Don’t Wait to Anticoagulate is now award-winning!

Our Don’t Wait to Anticoagulate (DWAC) project won a prestigious Anticoagulation Achievement Award this month for its achievements in stroke prevention.

DWAC won the category ‘The centre best able to demonstrate adherence to NICE quality standards for atrial fibrillation’. The Anticoagulation Achievement Awards celebrate outstanding practice in the management, education and provision of anticoagulation across the UK. Staff from the West of England AHSN attended the award ceremony on Wednesday 11 October at the House of Commons.

The West of England AHSN have been working in collaboration with Gloucestershire Clinical Commissioning Group (CCG) and Bayer Healthcare to prevent strokes amongst patients with atrial fibrillation by improving medicines management in primary care.

Effective anticoagulation has been shown to reduce the risk of stroke for patients with atrial fibrillation; an abnormal heart rhythm. Anticoagulation is the process of hindering the clotting of blood; especially the use of an anticoagulant medicine to prevent the formation of blood clots.

For the DWAC project, the West of England AHSN co-designed resources with a wide range of stakeholders, including NICE, patient representatives and clinical partners. These resources include guidance for clinicians, pharmacists and patients to aid shared decision making and improve take up of anti-coagulant medicines. The resources are supported by quality improvement (QI) and clinical skills training. For more information visit

During the 36 weeks of phases one, two and three of the project’s roll-out in the westcountry, DWAC has potentially prevented 27 strokes amongst people with atrial fibrillation, representing an estimated saving of over £629,000.

Additionally, feedback from users confirms that the DWAC approach has led to improved patient care, increased confidence in shared decision making, and improved working practices. There has been a strong shift in focus from “Why anticoagulate?” to “Why not anticoagulate?”

This award demonstrates that DWAC is an important part of the national drive to reduce the number of strokes. The project is being adopted across the North West of England, Yorkshire and Humberside, Buckinghamshire and East Berkshire with 85 GP practices involved and many more engaged to start, plus further spread is planned across the West.

“I am really proud that all the hard work in GP practices across Gloucestershire, with the support of the West of England AHSN, has been recognised by winning this award. Furthermore, it is fantastic that the principles and methods developed within the DWAC programme are being rolled out to primary care in other CCG areas across England.”

Dr Jim Moore, GP, Stoke Road Surgery, Cheltenham

The organisers were delighted at the level of interest and applications received for this first year of the Anticoagulation Achievement Awards. The awards are hosted by leading charities, Anticoagulation UK, AF Association, Thrombosis UK, Arrhythmia Alliance and training establishments – Anticoagulation in practice and Thrombus. They invited applications from teams and individuals across secondary, primary and community services who can demonstrate innovation and excellence in delivering anticoagulation services, resources or individual leadership. There were six award categories and DWAC was up against some tough competition.

The winning entries from each category received a £1,000 bursary, which will be used to aid continuous improvement of services.

For the full list of winners, visit the Anticoagulation Achievement Awards website.


Photo: Jim Moore, GP at Stoke Road Surgery; Steve Ray, Healthcare Partnership Manager at Bayer; Dave Evans, Quality Improvement Programme Manager at the West of England AHSN; Tasha Swinscoe, Chief Operating Officer at the West of England AHSN; and Tabinda Rashid-Fadel, Circulatory Programme Manager at Gloucestershire Clinical Commissioning Group.

Collaborating for a safety culture in primary care

At the end of May, colleagues from 13 primary care practices from across the West of England, including GPs, practice managers, practice nurses and quality and safety leads, came together for the first meeting of our new Primary Care Collaborative.

The event was opened by our  Patient Safety Programme Director Ann Remmers who spoke about the context for collaboration. Dr Hein Le Roux, GP & Primary Care Lead for Patient Safety for the West of England AHSN, then explained how collaboration was a combination of people and technical skills. He told a cautionary tale of the Choluteca bridge and painted a picture of what better could look like in primary care. He explained how taking a systems approach could tackle some of the challenges through collaboration, and gave an example of a patient in his care where their care could have been better, and shared the learning from that incident.

Stephen Ray, Quality Improvement Programme Manager, expored why things go wrong in a systems context and some of the methods to take a systematic approach to quality improvement to build reliable systems. He explained the clinical microsystems approach, the model for improvement, and case studies from his experience working on improvement with GP practices.

All the presentations from our speakers are available here.

Attendees told us they really valued the time to meet other practices, learn from others and discuss subjects that they don’t normally get time to. There was great feedback about the speakers and group sessions, and the bacon sandwiches first thing were a big hit! They made a list of actions to take away from the day including looking at their existing processes and communications, developing a map of responsibilities, using PDSA and changing their language from “significant event” to “learning event”.

At our next meeting in September, the Collaborative agreed to focus more on sharing learning from particular examples from practices, with in-depth support on a topic chosen by attendees. Suggestions included:

  • Engaging and motivating staff to make changes
  • Putting changes into practice
  • How to engage all staff to make real change
  • Motivating staff and changing culture
  • Bringing on board difficult characters – what impact can individuals have on instigating change?

About the Primary Care Collaborative

The Collaborative has been set up to promote a safety culture in the primary care setting through the use of incident reporting, whilst giving the practices involved tools and training in quality improvement methodology. It will also help practices to undertake their own improvement journeys and network with other practices in the region to share learning and facilitate collaboration.

Benefits for the practices involved in the new Primary Care Collaborative include helping their practice in its next Care Quality Commission inspection and will contribute to the revalidation and appraisal processes for all staff. Staff are receiving quality improvement methodology training and resources throughout. Being a part of the collaborative will also increase awareness amongst practice teams of the patient safety agenda, while promoting an open and honest culture.

Patient safety is high on the public agenda, and practice’s involvement in the scheme will improve assurance that their practice has an open and transparent approach towards patient safety, in addition to improving the overall patient experience. Patient representatives for each practice have also been invited to take part as members of the practice core team.

Future events

  • Swindon| Hilton Swindon, Wednesday, 7 September 2016 from 08:00 to 12:30
  • Gloucestershire | Stonehouse Court Hotel, Wednesday, 30 November 2016 from 08:00 to 12:30
  • Bath | Royal United Hospital, Wednesday, 1 March 2017 from 08:00 to 12:30


For more information on the Primary Care Collaborative, please contact Kevin Hunter at

The Leadership Series – Commissioning Musculo-Skeletal Care

The concept of the Leadership Series is to bring specific senior commissioners together from across the seven CCGs to focus on areas of common challenge, facilitate learning, spread knowledge across the patch and identify further areas to explore collaboratively.

Five Leadership Series meetings have been scheduled to date: three in 2016, covering the topics of ‘Primary Care Demand and Flow’, ‘Commissioning Musculo-skeletal care’ and ‘Commissioning Diabetes Care’, and two of which were held in 2015 on ‘Using Evidence & Evaluation in Commissioning’ (February 2015) and ‘Exploring different approaches to CCG prioritising and de-prioritising strategic initiatives’ (May 2015).

The Musculo Skeletal Care event was held on 19 April with 17 attendees from all seven WEAHSN member CCGs and two UWE researchers.  Feedback from the meeting from delegates was very positive, with a request to meet again in early September, in advance of the CCG business planning timetable.

Feedback after the event included:

“An excellent opportunity to share work in a supportive environment.  I have a far better understanding of what is happening locally and who is involved.” GP Clinical Lead

“Between us we can transform MSK; we need to coordinate much better.” Elective Care Lead

“Very helpful to see what is happening on the patch.  Good to combine clinical perspective with management transformation.” GP & Clinical lead for Planned Care

“We are all grappling with similar issues and it feels a less lonely place now!  There is a collective motivation to embed transformation.”  Service Improvement & Development Manager.

“Useful to collaborate.  We are all trying to do similar things.”  GP Clinical Evidence Fellow

There was also agreement that a musculo-skeletal ‘community of practice’ would be helpful to electronically enable attendees to stay in touch.

The Primary Care Collaborative

In May 2016 we launch our first Primary Care Collaborative. with up to 20 primary care practices from across our seven clinical commissioning groups (CCG) set to join the first cohort. This collaborative will form part of the wider West of England Patient Safety Collaborative.

The initial aim of the Primary Care Collaborative will be to promote a safety culture in the primary care setting through the use of incident reporting, leading to better outcomes for patients. It will also increase awareness amongst practice teams of the patient safety agenda, while promoting an open and honest culture.

Additional benefits for practices will include improving preparation for Care Quality Commission (CQC) inspections and the revalidation and appraisal process for all staff.

Each practice will complete a patient safety culture survey and we will support practices with tools and training in Quality Improvement (QI) methodology, enabling the identification of opportunities to improve patient safety. Practices in the collaborative will come together at four learning and sharing events during 2016/17.

Alison Moon, Transformation & Quality Director for Bristol Clinical Commissioning Group (CCG), says:

“It is really positive working with the AHSN on the primary care programme. There’s a combination of energised joint working, a structured improvement approach and the sharing of best practice and experiences, which gives us a really good chance of achieving our shared objectives on patient safety.”


For more information on the Primary Care Collaborative, please contact Kevin Hunter at

How inspiring leadership makes honesty possible

In his latest blog post, GP Hein Le Roux reflects on the differences between strategy and culture when it comes to patient safety.

In patient safety, an academic definition for strategy is a plan that takes you to your long-term safety goal, whilst the culture is more about people; the practice’s personality or ‘the way we do things around here’.  So for me, strategy is about talking the talk, whereas culture is about walking the walk. Clearly strategy and culture are both important, but often there is a gap between the two. Leadership attitudes and behaviours, particularly on honesty, form a crucial bridge in the quest to connect a safety strategy to the generative patient safety culture that we are all trying to build.

Changing mindsets

If our leadership is able to create a supportive environment, then it is so much easier to talk about an error or near miss in an open and just way. Whilst system and process factors are very important, my firm belief for what underpins the culture we are trying to create revolves around the mind-set of people. Medicine traditionally has been very hierarchical, often with power and thus decision-making based on tenure rather than merit. In my experience, this can inhibit openness and learning.

One recognised antidote is a move to a flatter organisational structure where leadership is distributed to the frontline; this is where the real clinical responsibility lies and is to be welcomed. Often this is where the safety and quality challenges occur, but it is also where much of the determination to change things for the better lies.

I feel attitudes are changing and in my view leaders need to continue to foster a culture of honesty particularly by exhibiting more versatile leadership, based less on command and control and more on coaching and visionary leadership styles. These behaviours can empower and liberate the front line to make things much better for patients.

“Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic”

We regularly talk as a practice about our individual significant events which provide powerful learning. Encouragingly, we are also talking more about the systems and processes which underpin our work, with an appreciation of the impact of a decision or behaviour on other parts of the practice. A recent example was where one of my nursing colleagues came to me saying that she had given an incorrect vaccine to a patient and what should she do? She could have kept quiet and no one would probably have been the wiser, but she actively chose to be open and honest. We discussed the incident and she phoned Public Health England, finding out that there was a low risk of harm. She then phoned up the patient to let them know what had happened and to say sorry. They valued her candour. Furthermore, she reported it on the National Reporting and Learning System.

As is often the case, our internal practice significant event analysis revealed more of a system and process error and some ‘human factor’ issues – in this case, a busy clinic. We have all learned from this and the nursing team are developing a vaccine check list to reduce the chances of such errors occurring again. On a personal level I found my colleague’s attitude to be both brave and inspiring. In particular I noticed her feelings of anxiety, which made her honesty in coming forward even more of an act of ‘bottle’. Seeing both a kind, vulnerable human being, as well as the competent nurse I know, makes her leadership so much more authentic.

Difficult conversations

So why can it be difficult to come forward with an error or near miss? What psychological factors can bring out our defensive feelings? The themes contained in a book that I read recently called ‘Difficult Conversations’ by Stone, Patton and Sheen seems very relevant to this particular blog. Whilst it is dangerous to generalise, an observation I would make about myself and some GP colleagues is that we can cling to a purely positive identity of ourselves, which leaves no place in our self-concept for negative feedback.

If I think of myself as a super-competent person who never makes mistakes, then feedback suggesting that I have made a mistake presents a problem. The only way to keep my identity intact is to deny the feedback – to figure out why it’s not really true, why it doesn’t really matter, or why what I did wasn’t actually a mistake. If we are going to engage in honesty and candour then we are going to come up against information about ourselves that we find unpleasant.

We all make mistakes

The bigger the gap between what we hope is true and what we fear is true, the easier it is for us to lose our balance. One way to get around the overly simplistic all-or-nothing thinking is to be aware that we are all probably more complex than just ‘I am perfect’ or ‘I am worthless’. Just because something is missed or goes awry does not mean that I am a bad person. We all make mistakes and if we can’t admit that to ourselves it becomes harder to learn, improve and move on because we spend all our time and energy defending ourselves.

One reason people are reluctant to admit to a mistake is that they fear being seen as weak or incompetent. Paradoxically, from my experience, it is generally competent people who take the possibility of mistakes in their stride and are seen as confident, secure and ‘big enough’ not to have to be perfect.

Bridging the gap

In summary there is a saying that ‘culture eats strategy for breakfast’. In other words, it is easy to talk the talk on honesty at a superficial level, but walking the walk is psychologically much more complex. Leadership attitudes and behaviours are crucial in order to bridge this gap. What I would say about our practice is that whilst we readily acknowledge that we are not perfect, we actively try to be open and reflective, so we can learn and improve the service we offer. Honesty has obvious benefits for our patients and also to our colleagues both within the practice and across the wider health and social care community.

As everyone already knows it is tough in general practice these days, but the esprit de corps that this honest culture generates is immeasurable.

This post was originally published on the Sign Up To Safety website.

Measuring demand in general practice – new report published

A new study has been published exploring how demand is measured and managed by GP practices in the West of England.

The West of England AHSN commissioned the study, in partnership with NIHR CLAHRC West, as part of its Commissioning Evidence Informed Care programme, which is led by Dr Peter Brindle.

Demand for Primary Care services exceeds capacity available. With increasing cost pressures, increase in patient expectation and advances in medicine, more people are visiting their GP than ever before. With no new monies available to significantly increase GP numbers, the West of England AHSN is advocating an evidence-based approach to measuring and managing demand.

There were three main aims to this research:

  1. To review existing literature and to scan regional and national projects that aim to measure
    and manage demand.
  2. To understand how GP practices currently measure and manage demand and how they use
    routinely collected data to predict demand and strengthen capacity planning.
  3. To gain an overview of the three Prime Minister Challenge Fund sites in the region and to determine their approach to measuring and managing demand.

The study highlights a lack of research in this area and a lack of continuity in national projects aimed
at supporting GP practices to understand demand. It therefore provided strong evidence supporting the need for a study of this kind and for further investigation of this area.

Work with GP practices revealed no definitive or widespread approach to measuring demand in primary care. However it confirmed that practices and clinical commissioning groups (CCGs) were struggling to cope with apparently increasing demand and were very keen to engage in further activities that might help understand and manage it better.

Download a copy of the full report here for a full analysis of the findings and recommendations for next steps.