Breaking down our habitual silos in primary care

Collaboration is an often used word in healthcare and conjures up happy images of us healthcare professionals working jointly with our colleagues within practices, but also across healthcare settings as a joint endeavour to improve the care we deliver our patients.

The reality is probably greyer. However, working as a ‘coal face’ GP, through my involvement with Gloucestershire Clinical Commissioning Group (CCG), the Sign up to Safety campaign (SU2S) and working for the West of England AHSN, the concept of collaboration is a ‘no brainier’.

How else do health systems provide safer patient care across multiple settings and between many different professions? In addition ‘the patient’ is rapidly becoming a more informed and sophisticated service user, who, through the Internet has access to limitless information which is equalising the traditional power differential between professional and patient. In my view this is to be welcomed, but does pose challenges.

For one, more doctor training is about tasks and science and less about people. At times there can seem to be so many ‘sharp edges’ between us professionals where we focus on our differences and this can hinder collaboration which perhaps does require more oblique interactions. This is nothing new as the 1787 painting ‘Doctors differ and their patients die’ testifies. When I think back to medical school, perhaps I would have got more out of studying Dale Carnegie’s ‘How to win friends and influence people’ rather than rote learning Krebs Citric Acid Cycle.

For me collaboration is a mind-set as much as a collection of behaviors and for which the front line is not well trained in. It is about finding common solutions to our shared challenges and using the strengths of patients, carers and professionals across settings to improve the safety of care we deliver.

In my opinion the current system of competition and fragmentation in our local system can, at times, feel like a zero sum game. Different payment mechanisms for different care settings and professions are incongruent with collaborative healthcare. It can allow us to agree to disagree and encourages unwarranted variation which can then affect the quality of healthcare we deliver. An aligned, patient outcome focused payment system, as proposed by Michael Porter in his paper on ‘What is Value in Healthcare’,  would certainly provide an enabler in the quest for a safety culture based on collaboration. In practice the new Accountable Care Organisation’s proposed in the Five Year Forward View should facilitate collaboration.

Our current management of sepsis across the system provides a useful example. If a patient has suspected sepsis then a one hour care regime (called the Sepsis 6 care bundle) is instigated as soon as that person arrives in the hospital. However, the admission of many older people can involve an element of sepsis and these people might remain in the community for many hours before being seen for lack of GP visit prioritisation and coordinated ambulance response. From a patient safety and commissioning point of view a collaborative approach between care settings and professions would allow for a more joined up and timely response that would improve patient morbidity and mortality.

When I’m back on the coal face, I can see why collaboration is sometimes hard. I often only think about the patient I am seeing in front of me and in the setting in which I am seeing them. The Sign up to Safety campaign and my wider roles have helped me to reflect on the aggregation of all the single decisions I make and to see the consequences of those in terms of patient safety not just on the single patient but also on the whole population.

Our practice has the same ups and downs as all practices and there can be a tension between, on the one hand, everyone agreeing to disagree and doing things differently and ‘group think’ where people don’t adequately think things through in their quest to agree. It is important to hear all views and concerns, but it is equally important to start with a problem solving and collaborative mind set, and then to all agree to implement in the same way. My work for the Gloucestershire Clinical Commissioning Group has made me acutely aware of how, across the system, we can all work in silos and thus see patient care only from our unique perspective. How we communicate with each other is vitally important in overcoming this tendency.

From my perspective collaboration is about moving away from individual ways of working and developing effective teams particularly on the front line. Some of the dysfunction that can arise in teams is due to an absence of trust which can lead people to conceal their weaknesses and mistakes from each other whilst hesitating to provide constructive feedback. There is a fear of conflict and this can create an environment where politics and personal attacks thrive, and waste time and energy.

For me collaboration is more about the journey than a destination. Through the experience gained via my various roles and also our practice’s involvement with Sign up to Safety I have noticed that when we are working collaboratively as a team, we do 5 things well:

  1. We have a team mission with planning and goal setting which allows colleagues to gain clarity around the reasons for needing to change.
  2. Team roles are clarified so colleagues understand what is expected of them and where their accountability lies.
  3. Our team has a collaborative operating process, which, at its heart has effective teamwork
  4. We are aware of our teams’ interpersonal relationships and we actively encourage team members to engage with and support each other with open communication and a willingness to share information.
  5. We are also aware of our inter-team relationships and our impact of our work on other teams across the health system.

‘Signing up to Safety’ has given us a much needed impetus to think differently about safety. I would urge all GP surgeries to actively consider how they might better influence their health system to be more collaborative, as this would help turn our attention away from organisational silos and towards the most important people, our shared patients.

This blog post was first published on the Sign up to Safety website on 11 April 2016.

Recent highlights of our work together

The West of England AHSN continues to be recognised for successfully bringing together healthcare, industry and academic partners across the region – but what are we are actually achieving together? Here are a few highlights from the last quarter, October to December 2015…

Patient safety

  • 10,000 people have benefitted from the emergency department safety checklist so far this last year, which has been piloted by University Hospitals Bristol NHS Foundation Trust. We are now supporting four other EDs to implement the checklist: Weston Area Health NHS Trust, North Bristol NHS Trust, Gloucestershire Hospitals NHS Foundation Trust, and Great Western Hospitals NHS Foundation Trust.
  • The two Bristol Trusts have successfully converted from the Bristol Early Warning Score to the National Early Warning Score (NEWS).
  • A great example of collaborative working: 80 delegates from across the South of England attended our Mental Health Collaborative learning event in December.
  • The Emergency Laparotomy Collaborative is live including all six acute trusts. This work will benefit 1,000 patients a year in the West of England.
  • To date, 435 staff from community organisations have already received Human Factors training. We are now providing funding to Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership to enable a further 2,500 staff in community settings to receive training.


  • Connecting Care has been used to review patient records on 110,000 occasions. Gloucestershire CCG has a final business case which will deliver interoperability in 2016/17. Wiltshire and BaNES are enhancing local systems to connect data for patient benefit across care settings.
  • Patients in the West of England are set to benefit from a new NHS Genomic Medicine Centre based in Bristol, which gained approval in December.

Quality improvement

  • 80 GP practices in Gloucestershire are working with us on our Atrial Fibrillation programme. The first 11 practices found 533 high risk patients who may need clinical review.
  • We have trained 46 GPs, 15 nurse practitioners and health care assistants, and 12 pharmacists as part of Don’t Wait to Anticoagulate, with a further pharmacist training session planned.


  • The OpenPrescribing platform been used on 25,000 occasions, with 94,000 page views, and shares on Twitter have reached a potential audience of 46 million people. The concept has now spread to Wales and Scotland.

Join Dementia Research

  • At Christmas the West of England had achieved number one slot for the highest number of local registrations to the Join Dementia Research service in the country.

Diabetes Digital Coach

  • The Diabetes Digital Coach programme, developed by a consortium led by the West of England AHSN, has been selected as an ‘internet of things’ Test Bed to help people with diabetes in the region self-manage their condition.

Supporting innovation

  • We have supported Folium Optics who have been awarded £1 million funding from SBRI Healthcare competition to further developed their ‘smart tag’ which reminds people to take their medication.

Everything we do and achieve is in collaboration with an extensive range of individuals and organisations across the West of England and beyond. Thank you to all our members, partners, public contributors and staff!

Reinforcing the power of AHSNs

Chief Executive of the NHS Confederation, Rob Webster visited the West of England AHSN on Tuesday 2 February and was clearly impressed by the work he saw being developed by our network.

Writing in his regular news briefing later that week, he said:

“We need to do what is in our gift within our organisations, as evidenced by the brilliant work on ‘crowding’ coming out of the Bristol Royal Infirmary. The excellent Dr Emma Redfern shared work on National Early Warning Scores (NEWS) and the development of an ED checklist that is saving lives and improving services. The work is spreading across the South West, under the Patient Safety Collaborative supported by the West of England AHSN.

“The AHSNs are currently collating their top three innovations for a compendium – after half a day at the brilliant WEAHSN, they will struggle to get it down to only three each.

“There are some days when you feel you are stealing a living and this was one of them. From the PreCePT work on preventing cerebral palsy in preterm babies to risk factors in atrial fibrillation in general practice, the work is clinically-led, evidence-based and having impact. Lives are being saved, clinicians enthused and the public informed. Check out things like and for examples of what they do.

“Thanks to Deborah Evans and her team at West of England AHSN for reinforcing the power of AHSNs. It was timely as Sir Hugh Taylor and I met this week to discuss how AHSNs play into the final recommendations of the Accelerated Access Review.”


Gloucestershire Hospitals’ Biophotonics Research Unit scoop innovation award

The Staff Awards 2015 for Gloucestershire Hospitals NHS Foundation Trust took place at Hatherley Manor last month, celebrating the hard work, loyalty and dedication of teams and individuals across the organisation.

The West of England AHSN was delighted to sponsor the Innovation Award, which was won by Professor Hugh Barr, Dr Catherine Kendall, Dr Gavin Lloyd of the Biophotonics Research Unit (BRU) team.

They were selected for their commitment to high quality research and innovation to improve the diagnosis and treatment of patients – and also for that very special ability which each of them has to inspire others – their colleagues, their peers and the scientists and clinicians of the future.

The application of this science holds enormous potential for improving the diagnosis and treatment of disease, including cancer

Progress in medicine and clinical care would never come about without the skills and enthusiasm of our researchers and innovators. A number of the Trust’s clinicians and scientists have been at the leading edge of novel advances in medicine over the years – and amongst this group are the members of the BRU team.

Biophotonics is the science of the interaction of light with tissue, which holds enormous potential for improving the diagnosis and treatment of disease, including cancer.

The BRU is a multidisciplinary team of clinicians and scientists working closely together, focused on translating science into the clinical environment and driving innovation forward.

The Unit was established 20 years ago by Professor Barr, a Consultant Upper GI Surgeon, who was inspired to develop new ways of diagnosing and treating disease – in particular oesophageal cancer. He remains Clinical Lead for the Unit, alongside Dr Catherine Kendall, Consultant Clinical Scientist who is the Scientific Lead. Dr Gavin Lloyd is a research fellow, with expertise in the field of chemometrics (data analysis).

The Unit creates opportunities for a wider team of clinicians and scientists to carry out high quality research and to gain higher degrees. Their contribution is invaluable in developing the research, which is funded by national and international grants.

The research focuses particularly on the clinical applications of Raman and Infrared spectroscopy. These technologies are being developed as a diagnostic platform for a range of clinical applications.

Collaborations both national, international and with industry are vital for the development of this research, in particular with Prof Nick Stone at the University of Exeter and Dr John Day at University of Bristol. Commercialisation aspects of the work are explored in conjunction with NHS Innovations SW.

A particular strength is that the Unit is not isolated, but is embedded as a recognised department within the Trust, much valued by colleagues for the wider contribution which it makes to the work of the hospitals.

As well as being outstanding in their clinical and scientific fields, each of these three colleagues also have a very special ability to communicate their science and to inspire others – their colleagues, their peers, and through their work with young people, the scientists and clinicians of the future.

The United Nations designated 2015 as the International Year of Light and Light-based Technologies, which makes it all the more fitting to these three leading members of the Biophotonics Research Unit won this award this year.