Is my jam spread too thin?

Most of us living in the 21st century have complex lives, multiples pressures and demands on time. This is especially true of our careers, with portfolio careers becoming the norm rather than the exception.
Medics in particular have a propensity to attract work, consultants working 14 PAs i.e. 7 days a week are routine, and a part time GP is seldom inactive, so the question arises- "is my jam spread too thin?"
To answer the question you must first understand the question.
In an industrial sense, based on time and process any failure to deliver or be present would suggest inadequate performance. However, the question is a judgement based on jam, and not an industrial metric at all.
Assume your customers ( employers, service users, co- workers, staff) were to respond on your behalf. Their response would be a judgement, a perception. In the jam analogy it's a matter of taste and perspective, if enough of the bread is covered by a non uniform distribution such that there is never a bite of the bread which contains insufficient jam for the taste of the diner then the answer is a negative.
And there's the rub. It is a matter of taste.

Think about the problem

My house has a conservatory. When it rains it leaks. I can use a bucket to catch the water and when it fills I can always get a bigger bucket. I could of course look up at the roof and move the panels about to stop the leak. I could even go up and fix the overflowing gutter.
Of course the NHS would buy a bigger bucket- secondary care. We need to look to the root of the issue and fix the self care agenda - the leaky gutter.
Each of those areas can only improve if the knowledge and skills moves up, towards the problem. The bucket minders need to fix the roof, the roofers need to fix the gutter. It's possible while we're changing the system that the rain will feel wetter than standing watching the bucket fill.
We either do it or keep buying buckets - but we have no money.

The NHS revolution

We need a revolution. Right now the NHS is at a turning point, as commentators have pointed out post Francis report we a now forced to look with fresh eyes. The emperor has no clothes, performance measures alone do not guarantee great care, they may indicate it, but they do not guarantee it. The friends and family test is a way of "outing" the patient experience beyond metrics, a soft measure which, according to experts, correlates with great care.
But what happens when the FFT shows things are not as good as they could or should be?
Will our staff be required to go the extra mile? Will we mandate smiles, greetings, corporate mantras to give the impression of enhanced service?
Probably, but that won't be revolutionary enough.
Neil Bacon, a champion of FFT has a web site www.iwantgreatcare.org which uses patient feedback to hold the mirror to hospitals and soon, primary care.
Useful though this resource may be, it ignores the voice of staff, frontline, support, engaged, disengaged, who have joined the NHS and are part of the equation which delivers great care.
The Mid Staffs lessons tell us that whistleblowers do badly in the NHS, that we need a duty of candour when things go wrong. Whilst that is laudable and right, it again misses the fact that the NHS should be able to use the staff experience before things go wrong to prevent errors, to raise issues before problems arise.
Outside of the corporate COMMs activities, the "listening into action" and staff brief we need to make the drive, commitment, concerns and solutions which all NHS staff handle on a daily basis , transparent. Transparent to the NHS as a whole, their management, the population.
How could we do this?
Let's set up www.iwanttogivegreatcare.nhs.uk it's not compulsory, but if you work for the NHS, have a problem, a solution, something to say then let's hear it.
I recall a staff intranet which had "peoplepages" for all the staff, on their page they could put practical details such as past jobs etc, but also space for a photo and statement. One HCA who worked on the cancer unit had her photo with the caption, "I love my job so much- I'd do it even if I wasn't paid". I know now that if I ended up on her unit I would get great care, but I also know that she would be able to suggest ways it could be better and alert us all if things were not right.
I know people will say we can't, that belly achers, disaffected, troublemakers will populate the pages. Maybe, but those people are caring for your friends and family right now. Unheard, unseen, needing a voice.
It's a revolution but we need it now.

When is offal awful?

Undoubtedly board rooms across the land will be full of cathartic conversation, heads shaken in disbelief that a tragedy of this magnitude could be allowed to happen. Some leaders will disembowel themselves with admissions of "we can do better".
The public outcry is stoked by a media aware that the industry has been caught putting profit first, that economic drivers have prevailed over quality and service.
Other nations will wonder what the fuss is about. Their cultural norms are not as ours, they will marvel at our dismay. What to them seems perfectly natural and normal has been "outed" as unacceptable.

Given our context as members of the NHS you will of course recognise that the issue in question is Mid Staffs, but step back and out of the NHS for a moment. The actual topic being described is the horse meet scandal.
In parts of Europe horse meat is an every day product, just as relatives providing basic care is a routine hospital activity. Families eating together at the patients bedside, sharing, supporting, caring is the norm in Eastern Europe just as horse is on the shelf in most french supermarkets.

Now don't get me wrong, there is no excuse for neglect, no apology deep enough for the loss of life and suffering caused by that neglect. I am simply pointing out that expectations, cultural norms and values set the context for any judgement.

In the UK we do not expect to be given horse when we ask for beef, we do not expect to be given neglect when we ask for care.

In both cases businesses under pressure to perform financially have compromised on quality in an effort to reduce costs. At some point in the processes individuals lost contact with the very nature of their key business. Many individuals in Findus, Tescos, Asda were totally unaware of the flawed nature of their product, others who knew of the issue felt it was acceptable and in economic terms sensible to work in such a way.
The real learning emerging from comparing these two very public standards is that legislation is not the answer.
Food standards have some very strict legislation, an army of inspectors, a host of quality metrics and legal powers enough to make your eyes water. There can't be an establishment across the country that hasn't has visits, inspections, ratings and awards, all backed up by inspectors with statutory powers.
Every supermarket and store will have been displaying a rating of their food and hygiene standards, more scores won't fix the NHS.
Our only hope rests in the hearts of every staff member, that they can find the passion to care for people, to do the right thing first time, every time, that they can care for patients as they would wish to be cared for.
The challenge for the boards will be to appease the system and inevitable knee jerk regulation whilst concentrating on the real prize, developing a culture in which great care delivers financial frugality as a by product, and not one in which financial frugality wastes the chance to care.

Mr Francis - too late, too little?

There's loads in the Francis report. 290 recommendations to be exact.
The report is critical but from a medical perspective it looks like a list of symptoms rather than a definitive diagnosis.
Occam's razor suggests that multiple answers to a problem are probably wrong, event root cause analysis gets down to the first thing that went wrong eventually. In the case of Francis it's still not diagnostic.
Neither is it really therapeutic either.
The recommendations are all worthy, sensible and predictable.
However the fundamental failure is not named clearly.
Drucker said "management is doing things right - leadership is doing the right things".
Francis names the management failures, there are loads, and in part the leadership failures, but for me misses the critical point.
Everyone in mid Staffs ceased caring.
The leadership challenge we face is how to introduce "discrete love" into our cynical safeguarded world. How to allow staff to care for patients like family, with compassion and empathy.
Sadly that's one element of care that can not be managed and must be lead. Leadership in the style of Shackleton and not Nicholson is what we require in the NHS.