Examination of Witnesses (Questions 420-439)
PROFESSOR BONNIE
SIBBALD, MS
DEBORAH O'DEA,
DR HUGO
MASCIE-TAYLOR
AND MS
ALISON NORMAN
15 JUNE 2006
Q420 Dr Naysmith: They have got lots
of other NHS employers who have lots of other things to do as
well; how can it be made a priority, if it should be a priority?
Ms Norman: I think its priority
would be brought about because unless we get service delivery
right, we will not manage our finances properly within the Health
Service; we will not manage quality properly and we will not manage
access properly. Really, it is about modernising the way we do
things and ensuring that people are being employed appropriately,
both for patient care and also for their own job satisfaction.
Sometimes organisations need something outside themselves to assist
them with dealing with those issues. Interestingly, we are just
spending money on bringing somebody who has got their training
in the Modernisation Agency and is now working independently,
to come and help us with our radiology waits in our organisation.
In times gone by, I suspect that we might have got that service
free!
Q421 Dr Naysmith: We also had evidence
suggesting that the Modernisation Agency's approach was sometimes
too simplistic, and also that it did not involve clinicians enough.
Were those two criticisms fair? We are talking about an agency
that has now been scrapped, and that is fair enough, but we are
learning lessons for the future as well.
Ms O'Dea: We are, but a great
deal of good came out of the Modernisation Agency. You have just
heard that we are still employing people who were trained by them
and a lot of us have received a lot of training and a lot of excellent
tools, and took that out into the field. Most of the work that
I have ever been involved with, with the Modernisation Agency,
gave me tools and attributes to take out and work with our clinicians.
At the coalface, I think clinicians have always been involved
where projects have been successful. When they are not involved,
projects are not.
Q422 Dr Naysmith: Do you agree with
that, Ms Norman?
Ms Norman: Yes, I do. Sometimes
it is difficult to engage clinicians of any discipline, in something
that feels theoretical and abstract. If you can show people it
makes a difference to the lives of their patients and their working
lives, that is when you really get hearts and minds.
Q423 Dr Naysmith: So you think that
if the agency trained enough evangelists to go out there and spread
the word...
Ms Norman: There can never be
enough evangelists.
Q424 Chairman: Is there any contradiction
between national evangelists and local ownership?
Ms Norman: I think it is about
a really good franchise, is it not? You sometimes need help outside
of yourself, and that is what the external resource can give you.
However, you have to have the capability, confidence and desire
to drive that locally. You cannot just take a solution from one
place and apply it without customising it.
Q425 Chairman: You do not think there
has been a reluctance to listen to evangelists, on the basis that
"your model does not fit here"? It seems to me that
there is no great national plan, although we might have a National
Health Service, about how we should run GP practices, because
the needs of different communities are so divergent in many instances.
Dr Mascie-Taylor: I do not think
I would take the view that all general practices should be run
in the same way, because, as you point out, the needs of their
populations are very different. Importantly though, general practices,
just like secondary services, should be run in a way which benefits
the patient as opposed to benefiting the people providing the
service. If there is an area here that should be tested, it is
what is the function of the organisation, not the need for symmetry,
but a need for an absolute focus on the function. Then the form
follows that function.
Q426 Dr Taylor: Can I go back to
some areas of concern, some of which has been touched on, the
first of which is the training of doctors. With the almost universal
use of phlebotomist at the moment do medical students get practice
with taking blood during their training?
Dr Mascie-Taylor: They do.
Q427 Dr Taylor: Enough?
Dr Mascie-Taylor: Well, is it
ever enough? They do get that practice, and indeed doctors in
training get that practice. I have to say that the amount of practice
that I had as a junior doctor far exceeded my requirements. There
is a difference here between that which is necessary for training
and that which is necessary to provide a service. The important
point is, let us discriminate between the two and let us not use
people for service where it is inappropriate, but equally let
us recognise that they have to be trained. If you are clear about
the purpose, you come to the right answer.
Q428 Dr Taylor: As far as putting
up drips, do they still get enough practice with that, even though
the nurses are doing most of that now?
Dr Mascie-Taylor: In part, the
answer to your question is that nurses are doing most of it. The
difficulty I think is that with the particular patient where the
nurse practitioner may fail—what was then inappropriate
is to let the doctors do it when they are less skilled at it.
I have absolutely no difficulty with nurses or indeed any other
group of people becoming skilled in areas where traditionally
doctors were skilled. My view is that if it is a particularly
difficult access problem then you might need to call on the skills
of a particularly skilled doctor, for example an anaesthetist,
rather than making the assumption that any doctor can do it simply
because they happen to be a doctor.
Q429 Dr Taylor: That is absolutely
right. One of the first examples of skills mix, which was absolutely
crucial, was the introduction of ward clerks, which took away
paperwork from both doctors and nurses. With deficits will there
be a threat to this sort of post?
Ms Norman: One can never predict
what pressure might do to people's common sense, but I would certainly
resist that in my organisation, should it be the case. I would
hope NHS employers can assist organisations that are in difficulty,
and that we could manage what may, I hope, be a short-term financial
difficulty well, so that we do not throw babies out with the bathwater
or do things that cost the organisation more money or cause dysfunction.
Q430 Dr Taylor: You would also be
protecting nursing assistants, the people who feed the patients
who need to be fed.
Ms Norman: I think what one has
to have at the heart of the whole thing is where the patient experience
comes in and the degree to which organisations can be as concerned
about evidence of good patient experience as they are about the
financial bottom line. That has always been a hard balance to
achieve. For organisations which aspire to be successful foundation
trusts, for example, they will not prosper if the evidence about
patient experience—and we have national surveys now that
can tell us if people do well or not—if those surveys suggest
people are doing badly, one of the questions in the national survey
is, for example, whether you got the help you needed with being
fed. If you find yourself falling to the bottom 20%, I would hope
the commissioners of your services would take an interest, and,
more importantly, that you would be interested in dealing with
that.
Q431 Dr Taylor: Can you expand a
little bit about nurse practitioners improving continuity of care?
One of the complaints I get consistently, particularly about in-patients,
is because of shift systems and continuity of care goes by the
board. Are nurse practitioners in a position in hospitals to assist
continuity of care?
Ms Norman: I think they are. We
have a system which is very common in many hospitals, where you
have a group of colleagues who work out of hours, supporting the
medical teams, forming the first line of support. They will be
on duty for a period of time during the week, and some patients
will see them quite frequently. Sometimes you may consider the
patient gets discontinuity because they may get a different person.
I suspect what is important to that patient is that the nurse
on the ward gives a proper brief and hand-over; and if that patient
is in pain or requires the siting of a cannula or they require
the commencement of treatment, my view is that what the patient
wants more than anything else is that that happens quickly and
competently. We obviously have to be concerned about not fragmenting
the care that patients get, but often it is efficiency, speed
and quick response to the need. If I can give you an illustration
of where this works well; we have colleagues working with teams,
largely in the out-patient setting, called nurse clinicians, who
effectively do the work that registrars used to do. So we now
have a colleague working in a firm or practice who has her own
out-patients' clinic; she works alongside the professorial team;
she undertakes quite invasive procedures for patients; and she
is somebody who, particularly for patients who have survived the
treatment but may require further intervention—she is the
continuity that has been there for a decade. That is what nurses
can very often add to the party for the patient, if you like.
Q432 Dr Taylor: The point that Professor
Sibbald made was that in some cases where nurses are taking over
work, doctors are not giving this up. Can you give us some examples
of that? What sorts of things were you thinking of?
Professor Sibbald: Nurses and
doctors both dealing with minor and self-limiting illness in patients
who are on same-day appointments in general practice—coughs,
cold and flu. Instead of surgeries being arranged with some sort
of triage for those patients that are directed to the nurse, both
the nurse and the doctor will continue seeing those patients.
Those types of problems are almost limitless in the population.
If you offer the places, the patients will fill them up!
Dr Mascie-Taylor: On continuity
of patient care, we can no longer rely on particular staff working
very long hours. We have not yet fully replaced that. We have
to look at single sets of notes—multi-disciplinary team
working and IT solutions. It is a real problem.
Q433 Dr Taylor: Single sets of notes
between nurses and doctors and all professionals, including psychiatrists?
Dr Mascie-Taylor: If appropriate,
yes. There may be some difficulty at the margins.
Mike Penning: They would have to be handwriting
experts!
Q434 Dr Taylor: So, single sets of
notes. Are we really coming towards that, whereby nursing and
medical notes are being combined?
Dr Mascie-Taylor: We are undoubtedly
moving in that direction. We need to move more quickly. More importantly,
it reflects an attitude of mind that what matters is not which
profession you are in, but that we are caring for the same patient
and the information can be shared. That is the challenge. The
challenge is not a physical set of notes; it is the attitude that
underlines multiple sets of notes. You can drive that through
IT solutions as well as in a number of other ways, which we can
discuss if you wish.
Q435 Dr Taylor: How are improvements
in technology affecting skill mix?
Ms O'Dea: Sadly, a number of my
staff find themselves jobless this week because of NHS jobs, which
was absolutely marvellous. We have saved hundreds of thousands
of pounds by having jobs on the Net rather than having to advertise
them, and by linking our workforce systems directly into the NHS
jobs network, so that we do not have to re-key. Nobody has to
photocopy bits of paper or run round the hospital handing them
out. I will end up with a group of staff that are more senior,
and more professional staff and less junior staff. We are having
to redeploy those staff, but that one action will have saved the
NHS hundreds and hundreds of thousands of pounds through technology.
Q436 Dr Taylor: Can you think of
any clinical technological advances that have reduced—
Ms O'Dea: PACS. It is fabulous
in what it does. Not only has that reduced the need for hundreds
of people in dungeons in hospitals to run around and try to find
films, and then try to get them to the right place at the right
time; but it also means that doctors have access to those images
immediately the patient is there, and anywhere for teaching. It
is fantastic!
Q437 Dr Taylor: How generalised is
PACS now?
Ms O'Dea: It is increasing.
Dr Mascie-Taylor: It is becoming
more generalised. It is an expensive system to put in, and I think
one of the difficulties with PACS is that—
Q438 Mike Penning: Where there are
deficits. Where there are financial problems, it is not coming
through.
Dr Mascie-Taylor: It is not simply
deficit; it is about the cost of—
Q439 Mike Penning: But it is a real
problem.
Dr Mascie-Taylor: It is a problem,
but then in medicine in its broader sense you will spend whatever
money is available. The skill of management is to make the best
use of resource. PACS drives through quality of care. What is
less clear about PACS is that it will cut cost, so again we need
to be clear about the objective. If you are looking to improve
quality of care, PACS will do it; if you want to reduce costs,
it will not. It is the same discussion about skill mix: what are
you trying to achieve?
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