Good for the L&D hospital: leading the way again...

It does the heart good to find your local hospital doing really rather well.

The L&D: glad it's my local hospital

More than once, I’ve commented on the silent ward initiative being pioneered at the Luton and Dunstable hospital just up the road from me. It has the merit of focusing nursing effort on nursing – as opposed to answering phones, completing paperwork or dealing with administration generally. Equally admirable was the investment it was making in Discharge Planning (where my wife worked for a while): hospital nurses, district nurses and social workers worked out of a common office in the hospital, to ensure that patients could be discharged quickly but safely, with all the necessary support services in place.

Now it seems that the L&D is leading the way in another key area. I wrote the other day about the work being done by University Hospitals Birmingham, under the leadership of Chief Executive Julie Moore, on keeping up permanent staff numbers. So I was pleased to see a report on ITV about how the L&D is at the forefront of this kind of work too.

It quoted Chief Nurse Patricia Reid:

It doesn't matter how good an agency [nurse] is – and some of them are absolutely brilliant. The fact is the way they work they are in different hospitals some days, on different clinical wards, and that impacts on the continuity of patient care and undoubtedly impacts on long term quality.

Much the same point as Julie Moore was making: she reported that their own studies found that as soon as there were two or more temporary nurses on a ward, care quality suffered. You need your own people, used to working in your own teams, who know the patients and the processes on specific wards.

In addition, and the ITV report makes this clear, interviewing Jeremy Hunt, Health Secretary, on the subject, expenditure on agency nursing is far too high – twice expected levels. It must be cut for financial reasons, which makes it all the more satisfying that the result is likely to be an improvement in quality, not a loss.

That’s a real case of win-win.

Like University Hospitals Birmingham, the L&D is working deliberately and resolutely to cut its dependence on agency staff.

Now, I’d rather not have to go there if I possibly can. But just in case I really can’t avoid it at some time, I’m delighted to know that my local hospital – alongside Julie Moore’s – is right up there in the forefront of enlightened thinking.

Let’s hope that all the other hospitals soon follow in their wake.

How the NHS can address its own problems

Employ two people for one job? As a way to improve productivity? And cut costs?

A curious notion. And I’m grateful to my wife for recommending I listen to the latest episode of Evan Davis’ BBC Radio 4 programme The Bottom Line to hear it.

The speaker was Julie Moore, a nurse by training, and Chief Executive of University Hospitals Birmingham. She had me on her side as soon as she stated a principle which can’t be stressed too much: though we keep being told that the NHS employs too many people in administrative, non care-related roles, the reality is that we need more, if only to free up nursing time.

Julie Moore with an acquaintance of hers

That’s a point I learned from an inspired initiative that my local hospital, the Luton and Dunstable, has been pioneering: the silent ward. 

It’s possible to keep wards quiet by employing a lot more word clerks, who take all the phone calls and deal with the paperwork, in rooms kept separate from wards so they disturb no patients. It’s a win-win arrangement, because if frees up their time, so nurses can constantly move among a small number of patients assigned to them, and it’s possible to eliminate call bells too – a nurse will be around to see you as part of the routine of work more quickly than if summoned by a bell – and, of course, with less noise.

Julie Moore talked about the application of the same principle in another context:

One of the things we have done is look at the various roles. I have a great concern that all we measure in the country at the moment is nurse staffing levels. What we did a while ago, was say we don’t want qualified nurses putting away stores… [and similar general work] … so we created housekeeper roles, storekeeper roles. That really did help productivity. You had someone whose job was to keep all the store cupboards stocked up with everything the nurses needed, make sure they’re not overstocked and, all the rest of it…

The results were excellent, though that should surprise no one. After all, the principle is simple. They had:

… qualified nurses looking after patients, and storekeepers looking after stores, and it worked very, very well.

But how about the counter-intuitive notion of appointing two people for one post? How can that work?

One of the major problems in the NHS is its over-dependence on temporary staff, agency or bank staff, to fill shortfalls. Since the Francis report into the disastrous failures of care at Mid Staffordshire hospital, there has been an obligation not to let staff numbers fall below certain levels, and that often makes it necessary to take on temporary staff.

Simon Stevens, Chief Executive of the NHS in England, pointed out recently that spending on agency nursing was running at twice the expected levels.

Here’s Julie Moore’s take on the problem:

It’s far more important to have permanent staff for your own staff than employ temporary staff like agency staff. We see productivity go down when we do that, but most importantly from our perspective, quality goes down. So we’ve run a policy in the past three or five years now of over-recruiting staff. So that the mantra is, if you interview two good people for one job, employ them both. And we’ve found productivity, every which way you want to measure that, not just around patients, but actually sick time, morale, the questionnaires that staff fill in, have all got better as a result of that, and we spend far less on our overall nursing bill.

The bill goes down, and quality goes up. As many have often argued, the best care is often the least expensive care. But it’s particularly striking, and highly refreshing, to discover that over-recruiting in the NHS can help.

The principle for Julie Moore is: “Don’t let a good person go unappointed…”

The results have been staggering.

The first year we did that our pay bill went down £850,000.

Julie Moore was made a dame (knighted) by a Tory government. On the other hand, the chair of the Trust that runs her hospital is Jacqui Smith, former Labour MP and the first woman to hold the post of Home Secretary. Julie Mooore’s approach is non-partisan.

It shows what can be done in the NHS. When you have leaders bold enough to take effective decisions, even when they’re counter-intuitive. And when politics is kept out of the equation.

Healthcare: choice is what you really want. Or so the politicians assure you

For years now, British governments – sadly, Labour as well as Conservative – have attempted to convince us that what we really need in healthcare is free choice.

The argument goes like this. Everyone wants to be sure that the care they’re receiving is the best available. And they can only tell if they’re given the information they need; and once they know which the best choice is, they need the right to exercise it.

What this leaves out of account is that at the moment you need care, there’s every chance that you’re sick, which is hardly the best position to be in if you’re trying to make an informed choice. Why, you might even be unconscious. I’ve known people whose qualities of judgement wouldn’t be harmed by being unconscious – they vote UKIP, for instance – but usually, being out of it doesn’t make us more judicious.

Their relatives might be in a better position to take a decision, but if they’re worried, borderline panicky, they may not be the best judges either.

What about a GP? There’s someone who might be able to help. But one doesn’t always have the luxury of waiting to call between 8:30 and 9:00 the following day, only to be told that the first available appointment is on Thursday week.

The reality is that, faced with a medical emergency, we don’t waste a lot of time making a choice. Or rather, we make the choice on purely pragmatic grounds, without taking medical performance into account.

For instance, I’ve taken people into Accident and Emergency on several occasions. How did I choose the A&E department? Simple. It was the closest.

The L&D: unprepossessing entrance but a centre of excellence
And also my closest A&E department

As it happens, I’m proud of our local hospital, the Luton and Dunstable. It scores highly on most comparative reviews of quality. It’s launched some exciting and innovative initiatives, such as “silent wards”: instead of cutting back on expenditure on administrative staff, it’s taken on large numbers of ward clerks, so that nurses can be freed to concentrate on nursing. Phones and faxes, as well as printers, are looked after by the clerks, behind closed doors. Each nurse has an assigned nursing assistant and looks after ten patients, who don’t even have bells – since nurses are constantly moving round their ten beds, they get to patients more quickly than if bell pushes were in use.

The result? The elimination of bells, phones and faxes, means that wards have a quieter, more restful atmosphere. Restfulness is a major contributor to healing. That enhances the effect of more frequent contact with a nurse.

So I’m perfect happy with the L&D. But what if I’d been told that Milton Keynes (40 minutes away) was even better? Or the great university hospital at Addenbrooke’s in Cambridge (an hour and a quarter)? Would I really have taken a friend or relative in pain to one of those hospitals instead of getting them to hospital in under a quarter of an hour?

To ask the question is to answer it.

Many others answer it the same way. 95% of all hospital treatment for Luton residents is provided by the L&D. What really is the choice? Or more to the point, offered the choice, Luton residents choose to be treated at their local hospital. After all, where else is it as convenient for their friends and relatives to visit them?

It was fascinating to be given a striking illustration of these ideas at a seminar I attended last week, on Clinical Audit. Dr Kevin Stewart, Clinical Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians, told the story of Bill Clinton’s heart attack.

The ex-President began to suffer severe mid-chest pain while walking in New York with Hillary Clinton who had to make a swift choice. Did she log on to the internet and check the published information on comparative performance of New York cardiologists? She did no such thing. She phoned one cardiologist – one who happened to be languishing in 137th place in the league tables.

On what basis did she pick that particular physician?

She knew him. Personally. His number was in her phone.

As we all know, he saved Bill Clinton, so he can’t have been that bad.

The essential point is that when we make choices of medical care, they’re as often as not arbitrary. So all that fuss about choice is just that: a lot froth, designed to whip up some support among certain voters who are currently in good health and lack the imagination to realise that, in an emergency, they wouldn’t exercise their right to choose anyway.

Choice is a lot cheaper than the real question. Which is care quality. If we could guarantee excellent care, in all hospitals, at all times, choice would be entirely irrelevant.

It’s a lot easier to pledge choice. Even if it would never be exercised.

Whistleblowing isn’t always good for your healthcare

‘The press lives by disclosure,’ wrote John Delane, iconic editor of the London Times in the nineteenth century. 

It isn’t even any old disclosure. News is something we all want to know and someone else wants to keep quiet. Publishing it is journalism at its most effective.

The whistleblower has a key role in making it happen.

Not the least shameful aspect of many recent scandals has been the attempt by people in authority to silence potential whistleblowers, and much of the outcry has been over the failure to listen to them in the past it time to correct problems: it’s often the people at the coalface who know what’s going wrong and who could launch action to correct it if only they could gain a hearing.

So I’m keen on a campaigning, disclosing press, and I’m keen on whistleblowers having the opportunity to make themselves heard.

However, there needs to be some intelligence in the way information is handled as well. Otherwise, as much damage can be done by irresponsible disclosure, as would have been done by unprincipled concealment.

My local hospital, the Luton and Dunstable, has in place a well-resourced discharge planning department, putting it at the cutting edge of health service management today because it embodies a goal pursued across the NHS, to encourage collaboration between social workers and district nurses as well as nurses and managerial staff from the hospital. 

The aim is to prepare for the earliest possible discharge of patients, under the best possible conditions: there is nothing to be said for keeping patients in hospital any longer than necessary, if only because hospitals are dangerous places (full of sick people) with a high chance of infection, patients recover better in their own beds, and beds are at a premium for others impatiently awaiting their turn.

Most discharges are uneventful. But sometimes discharge planning has to make sure that patients have district nurse or social care support in place, that their medication is ready, that they are going home to an environment in which they can continue to recover, and so forth. It’s hard work, under great pressure, involving the coordination of many different agencies and their staff.

Now it’s impossible to do good work without occasionally getting it wrong. The only people who never make mistakes are those who never make anything. The trick is not to be put off by fear of making errors, but to recognise them quickly, take action to correct them and learn the lessons.

So the Luton and Dunstable hospital is to be congratulated for carrying out regular audits of its discharge planning work. It’s entirely right that the department should understand its shortcomings and plan how to make sure they don’t occur again. Audit is a key way of providing information to support appropriate action.

So what a pity it is that a reporter on the Herald and Post, perhaps seeing himself as a latter-day Bob Woodward, got an article on the front page of the paper denouncing the cases that went wrong, such as the two patients discharged with cannulas still in place, or the dementia patient sent home with no-one ready to receive him. These are highly regrettable incidents, but the journalist might have mentioned that the problem discharges are a tiny proportion of the total, less than one in a hundred, and that the hospital has an exemplary record of handling discharges.

The press lives by disclosure.
But sometimes that’s less than helpful

The publicity won’t produce an improvement in service: the hospital was working on that already. Instead, what we’ll see is an increased reluctance to make information available if it can be abused. That can only increase the difficulty of achieving improvement.

Whistleblowers are essential in a healthy society. And the press does indeed owe it to itself, and to us, to live by disclosure. But it would be useful if the press learned that the disclosure of information is a right that comes with an obligation to exercise it intelligently.

Among all the noise about the NHS, a little quiet should be a great improvement

There’s been a lot of noise in Britain recently about the failings of the National Health Service.

Popular anger, or at least anger in the media, has focused above all on the Mid Staffordshire NHS Trust. The scandal has its roots in a study by hospital information company Dr Foster Intelligence, which found that 400 more people had died in the hospital over a three year period than might have been expected given how ill they were. A public enquiry revealed a harrowing string of cases of appalling care: patients suffering dehydration because they weren’t given anything to drink, patients left in their own faeces, patients left to suffer in pain as buzzers rang wildly throughout the wards with no nurses answering.

There’s been less talk about the people who sent flowers and chocolates to the hospital, to thank the nurses for the care they or their relatives had received, though some of those making the gifts have been among the most outspoken in their criticism since. Equally, not a lot is said of the encouragement the Trust was given to opt for the much vaunted status of a ‘Foundation Trust’, even at the cost of economies that left too few nurses to ensure adequate coverage. Nor is much said of the findings, again from Dr Foster, which classified the hospital ninth in the country for quality.

Instead, those orchestrating the media noise seem to be intent on directing outrage against nurses, once universally seen as angels, now increasingly portrayed as fiends.

The truth is that in a professional body of 370,000, there are bound to be a few rotten apples. But, overall, the vast majority of nurses are deeply committed to caring for patients, just as nurses always have been: it is after all the overriding motivation for choosing the profession in the first place. But the government chooses to proclaim that nurses have lost their compassion and demands, for example, that in future nurses have more hands-on care of patients – washing them, feeding them – as part of their training, to teach them the compassion it’s alleged they have lost.

This from a government that has just imposed the deepest cuts for a generation in benefits for the poorest people in Britain. But then I suppose we don’t all have the same notion of compassion.

It should also be said, in passing, that the government has launched a programme of reform of the NHS which seems destined to fragment it and undermine its public service commitment. That will encourage the government's friends in the private sector, who want to take over apparently lucrative parts of healthcare, although few of those who’ve tried so far have made any money from it and the scandals about quality from private providers have already begun.

Against this background, I was fascinated to hear of an initiative in my local hospital, the Luton and Dunstable, or ‘L&D’ as we fondly call it. 

Instead of responding to the problem of patients ringing buzzers to no avail by demanding that nurses answer them more quickly, the hospital is planning to do away with buzzers altogether. Rather than giving nurses more non-nursing duties, as the government seems to favour, they’re recruiting more clerical staff to free up qualified staff to concentrate on nursing.

The L&D: quietly improving where others just shout

The hospital has been piloting the idea of a ‘quiet ward’. The approach is widespread in Germany, which is where the L&D came across it. I believe something similar was tried in Gwent, in Wales. In England, however, it’s an innovation.

On a quiet ward, there are no buzzers, phones or faxes. There is a nurse and a healthcare assistant for every ten patients. Nurses are freed of tasks such as cleaning, ordering x-rays, coordinating discharges, answering phones or making beds. Instead, that work is carried out by support staff. 

This means that the nurse and healthcare assistant can devote far more of their time to nursing, including simply walking the ward and checking on patients’ welfare. So patients can expect to see a nurse far more quickly now, without a buzzer, than was ever possible by ringing one before. And without buzzers, phones or faxes the ward is quieter so the patient's experience better.

The pilot at the L&D went so well that the hospital is now rolling out the approach to other wards, and recruiting 105 ward clerks and other staff to support it. 

Without all the recriminations and impassioned debates that surrounded Mid Staffs, the L&D is quietly making radical changes in its approach to nursing, with the profession’s enthusiastic support. The pilot suggests the new arrangements will greatly improve healthcare quality.

It remains to be seen whether our ‘compassionate’ government will support this pioneering initiative by a hospital in the old, public and much-maligned NHS.


Postscript. On Mid Staffs, I was amused to see that 40,000 local people – or possibly 50,000, depending on who you believe – turned out to march through Stafford to try to save the hospital, now slated for closure. The difficulties the hospital experienced were always on the front pages, but the support march  received very little coverage. The march is just boring old news; the high death rates, on the other hand, were a story.

Prince Philip, Duke of Edinburgh and fine consort to our noble Queen, long to reign over us, popped round to see us yesterday. 

I mean, he didn’t drop in to my place for a cuppa and a chat, but he did go to our local hospital, the Luton and Dunstable, and open a new cardiac care unit there. Which was kind of him: I’m sure we need one. Not, you understand, that he paid for it himself or anything, but it’s the thought that counts, not what you spend.

He has a bit of a reputation for his little quips, and he did tell a Filipino nurse that her country must be half empty, as her compatriots were all over in Britain running the NHS for us, but that got him a smile and no-one seems to have been offended. Getting up someone’s nose wouldn't have been at all unusual: for instance, he told a bunch of British students in China that if they stayed too long they’d end up ‘slitty-eyed’, or commented on some lousy electrical work that it must have been done ‘by an Indian.’

Prince Philip chewing the fat with a Filipino nurse at the Luton and Dunstable
... and, miracle, not getting on anyone's nerves

The official comment yesterday was that hardy perennial of all royal visits: it provided a great boost to morale. Naturally, I’ve nothing against that: today’s economic woes rather tend to undermine morale, so anything that builds it back up is to be applauded. It just worries me that we get such a kick from something as banal as a visit by someone whose most striking achievement was getting born in the right place.

OK, in his case, he followed that one up by making an expedient marriage. Because he was born into a family justly celebrated for having done little of value for generations, and married into another, it only takes him to show up somewhere for us all to feel better. It may just be me, but that sounds basically nuts.

These issues have had a little more ventilation than usual this week thanks to comments by Hilary Mantel. They came from a thoughtful and thought-provoking speech, as one might expect from a talented novelist, well worth reading in full here. However, it contained a few uncomplimentary sentences about a woman I persist in thinking of as ‘Kate Middleton’, though I’m told she ought now to be referred to as ‘Catherine, Duchess of Cambridge.’ Sorry, Kate, too much of a mouthful.

Now this is a blog and I try to keep the posts short, but I’m nonetheless going to quote a little more of Mantel’s address than the papers have tended to reproduce. Mantel was talking about Marie-Antoinette, the unfortunate Queen of France, who:

…as a royal consort was a gliding, smiling disaster, much like Diana in another time and another country. But Kate Middleton, as she was, appeared to have been designed by a committee and built by craftsmen, with a perfect plastic smile and the spindles of her limbs hand-turned and gloss-varnished. When it was announced that Diana was to join the royal family, the Duke of Edinburgh is said to have given her his approval because she would ‘breed in some height’. Presumably Kate was designed to breed in some manners. She looks like a nicely brought up young lady, with ‘please’ and ‘thank you’ part of her vocabulary. But in her first official portrait by Paul Emsley, unveiled in January, her eyes are dead and she wears the strained smile of a woman who really wants to tell the painter to bugger off. One critic said perceptively that she appeared ‘weary of being looked at’.

Unsurprisingly the papers who sprang to her defence, supported by that intellectual heavyweight David Cameron, have fixated on the remarks about Kate’s plastic smile and design by committee. But it’s much more telling that Mantel focuses on our strange view of royal women, viewing them as people whose main purpose is to be looked at; I love the suggestion that Kate ought to be telling some of the spectators to bugger off. That sounds like a call to Kate to stand up for herself, to assert her personality and to stick a finger up to the whole complex of image and flummery and obsequiousness which, by her marriage, she sadly joined.

If Mantel criticises Kate, it’s principally for being the accomplice or the dupe – possibly both: a willing dupe – of a thoroughly unhealthy set of social relations which it would be an immense emancipation to reject. We suffer so much indignity, and indeed privation, for the belief that there are some who, by birth, marriage of simple naked wealth, particularly deserve our deference. Mitt Romney ran a whole presidential campaign on that premise, and what a relief it was that he went down to defeat.

Mantel does us all a great service by drawing our attention to the problem. Even poor benighted Kate with her permanent smile could benefit.