Get the Diagnosis right

When I was learning to be a doctor a very wise senior GP sat me down and told me that the secret of being a great diagnostician was to be a good listener. That surprised me. Not learning lots of clever examination techniques or learning to interpret fancy tests? No, You need to be able to do that of course but the most important thing is to listen to the story, because all the clues are there. Don’t be tempted to leave out the bits that don’t fit your working diagnosis , they are there for a reason. Work out why they are there and you will find the answer. Don’t interrupt the story teller, within a few seconds of them starting, give them time and you will hear all you need. And it works. As a GP sometimes I have literally bitten my tongue but I always tried to listen. This week a young man presented with intermittent abdominal pain and fever. He had symptoms for over 6 weeks. The GPs he saw ( and he saw 5) tried to tell him he had diarrhoea , but he said gently and with clarity, no not really… no one really listened to him or why he was there… some minor infection? IBS? Nothing to worry about, but he was worried. He was a fit young man, didn’t like doctors and rarely went to see them, had had several significant sports injuries and continued to play football despite pain. Something felt wrong. HE was given a myriad of medications. None worked and on reporting the ineffectiveness he was told to keep taking them and new ones were added. Then finally a documented fever of 40.4( no one picked up on the clear history of a fever because when he was seen before he didn’t have one). Well that isn’t normal and rebound so suddenly hospital and ? Appendicitis which turned out in fact to be a serious but rare infection which caused his abdominal nodes to be full of pus…he is okay now- home and full of the right antibiotics. Finally it was the senior surgeon who listened to the story without interruption or need to make it simple, who enjoyed the challenge of something out of the ordinary and found the problem he needed to solve.

And I wondered why did it take so long? Yes it was rare but the clues were there all along…we make dangerous assumptions based on prejudice. We excuse ourselves because we are busy but failing to listen in the end takes longer….

And I wonder do we listen to patients, to the public? To other clinicians? Do we listen to the evidence? In the complex world of health care do we seek the simple diagnosis, the simple fix and ignore the complexity because it doesn’t fit into a sound bite? Because when you identify how complicated and multifaceted a problem is it feels too big and scary to tackle whilst reducing it to something smaller and neater feels safer. But failing to diagnose the problems accurately is dangerous. Quick fixes may make us feel better because we have done something but ultimately don’t sort out the problem. The young man I mentioned was given antibiotics by the out of hours service doctor he saw for no particular reason and without a diagnosis. That was the wrong thing to do and it complicated the picture. Some problems take time to understand and then to fix a bit at a time. When we as a CCG are trying to do things differently do we listen well enough so we can actually define the precise issue we are trying to solve… do we as a system listen or do we just blindly stumble forward…It is a gift to be able to think freely…to look at an issue without the weight of a forgone conclusion…With so much pressure on the system now to make everything different really fast do we have the collective courage to do the right rather than the expedient thing? Don Berwick’s diagnosis was thoughtful, complex, clear. He has listened. It is really worth watching it. http://www.kingsfund.org.uk/audio-video/don-berwick-improving-safety-patients-england-full-presentation. Some have criticised it for being too woolly without enough concrete recommendations, but that is absolutely the point. It isn’t about implementing a new structure or a new set of rules. So much of what is wrong with the NHS is about a culture of blame, fear, and lack of transparency. We need to understand that and change it to pride, joy and openness. Doing that will take time and individual commitment from all those who lead the NHS. You don’t change how people feel and act overnight. More importantly will the system we work within give us the permissions we need to fix the problems fundamentally this time, or are we just in another cycle of short courses of ineffective medicines…

Give us a chance

It seems as though the NHS is never out of the news… and so very little of it is ever positive. So much of it though is rehashing things that have already hit the press in the past. This week we had the Select Committee report. It didn’t tell us anything we didn’t already know and we are working on it all. I sometimes want to shout.. please give us a chance.. .we have been here for 3 months… we know the issues we are trying to sort things out but the issues are complex and don’t get solved overnight and actually CAN’T be solved by centrally driven solutions. Each one is complex, multifaceted so you have to take each one and break it down in to all the little bits that don’t work, fix each of them and build it all up again into a service that works seamlessly. And that isn’t easy. Which is why is hasn’t been fixed before. Yes it is true that A&E is a pressure valve for the whole NHS ( actually so is primary care ) anywhere with an open front door is. But the reasons it is under pressure are complex…. A mysterious rise in the death rates of older people over the last 12 months, changes to the GP urgent care front door because of the introduction of NHS111, and general increase in demand across the service, more frailer older people, yes we need to change primary care, community care, GP out of hours care, how the ambulance service works, how social care works, and that is before we get to the A&E front door. WE are on the case. Changing things though actually means changing how people work and that isn’t like designing a new form it is about behaviours so it takes time. It doesn’t help then to have lots of structural things built over the work we are doing that require reports and attendances at meetings. Each of those requires someone who would otherwise be doing doing to be doing reporting and thus less doing gets done. Not rocket science is it? Maybe people just need to try to trust the system they have so recently designed and give us some time ( well a little more than 3 months) to get on with making things better.



And then there was the Keogh Report which I thought was brilliant. Simple. Succinct. Sensible. Coherent. And yes I believe described a way forward we could all sign up to and follow. So then came the recommendations from the new Inspector of Hospitals basically using that structure. Great I thought! But No! Why? Where are CCGs? We commission local services. We work every week with our acute trusts we know the details of every SUI, every never event, every case of hospital acquired infection. We discuss action plans and monitor compliance. We see trends. We live here. We hear from our local GPs and from our patient forums about their concerns and we feed them back to the hospitals and expect and get action. It is new and we are all just finding our feet but surely any new inspection regime should be co-hosted by the local commissioners, the ones who were there before the inspection team arrives and will be there when they leave… surely, surely we should be there too? If we really want to make this different we have to join up the dots. I don’t want to be in a focus group or submit a report I want to be there with the inspectors contributing with all the knowledge I will bring to the discussion and debate. WE had an NCAT review when we were considering reconfiguring our maternity and children’s services, the CCG with the NCAT reviewers worked together. It was good. It was obviously much smaller than a full inspection but as a model it worked really well. We will be the ones who work with the hospitals after the inspection to make things better, surely we should be round the same table. Why aren’t we? Are we invisible? Do people think we aren’t capable? Does everyone think we will be gone before this gets off the ground? Does the central NHS not think we are interested? WE are ALL about improving quality and safety in our service, our NHS. Please give us a chance to do our job.