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.
