ARK VOL.4
The Voice of Healthcare
In this issue A DIFFERENT WAY NHS – THE NATIONAL HOME SERVICE RE-IMAGINING HEALTHCARE IN THE 21ST CENTURY ACUTE CARE IN YOUR OWN HOME IF DISNEY RAN YOUR HOSPITAL AN APPLE A DAY
Caring for people is at the heart of everything we do POWERED BY
A DIFFERENT WAY A long time ago, I spent a part of my gap year working as a medical records clerk at Barts hospital in the City of London. In those days, medical records were stored in folders – slim, if you were lucky, By Geraldine Bedell bulging if you were not. Healthcare’s current hot topic, integrated care, looks set to become the inherent system of the future. Focusing on bringing together different areas of healthcare, integrated care is a collaborative approach that aims to combine the efforts of care providers across primary and secondary care as well as health and social care, whilst putting the patient first and empowering the individual to be in control of their health. According to the Kings Fund, the focus is to ‘improve patient experience and achieve greater efficiency and value from health delivery systems.’ But what does it actually mean, or more importantly look like? I work in a relatively small organisation and the challenge of breaking down silos and encouraging inter departmental communications, not to mention the future focused streamlining of processes and procedures, can sometimes appear insurmountable. So imagine trying to embed this across multiple organisations from a diverse range of healthcare areas and regions. Integrated care, at first glance, adopts a seemingly simple strategy but it becomes increasingly complex given the amount of people who need to be consulted and engaged. Communication in the public and private sector is key but communication with patients must also be a priority; giving them the choice and freedom on how and where they are cared for. In the pages that follow you will discover some great examples of this happening in practice, as well as discussion around the concept that is still very much in its infancy. The question remains though, how can we maximise the opportunities provided by scientific and technological advancement to fully integrate the UK’s healthcare system and revolutionise patient care? Editor in Chief Rachel McClelland 2
Our job, as medical records clerks, was to assemble all the patients’ notes for outpatient clinic lists. This was harder than it sounds: rarely did a clinic get its full complement of files. Long-unused records had to be called up from storage in Kent (I still cannot hear the word ‘Swanley’ without a little frisson of alarm) but the real problem was with the bulging folders, the ones belonging to patients who had complex needs, who were in and out of the hospital on a weekly basis. These files often didn’t make it back to us in time and had to be tracked down on the wards, or with medical secretaries at other, competing clinics. And then we had to go and wrest them from their grasp. A few decades on, my gap year job has gone the way of the spinning Jenny. From today’s digitally-enhanced vantage point, it’s strange to think that the availability of medical records to world-renowned clinicians so recently relied on the persistence - and the sensible shoes – of a handful of school leavers scurrying from a grubby basement across courtyards and up and down stairs. Much later, when I came to edit Gransnet, the social networking site for older people, I discovered that many of its users, who were often caring for elderly parents, were struggling to negotiate a hospital and care system where the notes, actual or virtual, weren’t available. Stories had to be told over and over, bits of them got lost, and care was every bit as disjointed as it would have been if one of my Barts doctors had had no access to the notes of what his colleague had prescribed the previous week. Of course, integrated care is about much more than the sharing of information: it’s about structures designed for
collaboration and different ways of thinking about patients’ health needs. But information is at the heart of it: none of the rest works if knowledge is not shared. Yet, despite the opportunities for clarity of communication that are presented by digital technology, health and care systems too often continue to be fragmented, disjointed, and clueless about what is going on in other parts of the machine. In the commercial sphere, algorithms monitor our preferences on a minute-byminute basis. Yet health and care workers have no such resources: they often have scant understanding of patients’ likes and dislikes; and, where they do, they have precious little opportunity to share their insights. The system often seems uninterested in the bigger picture – despite the fact that, as 2014 Reith lecturer Atul Gawande has argued, if patients understand the full implications for their particular daily lives of any particular treatment, they often make very different decisions. Back when I was a medical records clerk, I sometimes wondered how patients fared after they walked out of the front doors, how they communicated some of what was in those fat files to their carers and families. It must have been hopeless. But for many current patients, it’s still not much better. Even as hospitals endeavour to become less fortress-like, to embrace social care and mental health services and even some of the vast hinterland of wellness therapies, there remain all kinds of blockages to the sharing of information. Primary, secondary and tertiary care often struggle to join up, let alone to connect satisfactorily with care from family members or the myriad other services that impact directly on patients’ health.
The reason the revolution has come so slowly, of course, is that patients’ needs, especially as they age, are complex. Why would an overstretched NHS have any desire to contend with an elderly man’s housing problems, even if the damp and the noise and the presence of his stepson might be damaging his mental health and aggravating his angina; even if sorting out his housing might ultimately save significant amounts of money in hospital admissions? I learned one thing from my brief stint as a medical records clerk: if the patients’ notes weren’t there, the clinic appointment was next to useless. And it remains true: if you don’t have the fullest possible picture of what you’re dealing with – or of what, beyond drugs and operations, might help an individual patient with a particular sense of what makes life worth living – it’s very difficult to deliver the best care.
Tweet us your thoughts @arkmagazine
NHS – THE NATIONAL HOME SERVICE Out-of-hospital initiatives are at the forefront of UK government plans to modernise the way the NHS delivers care. THE NHS often gets a bad press for being slow to adopt new medical technologies or practices. But when it comes to out-of-hospital initiatives, the health service is no slouch. Earlier this year, NHS England Chief Simon Stevens announced that the government was working closely with innovators like Verily (formerly Google Life Sciences) and Philips Healthcare to deploy the latest technology in a bid to overhaul the way care is delivered.
At the heart of the shift is the firm belief that modern methods of gathering information and remotely monitoring vital health signs can be paired to improve the management of chronic conditions. In short, the aim is to allow more patients to be managed in their own homes rather than hospital. The NHS Test Beds will try out a variety of new systems for improving health care delivery through technology. The ambitious programme requires extensive co-operation between government departments, NHS hospitals, clinical commissioning groups and community care providers. But if it works, it could change the face of NHS care for good. So what exactly are these pilot projects, where are they taking place and how will they benefit patients?
NORTH-EAST LONDON An ambitious project to promote healthy ageing across a million-strong population, this pilot scheme aims to help patients manage their own conditions and remain as independent as possible. For example, it will include an online tool
4
for those with dementia, a social network app which offers peer-to-peer support safely online with guidance from credible organisations and institutions, and a device which assesses falls risk and mobility.
GREATER MANCHESTER In the Greater Manchester areas of Heywood, Middleton and Rochdale, the latest technology will be deployed to try and predict which patients are most at risk of long-term conditions. Verily, along with drug firm MSD, local GPs and academics, will analyse trends in areas such as heart failure and lung diseases like Chronic Obstructive Pulmonary Disease, to identify patients most likely to benefit from telehealth, tele-care and tele-medicine technology. Doctors hope to use predictive techniques to pre-empt serious illness.
LANCASHIRE AND CUMBRIA Here, Philips is involved with numerous agencies to try and find ways to support the frail elderly and people with long term conditions to remain out of hospital. The idea is to use new technological approaches to spot those likely to benefit from additional support and help them selfcare at home through improved education and tele-health technologies.
SHEFFIELD This pilot targets serious chronic illnesses such as diabetes, mental health problems, respiratory disorders and high blood pressure, all of which can lead to unnecessary hospital admissions. A local ‘intelligence centre’ is being set up – with the help of tech giants like IBM and GE Finnamore – to identify and target those most at risk of relapse in a bid to
By Pat Hagan
keep them well, independent and out of hospital by securing the clinical support they need when they really need it.
BIRMINGHAM AND SOLIHULL A mental health project here aims to team medical expertise with the strategic, marketing and digital skills of Accenture. The aim is to provide more proactive support for those with psychiatric issues through online back-up, regular risk assessments and crisis intervention plans. Predictive analytics will be used to try and identify those most likely heading for a mental health episode, allowing mobile crisis team members to intervene in time to prevent admissions. Announcing the plans earlier this year, Life Sciences Minister George Freeman MP said: ‘We are determined to ensure the NHS can remain a pioneer of new treatments and models of care, so that UK patients will be amongst the first in the world to benefit from these hugely exciting medical advances, made possible by the life sciences industry in partnership with the NHS. ‘Not only does it demonstrate the NHS’s attractiveness as a place to test and develop revolutionary new products, it is also another important step towards creating a truly twenty-first century NHS.’ Alongside these initiatives, there are also 15 Academic Health Service Networks across the UK. These are groups that aim to turn innovation into mainstream clinical practice – as quickly as possible. They are made up of NHS providers, commissioning groups, universities, research bodies and social care providers.
These groups are charged with exploring ways to use technology to get the very best value out of the NHS budget – primarily by keeping patients out of hospital. In Hounslow in London, for example, an extra £190m a year is being spent on out of hospital services, including integrated care and more access to general practice. GPs in the area are already starting to identify patients at highest risk of unscheduled admission to hospital. Practice nurses then co-develop a care plan with the patient and carer (where appropriate), ensuring that all the services the patient needs are working together to prevent them attending hospital when they don’t need to. A care navigator then works with the GP, the community matron and the social worker to support the highest risk patients. Diabetes is the number one target but the plan is to roll it out to respiratory illness too. It all makes clinical sense. But does it make financial sense? Definitely. It’s estimated that one in four people in hospital in the UK could be looked after in their own homes or the community. And some estimates suggest for every £1 spent in hospitals, alternative community care can be provided for 70p.
If you’d like to share your story, email arkmagazine@cmemedical.co.uk
RE-IMAGINING HEALTHCARE IN THE 21ST CENTURY Merav Dover, Chief Officer of Southwark and Lambeth integrated care (SLIC), has worked in the NHS and central government for over 20 years. She describes being able to redesign care across organisations, radically transforming care to improve people’s lives, as ‘a gift’. Here Merav talks to us about SLIC and how re-imagining 21st Century care requires extraordinary commitment, skills and resilience… What does integrated care mean to you? In Southwark and Lambeth it’s about radically redesigning how care is provided, breaking down silos and making the best use of our money and our people clinicians, professionals, carers and citizens by supporting them to work together to help local people live healthier and happier lives. It’s also about supporting people to take control of their care. The current system is designed for people to be dependent recipients of care, but local people told us they wanted to be in control of their own health and wellbeing, and integrated care is about supporting them to do that. Why is a holistic approach so important? A holistic approach means looking at a person in the round, not as a set of conditions, taking into account their social, mental and physical care needs. Holistic Assessments allow people to talk with their GP about their concerns, wants and needs and develop with them a comprehensive care plan to address these. [In one case], a lady was visiting her GP surgery every day, waiting for it to open each morning.
6
Through a Holistic Assessment her GP found out that her medical condition was less important to her than the fact that she had been very lonely since her mother had died and that she wanted to have a reason to leave the house. An Age UK Care Navigator, working in partnership with the practice, helped her gain confidence and took her to an arts and crafts class, which she still continues to attend. She’s made friends and now only visits her GP when she has a medical reason to do so.
realised we needed to focus on getting the basics in place – for example, we involved a range of stakeholders in co-designing a programme, and used quality improvement methodology to review its success. Ours is a story of learning, honesty and selfchallenge and I think it’s this which really brought about our success. We learned and adapted as we went along and it was having the courage to say ‘this isn’t working’ and then try again that allowed us to eventually get it right.
What has made SLIC so successful? It’s not just what we’ve done - it’s how we’ve done it. The ‘what’ to some extent was fairly obvious. For example, older people told us they wanted more transparency and communication between their GPs and hospitals to avoid having to explain their history at each appointment. In response, we implemented a system whereby every GP and every clinician within each of our three hospitals can see each other’s records in real time. We call it a ‘Local Care Record’. The ‘how’ wasn’t quite as straightforward. When SLIC began in 2012 we didn’t know precisely how to do things, as we were testing. We knew, for example, that we wanted to do a falls prevention project but we didn’t know precisely how it was going to work. We succeeded because we
The SLIC Framework for Success is broken down into three sections: 1. Producing your plan and communicating your vision - people are doing a fantastic job in delivering and improving care within their own organisations, but you need to create the conditions for change if transformation is to take place. This includes setting aside funding to ‘buy’ people’s time and incentivise collaboration. 2. Planning to deliver – Before you start delivering change, you must make sure that people really understand what is expected of them – it requires co-design and a commitment across organisations and with local citizens to get to the right solution. And make sure you are using all the available expertise in your local area. That might mean bringing in housing associations or the voluntary sector, for example. 3. How will you know if you are successful an easy question, a difficult answer! At the beginning we didn’t always measure the right things. For example, we measured how many Holistic Assessments had been carried out rather than what their impact was. This was problematic because it meant we couldn’t fully demonstrate success, something which is a huge motivator for people working in transformation programmes. Success breeds success.
We are very keen for others to learn from our experience – both what we did right, and what we did wrong – and have developed a SLIC Framework for Success to share our learning.
What can other organisations learn from this programme? And will we see this across the country? Integrated care is now a well-used term it’s a key part of the NHS Five Year Forward View, the focus of a number of Vanguard Programmes, and every local area has had to form Sustainability and Transformation Plans, which include integrating care, so it is certainly happening all over the country. However, I think we were, and probably still are, ahead of the curve in terms of our results because we started earlier and now have a good understanding of what it takes to integrate care, along with committed and talented staff, and strong leadership.
What have been the challenges and successes of SLIC? At times it is hard. There is always pressure to demonstrate success immediately, so even when you have groups of people working together successfully to redesign care, until you can really demonstrate that it is having an impact on experience, costs and population outcomes, you are met with a degree of negativity and people wanting quicker results than you can necessarily
deliver. You’re also asking people who don’t really know each other to work as a team, so we had to build trust and relationships from scratch. And, of course, all this is against a backdrop of steep cuts, so the environment can be very difficult. Despite this, we have had success over the four years of SLIC, and 24 of the 27 interventions that we have tried and tested are now mainstreamed, or undergoing continued testing. We have also stabilised emergency admission and bed days for older people, and have massively reduced the number going into nursing and care homes - and all within the context of a local 5% population increase in people aged over 65. CONTINUED OVER...
RE-IMAGINING HEALTHCARE IN THE 21ST CENTURY CONT. What does the second phase of the SLIC Partnership look like? What do we have to look forward to? While the four-year SLIC programme ended in March 2016, the partnership is continuing. As the Southwark and Lambeth Strategic Partnership they will build on the successes of SLIC to continue to improve care for even more local people. They have begun working on a big transformation programme for children’s and young people’s services, and there is a commitment to do a big piece of work on data, as we need to understand our population in order to be able to respond to their needs. At the moment, every organisation is holding a little bit of data and we need to pull all that together so we have a more complete picture. These are just some of the broad priorities of the partnership going forward - there is zero complacency and 100% commitment to continue with the good work that SLIC started.
Other than looking at children’s needs and over 65s are there any specific areas of healthcare that you would like to see more integrated or ‘at home’ as opposed to in a hospital? I think it is about providing care in the most appropriate place. Sometimes that is in hospital, but there are other places as well, for example in your own home or in residential care that can become your own
home. We need to think about which place is most appropriate so that people can really flourish. Helping people get home earlier from hospital so they don’t lose their independence is really important. In many cases people don’t need any more nursing or medical attention per se, but we are not really sure whether they can manage at home. In hospital things tend to be done
If you’d like to share your story, email arkmagazine@cmemedical.co.uk 8
THE STATS
•
for you, so it is not necessarily the best place to assess whether you can be independent or not. SLIC created Extra Care accommodation– flats that are made to feel like home – where people could do as much for themselves as possible like taking their own medicine, making a cup of tea, answering the doorbell, getting dressed, going to the toilet on their own, while being closely monitored. This also meant a comprehensive assessment of their needs could be carried out in a home-like environment and that they were able to recover in a safe environment before returning to their own homes. People tell us they want to be at home whenever it is appropriate to be at home, so it’s important to focus on prevention too. When it looks like people are getting to the stage where hospital admission may be likely at some point, we have an Enhanced Rapid Response team made up of social care, therapists and nurses, who are able to provide care in the home.
Finally, it is obvious that you are very passionate about what you do - you have to be to overcome all the challenges and stay motivated - but what is it that makes you passionate about integrated care, what draws you to that area? There are two things for me. Firstly, I love seeing first-hand the profound difference it makes to local people’s lives. Secondly, it’s the huge difference it makes to professional’s lives. We have superb social care workers, doctors, nurses, managers and leaders and seeing how working differently improves their working lives is incredibly motivating.
Tweet us your thoughts @arkmagazine
During the four-year lifespan of SLIC (2012-2016), despite the population of Lambeth and Southwark aged 65 years and over growing by 5%, hospital admissions and bed days were stabilised, and residential and nursing home placements were reduced 61% • 100% of patient records are now available to GPs and the three hospitals as a result of the Local Care Record, leading to 75% fewer calls from GPs to hospitals chasing information • 14,500 people have benefitted from a Holistic Assessment (HA), creating with their GP a care plan to address their needs • 1,500 calls to the Telephone Advice and Liaison (TALK) service have resulted in 720 people avoiding admission to hospital • 75% of people attending Strength and Balance classes reported increased confidence and quality of life, and no hospital admissions due to falls You can find out more by reading the full report Southwark and Lambeth integrated care: What we did and how we did it at www.slicare.org
SLIC THE PARTNERSHIP AND SLIC THE PROGRAMME
SLIC is one term with two definitions: • SLIC the partnership • SLIC the programme of interventions Set up in 2012, SLIC was a partnership of commissioners and providers, with citizens, working together to improve the value of care in Southwark and Lambeth to help local people live healthier and happier lives. The partnership comprised the local GP Federations, the three local NHS Foundation Hospital Trusts - Guy’s and St Thomas’s, South London & Maudsley and King’s College - Southwark and Lambeth Clinical Commissioning Groups, Southwark and Lambeth local authorities and local people, supported by the Guy’s and St Thomas’ (GST) Charity. The four-year £39.7m SLIC programme was funded by the partners, including a £10.6m grant from the GST Charity.
ACUTE CARE IN YOUR OWN HOME Imagine receiving hospital treatment without even staying in hospital. In the last two years, that’s what 1,700 NHS patients have experienced under a ground-breaking acute hospital-at-home scheme run by ORLA Healthcare. So how does it work and can it really help solve the crisis facing the health service? By Pat Hagan
They read like a list of potentially serious illnesses normally considered suitable only for treatment in a hospital setting. Indeed, if a doctor suggested staying at home with pneumonia, COPD or cellulitis, patients might wonder if it was time for a second opinion. But that’s exactly what’s happening with thousands of sick patients under a gamechanging initiative run by Essex-based ORLA Healthcare, in collaboration with NHS trusts. Between May 2014 and March 2016, more than 1,700 patients who would normally be admitted to hospital or were already existing in-patients were instead cared for in their own homes by an ORLA team of medical and nursing specialists. The patients ranged in age from 18 to 102 – although nearly two thirds are aged 71 or more – and as well as the conditions mentioned above also suffered with upper and lower respiratory infections, needed post-operative care and had severe electrolyte imbalances due to vomiting and diarrhoea. In the past, such patients would spend several days in hospital, taking up valuable resources that could be devoted to treat other in-patients. Under the new scheme, things are a bit different. First, a patient judged to need hospital admission is assessed by ORLA’s clinical team to see if they are suitable to be cared for at home. A care plan is then agreed with the patient, who is taken home, where all necessary equipment and medicines are then delivered. 10
Within an hour of getting home, a member of the ORLA clinical team visits. From that point on, the patient follows the same care pathway as in hospital, receiving up to six visits a day from the clinical team. Telemedicine monitoring equipment records blood pressure, pulse and oxygen saturation levels and the results are transmitted straight to an ORLA Consultant. ORLA’s Doctors, Nurses and Health Care Assistants administer treatments to the patients and are available 24 hours a day. Finally, when the patient has recovered, they are discharged back to the care of their GP. Technology plays a crucial part too. Patient notes are all electronic and accessible to all ORLA staff round-the-clock. Clinical staff, meanwhile, use iNurse technology to manage patients in their own home. This allows them to record and communicate patient information at the point of care using phones or tablets, sharing it with Consultants based in ORLA’s clinical office. In short, it’s just like being in hospital – without being in hospital. So what are the advantages? David Harrop, CEO of ORLA, says: ‘Imagine that, as a patient, you have a choice of being at home surrounded by your own things, your own family, your own furniture and your own bed, as opposed to being on a ward that has a lot of clutter and noise 24 hours a day. ‘You’re going to get a better night’s sleep and your family and others can visit you anytime without restrictions.
‘And if you want access to the kitchen to make yourself a drink, it’s your home. ‘On a ward, things are done for you, including when you can have your drink. ‘For older, frail patients, putting them in a hospital bed can increase disorientation. ‘But by being in a familiar home setting – whether it’s their own home or a nursing home - they are more actively in control of their life. ‘Very few patients have said no they don’t want to transfer their hospital treatment to ORLA’ Patients may be keen. But what has been the reaction within the NHS and how does the scheme work at a practical level? Jackie Row, ORLA’s Director of Nursing and Clinical Services, says working side-by-side with Trusts’ own medical teams is vital to the success of the initiative. ‘A patient who comes into the emergency department will be seen initially by the trust nursing and medical staff. ‘We have spent a lot of time working with the Trust medical staff so they understand our processes and pathways. ‘So quite early on in that patient’s journey it may be that people are beginning to think they could be cared for in their own home.’ The idea is discussed with the patient and three streams of assessment then kick in. The ORLA Consultant undertakes a full medical assessment, the ORLA nursing team assesses the patient’s nursing needs and finally home risk assessments and a risk management exercise are carried out.
We have to rethink how we deliver care and medical treatment to our population.
Jackie says: ‘Then there is a formal handover from the Trust consultant staff to our consultant staff and we assume clinical responsibility for that patient at that point.’ At home, various staff will attend the patient – depending upon their needs. These range from nursing staff, healthcare assistants and middle grade medical staff to consultants, physiotherapists and pharmacists. As they recover, the six visits a day will reduce. David says: ‘Nobody else is doing this in the UK on this scale, with our level of acuity, with our range of clinical conditions and being Consultant-led. ‘There is something very satisfying about bringing something new into the healthcare system of this country. ‘Our feedback from patients shows a very high level of satisfaction.’
‘This is just the beginning and there are many more things that we could do as time progresses. ‘Even immediate transfer home after surgery, or patients requiring ITU set up, could be delivered in the future.
Inevitably, the scheme is not suitable for all types of hospital patient.
So is ORLA’s model simply a fancy bit of innovation or a blueprint for the future of healthcare delivery in the UK?
At the moment it focuses on those needing acute medical care or acute post-operative surgical care.
David concludes: ‘We have to rethink how we deliver care and medical treatment to our population.
Paediatric patients are not covered by it and ORLA does not manage obstetric cases.
‘These demographic changes, particularly in the over 65 years old over the coming decades and advances in medical treatment and advances in technology mean we have to adapt and can do things differently, we can’t keep doing what we did before and try and make it work.
‘But there is nothing to say that future care could not encompass all of those,’ says Jackie.
‘So we have to think outside the box and come up with new ways of delivering services. ‘I believe that much of the work that Simon Stevens (NHS England Chief Executive) has initiated is very much in a response to that. ‘The Royal College of Physicians’ Future Hospital programmes is also very much in keeping with the need to do things differently. ‘Meanwhile, integrated care organisations are looking at how to deliver better services.’
Tweet us your thoughts @arkmagazine
If you’d like to share your story, email arkmagazine@cmemedical.co.uk
IF DISNEY RAN YOUR HOSPITAL AN INTERVIEW WITH FRED LEE
Fred Lee is an American Author who is a nationally recognised expert and consultant in patient relations and service excellence. His book ‘If Disney Ran Your Hospital: 9½ Things You Would Do Differently’ was awarded the 2005 Book of the Year from American College of Healthcare Executives. Here he talks to us about the differences between patient service and patient experience… What is the similarity between hospitals and Disney? I did not see the similarity myself in the beginning. The book that enlightened me was a book by two economists called, The Experience Economy, Where Work is Theater and Every Business a Stage. Their hypothesis is, that we need to add one more economic sector to commodities, goods and services. When we buy a ticket to a theater or a holiday destination, we are not looking for something tangible like commodities, goods or services, but an intrinsic memorable emotional experience or story to tell. They write: “All prior economic offerings (commodities, goods and services) remain at arms-length, outside the buyer, while experiences are inherently personal. They actually occur within any individual who has been engaged on an emotional level. The result? No two people can have the same experience—period.” In other words, commodities, goods and services are extrinsic and temporary, but experiences are by definition intrinsic and leave an emotional imprint on one’s memory that may last a lifetime. That is a world of difference from picking up your dry cleaning or getting the oil changed in your car, or ordering pizza, or dropping by the market to pick up a loaf of bread. Hospitals and Disney are both in the Experience business, not just the Service business. Nobody comes out of a theater and talks about the service they received. They talk about how the experience made them feel. Theater, however, is about all the emotional experiences of human beings from the things that make us laugh to the things that make us cry—the two icons of theater. Tom Hanks was the voice of Woody in Disney’s Toy Story, because Disney is primarily all about comedy. But Tom Hanks also played a person dying of Aids in the 12
movie, Philadelphia, which was a tragedy. Hospitals are on the tragedy end of the experience continuum, not the comedy end.
The great psychiatrist, Harry A. Wilmore, wrote, “The failure to empathise is the basis of most of the unhappy doctor patient relationships.”
So Disney tries to meet the emotional needs of a family to have fun together. Hospitals, on the other hand, are dealing with emotional needs of a family going through, fear, anxiety, pain and loss together. Both are emotional at the core, even though the emotions are vastly different. So I could say: “A hospital without compassion would be like Disney without fun.”
Can you give a few examples of what hospitals can learn from Disney? • Focus on the whole family, not just the patient • Do everything possible to meet people’s emotional needs, not just their physical needs • Make courtesy and compassion more important than efficiency • Use the power of imagination to put yourself in the guest’s shoes. Or, “What must this person be feeling?” • Use the theater metaphor instead service as your guide. Like: “In this scene, what do we want the audience (patient) to see, hear and feel?” • Co-design processes with actual users (patients)
Why is patient perception so important? Surely I do not need to convince anyone in medicine of the importance of the patient’s state of mind in the healing processes of the body. Patient perceptions are the basis of their emotions and state of mind. Ever since biological science discovered, first in animals and then in humans, the profound relationship between emotional distress and disease outcomes, there has been an explosion of clinical studies that prove the negative link between distress, fear, and anxiety, and immune function. Almost every major University Medical Center is now doing their own research in Psychoneuroimmunology, which is the study of the effect of a patent’s state of mind (perceptions) on their immune system. You can easily find studies which show, based on objective physiological markers, that empathetic connection between clinician and patient can affect better outcomes in wound healing, infection fighting, diabetes control, readmission to hospital, hypertension, open heart surgery, complications, and a host of others. Even insurance companies have shown that 72% of all medical malpractice claims could have been prevented by a better doctor patient relationship.
How exactly can hospitals bridge the gap between 'good' and 'great'? We need to define the terms. For me, “good” means meeting universal service expectations like courtesy and respect. But, “great” means exceeding universal service expectations by assessing and responding to a patient’s emotional state of mind, reducing their fear and stress, by listening to their story, empathising with them, and instilling hope and trust with assurance. Can you give a few tools/advice? We cannot operationalize compassion like we can courtesy behaviours, because we cannot script it. It must come from the heart. People don’t need tools for compassion. Clinicians simply need to be persuaded of its importance in the human healing process. What we need are managers who call their staff “caregivers” instead of employees, and explain the WHY
of caring, and talk about its importance every day.
an appointment?” Or, “Were you treated with courtesy and respect?”
After all, the word “patient” comes from the root word “pathos”, which means “one who suffers.” And the word “nurse,” comes from same root as “nurture” which is how we minister to one who suffers. And the word “compassion” means to enter into another person’s pathos with kindness and understanding.
But how do you measure how a person “felt” about the way they were treated during their stay, especially since they may have interacted with 80 or more different people during that time.
It concerns me that we seem to be losing these long held traditional values in medicine - what we once called the “art of medicine” as opposed to just the “science of medicine.” I do not buy the notion that some people have the ability to empathise or be kind, and others do not. It’s a human innate ability. It only needs to be stimulated and inspired every day by great managers. That’s the purpose of my book, which contains at least fifty suggestions and stories designed to inspire more caring from our caregivers. Is it possible to measure patient perception? And if yes: how? The answer is NO. But we can still get feedback. For instance, we can aggregate and quantify the percentage of patients who answered “yes” or “no” to objective questions like, “Did the doctor explain things in words you could understand?” Or, “Did you have to wait more than a week for
W. Edward Deming, the father of TQM (Total Quality Management), Six Sigma, Lean, and PDSA, which are all about what can be measured, wrote in his most influential book, Out of the Crisis. “The most important numbers for management are unknown and unknowable. What is the value, for instance, of the multiplying effect of a happy customer and the opposite effect of an unhappy customer?” So Deming would assert that patient perceptions cannot be objectively measured or quantified. When we use the term “good to great” we are alluding to a book by that name written by Jim Collins. Here is Jim Collins on things that cannot be measured: “Some leaders try to insist, "The only acceptable goals are measurable," but that's actually an undisciplined statement. Lots of goals—(like positive attitude, love, compassion, trust, loyalty, quality of life and motivation)—are worthy but not quantifiable. But you do have to be able to tell if you're making progress.”
I agree. However, if we accept the importance of qualitative information, we can certainly understand patient perceptions through their stories, comments, complaints, and fan mail. I encourage hospital leaders to start their journey to patient engagement by making a list of all the adjectives and adverbs in fan mail from patients. This will provide an accurate qualitative guide to what makes the difference between good and great. My wife, Aura, did this when she was the Chief Nursing Officer at a 300 bed hospital. By far the most common words used by a fan were: caring, cared, cares, compassion, kindness, warm, concerned, comforting, listened, reassuring, tender, loving, etc. I doubt it would be much different in The Netherlands. This is not a new thing. The limitations of objective measurement have given rise to major disciplines like: Narrative Medicine Experience Based Design (NBD) Empathic Design User Co-design Empathy Based Improvement My book belongs on the same shelf as the many books and articles that have been published in these disciplines.
AN APPLE A DAY ‘The patient’s perspective is at the heart of any discussion about integrated care. Achieving integrated care requires those involved with planning and providing services to impose the patient’s perspective as the organising principle of service delivery’ (Shaw et al 2011, after Lloyd and By Rachel McClelland Wait 2005) Over the last seventeen years there has been more technological and scientific advancement than that which occurred since mankind began which, when you think about it, is a staggering amount of progress. I think it’s fair to say that we now have at our fingertips the greatest opportunities with which to control and repair our health, by way of science and the digital revolution. What I find particularly fascinating is the role that technology plays in both proactive and reactive healthcare. At one end of the scale we are a multi demographic community of health conscious technophiles, citing Apple’s Health app and wearable technology like Fitbits among our favourite, and at the other, there are those who have fallen prey to the many internal and external factors that increase the chance of conditions like cancer and heart disease, finding themselves beholden to technology by way of communications, diagnostics and medical devices for treatment. An ageing population and an increase in long term conditions, for example, diabetes, heart failure, pulmonary hypertension, affecting 15 million people at present, have a huge impact on the health system with a need for an extra £5 billion expenditure predicted by 2018, according to a Department of Health report. One thing for certain is that technology will play a key role in our health, from both a preventative and a cure standpoint. Long term conditions in the UK account for 70% of health and social care spending, and one of the NHS’s long standing strategies is cost reduction through the use of technology and an out of hospital care strategy. 14
The aforementioned report also states that the use of technology has reduced: • Death rates by 45% • Visits to Accident and Emergency departments by 15% • Emergency admissions to hospitals by 20% The current UK healthcare system, designed during the post World War 2 era, was set up to focus on the diagnosis and treatment of illness and to, therefore, be reactive. This acute care model is embedded, not only in our healthcare system but within our society. As a child of the seventies, we put our trust in family doctors and I can invariably remember the sense of relief felt by both parents and grandparents after a visit confirmed there was nothing to worry about, usually accompanied by a prescription of sorts but never with an educational briefing as to what we could do to improve our own health. That’s not to cast aspersions in any way, it was simply a part of healthcare’s journey before shifting into a new paradigm. Over the last forty or so years, a new era has emerged. The 1980’s bore witness to a new wave of gurus who brought health and fitness into the mainstream via the popular medium of the day, television. Our family practitioners, nurses and consultants alike became increasingly keen to promote holistic alternatives as opposed to a reliance on treatment, a trend that has risen dramatically in recent years and one that has evolved to new technological mediums. A key area of focus for proactive care is to classify individuals based on four key risk factors that lead directly to over 90% of
chronic disease: 1 Tobacco use 2 Alcohol consumption 3 Physical inactivity 4 Unhealthy eating As seen in the recent Public Health England sugar tax campaigns, the focus is very much about taking control of one’s own destiny, in this instance by diet and the reduction of sugar consumption to prevent future diseases like diabetes. I mean when all said and done, it’s one thing that it will ease pressure on the NHS but let’s face it, the quality of our lives will be improved, not to mention longevity, and that is clearly more important than money to us and our families. So what does the future of healthcare look like? A return to that old adage of ‘an apple a day keeps the doctor away’, which in essence is the very heart of proactive healthcare, seems imminent. Millennials could herald a new era of healthcare; technologically savvy and passionate about personal fulfilment and good health, new generations are already taking responsibility for their own wellbeing. It would appear that those ‘bought in’ to technology will soon revel in virtual reality fitness studios and healthcare programmes, and those who are part of the chronic and acute healthcare systems will see the continued roll out of virtual wards and all manner of high technology devices, such as palliative care and pain management systems, all fully portable and with the capabilities for external monitoring. Meanwhile the likes of Verily, formerly Google Life Sciences, has ambitious
projects lined up such as its glucose detecting contact lens. And let me skip briefly to Big Data, the encouraging link between proactive and reactive healthcare whereby our health records (every minute detail of our physical and mental health) could be stored in one digital location, accessible by anyone who can have a tangible impact on our health, including us! Such a wealth of data could be used to not only develop care plans that suit us most efficiently but, as the holy grail of healthcare transformation and sustainability, will enable analytics algorithms to predict and help prevent sickness. With a combined top down (technological innovations), bottom up (citizens taking responsibility for their own healthcare) approach, and despite the constant political bickering about the NHS, my experience of which has always been first class just to interject, it would appear that the future is extremely bright for healthcare in the UK and, what’s most encouraging, is that we each have the power to play our part in a combined effort to positively influence our future.
The Voice of Healthcare
Our next issue of Ark will focus on Paediatrics. If you would like to contribute please email Rachel at rmcclelland@cmemedical.co.uk If you would like to request hard copies or if you would like to receive future issues of Ark please email arkmagazine@cmemedical.co.uk POWERED BY