Author Archives: @MelJClem

About @MelJClem

Consultant Paediatrician with a passion for Leadership and Innovation. On a mission to Improve services for and with Children, Young People and Families. Any one welcome to join me.

Reflections post the Francis report

We have now completed 12 of the 17 visits and over the last two weeks I have been reflecting on our visits in light of the Francis report.

I have picked out a few lines of recommendations from his summary

  • Foster a common culture shared by all in the service of putting the patient first;
  • Develop a set of fundamental standards, easily understood and accepted by patients, the Public and healthcare staff, the breach of which should not be tolerated;
  • Provide professionally endorsed and evidence-based means of compliance with these Fundamental standards which can be understood and adopted by the staff who have to Provide the service;
  • Ensure openness, transparency and candour throughout the system about matters of Concern;

The full report can be found by clicking on the link below.

http://cdn.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

After reading the executive summary I feel heartened that we are on the right journey with our visits:  To support teams in a peer review process to enable them to benchmark themselves against defined standards and to help develop an open and transparent culture which is continually learning, improving and one in which children, young people and families are at the centre of everything we do.

For me one of the important things to remember following the report is that we must continue to trust people. The vast majority of people in the NHS are doing their best and aim to do a good job. Some may not be achieving this but with support and the right systems will. There are very few people who wilfully cause harm. We know however that they do exist.  As a paediatrician this is something we juggle with every day. In the main we work in partnership with parents with the same shared interests – to do the best by their child. Most parents but not all work in partnership with us to achieve it. Some are not capable of it and a tiny minority actively work to deceive us. We have to go into each new relationship with trust and hope but the intelligence and willingness to think the unthinkable.

We aim with the peer review visits to engage, facilitate, enable, encourage and hopefully inspire teams. We hope that all the teams we visit will have spent some time preparing for our visit, meeting together and bench marking themselves against the standards. This will allow them to make the best use of time on our visit. The day itself allows them to stand back and review what they have achieved and identify their priorities going forward. It was great last week to see a team making their own action plan as we were preparing our feedback. It is fantastic when we are able to move the conversation and the journey on that little bit further with new ideas none of us have discussed before. We were even talking about how to make the ED environment less stressful!

The visit is also essential to allow the children’s agenda to be heard within the Trust. Constantly we hear that Children and Young People never reach the top of the trust’s agenda, always overtaken by overall numbers of patients in A&E or overall bed pressures. We have seen more than one purpose built Children’s ED department used by adult patients and the children seen amongst adults in a busy ED environment – daunting for even us adult professionals, not complaint with standards and not acceptable. The presence of representation from the Trust executive and/or non-executive teams is essential  to allow the local team to demonstrate the great work they have been doing and challenges they face and obtain the necessary support to take the actions forward. Without this support and recognition even the best teams struggle.

We make some assumptions on our visit and that is the vast majority of us choose to work in the NHS as we care and want to make a positive difference. We don’t come to work with the intention of getting it wrong and it affects us deeply when we do. One thing is for sure at some point to a greater or lesser degree we all will. In return we find teams are prepared to trust us back and generally are very open and frank.

What we observe time again on our visits is that the key to great teams are individuals – leaders who are able to establish relationships with those around them, who go the extra mile, role model and enable those around them. For a team to be really successful it takes more than one person. This leadership needs to be multi-professional and across and beyond the organisation. Few teams have managed this throughout the organisation. I have felt this year however that we are being taken more seriously. Last year it felt as though everyone was paralysed by financial constraints and salami slicing attempts to save money. This year trust executives are talking about the need to address issues raised and move forward.

It is essential in order to adapt to changing times teams need to be constantly looking outside themselves and learning from within the organisation and also outside. This is essential rather than desirable. This can be hard to achieve when staffing is tight and finances constrained. We have seen teams that were once ahead of the game and early adopters of change for example in developing children’s assessment units become behind the times. Going into organisations to see for ourselves the good practise as well as share practise from elsewhere and help teams to focus on an achievable list to assists with this Just being able to listen to challenges and show people another way can open minds. I am concerned that individuals in organisations are often not allowed to go to meetings where they will benefit from networking, shared learning and allowed the space to think innovatively and differently. I know from my own experiences just how much my practise and thinking has changed. I am in a very privileged position of constantly having the opportunity to think differently and learn from others. How do we measure this? To give an example last week on the ward round I was concerned about a 16yr old with spastic quadriplegia and whether we were following trust protocol to ensure his skin stayed intact and he did not get pressure sores, I am wondering if slipper socks have a use for children on our wards although falls are not a big issue, they do occur. I am so much more aware of patient stories and experiences and I am much more conscious of whether I am including the child or young person in a consultation and whether I am using appropriate language. I also found myself last week watching the sister in charge trying to juggle a large number of tasks and demands and fed this back to her appreciatively while questioning the level of staffing on the ward.

Focussing back on Emergency and Urgent care services for children and young people the workforce that delivers this service has changed considerably over the years. The roles and responsibilities of nursing and medical staff have mingled. The numbers of doctors on a rota at all levels has risen but different units have expanded at different rates. Some units have adapted the rotas to ensure more people are around to cover the peak evening period whilst others go to the skeleton crew or good will (not job planned) presence of senior doctors after 5pm. The diversity in the nursing profession is even greater. We have visited trusts where the role of the matron is clearly visible throughout the trust in ensuring high standards for children and young people and embedded rotation programmes for newly trained nurses to ED, theatres and even out to the community children’s nurses and school nursing teams. Specialist nurses such as practice development nurses, Safeguarding nurses have grown and are much needed but the overall nursing numbers in these departments have often not grown leaving fewer nurses on the rota. Children’s advanced nurse practitioners (CANP) are out there and there is so much potential but they are still gold dust. Even after completing their masters not uncommonly they discover the trust has not identified a role for them.  In some parts of the country they are now going into GP surgeries and children’s community nursing teams are also taking on acute care. So the picture and possibilities is complex. In some children’s ED departments we have seen a number of children’s trained staff also trained in minor injury and illness (CENP) this is a much shorter course and allows the nurses to work independently in the ED environment.Roles such as nursery nurse and health care assistants also vary with some taking on phlebotomy skills.This has to be put together with the philosophy of children’s assessment units where children and young people stay a short time but the process and assessment is the same but just sped up. Different trusts have different lengths of stay that may be related to the effectiveness of the team to deliver ambulatory care. There is much talk about short stay tariffs and not enough on addressing the issue of inappropriate attendances and GP referrals and expected length of stay.  In my own trust we have consultants on in the evenings and also have children’s nurse practitioners delivering the ambulatory service. We are dedicated to ambulatory care. We however have significant challenges in our ED department with currently only 1 part time children’s trained nurse and doctor vacancies. We are frequently asked to see ED patients due to capacity issues. The size of our trust alone before consultant delivered care means that our service is expensive.  We may be delivering a high quality service but when the trust works out the income generated by each consultant as they are now doing it will be low. We have to do much work ourselves. We deliver sub-speciality services and often don’t have data managers and multi-professional teams to help us. We often have to be several team members and for example have to do the paperwork or data input for peer review processes ourselves.  Another hospital may be allowing junior doctors to deliver emergency and urgent care services relatively unsupervised, have specialist nurses and due to larger population base seeing  more out-patient activity and seem to be more productive.

Across our region the variation in in-patient beds is large and not related to the activity. In order to start to work out how many staff we need we need to address some of this variation and look at the roles and responsibilities of staff members. I do think this is an essential piece of work.

Something I have also found truly shocking is the small numbers of ED consultants and large numbers of vacant posts at consultant and registrar level. There does not even seem to be a light at the end of the tunnel. It is not uncommon for ED consultants to be working a 1 in 4 rota which includes long shifts on the shop floor. How long is this sustainable? We have seen in our own region the development of the trauma centre which as a medical workforce of 16. 1 in 16 lots of new kit and funds or a 1 in 4 which would you choose? It is not necessarily the bigger departments that have the larger consultant body and so not necessarily the smaller units where it may fall apart first. We are continuing to see a rise in ED attendances and most ED’s have outgrown the space and the workforce. There are some innovative posts popping up consultant paediatricians with dedicated ED sessions, likewise GP’s and general physicians. An ED consultant I spoke to could see the value but was also sceptical that you would need several of these roles to do what one ED consultant can and none of them were participating in the ED on call rota.

We are heading for new and different times. There is a limited resource and workforce and the old ways are not working. There is something each of us can do whoever we are and whatever we do and that is to be prepared to think differently and to adopt to new ways of working and most importantly and starting from now always remember why it is we do what we do. The patient in my case the child or young person needs to be at the centre of our thinking. We must improve their experience, we must improve the way we communicate with patients and public and engage them in helping us design services for the future.

I will leave you with this letter that Kath was given by a teenage boy after he had spent a week in hospital with pneumonia. There is something we can all do today.

Messages to the NHS

Best Wishes

Mel

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Principles of Care for Children and Young people

Principles of care
This week I want to share with you some work we have been doing across the East of England. We have shared these on each of our visits

We have developed a set of principles that can be used by providers and commissioners, across the whole healthcare system wherever a child or young person is seen. The aim is to improve the health outcomes and experiences for children and young people (CYP.)

Poster

How were they developed?
The principles were developed by a multi-professional team of GPs, Health Visitors, School Nurses, Paediatricians, Public health, Children’s Nurses, patient and family representatives came together over a period of 6 months in a number of facilitated work- shops.
CYP and family engagement was central to this work with visits to Children’s Centres, primary and secondary schools to listen to families experiences of health services. A graphic illustrator captured the key messages from each engagement event.
The principles were referenced against the Children and Young People’s Outcome Forum Report and the NHS Mandate.

What are they?
A set of 6 principles; 1.Child and Family focussed, 2.Health Promotion, 3.Transformation, 4.Settings, 5.Information and Communication, 6.Evidence Based and Sustainable.
Each principle has an aspirational statement and then indicators to be used to evidence achievement towards a principle. They can be used to assess an existing service or to develop a new service and can be used for a condition across a pathway e.g asthma or for a service e.g GP practise.
The principles have been developed as a single A5 poster for ease of use and are colourful and visual.
A postcard has also been developed which summarises the feedback from young people and families but also translates the principles for families so that they know what they can expect from services.
Local organisations are encouraged to add their own and healthwatch websites to the postcards to allow continuing feedback from families.

Front PostcardBack Postcard

And so what?
The principles define a common language and shared sense of purpose for professionals and families and can be used as a platform of small or large scale change and improvement. They compliment the NHS mandate and the children’s and young person’ s outcome report and sit at the centre of the NHS change model. They are easy to use and flexible and can be used nationally and easily adapted for other services. They summarise the NSF on one page and could contribute to a NHS CYP constitution

And now what?
We would be delighted if the CYP community would use these principles nationally but also we think they could be adapted for use elsewhere – care homes, care of patients with dementia, patient safety etc…

Please feel free to comment and feedback.
I do have lots of things to share with you from our visits and I have asked for some contributions from some of the great practise we have seen such as children’s advanced nurse practitioners, the role of the children’s matron, productive ward. Any ideas please let me know.

COMING SOON To a school near you Monkey to teach your child about the NHS. A legacy for the Children and Young People’s Emergency and Urgent Care programme NHSIII and thanks to the hard work of @KathEvans2 and @ahhapublications

Overview slides_Page_17

Best Wishes
Mel

Week 1 of visits – Children’s trained staff in ED?

This week we have visited 4 Emergency departments and children’s assessment units across the East of England. The weather has followed us and unbeknown to many at the time it was really quite bad in Norfolk on Tuesday and lengthened our day considerably.  We later learned that many nursing and portering staff slept at the hospital to ensure they could work the following day. This is a true reflection of what is great in our NHS. The weather reports caught up afterwards and hung over us all week. Despite our concern about a repeat performance in Peterborough on Friday when it started to snow we managed to complete our visits.

We received a warm welcome everywhere we went. It has been a re-visiting of old friends and showed the value in taking time to work collaboratively, establish relationships and build trust. We used an appreciative enquiry approach last year but all our expectations have shifted slightly this year. Our stance is still supportive but in more than one trust it was recognised how important peer review is and any recommendations from an external visit are essential to move forward the agenda. We were asked for clear recommendations.

There have been lots of examples of professionals working collaboratively and passionately demonstrating real progress. For example:  The active recruitment of children’s trained nursing staff in a designated Paediatric Emergency Department. The appointment of a Paediatric ED Consultant. Collaboration between paediatricians and the lead GP CCG lead for children. Increased consultant delivered care in periods of peak activity. Even the development of Paediatric Nurse Practitioners.  I will focus on the good practise another week but this week there are a few things I have been reflecting on.

Children aged 0-16 account for ~25% of ED attendances. In the trusts we visited this was 10,000-25,000 children and Young People per year. Three out of the four trusts had >16,000 attendances which means according to the intercollegiate standards for Children and Young People in Emergency Care settings they should have a paediatric emergency department and at least one child trained nurse per shift. Only one trust had a Paediatric Emergency department. One had one when we visited last year but it had been taken over by the Adult Ambulatory unit. In the one trust that did have a paediatric emergency department it was a fantastic well thought through use of space and a truly child and young person friendly environment with good visibility of the waiting area. In the other trusts generally the waiting areas and designated space for children to be seen was inadequate and mixed amongst the adult ED department. ED departments are scary places for children and Young people. Adolescents are often the worst served, they don’t want to sit in a room with small children and babies but are more aware of what is going on around them and find it frightening.

If Children and Young People account for 25% of ED attendances why do children’s trained nursing staff not account for 25% of the staff?  We saw very small numbers of children’s trained nurses.  In two 2 trusts we were told that there were 3 but when we drilled down 1 had been appointed only that week, 1 was on maternity leave and the 1 actually working was part time. (So just to spell it out 20hrs per week and by the way even in those 20hrs they cannot just see the children but have to turn their hand to looking after adult patients.) Despite this only 1 trust was actively recruiting children’s trained staff. Most looked slightly incredulous and were more concerned about “bums on seats.” I have great respect for all staff working in an ED environment and recognise they have a diverse and challenging role. ED nursing staff numbers and ED consultant numbers nationally are very low and recruitment challenging. For many years they have just got on with it and have accrued a great deal of experience. I understand that children have always been part of the mix but” If we always do what we have always done, we always get, what we always got.” Sadly this isn’t good enough for our children. “Improving child health services in the UK: insights from Europe and their implications for the NHS reforms.” http://www.bmj.com/content/342/bmj.d1277

As we have visited ED departments nationally we have observed first hand in those hospitals where they have managed to get the numbers of children’s trained nursing staff up to a minimum number to allow them to see all the children coming through the department these staff are valued and they do have enough work to do. When numbers are minimal in reality most of the time there is no one with a child qualification and so the ED nurses have to do it themselves and the benefits of having a children’s trained nurse not appreciated.

The gold standard model is to have a co-located ED and children’s assessment unit to allow staff to work across and share skills and learn from each other. This is work in progress but very much on the agenda for the trusts we have visited. I know over the next few weeks we will see this model in action.

Another thing we have seen this week is a hospital recovering from the bruising experience of having the CQC and Monitor reviewing them and overseeing external inspections following the death of a child in their ED department.  Although not a common occurrence some children are more sick than realised and all trusts will experience this regretful occurrence at some time where the death was potentially preventable. The Confidential Enquiry into Maternal and Child Death (CEMACH) suggested up to 43% of child deaths had a possible modifiable outcome. (http://www.injuryobservatory.net/why_children_die.html)

The death of a child has a devastating effect on the staff involved. Just like the weather this week it can pass by under reported in one place and as top headlines in another. We heard about deaths in other trusts that were similar. It can be tempting to think a trust that has undergone an incident like this is bad or the staff not good, probably to reassure ourselves that it can’t happen to us. This is the trust that has a paediatric ED department and is actively recruiting children’s trained staff. It has a paediatrician who does sessions in ED and an ED consultant with an interest in children. It has increased the number of consultants and middle grade staff to cover periods of peak activity. Some of this was happening before the incident, some after.

To end on a positive there is always another way of doing things and sometimes we have to change. I don’t know all of the answers but I do know we must learn from each other especially trusts that have had these experiences. We must constantly review ourselves against standards and work through the priorities raised from these. We must talk about the challenges and find a way forward together. 

Best Wishes Mel 

 

Children’s Assessment Unit Standards and Peer Review Visits

Between October-December 2011 Kath Evans and I visited all 17 Acute Trusts in the East of England that provide Acute Care for Children and Young People. We walked the pathway from the Accident and Emergency Department through the Children’s Assessment Unit and In-patient Ward. We talked with as many professionals and patients throughout the day as we could and we were often accompanied by other external guests. During the feedback session we got as many people together as possible from across the trust and where possible the children’s commissioner and GP CCG lead. Some joined us throughout the day.
This was a supportive peer review process. We had asked each unit to assess themselves against “The East of England Children’s Assessment unit standards.”  https://www.eoe.nhs.uk/page.php?page_id=1144

The Aims of the visit were to raise the profile of Children and Young people within the trust, encourage professionals in the trust to get together to review the standards and bench mark themselves against the standards and support trusts to be able to improve their services.

In every Trust we were able to identify good practise and also share good practise we had seen elsewhere and give recommendations for them to progress.
At the end of all the visits we (hum… sorry KATH) wrote a summary report and we held a celebratory event. At the event all units hosted a market stool to demonstrate and share the good practise we had identified. The evaluation of the event and process exceeded our expectations. The process was highly valued. Comments included that the standards and visits gave an opportunity to raise the profile of children. One unit commented that the process re- envigorated them to be able to progress their services.

I learnt lots and one of the things that stuck out was that we were not the CQC, the visits were not mandatory but all 17 units engaged with us and took the visits seriously. We were supportive and being able to recognise the good practise really enabled us to gain the trust of units to help make suggestions to make their services even better! All 17 units had an assessment unit. Some were new and the publication of the standards had aided this development.
I always learn something from every visit and conversation. I know how difficult it can be however to implement changes in your own unit.
Maybe the most important thing we did was build relationships right across the East of England and link units together.

Did we make a difference?
We are about to re-start our tour. Doing the first 9 visits in the next 2 weeks. (I keep listening to the weather forecast with some trepidation – Kath has no doubt already got wellies/blankets/shovels etc in the back of her car.)
This year we are reviewing progress against the Assessment Unit Standards but also focussing on the Emergency Departments and have asked hospitals to review themselves against “The Standards for Children and Young People in Emergency Care Settings” – a document written jointly by the Royal Colleges. http://www.rcpch.ac.uk/emergencycare

I’ll sign off now – I have already had to for go the dog walk to write this blog and I am still sitting here in my dressing gown and can hear keys in the door….

One P.S
Let us know if you would like to join us!

Enjoy your Saturday
Mel x