Thursday 21 March 2013

Francis is an opportunity. A chance to re-assess what we are doing as commissioners and why!

At our CCG Governing Body meeting in March 2013, we held our first discussion in public about the consequences for commissioners of the Francis Report.
To simplify this we produced Francis on a page.  It was not meant to be comprehensive, but was intended to provoke an open discussion about change!

Quality first
  •   Basic standards of care should ALWAYS be applied.  If/where this is established not to be the case then commissioners should act on this.  Commissioners should challenge themselves with this.  ‘How would we know?’  Where appropriate commissioners should request the suspension of services on the grounds of safety
  • Nursing leadership and appropriate capacity should be in place on every Hospital ward, for every shift.  This should be properly resourced (and enforced through the contract)
  • More attention is needed on the fundamental care of the frail and elderly.  This should apply to all   commissioned settings of care.
Getting the basics right
  • Commissioners should have the tools to assess and/or assure themselves about service quality 
  •  National targets and pledges may not get to the fundamental requirements of safety.  
  •  Commissioners should have active and ongoing engagement with service users and the public, and  patient stories should be used to supplement and/or challenge data and other system/process outputs
  • Changes to organisational structure and/or configuration and/or leadership can lead to a loss of corporate memory regarding service quality and safety.  Mechanisms to provide continuity are important.
An open culture
Commissioners should:
  • Welcome complaints
  • Be open in acknowledging service difficulties, and encourage providers to do the same. 
  • Acknowledge and promote the need for transparency.

Contracts that work for patients and clinicians

Commissioners should consider how to enforce, and specifically :
  • Improve service specifications so that the quality of service and patient experience aspects are more relevant to the patient receiving the service, and the professionals providing the day to day care.
  • Enhanced quality standards should be devised and paid for by commissioners, local knowledge should lead to a more intelligent design.
  • Contractual service standards should be agreed with front-line clinicians, and expressed in a way that is relevant to day to day care.
  •   Monitoring of contract standards should be relevant to clinicians and the public.
  • Sanctions and incentives are legitimate, they need to be understandable, and acceptable to medical and nursing leadership.
  • Finance and contract leadership should recognise the importance of resources being deployed to the front-line.

We purchase care on your behalf

Commissioning is a confusing term.  CCG’s should explain to the public that ‘we purchase care on your behalf’.  CCG’s should also:
  • Use multiple ways of engaging, and keep refreshing this.
  • Find ways that work, of patients monitoring standards on our behalf.
  • Ask patients about their experience at an individual/practice level and collate this.
  • Encourage member Practices to follow-up with more patients to assess whether the care experience was positive.
  • Make more information available to patients so they can assess how good a doctor/ward/hospital is before making a choice.
  • Be prepared to tell good and bad stories about services and the patient experience.  Emphasising good care is also important.

This debate was important, it was stimulating and challenging, clinicians and lay members and the management team all offered their perspective.  What is more important is what we do and how we do it.  Contracts are about to be agreed for services in 2013/14.  It is essential that they provide a framework to improve quality and patient care.

Francis is an opportunity.  A chance to re-assess what we are doing as commissioners and why!

Wednesday 13 February 2013

Ambulance services

We are clear in the CCG about our focus, and how to improve care for our population. We have an unrelenting focus on quality and patient safety, we operate a model of 'clinical management', and we try to achieve the very best public and patient involvement that we can.

For the CCG team to be even more effective, we have committed ourselves to spend more time with front-line clinicians, professionals, and to talk to more patients, carers, and the public.

Last week I was privileged to join an ambulance crew from East Midlands Ambulance Service to observe a 13 hour daytime shift. Our local ambulance services are under pressure and the organisation is currently considering how to improve the situation for the future. I felt it would help me if I had a better understanding of our local service.

So for me this was new and very different. 

My overall thoughts include;

This was a richly rewarding experience, and it has led me to reflect on a number of learning points and issues to consider further. The professionals and managers who work closely with the service may already know about these issues. To me as a commissioner of services these were a real eye-opener. This in itself is a point worthy of reflection.

My hosts for the day were a Paramedic (with ten years experience), and a recently appointed Emergency Care Assistant. The teamwork and patient care provided by this crew was very impressive. 

I am familiar with the roles of doctors and nurses in hospitals, primary care and in the community. However, this was different. The environment in which the care was provided was so diverse and challenging, I observed fantastic care and teamwork to treat a patient who was immobilised halfway down a narrow set of stairs. In answering a different call we were agitated by aggressive loose running dogs. The first two calls were a middle-aged suicide risk, followed by a query meningitis in a young child, followed by an elderly person who had fallen. 

When the patient required onward transfer to hospital I observed excellent care provided in the back of a moving vehicle, one of the most impressive skills that was really apparent was the excellent communication skills of the crew. They were always looking for opportunities to build a conversation, gather the important information, and put the patient at ease. It also struck me how important it is for these professionals to understand how the rest of the local NHS should work together. This ranged from a need to understand care pathways (services such as trauma and stroke can differ across county boundaries), and to understand how to access local GP and community services, these can also vary across localities. 

Being able to talk to the elderly, and to calm the frightened was essential, this seems obvious to me now, and it has encouraged me to reflect on the importance of communication with the patient and family, particularly in the wider NHS, and in the context of the Francis enquiry.

It was interesting to experience driving under blue-light, this at times was particularly stressful for the driver, and on my own in the back of the ambulance I can tell you it was really stressful!

Efficiency and care;

·   One elderly patient who had collapsed had their blood pressure taken by the first professional on scene, then had their BP taken again twice during transfer, and then again on handover in A&E. Some of this was of course good practice, from a patient perspective I understand some patients find this comforting, other consider it a trial. It did make me think about the extent to which we optimise the use of our medical equipment, and use of professional time when a patient moves through our care system, the handover from one organisation to another should not matter to the patient or impact on the care.

During the day we visited a number of A&E departments, at one we had to queue each time (x3) to book the patient in. The departments were busy, and the cubicles mostly full, approximately two-thirds of all the patients I observed were elderly. This was an ordinary midweek day, I understand this patient profile and demand for services is common across the county.
There were a number of patient stories that revealed what appeared to be either service gaps, or examples of where care or the patient experience could be improved. Within the CCG we will of course follow these up, without this personal experience of the frontline I think it is very unlikely that I would ever have known.

I had the opportunity to chat with crews during the day. It was apparent that the crews have to be effective in managing themselves in what are often difficult circumstances. They often don't know the nature of the next call, or the environment in which they will be required to provide care. I heard stories which helped me understand the high level of sickness absence in ambulance services. It is a stressful role, and one which requires personal resilience and personal fitness. I heard stories of the physical strain on crews who have to lift and move patients who are often heavy and immobile, and/or can only be accessed through a car window (with vehicles often on their side or roof), often at night and in the dark.

The overall efficiency of the crews was interesting. The crew were responding to calls for 7 hours before the opportunity for a break. We had a 45 minute journey from Hospital to return to base, and then a 45 minute journey to the next deployment, because this break was relatively late I understand the crew members are paid more for this. Perhaps providing subsidised facilities in hospitals and community hospitals and/or LIFT facilities for ambulance staff would be more efficient. It could also offer opportunities for integration with local doctors, nurses and other staff

Morale and culture;

There are some relatively simple things that could make a big difference to staff. The stretcher trolleys are variable in style and functionality, the one I observed being used was excellent, very flexible and functional. However, I understand some are not as good, this can place a real physical strain on the staff and lead to injury.

Some crew members that I spoke to seemed to have relatively low morale. I have reflected on this and compared their outlook to that of other doctors and nurses with whom they worked during the day. It struck me that they were never part of any delivery system, (like the hospital or GP practice) and were not really integrated into the wider health system to which they visited. This probably creates a particular professional culture, it would be really interesting to consider this further, and the behaviours that it may generate.

Crew members also seem to have a limited professional career pathway. It is interesting to contrast this to the doctor, nursing and allied health professionals.

The crew members also had a number of good ideas. These included solar panels fitted to vehicles, and making more use of onboard technology to improve record keeping and handover where there is a potential safeguarding issue. I wonder if the Francis enquiry will create an environment where innovation and ideas from frontline staff can surface in organisations, and spread for the benefit for patients, clinicians, and other professionals?

Within the CCG team we will continue to try and learn more from front-line experience. The teamwork and professionalism of the crew was a privilege to observe, the care they provided first-class. I have reflected since on our discussions about ambulance services in the past at the PCT Board, these were often dominated by targets. Measuring standards of care is of course absolutely imperative for a Governing Body, how different the discussion could have been if we had all enjoyed more direct experience of the service, and had a greater understanding of the challenges in providing good care and a positive patient experience.

We are determined to make sure that all of our CCG Governing Body management members have more experience of frontline services, it can only strengthen our discussion and lead to improved care and services for our local people.

Next for me is shadowing a memory assessment nurse. Meanwhile the CFO will be walking the local pathway for the frail and elderly.