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.
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.