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The robot habit

r2d2 iconHaving successfully completed the challenge (thank you Abi) of finding something good to say each week about Cardiff and the Vale UHB for a year, I allowed myself a break from writing these blogs. There’s been a gentle murmuring however … some people are missing them. So I thought I would pick up my pen, so to speak and get back into the habit.

Some of you might know that I had a bit of a health scare over the summer. You can read a bit more about here if you’re interested. As a result I’ve been ruminating a bit about why we do the things we do and whether I’m being consistent about focushabitsing on what’s most important. I’ve been reading a couple of good books which discuss why we behave the way we do. The  ‘The Power of Habit’ by Charle Duhigg, explores the science behind habit formation and the ways in which our lives are often governed by these unconscious patterns of behaviour.

Habits it turns out are all based on the same simple
neurological sequence: a routine, a reward and a cue, something which the researchers at Massachusetts Institute of Technology called the ‘habit loop’. The person habit loopwho habitually bits their nails will have a cue – perhaps feeling a snag when running her thumb over a nail, which triggers a routine, hands to mouth and a reward, nibbling off the offending nail. To change this requires an amendment to one or more of these three parts. Some people have changed this habit by responding to the cue by rubbing their finger tip vigorously on their thigh until the cue stimulus subsides.

The other book is ‘Thinking, Fast and Slow’ by Daniel Kahneman which is equally fascinating. The brain it turns out has two systethinking fastms … which Kahneman calls System 1 and System 2.

System 1 is fast; it’s intuitive, associative, metaphorical, automatic, impressionistic, and it can’t be switched off. System 2 on the other hand is slow, deliberate, effortful. But System 2 is also lazy and tires easily (a process called “ego depletion”). The greater the cognitive load on System 2, the more susceptible we are to being governed by System 1.

If you want to test this for your self here’s a test you can do.

Step 1: Sit in front of your computer and open a browser.

Step 2: Attempt to do the following calculation in your head 13 x 27

Step 3 go to theinvisiblegorilla.com/videos.html and follow the instructions very carefully.

While System 1 allowed our ancestors to stay alive and is good at some things like responding to danger (think how we respond to a snarling dog) it unfortunately also loves to simplify, to assume WYSIATI (“what you see is all there is”). It’s hopeless at the kind of statistical thinking often required for good decisions, it jumps wildly to conclusions and it’s subject to a fantastic suite of irrational biases and interference effects. One you might have heard of is the halo effect – when interviewers make their minds up immediately in the first few seconds after the candidate appears.

All in all we’re astonishingly susceptible to being influenced – controlled even – by features of our surroundings in ways we don’t suspect. In plain speak for a big part of our day we are flying on automatic pilot.

So why am I going on about this then? Well, we are working towards a safer health care system, where we do everything we can to make errors harder to make, where we use good processes that give reliable results when appropriate, and where we respect each other and encourage openness and show a commitment to learning from our mistakes.

We often talk about human factors in systems – which actually means that we are rather error prone. We are in other words, not robots. These two books provide some of the reasons why.

Keep well.


If you’d like to have a look at another blog I’m starting or my attempt to get my life under control – you can do so here.

What’s it all about anyway?

Here’s a quote from Simon Sinek:

‘Our goals should serve as markers, measurements of the progress we make in pursuit of something greater than ourselves.’

‘Something greater than ourselves…’ I really like that because it means that we shouldn’t forget why we do what we do. It can be easy to forget how you felt when you first started to work in the NHS. I can remember as a young law graduate feeling so privileged to be rubbing shoulders with people who were doing such (to me) unbelievably good things. I mean ‘good’ in the way that a spiritual person might mean it, or the way someone who has shown character under fire might be seen, or a charity worker who feels compelled to work in a disaster area. I suppose I mean virtue.

There is so much that people who work in the NHS do that is virtuous. I know it’s a job, and that we all have to earn a crust. I also know that for some people work can become a prison, or it can feel oppressive or difficult. But I still can’t remove myself from the thought that people who I work with on the whole tend to be kind, thoughtful, caring, and respectful. I admire them – plain and simple.

It’s our job to care – even me. I care about how we treat our patients, whether we are helping people get what they need from us to help them keep well. I care about our organisation and the people in it. It’s my job.

What about those people though who aren’t paid and for whom being virtuous is reward enough in itself? People who aren’t employees, who we don’t have a right to expect anything from, but who nevertheless quietly and without a fuss just get up in the morning and want to do something good. I’m talking about the people who volunteer to help us and help the people we serve.

Pics Tim Dickeson 13-03-2015 - 2015 Staff Recognition Awards
Pics Tim Dickeson 13-03-2015 – 2015 Staff Recognition Awards

I was at an event in Barry last year and met a community first responder – someone who lived locally and who had decided he wanted to participate in a rota of people who would be called if someone might have had a cardiac arrest. I sat talking with this young man for a while and I learnt that he was unemployed currently, but lived in a street he’d been brought up in. One morning, he noticed one of his elderly neighbours struggling to open her gate. He went across and helped her and as he watched her walking away he thought about how long he’d known her, and remembered when she’d once looked after him when he’d fallen playing in the street as a boy. He saw how old she’d become and how frail she’d was and he started to worry that at some point something might happen to her. He felt like he would want to know what to do – and it was this thought that had led him to investigate becoming a first-responder. As we chatted he mentioned in passing that he went swimming each week on a Thursday and that was something else he really enjoyed. Slightly intrigued I asked him why, and he told me that that was when he took a group of people with learning disabilities swimming, acting as a volunteer. He said he loved the way they enjoyed it and he said he felt good afterwards. There’s that word again – ‘good’.

We’ve been celebrating the work of our volunteers over the past week. You can read what the Western Mail had to say about here. Our volunteers include some staff members who have retired but still feel the urge to do something good. I’d like to salute them, one and all. There’s a really interesting book I once read by a man called Jonathan Haidt called The Happiness Hypothesis. He examines the evidence for the causes of happiness. One of the things the evidence tells us we should do is: improve our connection to something beyond ourselves. He goes on to say: ‘Happiness is not the shallow state of feeling pleased and chipper all the time. Happiness is the state of a human being that has achieved cross-level coherence within herself, and between herself and the people, challenges, and institutions around her. Happiness comes from between’.

I’m guessing this is something our volunteers have worked out for themselves. If we want to increase our happiness potential he has a word of advice:

‘Join an organization that has a noble purpose and a long and noble past. Any volunteer work can take you out of yourself. But one that has history, traditions, and rituals is an easier place to find “vital engagement”’

Aren’t we lucky?

Keep well.

Staff treating a patient at the Stroke Rehabilitation Centre

The Future is Another Country

There are lots of ways of saying that, when we want to change the results we are getting, we should think about what we might need to do differently. Einstein is often quoted as saying: ‘the definition of insanity is doing the same thing and expecting different results.’ Tony Robbins (not remotely in Einstein’s league I know) has another spin on this: ‘there is no such thing as failure – there are only results.’ What he means by this is that if we are not getting the results we want the first step is to acknowledge that results don’t just happen – we make them happen. In fact, we might say that we are rather good at getting the results we are getting even if we don’t like them. I find this rather empowering because if we can learn to do one thing, there is no reason to believe we couldn’t in time and with some effort learn how to do another thing.

We can’t know what will happen in the future, just like we can’t change what happened in the past. If we want to modify what happens in the future, the best advice is to change what we do now.

When we look around us at the way things work and how we work together to make those things happen, how often can we say that the way things work is really the result of a whole series of choices we have made consciously to do things in that way? One simple definition of culture is that it is ‘the way we do things round here.’ Why things are done the way they are is not set in stone. It is possible for example to have two wards side by side, with roughly the same group of patients being cared for and for these two wards to feel remarkably unlike each other. What makes the difference is often the leadership in each ward which changes the setting on what is OK and what is not OK.

SRC therapist and patient

In the Stroke Rehabilitation Centre at Llandough Hospital the team are faced with the challenge of supporting patients with very complex needs as they make the transition from the person they were before they became a patient with a stroke to the person they have become as a result. The evidence for helping people make this transition back into their lives away from hospital as soon as possible is very good and this is why the team became focused on delays in managing this transition which highlighted the need for a different kind of support at ward level. The team considered a range of possibilities and were tempted to appoint a ward based social worker. In the end however, they went in a different direction and tried something new. They appointed a Discharge Support Officer (DSO). The DSO is a member of the Integrated Discharge Service, commissioned via Age Connect to support patients over the age of 60 to prepare for discharge from hospital. By working with patients and their families Discharge Support Officers help promote safe and timely discharge.

Laura Thomas commenced in the DSO role in February 2015 for a four month trial period and currently works three days a week with the multidisciplinary team in the Stroke Rehabilitation Centre, UHL. Evaluation of her role for the initial six week period showed that she had received 19 referrals in total, 15 of those being for family support including assisting families through the discharge process, decision making and signposting to relevant services. The evaluation also demonstrated time spent meeting with families, telephone contact, attending/arranging meetings – DST’s and goal planning as well as arranging Unified Assessments (UA). All of this was previously undertaken by the nursing staff who struggled to dedicate time to the process due to competing clinical demands.

The team on SRC have embraced the DSO role and further discussion will be had regarding sustainability of the role on a more permanent basis. The benefits identified within the four months include:

  • DSO is ward based and therefore gets to know patients and their families personally without the need to await a referral
  • DSO is recognised as a point of contact for patients and families in relation to discharge plans
  • picks up referrals during the early stages of rehabilitation
  • provides support on-site for patients and relatives from time of admission to the Stroke Rehabilitation Centre
  • attends UA reviews which has noticeably reduced length of review meetings and the speed at which these are completed; and provides additional support for patients who have no family support
  • sign posting staff/patient/relatives to appropriate services often Third Sector in the community
  • completes the consent process as part of the UA process
  • provides active assistance and increased momentum with discharge co-ordination
  • an Advocate for patient’s, and,
  • releases clinical staff time, previously occupied with some of the administrative side of discharge planning.

Overall the role is viewed very positively by all concerned and the team are continuing to evaluate the impact Laura’s role is having.

Time will tell whether this role will be one that the team conclude they need. What I like about this story is that they were prepared to try something out, to experiment based on what their wisdom and experience told them about what might work better for the people they are serving. I like that they are evaluating and adapting as they go. My hope is that this team continues to explore why things are done the way they are and to question whether the way we have always responded is necessarily the right way to do so now. I think of teams and people like this as explorers, people who are prepared to venture a little into the unknown and see what lies beyond.

Keep Well

Hitting the sweet spot

There are around 20,000 people in Cardiff and the Vale who live with type 2 diabetes and this is one of the reasons we have focused our attention as a health board on this particular health issue. Diabetes is one of those long term health care illnesses that are sometimes referred to as ‘long term conditions’.

In some parts of the world, there has been a move to downplay the disease specific treatment pathways and at least in planning terms try and aggregate up the care that people with many different kinds of long term conditions need. There are good reasons for this – not least that many people have to contend with more than one form of long term condition. Indeed in our health board the Primary, Community and Intermediate Care Clinical Board has done some fantastic work looking at some common conditions that are amenable to treatment without a need for admission to hospital and have shown that it is possible to organise some of these treatments along pathways that overlap or share many similar components.

diabetes-528678_640However there is a dilemma: how can we balance the depth of knowledge required about possible treatment options for individual patients with the growing patient numbers and increasing treatment complexity?

Sharing knowledge and sharing the care we offer is a challenge when the knowledge that individual practitioners have of necessity is getting deeper, but arguably narrower too. It is worth persevering with as doing so helps us see the whole patient rather than responding to the patient one illness at a time. All of this is the natural territory of primary care which is where the vast majority of our population’s contact with our services takes place. The fact that the public continue to see primary care as a real strength of our system is a real tribute to those who work in this part of our NHS. There is no denying that the pressure on primary care is rising due in part to the ageing of the population but also as the result of more complex and demanding treatment choices – which includes diabetes.

So how can this dilemma about the depth of knowledge acquired by a few and the breadth of knowledge required by many be handled?  That was the question that our physicians who look after patients with diabetes asked themselves. The facts are startling: the prevalence of type 2 diabetes is around 5% in South Wales but the condition accounts for 9% of our expenditure and audit data shows that 18% of all inpatients will have diabetes. Recognising the increasing demands that diabetes places on the NHS, the physicians are in the final stages of developing an integrated model of type two diabetes care with closer integration between primary and secondary care providers than has been possible in the past. The model aims to deliver care as close to the patients home as possible and to provide support and education to primary care (General Practitioner and Practice Nurse primarily) as well as allowing secondary care to better understand the difficulties of managing a complex chronic disease such as diabetes in the community.

The model is centred on the principle that each of six consultants in diabetes will be attached to between eight and ten named general practices and will remain with those practices for community clinics, case notes review and advice by email. The expectation is that this will allow primary care physicians to get access to senior decision making in a timely manner and without having to make a formal referral to the hospital outpatient clinic with the delays that may be incurred. Having a named consultant will offer continuity of care and will facilitate the development of closer links between primary and secondary care. GPs will quickly develop enhanced skills through discussion with the hospital specialist that will allow them to feel more confident in managing patients with increasingly complex needs.

Because of the increasing number of patients with type 2 diabetes and the increasingly complex treatment options and algorithms available it is often difficult for general practitioners to decide on the best treatment for an individual. Capacity in secondary care clinics is limited and increasingly restricted to managing the most complex type 2 diabetes cases as well as type 1 patients. It is important to recognise that each person’s diabetes management and treatment targets needs to be individualised and as patients are often taking many other drugs for other co-morbid conditions it can be challenging to decide on the best option. Giving access to consultant Diabetologists for help with complex decision making will allow most patients to have their treatment delivered by their GP in the practice without the need to travel or wait.

The physicians have a big and positive vision for the future. They aim to facilitate the delivery of high quality care to patients, whilst reducing inequalities in care from area to area and assuring an accountable and auditable service is maintained. This project is one of the biggest reorganisations of service delivery in the field of diabetes for many years and as such offers the opportunity to be innovative and forward thinking, keeping the patient at the heart of the service.

You might say that really is hitting the sweet spot.

Keep Well


That was the week that was

Last week Cardiff was at the centre of the largest security operation ever undertaken in the UK. Leaders from 28 countries were in town to attend the NATO summit and anyone in and around Cardiff cannot fail to have been impressed by the sight of huge numbers of police officers from around the country patrolling the streets, many of them armed with automatic weapons.

NATOIn fact there were more than ten thousand officers deployed. It is a sign of the times we live in that these precautions are necessary, and at the end of last week there will have been a collective sigh of relief, mingled with some pride that Wales and Cardiff and Newport had done the nation proud.

We have all heard of VIPs – very important people and from time to time we might go to an event when one of these types is around. What do you call someone like the President of the United States, though? Well it turns out these are VVIPs, very, very important people.

As you can imagine planning an event like the summit takes many months of careful preparation and a great deal of collaboration with many organisations, both in government at UK and Wales level, security forces, the police and many more. One element of the plan was thinking through what might happen if one of the VVIPs were to be taken ill, or if there had been some other kind of larger scale problem such as food poisoning, or even the possibility of some kind of security incident.

Nations take very seriously the health and well being of their leaders as you can imagine. In the weeks leading up to the summit, our emergency unit, critical care unit and theatres were visited by a number of embassies and officials from countries attending the summit, along with a White House team. This is because UHW was the designated receiving hospital for the region during the summit. As is normal in these circumstances they wanted to assure themselves about was the standard of care their leaders might expect to receive in the event of a problem and the kind of facilities that would be available and whether a VVIP could be looked after securely.

The UHB's Angela Stephenson, Sharon O'Brien and Linda Donovan.
The UHB’s Angela Stephenson, Sharon O’Brien and Linda Donovan.

To say that they were impressed with what they saw would be a huge understatement, and we were delighted to receive a certificate from Dr Ronny Jackson, President Obama’s personal physician that reads:

“Your professionalism reflects great credit upon yourself and is in keeping with the highest traditions of medical care. Thank you for a job well done.”

NATO2It wasn’t just the VVIPs that we needed to think about though. What about all those police officers? What would they do if the needed medical attention? How about the protestors, what would happen if there was significant disorder and people go hurt? Our response to these challenges was lead by Angela Stephenson, the UHB’s Strategic Partnership and Planning Manager. Angela is clear that every part of the UHB played a role in the months of preparations for the summit, from operational service to staff in clinical boards. Angela is also pleased that the messages we relayed to the public about what we were doing were understood and we are grateful that the public played their part in minimising any disruption to our services.

Our primary care teams organised access for the police to their services for the duration – something that proved to be required when quite a few police officers suffered nasty insect bites as they searched undergrowth and bushes. Sharon O’Brien, the UHB’s Lead Nurse for Emergency Medicine, worked closely with the foreign teams to offer the reassurance that led to the endorsement from the White House.

She said: “During the Summit all the staff within the Emergency Unit were incredibly professional working with all the different delegations and embassy staff as part of the preparatory visits.

“I would like to thank all the nursing and medical staff who worked so hard to ensure that the Emergency Unit and the City Centre Triage and Treatment Unit were fully prepared and equipped for this Summit and I would like to thank Assessment Unit staff for their help in looking after the White House security delegation including the FBI whilst they were based in the Assessment Unit.

“All the staff were very proud that the White House felt able to endorse the EU and the care we offer and that the department could cope with such a massive event.

“We have shown that we are prepared for the major events and all this work has helped to reinforce that.

“I am very proud to be part of such a dedicated team and one that has won such prestigious, international recognition.”

Well I can’t do anything but agree – as once again we have done Wales proud and have shown as we always do that when the chips are down we deliver for those who need us, whether they are VVIPs or people like you and me. Congratulations, thank you and well done to everyone involved.

Keep well.

PICTURE CREDIT: UHB Media Resources, Ann Beswick

Crossing Continents

There is a lot of international attention on Cardiff this week because of NATO and I’ll say a bit more about what’s been happening behind the scenes next week. However, with an eye on international matters I’d like to share something about how people in our organisation are helping and supporting communities in Africa, who don’t enjoy the privileges of a Welsh NHS service that is both comprehensive and modern and which is provided in a society that has by comparison a high standard of living.

OLYMPUS DIGITAL CAMERAThe UN Millennium Development Goals included an ambitious target to halve global poverty by 2015. As part of the Welsh Government’s contribution to this challenge it supports an International Learning Opportunities (ILO) Programme, which aims to provide public and third sector workers the opportunity to work on development projects in sub-Saharan Africa. The current focus is on Uganda and Lesotho. The idea behind this programme is to enable those who take part to develop their leadership skills by sharing their existing skills and knowledge in a new and challenging environment.

One of our experienced mental health nurses, Simone Joslyn, took up the challenge and travelled to Mbale in Uganda between February and April this year to work at a health centre with a maternity unit. As you can imagine this provided her with an amazing opportunity to enrich and develop her skills and experience in a totally new environment.ILO1

Talking about her experience Simone says:

 “During my placement I was able to improve my communication and managerial skills, utilize change management and assist in the delivery of babies, something that I had never done in Wales. The people I worked with and met showed such grace and inner strength and I returned to Wales feeling humbled by the relationships I forged.


“At Bushikori Health Centre, where I was placed, the facilities were not what we are used to in Wales but the care and attention given to the patients was as good. I am in awe of their kindness and the care that they offer and learnt much to bring back to my area of work.”

I think it’s remarkable that we work with colleagues who are prepared to extend themselves and give so generously of their knowledge and skills to a part of the world that really needs international support. This is no holiday as Simone would confirm and the challenges are real.

It’s also wonderful that one of the values that I hope we all share, kindness, is something which really stood out for Simone during her visit. Surely this lies at the heart of any good health care organisation, and Simone’s reflections are a reminder that being kind to the people who need us, and to our colleagues we work alongside is something that really can change lives for the better.

I’m sometimes asked how I decide something is OK to do or not. This is because many people still feel that they will ‘get into trouble’ for having a go at something, or trying to make a change. I always say that if in doubt people should ask themselves three questions.

  • Is what I’m proposing to do safe? I might like to help shorten the waiting list for orthopaedic surgery by offering to do a few hip replacements – but that is definitely not going to be safe.
  • Am I going to be spending someone else’s money without their say so? Apart from being good manners, it is also important that we take good care of taxpayer’s money.
  • Will it make us proud? As opposed to something we would be ashamed of or make us look bad, or which wouldn’t fit with our values.

I reckon Simone has definitely made us proud through what she has done, and I’m guessing that working in Mbale has developed her confidence to work through a problem and make things happen. After all, if things can be made to work in Mbale, why not Cardiff?  I’ll leave the last word to her.

 “I’d urge anyone who thinks they could benefit from the ILO programme to apply. My time in Uganda was a fantastic experience and one that I will never forget. No other training programme that I know of offers this kind of exposure and opportunity and I feel honoured to have been involved and supported by Cardiff & Vale UHB. It enhances your practice and your values like nothing I have ever known.”

Keep well.

OLYMPUS DIGITAL CAMERA If you are interested in learning more about the Wales for Africa programme then visit


What will you be doing ten years from now? I’m not sure I know, unless I win the lottery – but then I’d have to start buying tickets wouldn’t I? If we think about what the next ten years might have in store for us here in the health board we might start with what we already know to help us understand what the future might look like. Let’s begin with the size of the population we will be looking after ten years from now.

Cardiff, the capital city of Wales, is booming and it has become one of the fastest growing parts of the UK with unemployment falling and output growing. In the education sector Cardiff University is strengthening its position as the only Russell Group University in Wales and the other higher education sectors are flying high too.

The contrast with other parts of Wales is quite marked as the population growth forecasts demonstrate.New Picture (20)

As you can see the population in our part of the world is going to grow at least twice as fast as the rest of Wales and much more than that in many cases. This is before we factor in the growth the city council have pencilled into the housing stock in Cardiff, with 47,000 new homes to be built according to the Local Development Plan.

10883720543_b4fd2aac29_zWhat will this mean for health care services? The obvious conclusion is that there is going to be significantly more demand for healthcare, and here we will be experiencing a trend line that moves twice as fast as anywhere else. We need to ensure that the external economic growth taking place in the capital is matched by a commensurate adjustment in the way that resources in the NHS are shaped overall. This is a complex area and there are many nuances and difficulties to overcome, but we are making the case that equity of access to healthcare must have some linkage to equity of resources to provide that access. I will keep you posted on this situation.

It looks like in future we are going to have to become really expert at helping our population stay well and we will also need to ensure that we get even better at selecting the right treatments for the specific problems patients have. To help us with this latter challenge, there is a new era approaching when we will be able to match an individual’s genetic signature to a treatment that is tailored to their individual characteristics, including the responsiveness to the proposed treatment.

Although all LHB’s are now designated University Health Boards, I like to think that there remains something distinctive about our organisation. As I have mentioned before, we contribute more than half of the entire Wales research output, and we have many internationally renowned staff who are leaders in their field. Our close working relationship with Cardiff University is one of our great strengths and provides us with one of the most important ways in which we will be able to meet the challenges ahead.

As an illustration, we know that today, lung cancer is a devastating disease and the UK’s biggest cancer killer. It accounts for more than one in five cancer deaths and is the second most common cancer in men and women in the UK. Working with Cancer Research UK, Rachel Butler and the Medical Genetics Team want to change these odds for people with lung cancer.

Genetic testing is already used to detect DNA changes in lung cancer that point to whether a patient will (or will not) benefit from a particular drug, this is known as Personalised or Stratified medicine. Stratified medicine identifies key molecular changes common to different people’s cancers. Patients can then be grouped based on these shared genetic faults, allowing some people to receive a targeted treatment matched to their group. The challenge has been developing targeted treatments that show a long-term benefit for patients while accommodating the cost of widespread molecular testing in the NHS.

Cancer Research UK are preparing to launch an ambitious UK clinical trial for non-small cell lung cancer (NSCLC) called the Matrix trial which tests multiple drugs in multiple groups of patients. Each treatment has been developed to target precise genetic faults, which we’ll be testing for using our specialised ‘next generation sequencing’ system developed specifically for the programme. Our All Wales Genetic Laboratory here at Cardiff and the Vale is one of just three UK laboratories that will be providing the specialist genetic testing that will determine which drugs the lung cancer patients will receive.

Recruitment starts during Autumn 2014 from across the whole of the UK – we expect to recruit 15-20 patients to each of the 16 treatment arms. Additional treatment arms may be added as new therapies linked to genetic markers become available. If a treatment shows promise, then there’s the potential for that arm to break off from the main trial and grow into a larger independent trial with more patients who share that genetic profile.

Early evidence suggests that this genetic approach to the treatment of lung cancer will have a significant impact on patient outcomes.

There’s hope for you.

Keep well.

Picture credit: Diego Torres Silvestre