Category Archives: Audit and Quality Improvement

Genuine patient participation: implementing change in Islington

Philip WrigleyPhil Wrigley is a Commissioning Manager in Islington where he has worked for over 12 years; he currently leads on LTCs and Self Care – prior to 2004 he was a professional actor for 25 years.

There is a scenario frequently used by visual comedians which opens with an elderly, infirm lady standing at a busy crossroads looking a little glum as she watches the traffic whizz past. Our hero, (Benny Hill, Norman Wisdom, et al), assuming that she is trying unsuccessfully to negotiate her way to the other side, takes her by the arm and merrily frogmarches her to the other side. Setting her gently down and beaming at her, he stands back expecting grateful thanks. Instead he is met with a barrage of abuse and repeated thwacks from her handbag and walking stick. The woman of course had had other intentions: she wanted to go across the other road or in the opposite direction or she was standing waiting for her friend, etc. Whatever the reason for her irritation, the point is – the last place she wanted to be was where she ended up.

The story highlights the problems of well-meaning people (in our case care professionals) who fail to take into account the real needs and goals of the people whom they are trying to help. It’s extraordinary in this day and age that we still consider actually taking note of the views of patients/service users/people to be such an innovation.

In Islington for the last few years, we have been trying to change the way that our whole workforce delivers care, by ensuring that we commission services which support and promote a more personalised and collaborative interaction with our residents who are using the health and social care system.

The change is not an easy one and involves that heart sink phrase: “culture change”. As commissioners we tend to over use the phrase and it loses some of its weight. It is important constantly to remind ourselves that changing the way people work and interact with others is extremely difficult and can be the cause of a great deal of anxiety on both sides of the interaction.

In Islington we believe that it is not unreasonable to expect residents to take on some of the responsibility themselves and to work with their care professionals to take control of their own wellbeing. In order to take that opportunity, they must be provided with the education, support and the tools to take on the shared responsibility. We acknowledge that this concept is new for both professionals and the population itself, so expecting a whole workforce to move away from the paternalistic approach to healthcare and treat patients as experts in their own care can be unnerving to say the very least.

If this change is to happen the whole system needs to be committed to the approach and the people who will drive the change are the commissioners. No single method is correct but it must also be recognised that no single method will ever be enough. At Islington CCG, we like to refer to ourselves as a “patient centred care organisation”. This may be wishful thinking but I believe we are a little further down the road towards this goal than many other organisations.

The most important thing for us has been a commitment from the top in the CCG and the Council and we are lucky enough to have some extremely charismatic and committed leaders, both at a clinical and commissioning level. Make no mistake this is crucial to any shift in attitude and needs to be in place before you can start to drive the change from the bottom up. Professionals need to be secure in the knowledge that they have the approval from above in order to start changing the culture on the ground and to be confident that this is a strategic approach.

Once the commitment is in place from people who are passionate about care and support planning you have won the first battle, though the way ahead will undoubtedly present further skirmishes. Our commissioning approach to embedding person centred care in Islington is basically not to concentrate it on a single area but to try and make it business as usual across the whole health and social care setting. We have a range of initiatives which we are using to influence professionals across the whole system. As long as the people who implement the changes at the coal face can witness the improvements to patient care, patient well-being and their own job satisfaction, it doesn’t matter that there is no single implementation process. In fact if change is coming from all angles then that is a signal that you are getting it right and that the message is being broadcast and received across the whole landscape.

There are naysayers who will complain that there isn’t sufficient evidence to show that it works, but honestly, there is actually a lot of evidence out there and even in situations where it is thin, there has to be a point when you turn and say, “It’s just common sense to treat people as grown-ups and as experts of their own health conditions”. We just need to learn to step back from our compulsion to do things for people and start to work with them instead.

Have a little faith: trainee view of audit and paint-by-numbers medicine

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

The audit process is an important part of clinical governance to ensure standardised, high quality care.  It is encouraged by medical schools and a necessity of training programmes.  But for our generation of paint-by-numbers medicine and algorithm based practice, clinical audit has become another hoop to jump through for the eportfolio.  I recently completed an audit looking at the prescription of statins in patients with chronic kidney disease (CKD).  The standards were taken from the 2014 Lipid Modification NICE guidelines which advised all patients with CKD to be on atorvastatin 20mg or an equivalent regardless of age, comorbidity or qrisk.

My search revealed several high risk vasculopaths who weren’t on statins.  Yet, the largest proportion was octogenarians for whom improving 10 year survival seemed questionable.  The guidelines did not make allowances for multiple morbidity, polypharmacy or compliance in this cohort.  I marched on nevertheless as per my ARCP requirements; however, it became clear that patients are particularly astute at nuance and picking up indecision on the clinician’s part.  I found it difficult to convince those on the fence to take the statin because of my own ambivalence about its benefit.  The implementation of change was therefore weak leaving the audit suboptimal.

The need to complete an audit for the sake of it is just one facet in the NHS and its increasing ‘obsession with grip’ (as Keith McNeil, former chief executive of Addenbrookes Hospital, puts it).  The benefits of good patient care and effective training is secondary to outcomes, stringent documentation and rigorous regulation; the art and apprenticeship of medicine is being eroded.  Yes, regulation is important and safety paramount. But experience, skill and judgement – those things we only ever learn through autonomous practice and reflection – appears to have little value in the current climate.

In this context, one thing we can do to make clinical audit more relevant than just a CV exercise, is to bring a bit of ourselves into the process and have a little faith in the cycle.  Find something that piques curiosity and is not just a recent topical guideline; an idea that makes tangible sense to you as something that could actually improve practice rather than promising to do so. This belief and commitment will be visible to and appreciated by patients and other relevant stakeholders; which in turn will provide the real impetus to complete an effective audit, one that will maintain relevant clinical standards or effect real change in order to do so.