Brimming – thanks to Don.

Brimming with ideas,

Following a day spent in the company of Don Berwick.

A proper blog will follow,

once I have allowed

all the talking points

to filter from my little black book,

through subconsciousland and onto the page.

For the moment,

here are some snippets…

Don popped in to a meeting of the shadow

South Yorkshire and Bassetlaw Integrated Care System.

Don’t ask me what that is

or, to define roles or responsibilities.

It appeared to be

a group of doctors, nurses, pharmacists, healthcare leaders

in the company of



Felt like a groupie.

I can’t think of any other person

I would rather have spent the day with;


All this, probably because the guy distils the essence of what I would like to achieve –

Willy Loman… being well-liked, respected &

achieving effectiveness

that improves care and experience for patients and staff.


The setup was odd;

I sat next to an old colleague from Doncaster,

on the front row –

We were in a circle, with half the seats of the inner group reserved for the special folk who talked and provided examples of their experiences,



and a few others who sat up front,

In front of others.

Made me almost feel that I was important too.


The Integrated Care System, I’ll come clean – I do have an idea what it is…


a 21st Century plan to fix health and social care.

Across South Yorkshire and Bassetlaw, this is, 24 different statutory organisations, working with 208 GP practices, 850 GPs and five NHS commissioning bodies, all, providing care for upwards of 2.8 Million people.

Yes, a lot.

My first impression was of the impossible complexity of such a task – managing, understanding the numbers of possible relationships – think, to begin, 208 to the power of 24. Yes, (20824)

That’s a big number; something like the number of grains of sand on…

Many, many, many.


We began asking a couple of primer questions:

  1. How do you establish a system-wide vision for improvement that ensures meaningful staff engagement?


      2. How do you manage disagreement in the system?

The starting point was a reference to wicked problems; the complex, multi-dimensional challenges that have no clear beginning or end, with multiple stakeholders all of whom see the obstacles and opportunities differently.

Think, Israel/Palestine, drugs, the ageing population;

*I do have a talk on wicked and tame problems if anyone would like me to present.

A key, fundamental, central to all the debate was the challenge of workforce.

Having enough people to do the work needed to be done;

This superficially means not enough doctors, nurses or therapists; a deeper interpretation is an excess of people doing things that others could be doing and even, then, not enough of them.

Take as an example.

Historically, if you had an X-ray, a consultant radiologist, sitting in a darkened room would have lifted up the film, dictated a report which would have been sent to the requesting doctor.

roentgens wife.jpg

(Yes, this is a hand)

It seems that within radiology, indeed, most specialties, there is upwards of a 20% staffing gap; this means that without other ways of working, things do not get done.

Over time radiographers – the people who take the actual X-Rays have been trained to not only calculate the level of radiation, position, exposure and, press the button, but also to do the interpreting.

The old way was photographer taking a picture then sending it to a naturalist for them to say ‘blackbird’ – nowadays the wildlife photographer says ‘lark’ or whatever; there are still situations where the photographer isn’t certain, when they need to call on the lab-guy for help, but mostly things aren’t like that; they call this the Pareto principle – or, the 80/20 rule.

Within this new vision of workforce are the pressures to get from where we are now to where we need/want to be.

If you are a GP and your three partners retire next year, you will be OK if there are more GPs to recruit; there aren’t – no matter the golden hellos and fancy publicity; there aren’t even, at the moment enough people who can do jobs similar to GPs to help the GP who is left behind.

I guess, you call this a crisis.

I don’t want to freak-out our patients, but, the situation is not very stable.

So, the day was talking about ways to improve.


The Integrated Care System is a means to address this pot of boiling oil that is close to cracking.

Getting different GP surgeries to work together, collaborate with hospitals, councils and the voluntary sector, side-stepping provincialism and the enemy of integration – tribalism is at the core.

How to you move from the primitive ways of working, the reverting to type, inherent in all of us that gets in the way?

The bible says, first family, then tribe, then nation.

How do you stop Doncaster commissioners fighting for Doncaster patients, using strategies such as ‘poaching’ staff from across the border which leads to destabilisation here to settle things there; like turning up the gas on one pot only to switch it off on the other; you are left with overcooked and undercooked. No one has a pleasant dinner.

(Great use of metaphors, eh?)

One idea was to help people to look out of the immediate, see beyond their own back-yard and start seeing who the patients are.


I have already written recently about my experiences of arriving in Rotherham – voila, I find patients from Sheffield, Doncaster and Barnsley turning-up on my ward; emergencies don’t respect boundaries or borders, yet, because you are in Rotherham, you will get the Rotherham way; it is a bit of a lottery – I won’t say whether the prize is a dummy or a treasure.

None of us want to lose our identity – yet, seeing that patients are people of the country, then perhaps the region might be a way to mitigate this craziness.

What we are saying is collaboration – which Don described as one of the Prima facie principles we must all adopt, with anything getting in the way, any attempts at populism, separatism seen as damaging not only to the health of your neighbour, but the health of the entire system.

Perhaps we should run this as a sort of Indiana Jones / Mouth of Truth test… Collaborator? Ye shall pass… (Funny, isn’t it – when you consider a time when being a collaborator wasn’t something to promote).


Unintended consequences…

Another theme of the day was the unintended consequences of change – an example has been the noble plan to centralise hyper-acute stroke (HASU) services; this is the part of the stroke pathway (and, yes, you know what I think of those), into two hubs, where you go or the ambulance takes you if you qualify for the sexy part of stroke medicine – thrombolysis; this is where a doctor or nurse injects a powerful drug into your brain which dissolves the clot that threatens to kill you (or rob you of your self/independence) – it is a miracle treatment that has become established over the past ten years or so.

The problem with this treatment is the risk, if the team or doctor caring for you isn’t available 24/7 and they aren’t 100% expert in their management you could die as a side effect. Death or risk of death and disability.

To improve services there has been a plan to centralise HASU in South Yorkshire at Doncaster and Sheffield. This is great if you are one of the places that will receive investment and development, not so hot if you are very much in to the high-tech medicine and your hospital wasn’t one of the winners of the bid/tender process.

Consequently, consultant A who wants to continue doing the sexy-bit leaves organisation B and goes to hospital C, leaving B without a consultant and the nurses, therapists and patients without anyone to lead the service.

Alternatives would be non-doctors running the stroke services (any nurses out there interested in the role?) – but because of the original workforce planning balagan above, this isn’t an option.

I am strangely immune to all of this as I haven’t been for the sexy stuff since I was quite young, now, preferring person-centred, hand-holding, talking with patients and relatives to determine preferences and what matters to them.

As an aside…

I was talking with a colleague yesterday about my relationship with Mallard Ward, which I still feel such an affinity for (yes, Michelle), it is weird; back in the day, i.e. last year, I regarded Mallard as my ward – I took pride in the patient and staff experience, the environment, outcomes, treatments; I identified myself closely with the unit. If a colleague came to the ward, to me it was like they were visiting my house – they were my guest;

This personal/pride model of working is not universal across wards, departments or organisations and I wonder how we can achieve it?


There was also a brief allusion to evolution, which is another one of my favourite hobby-horses when considering quality improvement and change.

One of the attendees gave the example of human behaviour, where people are reluctant to change, not necessarily because they are comfortable with the status quo, but, because their present state, no matter how painful, awful or inefficient has managed to keep them alive; who knows what threats will come if we… venture out of the water – ironically, for the first amphibians, the outcome was fewer predators, but, they weren’t to know that at the time.

How do we overcome this aspect of our humanity? How do we encourage a love-affair with change and growth?

Don and others mentioned the topic of co-design, also called co-creation.

This is addressing healthcare where the patient is not acted upon, but with – they are an equal partner in the history taking, investigation and treatment. Or, come to think of it, they aren’t equal; to achieve real co-creation, if you are talking treatment, it should be the doctor who consults the patient, not the other way around (see, Doctor, the patient will see you now).

There is such an obsession within health and social care to find quick fixes; to convene a task and finish group to solve a problem, with the focus being on solution, any solution, even if it is wrong. Results, delivery, you said, we did, kind of thing.

Take your patients and partners along for the journey, don’t just meet them half way; let them decide the route. (This is a very metaphorical blog) (and long – sorry).


The second half of the day, we discussed emerging ways to deliver care – this is the corollary of accepting that what we have are multiple unsustainable systems – whether you look at GPs, hospitals, social care, and, the imperative to innovate. (With first, exnovation, as Don says – getting rid of what doesn’t add benefit) (Or, Bruce Lee – hacking away the unessential).

How fixed are we in traditional ways of working?

I think of my ward round; trawling round the 26 patients on ward A3, one after another, ‘Hello, good morning, how are you?’ Document in the notes, chat, examine, move-on. How better could my time be spent? Say, if I were to be out and about in the community, popping into homes and care homes, seeing people before the fall, before the deterioration. How cool, if, whatever data I transcribe electronically was immediately shared with the patient and GP; how about patients managing their own medicines? If it is so important to do blood pressure – why not the patients to check their own, record in the notes;

Egad; we are at risk of creating a self-managing Teal hospital; Helen… help!

I have been in Rotherham for almost three months and I still don’t have an outpatient clinic; at first this made me anxious, but, the more I have thought about it, the more I see all the alternative strategies to avoid dragging a 90-year-old man up to the hospital, with all the anxiety and disruption this causes.

I have been running outpatient clinics for ten years. Were they all necessary? How much quicker if a GP were to call me on the phone, send me a text or email?

We have to find ways to work differently as what we are doing is not working.

Some of this is rule breaking – I have a little card that I carry; I’ll post it here:


It provides our staff the permission to break rules, think differently and create.

How can we make work fun?

It is ironic.

We are living longer, yet, around me, doctors and nurses are either taking early retirement or getting out as quickly as they can.


Well, predominantly because of lack of flexibility, lack of fun, the pressures and costs of revalidation and appraisal, the bureaucratic messing that goes-on within organisations – the reorganisation, top-down schedules and decisions; do this, this way; log in here, not there, adopt this technology – we know it isn’t intuitive, we know it makes your life harder but, it’s our technology.

How much would the NHS save by adapting to the needs of staff and supporting retention? (Yes, operating a person-centred health service).

One fascinating statistic was of the 40,000 vacancies in the NHS, 90-odd per cent are filled with agency staff; these are doctors and nurses who previously worked for the NHS but have left in order to get away from the command and control, all to cost the health-service twice as much.

Would this cover the cost of a new computer system? Or – free car-parking?

Genug. I will try to close;

I began in poesy and I have twisted the narrative. Sorry.

It was such an inspiring day.

My challenge – to translate what I have heard, what I have learned, into action, into meaningful change for my patients and for the staff all of whom seek excellence but are frequently stifled by challenging pathways and processes.

Here is to Don, a guiding light!



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