David Gozzard
Medical Director
Conwy and Denbigshire Trust, Wales
“We thought we had sustainability absolutely right and then realized that we needed to do some more work.” (1:15)
I’m Dr. David Gozzard. I’m Medical Director at Conwy and Denbighshire Trust. That’s a hospital in North Wales in the United Kingdom. It has 700 beds. It’s quite different from the English Trust, being in Wales, because we have responsibility not only for the hospital but for the community and the community services. That’s not including primary care. It does everything a district general hospital will do, which means everything you can think of except from transplant surgery, cardiac surgery, and neurosurgery. My background is as a hematologist and I’ve been Medical Director for four years.
When I was a young doctor I’d be working 100 hours a week. And now, of course, the regulations are coming in so that by 2009 no doctor will work more than 48 hours. You need a lot more doctors. They’re coming out of the medical schools in droves, to take up the consultant load that would be required for consultant-led services. A consultant is really the only doctor who can practice autonomously within a hospital. And suddenly systems that were working well, we’ve had to train a lot of people and the systems have fallen down for a while. So we thought we had sustainability absolutely right and then realized that we needed to do some more work. So that’s what I’m looking at. I’m looking at really bringing more people on board and the improvement methodology that we have.
“I’ve heard consultants say one thing, and the patients have chirped in and said, ‘No, I don’t think you’re right there. That isn’t what we want.’” (1:26)
As a medical director in Wales, I’m rather an unusual beast. I’m the only medical director with an interest and a direct responsibility for modernization. I run my modernization team — it’s something that we’ve got together over the last two, three years — and we’re running a whole gamut of things. It’s really that I have a drive to try and improve the systems around me. And when I was introduced to the Safer Patients Initiative and IHI, I very quickly grasped that they were on a mission, too. And it just seemed that our paths had crossed at the right time.
Not only the Safer Patients Initiative but some things that have come from the Welsh Assembly Government, like managing waiting lists and bringing in queuing theory, etc., trying to cut down the waiting lists; of course you don’t recognize what waiting lists are in the States, but it’s a UK disease I’m afraid. Characteristically, we’ve just thrown money at it. We’ve had surgeons coming in and doing extra operating lists, and weekend work, and this sort of thing. And now, by putting in queuing theory and different capacity and demand models, we’ve brought waiting lists down without having to throw money at it. That money can be used for other things. I think also getting patients involved in the systems — that’s such a great benefit. I’ve managed to chair a couple of big projects within the Trust, where I’ve brought patients in to sit side-by-side with consultants. And I’ve heard consultants say one thing, and the patients have chirped in and said, “No, I don’t think you’re right there. That isn’t what we want.” And it’s a great tool, a great leverage to enable clinicians to see much more clearly the changes that are required.
“We’re a retirement area. You’ve always got in the back of your mind, ‘Does this patient have support in the community?’” (1:02)
We’re a retirement area. In fact, we’re affectionately known as the “Costa Geriatrica.” In North Wales it’s directly adjacent to the northwest of England, Liverpool and Manchester, and elderly residents from there come to North Wales for retirement. So actually, in Wales, we have the oldest demographics in terms of the local population. But, whereas my hospital serves 200,000, of course in the summer it goes up to over half a million because it’s a tourist area as well, so we have lots of challenges.
It’s not unusual for a couple to retire to North Wales and maybe one of them might prematurely die and that leaves somebody rather isolated in a community where they may not know anyone, where there’s a loss of the nuclear family. And therefore, any of the improvements that you want to do in terms of reducing length of stay in hospital, trying to do more day case surgery, trying to make sure that you can do out patient procedures, you’ve always got in the back of your mind, “Does this patient have support in the community?” And that’s where it’s important to have a good relationship with the social services and social care.
“If you’re only working 40 hours a week, you do need to hand over. And that’s something that culturally we’ve had to tackle.” (1:25)
I think “clinical hand-over” is a very important patient safety feature. When I was over here last year, I realized that a lot of the same issues that we have in terms of the safe handing of a patient from doctor to doctor, or nurse to nurse, or whatever, is exactly the same over here. We are making some in-roads into that and we’re getting good systems in place. But it is cultural. It’s something that generally we don’t think of as being the primary duty of a doctor; you come in, you see a patient, you deal with them. But of course, if I was working 100 hours, who do I need to hand over to? But if you’re only working 40 hours a week, you do need to hand over. And that’s something that culturally we’ve had to tackle and I believe we have solutions for.
I think you’ve got to be extremely patient focused. You’ve got to look at that patient and say, “What would I want for my family if I were that patient, and is there a better way of doing things?” And just have an open mind to new ideas. So many times I talk to my colleagues and they don’t, they can’t, glimpse the future that could be a difference. And of course when you show them, when you lead them the way, they suddenly say, “Wow, why didn’t we think of that?” But I think things are gradually changing. I think as the younger, vibrant consultants are coming through, who have seen lots of changes themselves, change seems to beget change.
The very first day I was a medical director, I wandered into a consultants’ coffee room and I was going to start a conversation, or participate in a conversation. I just said one word and suddenly the whole room hushed. And I very quickly realized that here was a situation that I hadn’t anticipated: that I had influence. I just want to use that influence to improve matters for patients.
“We look at targets as being a proxy for quality, but we know there are other things to measure.” (1:00)
I think the biggest challenge for me now is to mainstream quality improvement. The National Health Service is a target-based service. So we look at targets as being a proxy for quality, but we know there are other things to measure. And it’s trying to get that measurement system in. It’s trying to get the boards of the various hospitals interested in wanting to know about these outcome measures. A lot of people would say that quality costs. I don’t ascribe to that. I think if you get things right the first time, you actually save a lot of resource.
A target for me would be making sure that nobody that comes into the accident unit waits more than four hours. There’s absolutely nothing in there to say whether the patient should actually be seen at the hospital or not. And if you have to go to primary care doctor, and you have to wait for two days to see them, and you know you can go down to the accident unit and be seen in four hours, we’re actually shooting ourselves in the foot. And I think that’s the difference between an outcome measure and a target. And I think that’s a message I would really like to get over to the NHS.
04/23/2007
