Archive for the ‘Uncategorized’ Category

Integrated Care

Monday, February 18th, 2013

What is integrated care?

Integrated care means care which is organised around the needs of individual patients. . Integrated care is not about structures, organisations or pathways – it is about better outcomes for service users.

There is now a clear consensus that successful integrated care is primarily about patient experience, although all dimensions of quality and cost-effectiveness are relevant

Further, integrated care is clearly not an end in itself, but is an essential tool to improve outcomes for individuals and communities.

In order to show why a smooth journey through the NHS is desirable, it is important to understand what a non-integrated system looks like and the experience that service users face when navigating through a fragmented system. For e.g. a diabetic patient may need services of the following: cardiology team, GP, practice nurse, renal team, diabetic team, diabetes specialist nurse, GP, practice nurse, vascular team, foot team, eye team, retinal screening team etc. This illustrates the complexity service users must navigate and, therefore, highlight the need of a more integrated system.

What are the problems with the current non- integrated care system?

  • Lack of ‘ownership’ for the patient and her problems, so that information gets lost as she navigates the system
  • Lack of involvement by the user/patient in the management and strategy of care
  • Poor communication with the user/patient as well as between health and social care providers
  • Treating service users for one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment
  • Lack of integration between health and social care- although decisions made in the social care setting affect the impact of health care treatment, and vice versa.

Is integrated care really needed?

The NHS is faced with the major challenges of using resources more efficiently and of meeting the needs of an ageing population in which chronic medical conditions are increasingly prevalent. The key task therefore is to implement a new model of care in which clinicians work together more closely to meet the needs of patients and to co-ordinate services and enable people with complex needs to live healthy, fulfilling, independent lives.

This model of integrated care would focus much more on preventing ill health, supporting self-care, enhancing primary care, providing care in people’s homes and the community, and increasing co-ordination between primary care teams and specialists and between health and social care

Integrated care is the only way to make health system sustainable in the long term by transferring care out of expensive hospitals and nursing homes in the community or even in patients own home.

What are the aims of integrated care?

  • Improved patient experience- by providing a seamless service reducing gaps and duplication in service
  • Improved patient outcomes i.e. improved quality
  • Improved cost effectiveness of care by improving system efficiency
  • Better experience for medical staff

However it is important to point out that more integrated care is not always the right answer to improving the patient’s experience and system efficiency. Integrated care also carries some risks, such as that of reducing competition, and incentives to improve quality.

How would you develop integrated care?

  • There are no general rules
  • Benefits depend on the specific design and approach to integrated care  based on local circumstances
  • Learn from successful examples
  • Take patients view into account

Successful integration depend on which approach is used, how well it is implemented, and on features of the environment in which a provider is operating, including the financing system.

What are the barriers to integration?

  • Organisational boundaries- Primary or community care and secondary care or hospital care, social care (provided by LA) and health care- making it difficult for services to be properly coordinated. This leads to gaps and duplication of services. In a fully integrated system, patients’ needs not organisational boundaries would decide how care is provided
  • Lack of shared record keeping about a patient (GPs, hospital, nurses, social care workers)- hence patient and carers end up telling the same story to healthcare professionals. Lack of this info also cause poor care for e.g. a patient may turn up in ED and lack of info would not help

There are other barriers like:

  • Payment by Results provides hospitals with some incentives to keep patients in hospital rather than treating them in the community.
  • Service users choosing alternative providers: service users have freedom of choice regarding their elected place of care. However, this freedom can create deviations from the planned pathway of care and may cut across attempts to provide integrated care.

How can organisations enable integrated care?

Several measures could potentially mitigate these barriers. They may include:

  • Personal budgets
  • Make it easier for service users and carers to coordinate and navigate. This implies that every service user with long‐term or complex needs has easy access to a “care coordinator”, or federations of GP practices  who can act as the coordinating point for all of their care.
  • Information is a key enabler of integrated care. Care records should be electronic and accessible at the point of care throughout the whole care journey, regardless of sector or provider

Can we do it?

NHS has spent the last decade or more in ensuring faster and easier access to GPs and consultants; reducing waiting times etc. and indeed vast progress has been made in these areas.

This was made to matter to the managers and clinical leaders- we need the same focus- the same urgency and importance being attached to patients with long term conditions, frail older people- and only when it matters that integrated care will become a reality.

What can we do to facilitate integrated care?

  • Clear policy directive as to why integrated care is important- we spend too much in acute hospitals, care to individual patient is poor and if we don’t change the system- it will never become a sustainable system
  • Sustained support for people seeking to develop integrated care locally- support in the form of using data analysing population need, project management,
  • Evaluation of integrated care initiatives- so that we can learn

To me it means that things are joined up, not fragmented into different parts with no one person informing all the relevant agencies about your needs and condition. Importantly also integrated care must include the persons wishes and needs, too often at the moment the person is left out of the loop! In my experience I am ‘told’ what I can and can’t have regardless of my needs and wishes. This is the same for many unfortunately.

Psychometric Tests

Saturday, April 21st, 2012

Increasing number of trusts is employing psychometric tests as part of consultant recruitment process.

What is the purpose of psychometric tests?

These tests (sometimes known as personality profiling) are used to assess ability, performance and behaviour of the candidate. These tests can provide an insight into assess personal qualities, such as personality, beliefs, social competence, values and interests and to measure motivation or drive.

They are used to provide employers with a reliable method of selecting the most suitable job applicants or candidates for the job advertised.

How is psychometric test conducted?

The test generally consists of a series of multiple choice questions. Questions focus on specific traits of the individual’s personality.

The questionnaire is subsequently assessed by a psychologist or other trained assessor. The questionnaire may also be followed by an interview with a psychologist/trained assessor to validate the results further.

How do psychometric test results impact on consultant recruitment?

The tests provide additional useful information to inform the final selection of the candidate. The test results may be used in the interview to guide specific questions.

These tests are not about passing or failing but about giving a profile of the candidate  to the employer, whose task it is to match an applicant to the job or work place.

Can you prepare for the psychometric test?

No, because there are no right or wrong answers. Further, each department look for specific personality traits in the candidates and trying to second guess the answers may be counter- productive.

Tip: Try and provide honest answers rather than perceived best answer lest you come across as inconsistent.


Health and Social Care Bill

Tuesday, April 10th, 2012

The Health and Social Care Bill overcame its last hurdle after passing through the Houses of Lords and Commons and has received Royal Assent . There has clearly been much difference of opinion and debate regarding the content and potential impact of the Bill.

NHS constitution updated

Monday, April 2nd, 2012

An updated NHS Constitution was published on 8th March 2012. The new version of the Constitution, which applies to England, replaces the previous version of the Constitution published in 2010. There is also an updated handbook to accompany it.

As part of a series of measures intended to highlight the importance of whistleblowing in the NHS, the updated Constitution includes:

  • an expectation that staff should raise concerns at the earliest opportunity
  • a pledge that NHS organisations should support staff when raising concerns by ensuring their concerns are fully investigated and that there is someone independent, outside of their team, to speak to
  • clarity around the existing legal right for staff to raise concerns about safety, malpractice or other wrong doing without suffering any detriment

The hope is that the above change in NHS constitution would make it easier for staff to raise concerns about poor patient care and thus create a culture of patient safety.

New GMC guidance on Leadership and Management (2012)

Tuesday, February 14th, 2012

The General Medical Council has published new guidance on leadership and management for doctors that spells out their responsibility for the safety and wellbeing of patients when performing non-clinical duties. Leadership and Management for All Doctors, which comes into effect on 12 March, is available on the GMC website at

The guidance sets out the wider management and leadership responsibilities of doctors in the workplace, including in relation to employment issues, teaching and training, planning, using and managing resources, raising and acting on concerns and participating in service improvement and development. The principles in the guidance apply to all doctors regardless of whether they work directly with patients or whether they have a formal management role.

Doctors are still accountable to the GMC for their non-clinical duties, such as their behaviour as a manager, the guidance states.

The guidance states that being a good doctor involves more than simply being a good clinician. It involves commitment to improving the quality of services and to demonstrate leadership in managing and using resources effectively.

Doctors should also respect their colleagues and tackle discrimination where it arises, it adds.

The guidance reinforces that doctors should be prepared to contribute to discussions and decisions about the allocation of resources and the setting of priorities in any organisation in which you work and the commissioning of services for the wider population of patients.

The guidance also contains a section on allocating resources, in particular exploring some of the areas that doctors will need to think about when resources are limited, including:

  • Considering the needs of patients AND the wider population.
  • Being familiar with local and national policies on access to treatments.
  • Making sure that decisions about access to care are based on clinical need and the likely effectiveness of treatments.
  • Being honest with patients about then decision making process.

New GMC guidance ‘Raising and acting on concerns about patient safety’ (2012)

Tuesday, February 14th, 2012

Discuss the new GMC guidance ‘Raising and acting on concerns about patient safety’ (2012)?

The guidance comes into effect on 12 March 2012 and will replace Raising concerns about patient safety (2006). The publication of Raising and acting on concerns about patient safety is especially timely given the recent findings of the Mid Staffordshire enquiry.

Raising and acting on concerns about patient safety (2012) sets out that that all doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity is being compromised.

The guidance is separated into two parts.

Part 1: Raising a concern gives advice on raising a concern that patients might be at risk of serious harm, and on the help and support available to doctors.

Part 2: Acting on a concern explains doctors’ responsibilities when colleagues or others raise concerns with them and how those concerns should be handled.

Part 1: Raising a concern

  1. All doctors have a duty to raise concerns
  2. Overcoming obstacles to reporting

You may be reluctant to report a concern for a number of reasons. For example, because you fear that nothing will be done or that raising your concern may cause problems for colleagues; have a negative effect on working relationships; have a negative effect on your career; or result in a complaint about you. If you are hesitating about reporting a concern for these reasons, you should bear the following in mind.

  • You have a duty to put patients’ interests first and act to protect them, which overrides personal and professional loyalties.
  • The law provides legal protection against victimisation or dismissal for individuals who reveal information to raise genuine concerns and expose malpractice in the workplace.*
  • You do not need to wait for proof – you will be able to justify raising a concern if you do so honestly, on the basis of reasonable belief and through appropriate channels, even if you are mistaken.
  1. Steps to raise a concern
  • Local incident reporting systems
  • If you have reason to believe that patients are, or may be, at risk of death or serious harm for any reason, you should report your concern to the appropriate person or organisation immediately. Do not delay doing so because you yourself are not in a position to put the matter right.
  • Report to the regulatory body (GMC) in the following circumstances: a.If you cannot raise the issue with the responsible person or body locally because you believe them to be part of the problem. b. If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action. c. If there is an immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene
  • Making a concern public: You can consider making your concerns public if you: a. have done all you can to deal with any concern by raising it within the organisation in which you work or which you have a contract with, or with the appropriate external body, and b. have good reason to believe that patients are still at risk of harm, and c. do not breach patient confidentiality.

Wherever possible, you should first raise your concern with your manager or an appropriate officer of the organisation you have a contract with or which employs you – such as the consultant in charge of the team, the clinical or medical director or a practice partner. If your concern is about a partner, it may be appropriate to raise it outside the practice – for example, with the medical director or clinical governance lead responsible for your organisation. If you are a doctor in training, it may be appropriate to raise your concerns with a named person in the deanery – for example, the postgraduate dean or director of postgraduate general practice education.

Part 2: Acting on concerns

All doctors have a responsibility to encourage and support a culture in which staff can raise concerns openly and safely. Concerns about patient safety can come from a number of sources, such as patients’ complaints, colleagues’ concerns, critical incident reports and clinical audit. Concerns may be about inadequate premises, equipment, other resources, policies or systems, or the conduct, health or performance of staff or multidisciplinary teams. If you receive this information, you have a responsibility to act on it promptly and professionally. You can do this by putting the matter right (if that is possible), investigating and dealing with the concern locally, or referring serious or repeated incidents or complaints to senior management or the relevant regulatory authority.

Who can help if you are not sure what to do? Answer here

Link to the guidance

There are only three true job interview questions

Saturday, February 11th, 2012

The only three true job interview questions are:

1.  Can you do the job?- strengths
2.  Will you love the job?- motivation
3.  Can we tolerate working with you?- Fit

Read more

Useful article for interviews

Monday, December 5th, 2011

Mid Staffordshire NHS Inquiry

Sunday, November 27th, 2011

On 17 March 2009 the Healthcare Commission published its report into the severe failings in emergency care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2008.

Robert Francis QC led an inquiry following these concerns. The inquiry report made many recommendations and all of them were accepted by the Department of Health and the Trust Board.


The report concluded that the trust did not have a grip on operational and organisational issues, with no effective system for the admission and management of patients admitted as emergencies. Nor did it have a system to monitor outcomes for patients, so it failed to identify high mortality rates among patients admitted as emergencies. This was a serious failing.

When the high rate was drawn to the attention of the trust, it mainly looked to problems with data as an explanation, rather than considering problems in the care provided. The trust’s board and senior leaders did not develop an open, learning culture, inform themselves sufficiently about the quality of care, or appear willing to challenge themselves in the light of adverse information.

The clinical management of many patients admitted as emergencies fell short of an acceptable standard in at least one aspect of basic care. Some patients, who might have been expected to make a full recovery from their condition at the time of admission, did not have their condition adequately diagnosed or treated.  The trust was poor at identifying and investigating such incidents.

In the trust’s drive to become a foundation trust, it appears to have lost sight of its real priorities. The trust was galvanised into radical action by the imperative to save money and did not properly consider the effect of reductions in staff on the quality of care. It took a decision to significantly reduce staff without adequately assessing the consequences. Its strategic focus was on financial and business matters at a time when the quality of care of its patients admitted as emergencies was well below acceptable standards.

Based on the above findings, the inquiry reported a number of lessons relevant to the whole NHS. These include the need for:

• Trusts to be able to get access to timely and reliable information on comparative mortality and other outcomes, and for trusts to conduct objective and robust reviews of mortality rates and individual cases, rather than assuming errors in data.

• Trusts to identify when the quality of care provided to patients admitted as emergencies falls below acceptable standards and to ensure that a focus on elective work and targets is not to the detriment of emergency admissions. Care must be provided to an acceptable standard 24 hours a day, seven days a week.

• Trusts to ensure that a preoccupation with finances and strategic objectives does not cause insufficient focus on the quality of patients’ care.

• Trusts to ensure that systems for governance that appear to be persuasive on paper actually work in practice, and information presented to boards on performance (including complaints and incidents) is not so summarised that it fails to convey the experience of patients or enable nonexecutives to scrutinise and challenge on issues relating to patients’ care.

• Senior clinical staff to be personally involved in the management of vulnerable patients and in the training of junior members of staff, who manage so much of the hour-by-hour care of patients.

• Trusts to identify and resolve shortcomings in the quality of nursing care relating to hygiene, provision of medication, nutrition and hydration, use of equipment, and compassion, empathy and communication.

• Good handovers when reorganisations and mergers occur in the NHS.

• PCTs to ensure that they have effective mechanisms to find out about the experience of patients and the quality of care in the services that they commission.


Collins Report summary and Progress

Sunday, November 27th, 2011

Collins Review (published Oct 2010)

Foundation for Excellence: An Evaluation of the Foundation Programme

The report was commissioned by Medical Education England (MEE) to formally evaluate the Foundation programme. The Terms of Reference for the Evaluation were to assess how successfully the Foundation Programme is delivering against its original objectives, as well as against the future needs of the National Health Service and of trainees. The Evaluation was to recommend changes to the Foundation Programme to ensure that the first two postgraduate years deliver against future needs.

The Collins Review of Foundation Training has been published. The main recommendations are that the length of the Foundation Programme should remain unchanged at two years, but this should be reviewed in 2015 when the impact of the General Medical Council (GMC) recommendations in Tomorrow’s Doctors will be clearer, and that action should be taken to strengthen supervision for Trainees, many of whom have had to act beyond their level of competency. The review also recommended that trainers should be supported in providing the supervision for the trainees.

Other recommendations included:

  1. Standardised recruitment system for selection into training
  2. Need to define the balance between service and educational needs. It is essential that, in addition to delivering patient care, Trainees receive protected time with which to complete their Training. Failure to do so could lead to a generation of inadequately trained doctors and, in turn, compromise patient safety.
  3. The Foundation Programme curriculum should be revised to give greater emphasis to the total patient, long-term conditions and the increasing role of community care. It should also reflect the changing ways of working, in particular the need for team-working skills within a multi-professional environment.
  4. The successful completion of the Foundation Programme should normally require trainees to complete a rotation in a community placement, e.g. community paediatrics, general practice or psychiatry.  The distribution of specialty posts in the Foundation Programme is predominantly in two specialties and this must be reviewed by 2013 to ensure broader based beginnings, to share the supervision of trainees among a wider number of supervisors and to ensure closer matching with current and future workforce requirements.
  5. The importance of learning resources including skills labs and simulated patient environments is reaffirmed. Concerted efforts need to be made across the different organisations involved to co-invest in facilitating innovations in the delivery of education and training.
  6. Assessment is excessive, onerous and not valued: The range of assessment tools and the number of times assessment must be repeated in the Foundation Programme should be reviewed, with a view to reducing these to the minimum required by 2013. The opportunity to avoid repetitive assessments, by improved transfer of information between undergraduate and postgraduate schools, should be actively explored. Feedback from patients who have been in contact with the Foundation doctor should be part of assessment by 2013 and the GMC should be invited to oversee research to identify best practice in this regard.
  7. Inadequate transfer of information about trainees: In the interests of patient safety and in order to help trainees to address issues which have been identified, the transfer of relevant information about medical students and trainees across the continuum of education and training must take place (within carefully defined limits) by 2012.


Progress on the Collins Review:

The Academy of Medical Royal Colleges has revised the foundation programme curriculum for trainees who start in 2012 to deal with some of the concerns raised by John Collins’s review of the programme in 2010.

The updated curriculum aims to meet the purpose of the foundation programme and includes high level descriptors, differentiating between F1 and F2 outcomes, after the review by Professor Collins and Medical Education England said that the programme “lacks a clearly articulated and generally accepted purpose.”

Greater emphasis is given to long term conditions, in response to comments that the syllabus was too biased toward the acutely ill patient; and the “total patient” and the increasing role of community care are also given more precedence.

Formal assessment during foundation training will take place in supervised learning events evenly spread throughout each placement, instead of workplace based assessment. The Collins report described the current arrangements for assessment of foundation trainees as “excessive, onerous and not valued” and recommended that the number of times that foundation doctors are assessed should be cut.