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Chronic disease management
East Lincolnshire PCT -
COPD Programme
COPD is considered a high priority within East Lincolnshire due to its local high prevalence rate. This is due to the trend of people from the industrialised Midland towns retiring into the area resulting in a higher than average elderly population from lower socio-economic classes. There was also recognition of variable quality of care of COPD within the health community that needed to be addressed.
The initial drive to this programme was motivated by involvement in the Primary Care Collaborative. Five practices piloted a planned programme of targeting suspected COPD patients for spirometry for confirmation of diagnosis. Education and support was provided by both primary and secondary care clinicians working together. In 2001, 9 further practices joined this programme.
The programme was divided into 3 phases to ensure a systematic approach. The first phase looked at identifying patients and screening them for COPD within spirometry clinics. The second phase concerned training clinicians to manage COPD and setting up specific COPD clinics within the practices. Patients were identified for referral to secondary care for specialised treatments, such as pulmonary rehabilitation, long term O2 assessment, and lung volume reduction surgery. To aid practices in delivering on the programme a “site file” was provided based on evidence based guidelines for the care and management of COPD. Additional support was provided by an educational pathway available to all clinicians in primary care. The delivery of the programme was facilitated by clinical leaders in both primary and secondary care.
Utilizing initiatives within the GMS contract
Under the new GMS contract, and utilising the above model, East Lincolnshire has developed a Locally Enhanced Service for COPD, provided by practices throughout the locality. To date 28 out of the 37 practices have signed up to provide this service.
Results achieved from the initial programme
Impressive results were demonstrated over the first 3 years of the programme
• Hospital admissions and outpatient referrals
There was a 23% decrease in COPD admissions to the local hospital in 2003 compared to 2000. Referral patterns to secondary care also showed some interesting outcomes. Although East Lincolnshire PCT comprises 42% of the total population of Lincolnshire as a county, referrals to secondary care chest clinics only account for 22% of the whole. Other benefits have also been realised by the programme.
• Collaborative working
There is now an effective and shared approach to the care of COPD between primary and secondary care. Clinical forums exist where professionals from across the health community can meet and impact on the delivery of the programme. These forums have enabled the production of shared guidelines on the processes involved in the identification and management of COPD patients, so ensuring equity of access for all patients throughout the community.
The development of further specialised COPD within primary care
Phase three of the programme concerns the establishment of a specialised COPD intermediate care team spanning primary and secondary care (the “Inspire“team). The aim of the team is to support patients throughout the care pathways within the health community of East Lincolnshire. The team supports both patients and primary care clinicians in the recognition and management of COPD and acts as an in-reach service to secondary care providing an Acute Respiratory Assessment Service (ARAS) and an assisted discharge service for COPD patients. This team is a truly multidisciplinary team led by a GPwSI and nurse consultant. Other professionals within the team comprise a consultant in psychological medicine, respiratory nurse specialists (4), respiratory physiotherapist (1) and a physiotherapist assistant (1). In addition to these team members a respiratory nurse advisor works with practices specifically to develop their services for COPD patients.
Improved patient services in East Lincolnshire
• Early diagnosis of COPD
• Clinicians in primary care trained to develop evidence based treatments
• Streamlining of the referral pathways between secondary and primary care
• Choice of home care for acute exacerbations of COPD
• Specialist management of COPD within the community for those with complex medical and nursing needs
• Community pulmonary rehabilitation
• Patient self help groups- Breathe Easy Groups in conjunction with the British Lung Foundation (BLF)
Interagency partnership
The team works at the primary secondary interface and has developed working protocols of care throughout the health community. An audit of the service between February and April 2005 showed that 59 patients suffering from an acute exacerbation were managed at home of which only 2 required hospital admission. 44% of the total referrals to the team came from primary care, 50% from secondary care suggesting an acceptance and working relationship of the team with both primary and secondary care.
Other innovative initiatives within the programme include collaborative working with paramedics and Emergency Care Practitioners. They are involved in the implementation of a strategy to identify and refer patients suffering from acute exacerbations to the Inspire team as an alternative to hospital admission.
Spread of good practice locally and nationally
COPD services through Lincolnshire are now being spread out countywide, based on ELPCT’s model. The GPwSI in respiratory medicine for ELPCT leads on the strategic development of these services.
This service is considered a beacon example of delivery of care for a chronic disease within the NHS. The programme has extensively been presented as part of the Primary Care Collaborative for Chronic Diseases throughout England. Recently the results of the initial programme were presented at the BTS Winter Conference. Many NHS organisations throughout the United Kingdom have requested the help of the leaders of the programme in designing their own services for COPD patients. e.g. Blackburn PCT, Grampian Health Authority, the Celtic Conference for COPD (Scottish BLF). The development of new leadership roles as part of the programme was fairly unique within the NHS- both the respiratory nurse consultant and GPwSI in respiratory medicine posts were each one of the first nationally. Both these leadership roles have developed a national identity within the NHS and there have been other similar posts developed elsewhere based on these models.
For more information email jim.moss@eastlincs-PCT.nhs.uk
Clinical service redesign
Royal Free Hampstead trust
STEP (Stroke Treatment for Every Person) began in November 2000. The service is situated across two sites and comprises 12-18 (flexible bed policy) acute beds and 16-18 rehabilitation beds along with the accompanying muti-professional services. The stroke service was redesigned mainly within existing resources, with the notable exception of funding for a stroke coordinator and some additional therapy staff.
Prior to the start of this initiative, results from two consecutive years (1998/99) of the National Sentinel Stroke Audit showed the service to be amongst the worst in the country. The audit highlighted that despite being a teaching hospital with many national and international specialities, including neurosciences, stroke care at best was fragmented and uncoordinated, with patients being on any one of eighteen wards, without input from specialist staff.There was inequality in service based upon age and geographical location. Whereas patients aged over 70 could be admitted to one of three specialist elderly care wards offering a multi-disciplinary model of care, younger patients could end up on any ward in the 12-floor tower block. There was no rehabilitation for people under the age of 65, requiring patients to referred outside the locality, with family and friends often having to travle in excess of an hour to visit them.
Project objectives:
To improve the outcome of care for patients with stroke by providing a comprehensive, multidisciplinary, evidence based specialist stroke service (including prevention) for all patients admitted or referred to the Trust, regardless of age, location or severity of stroke.
To contribute to the emerging knowledge base in stroke.
The implementation process was framed within an action research approach. Key stakeholders involved members of the multi-professional stroke team and support staff within the unit, members of the hospital management team, patient and carer representatives. Three main co-existing action cycles based upon ongoing engagement with stakeholders formed the basis of the clinical redesign. In practice the cycles were co-existent.
The first action cycle focused around valuing and profiling stroke as it was recognised that stroke care was fragmented and marginalised within the many regional and national specialities within the Trust. Actions undertaken included publicising the unit by carrying out a wide consultation exercise with stakeholders, having an official launch in conjunction with the the Stroke Association, writing editorials for journals and articles in the local press and hospital newsletters, doing team and individual presentations locally and nationally, hosting a stroke conference and study days in the hospital and organising a fund raising Charity Ball attended by over 200 people including stroke survivors.
The second action cycle looked at building a specialist stroke team. There sites chosen for the Unit were closed wards so there was no foundation upon which to build a stroke team. Actions undertaken included organising multi-disciplinary project groups i.e. developing a local stroke booklet, information files about useful local resources, developing multi-disciplinary documentation, guidance for common problems and establishing team processes like goal planning, joint treatment sessions and a weekly "time out" STEP meeting.
The third action cycle was centred around sharing skills and knowledge as staff recognised that lacked specialist stroke expertise. Activites included dysphagia trainging for nurses, establishing a multi-diciplinary education programme, developing a computer based stroke care pathway, defining core competencies for Health Care Assistants, joint intervention sessions, goal setting and establishing rotational opportunites between the two sites.
Learning and evaluation of practice is central to the team's sustainability. This is facilitated through the one-hourly STEP meeting between core members of the STEP team from nursing, therapy and medicane. This "space" aloows busy clinical staff to have time out to reflect on process issues, plane further service improvements and seek to address learning needs of the whole team.
This initiative has culminated in a recognised and respected multi-disciplinary stroke service, including a weekly stroke prevention clinic, that is implementing the National Stroke Guidelines and the National Service Framework for Older People within a robust structure of clinical governance.The service has and will continue to be developed in line with the ongoing views and vision of users, clinicians and managers.
Breaking new ground
This project breaks new ground as whilst we have strong research evidence for establishing stroke units,government policy that sets out a timetable for implementation and guidelines to show what care should be delivered there is nothing to explain how to put this into practice. To date NO work has been conducted that systematically looks at the development and implementation of a stroke unit over time. This project is therefore unique in describing how a service was successfully redesigned and so may be findings are likely to be of interest to practitioners, managers and policy makers interested in supporting change in a learning organisation.
Outcome measures
The success criterion was to establish a stroke service that worked for all.
Based key outcomes measures on the National Sentinel Stroke Audit (NSSA) 2004:
Mortality rates = 14% at 30 days (was 35% before stroke unit opened)compared to national average of 24%
100% of patients treated in the Unit during their stay (46% nationally)
100% of stroke patients spent more than 50% of their stay on the stroke unit (40% nationally)
100% of patients commenced aspirin by 48 hours (68% nationally)
100% assessment by physiotherapy & occupational therapy (63% & 57% respectively nationally)
100% of patients had a home visit before discharge (69% nationally)
100% of patients on antithrombotic therapy by discharge (95% nationally)
The Unit came top in the NSSA 2004 which assesses organisation and process of care.
For more information email Philippa.Hutchinson@royalfree.nhs.uk
Communications
Chelsea and Westminster Healthcare trust
Collecting 1,000 Ideas to Improve Patient Care and Staff Satisfaction
Involving patients, the public and staff in generating ideas for service improvement and staff satisfaction is a key driver to sustain and develop quality service and in creating a positive environment for people to work.
In August 2004 the Trust Board agreed to lead a project that would:
• Give a clear signal that the Trust Board values patients and staff and the feedback it receives about the Hospital
• Collect 1,000 ideas by December 2004 to improve patient care and staff satisfaction
• Act positively on the ideas suggested and communicate this effectively
2 Initiatives
Key to the success of this project was the collection of the 1,000 ideas. To do this a number of initiatives were planned and advertised across the Hospital in September 2004; the aim being to make it as easy as possible for people to contribute their ideas.
• An ‘ideas postcard’ was sent to every member of staff with their August pay slip
• Posters advertising the project were distributed around the Hospital
• Articles about the project were carried in Trust News
• An ‘everyone’ email outlining the project was sent
• Information on the project was distributed through core briefing
• An ideas ‘scribble board’ was placed at the Hospital entrance
• An ideas telephone hotline and e-mail were established
• Staff and patients focus group were conducted
An important part of the project was the development and use of a tool for collecting ideas from focus groups.
The tool developed was a large sheet of paper (tablemat) that had a patient’s journey mapped out linked to service values. During focus groups participants were facilitated to work thought the ‘tablemat’ and to contribute their good ideas. The tablemat approach was useful as it could be used in staff, patient and mixed groups.
Patients and members of the public were contacted to participate in focus groups from the Trust database of people expressing an interest in becoming a Foundation Hospital Member when the Trust achieves NHS Foundation Hospital status. The focus group approach was also linked to the Trust Patients Accelerating Change project which is linked to acting on the results of the national patient’s survey.
In total eight focus groups were held with 295 staff and members of the public:
• 3 with 120 patients participating as part of the Trust accelerating Change project
• 3 with 35 staff participants
• 1 with 100 patient and staff participants as part of the Autumn Working Conference for Nurses, Midwives and Allied Health Professionals
• 1 with 40 patients and members of the public as part of the Trusts AGM
The Trust achieved its target of collecting 1,000 ideas by December 2004. Monthly tables of ideas received and action taken were taken to the Trust Board. Not surprisingly a large number of the ideas were already receiving attention within the Trust with many of the ideas being taken forward by the Trusts PEAT steering group.
Utilising the Trust’s Foundation Membership database paid dividends in attracting a wide range of local members of the public to the focus group. The focus group linked to the AGM bolstered attendance at the AGM making it the best attended AGM the Hospital has ever had with over 200 attendees.
The organisation for collecting the 1,000 ideas and facilitating the focus groups also played a part in the success of the project. A designated project worker was appointed to work with the Executive Lead (Director of Nursing) and Executive Team.
Key to the success of the project was in communicating the actions taken because of the project this was done by:
• Team briefing
• Trust News; a monthly newsletter
• Posters
• Staff meetings
• Press release
Conclusion
The campaign was a success because it involved a significant number of patients, staff and the public.
Aim Outcome
Give a clear signal that the Trust Board values patients and staff. It also values the feedback it receives about the Hospital
Through communication at all levels within the organisation a strong message was given that ideas for services improvement and general feedback was valued by the Trust.
Collect 1,000 ideas by December 2004 to improve patient care and staff satisfaction
Achieved. Over 1,000 ideas were collected in almost equal proportion from staff and patients
Act positively on the ideas suggested and communicate this effectively
Many of the actions were taken forward and reported in Trust News
e.g: soup back on the menu in our restaurant, childrens menu introduced in our Burn Unit, contact number to call if a public toilet is found unclean.
For more information email Sarah.McKellar@nexuspr.com
Good corporate citizenship
North Glamorgan trust
This project reports on the creation, development and evaluation of an integrated sustainability strategy with three separate, but strategically linked, streams of work. This strategy has generated new policies, procedures and importantly new ways of working. The strategy has been developed in three inter-related streams, which are:
§ waste management,
§ energy conservation, and
§ local community awareness and development through partnerships.
Why was the project started and what were its key objectives?
As part of an ambitious Trust modernisation programme, each directorate was charged with developing innovative ways of modernising their services in sustainable ways. Within corporate services, enthused leadership led to the creation of a number of new and exciting developments. These developments have been embodied in an integrated and evidence-based strategy. This over-arching strategy brings together the three streams of work in a coherent way.
What way does it break new ground?
The three integrated strategic ‘streams’ or objectives will be addressed separately:
Firstly, within waste management business process re-engineering led to the redesign of the ways by which waste was handled, collected and disposed. For example, the introduction of a metallocene bag was introduced as a constraint was the lost value from weaker polytheme backs. Secondly, three waste compactors have been installed. A new partner organisation has also been used to create new waste pathways for clinical sharps as this is now processed via a Gas Pyrolysis plant thus converting this specific waste into energy.
Evaluated Stream Outcomes:
The following levels of recycling have been sustained over the last 12 months:
§ Cardboard (20 tonnes)
§ Confidential Waste (45 tonnes)
§ IT Equipment (1.5. tonnes)
§ Fridges/White Goods (38)
§ Office Paper (current audit)
§ Plastic Vending Cups (current audit)
Secondly, the second identified in the energy ‘value stream’ related to reducing overall energy use through measures of conservation. To this end the Trust has introduced an innovative idea of the ‘energy league table’ demonstrating the highest and lowest energy users within the Organisation. This idea was later adopted by many other NHS organisations within Wales.
Through PFI the Trust has also developed a flagship £1 million contract energy management scheme with the following features:
§ a 500kW Combined Heat and Power Plant (CHP) and boilers
§ Computerised Building Energy Management System
§ 47 Heating Zones
§ Innovative lighting upgrade by retrofitting new T5 tubes and diffusers.
Evaluated Steam Outcomes:
Are as follows:
§ A combined reduction in CO2 emissions (3,968 tonnes p.a.), highly statistically significant on previous systems
§ Energy saving of some 11% via Building Management System
§ Improved patient and staff satisfaction levels (semi-structured interviews)
§ Savings of over £ 6000 per month from imported electricity
§ Savings in the Climate Change Levy of £ 34,000 p.a.
§ No capital investment and charges by the Trust.
Lastly, the third important streams relates to the ways by which the Trust has been strongly developing partnerships within the local health economy to raise awareness and responsibility as a partner in the local community. In this respect, in partnership with Biffa (who sponsored some £ 500) the Trust has:
§ launched the Annual Trust Environmental Award. This award invites local children through their schools to design an awareness poster which is adopted as the main logo in this respect.
§ Easter Environmental Prize Draw which helps staff awareness of the issues.
§ Fireworks Energy Saving Competition which links with 5th November.
§ Environmental Awareness Week for fun and games, etc for staff.
Evaluated Stream Outcomes:
Are as follows:
§ All local schools and children for respective years got involved and informal and formal feedback was very positive.
§ Staff awareness is developing as a function of staff events (questionnaire/quiz responses as well as semi-structured interviews).
Conclusions
The new sustainability strategy has demonstrated many advantages when compared with previous ways of working. The underpinning evidence-based approach and robustly evaluated outcomes have been recognised by other external organisations specifically within Wales. For example, in the last 12 months the Trust has won the Environmental Project Award for the NHS Sector (2004), and the award for Sustainable Waste Management in the Public Sector (2005). Thus, the Trust is keen to collaborate with NHS partners throughout the UK as part of the dissemination of ‘good practice’.
For more information email Rob.Thompson@nglam-tr.wales.nhs.uk
Implementing NICE guidance
Hull and East Riding clinical policy forum
Since 1999 the local health community in Hull and the East Riding of Yorkshire has held monthly meetings of the Clinical Policy Forum (CPF), a group of senior clinicians who provide authoritative recommendations on clinical policy and services, on a patch wide basis to the seven NHS Trusts whom they represent. These include four primary care trusts, a hospitals trust, a mental health trust and an ambulance trust. We believe very few strategic groups comparable to the CPF exist in the NHS, especially one that has been established for this length of time.
Where issues of clinical policy are complex or substantial, the CPF establishes Task Groups with an appointed, accountable person to lead and report back to the CPF and assume completion of the specified work stream. Initially, compliance with NICE guidance was monitored by the CPF group, but as more guidance was published, members concluded that greater progress would be made in the long-term by a dedicated CPF Task Group.
With the appointment of new staff to the Hull & East Yorkshire Hospitals Trust (HEYHT) Clinical Effectiveness Team and support staff to the CPF, the establishment of a NICE Task Group became possible and the group met for the first time in October 2004. It is Chaired by a PCT Medical Director and its membership comprises representatives from six of the local NHS Trusts. The overall agreed aim of the group is “to inform the CPF about the implementation of NICE guidance/guidelines across the health community of Hull and East Riding”. Terms of Reference were quickly established and ratified. The Task Group set about formalising protocols for receiving, disseminating, implementing and monitoring compliance with NICE guidance. Regular progress reports are fed back to the CPF membership and hence to senior clinicians across the local health community. The CPF also provides an easy mechanism to debate within a wider forum any controversial issues relating to NICE guidance and issues of non-compliance.
The CPF is co-ordinated by a Clinical Policy Support Manager (CPSM) who works on behalf of the local health community and also acts as a central point of contact for the NICE Task Group. The CPSM alerts the CPF and NICE Task Group members by email to long term NICE work programmes, as well as to all new NICE guidance and consultations, and these representatives in turn cascade the information to appropriate colleagues within their Trusts. This allows Trusts to plan in advance for guidance implementation.
Due to the volume of Technology Appraisal Guidance (TAG) and Interventional Procedure Guidance (IPG) published by NICE, the greatest burden of implementation falls to the Hull and East Yorkshire Hospitals Trust (HEYHT). As such, HEYHT have taken the lead in developing rigorous protocols for implementing and monitoring NICE guidance, in line with Standards for Better Health. These protocols are then shared and modified to suit the particular circumstances of other NHS Trusts in the partnership.
The protocol developed by HEYHT involves sending out letters and information packs to the nominated Divisional Lead with responsibility for NICE compliance monitoring. The information pack contains a standard letter to the Clinical Lead responsible for guidance implementation, the guidance itself (including any relevant patient information and audit tools) and a standard HEYHT template for a baseline compliance review (BCR), which is laid out in an easy-to-use tickbox style. The Clinical Lead completes and returns the BCR to the Clinical Effectiveness Team, and the team manager shares the information with the CPF Task Group.
The BCR gives an overview that determines whether an Implementation Plan will be necessary, based on the perceived risk. An Implementation Plan pro-forma is used to follow up those TAGs and IPGs where the BCR has identified a problem with compliance. This provides a framework for analysing partial or non-compliance and helps identify where audits might be useful or if an entry on the Risk Register is warranted. The plan will also provide a written defence where partial or non-compliance is deliberate, as was the case with the original TAG18 on inguinal hernia, until compliance was achieved when NICE replaced the guidance in TAG83, which then reflected local practice.
The initial undertaking was to review compliance with all existing NICE guidance up to October 2004 and establish procedures for monitoring compliance with new guidance as it is published. Through an information gathering exercise and collation of the historical data compiled prior to Oct 2004 by the CPF, a NICE Implementation spreadsheet was developed and populated. This is used as a tool for recording information on what is known about the current compliance status of each piece of guidance within the local health community. It is available for general view via the West Hull PCT website, and is updated monthly. There are separate sheets for recording information on IPGs, TAGs and CGs, with hyperlinks to each piece of guidance. There are columns for recording the names of clinical leads, applicability of guidance to local Trusts, compliance status by Trust (either compliant / partial compliance / non-compliant), audit and monitoring information, the numbers of patients affected by the guidance and any associated cost implications.
NICE Task Group members have derived tremendous strength and impetus from an integrated, collective approach, backed by authoritative CPF endorsement. In achieving such progress, using existing staff whose roles encompass much wider activities, the Group has demonstrated real value for money.
For more information email Myles.Howell@hey.nhs.uk
Improving care with e-technology
South Tees Hospitals trust
The Modernisation Agency piloted Hospital at Night (H@N) in May 2003. The model proposed to achieve effective clinical care at night by having one or more multidisciplinary teams working in the hospital, who would have the full range of skills and competencies to meet patients' immediate needs. Although not a pilot site, South Tees Acute Hospitals NHS Trust was keen to implement the H@N model.
A senior consultant and a senior nurse from ITU jointly led the project team along with the Medical Director, representatives from Senior Nurses and junior doctors, an EWTD lead and an ICT Business Analyst.
From the earliest discussions of the project team it was obvious that doctors cross covering specialties, required access to local protocols and online support. When covering a number of wards, they would need to access as much information about patients as possible. All of this information would have to be delivered “on the go” and at the point of care. The bleep system used was not an effective way of ‘calling for a doctor’.
The project team identified that it needed to utilise wireless technology and PDA’s. The Trust already had a part-installed wireless network and it was decided to extend this to cover the entire site.
An IT project team was created consisting of a systems analyst/programmer, the ICT training manager, an ICT project manager and consultant and nurse representatives. This team working closely with junior doctors, the night co-ordinators and nurses on wards proposed a rapid response messaging system. Using web technologies and utilising PDAs and desktop PCs, the system would generate, accept and interact with calls generated from the wards.
By July of 2004, the project team had a clear objective of what H@N would deliver. There would be a wireless network throughout the Hospital. Every junior doctor who was part of the on-call team would be issued with a PDA. If a doctor was required on a ward, a call would be raised through the system on a ward PC. Key information would be collected, patient name, bed number, reason for needing a doctor and some standard clinical information such as respiratory rate, blood pressure, etc in keeping with the Early Warning Scoring System.
This call would be delivered to a night co-ordinator, a senior nurse, with knowledge of the doctors and the hospital, who would then relay the call to a PDA carried by a junior doctor, according to their ability, availability and proximity.
The system would be icon based to make it easy to use particularly on the PDAs. On receiving the call, the junior doctors would click on the icons to indicate when they were on the way, when they were with the patient and when they had finished a call. This information will be constantly relayed back to the ward and the night co-ordinator.
The project team decided that it would go live with H@N on the 8th November 2004. This gave the IT project team approximately five months to install a wireless network into a large low-level hospital, develop and test the software and train all of the users.
Communicating with the organisation about H@N and the changes it would bring was crucial to the success of the project.
The team used a number of methods, including attending Divisional and Directorate meetings, attending junior doctor meetings, posters, flyers and articles in the Trust newspaper.
Training was given over several weeks, using different methods. A number of classroom training sessions, along with drop-in sessions were used for training the junior doctors and the night co-ordinators. For ward staff, training was given to staff in their own ward setting. When the system went live, additional training and support was given at night for several weeks. PDA training has now been included in all new doctor inductions.
The system has been running since November 2004 with minimum difficulties. The system is extremely well liked by junior doctors, the night co-ordinators and the ward staff. The junior doctors are now able to prioritise, manage and respond appropriately to all the calls they receive using the relevant information supplied about each call and accessing textbooks and protocols available on the PDA via the wireless network. The night co-ordinators have an understanding of what is happening across the hospital at night, where doctors are and how busy they are. The wards now know that a request for a doctor is being responded to, which doctor to expect and when they will arrive.
The night doctors and nurses now work as a team to allow cross-cover of different specialities confidently and safely. This has improved the care of the patients.
The Trust also now has very detailed information about the number and nature of calls created each night. As each stage of the call is time stamped, the Trust has detailed information about the types of calls raised, how long each call takes to respond to and how long it takes for a doctor to get to and treat a patient.
Any hospital that is looking to implement H@N would find this an invaluable tool. Any hospital that is keen to have accurate and detailed information about the type of work that takes place at night, or indeed any time would find this system indispensable.
The system has been demonstrated at a number of H@N seminars and has created a great deal of interest. Other Trusts have tried to measure work patterns at night, but have only been able to perform one off audits at great expense. With this system, audit data is available as a routine part of service delivery.
The total cost of this system has been approximately £100,000. This has included putting the entire wireless network into the hospital, supplying PDAs for the on-call doctors, a dedicated server to run the system on and the cost of developing the software. The software was developed and copyrighted completely in-house, the Trust is now actively seeking a private sector partner to develop the system further.
For more information email claire.young@stees.nhs.uk
Improving patient access
Eastern Birmingham PCT
Eastern Birmingham and Solihull PCTs are working in collaboration with Heart Of England NHS Foundation Trust to offer Orthopaedic Assessment in Primary Care with choice at the point of referral (at triage). Phase I concerned hip and knee triage performed by Physiotherapy Practitioners, from March 14th 2005 this has been extended to include full Musculoskeletal triage for all conditions where a GP feels an orthopaedic consultation is required. The patient is seen at their choice of clinic venue and added flexibility is possible with the use of the Mobile Clinic Van.
From the 6th July 2005 the "Partners in Health Centre" opened which is the first centre of its kind in the country. The whole ethos of the centre focuses on self care & education with patients taking responsibility for their own health working in partnership with health care professionals. The principles guiding this approach are based on the Working Together for Health approach taken by the local health economy.
This project has improved the quality of service by reducing waiting times, improving patient access and optimising the care pathway. Investigations are requested such as bloods, MRI, x-ray when appropriate by the Physiotherapy practitioner in primary care. The client is then referred for the most appropriate intervention.
Options include:
•Orthopaedic surgeon
•Pain management clinic
•Rheumatology
•Physiotherapy
•Biomechanics
•Acupuncture
•Exercise programmes held in leisure centres
•Mobility groups
•Expert patient programme
•Dietetics
•Occupational Therapy
Altered ways of working have resulted in a streamlined service with reduction of duplicate referrals and increased conversion rates in orthopaedic clinic. The number of referrals to an orthopaedic consultant as a result of the triage service has reduced. In 2004 a physiotherapy follow up clinic for patients who had undergone hip or knee replacement surgery was introduced
Work is now being done to improve the ROTT rate at pre operative assessment.
Why the Project was Started and Key Objectives
The Action on Orthopaedics programme is a Government initiative aimed at improving local services through an integrated approach. It supports the provision of models for patient journeys (e.g. the Total Hip Replacement Pathway) together with the achievement of sustainable change by expanding primary care capacity and infrastructure.
In 2000-2001, 76.8% of orthopaedic outpatients in our secondary care hospitals did not become inpatients. In 2001-2002, the expansion of primary care capacity for orthopaedics was part of the Primary Care Organisations commissioning objectives aiming to help manage demand on the acute sector and support care provision close to the patient’s home.
Key objectives were therefore to:
•Recruit and train Extended Scope Physiotherapists and Assistants
•Refurbish premises
•Develop and pilot referral guidelines and scoring systems with the lead orthopaedic consultant and a sample of GPs
•Roll out across the Orthopaedic Department and Primary Care Trusts
•Provide pain exercise programmes in leisure centre to move from medical model of care to a wellness model of care
•Production of a video advising on keeping active when in pain - aimed at clients whose first language is not English
•Elicit patient satisfaction with new service to influence further service redesign
How effective management has been ensured
Effective management has been achieved through the following measures:
•Regular meetings of a Project Steering Board consisting of clinical and managerial representatives from provider units.
•Appointment of a dedicated operational manager for the triage service
•Use of a RADAR plan by the Steering Board serving as a working document.
•Specific areas of the project, for example, development of GP Specialist role, progressed by sub-groups of appropriate individuals.
•Process mapping exercise across primary and secondary care
•Pilot study to evaluate referral process and patient pathway completed with report to Steering Board.
•Financial monitoring via monthly budget statements to facilitate tracking of capital and revenue funding
•Development of an output based specification for Joint Replacement Triage IT system.
•Implementation of the database (hosted in Eastern Birmingham PCT) accessed via the NHS Net facilitating cross-boundary working. Examples of reports produced included: referral patterns, waiting times, outcomes and referral pathways
•Reports to the Professional Executive Committees
•Reports to Strategic Health Authority
•Patient satisfaction surveys – continuous/ongoing
How this Project Breaks New Ground
The Joint Replacement Triage Project brings together primary and secondary care teams to work collaboratively in providing a patient centred service that is flexible and caters for client needs. This has been achieved through:
•Focusing on patient need
•Developing service provision models across primary and secondary care
•Flexible use of staff and facilities
•Improving patient access to services
•Identifying GP Specialist role, developing competencies and agreeing plan for mentorship and training.
•Improved co-ordination of working between GPs, Specialists, Physiotherapists and other health professionals
•Developing workforce to meet patients needs
•Choice co-ordinator
•Obesity management
•Self referral back to triage if condition changes or deteriorates
•Acupuncture
•Support helpline
•Development of exercise programmes in leisure centres
•Video
•Partners in Health Centre
Explanation and Measurement of Outcomes and the Impact on Patients/Services
The following information is collected via the Orthopaedic Assessment Service database, collated and reported to the Steering Board, SHA and Provider Units on a monthly basis:
•Waiting time for clinic appointment in secondary care, if required (to demonstrate that we have provided rapid access)
•Number and percentage of patients managed within primary care, to show provision of primary care capacity for orthopaedics
•Number and percentage of patients referred on to secondary care
•Conversion rate in those referred for surgical opinion
•Management pathways – for example, numbers of patients referred to other services
•Paper triage – within 24hrs of receipt of GP referral
•If client is to be seen and assessed in triage – 2 weeks
•Referral in secondary care - 13 weeks
•Patient satisfaction
•Quality of life measurement
•Life style change survey
For more information email David.Stenson@EasternBirminghamPCT.nhs.uk
Mental health
Doncaster and South Humber Healthcare trust
There is substantial and increasing evidence base for the benefits of nutritional approaches in the management of mental health problems. Despite the scientific evidence base and service user interest, nutritional approaches are seldom offered to people with mental health problems and most mental health staff have little knowledge of nutrition in relation to mental health. In order to facilitate the research and development of nutritional approaches to mental health, a research nutritionist was appointed on 15/03/04 to work with a Consultant Psychiatrist with a considerable track record of published research in the field of nutrition and mental health. This project breaks new ground since it is a unique service in the National Health Service. The main objectives of this project are to:
• Raise awareness of nutrition in relation to mental health amongst service users and carers and mental health staff
• Provide a resource which would enable service users to receive nutritional therapies for their mental health problems
• Improve the general standard of nutrition for service users in the Mental Health Service
• Engage in collaborative research into Nutrition and Mental Health
Specific activities in this programme include:
• Maintaining and developing and internationally recognised collaborative research program on nutrition and mental health.
• Disseminating information on nutrition and mental health through high quality publications and through presentations at local, national and international level.
• Informal presentations and workshops on nutrition and mental health for service user and carer groups have taken place in Rotherham. These have been well received with very positive feedback and further requests for more sessions. Individual leaders of these groups have also facilitated workshops on Nutrition and Mental Health.
• Liaising with local CMHT’s (Community Mental Health Teams) in order to reach a greater proportion of service users in the community.
• Presentations to multidisciplinary staff groups within Rotherham, on the topic of nutrition and mental health. We are increasingly requested to give similar presentations in other trusts, including to training courses on psychosocial interventions.
• Influencing national and international position statements on the benefits of nutritional approaches to the management of mental health. So far this has included membership of a working party of the American Psychiatric Association on omega-3 fatty acids in mental health; preparing a monograph for the Northern Centre for Mental Health; and inclusion of omega-3 fatty acids in the Maudsley Hospital Treatment Guidelines. Our aim is that nutritional approaches should be included in the next NICE guidelines for the treatment of depression.
• Together with the Institute of Psychiatry in London, we have established a national special interest group in nutrition and mental health.
• In collaboration with the Rotherham ‘5 A DAY’ Co-ordinator, the hospital shop is now selling subsidised fruit to service users. This is being evaluated by the Public Health Department of Rotherham PCT. Also all full sugar beverages have been removed from hospital vending machines.
• A formal academic research programme centred on Nutrition and Mental Health is ongoing and at this early stage has received a ‘medium’ rating from the Department of Health.
• The Nutrition and Mental Health project is part of the Clinical Governance development plan for Rotherham.
• Piloting specific clinical initiatives within DASH with the aim that these can be adopted by other Trusts. The specific initiatives break new ground as they have never been incorporated into the NHS services before. They include:
o The Mood and Lifestyle Clinic has been established by collaboration between the Research Nutritionist, Consultant Psychiatrist and a Senior Clinical Specialist Physiotherapist. We have applied the research evidence on nutrition and exercise approaches to depression, in an NHS clinical context. Our aim is to provide a working model simplified as much as possible which can then be adopted elsewhere. Part of this work has been a research based evaluation of the effectiveness of the clinic. In addition, outcome as assessed by rating scales as well as feedback from the service users and other involved clinical staff has been very positive.
o A video, “Eat Yourself Happy” has been commissioned in collaboration with the local Primary Care Trust. This video provides information for service users, carers and staff on nutritional approaches to depression. It is also intended to be used as an educational tool with the aim of mental illness prevention.
o Training for staff on issues of nutrition and mental health. An initial survey showed that the current knowledge base is poor. A course on nutrition and mental health was piloted in April 2005, which proved very successful and popular with the NHS staff. As a result of the course, staff have the knowledge base and skills necessary to apply nutritional approaches within their own practice. Our aim is to develop this into a certified course which would then be made available at a national level.
o Nutritional assessment and advice is offered to all clients treated by the Early Intervention in Psychosis Service. This benefits also physical health: the incidence of diabetes and heart disease is very high in this client group.
Programme Outcomes:
• The first 10 referrals in the Mood and Lifestyle Clinic were all people with long-term difficult-to-treat depression and even we were surprised to find that their depression rating scales went down from an average score of 22.7 (moderately depressed) to 13.11 (mild mood disturbance).
• The nutritional assessments in the Early Intervention in Psychosis Service have only recently commenced, and therefore is too soon to carry out a formal evaluation of the influence of the nutritional intervention in this client group. However the long term outcomes after one and two years, will be assessed using symptoms and quality of life rating scales as part of the FERN research programme.
• There is a growing interest in the topic of nutrition and mental health amongst service users and carers as well as health professionals and various charities and we are consistently invited back to various groups to show the ‘Eat Yourself Happy’ video and provide further information.
For more information email jane.stapleton@dsh.nhs.uk
Runner up (we are republishing this summary to replace the incorrect copy included in HSJ’s awards supplement)
Western Sussex PCT
Bognor Regis Mental Health Project
Communication between primary and secondary mental health services were improved along with appropriate assessment and access to services in a high need area.
In an area with high levels of need, up to 80 per cent of referrals to the local community mental health community team were inappropriate and communication levels between primary and secondary care providers had broken down. Professionals and service users alike were expressing dissatisfaction with the services provided
The project aims to improve access to mental health assessment and support in a community setting for primary care health staff and service users. This involved defining the respective roles of primary care and mental health specialists and developing a care pathway which ensured that only patients who need specialist support were referred on.
Two mental health practitioners moved from secondary care into GP surgeries and developing. More patients have been able to access specialist mental health assessment, support and direction whilst still remaining in the primary care setting.
A new self-management approach to clinical intervention has been implemented and clinical and administrative processes between the two services have been streamlined.
Access to specialist MH assessment, appropriate support and electronic/manual self- help material (including CBT) in primary care locations has been improved.
Insight:
Referrals to the CMHT have been reduced and the MHPs have seen an increasing number of service users. Communication time between referral and assessment and referral and feedback of the assessment have been greatly reduced.
Contacts:
Jo-anne de Courcy, public health specialist trainee, joanne.decourcy@mspct.nhs.uk
James Hooton, integrated team manager, James.hooton@wsha.nhs.uk
Patient-centred care
Royal Surrey County Hospital trust
Patient Centred Care: The “Patient Line of Sight” OD Programme
at The Royal Surrey County Hospital
Summary
Our patients vividly experience the care and treatment we give them as a “whole organisation” and not in the silos of wards and clinics that our employees are accustomed to working in. Our “Patient Line of Sight” programme uses the stories patients’ tell us to help our employees see our services from the patient’s point of view. This is enabling our employees to make changes in their wards and clinics that join up our sometimes fragmented services based on involving and engaging our patients and placing them at the centre of the care we provide. ( Appendix 1)
Why we started and our objectives
Our programme was initiated by our Chief Executive, Matthew Swindells. Having joined the Trust in March 2003, together with a new Executive team he led the turnaround of the organisation from 0 star to 2 star performance this year (2005). However, he recognised that for this transformation to be sustainable and to create a step change improvement in patient centred care we needed to change our culture and our mindset of how we work, behave and lead in the Trust. An experienced OD consultant, Sally-Anne Hart, was appointed and, together with a Change Team of senior managers in the Trust and with the support of the Executive team, began implementing an OD programme based on “Patient-Centred Care”.
Our objectives are:
The Trust is transformed into a “patient centred” organisation with patients feeling empowered and engaged in their care and experiencing our services in a joined-up way.
Patients feel confident to challenge assumptions, voice their opinions and feel these are taken into account by staff.
Patients are “engaged with” and not “talked at”.
Patients have sufficient information to make informed choices about their health.
Time is created to really listen to patients’ issues and concerns and action is taken where needed.
Patients experience a more seamless service with less gaps and their journey through the hospital is smoother and more effective.
Patients experience a more timely service, but when waiting is unavoidable they understand why.
Breaking new ground
The “Patient Line of Sight” programme is based entirely on what our patients tell us about how they experience our care. Going out and collecting stories from patients in our wards and clinics then helping our staff experience these stories is proving a very powerful catalyst for creating truly patient-centred care. (Appendix 2) We have shared patient stories with our “Top 70” (Matrons through to the Chief Executive) through Away Day events by reading some out, acting others and inviting the patients themselves to come along and talk about their experience. This programme is completely internally driven wholly based on what our patients are saying about us. The programme’s bottom-up approach has resulted in both innovation and enthusiasm for improvement. Consequently, we are finding that staff at all levels across the hospital own the issues brought to light by patients and are committed to changing things for the better.
We are rolling out “Patient Line of Sight” across our 44 wards and clinics - the heart of our hospital. Phase 1 began this Spring, with Phases 2 and 3 to follow from Autumn onwards. We are working with the Sister of each ward or clinic, as the “caller of the dance” – the leader who co-ordinates the complex interactions between patients, clinical and non-clinical staff in each area. The stories collected from patients using the area are shared with the Sister and a core team of people that she selects, which may include staff from other areas. This core team, facilitated by a couple of people from the Change Team, identify what the patients are saying about how things are now – the organisational messages – and how the team feel about both the compliments and criticisms. From the patient stories the team identify how “the dance” – complex interactions between patients, clinical and non-clinical staff – is now and describe how they would like it to be in the future. They identify the local changes they want to make in their ward or clinic and the wider changes that need managing across the hospital.
We are very excited about how the tools, techniques and interventions of a patient centred Organisation Development programme are creating systemic change in our hospital.
Outcomes and measures
Some of the outcomes so far are:
Ward routine on Care of Elderly ward changed to create more time for staff to talk with and give personal care to patients - foot massage started.
New nurse led ward round on Care of Elderly ward. Nursing team are now fully aware of each patient’s progress and condition leading to better communication between the nurses and doctors. Steady reduction in length of stay on the ward evident due in some measure to “Patient Line of Sight” work.
Ward staff are designing information leaflets with patients and relatives, addressing everyday questions and the key messages about care.
A patient library is being set up on one a medical wards in response to patients comments about being bored during their in-patient stay.
The X-ray team are looking at signage both to and within their department for patients.
The X-ray team are also improving communication to in-patients about when they will be scanned by confirming scheduled times with wards.
Sister has facilitated the extended Physiotherapy working times to fit with Orthopaedic clinic resulting in one stop visits for patients.
Paediatric Outpatient team have produced business cards giving parents contact details for those queries that arise between clinic appointments.
Outcomes as described by employees have been:
"We captured and implemented ideas from patients about the service."
" We went from a very disjointed service to one stop pre-assessment clinics that give that "special time" to the patient.
"Patients now say: 'I know what is going on and what is happening to me."
This kind of OD intervention helps staff to deliver truely patient-centred care.
For more information email c.webb@royalsurrey.nhs.uk
Patient Safety
Medway trust
The project was started in September 2004 to give direction and express clear expectations of the Modern Matrons in the Medway NHS Trust.
The key objectives were
a) To make care safer
b) To improve the standard of care
c) To empower Modern Matrons
d) To share good practice
Having done a literature search, there is very little about performance indicators for nursing and nothing about measuring the performance of Matrons, so therefore the Medway Nursing & Midwifery Accountability System was designed to reflect the priorities of nursing in the Trust and also the areas that the Matrons were accountable for.
Having drafted the first set of indicators the Director of Nursing and Operations wrote a proposal for discussion with the Heads of Nursing, the Matrons and the Ward Managers. Following the discussions and some alterations the first set of indicators were agreed.
These were:
? Number of patients with MRSA and C Difficile
? Number of Bed days lost due to closure
? Documentation Audit
? Number of nurses not wearing uniform as per policy
? Hours of Agency used
? Number of patients with pressure sores
? Hours lost due to short term sickness
? Number of nursing complaints
The project breaks new ground because it is a way to measure improvements in patient care that nurses and midwives have a direct impact on, as well as taking into account that there are other influences. It is also different to many performance management tools in that it measures data on a weekly basis and there is a weekly meeting to monitor performance, rather than monthly or quarterly. This results in real time data being discussed and disseminated at a clinical level rather than data that may be perceived as being out of date.
The outcomes are a reduction in acquired MRSA, improved standard of documentation and reduction in agency usage. Other outcomes include an accurate, current knowledge of the number of people in the Trust every week who had pressure sores and or were known to be MRSA positive at the time of their admission which will enable us to work with the PCTs to minimise the risk. Attached are SPC charts of the Trust’s totals in a number of the indicators that are measured, these demonstrate the outcomes visually.
Since November 2004 weekly NMAS meetings have taken place on a Friday, these are chaired by the Director of Nursing and Operations and attended by all Heads of Nursing and Modern Matrons. At these meetings we focus on two Matrons’ areas only. Their performance is judged on their previous scores and is not compared to their colleagues, as they manage different specialties with different priorities and resources. If their performance is stable or worsening they have to account in front of their colleagues, if it is excellent or improving they share good practice in the group and this has proved successful in improving others’ performance.
Every week we also review the total scores for the Trust and they compare their trends with those of the Trust and see if the Trust position is better or worse due to their performance; an example of this is where the Trust is consistently achieving over 90% in the documentation audit and if one area achieved only 80% they know they have reduced the Trust score.
The Matrons who are held to account each week are encouraged to be accompanied by their G grade nurses. This not only makes sure that staff in the clinical areas understand what happens to the data they collect every week but also helps the discussions and they share the good practice regarding different aspects of NMAS that they have improved.
One of the ways NMAS has been successful is that since its inception it has been owned by the Matrons as a benchmark to demonstrate their success, another aspect is that from the beginning it has always been clear that it can be changed to suit the climate and changing priorities. NMAS is evaluated on a weekly basis at the meetings as it essential that the information gained is helpful to the nursing staff and to the Trust. Following a couple of Matrons’ data collection and the first few weekly meetings it was suggested by the Matrons that there should be changes to the indicators. This has happened again in April and is not a cause for concern, indeed it is a measure of how well this tool is being owned and used throughout the Trust that they now measure 18 sets of data rather than the 8 we started with in September. It should also be noted that none of the initial indicators have been dropped, for example it was suggested that we could do without measuring the indicators on nurses’ uniforms because it is now very rare to see a nurse not wearing their uniform correctly. The Matrons disagreed and said this was a key measure in terms of public confidence and wanted it to continue to be measured.
The 18 sets of data now include subsets of the infection and pressure sore indicators including numbers of newly acquired each week and those who were admitted with infections or pressure sores, the hours of sickness is now broken down into registered nurses and clinical support workers, the hours of bank usage is new indicator.
Although there has not been explicit patient involvement in the project, it is very patient focused, everything that is measured is either to ensure care improves and is safer or to improve patient confidence in nursing. The Matrons build good relationships with the patients and ask for feedback and they will often talk to the patients about the initiatives they are putting in place as a result of NMAS.
NMAS has been successfully implemented due to the leadership of the Director of Nursing and Operations and the senior nursing team, it is transferable not only across organisations but also across different staff groups.
For more information email quentin.holden@medway.nhs.uk
Primary care innovation
Knowsley PCT
Joint Commissioning Team is responsible for commissioning of services for adults with Mental illness, Learning Disability and Substance Misuse. Serving areas of high deprivation the team has utilised joint planning across PCT & Social Services to establish integrated planning and financial procedures to deliver health and social services. To date all Local Delivery plan targets relating to Mental Health including Assertive Outreach, Crisis resolution and early intervention, have been achieved, the MH LIT is recognised as one of the higher performing LITs in England, Valuing People has been fully embraced with considerable activity in modernisation of learning disability reflect in delivery of LDP/DIS targets. Commissioning of substance misuse via the DAT has achieved all targets for drug users in treatment (3 years in advance of target date), eliminated waiting lists and high retention in treatment rates. This process is aided by user and carer input to all planning and review processes set within the context of a highly integrated local health and social care economy with formal partnership agreements between both the PCT and Knowsley MBC. This includes capacity for performance/contract monitoring.
Integration has contributed to achievement of 3 stars for Knowsley Social Services & 2 stars for Knowsley PCT.
Aims and objectives
1/ Achievement of full implementation of key targets relating to mental health, learning disability and substance misuse outlined in the NHS Plan, Mental Health NSF, Valuing People and Tackling Drugs to build a better Britain within target dates.
2/Utilise a interagency partnership across key stakeholders to ensure integrated planning, delivery and review of services.
3/ Ensure users and carers are central to planning, commissioning and review processes.
4/ Ensure full engagement of all partner agencies to tackle health inequalities and maximise independence
5/ Establish pooled budgets across health and social care as appropriate utilising Health Act Flexibilities
6/ Ensure Co-ordinated strategies are developed across partner agencies to tackle social exclusion in relation to mental health, learning disability and substance misuse.
7/ Ensure effective engagement of excluded and vulnerable communities including Black and Ethnic Minorities.
We have utilised the overarching partnership agreement between Knowsley PCT and Knowsley MBC to ensure effective planning, co-ordination and delivery of services relating to Mental Health, Learning Disabilities and Substance Misuse. Additionally each discreet area has established strategic groups to drive forward actions. These include the Mental Health Local Implementation Team drawing representation from Users, Carers, PCT Commissioning, elected members, Social Services, Public Health, Voluntary & independent sector and Primary Care. Learning Disability involvement is via the Valuing People partnership drawing on representation from service users, carers, elected members, PCT, Social Care, the independent and voluntary sector. Substance Misuse has been addressed via the Knowsley DAT with representation of PCT, Social Care, Police, Probation, education, Housing. The DAT co-ordinates in active consultation with users and treatment providers.
Steering groups where established for specific areas i.e. Mental Health, Learning Disability & Substance Misuse to drive forward strategic planning, delivery and performance monitoring. Each group has developed 3-year strategic plans to deliver target within specific areas reflective of both local need and national policy. Funding was identified to address priority areas.
A review process was established across all areas with bi annual reviews of each specific services based on agreed performance measures, service level agreements for NHS providers and contracts for the independent sector. Central to this review process was service improvement via reflective learning on the experience of service delivery.
Implementation has been aided by NIMH(E), Valuing People Support Team (North west) NTA for Substance misuse and Cheshire Mersey SHA.
Implementation sits within a wider framework of partnership working between Knowsley PCT, Knowsley Social Services department and the wider offices of Knowsley MBC particularly Leisure services and Regeneration.
Achievement of relevant targets has been both internally and externally monitored, external monitoring has been via Cheshire Mersey SHA, Social services inspectorate and National Treatment Agency/Government Office North West.
Outcomes
Mental Health - Delivery of Assertive Outreach Team to 62 clients (04/05), development of Crisis resolution and home Treatment team (274 clients 04/05), development of early intervention team 12 clients (04/05), completion of national pilot project on prescribing of anti psychotic medication in partnership with NIMH(E). Reduction in acute psychiatric bed occupancy rates by 10% of 04/05 and reduction of waiting time for psychology from 54 weeks to 12 weeks, development of a Primary Care Mental Health team, establishment of disease registers across all GPs for Schizophrenia and Bi Polar disorder. Delivery of Mental Health promotion activity, modernisation of social inclusion and housing projects, expansion of advocacy and welfare rights. Use of Health Act flexibilities to establish integrated health and social care community mental health teams
Learning Disability: Review of Day Services, Repatriation of clients within long term NHS accommodation to local accommodation, establishment of disease registers for Primary Care for Learning Disability ensuring access to full health screening & assessment, partnership with local leisure services to provide specialist exercise equipment for learning disabled clients in local sports centres, development of 3 year strategy for delivery of Valuing People
Substance Misuse; 79% expansion in the numbers of drug users in treatment over a two year period (447 rising to 816), achievement of retention in treatment of 61%, expansion of treatment services to address needs of stimulant users, elimination of waiting lists for treatment, development of multi agency alcohol strategy, provision of education, training and supported employment scheme for recovering drug users, establishment of a Drug Intervention Programme team to engage drug users on release from prison into treatment. Expansion of Shared Care from 15% to 51.4%.
The integration of planning, commissioning across health and social care enabled services to modernise and develop locally within a quality framework that effectively meets the health and social care needs of local communities for Mental Health, Learning Disability and Substance Misuse. These issues are now addressed via a whole systems approach resulting in sustainable and inclusive development. There is a clear sense of direction and achievement, which permeates services encouraging recruitment and retention and ongoing service improvement.
For more information email Ben.O'Brien@sthkhealth.nhs.uk
Recruitment and retention
Mersey Care trust
Mersey Care NHS Trust was established in April 2001 to provide specialist mental health and learning disability services for the people of Liverpool, Sefton and Kirkby.
Mersey Care employs over 4,500 staff, has contact with over 200,000 service users every year and provides services from 33 sites.
Service users and carers want a say about the staff who work with them; the people who come into their homes and their lives. Mersey Care believes that service users and carers have the right to be involved in decisions which affect their lives and:
* Trains service users and carers in recruitment and selection ( 82 to date)
* Involves service users and carers in the recruitment of all new staff (over 1000 appointments to date)
" Just the very knowledge that the service user and carer voice is valued sends a very potent message to existing staff and to candidates about the philosophy of the organisation" ( Service User and Carer)
2. Why the Project was Started and the Key Objectives
When Mersey Care NHS Trust was established, service users and carers said they wanted a different kind of organisation - one which was more responsive to what they had to say. They wanted staff who didn't just have the technical skills about treatment but were people with real empathy and understanding.
This came across loud and clear at the first Trust wide "Open Space" event. Service users, carers, staff, voluntary groups and other stakeholders discussed the things they felt passionate about. Changing staff attitudes was really important.
The Trust Board took all the ideas from Open Space seriously and set a particular objective for service users and carers to be involved in all staff appointments.
3. Breaking New Ground
Mersey Care is breaking new ground by :
* Taking a rights based approach - empowering service users and carers to take real and important decisions.
* Investing in service users and carers who are offered payment for their time ( £10 an hour plus expenses).
* Establishing and investing in a new role within a Human Resources Department (Human Resources Manager)to train and support service users and carers and match them into the recruitment process.
* Putting a coherent system in place to enable service users and carers to get involved in recruitment and selection across the whole Trust (not just pockets of good practice) at a time of huge organisational change ( seven organisations have been brought together under the Mersey Care umbrella).
* Challenging new recruits.
" Service users know what type of people are good for the job, whether they have the right attitude" ( Job applicant)
4. The Outcomes and how they are Measured
There have been a range of beneficial outcomes.
(1) Outcomes for Service Users and Carers
* Increased confidence (Trust Audit Report)
* Skills development (Trust Audit Report)
* Employment - of the 82 service users and carers who have been trained in recruitment and selection 24 (29%)have gone on to gain employment - 9 are now working for Mersey Care!
(2) Outcomes for Staff
* Staff are positively choosing to work for Mersey Care because of the involvement of service users and carers in recruitment and selection ( Trust Audit Report)
* Staff are selected for their attitudes as well as their competencies (Trust Audit Report)
(3) Outcomes for Managers
* Service users and carers have brought a positive new dimension to the recruitment process ( Trust Audit Report)
* The involvement of a service user or carer in every appointment process has resulted in a saving of staff time - 1000 appointments @ 6 hours per appointment = 6000 hours. Time saved on recruitment is time spent on patient care.
(4) Outcomes for Mersey Care
* Satisfaction of service users, carers, staff and managers ( Trust Audit Report)
* Cost effectiveness
The cost of involving service users and carers in 1000 appointment processes = £60,000 ( see above). This cost replaces the cost of involving a G Grade member of staff in the recruitment process (6000 hours x £18 per hour including on costs = £108,000) and backfilling those persons with E Grade staff (6000 hours x £14 per hour including on costs = £84,000). This would cost £192,000 - making a total cost saving of £ 132,000!
* Recognition of good practice by the Health Care Commission 2005
(5) Social Outcomes
24 service users and carers who have come off benefit and into employment resulting in a saving in benefit payments of £ 141,524 per annum ( calculated on an average weekly benefit of £113.09p)
For more information email Christine.hughes@merseycare.nhs.uk
Reducing health inequalities
Coventry Teaching PCT
PEOPLE living in disadvantaged areas of Coventry are benefiting from an innovative approach to reducing health inequalities which sees people from the community recruited and trained to give health information at grass roots level. Health minister Rosie Winterton, while visiting Coventry met Local Health Link Workers (LHLWs), heaping praise on the pioneering scheme, calling it a “great example” of what the Government is proposing in the rest of the country with NHS Trainers (White Paper “Choosing Health”). The Coventry scheme is a joint initiative between Coventry Teaching Primary Care Trust’s (PCT) Workforce Development and Reducing Health Inequalities Strategies. The PCT is supported in this initiative by Coventry’s Neighbourhood Renewal Fund, and the Coventry Partnership with funding until March 2006.
By developing LHLWs, the PCT can both “grow its own” workforce, providing employment and training opportunities for people from the six Health Action Areas in the city; and at the same time influence the inequalities in health by providing increased opportunities for individuals, and access to services for the most disadvantaged communities. Working as PCT employees for 16 hours a week, the LHLWs are a body of workers recruited from within the communities in which they live and therefore have an in depth understanding of those same communities.
LHLWs bring additional advantages of credibility, language skills and knowledge of the local area and issues and the time to listen to people. They also provide the following services:
• Provide up to date information and consistent messages on lifestyle issues,
• Provide information on, and promote and encourage uptake of immunisation and screening services,
• Signpost residents to range of services i.e. domestic violence, benefits agencies, drugs & alcohol services,
• Where necessary, provide advocacy, accompanying residents when they access services,
• Support community ‘health events’, where teams of professionals are on hand to answer questions,
• Act as a conduit, feeding information and views from local level into the PCT, and relaying information from the PCT into local communities.
In order to attract people into these grassroots posts, the criteria for applicants was as wide as possible – sex, ethnicity, disability and educational background were not the important factors. What was required was a genuine desire to work within their local neighbourhood, a genuine interest in health matters, common sense and an empathy with the community.
It was important to ensure that the LHLWs were equipped with information to share with the community, but, at the same time did not feel totally overwhelmed. In order to equip the LHLWs with the skills and information to carry out their roles, “bite sized” training was arranged comprising of short talks from a range of health and social care professionals. Those who delivered the training had expertise in areas as wide as Health Promotion, Drug and Alcohol Abuse, Neighbourhood Wardens and the School Nurses and each speaker provided the LHLW with information packs to assist them in their role. After 2 months in post, the LHLWs all agreed to be enrolled with a local college to take up the NVQ Level 2 in Customer Services.
LHLWs are on placements within their areas as diverse as local Health Centres and primary and secondary schools. The placements for the LHLW are a semi-permanent fixture rather than moving them around the community, as they take time to develop both professional and client ties and it would prove disruptive to all parties if the LHLW are moved.
Early links with the community leads are needed to ensure that all parties understand what the LHLWs are able to do – and what they are not able to do before the LHLWs are introduced. The needs of the LHLWs themselves cannot be underestimated, for many of them need significant support. Robust communication links are essential so that the LHLWs feel supported, this has been achieved by all LHLW being issued with mobile phones, and weekly meetings in the localities for the first 3 months are needed to help iron out problems which arise. All 34 of the LHLW from across the 6 Health Action Areas in Coventry meet together once a month enabling them to share information, problems and good practice.
Although LHLWs have only been in post since November 2004, there have been a number of early results which are demonstrating their worth:
• Some GP surgeries in the areas have noted an increase of between 2 and 5% uptake in the flu vaccine
• Increased access to local temples and mosques to promote breast screening through female Asian LHLW
• 125% increase in children accessing the Early Years Centre since the Health Visitor and LHLWs have been based there
• 2 issues of child protection have been uncovered
• A young mother with agoraphobia has been empowered to take her first steps outside her home
Working with the Community Research and Evaluation Service (part of Coventry Partnership) and as part of the project framework a series of evaluation criteria were established:
1. Numbers recruited to the project by age, gender and ethnicity
2. Numbers of people entering further education and/or work
3. Uptake of screening services within the 6 Health Action Areas
4. LHLWs diaries which record the main issues they are dealing with
5. Smoking cessation services have created a data recording ‘field’ to track referrals from LHLW’s.
6. Increased life expectancy within the 6 Health Action Areas as a longer term goal
Over time, it is anticipated that the LHLWs will have gained knowledge and experience - as well as an NVQ qualification – which will enable them to have built the requisite skills and confidence to apply for other work within the NHS. It is an aim of the overall project to encourage LHLWs to train and apply for substantive PCT or other health related vacancies providing an increased skilled workforce to improve both health status and the workforce base within the most disadvantaged areas of Coventry and already 2 members of the first cohort have moved into further health and social care based employment and training opportunities.
For more information email simon.buss@coventrypct.nhs.uk
Skills development
Sandwell and West Birmingham Hospitals trust
F2 National Occupational Standards (NOS) Programme
Introduction: The new F2 doctors programme has built in and continuous appraisal and management mechanisms for both clinical and management competency for assessment by appointed medical managers. The competencies were custom-built, not linked to National Occupational Standards (NOS). Therefore results could be construed as subjective and inconsistent across the wider NHS.
At S&WB a collaborative approach to the communication, delivery and assessment of a revised programme was identified and negotiated by Learning &Developments’s Business & Informatics Dept., with medics/clinicians, P.G.Deans. Both medic and pure business and informatics specialist trainer/assessors would contribute to the programme content and assessment of individuals competence against NOS.
Objectives:
- Introduce effective self management and efficient business concepts into a clinical learning environment.
- Improve client/colleague communications, which includes IT skills.
- Identify a consistent assessment model for F2 standards.
- Evaluate the feasibility of generic management NOS as an assessment tool which could be rolled out nationally.
The following NOS were used:
Manage Yourself:
Develop your own skills to improve your performance
Manage your time to meet your objectives
Manage Information for action
Gather information
Inform and advise others
Support the efficient use of resources
Make recommendations for the use and control of resources
Together with the European Computer Driving Licence (ECDL), integrated into communication skills delivery.
Breaking new ground:
- NVQs have never previously been associated, or used, with medical training. Therefore this proposal and its approval by the regional Post Graduate Dean is ground-breaking. Evaluation is now taking place regarding NOS inclusion going national for all future F2 programmes. Thus, the whole concept is extremely ambitious and radical.
- F2 Doctors, for the first time ever, hold recognised Management Charter Initiative (MCI) certification.
- The use of a blended learning approach, to maximise convenient learning time and usefully use tutor time in ‘think tank’ sessions increased performance confidence in the workplace aiding the assessment process.
- The awarding body – Edexcel – is most impressed with the innovation and achievement as no other organisation has taken on such a project, which in itself could be construed as controversial and political.
- The creation of a sound infrastructure to develop personal and professional management attributes and nurture further long life learning in its wider remit, i.e., not clinical.
Delivery and Measurement:
The trial group recruited consisted of 13 F2 doctors (8 male and 5 Female). The Post Graduate Dean approved the use of 3 MCI Units at the initial stage. Business skills (e.g., Time management, team skills, etc) were delivered to run concurrently and seamlessly with the medical input of the F2 programme. Prior to formal MCI assessment and after their learning episodes, F2’s had opportunity to practice newly learned skills in the workplace and also use their appointed medical and business assessors/ mentors as soundboards prior to negotiation of assessment planning. All assessments were undertaken in the workplace so that newly learned skills were transferable to a clinical environment with substantiating evidence at hand to support the rigour of assessment and competence, using all NVQ assessment methods. However professional discussion was found to be paramount accrediting the scope of knowledge. Assessor episodes were based on weekly visits and ad-hoc spontaneous support.
The small trial size allowed more frequent visits than the norm. This alleviated difficulties and allowed the redress of issues at the earliest opportunity. For example, programme flexibility regarding content enabled MacMillan nurses to be called upon to deliver a ‘Breaking bad news workshop’ as part of the communications section. This need was identified by daily contact with F2s and listening to their fears, which were not previously tutored or identified.
All tutors are qualified teachers, and assessors and internal verifiers hold national NVQ qualifications.
Assessment and IV was driven by pre-prepared strategy following JAVE and ALI regulations.
Delivery was by an integrated programme managed by the L&D Department which has strong leadership.
Individual learner appointments and appraisal reviews, assessor and management meetings at frequent stages supported programme management.
Outcome:
All F2 Doctors have achieved the MCI units planned for the trial. These units have been successfully externally verified and claimed from the awarding body.
42 ECDL module passes via on-line testing have been achieved.
Value for Money and Benefits:
- 100% learner achievement is now a benchmark in itself for the NHS and F2 programmes.
- F2 doctors leaving S&WB will hold nationally recognised MCI supervisory management certification.
- F2 doctors will be able to integrate into senior clinical and/or generic management posts within the NHS. This supporting current thinking to engage qualified staff into director/management roles in the wider NHS.
- Using this innovative approach has enabled consistent and meaningful assessment of not only performance competence but knowledge and understanding of performance actions. The benefit being a continuum of learning where deliverables are linked to real workplace scenarios, supporting transferable skills and motivating the F2 to analyse and reflect on “what and how they do” and its wider consequence.
- The profile of NOS and ECDL has been raised within the remit senior clinicians, medics and Post Graduate Deans and their benefits seen first hand, which has encouraged others development.
- The accreditation is able to be attributed against MCI 1st Line Management standards at level 4 via APL/APA as the F2 aspires through senior ranks.
- Value for money is achieved using an internally devised learning and assessment infrastructures adapted for F2 programme design.
- Inevitably a success factor has been internal commitment. Living with issues on a day to day basis – unlike external or college provision - has been key in a very busy and pressured F2 existence to enable total commitment.
- The concept is transferable to other programmes.
- The supporting infrastructure and its manager are alive and well within the NHS and therefore the model can be shared with others, again enhancing value for money long-term.
For more information email jessamy.kinghorn@swbh.nhs.uk
