Jane Dacre: Views from the front line - how can we improve hospital care?

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Professor Jane Dacre, President of the Royal College of Physicians, responds to our report, Organising care at the NHS front line and discusses the role of clinicians in addressing some of the issues it raises.

This presentation was recorded at our event Views from the front line: how can we improve hospital care? on 3 May 2017.

Transcript

Good morning everybody and thank you very much to The King’s Fund for inviting me. Thank you also to everybody in the room for listening to me.

I want to start by saying how grateful I am for shining the light on this because coming from the Royal College of Physicians we see this every day and one of the huge problems that I see is that physicians are the unsung heroes of the NHS. We’re not anybody’s mandate, we’re not anybody’s target but actually we’re doing a huge amount of the work and some of our fellows and members have actually totted up how much of the work in acute medicine we’re doing and it goes up to 80% because people come in with four hours and there’s a four hour thing that we notice, people don’t get out of hospital because of social care. So what happens in the middle is this enormous bulge of people coming in as emergencies, having nowhere to go, not being moved on to social care and then what that does is that it causes problems for surgery, it causes problems for outpatients because what happens is the whole hospital sludges up and when the hospital is sludging up the people with the problems tend to be medical problems and the people that are looking after them are the physicians and the physicians are occasionally on their knees.

So they are actually the unsung heroes of the NHS with the colleagues that help to look after medical patients. So the physicians, the nurses, the occupational therapists, the physiotherapists, the pharmacy that are all dealing with this huge bulge of patients that are older, patients that are sicker, patients that are more needy, patients that are less able to make decisions for themselves, patients that are less able to care for themselves and have to be lifted and the amount of demoralisation that that causes is absolutely huge and that is compounded by the fact that every Trust that I visit has rota gaps, staff shortages. So the doctors and the nurses are tired.  So not only is their job really difficult but they’re tired, they’re finding it very, very difficult to do that.  So that’s why I’m extraordinarily grateful for an organisation like The King’s Fund saying, “Look at this, look at these people.  You can make a lot policy decisions at very high level but look at these people who are doing the stuff, who are doing the work, they’re in deep trouble,” and that’s a big problem for the NHS.

So what are we doing in the Royal College of Physicians? Well we hugely welcome the report and we’ve done various surveys to say well is this really true what people say? Are we just a bunch of moaning Minnies our physicians?  Are we just like that bloke in Dad’s Army who says we’re all doomed?  I mean every Trust I went to last year it felt as if there was someone from Dad’s Army speaking to me in the one to one.  What are we going to do?  But actually the NHS staff are brilliant and surveys that we’ve done show the degree of the problem that they had.

So 44% of advertised consultant vacancies in the last year have not been filled. The Trusts have found the money, they’ve advertised the jobs, they need the staff and there are not enough trained people to come in and fill in. So they end up with gaps and people acting up and acting down.  A recent survey of RCP members across the UK actually supported one of the report’s findings which is that people are beginning to feel that any further reduction in resource is going to start to affect patient care.  55% of doctors believe that patients’ safety has deteriorated over the last twelve months and over one third cite lower quality care just in their last twelve months.  So the doctors who are working there are worried about it.

We need more doctors. We’ve gone on and on about needing more doctors, we’re going to get more doctors but the number of more doctors we’re going to get is like a drop in the ocean and it’s a drop in the ocean that isn’t going to even start for many years. So we have to do something in the interim.  We’ve got a problem in the interim.

We absolutely welcome STPs, also found it quite amusing when they were called sticky toffee puddings by the BBC, but we recognise from going around the country that one size doesn’t fit all, that if you want to really have change in the NHS front line that change needs to be led by patients working with clinicians to make sure that the change is appropriate and all too often the change is imposed from people at the higher levels in Trusts and it doesn’t have the buy in of the people who going to actually do the things. So patients and clinicians must sit at the heart of any change.

We must be given time, completely agree with the King’s Fund report. We must be given time to do that. You cannot think of how to change the system if you’re too busy replicating what happens in the system by running from one job to another.

IT, oh my goodness! I was an F1 on strike day. In order to get a CQUIN I had to go and ask a patient who was terribly ill, looked as if he was almost breathing his last, whether he had any problems with his memory because we had to get that question in so that we got the CQUIN target and in order to get the CQUIN target we had to get it on to the computer system by 11:00am.  So I had to say, “Do you have any problems with your  memory?” and this chap looked at me as if I was completely bonkers, run back to the doctors’ office and then queue for the computer because everybody had to get their CQUINs in by 11:00am.  Bonkers!  Absolutely bonkers!  Not a good use of my time.  Yes, okay I’m the President of the Royal College of Physicians but not good use of an F1’s time either.  So that sort of thing is mad.

However, at risk of sounding like we are all doomed we must be positive, we must not be part of the problem by allowing our morale to descend into the slough of despond. We have to be positive and we have to recognise that we doctors, nurses, people in the front line have got to be part of the solution because we know which solution s are going to work best for our patients. We must not walk away and say, “You sort it out.”  We must be involved in the solution.

So in the RCP we’ve already mentioned the Future Hospital program. So this was us flagging this up in 2012 with a document called Hospitals on the Edge and doing something about it to make recommendations in 2013 and now working tirelessly to try and implement some of the kinds of recommendations that we have talked about and those have been picked up and there are other programs like New Care Model programs and a lot of people all over the country are working on local positive things that help to sort things out.

One that I would like to flag up is our Chief Registrar program because one of the things that happens when you feel as if you’re a mushroom as a doctor sitting in the corner having dung thrown on you, is that you feel as if you cannot be part of the solution. In order to make trainees part of the solution they need to start to be empowered early on. So our Chief Registrar program is bringing doctors out of clinical practice for two days a week to get them involved in management projects.  We’re getting on to our second swathe now and actually there are a couple of my colleagues from the College of Physicians who are leading this and that’s a really, really positive thing that we’re doing. 

Another is quality improvement where we have set up a quality improvement hub led by John Dean from Blackburn who was one of the people who ran a future hospital program development site. So understands completely about the front line of the NHS. We’ve written documents about what it’s like being a junior doctor and we’ve now done a literature search, a look at the literature from occupational psychology to say well how do you make working lives better and how can we extrapolate that to the medical workforce?  Plugs, sorry, but they’re all on our website if you would like to see them.

We’ve also been working on NHS IT but these things are incredibly difficult problems and if I were to summarise from my examples of recent visits to physicians. So during the course of the year I travel round all of the regions and go and visit all sorts of different kinds of Trusts and to a certain extent they show me the nice shiny bits but I also talk to the people that are there and what I would say about the doctors, about the physicians, is that they are heroes, they are up for change but they need support. There is some local resistance and we need to breakdown the fiefdoms to make sure that we’re all working together and one of the things that would really help with that is adequate resourcing and what that adequate resourcing would do if there was one single thing that I would ask anybody to do it’s to look at sorting out the rota gaps because those are hugely destructive to doctor’s morale.  Then another thing I would say to people is that there are some fantastic examples locally all over the country even in outstanding Trusts and in Trusts that need improvement or in Trusts that are … well we’re not going to talk about those Trusts but some of those Trusts have fantastic doctors and have fantastic innovations that are going on, but roll out of those to other health economies that are slightly different is very difficult and needs focus.

So my final thing what I would like to say is who in the last year has been on the NHS front line? Who has actually worked with patients on the NHS front line? Okay, so a minority.  What I urge the rest of you that haven’t is to do what Chris and Don Berwick did, find a friendly Trust near you and go and visit the acute take and see what it’s like and see what it feels like for those doctors, nurses, physios, OTs that are working under those conditions because it is a real eye opener and final comment, we call it the shop floor, we call it the front line, patient care the nurse/doctor/clinician patient relationship should be the inner sanctum.  We’ve got to get it back to that because that’s what we do, that’s what we’re trained to do and that’s what we do best.

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