Tick box manifesto and dementia.

The National Audit for Dementia has just been released.

You can go online and check out the national picture.

It was an initiative led by the Royal College of Psychiatrists.

So far, so good.

I think we are on the fourth round; it isn’t run every year and its aim is, to improve the experiences of people living with dementia who encounter care in one of the UK’s 200-odd hospitals.

Again, that is all fine.

I had an initial criticism related to the timing of the audit – it requested information less than a year after the preceding one – which, because of its nature is retrospective, thus, the last but one audited the performance of hospitals two years ago and the most recent a year ago.

Again, that is fine, but, if you imagine, or have any knowledge of how slowly the wheels of change happen in the NHS, you will see that a year is not very long; sure, policies and procedures can be updated that quickly, new rules and regulations enacted, but, when dealing with something as complex, as complicated as the care of people living with dementia who become patients and the pressures, push and pull of the lives of doctors, nurses, therapists and other clinical staff who interact with patients, you will realise that a year is nothing.

Anyway, you see, these things (audits) whilst not mandated, because they are national, there is a bit of pride (aka competition) in completing and as I say, most of the almost 200 hospitals in the UK completed.

Even this is not my gripe.

It has to do with tick boxes.

Back in 2009, my not quite nemesis Atul Gawande published ‘The Checklist Manifesto’ – this showed that if you take some of the strategies employed in high-risk industries such as nuclear power and in particular airlines and apply it to certain branches of medicine – particularly operating theatres, you can have significant reductions in harm, risk and error.

In the UK it is now standard practice, prior to starting a surgical procedure for all staff to run through the surgical checklist – which includes making sure the equipment is working, the relevant people are assembled, you have the right patient and ideally are operating on the right organ or body-part.

All good, and this has no doubt saved countless lives.

I don’t really hate Atul, it is just that most people when talking about modern medicine refer to his book – Being Mortal which to my mind was a latecomer to the conversation.

Anyway;

You are no doubt wondering, what is his problem??!

Well, it is the specific of tick-boxes.

This is big business in the NHS.

It is often the response to a major or otherwise incident.

Did Mr P have his dinner? Yes/No

Has Mrs M received her paracetamol? Yes/No

Did Ms A have her blood taken? Yes/No

Was the catheter changed? Yes/No

Did we ask about their waterworks? Yes/No

Is all OK at home? Yes/No

These are just a sampling of some of the vast numbers of questions that are asked in the process of hospitalisation; again, there is nothing very wrong with this, indeed, without these systems you would probably be approaching chaos.

The thing… and, here it is, yes, the thing is the value of the questions – and answers.

I guess the questions in themselves are just questions – requests for information. Often, they are asked when something has gone wrong;

Mr P has lost weight, did he have his dinner?

Mrs M is in pain did she get the medicines?

And, so on.

Again, fair enough.

Yet, this is where the audit intersects with the tick-boxes and quality.

You see, much of the audit, which as I have already mentioned was completed in the wrong time-frame, relies about tick-boxes for information.

Did patient D123412 receive an assessment of continence? Yes/No

Was the patient asked about pain? Yes/No

Was the carer consulted? Yes/No

Did the therapist review? Yes/No

And, indeed, the audit is duly completed, in association with the tick or not of the relevant pain, continence or therapy box.

This tells you how many boxes are ticked – it doesn’t tell you anything else.

And that is the thing.

It doesn’t tell you about quality or whether the interaction led to change or care.

How does Mr D123412 feel about their continence? Has anything been done to help? Did they understand or hear the question? Were the questions even asked or the box just ticked?

These are the human factor elements (the parts that people play in processes and whether they go right, wrong or have any effect at all) and, when you rely upon them as evidence that is when caution is needed.

And, back to the audit.

For many hospitals, the data was collected on paper; usually by a doctor or nurse – taking-up the time that they would otherwise spend on patient care (or just chilling – what is wrong with that?) the data is extracted from clinical notes – often taking up to an hour of work per record, (such are the challenges of NHS filing), then, when the data is on paper, a clerk or data inputter will type the results into the database online.

At a minimum this has to happen for 50 patients per organisation.

I will not emphasise my frustration at the potential waste of time – don’t you know if there are issues and care that needs to be improved or changed? Can’t you just ask the staff, the patients, their carers, can’t you just review some of the complaints or incidents?

No, the audit doesn’t really do this – it does try to get staff, patient and carer feedback, which is necessarily very difficult.

So, they rely on tick box information.

Which is possibly as far away from quality of care as you can get.

Today’s NHS is like the dumpling in a pressure-cooker; boiling away, no one quite sure when it will blow, and too many of the staff who work under conditions that are in many respects akin to a war-zone.

Comparing quality is difficult in this context.

Sure, you can always make someone tick a box.

Can you make someone care?

Can you force compassion or empathy?

We are talking chalk and cheese.

I didn’t mean to criticise that hard work of the folk who ran and completed the audit – I was one of them; it is just important to see where this all sits in the sophistication of modern clinical care.

In many organisations, particularly those where the scores are less than great, there will be command and control dictates for improvement or change – likely dependent upon more tick-boxes and an increase in pressure.

It isn’t people that don’t care, it is the system that forces people into positions of automation, of numbness of process.

We need to fix the system not correct the people who themselves are frequently represented as tick-boxes themselves on their manager’s checklist.