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Grasping the Nettle

Mark Hazelwood reveals some of the thinking behind the SPPC's recently published report 'Grasping the nettle'.

Grasping the nettle aims to provide a clear consensus view on the way ahead for palliative and end of life care in Scotland.

In both polar exploring and public policy it is periodically a good thing to stop, take stock and consider carefully the direction of travel.

It is eight years since SPPC published its last sector-wide analysis of how to improve palliative and end of life care in Scotland [1].

Since then we've seen the first Scottish government action plan on palliative and end of life care, Living and Dying Well, the crisis in public finances as a result of an under-regulated banking sector, the demise of the Liverpool Care Pathway, the Francis Inquiry, and many very positive practical improvements in palliative and end of life care at the local level.

When the Scottish government made its welcome announcement in 2014 that it would produce a new strategic framework for action for palliative and end of life care, SPPC committed to supporting and informing the development of that strategy.

As the representative body for palliative care – with over 50 member organisations – we wanted to ensure that the experience and expertise of the people and organisations in our networks were brought to bear on the complex and large challenges needing to be thought through.

Policy and strategy are never sufficient on their own to achieve change, but they can be helpful. Conversely, a recent survey identified 'confusing strategies' as the number one barrier to change [2].

Grasping the nettle aims to provide a clear consensus view on the way ahead for palliative and end of life care in Scotland. Its purpose was to support inform and enrich development of the Scottish government’s strategic framework.

To that end, the structure of Grasping the nettle is based on the 3-step improvement framework for Scotland’s public services [3], so that palliative and end of life care issues are framed in terms which resonate with the Scottish government's wider public service reform agenda.

The vision articulated in Grasping the nettle is that Scotland will be a place where:

  • people’s wellbeing is supported even as their health declines
  • people die well
  • people are supported throughout bereavement.

In this vision – and throughout the report – we have tried very hard to achieve clarity of terminology and to shine a light on important differences of meaning which sometimes lurk behind stock phrases, creating a false impression of mutual understanding.

In producing the report, SPPC undertook many of the usual tasks of strategic thinking – an analysis of the world in which we are working, an assessment of where palliative and end of life care is at, an assessment of the main challenges and the things which need to change.

Engagement from our 50+ member organisations and other stakeholders has been excellent during a three-stage iterative process from May to November, which was overseen by a multi-disciplinary sub-group of SPPC’s council. Drafts were shared with the Scottish government at each stage, who welcomed the report as a very helpful input to their process of developing the strategic framework for action.

Perhaps the most difficult stage of thinking was to move beyond broad outcomes and to propose a set of specific actions which would achieve significant positive change.

The report identifies 38 actions – a busy agenda, but then this is a big issue and the scale of change required is huge.

The report’s proposals include – but also go beyond – specific issues such as education and advance care planning. In addition, we address leadership and the role of government and others in creating the conditions which support and enable change.

Taken together we believe the proposed actions create the necessary conditions for change, describe specific changes required and specify a broad framework of accountability.

This blog is by Mark Hazelwood, Chief Executive of the Scottish Partnership for Palliative Care.

References

  1. Scottish Partnership for Palliative Care. Palliative and end of life care in Scotland: the case for a cohesive approach. Scottish Partnership for Palliative Care; May 2007. Available from:http://www.palliativecarescotland.org.uk/content/publications/?cat=14
  2. Health Services Journal. The crowd speaks: Top 10 barriers to change. HSJ; 10 February 2015. Available at: http://www.hsj.co.uk/topics/technology-and-innovation/change-challenge/the-crowd-speaks-top-10-barriers-to-change/5081962.fullarticle
  3. The Scottish Government. The 3-step improvement framework for Scotland’s public services. The Scottish Government; 2013. Available at http://www.gov.scot/Resource/0042/00426552.pdf

The Silent Treatment

Drama, like palliative care, is concerned with exploring crises and change. So often characters in plays, like patients, find themselves facing shock, uncertainty and conflict. I have spent much time over the years thinking about how to meet these challenges and help patients and their families.

My son is a drama lecturer and we’ve often talked about how great playwrights like Shakespeare and Pinter can help clinicians to learn more about empathy and compassion. Although there has been work on the value of Applied Drama in a medical context, there has been little on the intersections between theatre texts and clinical practice. We decided to write a book exploring key areas of end of life care and relating these to insights from theatre texts.

The selection of plays was not easy - the dramas are challenging and often upsetting in their focus on suffering. In the busy clinical world of end of life care ethical dilemmas are heightened, and plays such as these highlight some of the key tensions in the human condition.

Within our book, we explore how particular plays provide useful lessons in enhancing empathy and compassion in a clinical context. As we all know, compassion is a vital element in the silent treatment and provision of effective care. The plays also illustrate the potential for good communication to help and to heal in time of crisis. From the time of the Greek tragedies to the present day, we owe a debt of gratitude to the authors of the plays who continue to teach us about communicating in a sensitive way.

Called Enhancing Compassion in End-of-Life Care Through Drama : The Silent Treatment, one of the themes the book explores is use of silence. Silence often drives the plot forward and creates tension for the characters. Some of the most powerful moments in the plays are those that take place without dialogue; for instance, in Journey’s End, when Stanhope comforts the dying Raleigh simply by moving a candle nearer his bed.

We hope the book will be a springboard for a wider consideration of how theatre can help healthcare professionals to increase their understanding of the dynamics and demands of end-of-life care. We wanted to show how theatre texts can engender creative problem solving ideas which promote an empathic approach to end-of-life care. Of course, as well as reading the book, I’d encourage people to attend performances of the plays - theatre text is only a formula for an act that should be live and engaging in the spirit of the moment.

This blog is by Dr David Jeffrey, Honorary Lecturer in Palliative Medicine , University of Edinburgh. The book he refers to is:

Enhancing Compassion in End-of-Life Care Through Drama : The Silent Treatment by Ewan Jeffrey, Lecturer in Drama, Queen’s Belfast and David Jeffrey Honorary Lecturer in Palliative Medicine, University of Edinburgh. Foreword by Professor Steve Field. Deputy National Medical Director, Health Inequalities, NHS England. Radcliffe Publishing , London 2013 CPD Certified.

The plays and themes referred to in the book are:

King Lear, William Shakespeare (1606) - Communication

The Caretaker, Harold Pinter (1960) - Care

Journey's End, RC Sherriff [1928] - Connection

Antigone, Sophocles (441 BC) - Choice

Little Eyolf, Henrik Ibsen (1894) - Change

All My Sons, Arthur Miller (1947) - Concealment

Blasted, Sarah Kane (1995) - Crises

Cloud 9, Caryl Churchill (1979) - Complexity

Behzti, Gurpreet Kaur Bhatti (2004) - Culture

An international exercise in compassion

Some people may think that I, and other ‘pioneers’ of hospice / palliative care, were alive with the dinosaurs.

Those far-off days brought much pleasure as well as challenge, though no-one could call them easy. Since we started planning in 1968 there have been many successes, and more to be proud of than we ever thought possible.

The comparative success of our ‘movement’ owes much to the national, international and professional organisations that have worked over the years to promote palliative care. In particular The International Association for Hospice and Palliative Care (IAHPC), has played a huge role, through its dedication to encouraging the development of palliative care worldwide.

The IAHPC has had its work cut out – so many people see palliative care as luxury care, and therefore very far down their priority list. This has meant endless negotiations with national and international leaders at political and professional levels, often with few results after 20 to 30 years.

Other major obstacles have been dose ceilings set for opioids and, persisting to this day in nearly half the countries of the world, the belief that opioids inevitably cause dependency addiction.

Now (I am tempted to say 'at long last' ) the WHO is throwing its authority and political influence behind us. The WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020 includes palliative care as one of the areas proposed to Member States. The WHO will soon publish a Global atlas of palliative care in collaboration with the Worldwide Palliative Care Alliance. And next week a report will be submitted to the WHO Executive Board on the growing need for palliative care services. The report broadens the scope of past efforts, to address the need for palliative care for people with conditions other than cancer.

But with this backing comes the reminder that 21 million people need palliative care each year and 42% of the world’s countries have no palliative care provision whatsoever.

We also know that only so called ’developed‘ countries teach palliative care in medical and nursing schools, that close on 50% of countries do not make opioids available, and that palliative care is a recognised specialty in only 10 countries.

Can we in Scotland do anything to help? The answer is a resounding YES!

  1. We can make provision for a doctor or nurse from a developing country to spend at least two weeks in a Scottish palliative care service. They should see everything we do, with 30 minutes each day spent with individual key members of our team in a Q&A session.

I know from experience this is an exhausting task for all concerned - it is not an excuse for a holiday for the visitor, and it brings no income to the unit. But the experience can be so valuable. If sufficient units were willing to do this it might attract funding from an interested charity.

  1. Secondly, palliative care doctors, funded by IAHPC, can go to a struggling unit / service abroad for a minimum of two weeks. There, they can demonstrate, teach and explain every aspect of palliation care provision to those working in that service

Once again this is no holiday – flights are at budget rate, accommodation basic, the hours are long – in fact this scheme almost came to a stop because so few doctors were prepared to make such sacrifices!

  1. My third suggestion is that we develop twinning schemes whereby units in a developing country are twinned with units of roughly similar size and staffing in a Scotland. Both parties would agree to be in regular and frequent contact with their ‘twin’, by email & Skype, as well as sharing with each other clinical problems, teaching material, specimen examinations papers, management problems, staff morale tips, and information about negotiations with government.

It is important to appreciate this is of most value when services are at roughly the same stage of development. It is a sharing exercise, both services being ready and eager to befriend and help each other.

A final challenging question:

Palliative care has always been an exercise in compassion, in caring for those in desperate need. Should that compassion not extend to our unseen friends abroad who are currently finding it even more difficult to get recognition than we did back in 1968?

I believe so.

This blog is by Dr Derek Doyle OBE, Honorary President of the Scottish Partnership for Palliative Care. Recognised worldwide for the contributions he has made to palliative care, he was the first Medical Director of St Columba’s Hospice, the first Chairman of the Association of Palliative Medicine, the founding Editor in Chief of Palliative Medicine and Senior Editor of the first three editions of the Oxford Textbook of Palliative Medicine.

An old man's anecdote

Forgive me if you have heard my story before. Old men tend to be anecdotal.

It concerns an old lady newly admitted to a hospice where I worked. As I did with all patients, I asked how she thought I might be able to help her on what she knew was her final journey.

"What do you expect of me?” I asked.

“If you had asked me that a year or more ago I would have said ‘Use some of those letters after your name. They tell me you are clever, well trained and well travelled and that your peers have honoured you.' But things are different now! What I want from you in the time that is left is….what shall I call it? Hand care.”

“Do you mean manicure?” I asked.

"Oh dear me no! I mean that when you come to see me I may hold your hand to feel safe, and when you come to me and find me asleep you will still touch my hand, and when my time comes one of these lovely nurses or you will hold it as I slip away. You see, dear, there comes a time when a loving hand is more useful than all those letters after your name!"

Busy we certainly are but never too busy to give a moment’s hand care.

This blog is by Dr Derek Doyle OBE, Honorary President of the Scottish Partnership for Palliative Care. Recognised worldwide for the contributions he has made to palliative care, he was the first Medical Director of St Columba’s Hospice, the first Chairman of the Association of Palliative Medicine, the founding Editor in Chief of Palliative Medicine and Senior Editor of the first three editions of the Oxford Textbook of Palliative Medicine.

I'm sorry to moan but...

I have been visiting terminally ill friends in Edinburgh though I suspect I might have had the same experience elsewhere. Two were in major NHS units, and one in a well-known hospice. Let me say at once that I have no doubt they have been thoroughly investigated, have been on the best therapeutic regimens, have had skilled care from nurses, physiotherapists, occupational therapists and social workers. What distressed me where the so-called “smaller things”. My experiences were those of a visitor (family or friend) and never once did I tell anyone that I was a retired doctor.

In the hospice I had hardly got in the door before I was welcomed by the receptionist, then by a nurse who took me to see my friend, offering me a tea or coffee, then telling that if I wanted to talk to any of the staff I had only to say so because they were all there to help me. A few minutes later she was back, putting her hand on my shoulder as I leant forward to sit closer to my friend- “Are you OK?” she asked. How often must it have been said in a busy hospice – and believe me it was busy – “How peaceful it feels!” When I left, another nurse walked to the door with me, asking if I was upset, if I wanted to speak to anyone, and reminding me that my friend would get the best care they could give. They kept that promise until he died.

In the general hospitals, no doubt looking lost or disorientated like many old men, no-one spoke to me when I went to the wards, no-one ever offered to tell me where my friends were and when I asked a nurse she pointed to a distant bed but said nothing. She had no speech problem because throughout all the time I was at my friend’s bedside she and her colleagues were chatting to each other at different bedsides, perhaps to interest or amuse hard-of-hearing patients because the conversation was all about their friends! On the way out on my first visit I asked if I might speak to someone who knew about my friend. "Sorry, none of us was here when he was admitted.” Quite what that had to do with their condition since admission days before, eluded me. A junior doctor was nearby so I coughed respectfully and asked if he had a minute to update me on my friend’s condition. "Nope! Sorry! Too busy." and he was off.

It struck me that many of the things that had disappointed me would never have come to light on a “tick box “ questionnaire yet they are central to compassionate care. CPD courses and evaluations for nurses or doctors might ensure they are up-to-date and “efficient” but how do you measure courtesy, empathy, compassion and sensitivity?

As you would expect, I think palliative care services have, by and large, got it right but, I wonder, have we failed to find how to teach and demonstrate what the public, and I, feel is missing in some big hospitals? We seem to have a some way to go!

This blog is by Dr Derek Doyle OBE, Honorary President of the Scottish Partnership for Palliative Care. Recognised worldwide for the contributions he has made to palliative care, he was the first Medical Director of St Columba’s Hospice, the first Chairman of the Association of Palliative Medicine, the founding Editor in Chief of Palliative Medicine and Senior Editor of the first three editions of the Oxford Textbook of Palliative Medicine.

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