ABSTRACT Intensive care medicine is a relatively new specialty. In developing standards of care, it became apparent that some aspects were not achievable by smaller units. Within the intensive care community, there has been a gradual acceptance that smaller hospitals cannot necessarily implement structures that are used in large hospitals, and that outcomes can be comparable with larger units despite this. The Faculty of Intensive Care Medicine set up a Smaller and Specialist Units Advisory Group to explore this area, and this article initially explains the background and work of the faculty to support and sustain these units. We then move on to look at critical care in the context of the recent emergence of wider work on remote and rural healthcare. Finally, we explore our future horizons and look in detail at the areas where further developments will transform the care of critically ill patients within the smaller hospitals of the next 20 years.
ABSTRACT Introduction The successful achievement of training requirements at core medical training level is central to gaining the competence and confidence to progress to higher specialty training. Achieving such requirements is, however, challenging in the context of busy medical rotas and numerous rota gaps. Solution/methodology To develop an online resource for core medical trainees which would facilitate the completion of such training requirements and provide information and support for those progressing to higher specialty training. Outcome The online resource has been well received in Wales with 478 users and regular use of the site being reported using Google Analytics. Qualitative feedback has also been favourable. Conclusion The use of digital resources, flexible training and focus on trainee-led innovation can positively affect the training of medical trainees. In the advent of internal medicine training, the support of the Royal College of Physicians is greatly appreciated in expanding this trainee-led innovation across the UK such that it can support a larger number of trainees.
ABSTRACT A problem was identified where patient care was affected because of delays in receiving specialist cardiology input. This report describes the experience of developing a specialist cardiac assessment where senior cardiac nurses were trained to provide a 24-hour presence in the emergency department (ED). We describe the service and our evaluation of the service. These dedicated specialised nurses can optimise patient management including admission or safely discharge patients with relevant follow-up when necessary. The team also runs three clinics per week with consultant support. The team of 10 nurses provides a cardiology opinion to approximately 400 patients a month in the ED and 100 patients a month in the acute medical unit (AMU). Eighty-seven per cent of patients are seen in the ED within 30 minutes of referral. Approximately 40% of patients reviewed are accepted directly into cardiology beds thus avoiding admission to the AMU. It has been estimated that 6 bed-days are saved each day, which translated to an estimated £400,000 each year. The team also provides outpatient rapid access services which generates £121,792 income for the directorate. We demonstrate that a cardiac nurse assessment team can provide a cost-effective 24-hour presence in the ED.
PURPOSE:The Reverse Mentoring for Equality, Diversity and Inclusion (ReMEDI) programme was rolled out in Guy's and St Thomas' NHS Foundation Trust in 2018 and paired senior white leaders (mentees) with black and minority ethnic (BME) staff (mentors) to help them explore their mentees' practices in relation to equality, diversity and inclusion.BACKGROUND:The authors, two BME staff, participated in the first cohort of the programme. We reverse mentored a senior white male director, who we met six times over a 6-month period.METHODS:We used a variety of methods to gain information about and to appraise our mentee, including one-to-one interviews, observations of his team meetings and visual inspections of his department.MAIN FINDINGS:We noted a number of positive practices in our mentee's various levels of operation, which we classified as individual, departmental, organisational and symbolic. These findings included the use of gender inclusive language and compliance with BME staff targets.CONCLUSIONS:This exercise was very useful to our mentee, however, more time with our mentee would have provided greater insight. It would also be helpful to obtain feedback from our mentee's BME staff, to provide a 360-degree view and complete appraisal of his performance.
ABSTRACT In the NHS, training occurs in nearly all our hospitals, and this is part of the NHS service model. As the shortage of doctors is increasingly recognised, so has the pull from remote, rural and smaller places to large urban centres. We discuss whether this is inevitable and what else could be done to ensure equitable access to healthcare for all, by making better use of the excellent clinical training the UK has in place in smaller as well as larger centres.
ABSTRACT The NHS Long Term Plan aims to transform how we tackle cardiovascular disease by improving the detection and treatment of high-risk conditions. One in five strokes are linked to atrial fibrillation (AF) and it is estimated that 500,000 people in the UK have undiagnosed AF. To increase detection of AF, in 2017 NHS England commissioned the Academic Health Science Networks to procure 6,000 mobile electrocardiography (ECG) devices, which were distributed to community settings across the county. The Health Innovation Network as the Academic Health Science Network for south London was responsible for the distribution of approximately 400 mobile ECG devices to a range of settings. A total of 14,835 pulse rhythm checks were performed, detecting 597 people with possible AF. This project provides insight into effectiveness of a wide range of settings in providing opportunistic testing for AF using mobile ECG devices.
ABSTRACT Mechanical thrombectomy (MT) is a very effective, but highly time dependent, reperfusion technique in the management of acute ischaemic stroke caused by large artery occlusion. MT is provided by 24 neuroscience centres (NSCs) in the UK which receive patients directly (‘mothership’) and via transfer from district general hospitals (DGHs), the ‘drip and ship’ pathway. NSCs currently provide a within hours service but are working on service expansion to enable 24/7 availability. DGHs, too, will need to prepare for this service expansion to ensure good outcomes for their patients. We discuss options for service expansion in a DGH and regional stroke network in south-west England and use Sentinel Stroke National Audit Programme data and discrete event simulation to model and compare alternative workflow options to aid the planning process. We suggest that our modelled options could be considered by all NHS DGHs in their preparation for MT service expansion.
ABSTRACT Objectives In 2015, three London cardiac centres, with different transfusion infrastructure support, merged to form the Barts Heart Centre. We describe the impact on transfusion rate, blood usage and interoperator variation. Design Data was collected on all adult patients undergoing cardiac surgery during 2014 as well as 2016, using the National Institute Cardiovascular Outcomes Research (NICOR) data set. Measurements and main results Over the two time periods, a total of 3,647 cardiac procedures were performed (1,930 in 2014 and 1,717 in 2016). There were no significant differences in type of surgery or patient comorbidity between the two epochs of time. Overall, red blood cell transfusion at 24 hours and until hospital discharge reduced significantly in 2016 (odds ratio 0.77; 95% confidence interval 0.68–0.89; p=0.0002). Interoperator variability (adjusted for comorbidities) reduced after merger from standard deviation 0.394 (standard error (SE) 0.096) to 0.269 (SE 0.082), p=0.001. Conclusion Clinical and organisational factors can improve transfusion service.
One of the current obsessions of the NHS is with economies of scale – the notion that healthcare would be safer, faster, cheaper and more efficient if services were provided by larger teams in bigger hospitals or across ever-enlarging networks of organisations. This could be seen as an extension, albeit in a mutated form, of the decades-long drive towards centralisation and specialisation of hospital services.1,2 To these ends, over half of all hospitals in England have been closed or merged in the last 20 years, while one of the purposes of sustainability and transformation partnerships (STPs) is to create unprecedented economies of scale at regional level across every type of NHS organisation.2–4 One of the consequences of this trend has been to make the smaller hospital seem a near irrelevance in the NHS landscape. Yet smaller hospitals provide care to nearly half the …
Every August, hundreds of foundation year 1 (FY1) doctors begin work in the NHS, with working out-of-hours being one of the most challenging aspects. To ensure a smooth change-over, all hospitals in the UK have locally planned compulsory induction periods. They range from 5–10 days, involving shadowing, orientation and lectures, however there are no formal requirements to utilise simulation. The following report evaluates an immersive on-call simulation that was developed and delivered as part of a hospital's FY1 induction programme in August 2018. In situ simulation is the gold standard for simulation activities due to increased psychological fidelity which, rather than technical fidelity, is crucial to learning transfer; hence this was the basis of this programme.1 The goal was to improve orientation and confidence with technical and non-technical skills associated with on-calls. There is some published evidence of simulated on-calls, however these are aimed at students and have evaluated generalised on-call confidence rather than specific skills.2,3 Twenty-eight new FY1 doctors underwent a 2.5 hour on-call in situ simulation during their induction week which required one consultant and six foundation year 2 doctors to facilitate. The simulation ran three times throughout …
As the surgical workforce, surgical techniques and patient expectations change, the Royal College of Surgeons of England is actively engaged in taking forward the recommendations of its Future of Surgery Commission. Here the commission's chair articulates the implications for smaller hospitals and the need for achieving interoperability and safe sharing of patient data across different systems, so enabling immediate access to patients' records across healthcare organisations; extension of regulation to surgical care practitioners, reflecting the recent decision to regulate physician associates and physician assistants; introducing a UK-wide registry of surgical devices, with tracking for implantable devices; implementing a robotics strategy to help the NHS plan and purchase new surgical robotics, as well as monitor their use and the effect on outcomes; and investing in genomic medicine and artificial intelligence for diagnostics, and in stem-cell research for treatment.
Smaller acute general hospitals, especially those in remote and rural locations, provide vital services to their populations who might otherwise struggle to access safe and effective healthcare. By the nature of their location and, often also reputation, these hospitals are challenging to resource in terms of staffing which makes traditional models of care very difficult to sustain. This article proposes adjustments to the conventional model of acute care that is designed to ensure that patients presenting acutely receive a rapid assessment, according to their medical needs. This is delivered by a multiprofessional team of clinicians delivering care focused on the patient. Hand-offs between clinical teams and duplication of clinical assessment is kept to a minimum. The goal is to deliver care from the most appropriate professional or team as rapidly as possible post presentation, with alternatives to hospital admission being prioritised where appropriate. Early evidence is that this model of care is safe and effective, if delivered within a suitable physical environment for its provision. It is designed to deliver a sustainable model of working for the smaller, remote, rural or challenged healthcare system and is likely to be applicable to such systems elsewhere.
Intoxicated, antagonistic and with no clear reason for being in the emergency department, a patient discloses information strongly suggesting that he has been a victim of labour exploitation, the most common form of modern slavery. This significant consultation demands prioritisation and trauma-informed expertise. As well as addressing immediate healthcare needs and safety, the complex sequelae of modern slavery must be considered. Victims are encountering healthcare services. Yet healthcare professionals don't feel equipped to recognise the signs or know what questions to ask, while key gaps within the healthcare service prevent these patients receiving the support they need. At all levels of professional development, the practice of safeguarding is not prioritised. This is due to lack of effective training and emphasis on softer communication and safeguarding skills. Simulation training provides a safe, educational environment to build confidence and practice conducting these challenging, complex consultations. Safeguarding leads, who receive these referrals from frontline staff, should be equipped to understand the complexity of modern slavery and the strengths and weaknesses of the support services available. Finally, healthcare professionals must be involved in shaping the wider national survivor-focused response to modern slavery.
The theme of this edition of the Future Healthcare Journal is education. Education which embraces training, learning, leadership and giving a voice to all. It’s hard to think of a set of subjects more relevant to developing an effective workforce for the NHS over the next 10 years and beyond. Drs Jo Szram and Emma Vaux, as associate editors, have done a fantastic job in drawing together a spectrum of articles across these areas and their own editorial puts these papers in context. In addition to the themed papers we focus on a wide variety of topics. Closely linked to the education theme is a paper by Dr Shuaib Quraishi and colleagues on the new General Medical Council curriculum for internal medicine and the application of ‘capabilities in practice’ rather than the previous use of ‘competencies’.1 The article describes the evolution of the new curriculum and the testing that was integrated into the development process. As this work progresses, trainees and, in particular, …
We are delighted to introduce an issue of FHJ in which we have focused our minds, and hopefully those of our readers, on the ever-present activity of all clinicians (and humans) – learning. This is such a wide topic, so we have considered a number of different dimensions with the confidence that these will stimulate interest, debate and discussion. Firstly, we have considered the important issue of learning to speak up in our workplaces. The need for us all to feel able to speak up within a culture of psychological safety is crucial and the national gurdian for the NHS, Dr Henrietta Hughes, describes what has happened since the introduction of freedom to speak up guardians to the NHS, and her intended future developments of the role.1 Barriers perceived by trainees in being able to raise concerns, and possible ways to overcome these are described by Dr Irene Gafson and colleagues.2 In addition, in response to the lack of gender balance on panels, …
ABSTRACT Physician associates (PAs) are a relatively new medical professional group working as part of the multidisciplinary team to deliver patient care. This article aims to look at how PAs can work effectively in teams, highlighting the benefits and current working practices of PAs across the NHS and address the concerns and challenges raised.
Medical education is changing. Simulation is increasingly becoming a cornerstone of clinical training and, though effective, is resource intensive. With increasing pressures on budgets and standardisation, virtual reality (VR) is emerging as a new method of delivering simulation. VR offers benefits for learners and educators, delivering cost-effective, repeatable, standardised clinical training on demand. A large body of evidence supports VR simulation in all industries, including healthcare. Though VR is not a panacea, it is a powerful educational tool for defined learning objectives and implementation is growing worldwide. The future of VR lies in its ongoing integration into curricula and with technological developments that allow shared simulated clinical experiences. This will facilitate quality interprofessional education at scale, independent of geography, and transform how we deliver education to the clinicians of the future.
ABSTRACT Background Behavioural insights or ‘nudge’ theory suggests that non-directional interventions may be used to modify human behaviour. We have tested the hypothesis that the provision of the cost of common blood tests with their results may modify subsequent demand for blood assays. Methods The study design was a prospective controlled intervention study. The individual and annual institutional cost of full blood count (FBC), urea and electrolytes (U&E) and liver function test (LFT) blood assays were added to the electronic results system for inpatients at the intervention teaching hospital, but not the control hospital. Results In the 12 months after the intervention was implemented, demand for FBC dropped by 3% (95% confidence interval (CI) 1–5; p<0.001), U&E by 2% (95% CI 0–4; p=0.054) and there was no change in demand for LFT compared to the control institution. Conclusions Providing cost feedback to clinicians for commonly used blood tests is a viable intervention that is associated with small reductions in demand for some, but not all blood assays. As this is an easily scalable approach, this has potential to enable efficient healthcare delivery, while also minimising the morbidity experienced by the patient.
ABSTRACT Introduction Delirium is common in the perioperative setting, particularly in those admitted with a neck of femur fracture. It is associated with poorer outcomes, including increasing mortality, morbidity and prolonged hospital stay. It is often poorly recognised and under diagnosed. Setting An urban district general hospital. Intervention A steering group was set up and used ‘plan, do, study, act’ methodology to develop a diagnostic pathway and educational programme for all staff working with patients admitted with neck of femur fracture. Results There was an increase in the multidisciplinary teams use of the 4AT delirium screening tool by 26% (p=0.0008). Staff surveys indicated an increase in the knowledge of delirium and confidence at explaining it to patients. Discussion By increasing staff confidence and use of recognised screening tools it is hoped that accurate diagnosis of this perioperative complication is improved, leading to improved management of these complex patients.
