With thanks to Nigel Kennedy…

Listening to This Cultural Life I heard Nigel Kennedy talk about how his dog provided unexpected insight. His dog, experienced each day with the same joy and excitement. Each walk or meal was a wonderful experience for the pet. Yet humans seem never to be satisfied with doing the same thing over and over again. Even those creatures who like habit, tend not to summon up quite the same delight at the mundane.

Wouldn’t it be nice if we did though, especially in healthcare where so much of what we do is routine. Wouldn’t it be nice to be excited about following a protocol. Wouldn’t it be great that the 10th patient in a clinic with a similar condition caused a sense of sheer joy… ?

But it doesn’t. So, we’ve tried to adapt. Firstly, it seems where we think we do things routinely we tend to make errors (another podcast). We lose focus, we lose attention to the detail. I find the first time I cook a recipe is often the best. By the 10th time I’m not following the recipe I’m adlibbing and often badly causing culinary mayhem. To try and mitigate this we have started to automate. The old days of manually signing off paper results are long (ish) past. So now we have electronic health records that register that the results have been seen and some systems with decision support tools, might even suggest next steps for the reviewer. We are even starting to use RPA (robotic processing automation) to take humans out of the mundane. This might be automating rostering or validating.

We are starting to go even further with AI. We have radiological programmes being tested that read X-Rays as well as humans – with fewer false negatives (missed diagnosis) but probably more false positives. It won’t be too long before we have support systems that suggest diagnoses or next steps.

But I think Nigel’s point is even more profound- humans always want more / better / different. The NHS struggles to keep up with these ever-changing expectations whether for patients or staff. In part the expectations are valid  -amazing advances in technology are matched by new drugs based on specific genomic realities. In part these expectations lead to unrealistic demands for specific patients. Leaving the system with limited ability to push back. Yes, there is NICE to help with drugs but even then, when a drug is unlicensed and unlabelled, families and indeed disease specific advocacy groups often push for compassionate or other routes to usage, for example drug company funds the drug but the pickup costs e.g. staffing / operational resource impacts are paid by the NHS.

There isn’t a simple system to manage this. We can try to communicate the challenges and the financial tension better through the media. We can continue to educate staff about how to explain these tensions to families. We can continue to have NHS wide drug planning (via NICE and NHSE). But do we do enough to support staff through the tsunami of understandable passion that families launch at them? Do we have nimble enough local ethics committees to help with these tricky moral questions? Do we have these committees set up to look at more than just the individual situation but to bring in the allocative equity angle? Each of these is very tricky, we know how we struggle to get clear messages to families through the fog of suspicion, and concerns around financial impact i.e. rationing. We have seen all to recently that measles vaccination messages even in the face of an outbreak due to low vaccine uptake often fail to hit home and lead to an uptick in disease and cause real preventable harm.

In the face of paucity of simple solutions. The despair seeps into staff’s underlying sense of contentment adding to the morale challenge caused by post covid catch up and cost of living / salaries failing to keep up. The first step will not be the final mechanism of management but we do need to keep re-focusing on the expectation gap.

Magical Meander

Magical meander is an anonymous blog series written by a medical manager working in the NHS and published on BMJ Leader Blog.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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