I've written a lot about the Francis inquiry into the failings of the Mid-Staffordshire NHS Trust. One of the most troubling findings was that in order to save costs, management had cut staff, primarily nursing, to levels that could not assure patients of a safe experience in that hospital. There is much chatter about what is a safe nurse-to-patient ratio going on right now. Notice that it is "nurse" to patient, not clinician to patient.
What could this mean? Physios could be sacrificed to provide a quick and easy fix to the nurse-to-patient ratio without changing overall costs to the NHS. This is dangerous because it doesn't really take into account the full spectrum of patient need, experience and outcomes. The Chartered Society of Physiotherapy (CSP) has already mobilized to ensure this doesn't happen. They are preparing materials on how outcomes in different settings, services and teams are not dependent solely upon nursing. The emphasis will be on sustaining service quality, reflecting all staff roles, and potential risks to patients and safety.
What I really like about the CSP is how nimble they are. As the playing field changes, they respond immediately with proactive plans to address challenges as they arise. I always thought the NHS was a bureaucracy beyond compare, but it actually changes much quicker and more dramatically than CMS does back in the States. The CSP has to work at an equal if not quicker pace. For that I have no problem paying my annual dues.
Next week I'm giving a presentation to the local authority and public health department on the problem of falling in older adults and what needs to be done about it. It's helpful that this is the same town I did my master's thesis on and that I'm starting up a falls service within.
What's really exciting is that nobody has the breadth of knowledge I do on this subject! I'll be giving the same presentation at the Northeast Regional Falls Group (a consortium of specialist doctors, nurses, physios, psychologists, and OTs from this region of the country) to demonstrate how the NHS (health services) and public health (prevention) can work together. The goal is not just how to deal with rehabilitating those who have fallen, but how to ensure fewer people fall over the next 20 years. During that time period, the population of older adults will grow by nearly 20% and the financial cost would be devastating.
I have prattled on about how physios (PTs) need to think beyond clinical degrees in order to effect change in the larger scope of things. An MPH, MBA, PhD, even MD will open doors not previously welcoming to PTs. It has taken me time, more than I expected, but I'm paving the way for younger PTs to assume leadership roles in the design, formation and implementation of healthcare. I think that degree might be paying off after all.
The National Health Service was in the news again this weekend, and not for good reasons. The children's hospital in Bristol has a high mortality rate. The medical director of NHS England, Sir Bruce Keogh, has ordered an independent review of the matter, which is remarkable in that normally investigations have to go through numerous levels before getting his attention. The hospital's chief executive defended the "good clinical outcomes" of her Trust, pointing out "98 percent of its patients' parents said in a survey that they had received excellent, very good, or good care." Patient perceptions are "good clinical outcomes?" Really?
I've written before about the imbalance between qualitative and quantitative measures used here in the UK. Both are important and neither should stand alone. One of the most widely disputed targets here in England is the 4-hour maximum wait time in Accident and Emergency Departments. The mid-Staffordshire Trusts did very well on those quantitative measures, but people still wound up dying unnecessarily.
We seem to be forgetting why these measures are in place in the first place. We want to be able to determine if our services are actually doing what they're supposed to be doing; getting people well and treating them well. If all we're doing as leaders is trying to achieve a target, we will fail.
This is not a situation unique to the UK. One need only look at the Medicare website to compare hospitals, home care agencies, and now even physicians! In the past, I've used the tools available on this site to see the rankings of providers I knew. Some brilliant companies were ranked low while some dodgy ones were ranked highly. So what do we really learn from these scores and how does that help us shape the future of healthcare?
I'm reminded of the old saying, "The operation was a success. Too bad the patient died."
I've just spent 10 hours on a plane. That is a long time and doesn't take into account the hour-long flight from Newcastle to Heathrow or the 3-hour layover in Heathrow. Of course I'm coming home to visit my mom, so it's worth it. However, I think we have the major airlines to thank for any future pain-relief work coming our way.
The equipment was an aging 747 which had been renovated a bit to seem newer. I always reserve an aisle seat so I can get up without disturbing anyone. There were two seats between me and the window. In those two seats was a lovely couple, very pleasant, not too chatty, and very obese.
She took up her own seat plus a quarter of his. He took up the remainder of his and part of mine -- even with the armrest down. He overflowed his seat and when we sat shoulder to shoulder, my trunk was laterally shifted to the left and my head hung in the aisle. I was afraid I would be decapitated every time the trolley went by! It was a completely full flight with not another seat on the plane (at least not in economy).
Don't even ask how mealtime went... Cirque de Soleil has nothing on the contortions we went through! Despite getting up frequently and spending a fair amount of time standing in the back near the restrooms, I was still pretty achy and uncomfortable by the time I got off that plane. To be fair, the gentleman (and he was indeed a gentleman) in the middle seat got the worst of it. Poor guy was wedged between the two armrests and could barely move for 10 hours.
Another flight I took over in September was even more cramped aboard a brand-new A380, the double-decker, where the seat was so narrow I couldn't sit on my own hands because there wasn't enough room. Now I'm no athlete but neither am I obese. That was also a tortuous flight.
As airlines try to squeeze more and more sellable space on their aircraft, people are getting more and more twisted at their expense. On a short flight, people can manage a slightly uncomfortable position for an hour or so if they're in reasonable health to begin with. A 10-hour flight? Nope, one needs PT after something like that.
I think we need PTs on the design teams at Boeing and Airbus! I think there needs to be some oversight as to what is permissible in aircraft design. I flew different carriers on both the trips I mentioned and both were equally painful. I can't afford to fly business class in those gorgeous individual pods that go nearly flat. Nope, I'm stuck with a narrow seat that's way too close to the one in front of me. When will the shrinkage stop? We are a captive audience that on occasion, just has to fly no matter how painful the price or the experience.
When I was getting my public health degree, we took numerous modules on statistics and research methods. One of the things we were taught, which I already knew, was that randomized clinical trial (RCT) was the best way to clearly answer a research question. It is the "gold standard." The other things we learned about RCTs were that they are time-consuming, the most expensive form of research, and contain some very ethical issues about who does and doesn't receive treatment.
The CMS has created the Innovation Center, which is looking at different ways to pay for and provide healthcare. What they are doing is a fair number of demonstration projects. What that means is they fund a project, evaluate the results, and apply mathematical models to determine things like efficacy, sustainability, and savings potential. I worked in a program in New York that began that way in 1998 and went on to become the benchmark in care management for the frail elderly as recognized by the Commonwealth Fund. There was no control group, yet the results bore out to be very beneficial.
Today, Gina Kolata of The New York Times (no friend to physical therapists after her article, "Treat Me but No Tricks Please") just came out with an article denouncing the Innovation Center as wasting funds because they're not using RCTs for most of their studies.
The responses are as interesting as her article. She's an MIT researcher by profession, so hardly an unbiased voice when commenting on this topic. It could mean whether or not she gets studies funded and articles to publish in professional journals.
So my question is: In this day and age, with shrinking resources and increasing demand, can we afford for all of our health policies to be based upon RCTs or should we make use of demonstration projects to accomplish more with less time and expense?
I'm having a whale of a time in my new post! I'm bringing American efficiency to my role as a consultant; evaluating people who have fallen in care homes and recommending a corrective course of action. I started out with a list of nearly 80 names of people who had been waiting from 1 to 3 months for an assessment, to a list of six people referred in January. The care home managers are rather happy with my work.
Then there's the other part of my role, revamping a fall-prevention service based at a small local hospital. The hard-working physios who have soldiered on through tough times previously haven't exactly welcomed the new carpetbagger with open arms. After today's meeting with the staff, I feel like I've been the board in a dart match. With much cooing and active listening (they have valid points after all), we were able to move forward with positive attitudes.
Wait lists are a big taboo here in the NHS. Government regulators come down hard on NHS services that make people wait for service. Unfortunately, sometimes the only way to get the people with purse strings to notice that additional support (budget lines) are required is to allow the wait lists to grow. For instance, see the paragraph above and you'll understand why my post was approved. It will all come out right in the end; of this I'm sure. Until then, I'm planning for the service I need rather than the service I can afford.
On another note: I won! The Trust, which erroneously called me across the "Pond" for an interview in August, has reimbursed my travel expenses. Never back down from unfair management! Pursue what is right, but do it in their language and on their terms. It may take time and patience, but right wins out in the end.
When I worked in New York in home care, I would always revisit a patient for whom I had ordered any piece of equipment. I needed to ensure the right item had been delivered, was installed and/or adjusted correctly, and that the patient was using it correctly.
I would argue with many insurance care managers about these visits. They would argue that vendors were paid to perform these tasks. I wish I had a dime for every time I would find a raised toilet seat still in the box, a commode with unadjusted legs, or a tub rail hanging by a thread. Patients also came up with the most inventive ways of using equipment. My particular favorite was the woman who had a potted palm in her bedside commode.
Here in England, equipment is loaned free of charge from the local council and the patients return it when it's no longer needed. It is then refurbished, sanitized and put back into service. Things unfortunately don't run smoothly here either. Today I went to visit a client who resides in a care home; something similar to assisted living as there are no nurses on staff.
His walker was delivered along with a set of wheels. At first I thought it odd that the wheels were sitting on the resident's bureau and not on the walker. I then realized the frame had been refurbished and was an older model than the wheels, so they didn't match. After being on hold for a while, a nice person apologized and arranged matching wheels to be delivered in seven days. The resident is able to use the walker without wheels safely, but will appreciate how much energy he'll save once the wheels arrive and I revisit again.
On both sides of the "pond," so much waste could be eliminated if people just did what they said they were going to do!
I'm on the train to Edinburgh for a night "on the lash with the lads" (a pub crawl with some friends) and I pick up The Independent, whose headline is "Battle Begins for the Soul of the NHS." I figure this should be interesting. Essentially the article states something I blogged about years ago, not long after the Tory party came into power. They're starving the NHS so that it will fail and have to be privatized. Really, Independent, you're just figuring this out?
If you think the Affordable Care Act has generated hot debate, you should hear the debate on this topic! Mud is being slung by both, or should I say all three, parties. I mentioned the Francis Report in my last blog. The Tory party is using that against Labour while Labour blames the Tories for reports of disjointed services and risks to patient safety.
If the NHS has a bad reputation overseas, it's the fault of the political parties using it as a bludgeon. Each blames the other for whatever is wrong... not so different from the US. Speaking of the US, if the free trade act goes through with Britain, US health companies may be able to enter the market here in Britain. Soon we may have Humana in Hounslow or Aetna in Alnwick.
It will be fascinating to see how the next few months play out for the NHS here in England. It might impact how other countries develop their health services. It may even impact the company you work for right now.
In the year I was back in the US, a very important paper came out here in the UK; the Francis Report, which details the failings of one institution in caring for its patients. This report is having ripple effects through the entire country in terms of lots of bureaucrats creating lots of forms and ticky-box exercises to ensure their Trust doesn't repeat the mistakes of the Mid-Staffordshire NHS Trust. This is frustrating because it means a lot more work.
Tonight I watched a documentary called "Unforgotten." It's about the patients of Willowbrook, the state school for the disabled on Staten Island that was exposed by Geraldo Rivera in the early 1970s. It was years after Robert F. Kennedy called it a "snake pit" that any staff member spoke up and helped bring to light the horrors that went on within its walls. One of the primary problems at Willowbrook was staffing cuts. By the end, the ratio was one staff member for 40 patients. Is that trend recurring now?
I've read my fellow ADVANCE bloggers' frustrations with insufficient weekend staffing, ridiculous productivity targets, and inappropriate orders for therapy. The responses to these blogs have been even more disheartening. In one case, Michael Kelley was told, "You're being compensated for it. If you don't like it, don't write an article... get a new job."
Other times I've read other professionals talk about how they would speak out if they weren't afraid of losing their job. This idea of toeing the line or suffering the consequences just doesn't sit right with me, it never has. I got into this profession to help people and I've done a fair amount of that in my two decades of being a PT. I'm not about to shut up if I see something unfair to patients. The end result of Willowbrook, the Mid-Staffordshire NHS Trust, and even two previous employers of mine was a shutdown of operations. I've seen companies come and go... but I'm still here.
I encourage my colleagues to speak out about poor working conditions and insufficient staffing. Don't succumb to the bullies or the fears. Why should a patient's therapy be less on a Saturday because there's fewer staff available? Management wants a seven-day service? Then staff appropriately for it! Management wants productivity targets? Then give the necessary tools and support to reach them! It's time for long-term thinking and planning, not short-term profits.
I think I shall be more patient with the bureaucrat tomorrow. She's just trying to keep Mid-Staffordshire from ever happening here.
Over the holidays, we were sitting and whinging (English for complaining) over drinks about the demise of clinical and critical thinking in practice. In both the US and the UK, algorithms have been employed to standardize care in an attempt to assure everyone gets the same quality of treatment. As a public health advocate, I almost always advocate for something that reduces variations in care. Why should a patient have better treatment from practitioner A than practitioner B? Algorithms are an essential component to telemedicine and tele-physio. NICE (National Institute of Clinical Excellence) in the UK and the Milliman guidelines in the US provide those frameworks we need to work within in order to get paid.
That would work perfectly if every person with back pain presented in the same way, or with chest pain, or a hip fracture. When did you last see two of any presentations that were identical? For an algorithm to capture every possible presentation, it would most likely be unmanageable and of little practical use. Many professions are now being trained according to an algorithmic approach. At my last post in the US, we actually taught new employees about critical thinking because it was a skill lacking in so many newly hired people. Are we dumbing down the health professions in an effort to standardize care?
When I took a practical exam in PT school, many years ago, there would be wildcards in the patient's presentations. Our skills of thinking on the spot were harshly tested. I'm grateful for that now that I'm older and minutely wiser. I wrote about taking an OSCE (Objective Structured Clinical Examination) here in the UK when I first arrived. There was no thinking involved, simply a checklist to run through in 7 minutes. It wasn't easy, but it didn't prepare me for a real situation.
Are we risking our patients and our careers by trying to stay safe?
I mentioned in an earlier blog that physiotherapists in the UK will soon be able to prescribe medications independently from doctors. A clarifying statement has been issued by the Chartered Society of Physiotherapists:
"The physiotherapist independent prescriber may prescribe any licensed medicine from the British National Formulary, within national and local guidelines, for any condition within the practitioner's area of expertise and competence within the overarching framework of human movement, performance and function. They may also mix medicines prior to administration and may prescribe from a restricted list of controlled drugs as set out in Regulations."
That is a pretty impressive responsibility! Physios will be required to complete a course at a university and practice with a mentoring medical doctor before they can begin this activity. Currently, phyios can be supplementary prescribers. This is where they partner with doctors and prescribe under a clear remit. For instance, if they work in community respiratory care, they may begin antibiotics and or aerosols for chest infections with a medical doctor ultimately responsible for their decision-making. Independent prescribing takes the doctor out of the equation.
Would you feel confident enough in your own practice to have this ability? How will this impact on physios' liability (and the insurance)? Could this practice ever take hold in the US? Would you want it to?
So I've finished my induction and have been happily plugging along for almost two weeks now. One of my major tasks is to consult on patients living in care homes (senior housing with ADL assistance that may or may not have nursing included) who have fallen. I work fairly independently and get my referrals from a wide range of sources: Accident and Emergency, doctors, community nurses, the care homes themselves, or community rehab teams.
It's a pretty comprehensive assessment of environment, medications, medical history, vitals, gait and balance. You name it, I look at it. I provide the patient's GP with a letter detailing the actions I've taken, like issuing a walker with wheels, and my suggestions for him, such as a medication review for the person on 19 meds, nine of which are designated as culprit medications for falls. I like it.
The other major task will start becoming clearer shortly. The last time I worked here, I helped redesign an outpatient clinic for people who had fallen. Now the neighboring town wants me to do the same for them. It sounds great, except they don't have the funding the first place did. Instead of 2 FTE nurses and 1 FTE physio, I have 0.4 FTE physio and no nurses at all. This could be very challenging indeed!
I saw my old New York doctor today. He was the main focus in a New York Times article about providing healthcare in a cash-only model. I really should point out that when he was my PCP, he was still accepting insurance and I was not paying the $25,000 annual fee for his services.
Frank Bruni, of the New York Times editorial staff, points out this practice is rife with potential for abuse and ethical dilemma. When a patient is paying $25,000 a year and demands an antibiotic for his viral infection or he will take his business elsewhere, it could be tempting to simply give him the drug he doesn't need.
What about testing? If someone demands a test that isn't warranted, could a doctor be tempted to order it anyway? So for that amount of money, one can get his toe held during a procedure (really, you have to read this article), but is he getting better quality care? What about the wrath of someone who has paid that much but has a negative outcome anyway? That should make for an interesting court case!
I should also disclose that I had a private clientele for a few years that paid on a cash-only basis. It worked well in that I was able to focus on rehab, spend whatever necessary time was required with each one, and not have to waste time arguing with insurance companies. My reputation was good enough that I never had to advertise and had a steady word-of-mouth referral base.
That being said, I charged a market-rate, reasonable fee for a house call, not the humongous retainer fee described in this article. I left that model of practice for a number of reasons, but primarily because I got bored with very similar presentations of my clientele (golf injuries and treatments around resuming the game or improving their performance at it).
How about your practice? Do you take insurance, a mix of insurance and cash, or cash only? Do you find any ethical issues arising if you have a cash-only business? I think the model can work, if reasonable fees are charged. Once outlandish fees are charged, I think that's where the ethical issues arise.
You know what that means... orientation! I'll be attending four continuous days of induction, which will cover all of the statutory/mandatory modules for this NHS Trust. Very interesting to compare it to the orientations I've experienced in the USA. Today five members of the executive board arrived, on time, to introduce themselves and each in a different way voiced how employees fulfill the mission of this organization.
At my last post in the USA, the president insisted on being on the agenda, and then rarely showed up. When he did, he informed new employees that if they didn't make the grade or like the way things worked, they could leave. Today we had security and fire safety training. The security bit amounted to "If you see something, say something" but the fire safety bit was something I've never done in more than two decades as a PT. We put out fires (yep, real fires) with fire extinguishers.
The head of safety quite reasonably made the point that if he was going to teach us how to use them, then it should include a practical component. The same topic in New York? Well, I'll admit it is difficult to create a flaming toaster in midtown Manhattan, but that head of safety was a retired NYPD detective. Nobody knew security better than he did, or had more interesting stories to tell.
What is on the agenda for the rest of this week? Bullying and harassment policy (not even touched on in NYC), manual handling (body mechanics with a practical lab for moving patients and objects), information governance, safeguarding children and adults, risk management, infection control, conflict resolution, and CPR. How does this list compare with what you have gone through with your employers?
Also, I have finally heard back from that NHS Trust that I interviewed with in August and requested reimbursement for travel expenses. I've successfully argued my case and they are agreeing to refund the cost of the flight. This week has started off just about as well as I could have hoped.
As I mentioned in my last blog, I'll be starting my new job next Monday. That has left me with a lot of downtime. Some of it has been productive; some of it has been rejuvenating. I managed to watch all five seasons of "Breaking Bad," the highly popular show that finished its run this year. I had never seen it before. I was pleasantly surprised to see a character who has cerebral palsy. The actor, RJ Mitte, actually has CP, a milder version than the character he portrays, but it's nice to see actors like this actually working.
There's another character, played by Dean Norris, who sustains a gunshot (or rather a few gunshots) and must portray a man with a spinal injury who recovers over the remainder of the show. He does a fairly decent job of making the physicality of the character believable. Were either of the actors perfect in their portrayal of the physicality? No, and we shouldn't fault them for that.
Making a movie, TV show or play requires a big suspension of disbelief. If you've seen any play on stage, you've noticed all the furniture faces in one direction, which nobody really does in their own home. Likewise, actors and directors have to make choices to get the story told. I learned in theatre school (many of you probably didn't know that was my first degree) that foreign accents are rarely accurate. Not because the actors are lazy (except for Gwyneth Paltrow in "Sliding Doors"), but because the audience needs to understand what's being said. If you've ever seen the film "Billy Elliot," you'll understand. The father sounds like he is speaking in tongues to an American ear, but is actually from Northeast England and speaking in his usual voice.
More and more we're seeing people with different disabilities being portrayed in TV and movies. These include Kevin McHale, who plays Artie Abrams the wheelchair-bound paraplegic on "Glee," Jamie Brewer's numerous characters on "American Horror Story," and now Blair Underwood as "Ironside." All help to improve the visibility of people with disabilities and combat stereotypes. This is a good trend!