Community, communication, learning and practice – think piece


These are just some thoughts that have been going around my head on and off for some months now, they will need developing and I will use this blog to go back to them from time to time. Please feel free to comment if you are driven to or just read. (Warning there be academic dragons ahead and you may feel I’m talking a load of burble!). I haven’t done much reading on the subject recently – books and papers are somewhere in the junk room…

In the early 2000’s, just after taking a 1st degree in Information & Communication Management I embarked on a PhD looking at how organisations change when the technology they use change and how they each affect the other.  I really did not anticipate that this would lead to the huge spread of reading that it did eventually lead to.  One of the issues about information, communication and knowledge is that the definitions are very woolly and professionals / academics in this area could be using those words in a conversation and mean entirely different things.  Anyway, small digression over one of the areas that I began to follow was that of the world of Communities of Practice & the Learning organisation.  This slotted into my work because I was looking at communication as part of the information continuum – that part of the process that added to the ‘knowledge’ inside someone’s head (note human not machine) and also allowed that knowledge to be shared with other individuals which resulted in their knowledge state to be affected. Hmm this sounds like learning to me!

Etienne and Wenger’s work was very interesting to me because it didn’t address structured, formally taught, learning but certainly in their early work – situated learning- learning that happened in the social context of the practice of the particular (in this case work) community the individual was part of.  They actually made a point of defining this ‘community’ as one other than the ‘normal’ one that is immediately thought of – the community around where you live but as one that is based on a collection of shared practice.  However, I’m wondering if that definition could be stretched to include the ‘traditional’ meaning – after all isn’t communication based on shared practices, repertoires, media and patterns?

I had a recent interview for a post as  public member of the local AAP board of the district where I live and they asked me the standard question about what improvements I would make to ‘my’ community. My answer surprised even myself – ‘it depends what community you are talking about as I regard myself as a member of many separate but overlapping communities’.  I’m the typical boundary spanner where I transfer learning around all of my communities…

I’m wondering if there is a way to use this concept with digital inclusion – enabling individual to become stars and boundary spanners – embed ‘digital skills’ within the practice of one area so that the boundary spanners can transfer this knowledge to another ‘community’ that they are part of …

Also this maybe an approach to take with co-production within social and health care services – both within patient ‘communities’ and in communities of HCP’s and patients.  (For instance the diabetes specialist team and their patients ).

More will come when I’ve had a chance to dig into my books, papers and the www. But comments appreciated!






Pancake Day


As in flat as a pancake day.

Sky is blue, sun is shining, its warm and here I am esconced in the study aimlessly clicking around the web. Why? 

Mood is flat and low – not because of anything in particular I’ve done or am worrying about but I just get like this sometimes where I have no energy to do anything, no directional thoughts and no urge in particular to do stuff. Don’t even have the motivation to read.  

Heading offline to do some knitting and maybe a nap – maybe I’ll return refreshed … 

Prawn crackers, FA Cups and me …


Its forty years since Sunderland won the cup. Up here in the NE, @christewartbbc has been presenting a series of pieces within Look North about the memories of the Sunderland Players & fans about that Cup Run. 

These pieces have always made me smile as it brought back lots of memories of my childhood in the 70’s. The all day build up to the match itself and then watching the match and being excited about the match. Haven’t watched one in years…

Anyway, what’s special about the 73 Cup Final?

I remember watching it with my Dad and for some reason he invited the guy who ran the Chinese restaurant along the way to come and watch it with him. And the man brought along a huge bag of prawn crackers. First time I’d tasted them.  I remember my dad being surprised that Sunderland won (but probably happy because he was a Lancs lad) . 

So everytime I have prawn crackers now, I always remember that day and miss FA Cup final days like they used to be. I also relish the taste of a happy day. 


How to blob the square of the OP process?


This blog has been inspired by the thoughtful piece by Anniecoops on Co-production and hope  and the excellent Parable of the Blobs & Squares video which she linked to in her blog.

My last entry on here was a description of my visit to an OP department a week or so back. It was a visit that left me feeling profoundly depressed, I just didn’t know why.  Looking back I now realise that I feel like after virtually every OP visit I make.  Just why has been niggling at me until I watched the blobs and squares video and had some more thinking time.

All the outpatient departments that I have visited are places where the process feels more important than the blobby contex bit.  Everyone knows how the appt is going to go, you stand in a queue to check in, then you’re told to sit somewhere, you are called through and sit again, get weighed (clinic dependant), other tests are done, then you sit again – perhaps moved into a different waiting area, you’re surrounded by signs warning of disease, uncomfortble seats, surrounded by uncertainty about who you are going to see, which door are you going to go through. You watch staff in nurses uniforms rush around carrying notes, calling people in, you may even hear details of consultations as doors open and close. You wait and then eventually you are called in, seen, a quick consultation and then you are out with a slip of paper and told to check in with the receptionist on the way out so your paperwork can be completed and further appointments issued.

I was upset about the last OP appt because from the very start of it, I was told ‘we don’t have a referral letter for you’ . Their process had broken down but my context was still there so that became my problem. The uncertainty of whether I would then be seen was added to my context – scar & lump on my face, ill from another infection somewhere else, have come 12-13 miles in a taxi for the appointment. There was a huge disconnect between the process and my context and it could have been that the process could have overridden everything and they could have refused to see me if they couldn’t have got hold of the referral letter because atm it is  the process in OP that is seen (or so it  feels to me at least) as all important.

Essentially patients (or the blobs) can’t change their context – the reason that they are coming to OP is because there is a, or has been, a problem with their health.   So really the process has to change. But how? I would say that it needs to become invisible, in the background – so that everyone – staff and patients- can focus on the context of the appointment – the health of the patient rather than making sure the process runs properly.

Some ideas:

– Ensure information sharing is as efficient as possible.  The NHS spine contains details of tests and medication that the pt is on, so why do they have to be the ones to bring it in again? Why does information like name, address, dr have to be given every time a pt checks in to an OP clinic?  Why can’t pts just check in using a simple machine? (& Surely repeat appts could be arranged within the consultation – rather than have to queue up again to be interrogated and sighed over by the ‘dragon’ at the front desk.)

– On check in pts could be allocated a seating area, an approximate time of being seen plus given information about who is going to see them. (I often wonder how the pts get parcelled out in clinics – luck of the draw?)  This may allow them to go for a drink, (or heaven forbid a smoke) lessen congestion in waiting areas etc.

–  In my (brief) time as a midwife one of the best bits for me was going down from the ward and doing the AN clinic for the Ward consultant – does that ever happen in general OP?  A lot of my OP apps have been simple review clinics, surely there are is a role for nurses to be doing some of this work.

Discussion welcomed!

Random tech ramblings


I’m increasingly moving over to using Google Calendar to help me schedule my day / week / month. I was using a filofax which I found very useful but found that due to some days with loads of appointments and some with none, it got a bit scrappy (plus all the cancellations and changes around that happen).

So decided to take the plunge and use Google Calendar but have found an unexpected but obvious wrinkle. As a creature of habit, I am used to looking up at a calendar on the wall as well. Rather than use two systems (and have stuff that falls between the two) . I was wondering if anybody had heard of an (cheap) electronic display unit that would sync with Google Calendar wirelessly?

I’m sure the technology exists…

We don’t have a referral letter … (or why is that the Pts problem?)


Had another bizarre encounter with the NHS today. Is it me or am I just becoming good at spotting them?

Had an OP appointment at a local hospital today for follow up about my cheek business of a month or so ago and quite frankly after it I was left wondering if the staff attitudes in the NHS were fossilised in the ‘good old days’ when patients weren’t the awkward cusses they are now.

Hospital is in a town some miles from where I live and now largely functions as an OP and UCC. I’ve visited it a few times over the last 20 years and for some reason, never fails to put the heebie jebbies up me – something always goes wrong when I head there. Either I get lost (even following sat nav) etc etc.

Walked into the reception area. One receptionist on duty, but not a huge queue -the hospital is being run down bit by bit and the OP area was very sparsely inhabited. Got to the desk. The conversation went like this

“I have an appointment with Mr X.”

“Name” I told her. She types rapidly and then frowns and types again. “Is your phone number ccc- hfeg? “

“No, its ccc-fheg.” (I don’t know why but no one in the local hospital system even after me telling them time and time again can’t seem to get the right phone number on file for me.)

First big sigh. “Someone’s put it in wrong.” (I didn’t see any signs of her correcting it – but she may have done) More tapping of the keyboard. “Who’s your dentist?”

I look at her puzzled – why on earth does she want to know that? Never been asked it before.

Question repeated. “I need to know your dentist.  We don’t have a referral letter for you so I need to know who to contact.”

“But my dentist didn’t refer me.”

Cutting me off midsentence, “Need to know your dentist anyway.”

I give her the details – but she asks for them again because she’s never heard of that one – despite it being a *very* longstanding practice in the area.  Completely confused now, I await the next question with dread.

She says how did you get referred here (at the same time as lifting the phone up and dialling someone) and I tell her. So I’m kind of stuck as the outer point of this conversation. She looks at me as if I’m nuts when I tell her the name of the clinic that referred me and relates this down the phone to  colleague. (I can hear the mental eye rolling s I do a lot of it myself!)

Eventually after moaning about another ladies missing referral letter, she puts the phone down and says “go straight through, but you haven’t got a referral letter so …”

I head on through and then a Nurse calls me onward and shakes her head, “You haven’t got a referral letter…”

Eventually I was seen. Scan and another review after scan in 6-8 weeks. During that conversation it turns out I can actually be seen at a more local clinic.  Given the green slip and told to go back to the front desk to hand it in.

I go back and yes, she is still on duty.

The desk is free so I go up to it and she looks at me and holding up some paperwork. “Go back and wait as I have to do this first.”  (I’ve been to the USA and she wouldn’t be out of place in border control)

I obediently go back (not before a man tried to sneak in and go up to the desk – he got the glacial stare of death). Apparently he thought I’d finished.

She then starts to have a conversation with a male colleague, about holidays, this and that and the other, all while shuffling paper very expertly. After 2-3 mins the guy disappears and she beckons me forward and takes the proffered green slip. 

“Six to eight weeks?” Her fingers begin to dance over the keyboard while she is perusing the rest of the slip. They stop abruptly. “They want you to be seen in Mr Y’s clinic at CC hospital?” A point of frustration appears.”I don’t know whether I can get into their system or not.”

(same trust so why not?)

“Are you going to have an operation or not?”

“Hmm I don’t know”

By this point I feel she’s looking at me as though I’m a bit slow.

She puts me an appointment on and then has to get up, leave the desk and go to the back office of the reception area to get the appointment letter. Why can’t the printer be next to the receptionist stations.

I am finally released from her workflow and await my transport home. All the while thinking about my OP experience and thinking why is something that should have been dealt with seamlessly, in a back office (cough) electronically be used to make the pt feel as though they’re somehow the cause of the problem?








Are you the lady with the swollen cheek?


Life is very busy at the moment with lots on the go and a number of projects starting to bubble away under the surface.. However, for the last month I’ve been struggling with a cheek problem that led to renal complications, numerous hospital visits and a lingering sense of -well its all not quite cleared up…

The meat of this post was prompted by this blogpost:  Lets Talk Sepsis by Vannesa Garrity. This is the story of my recent brush with what has not been admitted to as sepsis but as you will see…

I am a T2 diabetic, control could, to put it bluntly, be better. I’ve had a small fatty, soft lump/ cyst on my face for a few years now, always the same size  or near enough. Just before the end of February, in half term, it started to get sore to the touch.  Seeing as I had a review appt for my diabetes on the following Monday, I decided to let it lie until then. Was seen by the nurse for the clinic so came back to see the nurse practitioner the following day.  Got a script for Flucloxacillin and advised to come back if it got worse.

Everything was okay until Sunday – it hadn’t got any larger or smaller in that time. Woke up Sunday with it throbbing away (previously it had only been sore to the touch). After a bit of indecision, I finally rang 111 so that I could go and see a Doc in the OOH service.

I have used the NHS Direct service before but it obviously the service has changed and not, I think, for the better. All I wanted was to be told, yes you can go to see the doctor, because I knew that was what I needed. At no point was I asked about pre-existing conditions just the operator obviously going through a series of templates which required information that I’d already given her (by the end of the phone session about three times or so.) . She told me at the end that I didn’t need to be seen urgently,  that within 6 hrs should do and she fixed me up with an appointment at the local urgent care centre for a couple of hours hence. Phone call took about 15 mins in all.

Child care arranged, Hubby took me down – we both expected that they’d take action to lance it. UCC was empty apart from a couple of other people to be seen whereas the casualty waiting room across the way was very busy.  Didn’t have to wait long and was called in to see a Nurse Practitioner.  History given, temperature taken (apyrexial – more on this later) , medication queried and asked if it was due to hypertension or just diabetes? Shrugged my shoulders and said Diabetes, she checked my BP anyway. After checking my blood sugar and finding that it was up  and looking as though she was thinking of admitting me because of that (!), I explained that I’d only had lunch an hour or so before I came, but she looked at me as though I was lying… Anyway, she put a piece of granuflex on the abcess then some primapore (not asked bout any allergies). I queried this – had a bad reaction to adhesive dressings this time last year, she replied with oh there’s hardly any reports of allergy from primapore. I was told to keep it on until Tuesday at which point I could take it off  and I should see a blister forming or it might drain by itself – ‘one of her patients had one on her breast and it worked on her.’

Study day all the following day – really shouldn’t have gone, face was incredibly sore, abcess was throbbing. By Monday night it was actually painful to eat around that area of my mouth.

Tuesday am saw me in Nurse practitioner’s room at my GPs. She asked as I came into the room with dressing on,’what happened?’ I explained about the Sunday and then we took the  dressing off between us.  Cheek now very swollen, up to around my mouth and cyst had obviously swelled in size. Was put straight into see the on call dr who took one look and called another GP in. After some discussion between the two of them and me, I was given a script for double strength Flucloxacillin and Amoxycillin and given an appointment for the doc in the am with the word ‘admission’ hanging in the air.

Next morning, I’m feeling so bad, I can’t find my glasses before I leave to go to the docs and really feel ill and weak. Cyst is beginning to feel like a third cheek. At the last minute instead of driving the 1.5 mile to the surgery, or indeed walk to it like I had done the previous week, I call a taxi.  (£10 for the return journey  – expensive decision!) . Into see the GP. Temperature tested again – still apyrexial. Feel very weak and wobbly, no fight about the admission decision. Sent out of the room while she talks to the hospital – why do GPs do this? Back in again and she says to go to the acute medical ward at the local hospital and then she launches into a discussion about a certain overdue screening test.  By this point I’m leaning on her desk feeling basically c–p, managed to park the discussion for later, thank goodness!

Eventually got into the hospital a couple of hours later, walked into the acute medical ward and approached the nearest HCP.  I said I’d been told to report here, and he looked at me me and said, Are you the lady with the swollen cheek?” Well d’oh.

He wandered off to find where I should be. To my relief, as the ward was very, very noisy, with telephones ringing, trolleys being pushed, teams of docs stood chatting, nurses talking, I was shown around to the next ward which is part stroke unit / part urgent day care clinic (best way to describe it). I picked a chair by a stretcher. Usual processing obs – BP was nigh on textbook perfect (ie abnormally low for me ), bloods taken and seen by Dr running clinic. kind of a surprise but he had worked with Hubby. I was more disturbed by the fact that there was a sign stating  ‘please do not remove furniture as we won’t be able to see pts.’  Gave the impression of a clinic thrown together to meet a need.

Hubby goes, I’m left to get cannulated and 1st dose of abs. In between these two events, I manage to produce a hypo out of nowhere (no lunch) despite the fact that I’m supposed to be running a high blood sugar with the infection.  I get on the trolley, snaffle a packed lunch and then proceed to be a wimp while the incredibly skillful, efficient and friendly charge nurse cannulates me.  At this point I’m not bothered if they admit me – I’m feeling  so ill.

Sent home that evening with cannula in the crook of my right arm to return in the am for more IVs.

Return just after 8 and luckily IV still works to the relief of both me and said Charge Nurse.  BP is still down. Still apyrexial despite the fact that I now have three facial cheeks. The clinic dr refers me to the surgeons who eventually ring back and sy, ‘its on the face, refer to plastics’, Plastics say ‘its on the face refer to max-facs’ . Fax for urgent referral goes off (Thursday).

This is where it gets scary.  Nurse comes up and says we need some more bloods from you. I ask why and she says the Dr wants to send of some more immunoglobulin tests. I nod but then she gets distracted and she hares off to do something else . I look at the card she has left and see the words ‘acute renal impairment’.   Uh uh.

Bloods are done, Doc comes and chats with me, asking about flank / back pain. I shake my head. He says that the bloods yesterday show that my filtration rate has decreased significantly i.e my creatinine levels have shot up and a couple of the other results are badly off.  Function has severely declined since my last bloods in February.  I have an urgent renal USS which shows no blockages.  Doc says it could be down to a number of things, antibiotics (apparently I’m on high doses) etc. If I’m no better by Monday, he’ll arrange further tests. Instead of the three lots of ivs I’m scheduled to have, I only have two. Packed off home (iv free) to come back Monday. Blood electrophoresis will take a week.

Friday, Saturday, Sunday I languish at home, barely functional.

Arrange childcare for Monday (younger child had been excluded on Friday 😦 )  and then head back in for more bloods.  Third cheek is now fairly fluctculent and feels as if it could burst any second. I’m due at an AAP meeting at 6pm where I’m scheduled to contribute.  Bloods thankfully are improving.  The question is then asked, have the Facs-macs been in touch with you?  No.

The clerk calls  them up and reports back. Apparently the consultant had only just looked at the Urgent (!) referral. They’ll be in touch in a few days. The clinic doc calls me back in, does a physical exam of the thing and decides he’ll send me for an USS of it (I think just a subtle way of applying more pressure to it) and then get me seen by the macs -facs people.  USS done, (no pop) and off in a hospital taxi over to a nearby city where the macs-facs people operate from.

I land in the A & E waiting room and am called in for screening. Yay, for the first time in this whole saga, they take my oral temp – using some disposable thermometers that I have never seen before. Blood sugar done. Two nurses look disapprovingly at the BP monitor and the senior one asks for an ECG to be done.  Okay, yes, my heart is racing and my BP is up, I can tell.  ECG is done and I make sure she knows I have LBBB before she thinks I’m having a heart attack on her.

Head & Neck SHO appears and decides to take me into their room in A & E. All I can see is the chair looking really like a dentists chair, rather than a couch… He is really very patient  but really, really, this ‘thing’ is not like a giant spot that needs squeezing to get rid of. He jams my cheek full of local – that is most painful by the way.  And takes rather too much pleasure in slicing and dicing it – he’d be good on one of these TV RL medic shows.  He obviously enjoys his job and is good at it.  Off home with a reduced antibiotics and instructions to get my GP to refer to them so that they can take the cyst sac out. Couldn’t get to the meeting as the local decided to spread around the lower part of my face for the rest of the early evening – I could only drink with the aid of a straw!

The next week I’m back at the GPs getting yet another script as there is a sizable lump left.  Back on the double strength antibiotics. No report back yet from the hospital day clinic but one from the head & neck people and strangely also an outpatient appointment arrived for head & neck for the middle of April.

I’ve finally finished the antibiotics. I still feel very tired and my appetite is dipping up and down. Diabetes feels very labile at the moment and concentration is still not up to what it was.  There’s still a small sore lump on my face with tracking swelling but nothing major. Just don’t feel up to yet another course of antibiotics though. Not sure whether I need to get some bloods done – if only just to reassure myself that everything is okay.

Thanks for reading – I believe that if not septic by the guidelines, I was  or on the verge of being so – even if all I had was a swollen cheek.