This Weeks Roundup of News and Comments by Roy Lilley

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Scrap it…

The Nursing and Midwifery Council has been a troubled organisation for as long as I can remember.

If regulation were an escalator, the NMC would be running up the down-side.

Their problems were compounded when the Blair, Labour government ambushed them with the decision, they must become self sustaining; their income derived from registration fees.  Something they were unprepared for and ill equipped to cope with.

Efforts to streamline their processes, address the backlog of disciplinary hearings and changes in leadership seemed to do nothing to calm the tumult.  

The recent pay-rise awarded to their chief executive, at a time of austerity, thumbed the organisation’s nose at the staff, obliged to pay for it.

Now, it has come badly unstuck over it’s response to a baby death scandal.  

The chief executive has quit.

Once again we are left wondering at the role of a regulator.  Indeed, so uncertain are we, there is a regulator for the regulators that are too slow to catch a cold.

All professional regulators end up getting fat on either taxpayer’s or their member’s money.

What do we want of regulators?  Not much.  I’d just like to know the people who provide my care are appropriately qualified, share a mutual objective to keep up-to-date with their practice and will keep me safe.

How do we do that?  I would have thought it was simple.

Maintaining a register of people qualified to do a job is work for an 18 year old, bobble-hatter, a computer, some Cloud storage and an office above a chip shop in Milton Keynes.  Oh, and a simple App.  

All the records would be available to the public.  I’d guess it could be done for about a tenner a registrant.

And the rest?

Can we safely assume the objective of all decent care staff, working across the NHS, is to keep up-to-date, care for us safely and call time on people doing bad things?  Can we assume that’s the mission of doctors, nurses, allied health professionals and everyone involved?

If we can make that assumption, why do they all need separate regulators?  

Can’t they all sign up to the same promise, the same mission under one regulator and save everyone a fortune.  And, we could dump the ludicrous regulator of regulators.

Can we safely assume no employer will ever want staff who are not trained, up-to-date, will look after people safely and want to know when bad stuff happens.  Can we assume that the employer is best placed to sort that out?

If we can, exactly what does the panoply of regulation add?  Apart from cost, duplication, delay and confusion…

If an employee does something bad the employer is able discipline them or sack them….  

… the HR tribe will note the personnel record and the registration bloke, in the office over the chip shop, notified accordingly.  

As the records will be transparent and accessible to us all, when the person moves to another job, the record sticks to them.  What else is there?

If staff are poor, the employer is responsible.  Accountable for their performance.  Training, guidance and keeping up-to-date… down to the individual, the employer and Royal Colleges.

Education standards are for the employer and it is out of obvious frustration that some Trusts are now training their own nurses and doctors, on curricula that are realistic and deliver ward-ready staff.

The regulatory bodies were mostly born of an era when clubs were modelled on freemasonry, beer was twopence a pint and you could get drunk for a shilling.  

The NMC say they…

‘… regulate nurses and midwives… to protect the public.’

You’d be kidding yourself if you believed that.

 ‘… set standards of education, training, conduct and performance so that nurses and midwives can deliver high quality healthcare throughout their careers…’

That’s the employer’s job and so is this next bit…

‘… make sure that nurses and midwives keep their skills and knowledge up to date and uphold… professional standards…’

And the rest… 

‘… have clear and transparent processes to investigate nurses and midwives who fall short of our standards…’

Yes and it takes for ever.  Fitness to practice hearings can take months and months.

Professional regulation has once again failed; failed families and failed the professions they claim to regulate.  The temptation will be to re-regulate the regulator.  

The right answer is… scrap it.

Have a good weekend.

Get the juices flowing…

Depending on how you think, a Think Tank is either; the 7th album by Blur, released in 2003, or a concept that goes back to the time when emperors and kings argued with the Catholic Church about taxes and the tradition of hiring independent advice about royal prerogatives.

The military have a long tradition of think-tanks, the Institute for Defence and Strategic Studies was founded in 1831.  

I always think, think-tanks must be stuffed full of brain-boxes bigger than mine and I should listen to what they tell me.

Since I was in a learning set at the King’s Fund, I have been in awe how clever people are.  Give good people the time and space to think and they’ll come up with ideas that dazzle.

So it is, you can imagine, when I found out the combined brain-boxes of the Health Foundation and the King’s Fund had got together on the knotty topic of social care funding, I held my breath in eager anticipation.

Health think-tanks recycle their staff around each other, very few new thinkers have emerged over the last twenty, turbulent years of the NHS.  The names haven’t changed, it’s just email addresses that change. 

There’s not a lot to chose between them.  There might be a good argument for merging them into a super-thinking-tanker.

That aside, the great report, the sum total of the electric, super-fizzin’, deep-mind, combined think-tankery was published at midnight last night.

Wow!  ‘A Fork in the Road; next steps for social care funding.’

… what a disappointment.  With a free morning and Google you could have written it.  There are no ‘next steps’ just a dance around the problem’s handbag.

In fairness the report says they don’t seek solutions.  Why not.  Isn’t it what think-tanks do?  We need solutions not summaries.

The report is not entirely useless; it’s a lazy-man’s gazette of the problems.  Numbers to pinch for your next Powerpoint and some neatly laid out options.  Alas, nothing a more energetic person couldn’t have found out for themselves.

Any manager who has written a Board briefing on the topic will already have written this.

There’s a passage on public perceptions… from a polling company.  Mmm…  

Given polling’s form on elections I don’t know how reliable it is.  It does strike a chord with conversations over a coffee; people think taxes are a good way to syndicate their risks of old age and what-not.  My guess is, they’ve got this right. 

The report’s up-shot…

  • Sustaining the current system will be expensive.
  • ‘Doing nothing’ is not a safe.
  • To support reform, people need a better understanding of the problems, but politicians are not best placed to provide it. 
  • A cross-party coalition is required.

… see I told you… you could have written that.  You know this stuff.

As thinking goes this is musing, daydreaming, reflecting.  It’s reasonable but not reasoned.  It’s studious but not studied.  It’s intelligent but not bright.  There are no answers here.

Is funding elder care capable of a solution?  Of course;

  1. A couple of pence on income tax and you are out of jail.
  2. Pay relatives to give up work, train them and let them look after their family members.
  3. Create savings bonds for elder care with contributions of cash or assets and withdrawals, all tax-free.
  4. Place a cap on contributions and you have an insurable risk the markets can create products for.

There must be better ideas than my four.  

Disruptive, innovative, sizzling thinking that will take us into the future.   At the IHM we’ve been thinking, for some time, a fresh approach is needed hence the Integrated Care Expo conference on the 22nd May, in London.

We’re certain the ideas are out there, we are confident you will have a contribution to make.  The problem is, no one ever asks the people doing the job.

I know you will have a contribution to make and have better ideas than this.

So, let’s not worry about conferences making money.  Let’s forget ticket prices.  It’s more important we find some real, workable, problem-solving ideas.

I want you there…

Let’s make it easy… if you work in the NHS or social care, email us here and we will give you a free ticket.  

Come along and bring your best thinking.  The format is different and details are here.  Be part of the solution, for a change!

We’ll even give you a free glass of wine to get the juices flowing.

See you there…

Manage better…

‘My husband is leaving me.  No dramas, no slammed doors, no suitcases in the hall but there is another woman involved.  

Her name is Dementia.’

Laurie Graham.

—-

Before you know it, in the UK, there will be over a million people with dementia.  This fact is at the heart of the dilemma facing our NHS and care services.

How do we help our citizens through the most difficult challenge of their lifetime.  I used to think merging health and social care was the answer.  It’s not.

The more I look at the issues the more I realise it will be another top-down upheaval, take hours of parliamentary time, cost a fortune, distract us all, make consultancy firms and conference organisers rich.

The are plenty of examples of good practice, where health and social care work together, without turning the Town Hall upside-down and the NHS inside-out.  Forget it, just learn from people doing the good-stuff.

But… we do need an honest re-think.

Cruel fact; right now, there are some drugs aimed at the early onset of dementia, but they have limited impact.  There’s research a-plenty but nothing looking like a cure or even amelioration, on the horizon.

Dementia is no respecter of physical health.  Otherwise fit people can end up with lives hollowed-out.  The same is true of those suffering multi-morbidity.

Care services are ill equipped.  Domiciliary services generally mean fleeting visits from different carers, creating their own confusion and inconsistencies.  

Few care homes respond to the challenge, many collapsing with debt.  Time and again families report urine-stinking, confusion, drug errors, feeding problems, lost clothing and dirt.

People with dementia end up in mental health services, when they don’t have a mental illness and people with dementia end up in noisy, confusing health services never designed for hybrid patients.

The benefits system is a labyrinth.  Families trying to cope have very little idea how or where to start to look for help.  Eligibility criteria, fragmentation, we couldn’t have made it more difficult if we tried.  

A leaflet, Google and then what…

For people with dementia there are excellent therapeutic pathways of care involving the right environment, reminiscence therapy, music, art, routine, meaningful daytimes, nutrition… it sounds easy but it is highly specialised.  

Too much for most care homes and not, truly, ‘medical’, needing hospitalisation?

The forgotten victims of dementia are the families.  Finding support, selecting care, dealing with finances and legal issues.  Negotiating the benefits maze.  Coping with incontinence, sometimes violence, melancholy and depression.

Watching someone you love love slip from your embrace and fall from your grasp.  Knowing you are dissolving out of their memory.  Becoming a stranger.  Helpless and hopeless. 

All these factors tell us we need something different… but what?

Does the way midwives practice give us a clue?  

They support mum and dad before the birth; they care for mum, send dad to classes.  They coach, prepare, inform, reassure, are ready to answer questions and hold a hand.   Come the birth, they are there.  When needed, they can call for help.  After… they are still there.  Health Visitors carry on the work, seeing the whole family… 360 degrees of support and need.

Maternity services take a pride in not medicalising the start to life.  They are there 360, 24/7, for the whole family.  

We have Admiral Nurses, specialists in dementia but there are only 200 of them and their brief is not deep enough.

For people with dementia and their families, who don’t need to medicalise their journey, a 360 Service looks an attractive option.  Seeing the whole person, the whole family and the whole need.

Three-60 care-navigators, skilled in support, counselling, benefits, welfare and who understand dementia and its progression.  What it means, what it demands.

A named supporter, someone to turn to in the darkest moments.  To hold a hand.  Nursing skills, communication, across the repertoire; from living wills, to living with dementia.

In Holland Buurtzorg get close, in Australia Doc Rosenfeld got frustrated with poor services and is pioneering his own way-finding solution.  Widnes Rugby Club are on it!  Yes, really, have a look!

We have services that are bolted on, not bolted together.  

We must start with the family and work backwards; dealing with the impossible trinity: 

  • mental health when we know it’s not mental health; 
  • physical health when we know it’s not just physical health; 
  • and agency support when we know it’s not something a family can deal with alone.

We don’t need another merger, another muddle, another menu of change.  We just need another look at how to it manage better.

Obvious…

‘I have a cunning plan…‘ Blackadder!

Connoisseurs of the programme will tell you the phrase started in series one, first episode, with ‘cunning-trick’ and went from there.  

In the second episode the phrase was given birth;

Edmund: Ah, yes – a drawback. Yes… Perhaps we need something a little more cunning.

Baldrick: I have a cunning plan.

Edmund: Yes, perhaps, but I think I may have a more cunning one.

Baldrick: Well, mine’s pretty cunning, My Lord.

Edmund: Yes, but not cunning enough, I imagine.

Baldrick: Well, that depends how cunning you mean, My Lord.

Edmund: Well, pretty damn cunning. How cunning do you think I mean?

Baldrick: Well, mine’s quite cunning, My Lord.

Edmund: (fed up) Alright, then, let’s hear it! Let’s hear what’s so damn cunning!

I’m pleased to announce…. the NHS, also, has a cunning plan.  Well, The Tinkerman does.  Did you know he has a plan?  He confided it, exclusively, to the HSJ.  I think it was £walled so most, won’t be able to read it.

Fair-do’s, the HSJ have a living to earn.  No problem with that and a good reason to invest in a subscription. 

However, if The Tinkerman is expecting anyone but readers of the HSJ to deliver his cunning plan, he might want to tell a few more of us!  As bright as they all are… they might need a bit of help!

With acknowledgements to the HSJ, here are his four, top lines;

  • The plan should include “full integration of the health and social care system”
  • Over the 10 year plan period, the NHS will need to become “massively more teched up”
  • The plan is likely to identify “really big efficiency improvements” which can be made over 10 years
  • Meeting core performance targets, such as those for waiting in emergency departments and for planned operations, will be an “early milestone” for the NHS in the long-term plan.

I get the impression this lot will be scrubbed up, in time for the NHS 70th and the Tory Party Conference.  

Note; it’s a one way street; all the stuff he wants us to do.  What’s he going to do?  And, ten years?  The life of two Parliaments and the upheaval of Brexit?  I don’t think so.

The Tinkerman also confides to the HSJ; we have to be more ‘Singaporian’… really?  

Singapore spend 4.6% of GDP on health.  Under one third of health spend comes from the government.  Users pay the rest.  Hospitals have tiered facillities – the more you pay the better it gets.  

‘Elder Shield’ is their insurance based, top-up scheme for the cunningly badged ‘Pioneer Generation’, the +65’s to you and me!  Oh, and they are developing regional health authorities…

I wonder which bits the The Tinkerman is intending to inflict on us?

As for the rest… without major legislative changes and I guess a huge row with Parliament and local authorities… well… 

Integrating health and social care?  Mmmm…  

I’ve changed my view on this; there are more dangers in integration than there are making working together, work.  

There are plenty of good examples of excellent team based working.  

Co-payments and eligibility criteria hoops and hurdles, for health, like social care, are the inevitable consequence of cross-dressing health and social care.

Technology… be careful what you wish for.  Look at the chaos Babylon is causing.  Innovation, proper innovation is cruel and disruptive.  It will scythe through the status quo.  Ask Taxi drivers about Uber.  Shopkeepers about Amazon.

Why is GoodSAM, only now, getting traction?

Ask consultants why 60% of outpatient appointments can’t be undertaken by Skype or FaceTime.  Ask NHSDigital why I can’t access my health record without a palaver.

Targets?  Well, not very cunning but I’d like to know what it means when The Tinkerman says, return to hitting targets will be an ‘early milestone‘ in a ‘long-term’ plan?  It’s too cunning for me.

Massive efficiency savings?  If they are that massive, why aren’t we doing them now.  My guess is we probably are.  They are called Carter and austerity and maybe, code for stop doing things.

A proper plan for the future that we can all see, buy into and deliver, yes, a good idea but not this…

How about getting back to basics and do these four things, instead?

  • A proper, realistic, achievable workforce plan;
  • safe staffing on the wards; 
  • basic IT, like ubiquitous wifi and access to records; 
  • and a commitment to getting NHS funding back to a 4% pa uplift  by 2020.

Cunning? No, obvious.

Everyone’s voice…

The plight of Alfie Evans has dropped out of the headlines.  I still believed he, his family and the NHS was ill-served by the courts, not designed to be an interlocutor.

This morning have given my editorial space to Sarah Barclay, the Director of The Medical Mediation Foundation… I think she has a powerful message.  She writes…

-oOo-

Parents and medical teams can disagree about the treatment that should or shouldn’t be given to a child but disagreement doesn’t have to lead to conflict. 

Trying to weigh up what is “best” for a desperately ill child involves difficult conversations, careful negotiation, second opinions and perhaps above, all, trust between the family and the clinical team. 

It’s when that trust breaks down that conflict often follows. 

In the last 18 months three disputed end of life treatment cases involving children have been played out in the public domain –  Charlie Gard at Great Ormond Street, Isaiah Haastrup at King’s College Hospital and most recently, Alfie Evans at Alder Hey Hospital. 

Playing out medical complexity and parental and professional anguish in the public domain feels, for many, intolerable. 

The impact on parents and on the nurses and doctors is difficult to imagine. These are also immensely difficult cases for the judges themselves. 

These cases don’t end with the court’s ruling. 

Parents and professionals have to go back to the hospital and try to maintain a working relationship until the ventilator is switched off and the child dies. 

Often this doesn’t mean immediate death. In palliative care, the focus changes from cure to comfort. Death can take minutes, hours, days, sometimes weeks.

With each case, there have been increasingly fervent pleas for “something” to be done differently. In his judgement in the Charlie Gard case, Mr Justice Francis, said he hoped to see mediation attempted more often “even if all it does is achieve a greater understanding by the parties of each other’s positions.” 

How can mediation help? 

At its simplest, it facilitates conversations which might not otherwise take place. It is very difficult to mediate your own conflict but that is often what medical professionals, particularly those working in paediatrics, try to do. 

They want to work with parents not against them but when this doesn’t work, professionals are left feeling they’ve failed, parents are left feeling the doctors aren’t listening and the child is left somewhere in the middle while conflict escalates. 

Mediation is a much less confrontational way of trying to resolve disagreements between parents and professionals than going to court. 

Its flexibility can often help people re-think entrenched positions and find a way forward which parents and professionals can accept. 

If resolution is reached, relationships can be maintained rather than fractured. Most importantly, time and effort spent on conflict can then be spent on the child. Not all cases can be mediated. That doesn’t mean mediation isn’t worth trying. 

The three most recent cases have intensified calls for a different approach but in fact there has been work going on in a number of children’s hospitals since 2013 to pilot new ways of supporting parents and health professionals to recognise and manage conflict and to embed the use of mediation skills within paediatric teams. 

At the Evelina London Hospital, staff are trained in early identification of conflict with families and taught strategies and communication skills for engaging with families and de-escalating conflict. 

An initial cohort of more than 300 staff followed up at six months reported that more than half had experienced a conflict with a family since the training. 

Of these, 91% said that the training had helped them to de-escalate or resolve the conflict.

At Southampton Children’s Hospital, following the Ashya King case in 2014, health professionals who had found themselves subject to abuse in the media and in person, asked for advice and support in managing future cases. 

A framework for working collaboratively with families and managing conflict as a team was created. Two initial pilots reported significant falls in the number of conflicts. 

Four hospitals will join the second phase of the pilot in the autumn. 

The three most recent cases have focused attention on the need for early recognition and sensitive management of conflict and support for parents and staff. 

Hospitals need to be encouraged to try mediation before beginning court proceedings but parents and clinicians need to be able to have confidence in it as a genuinely impartial process which ensures that everyone’s voice is heard. 

-oOo-

Sarah Barclay can be found on Twitter @medmediation

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roy.lilley@nhsmanagers.net 

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Disclaimer

Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.