Michael Wise, patient, author and former specialist in oral surgery and restorative dentistry, gives his perspective as a patient on our report, Organising care at the NHS front line.
This presentation was recorded at our event Views from the front line: how can we improve hospital care? on 3 May 2017.
So good morning everybody. My history: 2009 I was very fit, well, healthy suddenly contracted sepsis which went to toxic shock, coma, ICU, multi organ failure, lost my kidneys permanently, dialysis, live donor transplant, rehabilitation, several episodes of acute admissions. So I am extremely grateful to be here today in more sense than one. So thank you for inviting me, and I’m also incredibly grateful to the NHS for the care that it has given to me.
However, over the last eight years, and I’m only talking about acute admissions, I have noticed a decline in the number of nurses sometimes on the wards which makes it difficult for patients let alone for the nurses, also it seems that senior nurses are spending more time answering to the powers above than organising their teams on the shop floor and because of the pressures of work as patients sometimes you get the feeling that the front line staff have lost compassion because they don’t have the time to sit or stand and talk and really feel what the patient is feeling and a big part of the healing process is the talking and the feeling of being cared for and that can get lost. So I think sometimes it’s because people genuinely aren’t compassionate and sometimes it’s because of the pressures of work and commensurate with that you get the feeling that people have lost the perspective of the environment in which they are working, they become desensitised to it and forget what it’s like to be a patient in this scary, different environment.
So I think it’s really important that all front line staff have roleplay exercises to do with feedback and I’m talking about from the porters, tea people, receptionists through to consultants. Must not assume that everybody knows how to relate to patients.
In the report there is suggestions about the need for teamwork and another observation has been that when agency staff, nurses in particular, are involved they often don’t understand the special needs of some patients. An example from myself as a transplant patient, so in hospital, acutely ill, high temperature, fever they just didn’t understand the need to keep fluids. If I would ask for water it didn’t come, they weren’t measuring my fluid outputs, urine bottles surrounding me and so I find it very difficult to understand how teams can be properly developed. In dentistry I’ve always talked about teams having to dance together, when you dance you know what your other partner is going to do you don’t have to talk to them, you don’t tread on their toes and if you’re going to develop teams like that you need people who are part of the team and committed to the team and that brings major, major advantages. There’s another problem and that is that many times the senior members of the team are not able to pick their team members anymore and that creates I think very, very big problems. So definitely teams need to be developed but it’s not quite so straightforward in the present circumstances.
Also together with this not having time to spend with patients there is the not having the time or will to listen to patients. Patients often know when something isn’t right far earlier than the clinician and they need to be listened to and if they’re not listened to then it breaks down trust and trust is an enormous part of healing. If you lose trust in your carers you’re in a very, very unpleasant place.
I’ve seen in dentistry that as treatment becomes more complex for patients more specialists are called in so the risk of the bystander effect occurs. Each person thinks somebody else is doing something and therefore it doesn’t get done and there is a real danger of that I think in acute medicine. There needs to be a holistic approach by somebody who is in ultimate control of what is happening and I have been at the receiving end of that myself, and you can see it as a patient it all seems a bit haphazard, everybody is doing their bit properly but it’s not actually joined up. Perhaps there is a real need for basic clinical checklists as there are in operating theatres which have been shown to reduce preventable harm and maybe there’s a need for that in acute medicine.
It’s very obvious that junior doctors spend an awful lot of time behind computers I’m not sure why, nurses’ changeover seem to take an inordinate amount of time. Surely in the digital age that could be streamlined. Frequently patients aren’t in the right place at the right time. It happened to me, a bed is moved and everybody is chasing around trying to find the patient. I’ve seen it with other patients in the wards next to me. I can find my iPhone if I lose it by looking on my iPad I can’t see why beds can’t have transmitters on them to have a central pattern of where patients are.
Multiple recounting of histories. I can’t tell you how many times I've recounted the same history it’s quite wearing and what a waste of time for the clinicians. So there must be something that can be done about that and at the Royal Free in the renal department with acute kidney injury they’re trialling an app called Streams developed with DeepMind which gives the clinician on a dedicated mobile phone blood test results when they’re important and the patient’s history right there at the bedside immediately without having to scramble around looking and perhaps that’s something else that needs to be looked at. Timing of bloods and other tests I just noticed that they seem to come back in clusters in the afternoon when the junior doctors are very busy, they don’t have time to look at them and then they’ve got to contact somebody about them, it’s not a very good system and actually Streams does overcome that.
I think in terms of staff levels with Brexit there needs to be some very definite strategic plans about that once everyone knows what’s going on and there is a real need for the introduction of digital technology and artificial intelligence in management systems but I think there needs to be a strategic plan centrally, people need to sit down and work out what is really needed within the NHS and develop a plan rather than having piecemeal.
I’ve been very fortunate to be involved with several acute kidney injury projects. There are 100,000 deaths associated with acute kidney injury in hospitals; it’s reckoned that 30% of those are preventable and not diagnosed. One in five acute admission are associated with it and so the NHS Think Kidneys program and quality improvement programs such as UCL Partners which I’m involved with are bringing about big changes and maybe could be used as a model to help in the projects that are going forwards, but it must be remembered that if changes are brought about in systems in such a big organisation as the NHS it’s very easy for there to be excitement at one minute and for then to drop off very rapidly. So it’s not just about implementing changes it’s about sustaining them.
So in conclusion I’ve highlighted some of the observations. Of course there are many, many more. I must finish by saying how grateful I am for the quality of care that I’ve received and I also feel that front line staff must be valued and told that they are valued and they mustn’t be made into scapegoats for failings of the system and finally I cannot see as a patient how further efficiencies are going to actually improve the quality of care in acute medicine, if anything it’s going to decrease the quality of care. A different approach needs to be taken.
So thank you for your time.