Quality and Efficiency

Category: HospitalsA session for members of Gloucestershire Hospitals NHS Foundation Trust was held in Gloucester on October 14. It was advertised as “Your NHS — Maintaining Quality, Improving Efficiency at Gloucestershire Hospitals NHS Foundation Trust”, but it seemed to me that it failed to connect either with its audience or with its advertised title.

The two dozen or so people in the audience seemed mostly to be pensioners, and they seemed to value the NHS brand that makes separate services delivered by separate management teams appear superficially joined up. Many of the complaints raised in the session (and there were quite a few) had resulted from communication failures — very often small things that revealed where services are not as joined up as people assume.

For example, a man told the story of his prescription for three weeks’ medication. At the hospital pharmacy he was given only one weeks’ supply. No one had told him (nor, presumably, the doctor who wrote the prescription) that there is some rule forbidding the hospital pharmacy from dispensing more.

The response from the presenters to this story was that, yes, this is just the way the system works and that problems were being “looked at”. There was no sense that the system should be driven by people’s medical needs.

The presentation

The session began with a badly prepared presentation. Only some of the slides were Hospitals Trust slides, and those were all dated 2008 (although at least some of the content was, in fact, recent). The other slides were primary care trust (PCT — NHS Gloucestershire) slides, and a PCT brochure was distributed to everyone attending.

To make things worse, the main presenter was not the author of the presentation, but someone from HR. He had previously worked for a bank, and he repeatedly reminded us that he was not a clinician.

Tellingly, though, his most difficult moment came when he tried to explain an HR issue. Fewer men than women are training as doctors these days, and this trend (described rather insultingly as ‘feminization’ in the presentation) is associated with more flexible working arrangements, such as part time jobs. The audience could not see what was special about this, why it deserved to be mentioned at all. The presenter seemed unable to explain.

Another telling moment was when someone mentioned speaking to a doctor on the telephone instead of having a face-to-face consultation. The presenter reacted to the idea that doctors might want to use the telephone or e-mail as an important planning issue that “we will have to get our heads around”. It seemed to suggest a culture of micro-management that routinely makes mountains out of molehills.

Using the PCT’s slides for some of the time gave that part of the presentation an odd slant. For example, there was a list of “drivers” for the next three to five years (never mind the government’s plan that the PCT will cease to exist in that time frame). The top three drivers (of about eight) were:

  • Patient expectations
  • Treatment closer to home
  • New drugs

It was very difficult to imagine that these could possibly be the top three things that will really drive the work of a hospitals trust. They are not what a hospitals trust does, not what it is for. Rather, they are external pressures that will affect the hospitals trust slightly, changing the emphasis a little here and there.

Other items in the PCT’s presentation were even less relevant. For example, it mentioned mental health, prompting the presenter to have a swipe at the mental health trust (2gether) by remarking that anorexia sufferers cannot be treated in the county. Unfortunately for him his attempted swipe missed, because 2gether has just put in place its own team of specialists to treat anorexia and other eating disorders.

Overall, the impression that the presentation gave me was that the trust has no actual drivers, no strategic goals of its own, no sense of its own clinical purpose, and that it is entirely caught up in reacting to external pressures.

The discussion

A lengthy discussion followed, structured around five headings taken from the PCT’s brochure.

Prevention and self care‘ led to a discussion about sources of health information. There was some enthusiasm for the trust maintaining its own health information on the Internet, as opposed to linking to other reliable sources. It was also pointed out that many people do not use the Internet.

Leaflets and a telephone helpline were thought to be good ways to make information available. The NHS Direct helpline was well thought of by the audience, and people thought it would be closed (although news reports suggest, rather, that it is to be replaced with a different service because it is very expensive to run).

Urgent care needs‘ led to a discussion about how people know when to go to an Accident & Emergency department, a community hospital, a GP or a pharmacist. The PCT has run a ‘Choose Well‘ campaign to inform people, but it does not seem to have worked very well.

I had never heard of this campaign. I saw its website for the very first time when I came to write this, and I notice it does not seem to mention the community hospitals.

Planned care‘, ‘Care in larger hospitals‘ and ‘Specialist services‘ led to the audience ignoring the headings, and there was a general discussion about joined-up services. For example, some people had found it difficult to get care after being discharged from hospital, and some had found transport to hospital appointments difficult.

The presenters wanted to know which hospital procedures the trust should stop providing, but although the question was repeated the audience did not respond with any suggestions. It would have been interesting to know what they were fishing for with this question!

Someone mentioned that patients do not automatically receive a written discharge summary containing all the information they will need after leaving hospital, but another point of view was that patients who need information only have to ask for it.

The extended discussion made this an interesting and useful meeting, but it could have been much more interesting and useful if the presenters had been closer to the clinical work at the core of the trust’s operations. Then they could have run a much more focussed session that really addressed the quality and efficiency in the title.

The presenters were aware of the LINk, and one made a passing reference to the LINk’s patient transport task group when transport issues came up. However, there was no reference to the LINk’s discharge pathway task group when hospital discharge issues came up. In another passing reference, monthly reports to the LINk were mentioned, but I have not yet seen any sign of these at the LINk end of things. There was no indication one way or the other of the audience’s awareness of the LINk.

The entire meeting, therefore, told a story of patchy communications and lack of clarity at every level.


About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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