Quality

National Botanic Garden of Wales, May 2013

Tuesday was a real throwback to my university studying. It's officially my day off but I've agreed to write an article about gastroparesis for a professional journal. I had thought the deadline was the end of May and had been procrastinating wildly, but decided it was time to start. When I checked the previous correspondence, I found that the original deadline I'd been given was 21st March...

Anyway, I settled down to get started on writing last week, and found all manner of distractions at home. Then I was told about a meeting on Tuesday. The Quality people (this is shorthand for all manner of administrators whose job it is to make sure that health professionals and associated personnel provide the best service possible to the public) recommended that the Diabetes Service in this Trust should have a multi-disciplinary meeting. Despite being another potentially tedious and time-wasting get-together, I actually think that this is a necessary evil, as change and improvement is very challenging when you don't know who the decision-makers are in your own service. It helps that a couple of new consultants have joined the team, who are young and dynamic and seem to be open to new ideas.

So the meeting was on Tuesday, my day off, in the main hospital of the Trust (not where I work), and I needed to get some work done away from the distractions at home. It made sense to work in the library at the hospital, which would give me the opportunity to go to the meeting too. I set my alarm for 'early', because my Couch to 5k run schedule usually includes a Tuesday morning.

The only problem was that I'd signed up for a badminton competition that took place last Sunday. It started at noon so I'd made some sandwiches, and then left them on the kitchen table. The teams were divided into groups, and we'd played everyone in our group by half past two, been soundly beaten by all but one team, and I was getting very hungry, so I was looking forward to going home without waiting to see the semi-final and final at the end of the competition (played by the top team in each group). Then they announced that we would be playing everyone in our group for a second time...

Needless to say we were beaten all over again (even by the team who had lost to us in the first round), and it was four o'clock and I was starving. I found out when I went to club night on Monday that the only team we had beaten were the eventual winners of the tournament, which was annoying. Having played six hours of badminton over the previous two days, it should have been no surprise that I decided not to respond immediately to my 'early' alarm heralding a 25-minute run on Tuesday morning.

An hour later I managed to get up and head off for the library, except that I had a couple of jobs to do first. One was straightforward, involving a signature on a form applying for a memory stick that is encrypted so that it can be used in Trust computers - obviously the risk of downloading and exposing confidential patient information means that ordinary memory sticks are not allowed. The Diabetes team in the hospital where I work is not particularly interested in technology, so we don't have a laptop or computer projector, and the old-style overhead projector with acetates is still used extensively. A laptop/projector combination can be borrowed from the Learning Centre, which I have done on a couple of occasions, but came up against the problem of transferring the file containing my presentation to the non-networked laptop.

The other job I had to do was around verifying my previous NHS service, which was a two year stretch in the 1990's. The only reason to bother with this is because length of service is one factor that determines how much annual leave you get, and those two extra years should give me an extra two days (or is it an extra five days? I can't remember any more). I had managed to extract a letter from the NHS Trust where I had worked, confirming the correct start date, but for some reason my record showed that I had worked there until 2006, which was clearly not true. Unfortunately, my contact in the HR department was still insisting that I get confirmation of the correct dates, and suggested that I use pension records (I didn't pay into the NHS pension in the 1990's) or tax records. I thought I would take the opportunity to visit the HR department in person, and see whether they could be brought round.

It was an interesting meeting - my HR contact had never personally dealt with the tax people, but seemed to accept my view that this was not going to be a desirable line of enquiry. It then transpired that a) she had thought we were talking about my previous employer rather than something that had happened two decades ago, and b) she hadn't realised I was asking for fewer years to be taken into account than were stated in my letter, rather than more. She is going to think again, and I hope that common sense will prevail.

So after all of this, I reached the library mid-morning, then found out that I couldn't access any work information from the library (again because of concerns that patient information might be left somewhere electronically insecure), then worked out (with assistance) how to get my laptop to access the Interwebs, and then, instead of knuckling down to work, I thought I'd do a bit of blogging. Just like my old student days.

The MDT meeting was a bit of an ordeal, all about how we can collect data to show whether we meet the 13 Quality Standards set out by NICE. Obviously it is important to provide patients with a service that includes all the things that contribute to high quality patient care. It is, however, an immense amount of work to record and then collate data to prove that we offered people structured education, foot clinics, retinopathy screenings and blood and urine tests even if they don't turn up for their appointments or provide samples and we can't actually deliver the structured education within current resourcing levels. Apparently, the Diabetes team in the community has a waiting list of 560 people for their structured education programme, which isn't actually being delivered due to lack of staff, or funding, or both.

We also have Quality Standards for clinical results like blood pressure and cholesterol levels as well as average blood glucose (HbA1c). Although I don't quibble with the targets, which are set at levels that ought to reduce patients' risk of cardiovascular disease, stroke and microvascular damage, I don't think the service should be held to account if patients don't achieve the targets - there's only so much that medications and health professionals can do. At the end of the day, if patients want to eat pies and burgers and drink Lucozade then the targets won't be met even if their doctors have dosed them up with as much medication as they dare, and done their best to let them know they're not doing themselves any favours.

I managed to do the run on Wednesday morning instead.

Ante-natal clinics

Dorset, July 2013

Time passes and there is always something blogworthy going on. This week it has mostly been pregnant women - my team leader is on holiday, and my colleague RSB is facilitating a week's worth of patient empowerment (calling it 'structured education' doesn't do justice to the cult that is DAFNE - Dosing Adjustment For Normal Eating. More about that another time perhaps). So it fell to me this week to support the multi-disciplinary ante-natal clinics in both hospitals within the NHS Trust where I work. I have had my fill of pregnant women this week, what with the Royal obsession to add to the mix.

In each hospital, the ante-natal diabetes multi-disciplinary team (MDT) is allocated a room that is much too small, and the poor patients are channelled through various procedures - scans, samples, tests - before they start the proper waiting. When a clinic room is free, a patient occupies it, and various members of the team visit them until everyone who needs to see them has done so and the patients moves on to wherever else they may have to go, freeing up the room for the next victim. The team office, waiting rooms and clinic rooms are all much too hot - the radiator in one of the team offices was actually pumping out heat, with no means of switching it off on the hottest day in 30 years.

In the hospital where I normally work, the ante-natal department has just been remodelled, and the team office has been created from a room that used to be a cupboard, without any ventilation at all and with a very unpleasant lingering smell. The room is long and thin, with space for about six people all standing in a line (there is no room for a chair except at the far end where there is a computer). The MDT consists of obstetrics and gynaecology doctors, diabetes doctors, Diabetes Specialist Midwives, Nurses and Dietitians, a Healthcare Assistant and various students within all these specialities. In other words, more than six people. The other hospital has a team office that is a more convenient shape, but with little more space - except it does have a window, which even opens.

I am very new to the ante-natal clinic, having observed a couple of times and taken part just once or twice. I don't know much about what goes on during a pregnancy, what tests or scans are required and when, and I don't really understand how the patient journey is conducted, either in general throughout a pregnancy, or on a specific clinic visit. The patients' files are filled with impenetrable graphs and printouts filed in seemingly random order, and there may be several pregnancies-worth of notes in a file. I noticed that there were a couple of heavy duty electric torches in the team office, the sort that you take out of the boot of the car on a snowy night to find out what the noise in the back garden is. I was going to enquire what they were for, but then thought about what sort of clinic this was, and decided against it.

I'm not sure how the different teams operating in the ante-natal clinic fit together - reception staff, then nurses and midwives managing the routine tests, then the fetal scanning team, and then our team at the end of the line. What I do know is that in the two days of ante-natal clinics I saw more patients than in my last two weeks of clinics put together - something like 22 of them - and most of them had to wait longer than in any other of my clinics, more than an hour in some cases. The majority have Gestational Diabetes, but there were a few with Type 1 and Type 2 Diabetes. It was tiring but satisfying to be occupied so intensely, rather than sitting in a general clinic room wondering how long to wait before assuming that the scheduled patient is definitely not coming.

There are some who need interpreters - Turkish and Arabic on this occasion - and I find this quite interesting, especially Arabic. Combining my knowledge of Hebrew with my recent study session on Ramadan, I was entertaining myself by trying to anticipate some of the words used. It turns out that words for 'onion' and 'carrot' are very similar in Hebrew and Arabic, but the Arabic for 'meat' sounds like the Hebrew for 'bread'. I had met the Arabic interpreter before. She told me that she teaches Arabic at evening classes at a nearby school, and I am tempted to sign up (if my employment contract is extended).

Four more Gestational Diabetes patients are booked in for Friday afternoon, my least favourite time of the week by a long way. Two patients are booked at 1.30 p.m., who are seen by myself and a Diabetes Specialist Midwife (we swap after half an hour), and two more arrive at 2.30 p.m. In theory we are all done and dusted by 3.30 p.m., enabling me to go home at my scheduled time of 4 p.m. In practice, I'm lucky to be out of there by 4.30 p.m., and often it is later. This is on a Friday afternoon, remember, and I then have to set off down the motorway for the journey home. We are all agreed that this is unsatisfactory, but so far there has been no alternative proposal for various legitimate reasons including a key member of staff being away, and lack of clinic space and time.

I will be taking over the Dietitian role in one of the two ante-natal clinic on a regular basis starting in September, so will be making more of an effort to understand how things are done and how I fit into the team. If we can streamline the workflow a little better, it will not only improve the patient experience, but ours too.