I have spent my last day here in Coimbra Portugal walking around the old town, soaking up the sunshine, buying small souvenirs I can squeeze into my suitcase and reflecting on my time here in Portugal on the Hope Exchange Programme.
When I very first arrived I remember thinking that everything looked a bit shabby and neglected. Windows were broken and the pavements and footpaths needed a good dose of Weedol. The paint was peeling off and everything was very old, some of it medieval in actual fact
Today however, I didn’t see any of that, instead I thought everywhere looked warm and vibrant and inviting. I didn’t notice anything shabby or neglected although those things were still there. I think this is because I have got to know the culture, the heart of the people and the place which is so overwhelmingly welcoming and optomistic that the shabbiness is pretty much irrelevant. If it was all sparkling, shiny and new it wouldn’t be Portugal but some other place instead.
Not surprisingly, I have had the same experience with the majority of the health care system I have visited here in Coimbra, Lisbon and in Porto. Hospitals that were designed in the 50s, but not built until the 1980s, painted mustard and khaki green, were not the most inspiring first impressions. One hospital was a converted leper colony and another looked derelict from the outside. Yet once I got inside, they were filled with incredibly bright, well educated, forward thinking individuals who all believe in their NHS. They try hard to deliver a high standard of care. Creativity and innovation are second nature to them because they don’t have much money and so they find a way to do what they want to do differently that doesn’t cost a lot.
Portuguese health care professionals are also impressively well connected to each other, to their patients and with colleagues across Europe. They have a national electronic patient database linked to all the hospitals and primary care centres with an integrated electronic prescription system that sends patients their prescription by text which they can take to any pharmacy. They have been delivering integrated care across all sectors for nearly 20 years and they visit each others hospitals to share good practice and help each other out on a regular basis. On top of all this, they also go to other countries to discover best and new practices for themselves and to support developing health systems. One hospital manager I met, had done 4 Hope Exchange programmes in 10 years and another manager had just gone to help out a hospital in Turkmenistan.
I have learned a lot here. I have recognised that it’s not all about being shiny and new and having all the latest gadgets but about attitudes and values and heart. The Portuguese live in a community, work in a community and go out and create new communities. It’s not perfect but it’s been great to take part in some of those communities and to remember that it is not what’s on the outside that counts but whats on the inside!
Over the last few weeks I have explored the health care system in and around Coimbra in Portugal and often visited departments that have been outside my general field of knowledge and expertise. This has not been a negative experience and in most cases has been doubly interesting because I learned so much more. So although I am still not an expert in radiotherapy and nuclear medicine I am certainly better informed from my multiple visits to these departments.
Today, however, I was looking forward to a visit to the acute mental health ward. Many years ago, as a newly qualified occupational therapist, I worked on an acute mental health ward and I was enthusiastically anticipating talking with professionals in this field and asking more informed questions.
On reflection of my visit I am sincerely hoping that I maintained an air of polite English interest and didn’t betray my inner turmoil. I should have done some homework! I was definitely not prepared for what I perceived to be an extreme biomedical approach to mental health. Everyone on the ward was in hospital pyjamas and dressing gowns except the doctors who wore white coats and all I could think about was the 1975 film “One flew over the cuckoo’s nest”. I don’t want to explore the pros and cons of this approach to mental health in this blog but what I do want to talk about is my reaction to a completely different and unexpected paradigm. Unlike my visits to nuclear medicine, I found I was unable to ask relevant questions. I was floundering to find an anchor on which to hook my thoughts and became completely silent when my guide suggested that as an Occupational Therapist I might want to see the pool table in the games room.
Eventually my training from the fabulous Kate Marlow kicked in and I was able to have a meaningful conversation about the merits of having psychiatrists in A&E for mental health emergencies and the success of the growing mental health community support programmes in Portugal. In A&E they have four psychiatrists and one nurse, as mental health emergencies require medical intervention. I did not criticise the biomedical approach at all during my visit but discussed the potential benefits of a biopsychosocial model to which my host felt there were few for an obvious biological disease. We didn’t discuss lobotomies directly but explored the benefits of electroconvulsive therapy and deep brain stimulation for some patient pathologies.
Today’s experience has caused me to think and reflect more than any other of my visits over the last few weeks. It motivated me to review some papers on the medical model versus the psychosocial model in mental health and made me think a lot more about how my views about health care are influenced.
This health care model will not be included in my presentation regarding innovation in the Portuguese health care system but for me it is definitely one of the most memorable.
Crossing the road in Portugal is a little bit more tricky than in the UK . There are lots of zebra crossings on the Portuguese roads but I have discovered that standing at the side of the road by the zebra crossing does not cause the traffic to stop. Standing on the first stripe of the zebra crossing does not cause the traffic to stop either. In fact you have to step out and start walking and then the traffic will stop, more or less!! If you stand on the side of the road waiting, you will wait all day, you have to take the risk and step out.
The zebra crossing experience pretty much epitomises the Portuguese health care system. There are few or none clinical academic roles within the system for medics, nurses or AHP’s and the ones that do research are the ones who just do it and step out regardless of the system and in fact there are many doctors and nurses doing research and getting published and telling people about their work even though there is no automatic pathway. It is the same at an organisational level where some hospitals are busy getting accreditation, using quality measures to build services and generally recognising the need to continuously improve despite the fact that there is no extra money or real incentive to do this. The organisations that do not step out are startling in contrast and they feel like a very bad day in the NHS circa 1980!
There is definitely a streak of the latin spirit here in Portugal that is feisty and challenging despite the odds which sometimes are stacked high against them…… the cars may not stop!! However, they are making the traffic stop and they are making changes and they are doing amazing work and I know that eventually there will be a well trodden path for others to follow.
When talking to nurses in the UK before I came to Portugal, the general consensus was that there was little or no research being done by nurses and allied health professionals in Portugal and all the research in health and social care was lead by medical doctors and academics.
This view was pretty much supported by the health care professionals I met during my first week at the Central Hospital University Coimbra in Portugal. However, I kept digging and kept asking the question and eventually found the gold. On Wednesday this week, I was privileged to meet three nurses, Joao, Johanne and Lisa, three pioneers pushing the frontier of nursing research in the Portuguese healthcare system. They met at university several years ago and are all experienced nurses in their field of practice. In 2012 they decided to enter a competition for a new research idea and unexpectedly they won and their research career was born. Over the last 5 years they have been researching the impact of functional rehabilitation on frail elderly. They have adapted and developed standardised tools and revalidated them for their patient group. They have worked evenings, weekends and holidays and also during this 5 years, Joao has completed his PhD and Johanne and Lisa have had their children.
They are now ready to publish their research and they have been given 3 days by their employers to write their submission.
Naturally they expressed some of their frustrations and disappointments with the system they work in and the lack of opportunity or career pathways open to them as clinical nurses doing research but I have no doubt that they will continue to do research regardless of the challenges they may face. They have real grit and determination to achieve so much more and because of them and many like them I am sure we will see many more Portuguese nurses and allied health professionals doing research in the future.
Sadly I did not take any photos of these impressive people so in their honour here is a picture of the most famous pioneering nurse.
Here’s what I have discovered recently:-
Put 6 people from 6 different countries in a room in Portugal and ask them to prepare and complete a joint project and within a matter of 2 hours you have a functioning and cohesive community of practice.
Last Friday I went to Lisbon to a meeting of all the HOPE participants in Portugal. In total there were 6 of us and my co-participants came from Poland, Latvia, Sweden, Spain and France. The common language was English but not everyone was fluent so we got by with Spinglish, Franglais and the odd Russian word I remembered from cold war films and helped along massively, of course, by Google Translate.
We bonded immediately and there was no hierarchy, although some had very senior director posts and others were clinical and middle managers in their home countries. We had been asked to prepare a group presentation for the final conference in Dublin on 14th June where all the HOPE participants will give a 15-minute presentation on what they have found most innovative about the healthcare system in their host country.
Obviously, what is seen as innovative Portuguese practice for some is not necessarily innovative for others but we managed to find common ground and are determined to present something creative and imaginative that will impress our Dublin audience.
I know that innovation is important for the future of health care and I have talked a lot about tele-medicine and digital innovations over recent days but I am also interested in the Portuguese culture and how this impacts the quality of care. I have spent the last week observing clinicians and managers alike relating to each other in warm, supportive and encouraging ways. I have seen senior managers stopping to direct patients to the right department and I have personally met nothing but a warm welcome. I know that people are on their best behaviour when they have visitors but I have toured whole departments and can see that this is just the way they are, not just a show for a visitor.
I have glimpsed a community of people that seem to genuinely care about each other and their patients and to be honest I hope that we don’t lose these caring communities in healthcare in the quest for improvement and innovation.
Here I am, now on my third day in Coimbra and I have managed to find reliable wifi in the hotel lounge. The hospital here is suffering from the international cyber attack and all email and internet is still down and proving to be a real challenge to my new Portuguese colleagues. However, the sun is shining and patients are being seen regardless of the technology failure!
The city of Coimbra itself is very beautiful and very old, dating back to Roman times. It sits on the top of a hill over looking the Mondego River and the old town is a maze of tiny winding streets leading up to the University of Coimbra, one of the oldest European universities, established in 1290.
The main hospital on the other hand is fairly modern built in the 1980s but feels older due to the brown and mustard coloured decor. Some bits are light and airy and very modern and others are not. The hospital is actually a merger of two sites that came together in 2011 creating Coimbra Health and University Centre (CHUC) the biggest integrated research and teaching hospital in Portugal.
My first day was spent with a great hospital manager called Jorge, who has himself done 4 HOPE exchange programmes!! His knowledge of health systems in the UK, Denmark and Spain as well as his own was impressive. He gave me a good introduction to the hospital and the work it does and was immensely proud of his organisation. He did look a little perplexed when I tried to explain that I worked for a devolved NHS function, hosted by Salford Royal, part funded by Health Education England, covering the North West with some national projects!
On my second day I found myself in scrubs, touring the day surgery facilities and observing part of a surgical procedure which I really enjoyed and despite this not being my professional area of expertise I managed to ask a number of appropriate questions. I saw both state of the art 21st century facilities and again some that weren’t. I also spent time with the kidney transplant team. CHUC is the transplant capital of Portugal performing transplants in kidney, heart, lung, bone marrow, cochlear and liver. It recently completed its 1000th liver transplant.
Finally today, I met the brilliant and talented Cardiologist Professor Doutor Lino Goncalves who was very interested in being creative and thinking differently and is involved in lots of innovations in tele-medicine. He has written several papers that were pinned to the notice board for everyone to read (this will be of special interest to my colleague Rob Young) and was keen for the whole team, including nurses and technicians to be involved in research. I liked him a lot!!
I am looking forward to the next few days and in particular a trip to Lisbon to meet with the rest of the HOPE Portuguese team.
Stay tuned for more Portuguese health service updates and tourist tips!
A detailed summary of NHS R&D North West’s activities and achievements last year.
Please click here to read the full report.
So just over 24hrs before I leave for Portugal and I have not packed. This blog is in fact packing procrastination.
The issue is what to pack? The HOPE guidelines for participants in Portugal said smart dress ( but not too smart). So initially I was fine with that. I have a current working wardrobe of smart but not too smart, all ready to go, just stick it in the case and job done. However, I then looked at the weather forecast for Coimbra and discovered that its going to be 32 degrees next week!! On inspection I think I might be boiled alive in my current working wardrobe at 32 degrees and anything I have that is cooler is more beach wear than work wear. This is a bit of a last minute dilemma. I imagine that the Portuguese workforce will either be in suitable cool clinical uniforms or effortlessly dressed in lightweight linen with matching bags and belts. I don’t really have the time now to purchase a whole new working wardrobe so it looks like I will just have to manage with what I have got, a beach/workwear combination, the Hawaii Five-O meets LA Law look, and where possible stick to air conditioned buildings.