High impact users – changing the culture

Sally Buckland from the Bristol Royal Infirmary reflects on setting up their High Impact User Team and the launch of the SHarED project with the West of England AHSN.

Within every Emergency Department you will find a cohort of patients who have multiple attendances. Many of these patients have multiple needs and a high proportion are known to the community mental health services. The liaison psychiatry team at the Bristol Royal Infirmary had long recognised that many of the patients they saw in the Emergency Department following self-harm had existing care plans with the community services, and early interventions sought to ensure that care coordinators were able to advise on psychiatric support of their patients who were frequent attenders to the emergency department.

Other specialist teams, such as drug and alcohol services within the hospital, were also seeing similar patterns of attendance, often this group of patients were known to several teams, who began to look at ways of ensuring consistency of care.

In 2014 the High Impact User Team was set up within the Bristol Royal Infirmary Emergency Department to work alongside this cohort of patients and healthcare professionals with the aim of reducing unnecessary attendances and relieving pressure on the Emergency Department.

What quickly transpired though through this work was that there was a negative culture surrounding High Impact Users that also needed to be addressed. Staff were often reluctant to deal with High Impact Users and there was a common theme of negativity around their attendances.

A problem SHarED

Through time the work of the High Impact User Team has grown and the team expanded to meet the demand. In 2019 we began working with the West of England AHSN and launched SHarED (Supporting High impAct useRs to the Emergency Department) – a project to establish a network of High Impact User Teams within the Emergency Departments across the West of England.

Culture has been an important part of this work and, in an attempt to understand it further, staff at all SHarED sites have completed a survey relating to their experiences. Through this we have been able to gather important information about the culture surrounding some of our most vulnerable and complex patients. High Impact Users are, and continue to be, a group that staff struggle to engage with. But why is this?

Understanding the culture

High Impact Users are time intensive. Their presentations are rarely purely for medical reasons. They often have complex social and safeguarding issues that take significant time and resources to work out. Staff can end up feeling resentful if they find themselves spending less time with other patients as a result. Due to the complexity of their care there is often a concern about a risk of medical mismanagement.

A high proportion High Impact Users can be violent and aggressive in their behaviour. Staff often feel afraid and vulnerable in their presence. There is a significant level of risk management involved when dealing with these patients.

As Healthcare professionals it can become ingrained in us that we need to ‘fix’ our patients. The solutions often required in the case of the High Impact User are often longer term and can take time to implement. The perception that we are not fixing the issue is demoralising.

This can be emotive work. High Impact Users can have a significant emotional impact on those caring for them and often raise feelings within us that make us feel uncomfortable. Dealing with pain, trauma and non-engagement is draining. Sometimes there can seem to be no way forward in breaking the cycle of attendance.

Many of this cohort of patients present with self-harm, or drug and alcohol addictions, issues which can be perceived as self-inflicted, and thus somehow less deserving of staff time.

Patients with mental illness and addictions are also less likely to be able to engage easily with support services, or follow suggested treatment plans.

Finding solutions

This is a chaotic and difficult group of patients to work with and it became quite apparent early on in our work that a collaborative multiagency approach was the way forward. We aim to work with the High Impact User, GP and other agencies involved in their care to create Personal Support Plans to be used when the patient attends the Emergency Department. It is a model that has proved to be extremely successful. Personal Support Plans are designed and written to inform clinicians of key information, including risks and appropriate management suggestions in order to support them to be able to provide the most appropriate care response.

Whilst Support Plans are in place to help guide and support clinicians in their decision making there have been other benefits that we have discovered through the course of our work. Through a support plan we can communicate vital information that will enable the clinician to understand someone’s journey to becoming a frequent attender. It is important to remember that right at the centre of this process is a person with complex needs, and often a history of trauma.  They are ultimately patients and deserve the same level of care regardless of the frequency of their attendances. We aim for clinicians to hear the voice of the patient through their Personal Support Plan.

Historically High Impact Users have been seen as a drain on resources, however we are now seeing that with the right management this can be overcome. By equipping healthcare professionals with the relevant information they can treat High Impact Users effectively thus saving time, money and ultimately, saving lives.

Through our experience of working with High Impact Users in The Bristol Royal Infirmary and the implementation of Personal Support Plans we have seen a culture start to change to one of compassion. We are excited to see the positive changes that the SHarED project will continue to engender within the other sites and within our own trust.

2020 was one of the most challenging years ever faced by the NHS. COVID has caused us to adapt and evolve our ways of working. We are grateful to the SHarED team for the way that they have kept to project running through these challenging times.

What next?

2021 will see the completion of the SHarED project. We look forward to working together as a network of High Impact User Teams across the West of England to continue to support our patients and clinicians and change and improve the culture around High Impact Users.

2020 – The year of learning through adversity

Natasha Swinscoe, Chief Executive of the West of England AHSN, looks back on the last 12 months.

As I reflect on the year that was 2020, two quotes spring to mind, from very different sources.

Firstly there are Michelle Obama’s motivational words:

“You should never view your challenges as a disadvantage. Instead, it’s important for you to understand that your experience facing and overcoming adversity is actually one of your biggest advantages.”

It’s with enormous pride and admiration that I look back on the work of our local health and care system over the last year and can see so many examples of how we’ve done exactly this. As an AHSN, our local network was ideally placed to act quickly to provide support to the system where it was most needed, bringing people together with the right skills and experience to collectively shoulder many of the challenges presented by the COVID-19 pandemic.

We were able to ‘turn on a sixpence’, pausing some programmes, adapting and accelerating others and tailoring a completely new set of COVID-19-specific offers to our member organisations for immediate delivery.

Partnering with Wessex and South West AHSNs, we supported 570 primary care practices across the NHS South West region to rapidly implement and then optimise the use of online and video consultation tools, and we are now scaling up use of remote monitoring technologies to support vulnerable residents and those who live with frailty.

Our regional focus on safer care for deteriorating patients has come into its own. We’ve identified and accelerated some of our most relevant work, in particular around RESTORE2, ReSPECT and NEWS2, turning our popular training programmes virtual and offering to all care homes in the West of England, including those for people with learning disabilities, domiciliary care and supported living providers. Our teams are now working with health and care colleagues to rapidly roll out the COVID Oximetry @home pathway, and have recently hosted a couple of webinars enabling colleagues to share learning and solutions.

We have also been working with our innovator community to identify products that could help in the COVID response. For example, we supported a pilot project with Wiltshire Health and Care to use KiActiv® Health, a mobile and web-based app, to support respiratory patients as an alternative to face-to-face pulmonary rehabilitation during the pandemic

Other parts of our work have had to adapt to changed circumstances. We managed to launch our perinatal care bundle PERIPrem  to all neonatal units across the West and South West without actually being able to visit them. We moved all of our West of England Academy courses online and our Summer QI programme was a sell-out. We’ve paused, adapted and pressed on with programmes like PreciSSIon and SharED, and are seeing them make real, measurable differences to the outcomes for patients and users. This is all testament to the passion and commitment of our regional health and care teams to continue the good work we’d started despite the challenges presented by the pandemic.

We’ve often had to draw out the essence of our programmes, to refine, reflect and sometimes reorient our work. A stretched system, populated by staff working at the limits might not sound like the ideal change environment, but we’ve found the appetite to improve has remained. We have felt an increased demand for our work, and were honoured to be nominated for awards for our PReCePT and ReSPECT programmes, as well for the clinical leadership of Anne Pullyblank, our Clinical Director.

Whilst working to meet the increase in demand we are also reflecting on what we’ve learnt about change and innovation over the last year, and how we can use that to continually improve our work. This leads me to the second, far pithier quote from Benjamin Disraeli:

“There is no education like adversity.”

Adversity has been a common theme this year, but I have been amazed at the appetite to continue to learn and improve in the face of it. All of this activity has only been possible as a result of being part of an engaged and dedicated health and care community. So most of all I want to say thank you.

Thank you to all the individuals and organisations that together comprise the West of England Academic Health Science Network family; to our team of staff who have embraced remote working and our new virtual world; thank you to the innovators and researchers for your new ideas and insights.

Thank you for what you’ve achieved in the last year. Thank you for collaborating with us to rapidly introduce new ways of doing things in response to COVID. And thank you for your energy and commitment in helping us to continue other areas of work that could so easily have been ‘one thing too many’ during the pandemic. I hope you get some time over the coming weeks to pause and reflect on all we’ve achieved together.

I’ve always been proud of our Network’s system-wide, inclusive approach, building supportive relationships with all those in our region who need and want to contribute. I’ve never been more proud as I am now looking back at what we’ve achieved together this year, and I very much look forward to continuing this work in 2021.

“So… what do they do?” A view from a new starter

Emma Ryan started with the West of England AHSN Communications team in September, and wrote this blog a couple of weeks into her new role.

In the Summer of COVID-19, I sat at home, 2 months into furlough with the likelihood of looming redundancies in the hospitality business I worked in and had grown to love. I decided I should start looking for a new job, even if the prospect of losing my role hadn’t quite sunk in or became a reality yet.

I have a background in Marcomms, and one of the first jobs in my search I came across was a Communications and Marketing Officer role for West of England AHSN. I do not come from a healthcare background and had no real inclination as to what an AHSN (Academic Health Science Network) was. The marketing aspects of the job seemed to align with my skillset so thought I should do some research, and then I couldn’t stop!

My notes from this research say of West of England AHSN; ‘finding new ideas and research to help make people better and then spreading these ideas’. Hopefully my insight will be a little more articulate throughout this blog!

So, I applied, had an interview and secured the job (congrats me!) Now the real learning would begin. I started at the beginning of September and it really did feel like going back to school. Over the first few weeks, I have met lots of people across the organisation and have learnt so much. Many of my friends and family, when I told them I had this new job, asked “So, what do they do?” Well, here’s what I have learnt so far…

What does the West of England AHSN do?

The NHS isn’t one big organisation; its various organisation of varying shapes and sizes working together to provide health care for you. Sometimes it can be hard for amazing ideas in one place, to be recognised and shared with other providers. It can also be hard to have the capacity or the knowhow to get ideas into fruition in the first place. AHSN’s across the country work to solve these problems.

At West of England AHSN, we do this in two main strands; firstly, Services Systems and Transformation. This is delivering change and adopting new ways of working by bringing evidence into practice. So, making sure amazing ideas are spread and picked up and implemented.

Secondly, Innovation and Growth; this is where we identify a problem. Then we find an innovator who can help, nurture and develop the innovator and their idea, and connect the innovator with an organisation which would benefit from their idea or innovation.

Who are the West of England AHSN?

The West of England AHSN is made up of the most incredible people; they have huge brains and mighty hearts. Sometimes, I felt like a goldfish in a pond with a bunch of koi because they are honestly all so passionate and knowledgeable, it can be a bit intimidating. However, they all have a great capacity for teaching and idea sharing. I have been told on more than once occasion that no question is too small or too stupid!

I would love to tell you about each of them, but I’ll just highlight a few to give you a flavour of who works here. First of all, Kay Haughton, Director of Transformation. Like many people working here, Kay has a background in nursing, and so knows the pressures and challenges front line NHS workers face. She has travelled all over the world undertaking various nursing roles. She saw in her work just how complicated in can be for private companies and innovators to work with the NHS, and so joined us to help manage this problem.

I’ve also had the pleasure of meeting Ben Bennett, Chief Operating Officer. During our first meeting, Ben said, “We are here to speed up the pipeline for innovation so patients get services quicker.” This really stuck in my mind as it’s a clear, succinct way to explain what we do. Ben has previously been a Hospital Manager and has over 30 years’ experience in the health care sector; he is also great at looking after people and runs regular team meetings to check in on us as we continue to adapt to working from home during COVID-19 restrictions.

Since I’ve started, I’ve also been working closely with Millie O’Keeffe, PA to Directors and Project Support Officer. Millie offered to be my work buddy when I joined, which was really appreciated. It can be hard starting a new job, and having her reach out made me feel super welcome. Millie has been my go to for silly questions, such as ‘how do I set up a Teams meeting?’ or ‘who actually is this person?’ …don’t tell anyone Millie!

Why does the West of England AHSN exist?

Simply, to make outcomes better for patients; whether that be providing increased dignity in end of life care or improving patient safety through minimising the risk of infection in surgery. We promote collaboration and idea sharing so that innovations or processes that will help people, get to the front line quicker.

Back in July, I was sat at my Grandads having a cup of tea. He had just returned home after time in the hospital with Pneumonia. He had been very sick and was still recovering and had pretty much lost his voice. However, his enthusiasm, respect and gratitude for the nurses and healthcare professionals that had treated him and really cared for him was in abundance; sometimes a bit too vigorously for an elderly man still recovering from pneumonia!

As we sat and laughed and drank tea, my phone rang. It was Vanesther – Head of Communications at West of England AHSN – to offer me the position of Marketing and Communications Officer. I thanked her, and went to tell my Grandad the good news. He was so proud and said, “so you’re joining the NHS superheroes?” and I thought, not quite, but maybe I can play a part in making their job a little easier; an Alfred to Batman perhaps?

COVID-19: collaboration is key

In the third of our series looking at our learning from COVID-19, Kay Haughton, Director of Transformation at West of England AHSN, explains how the AHSN used its existing expertise to help healthcare systems during the pandemic.

Covid blog badge

As COVID-19 took hold, we became very aware in the West of England AHSN just how busy our operational colleagues were, and that we needed to stop and refocus our work and our staff where possible to support front-line teams in local healthcare systems.

I was delighted to be able to respond when Gloucestershire Clinical Commissioning Group (CCG) asked if I could help them manage their Incident Control Centre. I loved my previous role as Deputy Director of Nursing and working with my colleagues at the CCG, so it was a privilege to help.

What did I learn? Well, a lot about PPE – and as I am a theatre nurse, I thought I knew all there was to know! I learnt how death rates are reported and worked more closely with Public Heath England than I ever have before. I also learnt a lot about testing for COVID-19 and marvelled at how quickly organisations across the county mobilised to respond together, including the military based locally.

Being exposed to this unprecedented situation and learning has really helped me to ground the work I was currently undertaking in the AHSN. I became involved with reporting on how care homes were managing and this resonated clearly with the enhanced care home project we had just got underway.

The work on the deteriorating patient we have been producing for the last couple of years had generated the perfect training programme for our colleagues in care homes on RESTORE2, a tool to recognise early deterioration in their residents. In the WEAHSN we are always proud to be ahead of the curve and the RESTORE2 training package is a good example of this.

I also became aware of the Gloucestershire CCG telephone service to support the most vulnerable people who are shielding and I am now part of an AHSN community of practice to share and learn what AHSN colleagues across England have piloted to support the vulnerable.

Clearly an important part of reset and recovery is to recognise the impact COVID-19 has had for the people affected by the pandemic, both physically and mentally. This applies to everyone in society and as such we are reworking our business plan to address the areas where we can add support. Some examples include support to increase the uptake of annual health checks for people with learning disabilities, medicines safety and suicide prevention work, supporting those with respiratory disease and women who go into premature labour, and help for people to make choices about their care at the end of life.

It is heartening to realise that we were already delivering on many of these programmes and we are working at pace to accelerate progress where we can.

COVID-19 has placed unprecedented pressure on our health and care system, particularly in primary care. Whilst immediate focus has been on supporting patients with or at risk of the virus, there is a large cohort of people living with long-term conditions that need ongoing, proactive management to prevent a wave of exacerbations in the months ahead.

We are keen to support primary care by offering support to roll out a risk stratification tool developed by UCL Partners, our AHSN colleagues in London. The package is based on new pathway development, virtual consultations, and the optimal use of the wider primary care team. Additionally, the package includes a selection of digital tools to support patient activation and help patients to manage their conditions at home. This is designed to help primary care teams deliver quality care to patients and meet Quality and Outcomes Framework and other contractual requirements, while releasing precious GP time. This is just one of many ways we are seeking to support front-line colleagues, for more information on this and other programmes please go to our COVID-19 resources page.

To finish on a personal note, I would like to thank my former colleagues at Gloucestershire CCG for welcoming me back so warmly and to my Service and System Transformation team for keeping up the good work in the AHSN. I look forward to working with and supporting you all in the months to come. Stay safe.

In the first of this blog series, our Chief Executive Natasha Swinscoe explores how healthcare is changing to manage Covid-19, and considers the factors that helped those on the front-line respond quickly and effectively. Read it here.

In the second of this blog series, Kevin Hunter, Associate Director for Patient Safety & Programme Delivery, discusses how working across systems with multiple partners and the blending of resources, irrespective of organisational boundaries, was a key element of the work we undertook with care homes. Read it here.

Coming up in the series next week, Alex Leach, Deputy Director of Innovation & Growth, reflects on the huge opportunities and risks that Covid-19 has presented to innovators.

Civility can save lives

Aless Glover Williams, Neonatal GRID Trainee ST7, St Michael’s Neonatal Unit and Neonatal QI Fellow supporting the PERIPrem Project on how knowing your team will help ensure Patient Safety.

On World Patient Safety Day, especially as this year highlights ‘Health Worker Safety’, I’m reflecting on the importance of knowing and valuing the individual members of the teams I work with.

Nearly everything we do as doctors centres around Patient Safety. It is in the morning safety brief, the staffing, the clinical decision making, the team-management, the drug checks, the Matching Michigan or WHO checklists, the governance and the documentation. Patient Safety underpins every outcome that we strive to achieve for our patients and awareness of how to make a difference as a professional is essential for every member of the team.

Quality improvement is but one string to this bow as it can not only directly but also indirectly effect change. Through building strong multi-disciplinary relationships and trust we will work better as teams, avoid a blame culture and avoid incivility, which is well-recognised to impact personal performance and functioning for the rest of the day all from a single interaction.

The PERIPrem Project which I’m proud to be a part of has built an amazing, supportive team culture despite being largely put together in the virtual world we now spend so much more time in. I have some close valued colleagues I’ve not met face to face, but that hasn’t stopped us building a fabulous team culture. My colleague Noshin does a fantastic job of describing it here.

So on this World Patient Safety Day take some time to really get to know your team; what is going on in their lives that might effect their functioning? Care for each other, look after each other, look after yourself, take breaks, value sleep and after prioritising kindness to ourselves we will find that we have space to care for others and embark upon new projects. #Civilitysaveslives

Reflecting on 2019/20

Natasha Swinscoe, Chief Executive, West of England AHSN, introduces our  2019/20 annual review, with a look back over some of our achievements from the last year.

All of us working in healthcare are familiar with the concept that the only constant is change. However, this year it feels as though things may never be the same again as we come to terms with the long-term impact of COVID-19. Above all, AHSNs are agile organisations and we were able to respond to this new crisis almost overnight, providing additional support to our members and partners.

So, as much as we look back with pride at our achievements from 2019/20 in this review, we already have an eye on how we can turn these experiences to our advantage, helping our local systems develop and test new pathways of care that will keep us safe and well, while living alongside the virus.

In 2018, AHSNs were set a challenge to increase the uptake of seven tried and tested innovations across the country. No less than four of them started life in the West of England. I’m particularly proud of PReCePT, which nationally has led to an additional 1,106 mothers receiving magnesium sulphate, preventing an estimated 30 very preterm babies developing cerebral palsy.

Working as a cohesive, national network allows us to have a wide reach while maintaining a local focus. This is evident through the Patient Safety Collaboratives, hosted by AHSNs to promote safer care through quality improvement programmes. I’ve been delighted to be the national AHSN Network’s chief officer lead for a dedicated group of patient safety leads working in areas such as maternity and neonatal, medicines safety and the management of deteriorating patients.

This year has seen a change of gear, as we exceeded the targets we were set for the spread of these national programmes. Going forward, we have the capacity and renewed confidence to refocus on developing further local pipeline programmes.

Innovation is not a single action. We see it as a journey, and the innovation spiral as the map, guiding the way ideas are generated, tested and implemented, ultimately impacting the whole healthcare system. This year we launched a series of thought leadership events, ‘Future of Care’, which have already debated the potential of genomics and personalised medicine, and robotics and autonomous systems to deliver care in radically different ways.

We also relaunched our West of England Academy, which is open to all health and care professionals in our region and aims to support a culture of innovation within our member organisations, encouraging innovation to be seen as part of everybody’s business.

And we’re excited to be supporting two projects identified through our Evidence into Practice challenge for regional adoption and spread. PERIPrem is a new perinatal care bundle designed to improve the outcomes for premature babies, and SHarED will help reduce attendance rates and support the most frequent and high-impact users of emergency departments.

All of this work is made easier thanks to our supportive Board, which shapes and directs our work and includes representatives from many of our members. This year we said goodbye to James Scott and Ian Orpen and you can read some of their reflections here and meet our new Board members in Steve West’s Chair’s update.

You can read more about all of this in our annual review – you can read it as an online magazine here, or pick and choose your way through the contents here.

Please contact us to find out more about any projects that interest you and we look forward to working together in future.

Innovating for economic growth

Steve West, Chair, West of England AHSN and Vice-Chancellor, University of the West of England and Chair, West of England Local Enterprise Partnership on the challenges and opportunities for health, care and the economy, and how the AHSN can help to meet them.

Who would have imagined six months ago that we would be in the middle of a global pandemic that requires us to reimagine our world, our relationships and our way of living, working and thinking? We are in a crisis and it will be human creativity, innovation and ingenuity that will help us through it.

There has been a lot of debate about the Health and Care Reset and how we can rebuild a system that capitalises on the positive changes we’ve had to make over the last few months, such as the rapid uptake of digital tools and the focus on patient safety. The economy is also in poor shape, and that is already having implications for disadvantaged groups and populations, such as people’s mental health.

It’s clear to me that health and wealth are entwined. There are massive opportunities for us to rethink our health and social care system. We need to embrace technology to enhance and free up what we do best – delivering care, human to human. The NHS and care sectors are also huge employers, with significant influence over the prosperity of their local communities.

AHSNs are of course designed to straddle these interfaces of industry, the NHS, social care and academia. The beauty of our board is its wide representation from chief executives and decision-makers across all these organisations, including the West of England Local Enterprise Partnership (LEP), which shares our values of innovation and economic growth.

In our first five years as an AHSN, we developed a great track record supporting innovations and helping them spread nationally. We now have the headroom and flexibility to step back as an organisation and so when COVID-19 hit, we were able to respond quickly. This has included supporting the development of a Nightingale Hospital in Bristol with training and resources, and reaching out to care homes and other community settings to ensure environments were safe and able to care for patients.

As well as being fleet of foot, AHSNs also have the ability to take a ‘helicopter view’ and look at where we need to get to in three or five years’ time. I think there is a danger that we don’t learn from COVID-19 and miss an opportunity to take a step forward, embracing artificial intelligence and technologies that support self-care and promote prevention.

The challenge is how we can shift the focus from illness and put the ‘health’ back into the National Health Service.

The care sector is one area where we are likely to see growth in employment, as we rethink the sorts of jobs we want people to do. Despite being a major employer, until COVID-19 it had been pretty invisible in most economic discourse. We also need to build resilience in communities and see a big effort to reduce obesity; the system will fall over if we don’t.

Midwives rise to the challenge in the International Year of the Nurse and Midwife

Ann Remmers, Maternal and Neonatal Clinical Lead for the West of England AHSN, reflects on how brilliantly midwives are adjusting to working in these unprecedented times, and thanks each and every midwife for the amazing job they are doing.

No one could ever have predicted what a momentous year the International Year of the Nurse and Midwife was going to be. And yet here we are in the grip of a worldwide pandemic which has completely turned everyone’s world upside down.

For the last four years we have been focussing on developing our maternity services to provide choice and personalised care for all women and their families in response to Better Births.

To meet the recommendations of Better Births, midwives have developed many innovative and exciting ways of working together with women and Maternity Voices Partnerships. For some midwives this has meant completely changing the way they work so that they can give women personalised care and continuity of carer.

Midwives have shown themselves to be adaptable to many changing situations but none have been more challenging than the current Covid-19 pandemic. Anyone who has ever met a midwife will know that we are a pretty huggy bunch! We spend so much of our time in close contact with women, none more so than when we are with women in labour. It is really hard to change our ways to social distancing when caring for women and to not use touch to reassure women. Wearing face masks, gloves and protective glasses means midwives have to work harder at creating that connection with women, using their voices and their eyes to convey feeling and support. But midwives are finding ways to overcome this and reassure women that despite the protective clothing they are still the same kind and caring midwife underneath.

At the Royal Cornwall NHS Trust, an innovative group of midwives have produced a video specifically aimed at reassuring women before they come into hospital. In the video one of the midwives shows what she looks like before donning personal protective equipment and gradually puts on her “work” gear reminding the viewer all the time that she is the same midwife with the big smile underneath it all. Watch the video:

I think back to my days as a community midwife many years ago when a call in the middle of the night could sometimes lead to the unexpected. One particular night a man called from a telephone box (not everyone had mobile phones then!) to say his wife was in labour and could I come straight away. As I rubbed the sleep from my eyes I asked him to give me his address. Well there wasn’t an address exactly, he said and directed me to a disused factory car park where he and his partner who were travellers were temporarily living in a caravan. I picked up my bag and headed off into the night; he met me at the edge of the car park and led me to the caravan with a torch shining the way. This was their home and they had prepared for the birth of their baby in the same way every parent does. After several hours in the caravan their baby arrived safely and it was wonderful to see this happy family able to have the birth they wanted despite the unusual location.

This reminds me of how midwives are used to adjusting to working in many different situations but what midwives and all healthcare workers are dealing with today is unprecedented in our lifetimes. Midwives are plunged into new situations and new ways of working for which they have not been prepared. Midwives are used to knowing the answers to women’s questions but now, because so much is new and unknown, sometimes they don’t always know the answers and that can be very unsettling.

Everyone is trying very hard to provide up-to-date information and guidance and the rate at which this excellent guidance is being produced by our national bodies is phenomenal. But sometimes the guidance raises more questions and anxiety: “Which PPE do we wear?” “What do we do about testing?”. This is where the frequent contact midwives are able to have with their leaders and each other is so important and reassuring. Through regular virtual meetings and calls we have all become more adept at using technology!  Midwives are good at supporting each other; there is always someone willing to share their experience and their learning.

Keeping contact with women and providing them with timely advice has become crucial and midwives are finding different ways to make this happen. Across the West of England and the South West midwives are working hard to support women to have the birth they dreamt of before the Covid-19 pandemic changed everything; this includes keeping our Birth Centres open for women to access. Midwives across the region are providing video consultations and telephone advice to women antenatally and postnatally. Across Bath, Swindon and Wiltshire, Community hubs are a focus for mothers and families to obtain advice and to keep in contact with each other. In Gloucestershire midwives have started online parent education classes and are now developing this to have the ability to do Facebook Live Q & A sessions across the county. There are many other examples where midwives are changing the way they provide care to adapt to the current situation.

Midwives really are rising to the challenge to ensure that despite the difficult circumstances women and their families receive the right care for them and their new born babies. Maternity services are keen to point out to women that they remain open and ready to provide them with the care and advice they need whenever they need it.

I am very proud of my profession and all my nursing and medical colleagues who are working so hard to ensure healthcare continues to be provided that is safe and timely. I think we all feel emotional when we stand on our doorsteps on Thursday evenings to applaud NHS and key workers for what they are doing and the sacrifices they are making right now.

This is the International Year of the Nurse and Midwife and 5 May is International Day of the Midwife, so I will be celebrating with all midwives and thanking them for continuing to provide support and care as women go through this remarkable experience in their lives. I hope each and every midwife gives themselves time to celebrate with their families and reflect a little on the amazing job they are doing.

It’s a big thank you from me for all you and your colleagues are doing in rising to this significant challenge.

What’s the NEWS? Supporting the identification of the deteriorating patient

Alison Tavaré, GP and Primary Care Clinical Lead here at the West of England AHSN shares a personal experience of surviving sepsis, and explains why she’s now such a strong advocate for the use of the National Early Warning Score (NEWS) in supporting the identification of the deteriorating patient.

Surgery to stabilise my spine sorted the pain and power was restored to my leg. I was re-admitted feeling vaguely unwell and with a CRP of 600, but that had returned to normal and I arrived home, admittedly with a PICC line in place, but relishing the peace and the contrast to a busy Nightingale Ward.

A few hours later I was deeply asleep, but suddenly woke with a profound feeling of doom. My husband called 999 saying something had happened but I was not making sense. Within minutes an ambulance crew were running into our house and, blue lights flashing, I was transferred to hospital.

I remember doors swinging as the F1 ran onto the ward, but this was followed by a very disjointed conversation when I kept saying ‘I feel really, really ill’ and being told ‘you can’t have an infection as you have a low temperature and low white cell count’.

My bewildered and non-medical husband watched as his confident and experienced GP wife transformed into an anxious, timid patient whispering ‘you don’t have to have a raised temperature to be sick’.

I remember my heart felt as if it were about to explode, but seeing the cardiac trolley at the end of the bed and knowing the team would not have to go far when I arrested was an odd kind of comfort.

Again something changed; I became very calm as I knew death was imminent and resigned to the inevitable. There was a grey tunnel over my husband’s shoulder and as I gently moved towards it, I told my husband I was about to die but that I loved him, our sons, and my family. Apparently I started to look very pale, and luckily the F1 returned to the ward and put up some fluids; although I still felt very unwell the feeling of doom ebbed away. I spent hours in theatre having the pus washed out and the spinal scaffolding replaced.

Although sepsis was one of the diagnoses on my discharge summary very few people knew what had happened as any discussion provoked vivid and distressing flashbacks.

However, the following year, clinicians at my local trust were raising awareness of sepsis and I offered to share my experience. In preparation I reviewed my notes; there was mention of recent surgery and the PICC line, but as I suspected the provisional diagnosis was a panic attack. Seeing my severely ischaemic electrocardiogram and the evidence that my perception I had been in peri-arrest was correct made me cry. National Early Warning Scores (NEWS) had not been in use at that time but I noted the individual observations, which included both a marked tachycardia and tachypnoea.

My very private experience has now become much more public. I am involved in raising awareness of sepsis and improving the identification and management of the deteriorating patient. As part of this I learned about NEWS and with curiosity I looked again at my observations; my NEWS was 6, or 9 if the NEWS2 update was used and my confusion included. There is increasing evidence that the higher the NEWS on admission, the more likely the patient is to die.

So why does NEWS matter? As a GP I use NEWS alongside clinical judgement when arranging admissions, so supporting secondary care colleagues deciding where patients should be seen, by whom, and with what urgency. However, I feel strongly that NEWS also protects me as a clinician; if a patient unexpectedly has a high NEWS it makes me think ‘have I missed something?’ Sepsis and an overwhelming feeling of doom undoubtedly made me anxious, so the F1 did not intentionally make a mistake but instead the diagnosis was informed by my behaviour and not my physiology. If NEWS had been in place, a NEWS of 9 would have led to immediate escalation and it is unlikely I would have progressed to peri-arrest.

We all want to do the best for our patients, so think about spreading the NEWS and if it helps you sleep better at night what’s not to like?

What is innovation, and how will an Academy help?

David Evans, Programme Manager for the West of England Academy reflects on innovation, and what role that we, as an AHSN, might play in helping others understand and embrace innovation.

Take a glance through the NHS Long Term Plan and the word ‘innovation’ appears time after time. Simon Stevens is accredited as saying, ‘the AHSNs are the innovation arm of the NHS.’

But what does innovation really mean here? And what is our role?

Reading up on innovation can lead you to stories like Edison’s 1000 tests to perfect the lightbulb or Dyson’s many thousands of bag-less vacuum cleaner prototypes. They are remarkable examples of persistence and resilience, but I don’t think it’s all about ‘lightbulb’ (or vacuum) invention moments.

My reading has helped me understand we are already innovating at the West of England AHSN. We have taken ideas from others, helped adapt and develop them for use in a different setting. Then we spread them. PReCePT, NEWS, the Emergency Department checklist are all examples of ideas taken from others and developed for a different setting. That is a powerful form of innovation.

Our pioneering of the use of Quality Improvement (QI) in healthcare is another form of innovation. We take ideas from other sectors (e.g. Toyota in the motor industry) and then adapt and use them to improve care in our own organisations. The ‘Godfathers’ of QI (Shewhart, Deming and Juran) didn’t work in healthcare, but we have adapted the approaches and the tools they used.

So, how can we encourage others to think and work more innovatively, more of the time?

A few minutes on Google and you can find lots of organisations who want to help you and a plethora of toolkits.  Many point to the fact that innovation is a state of mind, but using specific tools and techniques can help to develop new healthcare tools and procedures.

We have found ways to support individuals through our business support work and courses like our Health Innovation Programme (currently recruiting), but we will widen this support to everyone who wants to understand innovation and its role in healthcare.

I don’t think I am an innovator, but through my work here I’ve learnt a lot about innovation. What excites me is using my skills in project and programme management to help others that want to understand innovation and think and work innovatively. I work with talented individuals that can support any stage of innovation from the early stages of understanding a problem, through creative thinking, developing, testing and evaluating and implanting ideas.

What we are doing now to share this knowledge and expertise is developing a suite of courses, toolkits and online resources. These draw on our expertise, contacts, and the best external resources to support anyone wanting to understand innovation in healthcare. We are calling this the West of England Academy.

The West of England Academy will build on our successful work spreading Quality Improvement (QI) knowledge. We’ll work with our existing QI advocates and seek out new converts as well. We’re already running prototype courses and resources are currently being added to our website. The Academy offering will continue to grow throughout 2020. Perhaps you might explore and use our new online toolkit of resources or maybe I will see you at one of the many events we are planning to help spread the use of innovation and improvement tools and techniques. Or maybe you would like to discuss an idea you have.

Either way – do check out the West of England Academy