Claire Cox

In Maintaining motivation in uncertain times the King’s Fund advises leaders how they can best support their teams by offering structure and containment, protecting, encouraging, and creating opportunities. 

The BMA sent out its first survey at the beginning of April. The most recent survey closed on 13 August and nearly 4,000 doctors took part.  The 13 August 2020 results found: 60% of doctors said they were not very, or not at all, confident in their local health economy managing demand as normal NHS services resume. Half of doctors said they were not very, or not at all, confident in being able to manage a second wave of COVID-19. 26% of doctors said that in the last two weeks non-Covid demand had increased to pre-pandemic levels, with 17% saying that demand is now even higher than it was before. Previous survey results BMA COVID-19 survey results - 9 July 2020 BMA COVID-19 survey results - 18 June 2020 BMA COVID-19 survey results - 28 May 2020 BMA COVID-19 survey results - 14 May 2020 BMA COVID-19 survey results - 30 April 2020 BMA COVID-19 survey results - 16 April 2020 BMA COVID-19 survey results - 6 April 2020

RESTORE2 TM is a physical deterioration and escalation tool for care/nursing homes. It is designed to support homes and health professionals to: recognise when a resident may be deteriorating or at risk of physical deterioration act appropriately according to the resident’s care plan to protect and manage the resident obtain a complete set of physical observations to inform escalation and conversations with health professionals speak with the most appropriate health professional in a timely way to get the right support provide a concise escalation history to health professionals to support their professional decision making. Here you can find all the official resources to accompany the initiative.

In this article, published by the BMJ, Professor Russell Mannion and Professor Huw Davies explore how notions of culture relate to service performance, quality, safety and improvement. Key messages: Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations. Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives. A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics. Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity.

Is safety and a good experience two separate issues? This blog by Florence Wilcock, consultant obstetrician, discusses this issue.

Imagine a diverse workplace in which all employees felt a genuine sense of inclusion and belonging. It’s unlikely you work in such an organisation today. But it’s clear that every organisation, public and private sector alike, is increasingly aware of the need to get to work on making this a reality.  This article, written by Amy Edmondson and published in Psychology Today, recognises that a diverse workforce and psychological safety go hand in hand for a safer workplace.

When some patients leave hospital they can need extra support taking their prescribed medicines. This may be because their medicines have changed or they need a bit of help taking their medicines safely and effectively. The transfer of care process is associated with an increased risk of adverse effects. 30-70% of patients experience unintentional changes to their treatment or an error is made because of a miscommunication. This is what the Transfers of Care Around Medicine (TCAM) project aims to address: When patients discharged from hospital are identified as needing extra support, they are referred through a safe and secure digital platform for advice from their local community pharmacist. Original work in the North East showed that patients who see their community pharmacist after they’ve been in hospital are less likely to be readmitted and, if they are, will experience a shorter stay. Many AHSNs, including Wessex and the West of England, have worked with trusts and Local Pharmaceutical Committees to help set up a secure electronic interface between the hospital IT systems and PharmOutcomes, the community pharmacy system used in their area. This has further enhanced TCAM by providing patient data quickly and seamlessly to their community pharmacist. Wessex AHSN developed an awareness campaign to encourage people to seek help with their medicines, featuring a character called Mo in a series of animated films and accompanying poster resources for pharmacies. The films have been viewed almost 64,000 times. Through the national implementation of TCAM in 2018-2020, each AHSN will support their local trusts to establish a TCAM pathway. This will enable all suitable patients to be referred to their community pharmacy or GP pharmacist where appropriate.

e-PAIN is the place to start for anyone working in the NHS who wishes to better understand and manage pain. e-PAIN is a multidisciplinary programme based on the International Association for the Study of Pain's recommended multidisciplinary curriculum for healthcare professionals learning about pain management. Registration to the programme is free to all NHS staff members, those with OpenAthens accounts and students. e-PAIN uniquely distills the knowledge of a range of professionals into 12 Modules made up of interactive sessions to meet the needs of a multidisciplinary audience. e-PAIN is current, up to date and presented in an interactive way to make both basic and specialist knowledge accessible. Any module can be completed stand alone and you can download a certificate upon completion of each module. Sessions take on average 30 minutes to complete and modules have on average 5 sessions. e-PAIN is a collaboration between the Faculty of Pain Medicine, the British Pain Society and e-Learning for Healthcare. It is provided by Health Education England.

This info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.

The COVID-19 pandemic has required health systems to change much faster than normal. Many staff have experienced training in quality improvement and patient safety methods which can be used to support the design of new systems and to accelerate learning about new and adapted practices. This article, published in the International Journal for Quality in Health Care, sets out the principles of quality improvement and patient safety science, applying them in a selection of approaches, methods and tools, which may be useful in crisis situations such as the current pandemic. The article also makes reference to several resources which may be of use to those keen to advance their knowledge.

Good practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug. Initiating, tapering or stopping opioid medicines should be managed in agreement with the patient and all members of their healthcare team. This resource, developed by UK healthcare professionals and policymakers, provides the information to support a safe and effective prescribing decision. Key Messages 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation). 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration. 4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available. 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.

Psychotherapist, Donna Butler from Brighton and Sussex University Hospitals NHS Trust, talks through the mental and emotional challenges during and post-COVID-19. Recommended viewing for staff and managers.

For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. The result may lengthen a hospital stay, increase costs, or have life and death implications for the patient. So, what can you do to safely administer medications? This blog gives some tips on good practice.

Safe and effective pharmacological management of acute and procedural pain in neonates, infants and early childhood requires understanding of age-related changes in both the pharmacokinetic and pharmacodynamic profile of analgesics. Evidence based clinical practice guidelines incorporate both pharmacological and non-pharmacological techniques that can have complementary roles in acute pain management. The knowledge, skills, and attitudes of paediatric pain physicians must be appropriate to the developmental stage and clinical state of the patient and also encompass the role of parents and/or carers. The Faculty of Pain Medicine of the Royal College of Anaesthetists is concerned with the professional standards of Pain Medicine specialists, so this document focuses on the Pain Medicine specialist’s contribution to Paediatric Pain Medicine (PPM). This document describes two levels of involvement in the practice of PPM: • The first level outlines the core knowledge, skills and attitudes for all anaesthetists specialising in Pain Medicine who may need to be involved with this area e.g. making timely and appropriate referrals for paediatric pain management and emergency management of a child with pain. Whilst it is recognised that not all Pain Medicine specialists will be directly involved in providing a paediatric pain service, all need to have an understanding of this area. • The second level outlines the advanced knowledge, skills and attitudes required of Pain Medicine specialists who work in teams providing a paediatric pain service. These competencies reflect those of the paediatric pain module which is an option at Advanced level of Pain Medicine training of the Royal College of Anaesthetists’ CCT in Anaesthetics curriculum, which sets out competencies for trainees who elect to take a deeper interest in this area of Pain Medicine practice

Prof Nick Bishop, VP for Science and Research at the Royal College of Paediatrics and Child Health (RCPCH), outlines some of the key developments in the College's Research and Quality Improvement Division, recognising ongoing work despite the disruptions to members' schedules. He also discusses research on the effects of COVID-19 on child health and well-being.

Caring for people with learning disabilities in an acute hospital setting can be challenging, especially if that patient has transitioned from children’s services to adult services. The experience in children’s acute care differs to adult acute care; this difference in processes of care can cause great anxiety for the patient and their family and carers. The reasonable adjustments that were perhaps made and sustained in children’s services may now not exist. The purpose of this blog is to demonstrate the importance for services to be designed around patients’ needs with patients, families and carers. If we get this right, the quality of care given will be improved, patient satisfaction increases and, in turn, a reduction in patient harm. It is important to note that designing services around patients is not exclusive to learning disabilities; designing services with ALL patients at the centre with their involvement is crucial for trusts to provide safe care. The outpatient appointment Attending an outpatient appointment, in my experience, is daunting at the best of times. First, there is the appointment date. Often you have had to wait an exceptionally long time for this appointment (providing the referral letter hasn’t been lost). The date and time are chosen by the Trust. There are some Trusts and specialities that will allow you to choose a time and place, but more often than not you are not able to choose and changing the date and time can prove tricky. There are many reasons for a patient not to turn up for an appointment. These reasons and how to mitigate them are looked at by Trusts. The 'Did not attend' (DNA) rate is looked at by Trusts. DNAs have an enormous impact on the healthcare system in terms of increasing both costs and waiting times. Trusts often want to reduce these to: reduce costs improve clinic or service efficiency enable more effective booking of slots reduce mismatch between demand and capacity increase productivity. Then there is getting there. Getting time off work or college, making childcare arrangements, getting transport… finding parking! Before patients even get to the appointment, they have often been up a while planning this trip. Imagine what this must be like for a patient with learning disabilities. This poses even more planning. What medication might we meed to take with us? Are there changing facilities for adults? Can we get access? Is there space to wait? Will anyone understand me? How long will we be there for? Do they have all my information? Services need to be designed with patients' needs at the forefront: the ability to change appointment dates, the location in where the appointment is held, parking facilities, length of appointment, type of appointment, is a virtual appointment or telephone appointment more appropriate? If you have a learning disability, you may have a family member or carer with you. If you have transitioned out of children’s services you will be seeing someone new, in a new environment. You may not have had the time to discuss the fine nuances to your care that is really important to you. You have now left the comfort bubble of paediatrics where you and your family had built up trust with the previous consultant and care team, and you are now having to build up new relationships. What is in place for you to feel comfortable? Has anyone asked what would help? The consultation Reasonable adjustments such as a double-length consultation is a great way of ensuring people with learning disabilities have enough time to process information and are given time to answer questions. Extra time is only one of many reasonable adjustments that can be made. An example... I would like to reflect on a recent time when I cared for a patient with autism and I didn’t have all the information to enable me to plan care for them at this particular time. This patient had spinal surgery and spent a very brief period on the intensive care unit. As part of my role as a critical care outreach nurse, I see patients who have been in the intensive care unit to check that they are doing well, that ongoing plans of care are in place and that they understand what has happened to them. I read that this patient had autism, but I had no other information. I was unaware of how the autism affected her, if she needed a carer, what she likes, dislikes, how to approach conversations or anything that was important to her. There is a health passport that can be used to aid exactly this information, this is filled out by the patient with their family or carer. Unfortunately, I could not locate the passport. I read the medical notes and went in armed with my usual questions and proforma that we use for all patients. Usual visits like this last from around 10 minutes (for a quick check) to an hour if they are a complex long stay. With the operation that this patient had, I was expecting to be with the patient for around 20 minutes. After introducing myself to the patient, it was clear that the proforma I was going to use wasn’t going to work. Tick boxes and quick fire questions were not the right way of going about this consultation. This patient was scared. More scared than a patient without autism. Their usual routine was gone, they were unable to ask as many questions as they normally would as the nurses and doctors were busy, their surroundings were different, the food was different, new medications, new faces everyday – there was no consistency. The ward round had just happened, the patient had a good plan in place and was due to go home the following day. Normally, this would mean that my visit would be a quick one as the clinical needs of the patient are less complex. This visit took me 90 minutes. Not only did I not have the care passport to hand, due to the coronavirus pandemic I had a face mask on. I felt completely ill-equipped for this consultation. I knew I was missing vital pieces of information which would help me communicate with this patent more effectively. So much of our communication is from facial expressions. A smile for reassurance makes a huge difference. I now have yet another barrier to overcome to communicate with my patient in a way that they can understand and feel comfortable. This particular patient asked many questions. This I had not factored into my day. I have a list of 12 patients to see, in between answering calls from staff on wards who have unwell patients for me to review. It’s too late to abandon the consultation or leave it for a less busy time. I’m at the patient’s bedside and I’m already committed to giving this patient my full attention. After we spent around 20 minutes discussing why I had to wear a mask, what the mask was made of, how many I had to wear in a day, why patients were not wearing masks, we then got onto the subject of food. Where the food is made, how does it get here, who heats it up? Then it came to the other patients in the bay. She knew all of them by name and proceeded to tell me the goings on that happened during the night. I’m clearly not going to get my proforma completed here. This is because my proforma is not important to my patient. "What matters to you?" During my Darzi Fellowship I had the opportunity to visit the Royal Free. Here I met an amazing physiotherapist called Karen Turner. She introduced me to asking the question ‘What matters to you?’ Simple – but so very effective and empowering for your patient to be asked this. The food, my mask and the people around her were of greatest importance to my patient at this time – not what she thought of her stay or if she wanted me to go through the intensive care unit steps booklet; these were important for me to know, these were questions that gave the Trust insight of what is important to them. It dawned on me that we had designed our follow-up service to suit us and not involved families or the patient. I feel a quality improvement project coming on! Reasonable adjustments take planning, as clinicians we need to know about them. We need to factor them into our work. The NHS has just enough capacity to run if all patients followed the NHS pathways, if all patients grasped everything and followed all instructions, took their medications on time, turned up for their appointments – there wouldn’t be a problem. It takes me back to the clip from the BBC programme ‘Yes Minister’ of the fully functioning hospital with no patients and that services run very well without patients! Currently systems within the NHS are designed around the building, the staff within it and the targets that are set out by NHS England and the Department of Health and Social Care. If we started designing care and access around patient need and ask them what would make it easier – what helps? what matters to you? – what would healthcare look like? During this time of uncertainty and change, I see exciting opportunities to take stock and see what’s working and what isn’t – and lets start involving patients at every stage. Call to action What are you doing to ensure reasonable adjustments are made for people with learning disabilities where you work? What more needs to be done to ensure that people with learning disabilities feel part of the conversation and play an active role in their care? Are you a patient, carer or relative? What has your experience been like? Have you any experiences in designing services with patients? Perhaps you are a patient and have been a part of the process. Add your comments below, start a conversation in the Community area or contact us. We'd love to hear your thoughts and experiences.

Reasonable adjustments to the care of people with learning disabilities who receive hospital care are beneficial for all involved. This article, published in the Nursing Times, uses two case studies to demonstrate their benefits.  Author, Linda Phillips, is a learning disability health liaison nurse at Hywel Dda University Health Board.

Frontline staff and volunteers at the forefront of the national coronavirus response across England will be able to access a new Psychological First Aid (PFA) training course, the Minister for Mental Health Nadine Dorries announced, 15 June 2020. The free online course available through Future Learn enables responders to develop their skills and confidence in providing key psychological support to people affected by coronavirus, including on issues such as job worries, bereavement or isolation as they carry out their vital work as part of the ongoing coronavirus response. It will also help to develop understanding of how emergencies like the coronavirus pandemic can affect us all, how to recognise people who may be at increased risk of distress, and how to offer practical and emotional support. It follows a globally recommended model for supporting people during emergencies, tailored to the specific challenges of coronavirus (COVID-19)

The VIP scheme is supported by the learning disability liaison team in the acute hospital to improve health outcomes. The scheme promotes reasonable adjustments, person centred surgical care pathways, accessible information and decision making care plans to support those who may lack the capacity to make health decisions. It also includes VIP champions and promotes evidence based training. The scheme is supported by the Wakefield Patient Experience Group, made up of people who have a learning disability.  The VIP scheme has improved health outcomes of patients with learning disabilities at Mid-Yorkshire Hospitals Trust. The scheme, all though multi-faceted, has one common aim; achieving equality for patients with a learning disability.

An informational video for people being admitted to a ward at the Royal Derby Hospital, designed for our patients with learning disabilities.

People with learning disabilities, autism or both and their families and carers should be able to expect high quality care across all services provided by the NHS. They should receive treatment, care and support that are safe and personalised and have the same access to services and outcomes as their non-disabled peers. But we know some people with learning disabilities, autism or both encounter difficulties when accessing NHS services and can have much poorer experiences than the general population. Several inquiries and investigations have found that some NHS trusts and foundation trusts are failing to adequately respect and protect people’s rights, with devastating consequences for them and their families. Also, skills deficits in the NHS workforce mean people’s needs are sometimes misunderstood or responded to inappropriately. As a result of these failings, people with learning disabilities, autism or both are at risk of preventable, premature death and a grossly impoverished quality of life. With system partners, NHS Improvement, have developed four standards that trusts need to meet; doing so identifies them as delivering high quality services for people with learning disabilities, autism or both. These standards are supplemented by improvement measures or actions that trusts are expected to take to make sure they meet the standards and deliver the outcomes that people with learning disabilities, autism or both and their families expect and deserve. These four standards are: 1. respecting and protecting rights 2. inclusion and engagement 3. workforce 4. specialist learning disability services.