Normal or deviant? – culture in the caring professions

I have just been to the Lilly Lecture at the RCP in London, and owing to the fantastic opportunities to discuss the evening with colleagues after the lecture, I failed to ask Don Berwick a question that has been plaguing me.

In a guardian article Prof Berwick is quoted as saying that one of the problems at Mid Staffs was the normalisation of deviance.

My simple question is ‘have you got this the wrong way round?’

I personally feel that the medical tradition I have grown up in has not been one where the norm used to be total concern for the patient at the centre of every activity, but instead the legacy of 500 years of medical tradition where the doctor usually holds all if the cards and deals them to the patient.

I don’t mean to say that doctors are universally uncaring or dissociated from the suffering of their patients – far from it. But I feel our heritage points more to a culture where patients have not always been the centre; but -an increased transparency, patient involvement and empowerment have redressed some of the balance, and instead of a normalisation of deviance, we (society) have developed a new set of expectations against which the old normality fail to satisfy and it’s vestiges continue to fall short – and it us this which now appears as deviance rather than the expected or desired norm.

A moot point perhaps – but if we are to truly address the culture of the caring professions – we must understand where normal sits, and not put the cart before the horse.


Value and Carbon


Value is a concept which is making waves in the management / leadership / policy world of medicine at the moment.  It is not an entirely new concept, but has been worked on and promoted as an approach to the management of healthcare which will unite providers, commissioners, and payers in healthcare economies across the globe.

Michael E Porter has been looking at this area for some time, and has defined value as:

outcomes / $ spent

This deceptively simple equation helpfully focuses the mind on the numerator of outcomes – specifically those important to the patient – and cannot only be improved only by cutting at the denominator.

A recent seminar at City Hall in London (see here for slides from the talks) explored this idea further, highlighting to a number of prominent leaders from the world of medicine how this concept of value unites different actors in the system around the thing which matters – outcomes for patients.

Porter gave six steps in a strategy to realign objectives along the value agenda:

1.  Organise into Integrated Practice Units around patient medical conditions

2. Measure outcomes and cost for every patient

3. Reimburse through bundled prices for care cycles

4. Integrate care across separate facilities

5. Expand areas of excellence across geography

6. Build an enabling Information Technology platform

Of these 6 steps – one of the most complex is probably the costing of care.  This is not simply the tariff, or the invoiced cost,  but the true costs of each care cycle (this may be a short emergency admission, or a year of chronic condition care – depending on how the care is bundled up)

One cost of healthcare which at present is often hidden away, and not really counted in business cases, service proposals etc is the carbon cost of care.  Carbon useage has been estimated for the whole of the NHS (with updates regularly – here is the 2012 update– one of the first healthcare systems in the world to take this important step to understanging the impact of care on the environment.   It is not so simple to find out what the carbon costs of individual episodes or cycles of care – or what the solutions might be.

Understanding this aspect of care cycles is going to be increasingly important with the introduction of league tables of carbon useage (find your organisation on the current table here)  and with the UK having legally binding targets for reducing carbon consumption ( we  have a target to reduce CO2 emissions by 80% from 1990 levels by 2050 – and in the meantime need to get down to 34% of 1990 levels by 2020 – not that far away)

Simple efficiencies are not likely to make huge differences to the overall footprint – but re-examining the way we ‘do’ medicine could – building use makes up 19% of the current footprint, whilst procurement still makes up 65% – and pharmaceuticals making up the lions shar of this.  Frances Mortimer explored this in an opinion piece published in 2010 – and there remains considerable doubt about what could be done.

Respiratory disease is a major burden to the NHS (pdf), and the UK economy – £6.6 billion pounds spent on it in 2006, and around 1 in 5 people dying of respiratory disease (more than ischaemic heart disease for example)  The chronic nature of many respiratory diseases, characterised by periods of stability, punctuated by dramatic episodes of illness make it a complex care model to decipher.  However, the fact that respiratory disease – and in particular COPD can be both prevented, and ameliorated by non-pharmacological means, improved self-managment and better organised care make this area one of huge importance if we are to understand and control the carbon costs of the NHS.

I am pleased to be working with the Centre for Sustainable Healthcare on a project to determine what the carbon costs of different care models are for COPD, and use this to help focus the minds of commissioners when it comes to defining high value treatments and strategies for addressing respiratory disease.

It would be great to have your opinions and ideas about how respiratory care could be made more efficient, or if you think that counting carbon could help to discriminate between care models, and help us to improve not only the quality of respiratory care in the UK, but also enhance the value we can offer patients through smart commissioning.

Please visit the Centre for Sustainable Healthcare and sign up to the networks they have there to get the latest news and resources to inform your practice, and see how you can help to improve the services we offer – in terms of value, quality and carbon.

March 2011 – Plus ca change…

This was something I originally posted on March 21 2011 on another blog which has since morphed into something else… but I think it still outlines what I think is important to salvage from the NHS Reforms (if they go ahead) or indeed whatever happens in their stead.

Recently the BMA representatives had a knees up in London where they debated long and hard about the NHS Proposed Reforms.  I was following on  Twitter

As I was following the (often predictable) passing of motions (no pun intended) on the live feeds, I was left with the feeling that perhaps this is too little too late – if the medical profession truly wanted to oppose these reforms outright, this should have been done well in advance of the first reading of the Bill in Parliament (see here for the Bill’s progress to date)  I honestly feel that the PCTs and SHAs have had so many of their staff leave that they are unlikely to be able to function as effectively as they had done up until the time that the reforms were  first publicized.

So what to do now?  I am not a politician, but passionately believe that politics matters to me and my patients – the current reforms show that more clearly than ever.  I don’t think that the BMA passing comment is going to radically alter the reforms, and if it does – how much real good can it do now – the horse seems to have bolted.

I feel that the way forwards now is to ensure that, whatever proportion of the reforms makes it through parliament, we as the medical profession sort out three things no matter what:

1.     Secondary care doctors must look to their local community.  It is naïve to think that a hospital only serves those patients that happen to be in the clinic, or on the wards.  Hospitals, if they wish to truly serve the public, which funds them, must look outside their walls, to the community.  We cannot sit on the inside of ivory towers complaining about the standard of care given in the community for patients with our particular illness, and do little or nothing to change that care.  This is “population medicine” – concern for the wider population, not just the referred population.  With limited resources, we need to be sure that specialists are seeing specialist cases, not just whoever happens to turn up.  Only through collaboration in networks or systems of care will we achieve this.

2.  Primary care physicians need to look to each other.  The unwarranted variation in the standard of care between primary care practices is no longer acceptable.  GPs, acting in networks across a community, and in collaboration with specialists should strive to bring up the standards of care across their patch.  Under-performance should not be tolerated, and clinical leadership, with solid clinical support, is essential to provide the credibility to enforce high clinical standards within a local health community. (This applies to the secondary care community too by the way)

3. Primary care physicians need to look to their patients.  When patients come into the surgery looking for treatments that are of no benefit, or are not likely to lead to resolution of an illness or symptoms, GPs must be able to have rational discussions about the risks and benefits of treatment.  Shared decision making processes can help with this (Implementing shared decision making in the NHS — Elwyn et al. 341 …) and result in better-informed patients making better informed choices.  PROMS are an excellent way to make a start on this, and bring home the realities of life and illness to patients.  We have an NHS, we are very lucky – it can’t and won’t be able to provide everything, and you may not need a treatment, just because there was a report once saying it might help you.  Primary care physicians and teams really are the gatekeepers; we should not use a rationing mindset when discussing treatment with patients, but be highlighting the true intangible costs (physical and emotional) associated with some treatments where the benefits are marginal.

Something of the Spainish Inquisition came over me whilst writing – sorry…

4. We all need to look to what patients want.  When it comes to service re-design, we often look for examples of what works in one area, and think – this is what I must do for my clinics.  Involving patients in the work of service design can achieve surprising results.  I have mentioned examples in previous blogs where patient involvement blew apart assumptions of physicians, and service providers about what patients really wanted from a service.    Only by understanding what patients truly want to see in a system, and then making strides towards that, will we start to see “appropriate” use of services.

So, what should we do in light of the SRM outcomes.  Yes, we should push to amend the parts of the bill which threaten the ability of doctors to serve their patients well, but in accepting that we may not get our way (Mr Lansley is not known for giving in lightly) we must start to take a different, pro-active attitude to getting the NHS, our NHS, our patients NHS back on track.  I believe that if we can concentrate on some of the steps above, we have a chance to make the best of a bad job.

So that was what I thought then – and it seems that so much has changes, but also so little has that I can re-post this without any significant editing.


There is a phrase which goes around the wards and departments of many NHS hospitals:

Inappropriate attendance

This is most often used when talking about patients who pitch up to A+E with conditions which could usually be managed elsewhere.  These are the patients who are thought to cost the NHS a lot of money and are the target of various schemes to stream them to more appropriate settings.

So what are these ‘inappropriate attendances’?

I am very lucky to have benefited from a great education, am lucky enough to work in a pretty comprehensive health service, and because of my day job, have become pretty adept at navigating it, and getting help where and when I need it.

However, imagine if you haven’t had that benefit, and don’t know what a drop-in centre staffed by nurse practitioners can offer, or that you can get good advice over the phone from a GP out of hours, or that a pharmacist at the local chemists could deal with your ailment?  Well, what would you do then?

The decisions patients make about where to go for help are not simply random and unthinking, but they are made when patients are distressed, and searching for answers, and quickly at that.

The NHS is very good at taking a problem and designing a solution to it which works perfectly in a committee room, on paper and in a consultation document.  However, as Helmuth von Moltke the Elder once said, “no plan survives contact with the enemy”.  Similarly, no treatment pathway, referral criteria, single point of access or similar will survive in its original form, and the consequences are very often unintended rather than those set out by their architects.

Once we have set out a plan though, we often don’t recognise that patients (including ourselves) will follow the path of least resistance, and seek help where they will get it.  So if one sets up a system where the most efficient way to get a diagnosis for a funny rash “which isn’t a huge problem, but I don’t really want to take a day off work for it” is to go to A+E, then go to A+E the patients will.

We must recall also that “every system is designed perfectly to achieve the results it yields” (Paul Batalden)  In this case, we must recognise that we cannot force people to make choices which fit with our ideal, but instead that they will make choices which seem to them to make the most sense, and offer them the help the want as quickly as possible.

To change the way in which patients behave we must either match their behaviour (put urgent care centres staffed by GPs in A+E departments and hive off those we think are “inappropriate for A+E” to the GPs next door, or we must improve the alternative offer – and improve community services, awareness of community services such that they can compete with the A+E service to offer reassurance, diagnosis and therapy for those patients who seek it outwith office hours – however the promise of swift treatment and diagnosis at a hospital may prove too much – and the draw of A+E too strong 

There are positive points on both sides of the fence on this one, but one thing is clear – there really are very few cases where an attendance at A+E is “inappropriate”:

It may be that the patient didn’t want to wait and was playing the system – but then the system may be inappropriate, or it might just be that the patient was anxious, tired, scared and wanted some help. Equally, the patient might be lacking the skills and knowledge to manage and requires some additional information on how to navigate the complex health economies we have generated.

And I seem to remember that that falls fairly squarely into the lap of the caring profession of which I am proud to be a member.  It does not become us to castigate our patients for their lack of understanding or anxiety.

Failure – it is the only option

At a recent conference, a poster was published in abstract form showing a negative result.

This was not a ground-breaking moment which will be held up in years to come as an example of how to advance scientific progress, or, indeed as a shining example of a service re-organisation which led to widescale sustainable change across the UK.

As it turned out, when it came to the time for the authors to describe and expand on their work, they didn’t turn up.  There was no representative of the team to explain what they had tried to achieve with the scheme, what factors had made it less successful than they had hoped, and how they might approach it again, if they really did feel it was still a good idea.

I think it is a real shame that, having submitted an abstract, the authors were unable to attend, or send a representative.

What was a greater shame was the way in which the paper was described by the chair of the meeting.  I can’t remember the exact words, but they went along the lines of:

“Well here is another one of those pie in the sky schemes, which someone spends a whole load of money on and then it folds within a year – like so many of us have been involved in”

This was greeted by a ripple of knowing chuckles in the room.

Fair enough – the idea fell flat, it cost money, and didn’t really produce any improvments.


And that is a big but; there is in that statement, an subsequent laughter a failure more significant than that highlighted in the study.

It is the failure of the medical profession to tolerate less than perfect resuts, it is the reinforcing of a professional culture where teams are not allowed to help the world out by sharing lessons of a plan gone wrong, it is the failure of our wider culture to understand that one cannot propose the perfect answer first time, and it is the collective failure of the people in that room – me included – to say “hang on – lets look at this another way”

Instead of the statement above – why not:

“Well here is a record of an innovative scheme which sadly wasn’t successful, and highlights how even a well-resourced, committed group can discover that some ideas won’t make a huge difference – it would be great if the team could let us all know what they came up against so that we don’t all have to go through the same challenges and problems that they did.

Failure is the only option.  This talk by Tim Harford highlights the importance of failing as a route to ultimate success.

or view it here

Moreover, this editorial highlights that iterative change is what is required to advance the frontiers of the practice of medicine – and advocates the use of the SQUIRE guidelines to really explore what went right and wrong in studies – particularly those looking at changes in practice, or service innovations.  There are simpler versions of tools to write projects up too – like the one on The Network

So – I would encourage you when next looking at an attempt to improve a service or change practice which ‘failed’ not to dismiss it as another one to chalk up to experience, but instead as a rich opportunity to learn why the people involved came up against problems.  If as a profession we will only accept the finished article, and learn nothing of how the changes occur, we are doomed to repeat the failures of the past.

I applaud the authors of the poster for having the guts to publish the news that not all ideas work, but would have been bowled over if that committment went as far as explaining it to others working in the same field.

Uncertainty – and the NHS reforms

This is a blog I originally posted in June on The Network, but I thought that it was still relevant, so I would post it here too…

What are the three most significant words a doctor can use? When it comes to three word phrases, there are a few which stand out. Classics include “I love you” “I am Spartacus!” and “Run, Forrest, Run!”

There are seldom reasonable times or places in medicine to utilise these particular phrases, but there is another which is possibly under-utlised at all levels of the medical profession. “I don’t know”

When we enter medical school, we enter a new world and a new way of thinking. Over time we are moulded to a greater or lesser extent into a recognisable form of doctor. In the first few years this is the classical junior doctor – pale chinos, blue shirt, looking tired, bleep going off constantly, always slightly harassed. We move on, and acquire the trappings of authority – suit, real leather shoes, Mont-Blanc pen, more letters after the name. But one thing remains constant. We are expected to hold the answers. When seeing a patient for the first time as an FY1, we are often asked on the post-take round – “…and what’s the diagnosis?” As a registrar in clinic – “so what is it Doc?” As the consultant in the Grand Round / M+M meeting – “So, Dr/Mr …. What would you have done?” The whole of medical science it sometimes seems is about obtaining that final, all encompassing diagnosis of which Occam himself would have been proud.

However, as we know for ourselves, and have seen on the larger scale recently – we do not always know the answer. What then, are we supposed to do?

I would argue that we should not collude with the questioner, we should not give false reassurances, or misleading hope, but instead admit our uncertainty, and then set out a vision of how we are going to go about tackling the problem at hand, keeping to a guiding set of principles.
This is what we are facing at the moment in the NHS – a period of unequalled change, and challenge at a time when the economy is fragile, and there are perceived threats to the very fabric of the NHS.

In this context, it is only right to admit that we don’t hold all of the answers, but we are going to work very hard to understand where we are, and adhering to some fundamental principles, work our way towards a solution. Thinking about this, I am reminded of Shackleton, and his words after he lost ‘Endurance’:

“But although we have been compelled to abandon the ship,… we are alive and well and we have stores and equipment for the task ahead of us. The task is to reach land with all the members of the Expedition.”

As we navigate the health reforms, and continue to provide services to patients, we need to be aware that sometimes the most useful answer is “I don’t know… but” and that ‘but’ must include the principles of patient-centred, fair, effective and safe care. For if we keep those principles in mind, at every level of this fantastic organisation, we are more likely to succeed than if shaky answers are given, and false hopes raised.