical change with a single ring-fenced budget, simplified pathways and an increased provision of “free” social care.  As with anything worth doing there is a cost to all of this and the report recommends a package of taxation and charges which could be made to realise the proposals.

Of course this report is addressing the NHS in England and its worth bearing in mind that the structures and funding vary across the four nations of the UK.  Wales and Scotland have long since departed from the internal market approach utilised in both England and Northern Ireland and arrangements are quite different.  Scotland has been concentrating on this integrated care route for some time now with free personal care for those above pensionable age in place since 2002.  There are still major challenges ahead however, as the Herald reports the bill to the taxpayer now sits at almost £500 million per year compare with £110 million just 10 year ago – a trend which is only ever going to go in one direction.

On 8^th September, Monitor updated its Guidance on Enabling Integrated Care in the NHS in England.  It recognises the current problem and the resulting confusion, repetition, delay, duplication and gaps in service delivery as well as people getting lost in the system.  The organisation expresses the opinion that competition and integration are not mutually exclusive, that competition can exist with beneficial co-ordination.  It draws attention to the legal obligations for organisations with an NHS provider licence and highlights the Integrated Care pioneers – fourteen local areas who have been selected to pioneer ambitious and innovative approaches to person-centred and co-ordinated care.

Any doctor preparing for a medical interview, whether for a new consultant position or as part of forthcoming ST process would do well to look into the topic, be they in one of the 14 pioneering areas or in some other part of the UK.

One day before Peter Capaldi made his debut on the small screen as the new Doctor Who, the BBC reported that the Department of Health is planning to rapidly expand the number of people in “doctor’s assistant” roles.

The Patient Association has raised concern that hospitals will become more reliant on physician associates because they are paid less.  Regardless of how competent Clara Oswald is in the TV series, is it any surprise that in real life patients’ automatically reaction is that they want to deal directly with the Doctor?  There will definitely be a requirement for careful communication regarding this role and in time, with real experience, there should be acceptance.

But how do doctors themselves feel about the prospect of delegating a proportion of work to these new assistants?

Delegating new tasks to new people will come more naturally to some than to others and the pros, cons, barriers, do’s, don’ts are regularly discussed on our medical leadership and management courses.  Though everyone wants help and support, some will inevitable feel precious to some extent or lack belief that this is the right move.  Unlike Doctor Who, however, there is no suggestion that anyone should happen to end up with an assistant who has arrived there by chance and with no training for the unknown events about to unfold.

Effective delegation is quite different from abdication.  Genuine delegation implies that tasks are clearly allocated and outlined either to a competent person or to another as part of their ongoing development.  What is both in scope and out of scope must be explicit and understood, plus there has to be real supervision at all times.  Trust is essential.

The Department of Health’s intention is that these physician associates will be “supporting busy doctors to spend more time with patients, not replace them.”  The success of the initiative will in the large part be dependent upon doctors’ willingness and ability to delegate – a skill which has to be learned and practised.

“Listen to me – I’m a doctor!”  Such words may never have crossed your lips.  Many patients, however, with expectations of expertise, the perception of authority and feelings of trust will subconsciously hear this phrase at the end of every sentence spoken by their medical professional.  They will therefore usually at least try to listen – whether they can comprehend, recall or follow their doctor’s advice is a different matter altogether.

But what if the audience which you are trying to engage is made up of other doctors?

In the course of your work you may well find yourself presenting to your peers, to those less experienced than yourself and even to others, who are vastly more experienced or senior to you.  This may even form part of your medical interview.

Why should other doctors listen to you?

The skill set of the outstanding presenter is multi-facetted and, although some elements may come more naturally to some people than to others, there is much to be learned.  In a recently posted 10 minute talk on TED.com, “How to speak so that people want to listen,” sound consultant Julian Treasure first outlines some of the common things which stop people from listening.  He then concentrates upon the way which we can use our voice to improve our ability to hold the attention of others, exploring the importance of register, timbre, prosody, pace, pitch and volume.

Intelligent use and projection of the voice is one topic which we cover during our Teach the Teacher Presentation Skills Course for Doctors, where we also explore how to prepare effectively, handle post presentation questions and manage difficult audiences.  There is plenty of opportunity to practise, receive feedback and refine your techniques.

Improving as a presenter takes dedicated time and deliberate practise.  I hope you enjoy this 10 minute video talk.

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.

This week a fresh cohort of inexperienced, newly qualified doctors has arrived on hospital wards for the very first time.  Others will have changed discipline as part of their career progression.  Further along the experience scale, more senior doctors now have the challenge of supervising unknown subordinates.  Unfamiliar surroundings; new people; abilities being tested and stretched.  There is much to learn, relationships to be developed and endless questions to be answered – all of which takes dedicated effort and time.

Unfortunately, there is no change in the rate at which patients become ill, ongoing care must be maintained and the support expected for carers or families remains the same.  The inevitable result is that some degree of pressure is experienced by everyone involved.  Now a bit of pressure can be a positive driver, help us to get started, heighten our concentration levels and boost energy.  Too much however leads directly to stress which makes us lose focus and affects our approach to communication.  Confidence and tolerance decrease, mistakes and conflict increase.   The results……..more stress!

In 1968 Stephen Karpmann defined the Karpman Drama Triangle, where the people involved take on one of three roles:  Persecutor, Rescuer or Victim.  The result is that they all become locked into a no-win situation of blame, crisis and manipulation.  This can develop all too easily and at pace.  It can also be habit forming and even become addictive with the drama developing on a daily basis like a living soap opera.

Whether someone is a fresh face in a new environment or the long standing leader of the department, every member of a team has a role to play in ensuring that the balance is kept to the side of healthy pressure.  It is never too early to learn, or too late to refresh an understanding of how to avoid or to manage the drama.  It requires the development of self-awareness and to recognise why others may behave in different ways; an understanding of the differences between assertiveness and aggression and taking time to practice negotiation and conflict management techniques.

Unfamiliar surroundings; new people; abilities being tested and stretched.  What could be more exciting![/fusion_text]

The NHS is huge and complex.  The numerous organisations which form its constituent parts continually evolve, divide, grow, and merge.  Processes, authority and responsibilities forever shift with each change of the political winds.  How can any single doctor ever expect to exert a worthwhile degree of influence, even if they wanted to?

In the foreword of the recently published Understanding the New NHS booklet, Professor Sir Bruce Keogh, National Medical Director, eloquently communicates both the importance of and the key for doctors to play an active part in challenging and engaging to shape the future.  From an early position where he felt that “management” was someone else’s responsibility, Sir Bruce eventually realised, “If I really cared about how well patients were treated then I had a moral and professional responsibility to understand the system in which I practised.”  He emphasises that “Young, enthusiastic clinicians can add significant insight into our biggest healthcare challenges, but unless you know how to channel this enthusiasm and how the system works, nothing will happen.”  He ends by encouraging doctors “to empower yourself and your colleagues to get to know how the NHS works and really make it your own.”

Where all doctors share this “moral and professional responsibility” senior doctors should bear these words in mind when considering the development of their junior colleagues.  The need to see beyond the technical, clinical expertise and to support development in all aspects of practise is a regular topic of discussion in both our Teach the Teacher and our Medical Leadership and Management Courses.  Understanding who’s who, who does what, where, how, when and why takes both time and deliberate effort.  The booklet mentioned above is an excellent tool and will be of great benefit to many.  The encouraging support of a senior colleague who is skilled at passing on knowledge and enthusiasm is invaluable and has to be a key driver for doctors playing their essential part in shaping the future of the NHS.

“Live long and prosper”.  “Be healthy, wealthy and wise.”  “Lang may yer lum reek!”  In every culture there is a desire for a long and happy life and the advances in healthcare are playing a major part in significantly extending our life expectancy.  It goes without saying that we want these additional years to be both worthwhile and enjoyable where we are active and contributing, rather than experiencing a sad twilight of dependency.  However these advances and the resulting ageing population are bringing numerous challenges which affect everything from the funding of healthcare to the ratio of carers to those requiring support.

In line with the rest of the population, the retirement age of doctors and other healthcare workers is planned to increase and being medically qualified does not qualify the body for immunity to the impact of the ageing process.  Potential age related medical conditions and cognitive decline has serious implications for doctors.

What can and should be done to ensure that the increased later years of practice are both productive and are safe for patients?

Doctors would do well to consider this question, along with potential situations which could arise, in depth.  This is related, but distinct to the professional dilemmas and scenarios which are often explored in medical interview questions.  It is a topic which all experienced doctors should be able to discuss.

In response, the Academy of Medical Royal Colleges has organised a national conference to take place in October this year which aims to explore the problems associated with increasing the retirement age for healthcare professionals; explore possible solutions and develop an action plan to present to National Governments.

Of course we should not just view this from a negative viewpoint.  With age can come great experience and wisdom.  At the same time as considering how to avoid issues with performance and safety, effort should be also given to planning how to utilise such a valuable resource.