Why I believe in RESTORE2 training for all care home staff

Jacqui Croxford is a Care Home Manager with Darbyshire Care. In the summer of 2020 she completed our free online Train the Trainer programme for RESTORE2 and has been an advocate of this evidence-based tool ever since. In this blog, Jacqui explains why.

I have been a mental health nurse since 1996 and had the privilege of working in the NHS, community, ASC and abroad. I was a care assistant through my nurse training and a child carer. Prior to my current role managing a family run group of care and nursing homes, I was a CQC inspector for seven years.

I am always looking for the next thing out there to improve the quality of care we provide that has a positive impact on the people we care for and love.

It was during one of these afternoons googling, I came across the West of England AHSN’s RESTORE2 Train the Trainer Programme. A few weeks later in June 2020 on a hot, sunny afternoon we met Sandra and another lovely nurse virtually for our first RESTORE2 Train the Trainer virtual session. I think I signed up to about 20 and kept thinking I would be kicked off but no one ever noticed!

RESTORE2 is a no-brainer

Evidence-based research (NICE Guidance) indicated the use of RESTORE2 and NEWS2 could help services identify early deterioration in residents with COVID-19. To me this was a no-brainer, why would we not want to do this?

I made the decision with managers to train staff across the homes in this tool. I had no strategy, just me, a laptop and 200 staff. I did buy a projector. An hour’s training for all staff plus competency assessments did require persuasion. All teams were stretched and drained due to COVID and the guidance changing regularly, new PPE, new audits etc, I could hear the sighs of exasperation when managers and staff already felt so tired.

Hurdles to overcome

In some teams there was resistance to new ways of working. There were also other hurdles to overcome, for example staff access to IT to support virtual learning, space and distancing rules to support training large numbers of staff and the staff resources required to support competency checks. Explaining the purpose and potential benefits to people were key to staff involvement. Several staff undertook the Train the Trainer Programme.

Unfortunately, one home had an outbreak during the rollout. The NEWS scores were invaluable in helping staff identify early clinical deterioration, particularly the drop in oxygen levels some people experienced. The clinical observation checks supported care staff to escalate concerns quickly based on this evidence-based tool.

Backing up our gut instinct

We had about 75% of our residents affected in our outbreak and 90% of our staff – the only person left at the service at one point was the provider (non-clinical!) when my test came back positive.

When our gut instinct indicated people were not well, agency staff video called me and we did virtual observations with me guiding them through. As our regular staff returned to work I encouraged them to always take another staff member with them and teach them how to use it.

I absolutely, 100% believe in RESTORE2 for all staff, residential and nursing.

Most of our residents did not have a cough, often no temperature or a fluctuating temperature, but we knew they weren’t quite right.

Importance of clinical observations

The clinical observations showed people’s deterioration. We noticed people’s oxygen levels dropped, their pulse was higher, temperature spikes and they became more confused. The change in people was often so quick. We couldn’t always manage 15 minute observations as we had so many poorly people but we did our best.

When I was positive and couldn’t be in the service with them, I would join morning handover for a ‘virtual’ ward round.

We had a spreadsheet and discussed people’s NEWS scores. Those who were unwell with high scores were first. We colour coded them according to need. When we communicated with the surgery in advance of our daily ward round during the outbreak, we were able to tell them clinical observations, NEWS scores, any advance care plan and treatment escalation plan (TEP) information.

Communicating with external healthcare professionals

There were times we had to bypass the GP due to it being out-of-hours or the person being unwell very quickly. We had to be firm with external professionals that we were following an evidence-based tool and our escalation policy. If people were end of life, we stopped all observations and just gave comfort care.

I raised the training at my one-to-ones and every manager meeting, booked multiple sessions and carried my laptop around enticing staff to attend with goodies and a chance to put their feet up for an hour!

I chose staff to do the train the trainer programme who I knew would be passionate about taking on a new role and teaching others. I gave lots of positive feedback and thank-yous. If staff were isolating, well and on full pay I asked them to do the training.

When I also got COVID during the outbreak, I set up WhatsApp groups and shared the Health Education England short videos and bite size learning, used short YouTube videos to keep people it in people’s mind whilst I was not there. I added the training to our COVID audits, my staff supervisions and our service action plans. I was like a dog with a bone.

Learning from experience

However, there has been learning. The project and rollout was not complete when our one home had an outbreak. This resulted in large numbers of our core staff group being in isolation (over 90% were positive or isolating). The manager was also off sick. This delayed implementation. Not all staff had been competency tested.

Although our experience of this was largely positive, however on reflection, it seems that in view of the challenges experienced with the roll out, the staff could have benefitted from an extended period of practice with the tool in order to allow it to be fully embedded. Going forwards, we plan to adopt this strategy to enhance staff competence and confidence in RESTORE2 and its respective components.

I cannot say how much I would recommend investing in this training. Staff will feel upskilled, more competent and I truly believe our use of RESTORE2 saved lives.

Five questions to help you select the right digital solutions for remote monitoring during COVID-19

With the rise of COVID-19 and the need for increased home monitoring, in particular pulse oximetry, there is renewed interest in the role of digital in supporting this pathway.

Dr Shanil Mantri, GP and Clinical Digital Advisor to the West of England AHSN, shares his advice on what should to be considered when contemplating a digital solution.

With the current challenges of the COVID pandemic, the ability to monitor people remotely in their homes and in care homes has become an essential tool in detecting early signs of deterioration. Remote monitoring technologies have the potential to give clinicians (including GPs, community staff and hospital consultants) an up-to-date, more complete picture of a person’s health status, allowing better management and early detection of an acute illness. Use of these technologies can also promote more efficient, pro-active health care by directing health resources to the appropriate individuals.

Based on my own experience of introducing and supporting new digital technologies, here are what I believe are the key steps you need to work through.

1. What’s the pathway?

The most important first step in any digital programme is to decide what you are hoping to achieve. There is always a desire to be led by a digital product and fit the pathway around it. This can lead to potential gaps and compromises that may not be apparent until a programme is up and running. A clear pathway allows identification of what the requirement is for digital, which parts of the pathway are best suited to innovation, and what the requirements are.

The current pilots of COVID Oximetry @ Home do have a clear clinical pathway, which is helpful. However local systems need to decide on how and who will deliver the different elements, as this will have a bearing on a digital solution.

2. Which product (or products) best meets your pathway needs?

Once a pathway has been agreed the next step is to think through what type of digital product is required. Remote monitoring solutions currently being endorsed by NHSX can be split into three main categories with certain products being able to achieve one, two or all three:

  • Capture: Devices/services that collect information (such as oxygen saturation or a system that can capture clinical symptoms). This category spans the simple (a stand-alone pulse oximeter or paper forms to allow recording of symptoms) to the sophisticated (a Bluetooth pulse oximeter that automatically sends information to a patient’s clinical record or a smart phone app, which then transmits answers into an online dashboard). You should consider how frequently information needs to be captured. Certain systems can allow for continuous monitoring, but this requires engagement from the patient, for example would they tolerate walking around at home attached to a sensor? Others can automatically remind patients to take readings or give feedback on symptoms.
  • Communicate: Once information is captured how is this transmitted to the clinician? How does a clinician respond back to a patient, perhaps to ask for more information or to provide reassurance? The most straightforward solution in this category is the telephone. However, it can include SMS messages, web forms and smart phone apps.
  • Coordinate: With a number of patients on a virtual ‘ward’, how do clinicians organise the patient list? Can this list be seen by multiple professionals, perhaps on different sites? Can potential risk (based on readings / symptoms) be organised so that the most at risk are at the top? Can a system give a patient direct feedback without need for a clinician, perhaps if all parameters are normal?

3. Is the technology proven? Is it safe?

When rolling out a digital solution, consideration around clinical safety needs to be made locally. A company will take responsibility for the effectiveness of its product but ultimate clinical responsibility will be with the local system (clinical governance). When looking at a solution, you need to understand the underlying technology and whether it is proven. Is it being used for the same purpose in other parts of the country? Are there potential risks? For instance, if there is an automated system that ranks patients with COVID into different risk groups, how is this algorithm derived and has it been tested?

4. How does this product fit in with existing systems?

An understanding of your existing technology landscape is crucial in any new digital deployment. How will the new system interact with current IT systems? Is there an expectation that clinicians need to log into a different system (How easy will this be? What if they lose their login details? Might they forget to check?), or does all information flow into an existing patient record?

5. Who could be missed by a digital solution?

When rolling out a new solution, alternatives need to be considered. For instance, having a smart phone app as the only way to interact could exclude the less technology literate (including those without a smart phone or tablet), people with learning difficulties, those with a visual impairment or a patient for whom English is not their first language.

Going through the above will hopefully focus your mind on the thought process around a digital product roll out. It is easy to be seduced by technology and the latest gadgets. The importance of being clear about the pathway and what you want a digital solution to do cannot be overstated. Don’t just assume that a complex digital solution is the answer, as sometimes the simplest technology (pen, paper and telephone) can be all that is required.

Find out more

You’ll find more information about COVID Oximetry @ Home and the support available from the West of England AHSN on our website here, or email Nathalie Delaney at nathalie.delaney@weahsn.net.

And read more about our support for the NHSX-led remote monitoring programme across the South West on our website here.

COVID-19: a common purpose

Covid blog badgeIn the first of our series looking at how healthcare is changing to manage COVID-19, our Chief Executive Natasha Swinscoe considers the factors that helped those on the front-line respond quickly and effectively.

There has already been a lot written on the lessons learned from dealing with the pandemic. Many have commented on the positive impact of the sudden removal of barriers they previously experienced. It feels that during the last four months, clinicians have been empowered to make decisions closer to the action, with more licence to just get on with things.

This was certainly the message Secretary of State for Health Matt Hancock gave in his address to the Royal College of Physicians’ Future of Healthcare event in July. He was reflecting on what he’d witnessed during COVID-19, and espoused the benefits of unshackling health and care staff from the ‘barnacles of bureaucracy’. Coupled with doubling down on tech solutions, this speaks to the innovation world of the Academic Health Science Networks (AHSNs).

Here at the West of England AHSN, we have been supporting our local systems since the beginning of COVID-19, as the initial response to the pandemic was forming. We were able to ‘swivel on a sixpence’, pausing many of our existing programmes and creating new, COVID-specific offers to our systems for immediate delivery. Like everyone else, we also felt empowered to just get on with the job in hand.

Four months on, we are taking stock and trying to distil what we’ve learnt from our experience, to identify what we want to keep doing, but also what worked less well. We surveyed our teams locally and many of the answers will probably resonate with what you’ve already read about in other research: faster decision-making, flatter hierarchies, more collaboration between organisations, the massive uptake of remote working platforms, and the power of coalescing around one single common issue that focuses people’s minds and energies: a shared purpose trumps all.

Not all of this is new or specific to COVID, but it certainly underscores its importance. At the West of England AHSN, we often call this the ‘call to action’ phase, or winning hearts and minds. In the past this phase might have taken more time and was generally achieved through face-to-face contact and workshops. In the last few months though, we’ve launched our new PERIPrem bundle virtually and despite the circumstances, it has been very well received. Senior Project Manager Noshin Menzies shares her experiences of how it went in this blog post.

We’ve also seen the power of unlocking people’s potential to make decisions and activate great ideas, and Twitter has been a great way to share those ideas. Early on in the pandemic, the suggestions to help patients to see who you really are when in full PPE were fantastic examples of people spotting a problem, solving it and sharing it rapidly so others can do the same.

We’ve seen that if you give good people a good reason to do something and the tools to do it, they can respond at an amazing speed. A large number of our AHSN colleagues joined a blended team for three months to roll out digital triage and monitoring platforms across primary care. By putting more ‘boots on the ground’ (figuratively as we did it via Microsoft Teams!) we achieved in three months what might otherwise have taken years.

We’ve also met many new people during this phase, expanding our networks across the West of England, the South West and further afield. The relationship and trust we’ve built with industry and the commercial sector particularly has improved as they have came to the aid of the NHS. I hope this open-borders approach remains, as we have so much to learn from each other.

So, going forwards there are key things we want to retain, and in our Covid-19 blog series, some of my colleagues at the West of England AHSN discuss these further:

  • Working across systems with multiple partners and the blending our resources, irrespective of organisational boundaries, was a key element of the work we undertook with care homes. This work is ongoing and is discussed in more detail by Kevin Hunter, Associate Director for Patient Safety & Programme Delivery. Read it here.
  • Collaboration is key and this really works when focussed around common aims. Director of Service and System Transformation Kay Haughton explains more about our offer to help spread a stratification tool to support shielded patients with long-term conditions. Read it here.
  • Deputy Director of Innovation and Growth Alex Leach reflects on the huge opportunities and risks that Covid-19 has presented to innovators. Read it here.
  • Releasing the power of teams to solve problems is something Janina Cross, our Chief Digital Transformation Officer, has first-hand experience of working with three AHSNs, the NHS SW regional team and seven STPs to support the digitisation of primary care.
  • And Senior Programme Manager Jo Bangoura will be reflecting on the importance of working in a structured way with our systems to capture the learning from COVID-19.

Call the midwife: an AHSN special

Ann Remmers, our Maternal and Neonatal Clinical Lead, looks back at a lifelong career in midwifery from bell bottoms to bed baths…

Celebrating the 70th birthday of the NHS in 2018 has led to me to reflect on my career in the NHS as it has done for so many people.

Thinking back to my first day in the NHS as a student nurse at Guy’s Hospital, it is hard to believe that I was an 18-year-old, fresh from school, setting out on a career that would span from the 70s to today.

Then the fashion was bell bottoms, hot pants and tank tops. Now it’s… Well, maybe it hasn’t changed that much!  If I had followed the family tradition set by my three brothers, I would have become a professional drummer. I am still curious to know whether drumming is in the genes and once I am fully retired I might try my hand…

I still clearly remember my first day in PTS – Preliminary Training School. I felt so proud to be there. (We weren’t considered safe to go on the wards until we had completed our six weeks’ PTS). The Director of Nursing told me she really wanted to make a Guys nurse of me.

There were two other things I remember her telling us on that day. Guy’s Hospital is near London Bridge and in those days it wasn’t the trendy, thriving area it is now. There was no Borough Market as we know it now; there were some fruit and vegetable stalls and a few pubs but it wasn’t the sort of area you would hang around in for long at night. She was very proud of the area we worked in and of her nurses. She told us, if we went to the market stalls in our uniforms we would be rewarded with a free bag of fruit because Guy’s nurses were so well respected and we didn’t even know about five-a-day then!

The second piece of advice I remember her giving us was that it was impossible to catch venereal disease from sitting on a toilet and that we should sit comfortably on any toilet seat confident that it was safe to do so. It sounds crazy now but truly there was a view at the time that it was possible to catch a sexually transmitted disease in this way. Wow, we all thought – too much more to learn about life!

Our six weeks’ PTS was filled with learning on how to care for patients before we were let loose on the wards. It was such a lot of fun and I made lifelong friends in that time. We learnt how to make a patient feel comfortable during long periods when they would be bedbound. I particularly remember the class on how to wash a patient’s hair in bed. It was pretty hilarious, with many near misses like the removal of bed heads almost rendering a colleague unconscious. But we did learn how to provide basic nursing care in a way that I have never forgotten.

We all lived in the nurse’s home at that time and, as it was the first time we had been away from home, there was much excitement about having a degree of freedom. Of course there were strict rules about having visitors to your room after 10 pm!

On night duty we took our breaks in the changing rooms on the ward and often used this time to support each other and share our experiences. As student nurses we had a lot of responsibility, especially on night duty when as a second and third year student we were often in charge of the ward. This was both exciting and terrifying! We really needed the support of each other to keep us going.

The most memorable Christmas Day was as a staff nurse on a medical ward. Once the patients had all been given their dinner, the table was set down the centre of the ward and the consultant carved the turkey. It does sound a bit Nonnatus House à la Call the Midwife, and at times I suppose it was. It did feel very much as though we were a family and it was great for team building.

After completing six months working as a staff nurse on a male medical ward, I decided to do my midwifery training in Bristol. It was very common at the time to undertake the one year midwifery course once we had qualified as a nurse.

Following a two-month break to travel around Canada and the USA, I moved from London to Bristol. I have to admit that when I first started my midwifery training it was a bit of a shock. After all the responsibility of running a medical ward, to be asked if I knew how to do a blood pressure…

To be honest I wasn’t sure if I liked midwifery in the beginning. Some of the midwives were positively scary! It was not until I was qualified as a midwife and had my own autonomy that I started to love it. This was the 1970s and some of the practice then was definitely not woman-centred. We have come a long way since those days when it was routine to do perineal shaves and give enemas when women went into labour. And if you came out of a room having admitted and examined a woman, you would be questioned as to why you had not artificially ruptured her membranes, and started electronic foetal heart monitoring.

It all sounds a bit horrific now and it is thanks to years of campaigning from women and passionate midwives that things have changed to the degree that they have.

I remember one particular busy night when I was a newly qualified midwife being asked to go out on the ‘Flying Squad’. This was the obstetric emergency team that could be called to deal with problems at home births or in one of the maternity homes. The team consisted of the on call obstetric registrar, a midwife and an anaesthetist from the maternity unit. We did not exactly fly but were taken in the Blood Transfusion car. We had to pick up the kit first and then the registrar and anaesthetist.

This particular night the call was to a woman at home who was giving birth to twins. By the time we arrived, the twins were born and were both healthy. I remember feeling quite elated – it was quite an adventure – only to be brought back down to earth when we got back to the hospital and told to go to the sluice and clean the scalp electrodes before going off duty. I was expecting a pat on the back or at least a thank you! That stuck with me and I vowed if I did stay in midwifery and got into a senior position I would always make sure that my staff felt valued.

Although we still need to be reminded to ensure that women are at the centre of their care, the Better Births Maternity Transformation programme has certainly put the focus on safe and personal care for women. We are also reminded about the importance of kindness to each other and to the women and families that we care for. If it had not been for the midwives who I saw displaying this kindness to others I don’t think I would have stayed in the profession.

I recently heard Suzette Woodward speak at the annual Royal College of Midwives conference about the importance of kindness and how it has a positive effect on safety, which really struck a chord with me. I think the time I enjoyed most was when, working as a community midwife, getting to know women and their families, being there to care for them in labour was always a bonus, and then to visit them at home after they had had their baby was joyous.

Continuity of carer is one of the recommendations of Better Births and is both an opportunity and a challenge for midwives. Providing continuity for women and ensuring midwives are able to have work life balance is key to achieving the right balance.

I have been very fortunate to have a lifelong career in midwifery; it has at times been stressful, tiring, joyful, demanding and rewarding.

My hope is that midwives in the future will be able to have the same positive experience that I have had and will be supported and cared for to enable them to in turn support and care for women.



How to achieve a successful working relationship with public contributors

As with any member of our team, public contributors need to be properly valued and respected for the role they play in shaping and delivering our work, and need to be effectively managed. Here Hildegard Dumper draws on her professional experience to share her tips on how to achieve a successful working relationship with public contributors.

Here at the West of England AHSN we work with a wonderful group of individuals we call public contributors (also known as lay representatives, experts by experience and patient reps). Selected from people who have expressed an interest in our work with the regional healthcare community, their role is to provide the much valued voice of a critical friend, asking the questions that need to be asked and reflecting back to us things we hadn’t thought of.

The whole system works well but we have learnt that this is dependent on some essential ingredients.

Because of our experience in this area, I occasionally get asked by colleagues from other organisations to mediate between themselves and their public contributors when there has been a breakdown in the relationship. Over time, some common themes have emerged, which I thought I would share in case others find these insights useful.

I’ve chosen to illustrate these themes in the form of a story; a composite drawn from real events with names and identifiable features changed.

Pamela contributes as a member of the public to a project looking to improve health services for people with chronic obstructive pulmonary disease (COPD). She was invited to join the project after attending a public meeting to hear the views of users of existing services and their families. Pamela’s husband had recently died of a COPD related condition and she was keen to contribute her ideas based on her experience of caring for him through his illness.

The meeting was held one morning in a community hall near to where Pamela lives. There were about six people or so there who, like Pamela, were retired. The facilitator seemed unused to running such a group. There were no refreshments and no introductions, so Pamela found the meeting quite awkward. However, she is a retired teacher and very confident in social situations. This is perhaps why, at the end of the meeting, she was invited to join the project steering group.

Pamela was very excited to be on the steering group as she had lots of ideas about how things could be improved. At her first meeting, the project manager greeted her and invited her to join the others seated round a table. Several were engrossed in their laptops and the others avoided eye contact when she approached. The project manager was chairing and started the meeting assuming everyone knew each other. Pamela didn’t know anyone and felt at a disadvantage. In spite of her natural confidence, she didn’t want to create a fuss at her first meeting so didn’t say anything.

The meeting was conducted in a very formal way. The language used was undecipherable for ‘outsiders’, with lots of acronyms and specialist terms. Added to which, the people around the table continued to avoid eye contact or display any other encouraging body language. When Pamela said anything most people looked down at their papers and laptops, so she had no idea whether her comments made sense or not.

At the end of the meeting everyone rushed off. The project manager thanked her for coming and told her she would be receiving details of the next meeting.

The whole experience left Pamela feeling completely disempowered.

The meetings were held monthly and though Pamela had struggled with that first meeting, she told herself to persevere and that it could only get better. During the course of one meeting, Pamela volunteered to help out at the COPD stall being held at a health fair. Her offer was accepted enthusiastically as they were short staffed and didn’t have enough people to cover the stall for the whole day.

All the slights she felt she had received through her involvement in the project rose in her mind: the rude way she had been treated by not being introduced to other members of the project team; the lack of eye contact or welcoming smiles; the lack of reassurance that her views were valued, either through simple body language or spoken affirmations, all built up into a rage.

While at the stall, she got talking to some public contributors who were involved in projects elsewhere. She learnt that they were getting paid for their time on the stall as well as receiving travel expenses. She was surprised to hear this. No one had talked to her about claiming for travel expenses, let alone for her time.

As she started to think about this, she began to feel angry. All the slights she felt she had received through her involvement in the project rose in her mind: the rude way she had been treated by not being introduced to other members of the project team; the lack of eye contact or welcoming smiles; the lack of reassurance that her views were valued, either through simple body language or spoken affirmations, all built up into a rage.

 At the next meeting, she asked the project manager whether she could claim expenses for travel and her time on the stall, pointing out she had given a lot of her time to the project already. The manager looked horrified. “We don’t have a budget for this,” she explained. Pamela lost her temper. She stormed out and threatened to complain to the Chief Executive, her MP and others. The project manager told her line manager about this, who then asked me to help.

In disputes such as this, it is possible to see both sides. On one hand there is the hurt Pamela experienced, at being treated in such an excluding way. On the other side, overstretched health professionals are being asked to involve patients and the public in their work without any proper resources, training or guidance.

We identified two key areas for change going forward:

Put in place a role description spelling out the required time commitment and payment being offered

One of the first things I asked when I met with the project manager was whether there was a role description. This is essential for the smooth management of public contributors. It states the requirements of the role, the time commitments expected and the payments available. Any changes to this would have to be negotiated. So, for example, any extra activities or duties, whether initiated by a member of staff or by the public contributor, would be discussed and negotiated against the role description.

When Pamela volunteered to help with the stall, a role description would have made it easier for the project manager to discuss with Pamela whether she was prepared to do it in a voluntary capacity.

Make meetings feel welcoming and inclusive to all

Sometimes it feels like a revolution is required to change the way many meetings are conducted in the health sector. I sometimes fantasise about what it would be like if all meetings, from board meetings to team catch-ups, began with an ice-breaker, and whether this would help create the cultural change we are trying to achieve. But that feels like a pipedream. Instead, let’s aim for everyone to be treated with respect and courtesy, some human warmth and a more creative environment for the exchange of ideas.

In this case, the project manager put in place a ‘no jargon or acronym’ ruling for the meetings and reminded everyone that no question was too stupid to ask. She also introduced a less formal structure to the meetings, allowing space for the exchange of ideas, which gave Pamela the space to contribute.

Together, we managed to come to an understanding. The project manager found some funds to pay Pamela’s expenses and a role description was drawn up.

After a year, Pamela is still with the group. Her role is regularly reviewed and amended as the needs of the group changes. As a result of her contribution, the patient experience feedback for the service is now extremely positive, with the service regularly reaching their targets. In addition, she has been asked to participate as a public contributor in the respiratory steering group of the Sustainability Transformation Partnership (STP).

Getting involved in the group has lessened Pamela’s grief at losing her husband and she no longer feels so lonely. She once told me: “I never expected new doors to open for me at this stage of my life.”

The industrial strategy, right on man!

The government’s green paper on Building our Industrial Strategy was published in January. Our enterprise director, Lars Sundstrom says it’s about time…

Last month the government published its long awaited industrial strategy. “Frankly, my dear, I don’t give a darn,” I hear you say. Well, you should. When I read it, I thought to myself, “Finally. They’ve actually got it right this time. Absolutely spot on,” as you Brits would say!

The UK lags far behind other European countries like France and Germany in terms productivity, a trend which is now worsening quite rapidly.  So while our French neighbours enjoy a glass of wine having finished work while we are still toiling away with the longest working hours in Europe for lower output (and hence less money to buy decent French wine), one has to ask, what makes them so much smarter than us?

The science base in the UK is the best in the world. The UK, per capita, has the strongest academic sector by far, especially in terms of scientific output. It outperform its nearest rival the (United Stated) by almost three to one. In other words, the papers written by British boffins are more highly cited than anyone else. The UK has six universities ranked in the top 50, with three in the top 10 (Oxford holding the coveted number one spot), while Germany has only one and France has none.

So although the UK has the best science, its ability to translate that into economic growth seems to be lacking.

Some years before I joined the West of England AHSN I worked in biotechnology and spent a considerable amount of time in South San Francisco, which is where this new industry was born – only around 30 years ago. Biotechnology grew out of genetic engineering and cell biology, both of which owe their foundations to British scientific genius. Yet I remember, as I used to drive down Highway 101 in my open top Mustang, just how many British scientists I met who had brought their technology with them to develop it over there, and how frustrated they were that they couldn’t do that back home.

The industrial strategy is seeking to redress this and it has done two things that, in my view, are absolutely right on:

1) Invest heavily in translational science and infrastructure for applied research, and reward those that do it;

2) Not doing it at the expense of basic science but maintaining fundamental research budgets.

The secret to France and Germany’s comparative success in productivity is their ability to provide the right incentives and infrastructure for applied research and product development/testing, as well as a well-developed industry-university interface. In particular, success comes from the valorisation of people who want to do applied and industrial research and who are not considered inferior to university academics, far from it. The pinnacle is to work for a top company: Vorsprung durch Technik!

I am really pleased to see the recognition in the strategy that AHSNs will play an important role acting as catalysts for the conversion of innovation into new healthcare products and services through our involvement with the SBRI Healthcare programmes, test beds and the new accelerated access partnerships and innovation exchanges.

So I for one welcome this strategy. The government is absolutely on the right track, but it’s going to take a long time; in Germany it took over 25 years of continuous investment. But just imagine what the UK would be like now if that investment had been made 20-30 years ago and the UK had been the home of biotechnology!

Britain started it all with the first industrial revolution, it largely missed the second and third through lack of investment but. as we now enter the dawn of the fourth industrial revolution, it looks to me like the UK is now on the right track. See here if you are wondering what the fourth revolution is about.

California’s GDP is now around $2.5 trillion just behind the UK at $2.8 trillion, with biotech contributing about $200 billion, so I have to say thank you Britain for sending over all your scientists and the huge role you have played in building our local economy – I was born in California in case you hadn’t guessed. We will never forget what you’ve done for us, and have a nice day!

Read the NHS Confederation’s briefing on the Industrial Strategy.

We can and we should adopt NEWS

Steven West, Chair of the West of England AHSN and Vice-Chancellor of the University of the West of England, explores how we can come together to create solutions that are sustainable, affordable and acceptable to all NHS stakeholders?

Our NHS and social care system are one of the country’s greatest assets. They are a fantastic gift that we give to each other and one that is envied across the globe.

However, the world is changing and the need for us to continue to review, reset and reinvent our health and social care system has never been greater. The demands we are placing on it are huge and it is beginning to fail.

Whilst this is, in part, a reflection of us all living longer and increased potential through new technologies and new drugs to diagnose and treat more and more conditions and diseases, we have to face up to the challenges that this brings. More people are accessing services and there is often greater demand than we are currently able to meet.

The creation of Academic Health Science Networks by NHS England back in 2013 was an attempt to create partnerships to help us to better collaborate, innovate, disseminate and spread learning and best practice. It was done at a critical time as much of the infrastructure that had formerly been in place to facilitate this kind of learning and sharing had been dismantled in successive reorganisations. The uncomfortable truth was that the system had become fragmented, staff and expertise had been lost, resulting in us facing significant financial, social and staffing challenges.

Recent media reports have highlighted yet again just how fragile our health and social care eco-system is. It is difficult to ignore the reports when so many dedicated staff who have committed their whole lives to the service are signalling we have a problem. For those of us in the system it is heart-breaking to watch. We are working hard yet no matter how hard we try we are not gaining enough ground.

This is made worse when you listen to reports that seek to apportion blame in one direction or another. We are one NHS. The problems we face are not just about the funding – it is also about the structures, the interfaces, the mechanisms for collaboration, and the relationship between the government, the professionals and importantly the citizens. We all have a stake in this and it is important that we seek a collective solution to create the integrated and joined-up services that are required 365 days a year, 24 hours a day.

So how can we help, how can we get beyond the current ‘blame, denial and shouting’ culture that is so evident at the moment? How do we come together to really create solutions that are sustainable, affordable and acceptable to all the stakeholders? One of the answers is to look at what currently works. Where have we cracked some of this and can learn and spread this knowledge?

The West of England Academic Health Science Network (AHSN) is one of 15 AHSNs across England that has been innovating and spreading best practice. Each AHSN will have examples of best practice and innovation that have improved services locally. Our challenge now is spreading these beyond our local geography and partnerships.

Recently I read with sadness and frustration reports of critically ill patients dying on trolleys in over-crowded Emergency Departments. Sadly this is not new. But there are things we can, and have done, that is reducing the risks and has even eliminated the problem in some of our hospitals.

I want to shout about the National Early Warning Score (NEWS), which the West of England AHSN is supporting all our healthcare providers in the region to adopt and spread.

I urge our political and clinical leaders to stop arguing and blaming each other, and to wake up and work with us to spread this approach to every Emergency Department, every Ambulance Service, and every Community and Primary Care setting across the country. No more ‘lost’ critically ill patients need to die on trolleys for lack of basic care.

In the Emergency Departments in the West of England we now use NEWS alongside an Emergency Department safety checklist which should be universally adopted too.

This means care can be monitored across every handover throughout the system. This will ensure time is not wasted, and instead we are saving lives.

We have saved lives! We have a sound evidence base, training materials, toolkits and are happy to share and spread. Let’s not waste time and see more patients die needlessly. We can and we should adopt this approach and show we can spread best practice quickly, efficiently and safely.

Yes we can, yes we should, yes we have!


Thinking outside the STP box

Our Patient and Public Involvement Manager, Hildegard Dumper looks back to our annual conference and the delights of playing Partneropoly…

If you happened to be walking through the corridors of the Swindon Hilton back in October, might have been surprised to find yourself in a room of shoeless health professionals screeching at each other in competitive excitement. You’d have seen the entire floor covered by a vast colourful quilt, which, when your eyes adjusted you would have recognised as rather like a Monopoly board.

This was the Partneropoly workshop at the West of England AHSN’s annual conference, which was given over to the theme of Sustainability and Transformation Partnerships (STPs) and brought together all those involved in delivering the three STPs in our area (Gloucestershire; Bristol, North Somerset & South Gloucestershire; and Bath, Swindon & Wiltshire).

The Partneropoly workshop was an interactive approach to getting the different stakeholders in the STPs to think ‘outside the box’ and see how they could share resources and expertise to make their plans more effective. Inspired by that well-known game Monopoly, Partneropoly was the brilliant brain child of Jan Cobbett at Bristol Health Partners, originally designed to encourage their Health Integration Teams to work more collaboratively across their ‘silos’.

In our workshops, we divided participants into teams based on their STP footprint. Each team could be made up of any combination of people from all kinds of organisations: commissioning, trusts, public contributors, industry, education, and voluntary sector. Just like in the traditional game, teams got to choose their playing piece – there was a boot, iron, top hat, car and so on – the only difference being these were huge! They threw the two massive dice and picked up their boot, iron, car or whatever and physically walked it around the board. Instead of landing on real estate like Mayfair, Oxford Street and the like, our teams landed on a possible partner organisation. This could be the AHSN, your local trust, clinical commission group, housing, police, education or just about any other potential partner. On picking a Chance card they’d be asked to think through how their STP might work with that specific stakeholder organisation on a specific area of work, such as equalities, patient safety or making better use of estates or workforce development.

I was fascinated to observe individuals being made to leap (in stockinged feet) well out of their comfort zone and interact with people they would not normally have reason to talk to. Then to top it all, they were actually having to listen to each other. I watched one group being dominated by two commissioners who were assuming they had to have all the answers. Eventually the penny dropped when they realised they had a valuable resource in their voluntary sector team member.

Afterwards, several people said it made them realise that there is a wide range of organisations out there that might play a meaningful role in delivering the vision of our STPs. Someone from a large trust told me they really had no idea there were so many organisations that could be working with. Those from industry said it had helped them understand what STPs are all about and how they could work more effectively with the health sector.

We are planning to use the game as a tool to get people from all disciplines interacting with each other. One of its next ‘outings’ will be with our Patient and Public Leads in the region to see how it can be of benefit to them.


Why the AHSN is like a honeycomb helmet

In follow up to her last cycling-meets-leadership blog post, Deborah Evans reflects on the beauty of a new cycling innovation and draws comparisons with how we work here at the West of England AHSN…

Talking of cycling, I was fascinated to read an interview with a woman who had invented a cycling helmet made of paper. In a classic case of design mimicking nature, it used a honeycomb structure.

I’m not sure whether I’ll wear one until someone else has tested it (not just a dummy) and definitely not until it’s been waterproofed.

But I’m enthusiastic about the concept nonetheless, because like cycling itself, paper is very eco-friendly and makes for happiness.

It made me reflect on the similarities and differences with the innovation processes we use here in the AHSN.

Firstly, it’s a great example of ‘innovation pull’.  In this case the unmet need was a lack of helmets to go with the ‘Boris bikes’ which we can pick up on the streets of London and ride at will.

Our equivalent in the AHSN is that we ask clinicians what problems they would like to solve. Sometimes we work with them to identify innovations that are already on the market, having been tested and are ready for use. And sometimes we issue challenges for innovations that are still in the developmental stage. Our favourite, perhaps, is the Small Business Research Initiative (known as SBRI) which is nationally funded. Our latest initiative in this programme was called General Practice of the Future and we called for innovations responding to demand management in primary care; self care and diagnostics and earlier triage.

Another similarity is that we like to invite people who use services to help us design innovative products and services – such as our crowd sourcing project Design Together, Live Better, which in its first phase famously resulted in a prototype child  car seat which you can fasten with one hand.

As far as I could tell from the newspaper article, the honeycomb helmet results from the inspiration of a lone inventor, and we have plenty of those in health – especially clinicians. But Lars Sundstrom, our Director of Enterprise and my innovation muse, tells me that the future for innovation is largely about collaboration and open source activity. This seems to be most effective (many minds are better than one) and quicker. This is a feature of our Diabetes Digital Coach test bed project, where we have a hearty collaboration between a number of small and larger companies and the support of Diabetes UK to create an online service hosting a range of digital self management tools for people with diabetes.

Another reason to love the honeycomb helmet of course is that it’s cheap, and surely that’s what the NHS needs. Effective, cheap and recyclable innovations.

Get folding that paper!

Photo: EcoHelmet.com

How evidence-informed health can tackle the supply and demand gap

In this blog post, first published in the HSJ, Peter Brindle spells out three ingredients which can ensure that evidence – with all its money-saving potential – is incorporated into NHS practice…

The NHS should stand out as the most evidence-informed health system in the world. The worsening mismatch between the demand on the NHS and its resources of cash and staff mean we can’t afford not to have an evidence-informed approach to our health and care system.

This means making a deliberate and conscious effort to routinely look for and use the best available evidence before spending scarce resources on a new model of care or technology. And when the evidence is incomplete, which is most of the time, we need to commit to creating evidence through evaluating the change.

Having an evidence-informed approach makes sense. From a range of possible service designs, interventions or innovations, we will get better outcomes from those that have evidence of effectiveness compared to those that do not. Better outcomes mean spending less on the consequences of poor ones. Also having the evidence to hand makes it easier to defend stopping doing things that don’t work or that harm people.

“It is still not easy to create a truly evidence-informed system. One of the most potent reasons is the culture gap between the evidence producers and evidence users”

So how do we get the evidence informed approach into practice? The tens of thousands of NHS staff who have some management responsibility are the crucial link between the evidence and the beneficiaries – patients and the public. But while many people know this is the right approach, they find it hard to do. This we have to change and make the right way the easy way. Let’s consider three ingredients to making this happen:

Hardwire into the processes of normal business

Let’s get the paperwork right and make sure that business cases and priority-setting templates have sections asking about a balanced evidence appraisal and how the proposals are to be evaluated – and with what resource? Service specifications also need to be clear from the outset that potential providers must demonstrate an evidence-informed approach. Signing up to these 10 statements to improve decision-making in the commissioning of health services would be an excellent start.

Engage the right people

Leaders should understand that not following an evidence-informed approach is unaffordable and risky. They need to expect the same from their teams, creating the culture that working in an evidence-informed way is everybody’s business.

But even with good leadership and willing teams, it is still not easy to create a truly evidence-informed system. There are many reasons for this, but perhaps one of the most potent is the culture gap between the evidence producers – primarily researchers – and the evidence users who commission and provide services. Researchers might be seen as being out of touch with current service priorities and pressures, and those working in the service are sometimes seen by researchers as having a disregard for their evidence.

There is also reluctance from those on the service side to take responsibility for creating their own evidence through a routine approach to service evaluation – they cannot always expect researchers and academia to produce the kind of evidence they need.

One way of tackling these issues is having people and teams who have a specific role in promoting better evidenced services and more impactful research and who can successfully cross the boundary between the service and research worlds. Some of the approaches we are using in the West of England include:

Health integration teams, which bring together patients, commissioners, providers, researchers and clinicians to tackle specific service related issues and in some cases become the main governance structure for a particular service area.

GP clinical evidence fellows are GPs seconded for one or two sessions per week into CCG leadership position to champion the use of evidence, conduct evidence appraisals and support an evidence informed business planning process. A similar programme has recently been launched in the North West of England.

NHS management fellows are commissioners who are seconded into a university research team and their colleagues, Researchers in Residence, are the reverse – researchers seconded to a CCG commissioning team. Their role is to act as translators between the academic and service environment, bringing their skills and knowledge from one environment to the other, identifying NHS-relevant research questions and promoting the co-production of high impact research.


Despite having the right leadership and organisational processes guiding staff to work in an evidence-informed way, knowledge and skills are still needed to make the right way the easy way. Training workshops based on practical toolkits can give the confidence to get started and signpost to existing but often under-used resources such as the library and knowledge services, public health, commissioning support units and regional CLAHRCs (Collaboration for Leadership in Applied Health Research and Care).

The challenge

In a world of crushing timelines and the need for in-year savings, how do organisations create the financial and strategic space to develop an evidence informed approach – one that offers few quick fixes but longer term benefits? But then that’s the point: The less money and time there is, the greater the need for a culture that reduces the waste from initiating or continuing ineffective and harmful services and products.

By using just a tiny proportion of the health and care spend in a better evidenced and evaluated way, it would save millions. Now more than ever, there is too much at stake in the NHS to take anything other than an evidence-informed approach. We can’t afford not to.