EHI Live interview: Professor Jane Dacre

Jane Dacre decided on a career in medicine at an early age. “Even at 12, I said I was going to be a doctor – and I have stuck to that against all odds, really,” she says.

Before the sex discrimination act was passed, medical schools had quotes for female students that fixed their numbers well below those of men (after a period in which more women than men trained as doctors, the proportions are now about half and half).

However, she obtained a place at University College Hospital Medical School, and qualified in 1980. Since then, she has pursued two main interests; working as a physical rheumatologist, and promoting medical education.

Professor Dacre was the co-author of the GALS screen, a widely used method of joint examination, and still works one day a week at the Whittington Hospital.

“It is my bread and butter,” she says. “I like to keep up with what I started with. I do not want to give up those skills. And I think it is important to understand the things that my colleagues are dealing with day to day.”

In her medical education work, perhaps driven by overcoming those odds on becoming a doctor herself, Professor Dacre has become an expert in assessment.

She developed the medical examinations used by a number of medical schools, and was the medical director of the MRCP Unit at the Royal College of Physicians, which develops and oversees the postgraduate medical diploma used by the three royal colleges of physicians in the UK.

The NHS and politics, 2015

In April, Professor Dacre was elected president of the RCP, becoming its third female president.

At the time, policy and financial experts were warning that the NHS was about to enter a critical year, as trusts fell behind the ‘Nicholson Challenge’ to find enough funds to bridge the gap between flat funding and rising demand.

But there wasn’t undue public attention on the service, which had managed to get through the winter without a flu crisis.

Over the past six months, however, the NHS has been put back on the political agenda, as the main political parties struggle to promise to “protect” it in the run up to the May general election; without pledging significant new sums of money.

The RCP has stepped into the debate, joining the 2015 Challenge set up by the NHS Confederation to encourage any future government to support constructive public health and reform measures, and issuing its own ‘five point plan for the next government.’

“It’s become a big item,” says Professor Dacre, who describes her new role as “a good opportunity” to speak out on behalf of doctors and their patients.

“I have worked in the NHS for 30 years. I have worked in big hospitals and small hospitals. I was on the General Medical Council. I have looked at the profession from a lot of different viewpoints. So I know what works.

“Also, physicians have conversations with patients all the time, and they tell us what works and what does not work, for them. So I think we are very well placed to speak up on this.”

We need a plan; and money

The RCP’s five point plan urges a future government to focus on public health, on removing the “financial and structural barriers to joined-up care for patients.”

Over the past year or so, there has been an upsurge in interest in ‘joined up’ care and ‘integrated care’ – in the specific sense of joint health and social care services – as one way of cutting hospital admissions and delayed discharges, and to removing other inefficiencies from the system.

For example, both Norman Lamb, the Liberal Democrats’ health minister, and Andy Burnham, the shadow health secretary, have called for pooled budgets for health and social care; while the King’s Fund has called for joint commissioning bodies to address the hidden but serious social care crisis.

The problem is that these ideas tend to be vague; and to make worrying assumptions about potential savings, without considering the up-front costs involved (although the King’s Fund’s Barker Commission was clear that more money will be needed, whatever happens).

The RCP has sought to head-off these pitfalls by running its own Future Hospital commission, and promoting its final report as a “template for service redesign” in its five point plan.

Like other members of the 2015 Challenge, which is calling for a £2 billion change fund, it also argues that the government must “invest now” if it wants to “deliver good care in the future.” Professor Dacre emphasises this point.

“One of the things we are concerned about is that everybody talks about saving money, but nobody talks about putting in the investment that is needed to get services right,” she says. “We cannot do this without investment in things like training staff to achieve what is required.”

The Future Hospital; IT enabled

The Future Hospital report called for a new relationship between hospitals and their healthcare communities, to improve care for patients moving between acute and primary care.

So, on the one hand, it argued that hospitals should set up new acute care hubs, to make sure new patients  were seen and stabilised as soon as possible, and that they should create new medical divisions to oversee the care of those admitted and stop them being moved between specialists and wards.

On the other, it argued that hospitals should move away from the idea of ‘discharging’ patients, and physicians should take a more active role in extending their care into the community, working to prevent admissions and readmissions.

The RCP recently announced five hospitals that will explore different aspects of the report; which Professor Dacre stresses are not intended to lead to another, top-down shake-up of hospitals or health services.

“The solution to local problems has to be found locally,” she says. “In some places, GPs may come into hospitals; in other places, consultants may go out into practices. But the point is to put the patient at the centre.”

The Future Hospital report devoted a whole chapter to IT, arguing that none of its proposals will work without “detailed, real-time information on patients’ care and status.”

It called for all information about a patient to be held within a “single, electronic patient record”, developed to the common standards developed by the RCP’s Health Informatics Unit, and more recently by the Professional Record Standards Body, which was launched at EHI Live last year.

Professor Dacre naturally understands the importance of all this. But, as a working physician, she is also sensitive to some of the cultural barriers to achieving it.

“We doctors tend to use the medical record as a prompt for the care of the patient in front of us,” she says. “Making it [the record] systematic, so it is ready for data, means it doesn’t always do that job as well.

“It makes it harder to recall that ‘this was the patient with the parrot that died’ or whatever. Which is important; medicine is an art and not just a science.”

Speaking up and speaking out

In addition, Professor Dacre notes that the ‘big bang’ approach of the National Programme for IT has left hospitals facing all kinds of technology problems; from ageing systems, to “computers of all shapes and sizes that don’t talk to each other”, to IT set-ups that require doctors to log-in multiple times to get the information they need.

Indeed, she politely declines to comment on some of the IT that she has used in her day job, unless the remarks stay “off the record.”

Yet she believes that things are changing. “When I started out, there was no computer on my desk,” she says; yet now she “cannot do” without access to electronic letters in her outpatient department – and she is keen to see young doctors improve their IT skills.

Indeed, one of her priorities as RCP president is to persuade what she calls “jobbing doctors” to take on and find solutions to some of the problems they face; and not just to give in to what must sometimes seem like the overwhelming pressure of politics, funding, management, and demand.

“If you work in a hospital, you see how disempowered people can become,” she says. “We need to encourage people to change that behaviour; to use a computer to manage their ‘did not attends’ and not just to expect someone else to sort it out.”

Her other, personal priorities are clearly rooted in her career. She wants to see more action on diversity, to make sure that the medical profession reflects its patients – not just in terms of their gender, but their ethnicity and class.

She wants to make sure that “the top” of the profession in the royal colleges reflects those working on the front line. And she wants to see young doctors valued. “Physicians have a lot to offer,” she concludes. “We need to get that message out.”