Teams

I have a good working relationship with folk within our PCT. A few months ago I thought part of our service wasn't good enough and we needed more staff to do the job right. 3 months later and they've given me all the cash I asked for, for 4 more staff and development of the team. Surprisingly, they've given it as recurrent funding, which I reckon's a mistake on their part since new teams and projects tend to be done as a fixed pot of cash to then evidence and evaluate at the end. Still, happy days, it means we can appoint substantively and have more goodly folk join our merry throng.

A Modern Matron was asking me about the team and how having more folk join would affect things, how is it we can ensure that a team functions well? Got me thinking.

Bigger office, for a start. If we've 4 more folk we'll need more room, or people at desks sitting on one another's laps, and whilst a relaxed working environment's laudable I reckon that's taking the notion of "hot desking" one step too far.

Time out to think through how they'll work. Or, less euphemistically, to be guided by the Team Leader and myself on how we wish (or need) things to be. How they deliver it, I'm pretty happy to leave to them. But how the service works, the absence of waiting times, the collaborative work with colleagues, the multidisciplinary input into every case, the letters to GPs generated when the patient's seen, the ethos of support of patients in a least restrictive manner, of advocacy for them, of being relentlessly uncompromising in delivering exceptional care to everyone, all the time.

How do we know when we get there, when the community team is working together well? Part of it's through numbers. Is everyone pulling their weight, with comparable numbers of new patients seen, of follow up visits undertaken, of teaching sessions delivered, of conferences presented, of carer forums facilitated, of night shifts covered, of students allocated. Part of it's through the feedback (which I get a lot of ) from PCT, GPs, care homes, patient/carer forums, families, 360 degree appraisal, Your Opinion Counts forms and so on.

But it boiled down to just a couple of things that highly effective teams seem to have in common. First, there's the coffee. A good team can sort out the tea/coffee money and who makes the drinks (we all do) and who washes up and so on. Got that right and I reckon it's a fantastic correlate with a cohesive and organised team. Second, it's the attitude to one another. Respect that's genuine, so banter can be taken with good humour . . . as well as sorting coffee, in effective teams I've been in we've all been able to tell one another, in good humour, to fuck off, without causing offense.

So there's my plan, for my Modern Matron. Get the new staff appointed, get 'em sorting the tea and coffee with the rest of us, and get 'em confortable speaking their mind with all of us.

Wards

Well this all sounds less than ideal . . .

Being approachable

Milk and Two Sugar, over at Tea at Ten, got me thinking on a comment she made.

It got me thinking about how approachable Consultants are. Or aren't.

I think of myself as approachable, because patients and families are frequently seeking me out, "Just to tell me blah," which was worrying them and on their mind, or "I've not told anyone else, doctor, but . . . " then opening up. All doctors experience this, it was very common in General Practice, too.

Since I joined this Trust none of my patients have sought a second opinion or change of Consultant. Every other sector have had folk wishing to change Consultants and, for whatever reasons, have asked to change to me. I'm no better a clinician than my colleagues, it's got to be something about how people work (not the work that's done).

I cover a wider geographical area than I should, by mistake, which I won't bore you with. Patients live in areas between our hospital and 3 other hospitals. Patients on the borders have choices of where they wish to go, with our PCT paying us to see patients out of our area, recognising in our contract that 6% of activity should be out of area referrals. Locally, our service is well regarded. Patients outside my catchment area know of me and our team, through this rather fluid boundary. Oddly, the Medical Director and service manager at the neighbouring hospital met with me in March and the amount of patients they saw from my patch within their hospital in the last financial year was 0%. Patients have moved home from neighbouring Trusts to be in our catchment area. Clinical care isn't particularly better in my corner than it is in the university teaching hospital they're moving from. People have said they've moved so they can get good care. People do this with GPs often, too, not letting them know of change of addresses or being coy with details so they can see "their doctor" still. Lord Darzi should heed this. It matters. Still, for folk to be so enthusiastic to have care from my team reflects, I think, the approachability and compassionate care provided (rather than us doing anything miraculous, clinically).

We're signed up to 360 degree appraisal. This means I give a list of secretaries, clerical support staff, domestics, physios, OTs, nurses, social workers, Consultant Colleagues, GPs, junior doctors and managers who I work with over 4 hospitals, in-patients and community, from which random folk are anonymously sampled and give feedback on me. My secretary also generates a lengthy list of consecutive patients seen, from which a random sample are anonymously sampled with questionnaires about me. Their results are mailed back to the Royal College of Psychiatrists (so it's independent) to crunch the numbers and give feedback. They give feedback as graphs, showing the average range, top and bottom of the range, where you rate yourself and where staff and patients rate you. Feedback was embarrasingly positive, with scores at the top of the reference range, and some well above it. This can't be, I know I'm no better than most colleagues and certainly am not the best in the country! It has to be about perception of those staff and patients scoring me, of which I reckon approachability's key.

This really can be encapsulated in a conversation I recently had with a senior nurse. It's been busy in our team. I'd been working particularly long hours, which happens from time to time, but there'd been a run of this. She'd been working a couple extra hours a day too, doing far more work than she should. She'd mentioned that I was doing too much work, laughingly chiding me, "I don't like seeing you busy, it's not normal!"
We joke that she does all my work for me, because she does so much. And there's truth there, she does a stunning job that eases my workload big time.

We had a patient referred. It was a patient I'd seen before, a few years ago, with vascular dementia. Strokes had caused widespread damage, particularly affecting word finding and judgement. After a few months of assessment and advice, the patient was picked up by social services and day care and Alzheimer's Society input and was discharged with an open appointment, since there was nothing further at that point that our service could usefully do. She'd been seen by both me (for assessment and diagnosis) and the nurse (for advice/psychoeducation, coordinating social service and other care, and carer support). They were re-referred because the patient's dementia had progressed and the family wanted advice on what the referrals letter suggested amounted to wandering, a reversed sleep/wake pattern and respite care.

The nurse wanted to take the referral, since she knew I was busy and there wasn't any medical work to do, she could pick this re-referral up and discuss it with me. I wanted to take the referral, since I knew she was busy, I'd seen the patient already so could pick it up and easily see them again.

I don't think she finds me unapproachable and difficult to talk with. She jokes I do no work and she does it all, but everyone knows that everyone in our team all pull their weight. It was with kindness that she took the referral, flounced off (she's good at flouncing) telling me, "Oooh, stop being an idiot and fuck off back to your office and go pretend to do some work!"

I love this team.

What matters?

I've been to a number of meetings and conferences committees that have left me thoughtfully confused. As I've said before, I invest time in this malarky because if someone doesn't we'll get sold down the river, so it's best to at least chip in to have a voice in the process.

I think the GMC expect us to, aren't they about protecting patients? Ah no, their tag line now summaries that they too now are focussed on, "Regulating doctors, ensuring good medical practce." Well, they used to care about protecting patients. I'm sure as a doctor we're still obliged to protect patients from malign care. Thus, if managers are having a brainstorming session and generate what I would charitably call "idiosyncratic ideas" that will affect clinical practice unhelpfully, I like to be able to interject a bit of common sense and pragmatism in to the deliberations.

Mostly this works, which is why I keep doing it. I'm over stating it a bit, since in my corner the managers are actually pretty sensible and clever and helpful folk. The problems mostly involve evidencing something or doing something that we all know is nonsense but, for mind numbingly frustratingly incomprehensible and labyrinthine reasons just, "has to be done." So we get around a table and mull over how we do something we mostly agree doesn't truly need doing, and think of how it can have the least hassle for staff and least nuisance for patients.

Meetings with the SHA and PCT and partner organisations have been more . . . curious.

There's an enthusiasm to measure things. Evidence things. Prove things. Monitor things. Manage things.

This has lead to me knowing far too much about "things" which no sane man should know. Things like "quality metrics" which I won't sully your pure and beautiful minds with; enjoy the innocence, unfettered with such nonsense.

The notion proposed in my corner is that "quality" and "outcomes" are measured. Along with the work done (the content of a service line, i.e. the staff and resources). And the activity undertaken. And, for this work, the cost to our Trust for this. Anyone flirting with management will recognise this unholity trinity of Service Line Reporting (SLR) there, which is then fused with quality and outcomes and Payment By Results (PbR) and Quality Outcomes into some hideously ghastly abomination.

Zarathustra will love this. H P Lovecraft couldn't craft a finer tale of complexity, understated malevolence, despair and of something slumbering, quiescent, about to errupt causing "much badness." Reality is indeed more curious than fiction.

For now, within our corner, we're having to report to the SHA on quality. And report on Service Line Reporting to entertain Monitor.

So, over to you. What do you think will be looked at, when considering quality? For a patient, going through our service, what things matter? What is quality, what things should be recorded and reported and publically shared, to reflect whether we're doing well or not? I've my views, which I'll whitter on about another time, but for now, have a blank bit of paper. Add what so ever you will. If you're interested in a quality mental health care from our Trust, what would you be wanting to know about? What's on your list? What matters?

Laws

I met with the manager from a care home.

The manager claimed to be in a state of amazement, knowing naught of the unacceptable practice within her home. Ignorance that is impacting 'pon dozens of folks care. Not good.

We discussed care plans and implementation of care. Because they're out of hospital, local GPs will need to be involved in discussing medication protocols. This will take many months. So it goes.

Given her self confessed ignorance of malign care in her establishment, it became clear that we were correct in our assumption that she wasn't clued up on her statutory obligations to provide care under the Mental Capacity Act 2005.

In particular, she wasn't familiar with section 44 and the prospect of her, and staff, spending up to 5 years in prison.

Care

I feel vexed.

This is A Bad Thing because, although I don't get cross often, when I do I'm not always wholly reasonable. No no no, not in a "red mist" kind of way. More in a didactic, assertive, "I know best" kind of way which surprises folks 'cause it's typically alien for them to see this, coming from me. But, when vexed, I am wont to be classically Consultoid and Have Things My Way and assertively progress this state of affairs.

By chance, a social worker commented on assessing capacity. Her rather splendid blog should be known to you, if not, shame on you. Nip on over to here and rummage around.

What perturbed my calm mien was after a member of our CMHT visited a care home for a meeting around a patient's care, returned to the office and discussed things with me. Let's call the care home Limbo. Most care homes in my area were woeful, most are now decent, two are excellent (and I would happily have them care for my kith and kin). This care home she visited is a curious place. The environment is spot on. A modern, purpose built home with structure and content that's pretty much without fault. The staffing is uncertain. Really uncertain. Sometimes I speak with a nurse who's got oodles of common sense, is very patient centred and utterly devoted to those in her care. Popping in to Limbo when she's on shift is a joy. Every other RMN has less enthusiasm, motivation, common sense or interest in residents than my daughter's goldfish. This is not a slur against nurses, it's a comment on the dichotomy 'tween great nurses and those undertaking poor nursing practice.

This makes for curious states of affairs. One care home in our area that's poor (an in, CSCI are involved and they's an embargo sort of poor) had a resident moved to Limbo where care could be better. It was a transfer made from one home to another with the same registration, notionally providing the same level of care. A gentleman who wasn't being cared for by staff was moved to Limbo to receive appropriate care, which he wasn't getting in his previous placement. In Limbo he had exceptional care.

Seeing him in his old home, he was a state. Wild hair, soiled clothes, smelling rank (from not bathing for many months, from incontinence that wasn't attended to, faeces matting up in his pubic hair), he had food that had drippled on to him, his clothes, his beard, had dried and become adherent to him, his beard. Not good.

He was moved to Limbo, the next day I didn't recognise him. No, not an idle comment, I really did walk past him in the entrance foyer, failing to clock who he was. He'd been bathed, shaved, cared for. The nurse (who's exceptional) gave a rich account of how he'd been, despite only having known him for a two shifts.

She had spoken to him and his family. She knew what he liked, what irritated him, what relaxed him, what topics/hobbies interested him, she'd sought an understanding of him even down to what flavours of food he liked and didn't. Person centred care. Superb.

Limbo has other nurses and, sadly, to a one they're not as good. Not even in the same league. Their unqualified carers are, rightly, directed by the nurses. They're a mixed crowd but, typically, have time and interest and common sense in their delivery of care. But if nurses aren't directing them to undertake appropriate care, then appropriate care's not undertaken. Less superb.

Back to a different patient, stuck in Limbo, and a different experience. My CMHT colleague (a social worker) returned from Limbo where they'd had a meeting with 3 nursing staff. Three, on one shift, for one meeting?! The home's not that well staffed. Folk had axes to grind and had come in to make themselves clear. The social worker was concerned that no medication had been given for weeks. The nurses explained that the patient had declined medication offered. The social worker explained that, indeed, this was known and expected, because the patient was severely demented and didn't appreciate their illnesses, the impact of their illnesses, the consequent effects of this on their health and wellbeing, and the desire/need for medication to help manage this. My social worker described how the nurses in Limbo shook their heads and tutted a lot, saying they could only give medication to the patient, including his insulin, when he was unconscious.

This patient is an incapacitated adult, unable to either give or to withhold consent. The nurses just couldn't (or wouldn't) get that.

My social worker sadly didn't know the NMC guidance on covert medication so had to accept the 3 nurses telling him that they couldn't provide appropriate medication for the patient. He quoted the relevant bits of the Mental Capacity Act 2005 to them. They were having none of it. If that patient says no, the patient gets no treatment. All this is becoming much less than superb.

Worse, on review, the patient was in a state. Sitting in urine sodden clothes. Not moist, but apparently soaked. The social worker was astonished, since the urine was even dripping down the chair. He backed out of the room so staff could attend to the patient with dignity, undressing and attending to him without the social worker present. The staff left the room too. They left the patient. They wouldn't change him. He told them he'd not been incontinent and didn't need to change his clothes. The social worker questioned if, being diabetic, leaving him sat in urine was okay for his skin. Nurses said it was his choice. If that's how he wanted to live, they wouldn't and couldn't force anything on him.

Nothing polite can convey what I was thinking, feeling and expressing to my social worker at this point. Suffice to say, I was animated and more than a little vexed.

A nurse and I'm meeting with their manager tomorrow.

Advocacy

I am sure, of course, that all commissioners have ensured that robust, effective advocacy services are in place for next week. Because they have had to do so. They got the cash last November, but it wasn't ring fenced, so I'm a little uneasy about how much has been used to commission front line staff to do this work.

Why does it matter?

Because every patient in my corner detained under section 2, 3, 7, 37, a Supervised Community Treatment order (SCT) or conditionally discharged will, from next week, be a "qualifying patient" and entitled, nay obliged to have offered to them, an Independent Mental Health Advocate (IMHA). Why? The Mental Health Act 1983 was ammended in 2007 and from next week advocacy is a statutory requirement.

Does it matter? Well, quite probably. There are very few patients detained, in my corner. Although I've a typical (according to the Royal College) size of patient population in my patch, who I'm responsible for, my team and I don't use the Mental Health Act 1983 very often, at all. In case my memory failed me, and in the interests of determining how often SCTs may be considered, my Mental Health Act office kindly let me know how often I've had patients under my care detained under section 3. Since 2003, there have been 3 of them. Not many, then. What can I say, I'm blessed to work with exceptional staff. Nationally, it's a different story. The total number of people detained under the Mental Health Act 1983 is about 42000 in a year. That's a lot of pink forms.

Quite how we'll suddenly, from next week, be awash with advocacy services (that are qualified or will have the national level 4 City & Guilds IMHA qualification within a year), to manage the advocacy needs of 42000 people perplexes me. Every detention, every meeting, every Hospital Managers hearing, every Tribunal, an IMHA should be offered.

The IMHAs have powers. They have a right to see the patient in private. They have a right to interview clinical staff (nurses, psychiatrists, whoever). With the patient's consent, or without if they're incapacitated and it's in their best interests, the IMHA has a right to access the patient's medical records. Good luck to them accessing the electronic medical records in my corner. And even more luck in deciphering the meaning of what's documented. Interesting times.

Okay, I've no patients detained under the MHA 1983 and haven't had any for an age. But in forensic and LD corners, I can see April being a very, very busy month . . .

Cured!

Happy days.

I was referred a gentleman with memory problems, over a couple of years, who had a daughter who, "wanted something doing about it." Unlike Dr Crippen's locale, I read each and every referral letter, even if they're addressed to a CPN or psychologist or social worker. We work as a team, not as individuals in the same building, so I've no qualms in contributing to each and every referral made. Likewise, letters addressed to me are shared with the team every day. People have good ideas. Thoughts are stirred.

I thought this elderly gentlemen had symptoms suggesting Alzheimer's disease and may merit treatment, but he'd had a few falls and was on more drugs that I could count, so a CPN saw him at home first to look at his mood, his function, realistic goals we could achieve, his drug regimen and daughter's input and expectations.

The CPN then met with me that afternoon and talked it through. He was woeful with medication. My CPNs are canny, on this occasion she'd asked about his medication and he'd told her, then she'd checked his account out with the daughter who'd corroborated this. She then looked at the dates on the boxes of pills and realised they should have been replaced. She saw each was for 28 days. Over 365 days, that means a little over 13 requests for repeat prescriptions. The GP surgery confirmed he'd had 8 repeat prescriptions issued in the last 12 months. Ah ha! Suboptimal complicance with medication, another relevant factor. I'm so blessed by savvy CPNs.

So she'd sorted out home care, drugs in a Nomad box for home care to prompt, done a lot of information gathering and assessment but felt, "It wasn't quite right." I saw him at home, with the CPN. It all seemed quite right to me. Elderly man, losing his memory for 3 years, steady decline, increasing periods of confusion. On lots of meds for COPD and OA and prostatism and management of hypertension. One fall of late, no head injury sustained, attributed to joint pain (with NSAIDs bd and co-codamol being used qds to manage this). I spent an hour with him. No worrying symptoms. No new problems, other than his prostatism being more of a nuisance so some more nocturia. No recent infections to destabilise things (with normal WCC and CRP). But my CPN is clever. If she doesn't think it stacks up, there's a high index of suspicion that something's afoot.

I organised a CT brain scan. It showed no vascular damage at all, which for a bloke in his 70's with hypertension necessitating 4 tablets, surprised me. It showed modest atrophy, in keeping with a brain that was 70-odd years old. There were no infracts. There were no space occupying lesions. Phew. There was enlargement of ventricles. Normal pressure hydrocephalus (NPH) was suggested.

NPH classically presents with cognitive changes suggesting dementia, urinary incontinence and gait disturbance. I thought his dementia was likely to be through Alzheimer's disease since he had a global, progressive deterioration in all domains consistent with this. I'd put his urinary disturbance down to his prostatism. His gait I'd assumed was antalgic, through his arthritis (and somewhat affected through 240mg codeine a day on top of everything else). I'd not thought of NPH since I'd ascribed other significance to his symptoms.

I referred him on to a neurosurgeon. This happens fairly often. On this occasion the neurosurgeon agreed he had NPH and operated last year. Unusually, things didn't get a fair bit better, they got completely better. His procedural and declarative memory, sequencing, decision making, concentration, praxis, registration and new learning, all ticking along nicely. Fantastic.

I reviewed him. He thanked me enormously for, "being cured."
Okay, I had a small role to play. But really, it was a CPN seeing a pattern that didn't quite fit with Alzheimer's disease progressing over time, then a radiologist seeing atrophic changes but ventricular abnormalities on the CT scan suggesting increased pressure, then a neurosurgeon who fixed it.

But the outcome's excellent. A person's referred with dementia, an incurable condition that'll get worse. They leave, cured. A heartening result, in otherwise chequered times.

Continuity

Yet another post that's not clinical, isn't positive and is about management. Such is my life, at present. Ho hum!

In a previous hospital, when I was training as a psychiatrist, the Chief Executive changed. In my previous job, in the previous hospital, the Chief Exec changed. In my current job, in my current hospital, I asked about management before even entertaining the post. The Medical Director explained that the Chief Exec was a reasonable enough soul and basically let him get on and do what was sensible. He also commented that he'd seen 3 Chief Exec's since he'd been Medical Director. There have been 2 more have since he made that statement, 6 years ago.

Nurses come and go. It's necessary for their career progression. In my corner they tend to start at band 5 on the wards, then progress to a band 5 post in the community, then band 6 in a CMHT or specialist team, then band 7 as a team leader or ward manager, then they're stuck. Band 8a Modern Matrons are managers. Band 8b Nurse Consultants are managers. So it goes. To progress from band 5 to a senior role, nurses need to move around and gain experience in different arenas, so often there's turnover of staff, in a good way.

It does mean, though, that managers and nurses are coming and going at a fair rate of knots. The stability, both within the organisation and with patient care, is through the medical workforce. Senior doctors (GP partners and hospital Consultants) tend to stick around for the long haul. It's been suggested in mental health that all that's good from New Ways of Working is jettisoned and, instead, a "modular" approach is used. A care coordinator (who's re-written as some sort of journies facilitator in new CPA speak) will stick with a patient as they move through Single Point of Access, Assessment teams, Early Intervention teams, Crisis Resolution teams, Home Treatment teams, In-patient care, Rehabilitation Teams, Severe Enduring teams and so on. The fact that a patient's bounced from team to team doesn't matter - the care coordinator will remain a stable point of contact. The fact they've squillions of people to tell their tale to and no continuity doesn't matter - their care coordinator will be that continuity. The fact that each team will have a different doctor (somewhere, that's accessible some of the time, to some people) won't matter - the care coordinator will magically ensure that biomedical and psychosocial psychiatrists and GPs seemlessly deliver the same consistent care.

It's an epic work of contemporary fiction that I fully expected to see shortlisted for the Man Booker Prize. I've been disappointed. Ho hum.

The crux of it is that care coordinators come and go at frequent intervals. A band 5 CPN will be after a band 6 post. A band 6 CPN will need some experience teaching student nurses or doing CBT or undertaking nurse prescribing or managing acute care or supervising colleagues or developing management expertise so will move through posts to gain the requisite skills to then apply for a team manager or more specialist role at band 7. After time at band 7, many will look to band 8. Care coordinators are set up to fail, "navigating" the various teams and services, but equally they sure ain't providing the continuity over the long term.

Doctors can. Doctors do.

The notion of polyclinics worries many folk. Jobbing Doctor has, astutely and succinctly, narrated the zeitgeist within ivory towers and how choice is eschewed in favour of didactic This Is How It Shalt Be. Today he posts on how there will be self evident bad consequences.

It's obvious.

This perturbs me. Private healthcare can (and often is) riskier than NHS care. When my wife needed to see a Consultant, we waited a year rather than going to a private specialist. Private hospitals concern me, because I know just how scary a place they are outside of the working week. Friends work in them. The NHS does out of hours care better. The NHS has flaws, which are magnified by managers (at all levels, up to the DoH) making wholly unhelpful changes. Well, it's their job. They've got to do something.

Doctors need to be in the thick of it. We know what systems work. Folk have already said, we can sort it out on the back of an envelope over coffee in 20 minutes. Patients talk to us, day in day out. We're at the coal face. More, we're there for the long haul. For our patients, for our teams, for our organisations, doctors provide stability and continuity. It'll be a tragic day if that's lost.

Motivation

I've had to spend a lot of time of late mixing with managers. This used to be seen as fraternising with the enemy but increasingly I do see it as A Good Thing because there's then the opportunity for managers to appreciate what life's like for clinicians at the coal face (so make more valid and helpful decisions for us) and for clinicians to interject in to decision making to minimise how unhelpful decisions are implemented.

Part of the managers' agenda is "clinical engagement" and motivating clinical staff to improve things, as managers desire/are tasked to do/are required to evidence.

Some things really are about just showing that we do what we do. Our PCT knows what we do. The commissioner for our services was a senior manager within our Directorate and knows exactly what we deliver on. A request for information on what clinical activity we're undertaking is purely a tick box exercise to evidence a target's been met. Staff take time to record the activity explicitly for no additional benefits, no change in patient care, but it's done for the direct benefit of managers.

How much clinician time can be eroded in such a way? How many audits, data capture, clinical review, risk management proforma, benchmarking, key performance indicator outcomes, quality metric data and target data can clinicians be asked to complete, on every patient, before really it's compromising their work as clinicians and really should be work a data analyst or clinical governance staff or clinical effectiveness staff or a service manager should be undertaking?

But through habit and good will, clinical staff keep filling in the forms. If their boss tells them to, it's hard to say no.

Hardly the best way to inspire clinicians, to engender "clinical engagement" and improve quality, though.

A clever man shared a moment of insight with me, recently. He was of the opinion that staff motivation and drawing on the good will and expertise of clinical staff is a tricky job for managers because loyalties are divided and diffuse. His thought was that most clinical staff feel principal loyalty to their professional group, identifying themselves primarily in this way. "I'm a doctor. I'm a nurse. I'm an occupational therapist." At work, what I am is defined by my profession. This can be a modest factor or a very strong factor, as animated discourse on Dr Crippen's blog and Mental Nurse have evidenced.

After the professional role comes the discpline. "I'm a surgeon. I'm a GP. I'm an RMN. I'm a forensic psychologist." We identify ourselves by our discpline. I'm a psychiatrist.

Next, we identify ourselves with our service or our team. "I work as a cardiac surgeon within the Aceness on a Stick Unit. I'm a rehab OT in the orthopaedic ward for smashed up motorbike people. I'm a diabetes nurse working within the prison in-reach services." We think of ourselves as in-patient paediatric staff or as ITU staff or as community mental health workers in the CMHT or as palliative care staff in the hospice or whatever.

Then we've affilliation to the place, "I work for the Royal Magnificent Hospital. I work at the Wondrous Care Practice." We identify ourselves with the place and locality we work within.

We've then some understanding of the organisation. "I work for the Best Care Ever NHS Foundation Trust." The organisation tells us how we work, what we do, pays our wage so figures somewhere in our thinking, but is too abstract to be in the fore of our thoughts or loyalties.

Lastly it was suggested we've loyalty, "scattered like magical dust throughout this," to the NHS.

You could tell it was a senior and experienced clinician who'd suggested this, 'cause he's right on the money. When with a patient, our loyalty is to our patient. When thinking more abstractly, our loyalty tends to be to profession, discpline, team, hospital, then organisation.

Our Trust needs to do a lot of work in wooing and rewarding staff if clinicians are to be enamoured with the Trust agenda and do yet ever more for them . . .