A special experience at the Royal Marsden

On Thursday 4^th and Friday 5^th of October I visited the Royal Marsden hospital in Sutton. This is a cancer specialist hospital trust that has another base in Chelsea.

Thursday
On Thursday morning I arrived at the Royal Marsden in Sutton. I had a briefing as to the plan and the requirements for my visit and an MRSA swab test before I could get started.

My first experience was with the Administration and Pre-Assessment unit (APU). Here I shadowed a lead nurse who was conducting bed rounds. This involved going to each ward and speaking to the ward manager about their bed availability, their predictions of discharge dates and why a patient may be staying longer now than what was originally predicted. This method was a useful way of gaining accurate information as to bed availability early on in the day so that if any problems occurred they could be managed as early as possible. It seemed beneficial to have a senior nurse conducting this as sometimes nurses would consult with her on particular issues or on their view as to how many more days the patient might require. Additionally the nurse could double check certain procedures had been followed with more complex patients.

I was then escorted to the Medical Day Unit. I spent a little time talking to the manager of the unit about the function of the unit and the patients it treats. This unit is used to deliver chemotherapy to patients who can come in for the time needed and then return to their lives. Having a day unit like this means that patients can spend less time in hospital and may not have to stay overnight where otherwise they would have. This means patients can get on with their lives much easier and feel more in control of their own treatment. This unit could get very busy as the prescriptions would be checked, the drugs prepared in the clinical room, patient assessments would be made and the drugs are administered for up to 8 hours all within this one unit. Organising the logistics of patient appointment times, reducing waiting times and ensuring chairs are available for administration is a very complicated and difficult task that seemed to be well managed within the unit. I was given a tour of the unit, spoke briefly to some of the pharmacists about their role and spoke to a patient whilst a nurse was administering their treatment. The experience was a very humbling one and despite the treatment being very serious and potentially upsetting there was a positive atmosphere on the unit thanks to staff and patients alike.

After lunch I attended the radiotherapy department. I was very interested to learn about this treatment and I found the experience fascinating. The department was very research focussed and was pioneering much world class research. They had developed cost effective ways of improving patient care which were inspirational. The nature of the treatment was very technology driven and therefore changes were taking place all the time which staff had to learn and adapt to quickly. Managers also had an important balance to strike between using machines as effectively as possible whilst not rushing patients. Therefore they had developed initiatives such as creating small changing cubicles outside the radiotherapy room which meant patients could change in private whilst another patient was undergoing treatment whereas previously staff would have waited for a patient to change in the radiotherapy room. In terms of their workforce the radiotherapy department employs a highly skilled and qualified workforce and four staff are required for each administration of treatment. Additionally there are high numbers of students within the department which can be beneficial in terms of ensuring practice is relevant and up-to-date, having a new set of eyes on current practice and in terms of long term planning for the department. However this can be time consuming and expectations of students must be managed as patients cannot be put at risk. Additionally within radiotherapy there is an attrition rate of 30% in students which can mean valuable investment is not rewarded.

Finally I met with the head of learning and development within the Royal Marsden trust. It was interesting to learn how fundamental it is for L&D to fit into and support an organisation. The integration of learning and development within an organisation is vital in terms of creating a positive, inquisitive and proactive culture. Within tight budget constraints though, it is important that all training is necessary and beneficial for the hospital and its outcomes and additionally that attendance to training events is high. These seem to be some of the focuses of the team to make sure their input is as advantageous as possible.

Friday
On Friday I spent the morning with the assistant chief nurse in charge of operations. We began by discussing some of the recent changes in the NHS and how they have impacted on nursing practice. It was interesting to gain her perspective on some of these very relevant topics.

We then visited some of the wards and I helped her to change some of the patient's bed sheets. I was shocked by how process driven every task is on the wards - right down to the way you remove your disposable bib. However every process had reasoning behind it, for example sheets must be removed in a methodical manner and must not be shaken to remove risk of transmitting infection.

I then witnessed a clinic that was running for testicular cancer. It was interesting to see the processes that were in place to ensure the most efficient use of clinician's time whilst ensuring patients had a positive experience of the service. I was able to sit in on some of the appointments taking place and I saw how the doctor was able to discuss various options with the patient to involve them in the decision making of their treatment plan whilst also advising them as to the most appropriate route in their opinion. This was done by providing the patient with facts about the different side effects of each treatment plan and the likely outcomes from each. They also took care to involve the family by considering their opinions and concerns and talking to and reassuring them.

In the afternoon I went to visit the Pathology department which is a generic term for the analysis of bodily fluids to aid diagnosis or assess condition. It was very useful to see this department as it is not a patient facing part of the patient pathway but it is so essential to patient's accurate diagnosis and care. This department has to work under the constraints of a high workload in a highly pressured environment where processes must be highly accurate and double checked throughout. This department also provided an emergency service on-call throughout the night which can add to the pressures. Despite this the department seemed to be operating efficiently and productively and there was a positive atmosphere.

It was useful to talk to some of the managers in the Pathology department about where some of the efficiency savings could be made. They felt that often as an act of precaution clinicians would ask for all tests to be conducted on a patients fluid where in reality only a few of those tests would actually yield useful results for the patient's condition. On the one hand you can understand why clinicians would take a precautionary approach to tests as important as these but on the other the pathology department estimated that approximately half the tests they conducted were not useful. The pathology department felt that additional training with regards to blood testing for doctors could be beneficial or internally charging for blood tests instead of giving a yearly budget to the pathology department may encourage clinicians to think twice before they decide what information they need. I thought this was a really interesting situation that would have been interesting to look further into.

Finally on Friday I spent an hour in the radiology department where the scans are conducted to enable diagnosis. It was very useful to see this early stage of the patient's pathway at the Marsden. I had a tour of the department and saw all the different scanning machines that were available. This highly technical environment could be very intimidating for a new patient and therefore staff had to ensure that they offered comfort and created a calm and reassuring atmosphere for patients. For example, I watched one lady have an MRI scan and she became quite nervous and uncomfortable with the idea but staff reassured her and relaxed her and ensured she was ready before they began the process. They then spoke to her throughout through an audio system that is installed to check she was still okay and to reassure her that she was safe.

It was a really valuable to see a hospital that was so specialised and performing to such a high standard and conducting clinical trials and research. The hospital also took on some private patients which was an interesting element to understand in terms of generating profits but also ensuring everyone receives equal treatment.