Caroline Whymark

Caroline Whymark is a consultant anaesthetist in Scotland

Pensions - straw that will break the camel’s back

By Caroline Whymark - 16th January 2012 10:52 am

I breathed a sigh of relief this week as my children returned to school after the interminable excitement and chaos of christmas holidays.

My thoughts quickly turned to my own 3 R’s.cResolutions. Revalidation. Retirement.

Resolutions first then. Easy. Resolved to stick to resolutions this year.

Revalidation. Looks like it might actually be happening soon! The last time I heard this was in 2004 on an ‘introduction to appraisal’ session where the trainer remarked that as my GMC number ended in 2, I would be in the first of a five year cycle. I thanked him and quickly got myself off to a fire safety lecture.

Then it paused and paused, and paused. This was a good thing because it gave both parties on either side of the deal a chance to realise what was required and how it could be achieved. It’s fair to say in the intervening eight years the GMC have met doctors in a reasonably fair middle ground of sensibility and practicality. Appraisals this year will be the first mandatory step of this much pared down revalidation process and I’m happy to comply (but I’ll still be nipping off to Moving and Handling and such like).

So to Retirement. I wrote about this barely six months ago. I remember actively looking forward to this not least of all due to my perceived time of impending wealth. Mortgage paid, kids independent a big lump sum and a great on going pension. A reward reaped from my preceding years of hard toil and payment of dues.

How quickly things can change.

Today is the closing date for the BMA members survey of feelings and attitudes towards the rather snappy title of ‘Pension Tension‘.

Being outwith the 10 (or 13.5) year period of relative safety (albeit with planed increase in contributions) I am more interested than many. I’ve actually read the bumpf before it went into the recycling, I’ve filled in (and returned) the questionnaires, spread the word, and for once I actually feel quite motivated to take some active steps rather than stick with the masses in an apathetic state of resignation.

I’m thinking that for once I may get involved. Try to help the cause. Attend the meetings and vocalise.

So what’s changed? I never felt like this about the New Deal, the EWTD reduction in hours , the new consultant contract. Each of those things, even when not  affecting me for the better, seemed reasonable and for the greater benefit in what is a publicly funded service. Some costs and payments were indeed excessive/unfair/outdated and irrelevant in modern day practice.

Our pension is none of these things.

It is recently overhauled. Fit for purpose. Self-funding.

We are currently being ripped off. Being viewed as a target population traditionally disparate who do very little to oppose changes, we are a soft cohort of higher tax rate payers being used to ease the dire financial state which government  has allowed to develop. Dividing the public sector into higher and lower earners sees our increased contributions as nothing other than a blatant additional super tax on those whom they think will afford it easily enough not to bother. And it’s double ended: take more from us, take it for longer and give us back less in return during our decreasing number of senior years.

This may have been true in the past but things are different now. We are in the midst of a prolonged real and relative pay freeze, increased National Insurance contributions, removal of child benefit and an increased cost of living.

Pension tension will be the straw that breaks the camel’s back.

What we fear most is not the 2.5% annual increase in contributions this April, nor having an 68-year-old tremulous ophthalmic surgeon with failing faculties operating on our cataracts. It is the fear that a precedent is being set and accepting this will only be the beginning. We are very close to having unilateral changes imposed upon our contracts. If we accept this lying down, the government will be back every few years demanding, or taking, more and more.

Bullying is perpetuated in playgrounds until the victims are brave enough to tell someone about it, to actively do something. The same is true for doctors. We must take action. We must be strong and cohesive. We must try to gain some public support. We must do SOMETHING rather than nothing and stop issuing thinly veiled threats with no substance, which no one believes.

The government means business and so must we.

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My top ten Christmas NHS favourites…

By Caroline Whymark - 19th December 2011 4:20 pm

Only six more sleeps to go and I can hardly wait!

One of the main things I love about Christmas is watching the traditions unfold in the hospital each year. In true end of year style, here are my top ten observations from this year’s festive countdown:

1. Big round tins of Roses/Quality streets. These seem to have multiplied exponentially this year. No-one, including the shops, seem to be able to give these away. They are now price slashed to under a fiver and still piled high at the doors. I’m convinced no-one actually likes them and does indeed give them away. It is like a game of pass the parcel except no-one really wants to win. This self fulfilling global chocolate merry-go-round would be solved if everyone bought just one tin and kept it. Resist the BOGOFs and donate to the homeless.

2. Festive earrings. After a couple of years of being banished for non compliance with hospital hygiene dangly Christmas tree earrings seem to have returned to an operating theatre near you. This always cheers me up, especially on call and does not breach the ‘bare below the elbows’ mantra of hand hygiene.

3. Also making a return at number three is tinsel around name badges. A firm favourite blamed for cross infection is now back (perhaps silver impregnated to render it bacteriostatic).

4. Keep Calm and…posters/mugs/notebooks/magnets/calendars. My favourite was put on our department door by a witty colleague: “Keep Calm, the Anaesthetists are here.”

5. Christmas cards. The etiquette surrounding these is tricky in our instant messaging era. In our bijou office we all get on well and see each other most days. We don’t know each other’s families. Should we send a card to confirm we wish them well? Should it be from us as individuals or from and to extended families including hamsters and goldfish? Would a “send to all” e-greeting suffice (accompanied by a promise of an equivalent charitable donation of course). I don’t know. Personally I’m not bothering.

6. The Christmas party. Our theatre party is now booked for 2012 and speculation has already started. How drunk will the nurses be? How late will the orthopods turn up? Who will arrive wearing car crash couture or suffer a wardrobe ‘malfunction’ on the dancefloor. Will any male doctor not be blessed with a giggly nurse on his knee or gyrating around him in time to the music? I imagine similar scenes were evolving simultaneously up and down the country last Friday 16 December. Wouldn’t miss it for the world.

7. The Christmas quiz. Now this I usually do miss. Increasing in obscurity each year, held in a department with little 3G access to Google and copious quantities of items 1 and 10. Enough said.

8. The on call rota. Always a source of conflict. Always compiled before the trainees one so you don’t know who you’re on with. They, on the other hand pick and choose when to be on call by seeing who the consultant is. Hopefully a ‘good’ one will choose my watch on the 27th when I will be escaping from my family, avoiding the sales and gaining a lieu day. Win Win Win!

9. The weather: despite a recent national day of strike action, much more havoc was caused by the weather. Sudden heavy snow and freezing temperatures brought virtual gridlock to life as we know it here in Scotland. Schools were closed, roads were blocked and everyone was friendly, exchanging pleasantries with neighbours we have not spoken with in years. See item 4. Unions take note, the surprise element is much more effective.

10. Pringles: a firm ‘favourite’ everywhere you go at this time of year’ See item 1.

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Stop wasting NHS money on worrying about money

By Caroline Whymark - 28th November 2011 10:57 am

So back to the original question: how can the ever spiralling costs of delivering a high quality NHS free-at-the-point-of-use be met? In true political speak, I think if we were to address some tough questions and make some unpopular decisions (and actually follow them through) there would be no need for budgetary panic.

1. Rationing:

Not by postcode or by local practice variations dependent on the prevailing wind direction, but by doing the big things first and then assessing what you are going to spend the left over money on. There is a well known adage about fitting stones in a jar - if the big ones don’t go in first they will never fit. The smaller stones always slot in around them in the little left over spaces. Surgery is like stones. Spend money on all the small frivolities and the budget will fall short for the big essentials. Use the budget with this in mind. Do the emergencies, the cancer, the trauma and forget about questionable cosmetic procedures treating self-esteem issues unless you have money to burn in March.

2. Stop robbing Peter to pay Paul:

Time-wise and budget-wise this repeatedly occurs. Let’s say healthcare costs X amount. Whether time and money is spent in pre-assessment clinics, ward bed days, or increasing day surgery capacity, the work required still costs X regardless of whether it is done by a doctor, a nurse or any number of advanced and extended roles. We often simply redistribute where the time is spent and which budget the money comes from. Stop wasting time, effort and more money trying to find more cost efficient ways of doing things. Savings in one area generally mean increased expenditure and reduced time available in another and false economies prevail.

3. Stop measuring things we already know and/or cannot change:

There must come a point when measuring any variable that the process becomes more costly than any potential savings that could be made from removing inefficiencies. Further, when measuring a load of variables (read theatre start time, end time, in between time) which finds we are actually pretty efficient, the actual process of the measuring is a cost which generates no reciprocal saving. Why keep doing it over and over again? Some systems by their very nature are slow. A trauma list finally deciding on clinical priority at 0830, after taking into account overnight admissions, will not start at 0845. This is not inefficient.

It is a fact of this type of work. Priorities change, theatre readiness of a patient changes. Long gone are the days of the instant orthopaedic patient (read ‘add water when ready to operate’). Measuring the ‘delays’ on this type of list goes no way to reducing them. They are not delays, they are the inherent time required in the system to follow due procedure and carry out repetitive safety checks. Measuring them will not change this.

4. Accept clinical risk is the nature of the beast:

Things don’t always go well and this may be no-one’s fault. Accept that complaints and litigation are more prevalent throughout society and not just in medicine. Stop investigating, escalating, referring and reviewing practice in the light of a complaint. Endless meetings and paperwork result from tiers of investigative staff tasked with determining what went wrong when often nothing did. Medicine is a risky business with no guarantees. Sometimes the outcome is not good. Accept that or get out of healthcare.

5. Staffing:

Approximately 80% of the total budget is spent on staffing. Approximately 50% of these are non clinical. Does 50% of Apple’s staff have nothing to do with producing an i-gadget? I think not. Many managers have necessary roles and do the stuff that someone has to do. But their numbers seem to be escalating and at the end of the day the NHS is in the business of delivering healthcare to patients and that should be the main focus of the organisation.

A high quality service free-at-the-point-of-use, encompassing modern medicine as it evolves is expensive. It would be easier to meet this cost if we stopped wasting money on wondering where the money goes.

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Savings drive shouldn’t have started with syringes

By Caroline Whymark - 31st October 2011 10:42 am

Recently I arrived at work and began preparing for my list as normal. When I got to drawing up the drugs I noticed something was amiss. The 10ml syringes were now 12mls, the 2ml syringes now 3mls and so on. Confused? Yes, I was too.

The answer given to my queries was ‘national procurement’. It seems that on its cost cutting mission, NHS Scotland has decided this is the way to go on consumables. You can read all about it on their website but essentially national procurement delivers “less for more” allowing re-investment of savings into patient care.

I’m all for cost saving. We are asked about it every year. Management are always open to hearing ideas from foot soldiers on the frontline. Each year I propose a shutdown of the theatre suite for the first 3 weeks of the summer holidays (emergency, trauma and cancer work excepted) to bring about a win-win-win solution. Surgeons get the holidays they want,  anaesthetists do too and management save massively on the time and effort usually spent trying to match - often unsuccessfully - different surgical lists to the few anaesthetists who are free.

Sometimes if I’m really brave I suggest this happens over the Christmas and New Year period also but to date no one who matters thinks this a good enough idea to implement (although the same idea seemed to work well a few years ago when management decided this was the most efficient way to re-floor the whole theatre complex).

But I digress. Saving money is the priority but this time it seems the stakes have been raised even higher - we don’t just need to save money, apparently we don’t have the money to spend. Each and every budget is slashed.

And therein lies the problem. Multiple budgets and increasing fragmentation of the costs of healthcare - each looking after there own. No-one, it seems looking at the bigger picture. Indulge me if you will…

The syringes have been changed to another brand because they are cheaper. Apparently clinicians were asked for their views on this change but I must have been blinking at the time and missed the opportunity. Admittedly it didn’t take me long to re-learn to draw up drugs to the 10ml mark and not until the syringe was full but that became the least of the worries.

Some colleagues have taken the tone of “things change, quit moaning and get on with it”. I would direct them to any of several drug manufacturers who have tried to market newer, better, anaesthetic drugs in recent years only to find they never take off because they have failed to appreciate the induction agent MUST come in a 20ml dose and muscle relaxants must fit into the 5ml syringe.

We anaesthetists are simple creatures of habit, and for very good reason. The potential cost of a drug error made in patient care is not easily measured (so cannot be reduced by the required percentage). Clinical risk is a different department and not concerned by the cost of syringes.

Shortly after introduction someone realised the new syringes were not accurately compatible with our universal syringe drivers. Action: old syringes should be used with syringe pumps and only 50ml syringes should be used. These will continue to be sourced from original manufacturer. The new syringe, while recognised by the syringe drivers, could lead to over or under infusion and it’s consequences. Cost saving? Not in the face of any potential episodes of patient harm (not to mention increased costs of buying reduced quantity of only large syringes from original manufacturer).

Next I realise that my emergency drug (1ml of atropine) usually carried around by me and most anaesthetists for the duration of the list like some sort of comfort blanket, was being discarded by the excellent anaesthetic nurse after each case.

“Why do you keep throwing out the atropine?” I ask puzzled.

“It looked like you’d used half of it and therefore the syringe was dirty,” came the reply.

Fair point except I hadn’t used half of it. It was just that the usual 1ml took up a smaller proportion of the 3.5ml (2ml) syringe and gave this impression. Any cost saving from the syringe purchase was rapidly diminishing when offset by the increased drug usage cost.

Anyway, despite it all we get the first patient into theatre. Midway through fixing the ankle the surgeons drops a screw on the floor. It can no longer be used.

“How much does that screw cost?” he asks the charge nurse.

“£85,” comes the reply.

I feel my blood pressure rising. Any potential syringe saving is dwarfed by the orthopaedic consumable overspend. Perhaps it shouldn’t matter to me, after all it’s coming out of the orthopaedic (or perhaps the theatre) budget. But that’s not helpful.

An umbrella approach to budget management is required. Savings will only be made when costs are considered in context of the overall delivery of healthcare rather than by each department’s budget.

It’s a shame only the measurable costs are deemed important and this is a rare case of looking after the pounds before the pennies.

To be continued…

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Are doctors just another one of the trades?

By Caroline Whymark - 30th September 2011 3:02 pm

Doctor, plumber, car mechanic. At first these appear diverse professions. The former a highly trained professional, a master of his craft. The other two a pair of air-sucking- through-teeth-oh-it-will-cost-you-missus rip-off merchants.

My recent experiences have had that rare effect of reversing one’s first opinion. The two workmen I’ve had the fortune (or misfortune, depending on your perspective) to deal with of late have made we wonder that perhaps there is not actually all that much difference between our working processes.

Let’s take the car mechanic first. I drew up wearing jeans and trainers - trying to look non doctor-ish - in the belief that this would prevent me being ripped off.

“The engine warning light is on and the coolant chamber is only half full. I wonder if the radiator is leaking?” I suggested.

Chief mechanic - John - looks at me and shakes his head. I wait to hear the extortionate diagnosis but there is no slow, sad shaking of the head. Instead he says “it’s not quite that simple”.

Well, it never is I surmised.

John continued: “First we need to know what we call the Presenting Complaint. What did you first notice was wrong? How long has it been going on for? Anything else you’ve noticed different about the car?”

I nodded solemnly as he continued: “Then you need to think about past problems. Did it pass its last MOT? Servicing up to date?”

I was still reflecting on my cars past medical history when we got to the differential diagnosis…“It could be any of several faults. There are simple things that commonly go wrong but it may be more than that - rare things happen too you know.”

Oh I know I thought.

“We’ll need to do some tests to find out…the first will be to pressure test the system. I give you a ring to let you know what we find.”

I smiled inwardly and felt that me and my car were being well looked after.

The next week the boiler broke down. The plumber arrived and, following my experience at the garage, I gave a succinct and accurate history of my heating systems problems, past and present, culminating with what I thought might be wrong although clarifying that I sought and deferred to his expert opinion.

“Well it’s not that simple” he said. I rolled my eyes and thought here we go again. This did not go unnoticed.

“What is it you do for a living?” he demanded.

I explained I was an anaesthetic doctor and put people off to sleep for their operations.

“Well,” he said. “It’s much easier for you. Patients are all made the same, same parts, same plumbing, same joints and all get the same faults. I bet they all go off to sleep the same way too. In my job it’s different,” he explained as if I was slightly slow.

“All heating systems are different, they all react in different ways to different stresses, have different weaknesses and any one fault can appear as several different problems. It can be very complicated to work out the cause of the problem,” he concluded.

I nodded. “Well I’ll leave you to do some tests on it shall I? Milk and two sugars I presume?”

My sarcasm was lost on him but still I gave him a Kit Kat with his tea. Like emergency abdominal aortic aneurysms crashing into emergency theatres, bad news tends to come in sets of three. After my car and my heating, I’m just waiting and wondering what will go wrong next.

Who knows what I might learn from a joiner.

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The secret to a happy, motivated NHS workforce…

By Caroline Whymark - 23rd August 2011 9:57 am

“It’s Friday, it’s five-to-five, and it’s Crackerjack!” is something that I remember from my childhood. As an anaesthetist on call this became: “It’s Friday, it’s five-to-five, and it’s time to refer all sick patients to Intensive Care for the weekend.” This is inevitably followed by the inevitable deluge of ‘crackerjack referrals’ i.e. chronic problems becoming urgent just before the weekend.

But it’s not just on Fridays anymore. In our theatre suite, there is now a regular cry of: “It’s Thursday, it’s ten-to-ten, and it’s time for Phil’s Quiz”. Please allow me to explain. Phil was once the new consultant anaesthetist. He clearly had too much time on his hands and had to justify his SPA somehow. This he did by devising an increasingly obscure general knowledge quiz each week. Not only did he create it, he typed it, photocopied it and distributed it throughout the Anaesthetic Department and theatre suite.

At first no one took it too seriously, but as time has gone on, Phil’s Quiz has developed a following of its own. Everyone talks about it; everyone wants to be involved. Week after week the challenge seems to intensify.

What had started as a vague stretching of the boundaries of what could be classed as ‘admin duties’ had mushroomed into something akin to the X-Factor. Distribution increased to include the Intensive Care and Maternity units, day surgery and endoscopy suites, theatre reception and recovery staff, secretaries and the porters restocking the store rooms.

As the juggernaut grew, so the rules had to be tightened. Strictly no Googling allowed, completed papers to be returned by 1pm SHARP! The scores were calculated and a leader board set up.

The competition was fierce and even extended to team names. Ever Ready (emergency theatre) trumped Broken Bones (trauma theatre); Size 0 (theatre 4) was outdone by American Size 6 (theatre 10); Eye see you (ICU, intensive care unit) was careful not to be confused with Ophthalmic theatre (Eye, Eye); Flying Start (theatre 1 renowned for its efficiency first thing in the morning) were desperate to win and The House of Pain (labour ward) often collaborated with Maternity Mayhem (obstetric theatre) to increase their chances of success.

The team consistently at the top of the leader board is the Glamorous Grans (our three secretaries). Their secret of success is a mystery to us. Whether it’s about film stars from the 1920’s or rivers in South America, they seem to know all the answers. Time spent at the University of Life is what they claim.

One thing that is clear is the sense of camaraderie that has developed from the quiz. Surgeons chat to the scrub nurses, anaesthetists banter with the recovery staff. Even the midwives have stopped moaning to concentrate on ‘The Quiz’. Phil’s Quiz transgresses traditional hierarchy and boundaries. There is now common ground between ranks and seniority. Doctors can be heard discussing the questions with porters in the washrooms, trainees and students immediately feel part of the team as they join in trying to help find the answers before, in true Countdown style, time has ticked away.

Team bonding is a highly sought after cliché in many workplaces. Private companies, encouraged by generous tax deductable allowances, send their staff on muddy weekend team building courses in the hope of increasing morale and therefore productivity in the workplace. Phil’s Quiz achieves much more for much less.

Far from being a distraction from work, Phil’s Quiz seems to oil the big rusty wheels of the NHS. On Thursdays the theatres run as usual but the mood is better, the troops are happier, there is less moaning and the frisson of healthy competition is apparent. Thank goodness the holidays are over and Phil’s back.

If only the politicians would listen to what really works at the frontline.

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Why signing on the dotted line is a waste of time

By Caroline Whymark - 4th August 2011 1:21 pm

I have just been involved with the induction process for our new doctors. This was not just induction. This was PMETB/GMC prescribed, documented, accountable, measureable induction (you’ll have to imagine the seductive background music).

Although there were two main parts to the process, a generic hospital induction and a departmental induction, there was one clear theme throughout the day: signing your name. One’s signature seems to be required for less and less in day-to-day work but more and more during the induction period and seems to have been extrapolated to the nth degree such that I now question the value of a doctor’s signature beyond absolving the hospital of corporate liability. Let me explain.

For case note entries we have an ink stamp with our printed name and GMC number. Several departments have computerised notes meaning the doctor entering the data is identifiable by a personalised login. Confidential reporting and feedback forms can be traced via GMC numbers only. The flourish of a signature at the end of written notes, practiced and perfected by many an enthusiastic medical student, nowadays seems superfluous to need.

Except for on induction day.

Trainees now have to sign their lives away on a whole list of requirements including (but not limited to) attendance at induction, confirmation they have seen the arrest trolley, acknowledgement of name of Educational Supervisor, receipt of a bleep, successful procurement of a theatre locker (key requires additional £5 deposit), promise of adherence to internet code of conduct, solemn declaration not to use their security swipe badge to allow undesirables to access clinical areas, confirmation that they’ve seen master rota and received details of expected remit of duties. I won’t go on to mention the fire lecture, hand hygiene protocol and dress codes; you get the idea.

Today I asked them all to sign the various bits of papers and returned it all to the postgraduate manager as required.

I then wondered what had been achieved. Was it really necessary? In the same way as Assessment of Training induction has now been broken down into smaller and smaller component parts which require to be ‘signed off’.

I worry that the result will be the same: more and more paperwork giving less and less information about the sum total of the component parts. What do they actually know now, what can they actually do? In other words, does the information we have gathered still allow us to see the wood despite the trees? I wonder.

Anyway after induction the next job is to get the Learning Agreements signed off. Will a signature have any more meaning in this domain? I don’t know. It depends if it is legible or not, I guess.

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I’m planning my retirement party already

By Caroline Whymark - 23rd June 2011 10:23 pm

Recently I have begun to think about my retirement party. Not because I’m nearing my late fifties but because I’ve organised and attended several recently and can’t help but wonder what it’ll be like when it’s my turn.

You see it’s another phase in life. Phases I’ve identified so far include eighteenth and twenty first birthdays, engagement parties, hen parties, weddings, christenings, fortieths, divorce parties and funerals.

Chronologically, retirement was a phase I hadn’t really given much thought to until now. Like death and taxes, retirement will come to us all (admittedly to some much sooner than others). It now presents another large stressful organisation of excess: venues, presents, speeches, what to wear dilemmas, alcohol and undoubtedly regrets. And of course cost.

In years now gone, if you worked until you were 60 in the NHS you received a farewell ‘tea’ free gratis. It was seen as a thank you for your service and having stuck the distance. It rose above usual canteen fare. Sandwiches were garnished with salad and often strawberry tarts put in an appearance. These delights formed the basis of the resulting banquet due mainly to the efforts of nursing staff, each bringing in something homemade and calorific to send you on your way. But no more. Not only is there no free lunch at retirement, your guests are now expected to pay to attend and bank roll a proper celebratory bash.

Then unintentionally, it turns from a celebration into a popularity contest and public measure of your career success (or otherwise). How big a venue do you need? How many nurses want to come? How many mid wives? How many can afford to? Do the trainees like you enough to bother attending now that your job will be replaced with one nowhere near as attractive? Can you attract people from your past as well as your present? The attendance of your spouse, your children with perhaps partners and offspring of their own is yet another marker of your success or otherwise.

The party itself is like a strange juxtaposition of various other celebrated life events. Like a wedding a standard format has evolved: gifts, speeches, polite chit chat deteriorating into drunken declarations of everlasting love, not forgetting disinhibition on the dance floor. Like a funeral, no one is specifically invited or excluded and inevitably you glance around wondering who’ll be next. Throw in the gleeful delight of impending release from a life sentence in the NHS and you’d be forgiven for thinking you’re at a divorce party.

I had always planned to have a massive party at my funeral. People enjoying themselves, wearing bright clothes and remembering me fondly. But why miss the party? I am now a big fan of this ‘retirement do’ lark and have decided to bring the party forward a few years to mark my retirement instead of my passing (assuming nature and fate allow that sequence of events). I’m going to plan it, organise it and pay for it myself. I’ll have a theme, flowers, a gift list and will bequeath all items from my office to those most deserving. I’ll even cry if I want to. I can hardly wait!

Who knows how many more years it’ll be until my big day arrives, but when it does, you can rest assured you’re all invited

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Q: What time does theatre start at? Part II

By Caroline Whymark - 1st June 2011 9:41 am

OK, so maybe I was having a bad day. As Kathy Teale pointed out, the system can work but the key is that you need buy in from all parties. I agree.

But, currently all parties feel sold out.

The fact of the matter is that only a few years ago there was a true team spirit working well in theatre and it has disappeared due to the removal of incentives which made this natural, uncontrived multi-disciplinary team work well together.

Whether it’s being good for the whole year waiting for Santa to come, or a Waiting List Initiative payment on a Saturday morning, incentives work.

Let me explain. As an SHO I arrived in a new hospital. Saw all my patients on the morning of surgery then went to theatre and got everything ready. Wandering into the communal coffee room shared by all ranks of staff I was offered a scone and coffee. “What time does theatre start?” I asked concerned that it was already 8.50 and we’d never get through the list. There was surprise in the room at this question. “When Sister tells us it’s time” was the answer.

The motivation to work hard became obvious very quickly. Speeding through the first couple of cases was rewarded with a team wide sit down (with more scones). The forces were revitalised and momentum stayed high until lunchtime when again the team stopped for a break. With the home straight in sight, it was common to cut short the lunch break to get on with the remainder of the list. As the light at the end of the list grew brighter and brighter so did our spirits, for we were heading for an early finish. If we were done by 4, we were rewarded by being able to leave at 4. All of us.

Fast forward to 2011. It is no surprise that everyone waits for everyone else and no one starts the ball rolling. It is in no one’s interest to finish early. If we speed through the day and finish at 3.30pm the nurses merely get redeployed to another theatre or given extra cleaning duties. They are paid until 5 pm and so will be there until 5pm.

The anaesthetist usually gets asked to help with a couple of quick trauma cases and it’s the same for the surgeons. If they get through the work more efficiently they have to explain their perceived under utilisation of theatre time to management and be told to list more cases in future.

I am not saying this is wrong. What I am saying is that there are pros and cons to everything and management style is no different. If you want a time centred workforce, you will get a time centred workforce. They will turn up on time, expect their (often unpaid) breaks and stay until clocking off time. Productivity will be defined by the rate limiting step in the system. But a little bit of give and take from one side will be reciprocated by the other and may well achieve a lot more for a lot less.

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Q: What time does theatre start at? A: Er…

By Caroline Whymark - 21st May 2011 10:16 pm

“What time does theatre start at?” was the first item on the agenda when we anaesthetists were invited to a meeting by the ‘lean team’ running our improved theatre efficiency, Kaizen-type project. The whole meeting was typified by the fact that we never got beyond this item. But why should this be a difficult question to answer? The theatre lists clearly state ‘0830hrs’. Job plans generally start at 0815 or 0830 in anaesthesia. Most of us naively assume that means we start anaesthetising the first patient at 0830hours. What else could it possibly mean?

Well, in this new, patient safe lean way of working it can mean many things, or can actually have no meaning at all. In days gone by we did indeed turn up early to check machines, draw up the drugs and start with the first patient at 0830. More recently things are less straightforward. On a typical list, for example, the anaesthetist turns up at 0815 to prepare. All the theatre staff are ‘having breakfast’ followed by cigarette as ‘they started work’ at 0800.

Nothing is prepared in theatre because they aren’t sure which case we’ll be doing first, they need to see the surgeon. The anaesthetist nips round to the day surgery unit which functions more and more each day as a same day admission lounge and sees the first two patients for the list who arrived at 0730. The others are due to arrive at 1100, then noon, and finally at 1300 to reduce the amount of time they are ‘kept waiting’ for their operation.

This means the list needs to stop while surgeon and anaesthetist return later in the day to mark the correct side, establish their various fasting states and deal with the unexpected problems. Back to theatre, 0845, “can we get the first patient round?” the anaesthetist asks. Of course not. “We’ve not seen the surgeon yet,” state the theatre staff. Fair enough. “I’ve seen him”, the anaesthetist ventures, ever hopeful of getting the list started, “he’s in the admission area consenting and marking the two patients who have arrived”.

Now we need to wait for him to come to theatre so we can have the ‘team huddle’. 0900, surgeon arrives and the huddle begins. Everyone introduces themselves and that goes smoothly as we all know each other having worked together on this list for the past five years. Then, onto the first patient, confirmed as being the first name on the list, having the operation described on the list, with the routine set of equipment available. I comment that he’ll take 20 seconds to be knocked off to sleep. I don’t feel the need to explain my decision making processes when formulating my anaesthetic plan. I have 15 years experience in weighing up the risks and benefits as they pertain to individual patients and feel that dealing with those problems is my job, my responsibility, with the anaesthetic nurse or ODP being informed and prepared on a need to know basis.

We continue by huddling the second patient and then abruptly stop. The following four patients have not yet arrived. The surgeon cannot confirm the correct side of the planned surgery. I hope the patients will have been to the pre-assessment clinic, found it in good working order and have no special considerations. But we don’t know. Shall we just get started then? Shall we re-huddle at regular intervals? Again in the afternoon? Not bother? No one is sure and several of the staff are on half days anyway so lose interest.

The box on the form gets ticked that we have indeed performed the huddle and the first patient is brought to the anaesthetic room. It is 0910hours. Is that our start time? Or is when eventually the knife gets to the skin? The latter of course only happening after the surgical pause, and that’s a whole other story.

It’s going to be a long day…

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Posted in Caroline Whymark | 2 Comments »