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Tackling a culture of bullying

It’s time to take bullying out of healthcare. That’s the aim of an anti-bullying and undermining resource which has been launched by a coalition of health organisations including the Royal Medical Colleges.


Why is this campaign required? Surely with health being a caring profession bullying at most occurs in isolated incidences and only affects a few individuals? Sadly not! Studies have shown that over a quarter of NHS staff have experienced some form of bullying or undermining within the last year. And when someone is being bullied there are ongoing consequences not just for the individual, not just across the immediate team, but also in terms of levels of care and patient outcomes.


Shockingly, an analysis has suggested that bullying and harassment costs the NHS in England at least £2.28 billion per year. Moreover, in the perioperative area alone, 67% of adverse events, 71% of medical errors, and 27% of deaths have been attributed to bullying and disruptive behaviours by members of the health team.


Those statistics alone take bullying away from being a one-on-one behaviour. Quite simply, the responsibility for stamping out negative behaviour rests with every healthcare professional. With this in mind the Royal College of Surgeons of Edinburgh have developed a set of standards which they expect all of their members to uphold. These include a requirement to challenge and report bullying and undermining behaviour, to investigate all allegations as appropriate, and to demonstrate exemplary professional behaviour in ensuring that they themselves do not bully or undermine colleagues, either deliberately or inadvertently.


Being honest, when patients’ lives and livelihoods are at risk and when the demand for services outstrips available resources, the provision of healthcare can be a stressful and demanding occupation. But when patient outcomes are negatively affected by negative behaviour, the answer has to be for health professionals to provide mutual support by working together to promote a culture of positivity.


The NHS isn’t alone in experiencing bullying behaviour. Other health professionals including dentists and physiotherapists may well have also experienced negative levels of behaviour and indeed so too will businesses in other walks of life. And whilst awareness and be prepared to challenge unacceptable behaviour is one line of approach, health leaders can also take action in other ways in order to reduce levels of stress. Working smarter not harder may be a cliché, but every time that technology is successfully deployed in order to reduce or smooth out routine tasks, potential sources of stress are removed.


That’s where true teamwork comes into play, not only looking out for each other on a day-to-day basis but also finding ways to help each other over the long-term. It might be something as simple as digitising patient notes in order to make access and transfer easier. It may be a concerted effort to reduce patient no-shows by telephoning or sending SMS text reminders. It may even be a move towards online booking of appointments in order to reduce administration time. Whatever the approach, when we stop undermining and start building positivity that we ourselves, our patients and the health service as a whole can only benefit.

Spring Statement – Better outcomes for patients

On 13th March 2019 the Chancellor of the Exchequer, Philip Hammond, set out his Spring Statement. Unsurprisingly, predictions of future growth were heavily caveated in the light of uncertainties surrounding the final shape of a Brexit deal. So, relatively early within the speech, the Chancellor commented that “if the UK’s withdrawal is less than orderly, then the OBR’s (Office for Budgetary Responsibility) outlook for the economy and public finances is likely to become more pessimistic.”


Nevertheless, with borrowing in 2019 likely to be just 1.1% of GDP and debt levels falling, the Chancellor commented that the country currently remains on track to meet fiscal targets earlier than originally forecast. Fiscal highlights include nine years of growth with the OBR forecasting further growth in the next five years and the best employment figures since 1975. These include the comment that 96% of new jobs created in the UK in 2018 were full time and the OBR forecasting a further 600,000 new jobs in the economy by 2023.


With the positive economic forecasts in mind the Chancellor highlighted the Prime Minister’s earlier announcement of £34b additional funding per year for the NHS by the end of the current spending review period. Philip Hammond commented that this additional spending “putting the NHS first in line – as the British public would expect” is intended to deliver:

  • improved cancer and mental health care
  • a transformation of GP services
  • more doctors, more nurses and better outcomes for patients


Looking forward, the Chancellor took the Spring Statement opportunity to announce a further spending review which, subject to Brexit outcomes, is to be launched before Parliament’s summer recess and which will report in time for the autumn budget. This is intended to “set departmental budgets beyond the NHS” in areas such as social care, local government, schools, police, defence and the environment. This further spending review will have a renewed focus on delivering high quality outcomes, thereby maximising value for taxpayers’ money.


Other areas in which health services may indirectly benefit from government initiatives include action in respect of the digital infrastructure. The Chancellor commented that the government has a strategy for delivering a nationwide full fibre network by 2033; something which will in particular benefit outlying health practices which are present are unable to optimise their processes due to the existence of a slow broadband connection. Areas such as online appointment booking or the digital transfer of patient records depend on fast reliable broadband if they are to deliver efficiency savings.


A review of competition in the digital marketplace was published alongside the Spring statement. Actions arising out of this review, including a study by the Competition and Markets Authority into the digital advertising market, are designed to ensure that the UK’s regulatory model for the digital age will “ensure that competition policy works in consumers interests” and that “the public are protected from online harms.” This too may have implications for health services, particularly if further action is required to strengthen protections around patient confidentiality, including the maintenance and transfer of patient records.

A major breakthrough for physiotherapy

The Chartered Society of Physiotherapy (CSP) has hailed the NHS’s new long term plan as “a major breakthrough for physiotherapy.” The ten year plan which was launched on 7 January 2019 aims to improve the quality of patient care and health outcomes by focusing not only on treatment and ongoing management of conditions but also on prevention. There is also a renewed emphasis on developing digital solutions in order to speed up access to health services and treatments.


With this in mind the core of the new plan aims to enable everyone to get the best start in life, to help communities to live well and to help people to age well. This includes a focus on treatment of major conditions such as cancer, heart and respiratory disease as well as a renewed emphasis on mental wellbeing.


Key to implementation is a move towards an integrated service which will provide both in-patient and home care as required. Treatments are to be patient-focused and will look towards providing an integrated solution. For example, breathlessness can be caused by both pulmonary and cardiac problems so collaboration between those two disciplines could lead to a combined treatment programme.


In terms of physiotherapy specifically, deployment of the new plan will lead to an increase in the number of physiotherapists in primary care alongside the use of first contact physiotherapists. In addition the new emphasis on whole person rehabilitation will require increased levels of physiotherapy contact in a number of disciplines.


But it is not just physiotherapists who will be positively impacted by this new plan. The fresh emphasis on whole patient care will impact a range of health professions from podiatrists to dentists and hair care professionals. The challenge will be to ensure that not only is the right support identified for an individual, the resources are in place to provide that support. Whether that leads to increased training requirements is perhaps a discussion for another time. What is certainly true is that existing health professionals are going to have to work smarter in order to optimise patient care.


The What Happens Next section of the NHS site dedicated to the ten year plan says that “From publication until the summer of 2019 staff, patients and the public will have the opportunity to help their local NHS work out what NHS Long Term Plan means for their area and how to meet our national ambitions in their community.”  This could also be an opportune time for health practices to review their own practices, perhaps looking for time savings in areas such as appointment booking, diary management and the electronic filing of patient records.


Announcing the new plan the Health and Social Care Secretary, Matt Hancock, said the plan “marks an important moment not just for the health service but for the lives of millions of patients and hardworking NHS staff across the country.” But its ambition to deliver integrated care will require it to also draw in professionals from outside the NHS, helping people to manage their conditions in their own homes and communities and to lead independent lives.


The NHS – 70 years young

1948: a time of austerity, of taking stock and coming to terms with the aftermath of war. The initial euphoria of victory has worn off and the work of rebuilding shattered lives, homes and infrastructure is underway. But this too was a time of hope and ambition; a determination not simply to rebuild the past but to create the future. One of the great projects to arise from that time was the National Health Service (NHS).


Seventy years on and the NHS continues to deliver its initial promise to provide healthcare which is free at the point of delivery. The road hasn’t always been smooth and in a strange way the NHS’s success has been the root cause of one of its prime challenges. Pioneering research allied to a drive to develop new techniques and skills has helped people to live on average ten years longer nowadays than at its inception; in the process placing additional strains on resources.


Nevertheless we shouldn’t underestimate the impact which the NHS has had not simply on lives but also on society. For example, this writer’s mother joined the NHS as a nurse in the year of its birth. Following initial training in England she was offered an opportunity to further her skills, firstly in France and then in America; a far cry from post-blitz London and offering a level of mobility which may not have been so available for young women before the war. Those skills that she learnt at the infancy of the NHS were then used throughout her life to benefit others.


This is only one story, but as we had heard time and time again over recent weeks it is the individual stories which demonstrate the true worth of our health services. Stories of lives saved or transformed thanks to pioneering techniques; stories of humanity and compassion; and tales highlighting the dedication of those who have followed the path of medicine in order to help others.


But whilst it may be true that in part the NHS is the victim of its own success, technological advances are already making a measurable difference. Online appointment booking, automated appointment reminders and digital records are all helping to reduce admin time. Remote health monitoring is removing the need for multiple hospital appointments, whilst the availability of video links brings specialist knowledge to remote areas of the country. And new developments are coming out all the time. Who would have thought only a few years ago that cancer treatments could be personalised based on an individual’s genetic make-up?


When the NHS started seventy years ago innovations such as these would never have been envisaged, let alone possible. In seventy years time they may be seen as somewhat old-fashioned, replaced by ever improving technologies delivering individual healthcare. But progress or not, one thing remains at the heart of our national health service and that is the relationship of care between those in need and the doctors, nurses, physiotherapists, osteopaths and other health professionals who provide lifelong health services.


A pain in the back….

There’s no escaping back pain. A sore back can not only affect neck and limbs as attempts to get comfy result in collateral pain elsewhere, it can also lead to headaches and depression as painful movement hampers and frustrates efforts to get on with daily life.

In the past treatments for back pain were largely along the lines of taking to bed with a few painkillers in the hope that the pain would ease. Nowadays the thinking is very much more along the lines of staying active; with the NHS choices website recommending a series of stretching exercises alongside gentle activities such as walking, cycling or water-based activities.

As with any other pain the temptation for those suffering from a bad back has still been to head for the pill box in a bid to feel more comfortable. However, a peer review has thrown up questions about the efficacy of taking non-steroidal anti-inflammatory drugs (NSAIDs) for back pain. The review concluded that taking NSAIDs was little better than taking a placebo with only one in six patients receiving any benefit from NSAID treatment. In addition, those patients who took the anti-inflammatory drugs were at a higher risk of gastrointestinal upset; perhaps the last thing which someone would want when already suffering from back pain!

The researchers concluded that there was an urgent need to develop analgesics which were more effective in treating back pain. However it would appear that more research is required as the peer review did not examine the efficacy or otherwise of exercise or direct interventions such as physiotherapy or chiropractic treatments. Certainly these are options to consider when looking to treat back pain as musculoskeletal professionals may be able to identify the root cause and suggest changes to posture or lifestyle which may help to speed up treatment and prevent re-occurrence.

Within the workplace too occupational therapists may also be able to suggest the best way for using equipment, or even sitting at a desk, which will optimise back health. For employers this is one area which should not be ignored as statistics from the health and safety executive indicate that in 2015/16 an estimated 8.8 million working days were lost due to work-related musculoskeletal disorders.

Work-related or not there is no doubt that back pain is something we can all do without, putting a strain not only on individuals and their families but also the health service as a whole. It’s one reason why health professionals are increasingly looking to find remedies which will help to relieve the strain on their own practices and maximise treatment times. For some, gentle remedies such as instituting online booking forms allied to automated appointment reminders have proved effective. Others have resorted to more intensive measures such as appointing virtual assistants or electronically filing patient records in a bid to reduce the strain on resources.

Whatever the remedy chosen, the more that health professionals are able to focus on working with patients to identify and treat the causes of back pain, the better it is not only for individuals but the country as a whole. With the study largely ruling NSAIDs out of the picture, the more we can focus on developing effective treatments, the quicker people will be able to get back to a pain-free lifestyle.



Providing specialist rehabilitation

When a traumatic event occurs we’d like to think that our health services are there for us. Particularly so if the event results in a form of trauma which requires long-term recuperative treatment. So would it surprise you to hear that in-patient specialist rehabilitation units only have the capacity to cater for 5% of the total number of individuals who are admitted each year to major trauma centres?

Those are the findings of a report commissioned by the Health Quality Improvement Partnership (HQIP) which looked into the provision of trauma care across England. As with many other health services the provision of specialist trauma care seems to be a postcode lottery with, according to district, between 1 and 8 adult trauma specialist rehabilitation beds available per 1 million people.

In bald terms, this means that across England only some 950 patients can be treated each year in specialist rehabilitation beds. The report also commented that under commissioning and insufficient staffing resulted in specialist rehabilitation units struggling to manage a complex caseload. Cost efficiency calculations were also not recorded by a quarter of the providers resulting in uncertainty about the balance between specialist treatment and long-term care in the community.

Now admittedly some of those who initially find themselves at major trauma centres may not require a high level of support but the report’s authors are calling on major trauma centres to “review the capacity and pathways for specialist rehabilitation following major trauma” in the light of the report. This should include the drawing up of local action plans together with an increase in the capacity of level Ic (cognative / behavioural) beds in order to shorten waiting times for these patients.

Trauma at all levels from major to relatively minor has an impact not only on the individual affected, but also on their family and their capacity to work. For the good of the individual as well as for the long-term health and productivity of the country it is therefore important that when an incident occurs priority is given to helping the individual to recover as swiftly as practicable. This means that all health professionals, whether they work in specialist NHS units or in private clinics have their part to play in providing rehabilitation treatments in a timely manner. Psychiatrists and counsellors, physiotherapists and mobility specialists, dentists and opticians; whatever the requirement, in helping the individual they are also helping the country.

But health professionals will only be able to give of their best when they in turn are supported by an efficient administration system. Addressing the rehabilitation needs of individuals requires concentration and a clear brain in order to draw on best practice knowledge. Health professionals won’t be able to give patients their full attention if they have worked late into the night in finding and filing notes, managing the appointment diary and dealing with the finances.

This is where backup systems such as online diaries, electronic filing of notes and card payments can make all the difference. In effect, by taking advantage of the support which is available to them, health professionals can in turn provide the best support possible to help their patients to recover. Yes, some will require the services of a specialist treatment centre; but for the rest, being able to call upon swift and timely rehabilitation services could make a significant difference to their long-term recovery.



Changing the UK’s Health

Sometimes for change to happen it requires a seismic shift in technology or actions, but on other occasions a series of small individual acts can come together to create something special.  That was the idea behind NHS Change day; a time when individuals can make small pledges which could result in significant change for the NHS.

At the time of writing over 450,000 people have made their pledges and with the last pledge date for 2014 still some weeks away the final total is expected to be far higher.  Some pledges are designed to support and strengthen local campaigns whilst others have been made on a far more individual basis.

One national campaign which the NHS is promoting through NHS Change Day is the idea of reducing no-shows.  With 12 million GP and 6.9 million hospital appointments missed in the last year costing a total of £270m, every person who makes an individual pledge not to miss an appointment in future will be saving the NHS money and improving treatment for themselves and others.

In an attempt to cut down on no-shows NHS practices are adopting a range of measures from reminder calls and texts to encouraging direct booking online.  But it is not just health practitioners within the NHS who suffer from missed appointments.  Health practitioners across the board from chiropractors to physiotherapists and from beauticians to counsellors all suffer if a patient fails to attend an appointment.  And in many of these cases it is not just the taxpayer who loses out but the health practitioner themselves, not to mention other patients who could have taken that vacant slot.

So for health practices everywhere, anything which can be done to cut down on no-shows should be done.  Appointment reminders, online booking services, ensuring continuity of telephone answering; all can play their part in working towards a full diary and effective treatments.

The pledges being made for NHS Change day are not just confined to reducing missed appointments.  Challenging culture, enhancing leadership, patient safety, improving skills, the list goes on.  Some of the pledges are from patients, others from those on the front line or back office who are working to improve the NHS from within and without.  From individual pledges to walk more or eat healthily to sharing knowledge and experience with others, the pledges may individually not be earth shattering.  But if enough people see the pledges and join in then health care for all could be the winner.

Whole person care

The Institute for Public Policy Research (IPPR) has issued a report examining the measures required should England’s health and care system move towards the provision of ‘whole person care.’  With the benefit of making the connections between physical health, mental health and social care needs, and supporting people to remain in their own homes as long as they wish, whole person care provides joined up responses to individual needs.

Success is dependent on a number of factors including a long-term investment mindset, aligned incentives, effective use of technology and a flexible workforce. The report concludes that there is clear potential to deliver better outcomes if care services are more coordinated.

Commenting on the report Chartered Society of Physiotherapy (CSP) professional adviser, Eve Jenner, said that “physiotherapists were well placed to support whole person care” adding:

“They can act as single point of contact, care coordinators or as part of a team of health and social care professionals providing holistic assessment and treatment to people with long-term conditions.Key success points for whole person care include peer support, tapping into the expertise of others with the same condition, and personalised care plans.  For professionals, the ability to share online access to personal health and care records is also vital.  This last point echoes moves already being made within the health profession to share records.  Not only does this lead to streamlined care, it also saves time and costs and helps to speed up effective treatments.

Simple measures such as electronic storage of patient records are a key step towards this goal.  But not only does electronic storage facilitate the sharing of records, it also streamlines processes.  When patient records are available at the touch of a button there is no wasted time in searching for mis-filed records, no wondering if the record shown is the latest one and no time spent on gathering evidence in preparation for each client appointment.

For health professionals such as physiotherapists and osteopaths, the electronic storing of patient records helps to save administration time which can better be spent on patient treatments.  For health and care professionals as a whole, the move towards whole person care will help them to cost effectively provide the best treatment pathway available for the individual.  The IPPR has identified many issues which are critical for the success of whole person care and they will be looking at these in more depth over the next 12 months.   We’ll keep an eye out for these follow-ups and report as appropriate.

Designing care pathways around patients’ needs

A report by The King’s Fund has recommended that local organisations be given the freedom to prioritise quality patient care under the supervision of NHS boards.  Entitled “Patient-centred leadership” the report acts as a follow-up to the Francis inquiry.

One of the central themes of the report relates to the need to move away from externally imposed targets and towards a culture which puts patient-care at the centre of the NHS.   Commenting on the report the NHS Confederation chief operating officer Matt Tee said: “It is very worrying that such a significant proportion of respondents to the King’s Fund survey think the NHS does not sufficiently prioritise quality of care.”

The president of the Royal College of Physicians, Sir Richard Thompson, backed the report but highlighted the way in which technology can play its part in aiding, or hampering, a physician’s attempt to provide quality care.  A report on the national health executive website quotes Sir Richard as saying that “Clinicians desperately want to provide high quality care, but problems with systems and resources can often make it difficult for doctors and nurses to treat their patients well.”

Certainly the old days of scribbling a note on a piece of paper and putting it in a patient’s file are gone.  But whether the introduction of technology has improved and streamlined care processes is a matter of debate by many health practitioners.  As with any new technology, some systems prove a boon in terms of time saving whilst others are so complex that the practitioner sometimes feels they are spending every moment in satisfying the ever gaping maw of IT and processes.

But there are some technologies which can make a real difference to maximising patient care times.  For example, systems which record and store patient files electronically can generate huge time savings.  Gone are the hours of filing and the wasted time whilst you search for a note which has been misplaced.  Instead, a touch of a button and the entire patient file is there before you, with notes, MRI images and other documents available to view instantly. Not only does an automated patient record help to manage multi-practitioner cases, it can prove to be a boon in smaller practices such as those provided by osteopaths or physiotherapists.

Undoubtedly our health practitioners have the will to provide top quality patient care at all times.  With automated patient records freeing up valuable time, perhaps technology can lead the way in this transformation.

Learning the lessons of 111

NHS England has reported that the 111 telephone service has successfully coped with the May Bank Holiday weekend without major problems.  With providers taking on more call handlers in the run up to the weekend the early signs are that the 111 service responded to the vast majority of the 100,000 callers over the weekend.

However, chief nursing officer Jane Cummings acknowledged that improvements were still required before all forty-six 111 services were up and running as expected.  Run by a mix of providers including private firms and ambulance services, the 111 service has seen some teething problems.  This has resulted in some services being suspended or receiving special help.

Last week NHS England agreed to commission an external review to look at the problems which have beset the introduction of the 111 telephone service; both as a guide to actions required to bring the service up to full strength and as a learning point for future projects.  Whilst some areas of the country seem to have experienced a fairly smooth transition, others have been beset with problems including calls not being answered and major delays experienced by those waiting for calls back from medical specialists.

Designed to serve the needs of those who are too ill to be able to wait until they can see their doctor within hours but are uncertain if they should call an ambulance the 111 service is designed to be able to direct callers to the most appropriate service for their needs including GP out of hours, A&E or calling an ambulance if required.  This means that the service may receive a wide variety of calls from those who are concerned about their own, or a loved one’s, health and in those circumstances any delay in responding can lead to distress and anxiety.

In fact it’s not just the 111 service which can suffer from delayed call answering.  Any call which goes unanswered can potentially lead to frustration on the part of the caller, whether the call is to a health practitioner or not.  For those health practitioners who work closely with patients this can cause a dilemma.  If the answer a call they may be interrupting an existing treatment but if they ignore the call they risk losing a potential patient or their goodwill.

The solution is to appoint a virtual assistant service which will respond to callers, book appointments, manage diaries and take messages.   Appointing a virtual assistant service which specialises in health matters will also pay dividends as the call answerers will be able to talk knowledgeably to patients about their treatments with empathy and attention to detail and will better understand when messages should be marked as urgent.  We will be keeping an eye on the NHS England review as well as the progress of the 111 service and will report on any findings which may be of interest to our health practitioner clients.

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