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'We won’t win Brain of Britain as long as protocols deskill us'


My wife is away and I have a cold.

I know what you’re thinking and I agree; what sort of woman goes gallivanting around the country when her husband sits on the cusp of man flu?

The flighty little madam takes off for the north leaving me alone (yes, my daughter is here but mostly tuts when I suggest she might want to put the kettle on) to decide at what point of the day I should drink hot lemon.

Frankly, there was a time on Saturday night – it was during Radio 4’s Brain of Britain and I realised that I had answered only three questions correctly – when I wondered if the darkness was descending. Fortunately, something primeval kicked in; call it resilience, call it courage if you like, but I realised two very important things. The first was that I never get more than three questions right on Brain of Britain before falling asleep and the second was that I was falling asleep.

Anyway, the reason for my wife’s absence in my time of need is her octogenarian mum has just had a hip replacement and my wife went to help. Mrs B is a redoubtable and independent woman of strong Irish working-class stock. Fit, independent, healthy and, like many women of around her age, was increasingly unable to walk comfortably and was told she needed a hip replacement. She baulked at the idea having already had one but her doctor quite rightly pointed out that a new hip would mean renewed mobility and less pain, so she relented.

As it turned out, this wholly healthy decision did not sit well with the protocols that in these modern times dictate what comes next. Had Mrs B left the surgery and thrown herself down some stairs fracturing her hip, she would have required non-elective surgery. As it was, she simply agreed to the operation and waited for a time. And a time was sent.

Well, in all, eight appointment times were sent, two of them arriving on the same day in different letters. Mrs B shrugged and smiled at these modern ways and her daughter phoned a harassed and socially unskilled appointment maker for clarification. “Which letter came last?” she snapped. “Well, two of them are dated the same and arrived on the same day. Do you need to know which hit the mat last? Because there is no way of knowing.” Another letter was sent. Another date. She got there in the end.

The surgery went well. Well done clinicians for doing the health intervention, except the nurse who “had” to ask Mrs B if she could be pregnant – you might want to use your assessment skills there, particularly given you knew her age to be 82.

However, post surgery, the system kicked in, robbing anybody of the opportunity of doing the obvious things well. Elective surgery means no proper follow-up care. Discharge was done quickly with no home visits. Mrs B didn’t mind; she had daughters who would help – not that anyone asked her or a family member about her home circumstances. Mrs M in the bed next to her, however, had no daughters and a son in another country. She was discharged too. Out of sight out of mind?

Do you ever wonder how we got to this place? How clinicians and services were undermined by protocols and deskilled by process? I do. And I wonder how patients experience being nursed not by people able to take into account personal circumstance but instead by forms? Standardised procedures, right? Pathways and protocols that measure effectiveness, yes? Sometimes doesn’t that just amount to unconsidered and half-hearted care provision?

Mark Radcliffe is a senior lecturer and author of Gabriel’s Angel.


Readers' comments (3)

  • It is true that some healthcare practitioners seem to think they will get thrown into prison or the world will end if they deviate from "THE PROTOCOL". Luckily I think (well I hope) these people are in the monority.

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  • well, I consider myself a fairly typical example of the fair sex and was rather surprised by a young doctor who wanted to prescribe some medication for me, and staring at his computer screen, inquired whether I had a history of prostate problems! I had seen him quite regularly prior to this and had assumed that he had established the fact that he was dealing with a female patient!

    I offered him a brief anatomy revision lesson but he seemed to think this was not necessary! Perhaps it was just his glasses that needed cleaning or a new prescription for the lenses.

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  • michael stone

    Protocols do 2 things:

    1) they make people who are inexpert and would probably not make decent choices, and need 'tick-box' guidance, usually make a better decision, and

    2) they fail in complex situations which are also rare (because any simple set of rules, must perforce ignore the deges of the distribution spectrum or else it would be too long to actually use), and they seriously annoy the people who are expert and experienced enough to be using their own expertise !

    Typical example; 'lower the landing gear before you touch down'. Yes, normally good advice - but if you are landing on water, instead of a runway, lowered wheels will catch the water and act as a pivot, throwing the plane nose-first into the water, and probably killing everyone on board. Ditto working through an engine re-start check-list if your engine fails at 1000 ft, when before you have worked through it you will be dead !

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