The hospital clinic letter made it sound so straightforward:
‘He had X-rays which demonstrated a Weber B distal fibula fracture and no evidence of any talar shift. He was put in a moon boot and given tinzaparin.’
Except that he wasn’t given any tinzaparin. He was given a piece of paper on which was written his NHS number and his son was told to take it to a high street pharmacist the following day to collect the tinzaparin syringes. The first pharmacist he visited explained that the prescription was for ten days’ supply, but that she didn’t have enough of the correct dose. A phone call to a second pharmacist was enough to find one that did have ten syringes of the correct dose.
The clinic letter hadn’t been written following a visit to a hospital clinic. It was written by a doctor who had reviewed the record of a late-night visit to an Urgent Care Centre (UCC). The nurse specialist who saw the patient there had not only interpreted the X-ray, fitted the moon boot, and ensured that a prescription for tinzaparin would be ready the following morning, she had also arranged for a district nurse to visit each day to carry out the tinzaparin injection. (For any patient temporarily immobilized following an operation or a lower limb fracture, there is always the risk that inactivity during the recuperation will lead to a blood clot which could be fatal; tinzaparin is an anticoagulant that prevents the formation of blood clots.)
The final action of the UCC nurse sitting at her computer had worked: the district nurse arrived on the day after the fracture and gave the injection.
“How long have you got to wear the boot for?” she asked. “Six weeks!” replied the patient. “But there’s only ten syringes here. When are you getting the rest of the syringes?”
The patient is not an expert in how to navigate the various parts of the NHS (hospitals, district nurses, GPs) and the others who provide NHS services (like the high-street pharmacists), so he couldn’t answer the question. Further anxiety was caused the following day when that day’s district nurse asked the same question.
On the following day the patient raised the issue with a third district nurse.
“No problem. I can sort that,” she said. “I’ll go to your GP practice, get a prescription and then get the rest of the syringes.”
To understand where the GP comes in you need to know that once a patient has been discharged from hospital their GP practice has responsibility for providing any further necessary prescriptions.
A few days later (and, crucially, before the initial ten syringes had all been used) the district nurse arrived with boxes of syringes – enough to last until the moon boot was due to come off.
Why did the third district nurse know what to do while the first two didn’t? Whether or not she had studied quality improvement techniques, or been on a course, I don’t know, but she certainly used so-called QI techniques to solve the problem and so remove the patient’s anxiety and ensure that the crucial prescribed treatment could be given.
She knew the importance of understanding the working not only of her part of the NHS, but also the other parts with which she has contact, and what happens when responsibility for the patient’s care moves from one part to the next. Perhaps she had been taught systems thinking or perhaps she was just naturally curious. She probably also knew about the variation that exists between GP practices in how they process clinic letters and other notifications of hospital discharges: some would see the letter saying ‘He was … given tinzaparin….He will have a telephone review in six weeks’ time,’ and conclude that this meant the practice needed to ensure the patient had a prescription for enough tinzaparin to last six weeks; others would wait for the patient, his son or the district nurse to request a prescription. She also knew she needed to breakdown barriers (number nine of W Edwards Deming’s 14 Points for Management) between the silos of district nursing and general practice.
I’d like to think that she had by now realised that one of the privileges of working in the NHS is that every day you learn something new about how it works in practice. When faced with a new situation you can either get annoyed and stressed about it, or you can use it as an opportunity for new learning, accepting that working in the NHS does not mean that you work in just one system. It would be tempting for front-line staff to read about the new Integrated Care Systems and to conclude that all their frustrations are magically going to be removed by the actions of senior people who will agree new rules for how staff in each part behave or who will implement new computer systems (surely there’s an app for that?) to facilitate more integration. These actions will hopefully help in breaking down barriers to create more ‘joined-up’ working environments which are better for front-line staff and for patients. But the ever-changing nature of healthcare, and the inherent variation between NHS organisations (sometimes as a result of history and sometimes because of recent localised innovation creating new ways of working which have not yet spread), will always mean that front-line staff will be able to make work easier for themselves and their colleagues – and better for the patient – by using QI techniques such as curiosity, systems thinking, understanding variation and breaking down barriers.
The views and opinions expressed in this article are personal and are not necessarily those of Northumbria Healthcare NHS FT.
The NHS: observations of an Information Specialist 