Hancock’s half hour and condiments

Been kind of distracted by a focus on condiments this week in our newly, unexpectedly empty home. A tweet about condiment gathering earlier generated a cracking list of missing flavours and textures. Thank you.

Meanwhile, Matt Hancock, Secretary of State for summat and summat gave his first patient safety talk earlier today. It took months for the Department of Health/NHS England to comment on the findings of the #leder review. They were, however, able to publish the text of this talk immediately. Kind of extraordinary really.
Without wanting to give any spoilers, it’s seriously shite. (Comments in bold.)

Thanks for having me today.

Anyone who has had family members needing care knows what it feels like to sit and wonder whether or not someone you love is going to be OK. You take it for granted that the care you receive will be safe, but sadly we know that’s not always the case.

Crumbs. Bit all over the place here. This is the guy who called health professionals ‘carers’ the other day mind.

Ensuring patients are safe underpins everything we do. I’ve set out my early priorities – workforce, technology and prevention.

What does prevention mean?

Patient safety is the golden thread that runs through all of them.

Eh? Golden thread? Why? How? What do you mean? Did you initially forget patient safety?

I’m fresh off the night shift with the fantastic staff at Derriford Hospital in Plymouth so forgive me if I look a bit tired!

White noise.

The compassionate and good-humoured nurses, doctors, managers and paramedics I met all told me the same thing: they focus relentlessly on patient safety.

White noise.

They said they need safe systems around them. Opportunities to learn from mistakes are crucial. And a culture where staff are empowered to speak out when things go wrong.

In my first few days in the job, I agreed with Dr Aidan Fowler, the new NHS Director of Patient Safety, that the new national patient safety strategy will mean safety is cemented into our long-term plan for the NHS.

NHS Director of what? [Just googled, he’s NHS Director of Patient Safety of NHS Improvement.]

What does ‘safety is cemented into our long term plan mean’? What do these words mean Matt? None of these words mean anything.

I want to pay heartfelt tribute to Jeremy Hunt, who led this agenda and drove it for so many years. Be in no doubt: we will drive it for years and years to come.

How much longer do you anticipate driving an agenda for patient safety? Do you not work to clear, measurable outcomes? Surely you should be looking to removing the need to ‘drive’ stuff not boast about driving it for years.

We’ve made huge progress over the last few years. The CQC is internationally recognised for its inspection regime – driving up standards across the NHS and improving care for patients.

Is it? Where’s the evidence?

Patient Safety Learning have put forward a very positive set of proposals. Dr Fowler will soon set out an exciting and powerful vision for patient safety over the next decade. Every patient – whether in hospital, at home, in a GP surgery – expects compassionate, effective and safe care.

Who or what are Patient Safety Learning? Why are you talking at an event organised by this group? What is exciting and powerful about expecting ‘compassionate, effective and safe care’? There’s nothing new here.

To achieve that, we need to improve learning, we need to better shout about the work that the best trusts are doing, and the NHS must be as open and transparent as we can.

Christ. Who wrote this? You are saying nothing new incredibly badly.

Commitment to learning

There are many figures I could quote – numbers of errors, adverse events. But in some ways they hide the real issue – which is the impact on people and families.

A bit of actual evidence would probably be useful here. So far you’ve demonstrated no evidence. Just words.

I won’t ever forget, James, the hot summer day you came into my office in the department overlooking Parliament and told me the sad, sad story of Joshua. We cried together, because nothing can bring Joshua back. And in so many ways the huge progress on patient safety is his legacy. James, I pay tribute to your work, to this series of conferences, and to your publication today which is a blueprint for the change we need to see.

Eh? James? James who? The same James who organised this gig? Can we have a bit of transparency around your involvement in this event? Chumminess is deeply unprofessional and concerning.

We’ve heard today of the things we can all learn from those tragic events at Morecambe Bay. We’ve also heard of the emerging lessons from the first few HSIB investigations.

These lessons are vital. We must learn from them in our quest to make the NHS the safest healthcare system in the world. And we must apply those lessons to the whole health and care system.

‘Those tragic events at Morecambe Bay…‘…emerging lessons from the first few HSIB investigations’. An exemplar in a light touch Hancock talk and more words. Just words.

Safety is not just about telling people to do better. Patient safety is about accountability, not blame. It’s an irony that to build a safer system we need less of a blame culture.

When is safety ever about telling people to ‘do better’. We saw a tot riding one of those wooden bikes without peddles across the road earlier. He got a bit of speed on and his mum, some way behind, started shouting ‘stop!’ to him. She didn’t shout ‘do better!’ The poverty of understanding, knowledge and engagement here is woeful.

Instead, we need transparency and accountability in a positive culture, where people can have the confidence to be self-critical, because only then will we get the continuous improvement. And we need to improve the systems and processes that support staff. All with the goal of minimising human error.

Words.

The Learning from Deaths programme has been a major step. It means trusts better understand where care needs to improve. And it says trusts must have proper arrangements for learning from deaths of patients including, crucially, supporting and engaging with families.

Words. Meaningless words.

And from April, medical examiners will significantly overhaul the way we learn from the care given to patients who die. They will confirm the cause of all deaths that don’t need to be investigated by a coroner. Bereaved families will be better involved and offered more opportunities to raise concerns so we can ensure that we learn from mistakes and more families don’t have to go through the agony of unnecessarily losing a loved one.

Christ Matt. Do you not think about any of this stuff before saying it? And those listening, do you not critically engage with what he’s saying? It’s not happened so far and it certainly won’t happen magically from April. Do you have any understanding of concerns around the coronial process? Around Prevention of Future Deaths reports disappearing into the never never? Introducing medical examiners (and the myriad questions around this role) won’t lead to better involved families.

At a national level, the Healthcare Safety Investigation Branch is a world first. It uses independent professional investigators to get to the root cause of some of the most serious patient safety incidents.

HSIB CEO Conradi earlier today spoke about the lack of knowledge about and engagement with this body (because it’s also shite and doesn’t have a clue about communication). And it ain’t independent.

But I still want to go further. We will set up a new independent body to conduct investigations.

We have published our Health Services Safety Investigation Bill in draft, and I want to hear your views on how it should work.

And I want to ensure Professor Tim Briggs’s excellent work on ‘Getting It Right First Time’ helps us spread best practice on patient safety across the NHS.

The National Clinical Improvement Programme is emulating this approach at a consultant level. I was really impressed to see there’s a way for doctors to be totally upfront, sharing their individual clinical outcomes so they can learn from each other.

Eh, new Bill? Briggs? National Clinical Improvement Programme? You’re skittering around stuff quicker than a skittering squirrel. Slow down. What do you actually mean? What are you talking about?

I also know that there’s often a case of information overload. Multiple patient safety alerts about a huge range of issues, meaning it’s hard to prioritise which matters the most.

The irony. The fucking irony…

So Aidan Fowler will head up a group of experts who will help you understand the clear actions that need to be taken, protecting patients from the most serious risks.

Who? What group of experts? What ‘you’ do you mean? Health professionals? The public?

Opportunities of technology in health

Hancock suddenly switches on here and begins to talk with a bit more confidence.

Finally, we must harness the power of data and technology. IT issues can lead to patients being given poor care because systems don’t communicate. Ultimately lives can be lost.

Such blatant disconnect/hobby horsing here. We know lives can be lost. You’ve touched on this above remember.

We need to use cutting-edge technology to deliver safe, high quality and patient-centred care. And we need to use transparent open data to be able to spot anomalies that might indicate systemic failures. We’re moving towards full roll-out of electronic prescribing and medicines administration in secondary care to extend inter-operability and reduce medication-related error.

On a roll Matty boy, on a roll. Safer ground (ironically) from the above fudge stuff.

Our new Patient Safety Incident Management System will improve how we capture and spread the insight that we can gain from incident reporting in the NHS, harnessing the new opportunities for analysis that machine learning can offer, to ensure our safety intelligence remains cutting edge.

This ain’t the answer.

And we must – we must – improve the way we spot sepsis and save lives starting with our new ‘suspicion of sepsis dashboard’. Sepsis is such a devastating condition and I’ve been so incredibly moved listening to stories from families who have lost loved ones. We must do all we can to stop it.

The new dashboard will measure the number of patients who come to hospital with serious infections, and give quick information so doctors can see which of those infections cause patients to deteriorate very quickly and help them understand which treatments are most effective, and how to intervene quickly.

In the future, all this data will be used to help analyse which infections most often lead to sepsis. It is yet another example of how technology has the potential to improve patient care in the NHS when we can get the systems to talk to each other. And I’d like to thank the clinicians and experts at Imperial who have helped develop it. It is the next step in the NHS’s fight against sepsis. But we need to go further.

No comment.

No complacency

Improving patient safety is a determined and unwavering commitment for us all. We must constantly strive to listen to patients and their families and listen to staff so that we can learn from mistakes, be innovative and continually improve.

We need a culture of humility, openness and learning. There is no room for complacency.

I want every one of those staff who care for patients to be able to work safely and deliver safe care. I want patients and their families to have total confidence in the care they receive. I want the NHS to rise to the challenge of being the safest health system in the world.

That is our goal. We can achieve it. And I look forward to working with all of you to get there.

The end. Zero confidence in this man achieving anything meaningful. A jumble of poorly written, ill informed and empty words.

An inventory of stuff, silence and grubby feet

I’ve gotten into the habit of looking at family photos with a (love drenched) forensic lens. Trying to remember the moment, the meaning of the moment, bits around the moment… the colour, detail, design and detritus. The grubby feet.

Those grubby little feet.

“Plain tops, different coloured plain tops if possible. That’s all,” said the photographer cheerfully in advance of Rich’s surprise 40th birthday photoshoot. We sorted this instruction with plotting and excitement. Magic captured in the glow of the photo. I missed the finer detail at the time and for years. The earthy, organic, dirty detail.

Give me those grubby little feet to hold for just one moment more… please.

I love photos. I’ve always loved photos. Now I examine peeps, objects and stuff in and around photos. Peering beyond, at the outer edges of the image to try to see more.

When someone dies unexpectedly (maybe any time someone dies) you’re left trying to make sense of, and hold on to, stuff desperately. Precariously. Trying to keep the person, not alive because you know they’re not, but real and crystal clear.

This week Rich and I have been home alone. Unusual silence. Quiet silence. He found a (rare) photo of me with Tom as a baby. On a family day out. London Zoo yonks ago.

The memories. The wonder. The logistics. The weather. Stand out moments. Remembering getting home after. Tired, grouchy, overwhelmed kids. Shortcuts and grubby feet.

“Blimey,” I said, looking at the photo. “I can actually remember eating those sarnies…” [Plain. Cheese. No frills. Sliced (by us) cheddar].]

I’d forgotten about the top I was wearing.

“I always liked that top”, said Rich.

“Where did it go?” I wondered.

Bulk buying Weetabix

Tom’s off to Sheffield University today.

The tears started in a supermarket aisle a week or so ago. I’ve been kind of distracted by the timing of the #leder non-response published this week. Pre-publication leakages, conversations and ever present rage. ‘Campaign’ shite as ever bleeding into and polluting key moments. Life moments…

Weetabix

Seven year ago (seven years…) when Rosie went to university I was in pieces. I was a wreck. Blissfully unaware how deep ‘in pieces’ can go.

Will and Owen went under the wire almost, getting degrees with/despite a backdrop of the inquest, other hearings and so much more.

The supermarket thing was around buying cereal. I went to get the bulk pack of 72 Weetabix. Tom’s been a regular daily sixer for years…

‘We don’t need a big pack’, said Rich. ‘Tom’s going to Sheffield on Sunday’.

Nought to 10 on the Sooty tear front.

Eh? How? When? What?

The aisle dissolved.

Years ago Tom said he’d like to live in a house in which the cereal didn’t fall off the fridge when it was opened.

How did we leapfrog from falling cereal boxes to death, bereavement and a massive fuck you fight? Getting to an empty home without the tumbling, bumbling, brilliant bunch of pups who have taught us so much about life, love, decency? Where did the years go?

I miss LB so much it’s sometimes like a kind of careening thing that ricochets (is this a word?) off discordant surfaces and dazzles and blisters an unbearable raw pain. Other times I hold him so fucking tight in my heart I feel the warmth, power and love of an elephant march that brushes aside the relentlessly offensive and grotesque actions of those who should know better (and I suspect do).

Sheffield

Will, Owen and Owen’s partner Catherine pitched up unexpectedly yesterday. They all rock ‘siblingstuff’ in a beautifully understated and full on love way.

Footy watching, Fortnight playing, nosh and banter. I cooked, crocheted and cried.

We’ve landed an ’empty nest’ card we never expected or anticipated. And a set of grown up kids who I love off the planet.

Tom, have a brilliant, extraordinary time at Sheffield.

❤️

Crocodile tears and the ‘do nothing’ advice

Early morning, a column by Clare Gerada appeared in my twitter timeline. Gerada is an ex-chair of the Royal College of GPs so no fly by night. She campaigns (as part of a heavily, heavily NHS England funded gig ‘Practitioner Health’) about doctors’ mental health. This week there has been coverage of doctor suicides with some loose reporting of figures (there were 81 suicides not 430*). Gerada is trying to extend the Practitioner Health service beyond London.

I dunno. You can sit on either side of the fence, or on it. As is too often the case with the NHS following the dosh is an instructive exercise.

‘Sensible advice’ say some replies to Gerada’s column. ‘Best advice I’ve ever seen…’

The heading kind of made my eyes water. Those blooming tears. Still.

Do nothing… immediately.’ I can only now imagine this ‘luxury’ over the past five years. There is no space to ‘Do nothing… immediately‘ for families. We face years of unrelenting, unremitting fighting, policing, and uncovering. Pretty much every NHS related scandal is the outcome of persistent, committed and astonishing actions by families and their allies. Activity that allows no downtime in a grief drenched space.

‘Do nothing… immediately’

‘When a complaint lands on your desk…’ says Gerada. Deliberately disembodying the ‘complaint’ from the person making it. And the space in which it materialises.

The person (human) who probably never dreamed of making a ‘complaint’ to the NHS. I mean why would you? Why would any of us**? It’s a national institution. A treasure. Free healthcare at the point of delivery and all that…

How often do we actually make a complaint about stuff? About trains, airlines, education, retail outlets, telecoms, restaurants? Why would any of us want to make an official complaint against the NHS? What would make us feel driven do this? Complaints in any setting are important for improving service. Complaints in the NHS are crucial because they involve lives.

For Gerada the complaint isn’t delivered or received. It ‘lands’ on the workspace. Disconnected from action and intent. Allowing her to (brutally) focus solely on the practitioner.

‘Do nothing’, she advises. ‘If you can, take the rest of the day off.’ Take the rest of the day off…

‘Do not rant and rave…’ I still can’t understand why the assumed position of a medic would be to rant and ‘rave’ about a complaint. Getting a 3/5 mark on student evaluations is enough to cause some right old soul searching/scrutiny of our learning and teaching practice at work (even after 10 years). The idea we would leap straight to defence of our practice – to ranting and raving – is baffling.

‘Wait for the first waves of shock to pass…’ Still no consideration of the person or family who made the complaint. Of what they may be experiencing; their pain, distress, grief. The piece descends into a google translate type extract. Clunky. Missing meaning. Swerving on substance. With the odd hand grenade planted between platitudes: ‘At the earliest opportunity contact your medical defence organisation (even if the complaint is trivial)’.

In short, Gerada’s advice seems to be ignore the substance of the complaint, buggar off for the rest of day and get your legal defence ducks in line. She ends with ‘don’t suffer in silence and don’t take it personally’.

Wow. Just extraordinary ‘advice’.

She has previous on complaining.

And clearly remains obdurate on the subject. A road traffic accident… From last night.

What I don’t understand is why there remains little critical (in a good way) and open questioning of what is clearly shite and offensive advice by medics. It’s as if once harm has happened or been done, the drawbridge is raised and the profession becomes a pack.

Where is the thought, the reflection. Humility. Or challenge?

*This is in no way to dismiss, belittle or otherwise every health professional who has died.

** For the sake of transparency, I made a complaint to Southern Health NHS Trust when LB was in the unit. I said they didn’t listen to my concerns about his care. About 5 days before he drowned in the bath I was told it was not upheld.