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.

Building strong foundations to support the most vulnerable in society

The West of England AHSN held a meeting recently, marking the first steps towards building a valuable partnership with the regional voluntary and community sectors.

The aim was to build relationships with organisations that could help us effectively engage with the most vulnerable groups in society, those who are isolated, housebound, the frail and elderly. Organisations that attended were Age UK, LinkAge, the Red Cross and West of England Care and Repair.

Two of our workstreams found the meeting particularly useful in terms of informing and supporting future areas of work.

Our Enterprise team is keen to make sure they are reaching people who might want to get involved in the next phase of our Design Together, Live Better project. This is providing the opportunity for people living with long-term health conditions, carers, family, friends and anyone else interested in healthcare, to suggest or give feedback on product ideas that might improve quality of life and independence. Last year, the first phase of the project developed three product prototypes, based on the experiences of people that attended a series of workshops and crowd-sourcing activities across the region. This next phase is looking to widen and increase our reach, and so voluntary and community organisations, through their membership and users, are extremely well placed to help us do that.

For some time, our Patient Safety Collaborative has been aware that its focus has been on acute care. With an increasing emphasis on healthcare in the community, it is important for us to influence those who have a role to play in safety in the home. Organisations like the Red Cross and Care & Repair often go into people’s homes and provide support to vulnerable people who might be just under the radar of health professionals. The role of staff in these organisations could be vital in improving patient safety and preventing avoidable Emergency Department admissions.

By the end of the meeting, there was great excitement about the potential for working together. A start was been made at the recent ‘Wisdom of the Crowd’ event to launch phase two of Design Together, Live Better, attended by several voluntary and community sector organisations. The Patient Safety team is also planning to offer SBAR (Situation, Background, Assessment, Recommendation ) training to several of the organisations.

People in Health West of England goes from strength to strength

People in Health West of England (PHWE) was established to promote innovative and effective public involvement in health research and evidence-based service improvement, and works with four core partners: the West of England AHSN; Bristol Health Partners (BHP); the NIHR Clinical Research Network (CRN): West of England; and CLAHRC West.

Here are some highlights of its work over the last year.

PHWE continues to provide a shared resource for its partners and for the West of England generally. In the last year it launched its website, which aims to provide a central hub for accessing resources and information on training and events relating to public involvement. Their fortnightly Newsflash distribution is up by 59% from May 2015 and now reaches 585 subscribers, and advertised 68 involvement opportunities for people locally.

Over the past year PHWE held a range of workshops to raise awareness and skills in health research. Topics covered research question generation, using and understanding research evidence, and building research partnerships. Geared towards both healthcare professionals and the public, they were held in the four main population centres of Bath, Bristol, Gloucester and Swindon. To date their training programme has attracted 390 attendees coming from across the region.

The practicalities of working with members of the public in the spirit of co-production is one that has challenged all our partners and PHWE has benefited from having a specialised team to put in place the thought and mechanics needed to make this successful. One example of this way of working has been the consultation carried out with members of the public on BHP’s strategic aims. This involved staff and the two public contributors on the BHP Executive working together to run a workshop to listen to the views of a range of people attending.

PHWE offers support for co-production based on an approach that is proven to work. Over the past year they have developed a shared approach to the selection and management of public contributors, helping to co-produce the work in their partners’ organisations. Guidance for managing volunteer payments, codes of conduct and sample role descriptions are all freely available on their website.

PHWE now has a team of nine, located with their various partner organisations, as well as centrally in Whitefriars. This sharing of experience and expertise is already demonstrating the benefits of the initiative. For example, many of the Health Integration Teams (HITs) are at the early stages of involving public contributors in their work. They are able to build on the networks, experience and resources outlined above to put this in place without having to re-invent the wheel.

The training course ‘Building Research Partners’, which PHWE had already started to run, is also one of the CRN’s national objectives.

For the West of England AHSN, it was involvement by team members in their ‘Design Together, Live Better’ ideas generation workshops that led to the suggestion for a portable bidet for people with disabilities, which is now at design prototype stage.

PHWE is able to offer access to the views of children and young people though the BHP-funded Young People’s Facilitator. Because of the support of BHP, PHWE is able to continue to support the Young People’s Action Group that meets at the Bristol Children’s Hospital and was set up by the CRN.

PHWE recently held a review of current working and governance arrangements of partners. This confirmed the current approach to drawing up a shared work programme. Plans for next year include carrying out an evaluation of PHWE so that they can ascertain the sustainability of this model and its viability for replication elsewhere.

For more information, contact Hildegard Dumper, PHWE Manager: hildegard.dumper@weahsn.net or visit www.phwe.org.uk.