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How can we make healthcare services 'as good as the best'?

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The Reith Lectures used a series of scenarios to explore how healthcare can be improved. Specialist nurse, Catherine Gleeson, has analysed these lectures and looked at how the lessons relate to everyday care.

The Reith Lectures, broadcast on BBC Radio 4, provided inspiring messages for health professionals – including nurses. 

The lectures focussed on challenges worldwide of making healthcare services ‘as good as the best’.  Delivered by Harvard Professor of Medicine Atul Gawande, a surgeon and leading thinker on public health, the lectures were more about attitudes, behaviours and teamwork than advances in medical science, per se. 

In the first lecture, “Why do doctors fail?”, Gawande used a personal example of his son, who was born with a heart problem, to illustrate the challenge. 

The baby was referred to a paediatrician who made an accurate diagnosis. Surgical treatment at 11 days old, with a further procedure at 14 years old meant that he could live a normal life. 

In contrast, a child with the same condition in the next bed had had delayed diagnosis, leading to liver and kidney failure, with the only hope of any normal life being of transplantation. 

Gawande explored the question further, outlining the challenge for modern medicine as being that of doctors (and all health professionals) asking themselves “ to ….fulfil their duty to make it possible for others?”

His conclusion was that the only way this can happen is by “..removing the veil around what happens in the clinic, office or hospital…”, thereby “…making what has been invisible, visible”. 

The second lecture entitled ‘The Century of the System’, was especially relevant to our NHS in building upon his theme.

Using another scenario, that of a three year old girl who, in 1999, had fallen into icy water and was eventually saved. 

This was achieved by the team taking a systematic approach to restoring each bodily function, leading to the child’s ultimate recovery and discharge home. 

The case exemplified the diverse complexity in medical care, and the challenge of how to make such successes ‘the norm’ for others. Making this happen is not easy, but the problems to be overcome in each situation are the same – of identifying barriers to change and finding ways to enable implementation of standards based on scientific knowledge. 

The World Health Organisation’s project aimed at reducing deaths in surgery led to development of a ‘checklist’ covering known key aspects of safety in the operating theatre and seeing how they all fit together. 

Implementation of the checklist has led to major reductions in average complications (by 35%) and deaths (by 47%). 

Survey data of surgeons revealed that around a fifth were reluctant to implement it, but when asked if they were being operated upon themselves, almost all (94%) said they would like the team to use it.

“Implementation of the checklist has led to major reductions in average complications and deaths”

Moving closer to home, just two hospitals in England have been rated as ‘Outstanding’ by the CQC. As reported in Nursing Times (26 September 2014) Frimley Park Hospital NHS Foundation Trust was the first in the country to be rated as ‘Outstanding’, followed  six months later by Salford Royal (Nursing Times 30 March, 2015).

On hearing about these outstanding ratings, I wondered how these two NHS Trusts had fared in relation to the messages from the Reith Lectures. 

A check of their Quality Accounts (QA) on their websites showed a strong focus on clear leadership. 

Data on indicators of nursing quality in the NHS Safety Thermometer show year on year improvement with, for example, Grade 3 and 4 pressure ulcers being almost totally prevented. 

The veil has long been removed at Salford, which is an excellent example of presenting its QA data in a very clear and user-friendly way for the lay reader.

In the 4th Lecture “The Idea of Wellbeing”, presented in New Delhi, described a project about handwashing by birth attendants in North India. 

The aim was to embed handwashing into the routine work by birth attendants. Success was only achieved by identifying the gaps in each situation, and helping the attendants to find solutions. 

“Success was only achieved by identifying the gaps in each situation”

These included:

  • making it known that handwashing matters;
  • getting ‘sweepers’ to bring a basin of fresh water and soap to the delivery room as part of the cleaning routine;
  • medical officers in charge ordering supplies of alcohol hand sanitizers for the birth attendants.

But, at a system level, a discouragement to good care everywhere is “no one notices excellence and no one cares”.

Gawande highlights this as “the biggest cause of burnout for frontline healthcare workers worldwide”. 

His hope is that by investing in the science of how systems succeed and fail will reveal better solutions to making medical treatment and care as good as the best.

Catherine Gleeson, MPhil, RGN, RSCN, RCNT, SN Cert, Dip in Asthma Care, Dip in COPD, Steering Group Member of Healthwatch and Public Involvement Association (HAPIA)


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Readers' comments (1)

  • michael stone

    I listened to the lectures, but cannot recall much, beyond that Atul Gawande was saying essentially the same things about end-of-life, that I keep banging on about.

    Catherine mentions 'at a systemic level', and by coincidence I was writing very recently about the problems of 'systemic behaviour' in a BMJ rapid response:

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