Sustainable Healthcare – an impossible challenge?

Sustainability is a huge topic, and is going to be in the headlines more and more as this century progresses.

There are many facets to the subject, and some are controversial. However, manmade global warming is pretty much accepted as happening by the scientific community, and government policies are being formulated with climate change mitigation and adaptation in mind. Indeed there is even a bit of a land and water grab going on around the world as economies start to realise the growing importance of food and water security.

And what does all this mean for health? And in particular health in the uk?

I was at a meeting this week which was looking at how the NHS in London could plan for the future and how it could build on the good work that has already been done in the capital.

I was asked to give my perspective on how clinicians view climate change, and what impact it has on their day to day practice. Well, for out I think that consideration of the impact of clinical activity on the carbon footprint of a Trust is a non-thought. There are relatively few doctors who have thought about how clinical activity translates into carbon emissions.

There are some, and their numbers are growing… The green nephrology network has done great work to raise awareness of the environmental impact of treatment, especially dialysis and has success stories of how units have made carbon, water and financial savings through innovation in clinical practice.

So why don’t all clinicians take note? I think that we are often too busy in clinical practice to take notice of the wider impacts of the work we do, but in an era where a new model of professionalism which takes into account the value of the treatments we are offering has been proposed, clinicians need to become more aware of the implications of the choices of treatment they make with patients when confronting a disease.

In London, resources have been made available to physicians working with smokers with respiratory disease which highlight the value of different interventions – an approach which will become more common as resources become ever more scarce.

In contrast to this slow uptake of so-called ‘green’ behaviour at work, most people now recycle at least part of their household waste, increasing numbers are seeing the sense in ensuring their homes are well insulated, and with smart meters in the home, energy consumption and preservation is part of the conversation of life outside of work.

What is the disconnect then? Why do people shift from one mindset to another when going to work. There are a wide range of reasons, and each person will have their own.

Moral offset could be a major one – that is, “I work for the NHS, often put in overtime, am constantly caring and giving of myself – climate change and being green is just one step too far”

Another is as I mentioned before, the wider implications of the models of care we use are often not examined, and time at work does not often allow for such theorising.

It is also that sustainability might just be too big a thing for any one team or individual to concentrate on. However, when you list the things that make up a number of quality improvement projects and schemes…

Avoiding hospital admissions for chronic diseases through self management
Reducing hospital stays by using more local and regional anaesthetic techniques
Improving exercise tolerance through community based physio courses
Reducing expenditure on waste in hospital theatres
Reducing outpatient appointments through better use of technology
Improving long term condition management through telemedicine
Improving the prescribing of oxygen, both long term and for inpatients
Saving money through better sourcing of hospital food

…then it is possible to see that a great many of these have direct links to the sustainability movement, and yet all of the above are not seen as dubious on grounds of being a ‘fad’ or ‘green’. Instead they mark innovations in clinical care which are often welcomed by clinician and patient alike.

So what is my take home message from the day? Well, strangely, it is that aiming for a greener future may not be the best way to engage NHS workers in the sustainability agenda. Instead, let’s get better at the day job, but bring in some other factors to the thinking… When a service is being redesigned, or a pathway being developed, use the best evidence to inform the process, but we must start to become better stewards of the limited resources of the health service.

Of course it is right that there is an overall strategy towards sustainable working in the NHS, but on a local, team and service level, we might need to aim for a slightly different outcome to make these targets tangible and relevant. We need to start to think more about value ( Outcome / £ spent ) and include some thinking about the wider cost implications of our service designs. Through concentrating on the efficient use of resources, we will be able to not only make care better for patients, but also save money, and reduce our impact on the world around us.

If you are interested in this subject area, please take a look at these resources, in the next few years they will become more and more important

If you are a respiratory clinician then take a look at this advert, a fantastic opportunity to explore this area in more detail with some fantastic people.


Incident reporting: a necessary evil?

I did something out of the ordinary today. I filled in two incident forms.

This may not seem groundbreaking to some of you. Perhaps you are the sort of person who regularly fills out incident forms and sends them off to the risk manager. Or maybe you are of the type who assumes that incident forms make no difference at all, and are not worth the paper they are written on?

Well, I am some way between the two… I appreciate that it is important to report near misses and failings to ‘the system’ so that data can be collected, collated, patterns noted, and steps taken to reduce systematic failings. However, I am also busy, and filling in incident forms when they seem to have a negligible impact feels like a waste of time, and the forms themselves seem to have little to commend them, not least because of the details required: (junior doctors do not often know which department they work for… This is not a joke, the groupings of specialities in different trusts is so random as to make keeping up with who you work for a pointless task)

So, what prompted the strange enthusiasm for incident forms?

Strangely, one I think was probably not a appropriate use of an incident form, and the other was absolutely required. What I found most interesting was that the form I thought least worth produced the greatest result, and the other remains stuck in the cogs of the risk management system.

I went to work quite early this morning, and reviewed a couple of patients. On one ward I saw some staff behaving dreadfully in front of some vulnerable patients. This wasn’t putting the patients in danger, or at risk, and did not affect the course of their illness. However, I thought the behaviour was not becoming of health professionals, and said so, to those involved, and to the nurse in charge of the ward. Later in the day I was requested to fill in an incident form as the ward Sister was incandescent that this could be going on on her ward. Given how seriously my complaint was being taken, I couldn’t really do anything except oblige, and record my concerns officially.

In contrast, the other report was about a serious clinical failing. I learned throughout the day that this incident had already been reported, but 4 weeks down the line, despite being one of the key players in the incident, I had not been contacted for my version of events.

So, the clinically less relevant incident yielded an almost instantaneous response, with immediate input from the leader of the clinical team, whereas the more important (in my view) in incident has progressed very little since it was submitted.

I suppose there are a couple of lessons for me here:

Challenge inappropriate behaviour.

It is not breaking some sort of moral code, but in fact is vitally important to challenge bad behaviour when we see it, and contrary to what one might think, you are likely to be supported if your stance is a justified and balanced one.

2. Incident reporting needs to be, and seen to be more responsive.

If clinicians are going to be involved in incident reporting in any meaningful way, it is vital that their concerns are listened to.

Consumer and service industries have learned that silence in response to trouble is not effective (see how Blackberry scored a massive own goal with a media silence when their servers went down earlier this year. ) and does not lead to satisfied users.

The immediate feedback, and promise of effective action as a result of my actions earlier today encouraged me that there can be real value in incident forms. Sadly the second experience still leaves me wondering of I should bother again in the future.

NHS organisations need to learn. The only way they can learn is through knowledge about what is really going on on the ground. If incident reporting is to be a useful tool, I then there needs to be less of the low level complaining. ( I think my first form today could have been dealt with at a ward level, with no recourse to the official system)

Instead, a far greater, urgent and powerful response to incidents which really do reflect significant systematic, or individual failings should be evident, and preferably the lessons learned publicised.

At the moment, there is sadly little incentive for the eyes and ears of the system ( the juniors ) to report incidents. Until it feels like it does some good, I suspect that they won’t want to spend time on this key responsibility, to the detriment of the system as a whole, and ultimately to he detriment of patient safety.

Language – a double edged sword

Doctors are like a number of other professions in that they have a specialized language which helps them to communicate all sorts of complex information to each other, and helps them to be precise in what they are describing to one another.

The process of learning this language can be confusing.

Recently some medical students were asking what was meant by the term ‘pulmonary congestion’ and how this was different to ‘alveolar oedema’ or ‘pulmonary oedema’ or ‘interstitiial oedema’ or   I struggled to provide a decent explanation for each of the terms other than that they were basically all the same thing.

We then discussed how you might go on to explain such a process to a patient – out came a reliable phrase: ‘fluid on the lungs.’  The conversation continued, and we started to discuss how you might explain a pleural effusion to a patient…  And again – “fluid on the lungs”

So there, we go – doctors have managed to reduce two incredibly different and distinct processes which require entirely different treatment modalities, and hold very different implications to a single ‘simple’ phrase to communicate these things to patients.

The common term for describing technical language is ‘jargon’ – defined as language or terms which are  ‘not likely to be easily understood by persons outside the profession

If we look at how this affects doctors and patients – we can see from a few studies, and from experience that using jargon can reduce patient understanding in consultations – this review highlights some of the points about patient-doctor communication which would be sensible to keep in mind when talking to patients and this consensus statement offers a framework for key elements of communication in medical encounters.

There is less guidance for what phrases we should use to describe pathological processes to patients – and so a vocabulary has arisen which is in common usage but seems to be oversimplified and hence confusing to patients and students alike.

So what is the solution?  Well jargon – as well as being a tool of exclusion to keep students on their toes, can also be useful.  It is sometimes helpful to be able to discuss elements of a case with colleagues using a ‘code’ instead of graphic detail – and this is done all the time in front of patients, and in corridors.  Jargon, therefore can be useful – if it is justified is more contentious.

However, when explaining things to patients, I really think that we don’t have to oversimplify things – using diagrams, simple language and examples from other areas of everyday experience it is possible to communicate quite complex processes to patients.  If we do not take the time, and instead use phrases which are so simple as to be opaque, we are at risk of misleading patients, causing confusion and therefore reducing their chances of understanding their disease.

Higher rates of health literacy and effective education have been associated with better outcomes in some areas but in others, may have contributed to non-adherence following discharge from hospital (possibly a good thing – health outcomes weren’t measures in this study- but prescription inaccuracy was quite high!)

Ultimately, jargon is here to stay.  For those interested in the NHS, and respiratory medicine in general there is a fantastic glossary published and kept up to date by IMPRESS.

Without being aware of how we are using language at work – either through excessive complexity, or inaccurate simplification – we are at risk of excluding patients, colleagues and students from the conversation, at the very points where they should be integral to it.

Power and persuasion…

During the course of most shifts, it is possible to find a clinical situation that requires input from other teams, from individuals with greater specialist expertise than yourself, or who have special skills which you would like to access.  This is a feature of modern medicine, and working in distributed teams is an essential skill to acquire.

Recently I have come to notice though, that the facts of a case are often not enough to achieve the results that  are needed.

For example, a patient really needs the input of a specialist team.  The facts of the case are clear – and available to anyone with access to the notes, the results on the computer system, and the PACS system. BUT, when a house officer, or and SHO calls the registrar of the specialist team, the referral is refused / batted / turfed / delayed.  For some reason there is something within the history which is so significant that the specialist feels other differentials are more likely, or the case is not as severe as presented, or not as urgent as implied by the junior.

However, if the same information is conveyed by a registrar, very often the case is taken by the receiving specialist team, but even then there can be a significant proportion refused or delayed.

When a consultant makes the same referral, often less information is conveyed, but the action requested initially is often carried out, without question, and without quibble.

So, if the facts of the case remain the same, what is it about the delivery of each above which changes the outcome?

Clearly presentation of the relevant information  – there is a whole industry going on in hospital to get patients accepted by teams – the old “buff and turf” of the House of God – but also in reality – see here

But is that all it is, a more skilled salesperson?

Clearly not – hierarchies are involved here – especially hierarchies of power.  Consultants have almost ultimate power owing to their stature within the hierarchy – they are perceived to have a high level of  coercive, legitimate, expert and  referent power.

Registrar grade doctors probably hold a degree of expert power, and referent power, whereas the SHO and FY1 have little power of any kind, unless, by happy chance they previously worked with the person receiving the referral, conferring some referent power.  (French and Raven proposed this taxonomy of power)

Is this right, and correct as system of referral and obtaining specialist input?  I have a mixed view on this – it is helpful when receiving referrals to have the story explained by someone with enough expertise as to make the argument for my involvement compelling, and the most frustrating referral is simply a stream of information with no focus, and no request – just an expectation of input, but I try to take each case on its merits – and try to be blinded to the grade of the referrer. So yes, I pay attention to expertise – and clearly it is advisable to ensure that those who control your working conditions don’t get too hacked off with you!

I’m not sure how well this serves me, as I am probably seen as a bit of a ‘soft touch’ – but I do believe that if a team needs specialist help – it benefits the patient more to have a swift, easy answer, rather than a frustrated team looking after them who are probably beyond their level of comfort and expertise, and are therefore more likely to make poor decisions, or misguided interventions.

So when you are next called by a house officer or nurse – don’t just use the power differential to rubbish what they are saying, but take the facts on their merit – the messenger might misrepresent the facts of the case, but the facts will remain – and on the end of them will be a patient that is likely to benefit from a specialist opinion, even if it is a clear and justified rationale for why specialist procedures, treatments or interventions are not required.

And if you take the time to educate, you may not save yourself some time, but you will be raising the floor of the knowledge of the health service – and that can be just as important as getting off the phone to do whatever it was you were engrossed in.

Rippling conversations

Ripples - try to make them positive

There is a school of thought that looks upon the culture of an organisation as the sum total of the conversations taking place within it.

(this is an interesting blog with application to patient safety)

This seems fairly abstract when you first hear it – and it is possible to dismiss it easily as some sort of sociology psych-babble.  However, I would recommend that you give it a chance.

In the past few weeks I have been on call – taking referrals from GPs, other teams, and the Accident and Emergency department – and attending emergencies for inpatients.  This has led to a LOT of conversations.

I made a conscious decision at the start of this set of shifts that I would take a positive, engaging approach to each of the interactions I had with others.  Wow – what a surprise, someone willing to be positive at work. (Believe me, it seems far easier sometimes just to play to type and be the grumpy medical registrar)

So how did I do this – well, taking the advice of my mate Riaz (who has an excellent blog HERE and HERE   by the way) and starting to expect to be on first name terms with everyone I converse with.  This met with mixed success – and some consternation from the A+E nurse who was confronted with “No – I am not “Medics” – I am Toby, and I happen to be the medical registrar on call” but by the end of the first few shifts, I was on great terms with the A+E Sisters and Charge Nurses, most of the A+E SHOs and a large number of the site managers etc.

My experience of being on call, as a result of this charm offensive was far more pleasant, involved far more positive conversations, and I believe that this showed through in the attitude from my team, in the experiences my patients had, and, I hope will show through the outcomes for the patients I helped to manage.

One case in particular was a highlight.  An elderly patient had come in with a suspected DVT, and this was confirmed.  The A+E SHO referred the patient to be admitted as there was concern about the patient being formally anticoagulated (standard therapy) as an outpatient.  As a consequence of my previous interactions with the SHO, I was able to coordinate a ring-around of the various specialists who might need to manage this patient, and then with a final phone call from me, managed to get the patient home, and treated in their own, familiar environment with safety nets in place to make sure that any side effects were detected and managed swiftly.

I believe that if, earlier in the block of shifts I had taken to shouting, berating and generally being abrasive to my A+E colleagues, this patient would have been admitted for several days, and owing to their mental state, may well have suffered with delerium, acquired a health-care associated infection,  and generally would have been the poorer for it.

So – being nice to people helps to grease the cogs, and can help out occasionally. So what?

Well, having been taking note of the conversations I had throughout this time on call, I think that the vibe generated from the positive interactions I was having actually spread beyond my team, and I can easily see that if sufficient numbers of people in an organisation are having positive conversations – the culture of that company / hospital / institution will change for the better .

Indeed, such an intervention was studied at Indiana Medical School – and the resulting report makes for fascinating reading.

So next time you are on call, or even next time you are at work – pay attention to the conversations you are having – like a stone thrown into a pond, they will have ripples.  Make those ripples positive and who knows what benefits lie ahead…



In the lift today I overheard a really positive conversation between a few senior matrons and service managers – although I did not know what on earth they were talking about – it felt positive to be in a place where those with senior roles were excited about their jobs, and enthusiastic enough to be chatting about a meeting in the lift!

Maslow On Call – an inverted pyramid?

It may seem that the medical registrar on call is floating around serenely on a cloud of medical knowledge, ready to dispense advice left right and centre, and all the while coordinating the take so that the consultant knows where each patient he or she is responsible for, and what the plan, progress and prognosis is for each, all whilst maintaing their composure so that they appear unruffled, stress free and in control.

Well it may seem that way, and I am sure, for some that it really is like that. But, for mere mortals like myself, it is hard work. Sometimes really hard. Managing multiple patients at arms length, ensuring that the sickest get the right amount of attention but that those who have the potential to become sick are not allowed to deteriorate, and to ensure that those who are beyond cure are offered as much dignity and comfort as we can muster. Oh, and trying to keep the medical students entertained, the juniors educated, and the seniors informed. Yeah – there is lots going on.

What I have noticed recently is that my cognitive abilities, and the quality of the information I am able to convey about cases, and the acuity of my decision making seem to deteriorate significantly if I have not eaten, drunk or rested at all in the 13 hour shift. There are a few studies looking at the basic human functions which are monitored in patients – but in ‘normal’ controls of the staff looking after them – and the results are not exactly encouraging. A number of the junior medical staff on call at any one time could be classed to be ill by standard indices used to monitor their patients.

Maslow proposed a hierarchy of human needs in 1943. This is often represented as a pyramid, with the ‘basic needs’ of food, water, shelter, sleep and excretion at the bottom, and levels encompassing safety, love or belonging, esteem and finally self-actualisation. The self-actualisation strata contains ‘problem-solving’ ‘morality’ ‘creativity’ ‘lack of predjudice’.

The experience of junior doctors on call (and a number of other professions in the hospital) often includes a denial of the basic needs in an attempt to keep up with the demands of the job. This is in spite of the fact that to really perform at the best of their abilities, they should probably be satisfying all of the lower stratas of the pyramid to reach the higher functions of problem solving and creativity. Perhaps an inverted pyramid more accurately describes the priority given to each layer of the pyramid by on call staff.

It is not clear that doctors are ever going to adopt working patterns which allow them to always have water on tap, food available and time and space but it is important that we keep in mind the pre-conditions for high performance. Next time you see a doctor at work who is looking more like a patient than the person they are trying to clerk in, remind them that they owe it to their next patient to ensure that they are at least hydrated and fed – it really should not be an option when you consider the impact that they will be having on a person in need (or patient as we tend to like to call them)

Play nicely – or you’ll drop the ball


When working in a complex organisation, especially one which is split up into different teams dealing with an overlapping number of projects, it is important to understand the rules of engagement.  This is even more so in healthcare, where conflicts over responsibility and disagreements about the roles of others can lead to significant harm for patients.

I have been on call quite a lot recently, and it has been both a wonder to behold teams coming together to solve massively complex cases in the best possible way, but also a huge disappointment to see squabbling, ping-pong, and downright obstructive behaviour have a negative impact on the experience, care and potentially (although I cannot claim to have seen this) outcomes.

The complexities of modern medicine mean that no one team or person can really be able to treat each and every patient that comes to the hospital to the highest standard, and where specialist skills are required 24/7 (to provide acute diagnostic and interventional procedures for example) it is seemingly obvious that specialist teams will be on call to provide such a service.

Recently there have been times when it has not been clear where a patient would be best cared for, or who should be providing that care.  It is at times like these that stretched teams all over the hospital can become more stretched, and tempers can flare.  I have been guilty of venting frustration at the system on occasion, and this week I have been able to look back and realize one of the key elements to the frustration:

Teams not seeming to play by the same rules…

If a football team gets on the pitch with a rugby team, and each team tries to play by their own rules – chaos would ensue.  That much is obvious, and the division of work within the medical take is not quite so obviously different as rugby and football.  It is slightly more like when two strangers play each other at squash, and may not have agreed beforehand what would constitute a let, or fully understood what each others house rules are.

For the majority of the time, they will play nicely, but, when the stakes are high, and they have invested considerable effort in winning a point and their opponent calls a let – then conflict can arise, and the game can descend into farce.

Caring for patients is not a competitive sport, but for those who care about their patients, care that they get what is required, and care that they get the best standard of care for their particular problem – the emotion invested can be of a similar order.

So what, I hear you cry – why should I be bothered if you get upset by the way some teams seem to be Teflon when it comes to admitting patients, but you have to take them all?  Well, it is not me that I am particularly worried about – I can always go home at the end of the shift, and ultimately I will be ok when the dust settles.

But in these days of increasing specialisation, and centralisation of services, we need to be sure that we do not construct a system that works perfectly for those patients that fit into diagnostic boxes nicely, but resolutely fails to address the needs of those who fall between the specialty lines.

We must remember that the focus of care should be the patient – not just the diagnosis, not just the disease, and especially not just the procedure required to sort them out.