The collected observations

As promised, my collected observations are set out below and shared with you, as loyal readers, before I send them on to the Hospital, Care Quality Commission and Clinical Commissioning Group. I apologise for the formatting, but I wrote this out in Word and copied it here. Nothing amusing in this one, and no song, but you might find bits of it interesting.....

Observations arising from investigations for prostate cancer at Medway Maritime Hospital 2014

 

1.         Introduction

As context, I am a former NHS manager with a background which does not include acute hospital provision. I was well aware of the difficulties facing Medway Maritime Hospital when I was referred and used my knowledge, together with that of friends, family and colleagues to map out potential allies / points of influence should I need them.

Set out below are a series of observations based on a journey through Medway Maritime Hospital in September and October 2014. They are culled from a daily “blog” that I posted online documenting my experiences and sharing them with anyone who was interested. The existence of the blog was shared with the Hospital, CCG, CQC and clinical staff.

During the course of the journey, attitudes towards me changed markedly and I suspect that, by the end, the treatment that I was afforded was very different from that offered to the majority of people using the hospital’s services.

This document ends with a description of the excellent service that I received at the very end of that journey which should set the standards for all other parts of the hospital.

 

2.         Environment

The general environment at Medway Hospital is poor. Although the problems are probably mostly due to the failure to secure funding for re-development, there are some basics which would not be difficult to rectify:

2.1       Piped radio

At least one main outpatient waiting area had continuous commercial music radio piped through its PA system. Given that the vast majority of the people waiting were middle aged or older, the up to date pop music did not create a relaxing atmosphere.

 

2.2       Signposting

Signposting throughout the hospital was poor and the hospital maps on display were both too small for people with a visual impairment and out of date.

The route-finding design within buildings may be helpful to people who have visited frequently and only need reminders, but are very confusing for anyone visiting the hospital for the first time. Symbols and colours are used, but their application is poor.

 

2.3       Automatic doors

At least two sets of automatic doors were not functioning. Unfortunately, these were at the entrance that serves the Day Unit, rendering access to people with wheelchairs virtually impossible without assistance.

 

2.4       General decor

In most clinical areas, the decor was shabby giving the impression that people using the hospital were not valued.

 

2.5       WCs

These were of variable standards of cleanliness. One was an evident hazard to health, obviously not having been inspected or cleaned for some time and with a broken pedal bin which left people either to lift the lid by hand or dispose of used paper towels on the floor.

 

 

3.         Privacy and Dignity

3.1       Gowns

The hospital still uses open back gowns in the areas that I experienced. It might do well to check the dignityincare.org.uk website to see the work of Fatima Ba-Alawi, and the NHSIQ.nhs.uk website.

 

3.2       Cublicles

Perhaps the most shocking sight I saw was of someone on a trolley recovering from the effects of sedation in an area which was clearly visible to me when I went to collect a preparation pack. No effort was made by the staff to shield her and she was in my direct line of sight as I left the unit. On asking at a later date I was told that this was primarily a clinical area and that only “patients” are normally in it. I am still at a loss to understand this attempt at justification.

 

3.3       Changing rooms

In one diagnostic area, I was shown to a small, lockable, cubicle to change into a gown before returning to the waiting area. This department was clearly aware of the potential problems with hospital gowns and had a policy of asking people to don two: one facing forwards, the other backwards.

To store my clothes, I was provided with a second hand plastic bag marked “patients property”. It had clearly been used many times previously. On the plus side, a lockable cabinet was provided to store any valuable metal items I had with me.

 

3.4       Confidentiality

The clerking in process in every area involved me confirming my name, date of birth and address. This was invariably done in full hearing of a waiting room full of people.

 

4.         Staff attitudes

Staff attitudes were variable, with the most junior and most senior generally exhibiting a much better attitude than others.

 

4.1       Introductions

At the start of my journey through Medway Maritime Hospital, very few members of staff introduced themselves either by name or profession without prompting. In one case, I had to prompt a second time to elicit the fact that one of the people present was a student.

By the end of my journey, introductions were made universally and without prompting.

 

4.2       Person vs “patient”

There was a marked reluctance to refer to me as a person, the preference being for the use of the impersonal word patient. Despite asking that I be seen as a person, some staff insisted that, whilst I was under their care, I was a patient. Given that empathy is at the heart of most professional training, I found this disappointing.

A notable exception was a healthcare assistant who told me that she was there because she liked people and felt it important to relate to the person as much as the reason they were there.

 

 

5.         Protocols / administration

5.1       Delay

Following a biopsy, I was told that I would be invited back for a consultation within 2 weeks to hear the results and talk about what needed to happen next. In the event, it took 4 weeks and no satisfactory explanation was ever offered. My hope is that this was an exception.

 

5.2       Series vs parallel

On receiving the results of a biopsy, scan or other test, it should have been obvious to those reporting or making clinical decisions what the next steps should be; I would have expected to arrive at a consultation to find the next investigations already booked. As it was, referrals were only made to CT, MRI etc. after the meeting with me.

 

Whilst on paper it may seem good that decisions are not made in advance of seeing someone, it introduces further delays. In cases where there is no practical choice about the next course of action, it seems nonsensical to introduce administrative delays.

 

5.3       Appointment times

Outpatient appointments were almost universally 30 minutes behind time with a range from 0 (Oncology) to 50 (Urology). I understand that it is impossible to predict accurately how a clinic will progress due to emergencies etc., but it might be helpful if people with booked appointments were sent a text message in advance warning them of delay.

Much emphasis is placed on the user of services letting the hospital know if they are unlikely to turn up, but none on the hospital letting the service user know. If appointment times are seen as a mutual responsibility with a commitment from both sides to tell each other about delays, the DNA rate may fall dramatically.

 

5.4       Website

The Hospital website is extremely poor. It contains very little useful information, is out of date, incomplete and difficult to navigate Given that websites are often people’s first point of call, a good website is vital. Medway Maritime’s website is probably the worst hospital website that I have ever seen. For an example of excellence, I would commend Darenth Valley Hospital’s excellent site.

 

5.5       Appointment notification

Medway Maritime’s practice of a personal telephone call advising of an appointment is excellent.

The appointment letters may be a problem for some as the clinic codes can reveal diagnoses. I my case, I was invited to a clinic with the code MDT, to hear the results of a biopsy. This code told me that I had been diagnosed with cancer. For me, this was not a problem, but others may find it distressing.

 

 

6.         Expertise & knowledge

6.1       Cannulae etc

The insertion of a cannula without leaving residual bruising is a difficult challenge for even the best trained staff. It was a member of staff at Medway Hospital who showed that it is possible, even with a relatively large cannula, to insert it perfectly.

  

6.2       Side effects

For an MRI scan, I was told on arrival in the scanner room that I would need to be injected with a muscle relaxant in order to ensure that clear images were obtained. I asked about potential side effects and was told that the drug had none.

Having driven home directly after the scan, I checked the manufacturer’s data sheet and discovered that a common side effect was dizziness or disorientation and that driving should be avoided. This was a potentially lethal lack of knowledge on the part of staff administering intravenous medication.

 

6.3       Doctors

Three of the consultants that I met appeared to be of outstanding quality, willing to treat me as an equal partner in decision making and having an excellent knowledge base.  

One consultant is mentioned in “National Targets” below

One consultant exhibited the most appallingly arrogant and poor bedside manner, and was evidently lacking in either skill or care in the use of a biopsy needle.

The one SpR that I met should go far and I wish him all the best with his career.

 

6.4       National targets

On receiving a verbal confirmation of a diagnosis of cancer, I mentioned the national cancer treatment targets with particular reference to the 62 day target from referral to commencement of treatment. Neither the locum consultant nor the specialist nurse present was aware of this; the nurse told me that she believed me, but would have to look it up.

This lack of basic knowledge was more than made up for by the attention and help of another specialist nurse later in my journey.

 

6.5       Sedation

Prior to undergoing a colonoscopy, I queried the use of sedation. It was explained to me that a fairly major mix of drugs was used and that I would not be able to drive, make decisions etc. for 24 hours after the procedure. It was only on vigorous challenge that I was offered Entonox as an alternative. Apparently the use of entonox is an innovation in Medway Hospital.

By only offering debilitating sedation, people have to stay in the department for some time post procedure. If entonox is offered as an alternative, the recovery time is measured in minutes rather than hours and there is reduced need for some people to arrange for care on their return home.

 

7.         Endoscopy Suite experience

Having made clear my preference regarding sedation in advance, and, I suspect, the staff having been warned about me by the manager who took an interest in the blog, the preparation, procedure and discharge from the endoscopy suite were a study in excellence.

I knew in advance that the Colorectal consultant was coming in especially to carry out the procedure, so had no doubts about his abilities, either clinical or interpersonal and was fully confident in both. The nursing staff were an unknown.

 

Ø  My partner and I were greeted very cordially by a nurse who introduced herself without prompting and showed us to a consulting room. Following a brief discussion about when she should return to collect me, my partner left.

 

Ø  Clerked in efficiently, BP etc. checked, introduced to the nurses who would be accompanying me into the procedure room, and led to a private cubicle to change.

 

Ø  Informed when the consultant arrived.

 

Ø  In the procedure room, made comfortable, entonox provided for use on demand and pillows placed to allow me a clear view of the screen.

 

Ø  Running commentary from the consultant which was both interesting and informative. He was joined by a colleague, who was also introduced to me, who provided advice when required.

 

Ø  Returned to cubicle and informed that my partner had arrived. Consultant arrived and gave me a summary of how he thought things had gone, along with his recommendation for surveillance; shook my hand before leaving.

 

Ø  Changed, clerked out and left. Elapsed time 1.5 hours of which 55 minutes was direct clinical intervention.

 

Ø  In the meantime, my partner had been informed about progress and how long she might have to wait.

 

Ø  I was listened to, treated with dignity and respect and stayed in the unit for the minimum time necessary. I would like to think that this is standard treatment for all.

 

8.         Conclusion

I was not the average “patient” using the services of Medway Hospital and managed to negotiate a reasonably timely path through its services by virtue of knowledge, influence and refusing to accept the unacceptable. It was not an easy journey even for me as an informed, assertive and persistent customer, negotiating systems that appeared disconnected and uninterested. I have no doubt that the managers and some of the clinical staff are glad that I have been referred on.

I have no complaint about how I was treated or the generally high clinical standards that I experienced, but I would like to feel that this feedback is taken seriously by the Board and used as part of its drive to improve services for all.

 

 

 

 

Phil Woods 23.10.14.