I’m in the business of medicine, but do I really want medicine to be a business?

Today is the beginning of a new era in the NHS. For supporters of the Health and Social Care Act it represents the implementation of a necessary shift to cope with rising demand and cost:

“[6] The main aims of the Act are to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and patient voice; to give NHS providers new freedoms to improve quality of care; and to establish a provider regulator to promote economic, efficient and effective provision.” [explanatory notes for Health and Social Care Act]

For its detractors, it is popularly described as the end of the NHS and an entire political party has arisen as a result. The debate has often been extremely heated but generally confined to those already in touch with medical “politics”. Anecdotally  (I have no supporting evidence for this) wondering around the corridors of a random english hospital may not find you many staff with a clear knowledge of the details of what has happened on 1st April 2013.  It is this lack of knowledge that may explain, despite some of the vitriol, why contributions by members voting on the Royal Colleges support for and against the bill last year were not that impressive.

College Total Voting Members Number of Respondents Votes against the Bill Response Rate
RCPL [1] 25,417 8,878 6,092 (69%) 35%
RCPCH [2] 10,289 1,492 1,184 (79.36%) 14.5%
RCGP [3] 33,837 in England nearly 2,600 completed responses 90% support withdrawal of Bill 7.7%

Independents have attempted to explain the detail (this summary from fullfact.org is good). There is also a visual timeline of events via the Kings Fund.

A great many commentators have put their hats into the ring about what will happen in the future. I am neither experienced or wise enough to do this. As a trainee, albeit a relatively senior one, I have been disappointed about the level of information given to the future workforce about the changes. It is is a complex area, the Health Act is a huge piece of legislation with arguments of recent terminology on the section 75 amendment making the area even more confusing.

What is without doubt is new ability to widen opportunity for any “provider” to deliver services for patients. I don’t think I am naive about healthcare as a business. The NHS has always run to accounts, tendered and has paid private companies to deliver operations it was falling behind on. But I am old enough to remember a day when there was one National Rail Service. I don’t know if it was true that ‘nationalisation’ was not providing effecient, cost effective services but rail is now clearly a competitive business, even though the trains are often not competing for the same track. However, as a regular train traveller, I know my experiences between the companies are often very different, that even if they do run on time it is at a cost or comfort detriment and I certainly don’t know who best embodies the rail service.

I ask myself is this really how I want to see the NHS?


1. Results of RCP Health and Social Care Bill Survey.

http://www.rcplondon.ac.uk/press-releases/results-rcp-health-and-social-care-bill-survey (last accessed 1st April 2013)

2. RCPCH votes for Government to withdraw the Health and Social Care Bill.

http://www.rcpch.ac.uk/news/rcpch-votes-government-withdraw-health-and-social-care-bill (last accessed 1st April 2013)

3. RCGP members support withdrawal of the Bill, says RCGP survey.

http://www.rcgp.org.uk/news/2012/january/rcgp-members-support-withdrawal-of-the-bill-says-rcgp-survey.aspx (last accessed 1st April 2013)

A number counter that works within Powerpoint

This great little customisable presentation was put together by Craig Sayers in response to a request I had put out via twitter

(it did help he also happened to be my best man)

The presentation is need for something I am doing to feedback on NHS Change Day  but I suspect a counter mechanism may be useful for other presenters. Just to note it won’t work in Powerpoint for Mac 2008 (I’m trying to find out if it works in 2011!)

If you want to change any of the settings you need to go into Visual Basic from within Powerpoint.  Do this either by pressing F11 or double clicking on the Start Counter button on Slide 1 when editing it (not from within the slideshow).  You should then see a text editor-type box with the code in it.  I’ve added little comments (in green) to show which numbers need changing to do different things.  Just alter a number then close the Visual Basic window.  Next time you start the slideshow it should make the alterations.”

A huge thanks to Craig Sayers for putting this together (and providing the editing instructions)

Please send any feedback to @damian_roland or @tonythepianoguy

The presentation can be found here: Powerpoint Counter

Consent Cam: Want? Need?….Can?

It all started with the following tweet:

and in no time at all the enthusiasm for all things #FOAMed found ourselves with a number of volunteers, a catchy 4’D’ mnemonic courtesy of Mike Cadogan and a working title “ConsentCam”

  • Dissemination: the power of global conversation through #FOAMed
  • Discussion: it marks the starting point for a conversation which can continue on twitter and through blogs, then onto #SMAC2013 so that a global perspective can be obtained
  • Development: the seedling inclination to pursue a random thought can be magnified with altruistic assistance
  • Deployment: this may well result in a collaboration which leads to the production of an essential element for medical education provision

An neat summary can be found here – please do contribute to the ongoing discussion and upload your consent forms to the dropbox!

Just wanted to answer a few questions which have sprung up during the process which I thought might be useful to clarify.

Do we want this?

The proof of the pudding for me is the fact that as soon as you mention consent, apps and patients on social media you are guaranteed to get a reply. Not always constructive I may add but the debate is there. Health care professionals want to be able to share key learning points with others and audio-visual media represents a great way of doing this. If you can find me a clinician who wouldn’t want a quick way of taking a picture and obtaining patient consent with regulatory approval then I will pledge to dance the funky chicken on a live you-tube feed on #nhschangeday

Do we need this?

Using audio-visual media to enhance medical education has been happening since even before we had VHS (thats a long time for those who have never actually seen a video cassette). Discussion fora, blogs and publications abound on the use of photos to highlight key clinical signs (although probably need to be clear that the evidence of clear benefit of video does still need demonstrating!). Is it an absolute necessity that a simpler way of simultaneously consenting and taking pictures is found – probably not. Would it transform resources such as gmep.org very much so.

Can we do this?

The appetite for #FOAMed extends to peoples own time and resources. The increasing use of hack days to create bespoke health care devices and an appetite for app development at a government level means the market is awash with individuals willing to give for free their skills to make ConsentCam a possibility

Are we allowed to do this?

This is probably the only significant issue so far. As long as patient confidentiality is not breached or impinged and the data is secure it should be possible to gain approval. There will be initial caution, and potentially some critics, but the very production of guidance on audiovisual records and social media by regulators such as the GMC means engagement is more likely to happen now than ever before.

So -please do comment on the life in the fastline blog and lets make the first #FOAMed inspired, designed, produced and utilised app a reality

Was Clare Balding right? (and was it relevant I was slightly wrong)

One of the great things about blogging is the permanency of your thoughts. Ideas and thoughts developed on a train journey are often lost forever but if you can encapsulate them in writing they are always available for ongoing reflection. Comments on your work are a functional way for this reflection to be forced upon you but I’d be interested to know how many other bloggers review their material, amend, maybe even comment their now changed views?

With this in mind a while back I posted on the Network site (@thenetwork001) a brief piece on an event that occurred during the Olympics “Was Clare Balding right? Adequacy versus Aspiration”. For those outside the UK Clare is a well respected BBC journalist and presenter. It’s short enough to share below:

During the Olympics Clare Balding apologised to the nation, “I am sorry we can only offer you a bronze.” her words after Rebecca Adlington’s performance. There was an instant twitter and email response with a prompt, and sincere, apology. In a different event, but with a similar theme, a number of commentators during the games made reference to counterfactual thinking on how actually getting a bronze maybe better than a silver.

The post-Darzi drive for Quality remains a powerful influence in commissioning, service delivery and outcome metrics. Appreciating quality has rarely been defined in terms of Gold, Silver, Bronze and ‘placed’ an exploration of delivery of healthcare find being ‘placed’ a common place event. Take, for example, Medical Education; those despairing at the acquisition of a host of work-place based assessments find the target to achieve a fixed number at a minimum standard. Achieving a gold standard performance is not really an option. How about a service delivery standard? The four hour wait is one part of the Emergency Medicine clinical quality indicators along with unplanned re-attendance and left without being seen amongst others. Trusts stagger towards achieving each of the minimum required standards but it would be more than possible to cluster performance across indicators to enable ‘medals’ to be awarded for going the extra mile. 

How do you rate your own performance? – are you happy that the patient was treated efficiently or effectively? Perhaps just treated? Do you check that your contribution to their care was as evidence based as possible? Do you hope that a percentage of patients thank you specifically for your role in their care. 

Ultimately, as unsustainable as it may feel, are you happy with your bronze performance…

Reading back now, not sure I would change much, but I did get an e-mail from my educational supervisor (a line manager in a medical training sense) saying it was important I got my facts right. My immediate reaction was concern that I had mis-quoted Clare Balding! However, this was not the case – I had used the term “wait” instead of ‘target”. This may not appear to be a significant error to the casual reader but it is an important principle. The NHS four hour target is well known throughout the world. It is not a ‘wait’ though, the “target” is that the patient spends no more than 4 hours in the department from the moment they register (which includes the consultation, investigations and decision to either discharge or move to a ward). For some in the Emergency Department world the distinction is really important both for public perception and the fact the target is dependant on a number of factors outside of the control of the Emergency Department.

Ultimately this is a really minor point. However lets say I had said something very  incorrect – does this really matter? I have never had a comment on a blog from a member of my own institution, and one involved in my training. What questions does this raise about blogging (and wider social media) as a means of assessment or professionalism. Obviously stripping naked on a night out isn’t an ideal thing for a line manager to see, but what degree of error is needed in a quasi-professional social media to attract the attention of an educational supervisor? As Social Media closes the boundaries between work and home-life these questions are likely to continue to be asked.

Presentation to TASME (Leicester) 19th January 2013

I was due to given a talk to the Trainee section of ASME (TASME) on the 19th January 2013. Unfortunately the event was cancelled due to the weather  conditions. I therefore recorded a practice run through (or at least a portion of it).

It is a bit rough and ready and maybe missing an introduction about the aims (which were to talk about my experience of research, leadership and entrepreneurship).  I will probably update it at a later date and the presentation at this stage is just about the research element.

Hope it gives you at least food for thought and I have certainly learnt a great deal about narrating over powerpoint presentations! The lack of interactivity or audio-visual cues from the audience was quite disconcerting! Also on play back its amazing to hear how many unnecessary words I use so a learning experience all round….

A related resource is a storify of a question I had asked on Twitter prior to the event – click here

Peer Review – Pointless, Perfunctionary or Practical?

The twitter heaven gates opened today, although they have been building for some time, with postings around the following blog noted in the tweet below

There has been mixed response to this – some quite clear

Some more contemplative

and some amazingly not related in any way shape or form to the #FOAMed discussion but yet highly relevant!

The term scholarship has been used a lot. How do educators prove to institutions that they have been undertaking ‘scholarly’ activity by producing FOAM materials? What is scholarship? Well there are a few key papers

1. Fincher and Work (2006) Perspectives on the scholarship of teaching

2. Boyer (1990) Scholarship Reconsidered

3. McGaghie (2010) Scholarship, Publications and Career Advancement in Health Professions Education (AMEE Guide 43)

(1 and 2 don’t have a pay wall!) But I am struggling to find a definition I really like. Adrian Stanley at the University of Leicester has talked about

“Scholarship is the body of principles and practices used by scholars to make their claims about the world as valid and trustworthy as possible”

The key issue is the quoted need  (paper 1 above) to have peer review as a fail safe to ensure that standards are up held and maintained. Three issues arise for #FOAMed

i. Time

The beauty of anything #FOAMed is that it exists in the realtime of its creator. When it is ready it goes online. There is no delay. Peer review by the very nature of its objectivity requires a period of reflection which delays the product getting to the people who want to see it.

ii. Standards

Peer review is typically based on ‘peers’ judging your work against some implicit or explicit standards and then having those cross-referenced against a third party editor. These standards may vary between journals, grant reviewers or regulators but there is some criteria none-the-less. #FOAMed is  by definition what the user makes of it. If they like it they go back or spread the word and if they don’t, they don’t (and if they really don’t like it then they may tell people they don’t!). But the burden of ‘peer judgement’  is spread across many peers in what some might describe as crowd sourcing. However the open access nature of FOAMed allows anyone to have there say in a fashion that is easily counted via hits, tweets and likes.

iii. Relevance to a new age

When scholarship began the internet didn’t exist. Who would have thought 100 years ago that a musician may have more followers than an entire country (Lady Ga-Ga), who would have predicted that entire university courses may be taught without you physically being in a lecture (Distance Education at Harvard) and who would have believed that a academic conference in Australia may be accessible to anyone in the world (#SMACC2013)

So if I am an institutional director and I want to promote scholarship in my staff. Do I proceed with a system which takes time, may not be accessible to anyone outside my institution, the published beneficial outcomes only read by a small minority and in which there is no social media presence at all?  If educational resources are of poor quality – how do I know?

Or do I promote my staff producing resources which are instantly available to all, may have hits of 1000s and, if popular, are discussed across a spectrum of discussion sites. If they are of poor quality they will not get used.

Academics will continue to discuss peer-review into the next decade

IF #FOAMed is good enough it simply won’t matter

Why do you do what you do?

This blog actually appeared in its first form on the The-Network Blog site (well worth joining this free initiative if you are interested in quality improvement and health system leadership and management – there are 2000+ other members!). Its posting here was prompted by the following tweet

So writing back in July 2012…..

At the end of last week I attended the International Conference on Emergency Medicine (#icem2012) in Dublin. Like many conferences the benefits of attending (meeting friends and networking) outweighed the costs (exorbitant registration and travel) but resulted in very little practical knowledge gain.

One lecture particularly stuck in my mind and has re-shaped my enthusiasm for medicine. The speaker, from America, was introduced as a giant in the field of Emergency Medicine and an expert in paediatric emergency care. He was speaking on the topic of “Neonatal Emergencies”. About half way he started talking about a 5 day old presenting to the Emergency Department with Jaundice. His slide set finished with the comment – “stopping breast feeding can be used to confirm the diagnosis of Breast Milk Jaundice”. I have rarely been so angry in my entire life. This is not far off saying “to confirm that people get dehydrated don’t let them drink”. Breast milk jaundice is a physiological process which does not need confirming (other causes of jaundice need excluding if you are unable to do this clinically).

In the middle of the lecture I started waving my hand frantically in the air and stopped when I realised people were looking at me strangely (although this is not the first and last time that will happen). I was the first to put my hand up for questions at the end of the talk and politely asked if I had misheard the speaker in their assertion that stopping a normal process to confirm a diagnosis of no practical relevance was a useful medical intervention. The reply included a denial of being in the pay of a formula manufacturer (something I hadn’t been concerned about but now was) and the fact practices varied so discussion with the family should always take place. I remain perplexed that even in America this could be deemed a suitable practice and was relatively reassured by the number of delegates who came up to my afterwards to agree with my concern. I was also equally horrified that a number of non-paediatric emergency physicians were dutifully scribbling down every word.

Recently I have taken on a little too much and my enthusiasm for the clinical side of my work has waned. I have been reflecting on what matters most to me and which direction I should be taking. Clinical credibility has now firmly been planted back into my life plans and I never wish to become so distant from actual clinical practice that I lose sight of fundamental principles.

I am sure I said at some point in my Medical School interview I came into medicine to help people but this also includes helping my colleagues understand bad practice. On reflection this is what I do with my research, representative and leadership roles and is actually what really drives me forward.

Why do you do what you do?

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