Friday 30 November 2012

My small part in the history of Liver Transplantation. Every interaction has an impact.

I have been blogging for a few months now and I wonder if my thoughts have had any impact on anyone. However a twitter conversation with Michael Seres (@mjseres) made me think about how little things can influence the bigger picture.

He tweeted about the death of the American surgeon, Dr Joseph Murray, who with Dr David Hume carried out the first successful kidney transplant in 1954. What got my attention was that Michael added the name of Thomas Starzl to that of Murray's and said that they were his heroes - the doctors who had made his own transplant possible.

The name of Thomas Starzl made a connection for me because I did some technical work as part of his research on liver transplantation back in the distant past. I used to work at St Mary's Hospital Medical School in the Department of Experimental Pathology. It was my second job after leaving university with a simple zoology degree in 1970. Between 1971 and 1988 I was technician carrying out diagnostic work and research as part of a team.  It was an exciting time, lots of research going on, the buzz of student life, living in London - you know the sort of thing.

There were lots of researchers who passed through the labs, learning and sharing ideas, and we were involved in their work. One of those people was Tom Starzl.

He and my boss, Prof Ken Porter, had worked together for many years on kidney and liver transplants.  In fact they developed an understanding of how rejection of the transplant happened and that discovery in turn led to the development of the immunosuppressive drugs that prevent rejection. Starzl carried out the first successful liver transplant in 1967 in Denver, Colorado and later developed the use of cyclosporin, a crucial immunosupressive drug, in 1982. Their original work had taken place well before I arrived at the lab but their transatlantic collaboration had continued and they often shared ideas and carried out research together.

So there I was, a relatively new graduate technician, still learning and I suddenly found myself contributing to the work of these amazing scientists. We did diagnostic work on the transplants from Denver and also lots of research into improving the chances of survival for transplants. Prof. Starzl would come over to London every couple of years but there was a constant flow of samples to be processed, cut and stained. We did light and electron microscopy but the most exciting technique was the auto-radiography that I did to see how the liver cells were regenerating.

I am sure the two professors could have done all the technical work we did but we did it all the time and they did all the thinking! They always appreciated the work we did and occasionally added our names to their scientific papers describing the results of the experiments. It was a great honour to be associated with them in this way.  Tom Starzl was always very friendly, a charming man. I remember that he used to ride around London on a push bike.  He would bring it into the lab and store it in one of the offices.

My conversation with @mjseres made me think about that part of my life again. I did a little research (Thank you Google) and found how just how important the work of these men was to the success of transplantation.  I realised that I, in a small way, contributed to their work and to the effect it had on the thousands of people who have successful transplants.  I now realise how fortunate I was to be associated with these amazing people and the wonderful things that they achieved.

So, thank you Michael, for reminding me about how important teamwork is and how everything, no matter how small, insignificant or routine it appears, is important.

We all have influence, every interaction has an impact and can produce slight changes in the way that others think and act.




Wednesday 21 November 2012

How Health and Wellbeing Boards can involve the public

It is difficult to get the public involved in decision making about the big, strategic issues in Health and Social Care.  We are much more interested in things that concern us at a personal level.  

The Health and Wellbeing Boards that exist in shadow form in all local authority area are intended to promote the health and wellbeing of all residents in their area. Through the production of a needs assessment they will set the priorities for health and social service commissioning so that the best possible outcomes are obtained for local people. 

Or something like that anyway. 

The members of the board come from the local councils, health and social service managers and one member from Local Healthwatch. They are expected to involve the public in their work 

So I thought I would give them a few of my ideas, a few basic principles on how to involve the public. 

  1. The Health and Wellbeing Board must know what it means by 'involvement' AND the purpose of such involvement.
  2. The board must inform the public about its ideas on involvement and the purpose of public involvement.
  3. The board must inform the public about what it can and cannot do with the results of the involvement process.
  4. The board should use lots of different methods to involve the public.
  5. The board should involve the public at an early stage in the development of ideas and plans.
  6. The board should involve the public all through the process of developing plans.
  7. The board should try to ask specific questions rather than vague ones.
  8. The board should think and act 'locally' (small scale).
  9. It will be more productive to look at single issues, conditions, treatments or groups of patients.
  10. Use existing networks, service user groups, charities & voluntary sector organisations.
  11. Face to face, informal events tend to be more successful than formal ones.
  12. Go out to people, go to the workplace, the schools, clinics  shops, clubs & wards.  Do not expect people to come to you.
  13. Use language that people understand, no jargon, and ask short questions.
  14. The board must feedback to the public what information in gets through involvement and how it uses it.
  15. The board will need to inform people and educate them about how decisions are made and how evidence is used.
  16. Read the literature and research on patient and public involvement.
  17. Patients and the public are different and so they will need different approaches .
  18. We, the public will NOT be 'representative'.

 Any more ideas would be welcome.  Feel free to contribute.


Friday 16 November 2012

Measuring improvement in the quality of care after reconfiguration of NHS services

I asked a question at a public meeting of our local Health Overview and Scrutiny Committee. They have a slot for questions from the public.  I asked if the PCT and hospital would provide a baseline from which to measure the improvement in care promised as a result of the centralising of services on one hospital site.   

I have posted a couple of stories about the difficulty I have had in getting an answer to this relatively simple but important question:  "Like getting blood from a stone" & "What is a 'benefits realisation'?".  I finally arranged a meeting with the hospital managers who are delivering the data. It is really important to talk to the right people.

They were very helpful and, despite being busy implementing the changes, they spared an hour of their time to talk with me about how they are measuring the quality of care.  They reassured me that they have plenty of quantitative data, such as re-admission rates, length of stay, avoidable admissions and mortality rates from before the changes and they will be collecting similar data from the newly reconfigured services.   Now that is good news.

They will not be publishing the data until they have the first set of new data so that there can be a comparison made between the old and the new.   This data will be collected routinely and published regularly. More good news.

We had a discussion about how to present the results in a form that the patients and public can understand.  Not an easy problem to solve. 

We also talked about using qualitative data from the patient experience to complement the hard numbers.  Now I think that the patient experience is a really good test of quality.  The government thinks so too because the 'Friends and Family' test depends on patients feeling they had a 'good' experience in a hospital.  I am not sure that any time spent in hospital can be considered good though.  This sort of data is more difficult to get and use but we agreed that it is important as the patient can have a different perspective compared to a healthcare professional or a manager. 

The hospital has been collecting this sort of information for some years and they said that they will be using it in the baseline measure as well as in the future. 

So my question has been answered at last and I feel reasonably certain that they have the data, both quantitative and qualitative, to measure the quality of the services in some way. 

What will be more interesting is what will the patients and public make of it?  Do they care about tables and charts showing that the number of people re-admitted within 28 days has been reduced by 5%?  Will they care that 95% of patients in a recent survey said that they had a satisfactory experience in the hospital?  Will they use this data to compare the quality of different service providers? Will quality information from other providers be comparable? 

Only time will tell.

Tuesday 6 November 2012

The Tipping Point?

Has General Practice in England reached a tipping point?


During the last eight years, since the negotiations that led to the new GP Contract of 2004, there has been an increase in the workload and an increase in the complexity of the work of GPs and their staff. Work as moved out of hospitals and is now done in the community and in the surgery.  Most doctors work long hours into the evening after seeing patients doing their paperwork. They are checking repeat prescriptions, writing referral letters, checking the results of investigations and consultant letters.  The quality of their lives and that of their families is suffering.  Many doctors already work only 4 days a week and other for less.  This is the only way they can survive.

More recently the NHS reforms and the Health and Social Care Act has further increased the workload by making them take on the task of commissioning healthcare as part of the Clinical Commissioning Groups.

The Government has changed the pension arrangements for many public sector workers including doctors and nurses.  This has meant increased contributions and reduced pensions.

Within the last few weeks the Government has proposed to change up to 30% of the GP contract by next April. If this proposal is not accepted they will impose it. They are offering1.5% extra to practice resources knowing that 61% of all gross income is currently used to pay expenses such as staff costs. They acknowledge that GPs are looking after an extra 3.7 million people for no extra funding. In addition they are asking for an extra 4% work for no extra funding. The GPs are not impressed!

A considerable number of current GPs are in their 50's and 60's and so near retirement age. It is possible that many of them will jump ship early due to the changes mentioned above.  Certainly their families hope they will.

This could mean that surgeries, already stretched to the limit by increasing demand, will not be able to continue to work safely.

Is this the tipping point?

Is General Practice sustainable in its current form?

Will anyone want to become  GP?