Posts from the “Uncategorized” Category

Our Death Certification Review Service is helping drive improvement in how doctors record information on deaths – George Fernie

Posted on October 3, 2018

We recently published the third Death Certification Review Service annual report. The report highlights that, since the Death Certification Review Service was established as part of Healthcare Improvement Scotland in 2015, there has been a significant reduction in errors made by doctors in the information they complete when someone dies. In fact, accuracy errors by certifying doctors have reduced by more than a third – 37% to be precise – since the service was introduced to help improve the quality and accuracy of Medical Certificates of Cause of Death (MCCD). An MCCD is the form that must be completed by a certifying doctor when someone dies in Scotland. The MCCD provides a permanent legal record of the death, records information about the death (including…

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How sharing intelligence can help keep people safe – Donald Morrison

Posted on September 28, 2018

A number of years ago I was watching the news on TV and there was a tragic report about a child who had died as result of domestic abuse. Scrolling on the TV screen was a list of the numerous occasions when this child had come into contact with health or social care services. The pressure these services were working under was acknowledged, but the question remained: why did these services not communicate better with each other to see what was happening to this child and to step in? How did they miss the signs? As well as feeling sad and frustrated, it got me thinking about my own work at Healthcare Improvement Scotland. Was there anything more I could do to help avoid…

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Developing a community driven health and social care system on the Orkney Islands – Zaid Tariq

Posted on September 20, 2018

Zaid Border The Orkney Islands are unique in Scotland’s health and social care system. Home to around 21,000 people, and spread over 70 isles, these are mostly rural communities, diverse in size and setting, with fewer than 20 residents on some of the smaller islands.

And while this can complicate the delivery of joined up care, what struck me on my first visit to the islands was the passion and keenness everyone I spoke to had for improving health and wellbeing for the people there. Whether working in statutory services or the third and independent sector, they were all saying and wanting the same things.

The challenge for the Health and Social Care Partnership (HSCP) is how to develop a more singular, flexible and community-driven approach that matches their health and social care resources with community needs and priorities.

With that in mind, the HSCP asked for support as they considered different approaches to commissioning care.

“The challenge for the Health and Social Care Partnership is how to develop a more singular, flexible and community-driven approach that matches their health and social care resources with community needs and priorities.”

We initially facilitated a learning session with strategic managers on best practice and community priorities. There was clearly already very good tacit understanding of the lay of the land, which is a great place to start from.

From these discussions it became clear that a shared visual understanding of the current structure of health and social care services could enable local conversations around optimising how resources, assets and ultimately people connect on the Orkney Islands.

As a bespoke way to respond to this, our team used a technique called Integrated Systems Mapping (ISM). Working with the Health and Care Partnership team, the local authority, and third sector organisations, we spent several months building a picture of the various connections between the Orkney Islands’ current health and social care services.

We asked ourselves the question: how do we work together and build relationships to make better use of our resources?

Co-production with the partnership is key to this process and important for our future aims and ambitions to improve health and social care and wellbeing for the people of Orkney. By identifying local solutions to local needs, community is placed at the heart of the integrated health and social care system.

The map helps present something which is complex in a clear and accessible way, which is something which hadn’t been done before – this includes cross-sector adult and children’s health and care resources and Orkney’s community assets. This whole system view enables Orkney HSCP to facilitate local conversations around how the totality of Orkney Island’s health and care resources and community assets could be optimised to meet its populations needs in the future.

The map is ultimately a strategic tool that can be used to encourage conversations with all the relevant people, to think about how resources are used and distributed. By capturing and visualising clearly on one page the totality of the health and care system, it should help build a consensus locally on what needs to change, what can be refined, and what should be invested in further.

John Trainor, Head of Health and Community Care with Orkney Islands HSCP, was pleased with the technique and its results, commenting: “ISM has pulled the intelligence together in a way we haven’t done before, and it is a really useful way to present and share with others.”

In parallel to this, we’ve been working with the Care Inspectorate, Scottish Social Services Council, and others, to share learning around the Neighbourhood Care model.

“We are continuing to work with the HSCP to design working practices that are community supported, test new models of care and build on the learning from the Integrated Systems Map work.”

Based on Buurtzorg, a Dutch approach to holistic neighbourhood care, this model offers more flexible ways of working, presents opportunities for more non-formal care providers, greater self-management for workers, and the use of funds to better meet individual and service outcomes in line with self-directed support and person-centred care.

We hope this will help shape a new health and social care system for the Orkney Islands.

As I mentioned, the Orkney Islands are unique, relying on few people to have or share multiple roles in the community. Flexibility is a welcome foundation for them. For a small island community, inward investment is vital to support a thriving local economy, to support the development of integrated services, and to retain a flexible workforce.

We are continuing to work with the HSCP to design working practices that are community supported, test new models of care and build on the learning from the Integrated Systems Map work.

These approaches are a more sustainable, long-term way to address the challenges and opportunities around health and social care, in Orkney and potentially across Scotland.

For the partners and Orkney, the next step is to embrace these challenges, to build on what makes them unique. This is the spirit and the strength I saw in their communities.

Zaid Tariq is Strategic Planning Portfolio Lead with Healthcare Improvement Scotland

More information

Video – Zaid Tariq on developing a community driven health and social care system on the Orkney Islands

For more information visit the ihub website.

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The Rule of Rescue – Richard Norris

Posted on September 17, 2018

What does the story of 12 boys and their football coach rescued from an underground cave in Thailand and decisions made in Scotland about allocating healthcare resources have in common?

Many people will be aware of the recent story in the media about the rescue of 12 boys and their football coach who were trapped in an underground cave in Thailand. Huge resources were devoted to rescuing them, although there is no reliable estimate of how much the concerted rescue efforts cost. Nobody (to my knowledge) raised the issue of cost or questioned whether the amount of resource being expended could be used in better ways.

And yet, more commonly, when we are examining how we spend healthcare resource, a very major consideration is whether we are spending money effectively, i.e. getting the most benefit for the money we spend.

The term ‘Rule of Rescue’ was coined by Albert Jonsen, (a biomedical ethicist and author) in 1986. By this he was referring to the sense of duty we feel, as human beings, to aid or rescue others who are clearly in peril. There are many examples of this ‘rule’ in operation – rescuing people lost on mountains, from burning buildings, in shipwrecks. But this principle also extends to healthcare, as Jonsen himself says:

“Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search for the snowbound. This rescue morality spills over into medical care, where our ropes are artificial hearts, our rush is the mobile critical care unit, our teams the transplant services.”

“And yet, more commonly, when we are examining how we spend healthcare resource, a very major consideration is whether we are spending money effectively, i.e. getting the most benefit for the money we spend.”

But what happens if there is a limit to the amount of resource we can expend? Unlike in emergency situations where an instant and energetic, and sometimes ad hoc, response is required (as in the Thai cave rescue) medical rescues tend to take place within a much more structured and managed environment, where interventions are calculated, within a matrix of other possible interventions, opportunity costs, and limitations to knowledge and resource.

If the Rule of Rescue is our intuitive sense of duty to save those in peril, modern health care services, medical knowledge and technology, with its constant discovery and innovation, have created a situation in which our instincts, unfettered, could mean our entire economic output (GDP) is used in facilitating rescue. This is because the situation of peril, or avoidable death, in a medical setting, is far less a rare emergency event, and much more an ever present reality, a drama being played out in hospitals and non-medical settings all around us every day. And new technological developments, including medicines, are creating new Rule of Rescue situations, where, a few years ago, no rescue would have been possible.

So how do we decide what amount of resources to devote to rescue? Health economists have devised an approach called the QALY (quality of life year) to compare the benefits of diverse treatments, including medicines, with their costs. However, this formal calculation, based on comparing different treatments to identify the most cost-effective, can become controversial when used to make assessments on treatments for conditions that appear to evoke our ‘rule of rescue’ moral instinct, for example, expensive new drug treatments for those severely ill, but which have limited effectiveness.

One ethical issue raised by the ‘Rule of Rescue’ is visibility, in the sense that we have to be aware that someone is in danger and there is a clear opportunity to try and save their life. If we prioritise interventions based on rescuing people who are clearly present and in visible peril, there is a risk that we neglect those who are in just as much peril, but for whatever reason, are not as present or visible to us.

In the professional health care world, based on costs and benefits and calculations about the efficacy of different treatments, it seems only natural to prioritise those approaches and treatments that seem to offer the most value. However, when decisions affect real lives, to some people this calculation can seem ‘out of sync’ with the moral intuition to rescue people in peril. There is a strong pull towards rescuing in a way that precludes the calculation of cost.

Although prioritising those healthcare treatments that offer the most benefit seems a statement of the obvious, the view that we should do our utmost to alleviate avoidable deaths or suffering also seems a statement of the obvious. In practice, these two ‘statements of the obvious’ can come into conflict when allocating healthcare resources to different areas and priorities. And this is before we get into other ethical issues regarding health care allocation, e.g. the strongly held view that there should be equity of access for all.

“only by continuing to be open, and questioning, and sensitive to the conflicting viewpoints and interests, can we be certain – not that we are making the right decisions – but that we are trying our best to make the fairest decisions. And that process involves being fully aware of the opportunity costs of decisions, i.e. not just having more transparency about a priority setting decision, but also about the alternative benefits we could have realised with the funding.”

One answer that can be given is that we engage with the public to understand how they would manage the trade-off that is necessary between our natural desire to rescue, and the limitation of resources we have to carry that out. Such studies that have been done suggest that although the public, just like the professionals, holds a variety of views, a reasonable proportion of the public would be prepared to spend more resource on ‘rescue’ than is justified under strict cost benefit calculations.

For example in 2006 the NICE (National Institute for Health and Care Excellence) Citizen Council looked at the Rule of Rescue and the majority (21 out of 27 members) decided that there are occasions where extra resources, over and above the level required under cost benefit calculations, should be provided, and developed a list of examples, including where there was the chance to avoid immediate loss of life. Importantly the Citizens Council felt that society’s worth could be diminished if ignoring the Rule of Rescue appeared as inhumane, and that there was a greater societal good provided by the Rule of Rescue, that went beyond the immediate benefits to particular people.

And in practice NICE does tolerate higher costs for end of life cases and in examples of rare or severe diseases. In Scotland, similarly, the Scottish Medicines Consortium applies additional flexibility in its decision making to medicines for rare conditions or for end of life conditions, where quite usually costs of medicines can be higher. Is this fair?

It could be argued that this is unfair to patients who miss out on treatments that they would have otherwise received, if we hadn’t spent the money on ‘rule of rescue’ cases. Quite often these patients are difficult to identify, and they may not know that they have missed out, or they may be statistical, hypothetical patients in the future rather than actual patients now. This may be ethically hard to justify, but when the public have been asked for their views on this, they tend to think that we have a greater duty to help those in need now rather than those potentially in need in the future. However, just like ethical experts, the public, when consulted, don’t give us easy answers or precise formulas for resolving these issues in practice. And the ‘future hypothetical patients’ point doesn’t answer the question of whether it is fair to patients who are also in need now, but for some reason miss out. One reason they may miss out is because they do not have strong advocates in the medical world or the media to argue their case.

There is probably no perfect formula or criteria for making these decisions. It feels uncomfortable precisely because there is no right or wrong answer. However only by continuing to be open, and questioning, and sensitive to the conflicting viewpoints and interests, can we be certain – not that we are making the right decisions – but that we are trying our best to make the fairest decisions. And that process involves being fully aware of the opportunity costs of decisions, i.e. not just having more transparency about a priority setting decision, but also about the alternative benefits we could have realised with the funding.

Richard Norris works for Healthcare Improvement Scotland and is a Honorary Fellow at the University of Edinburgh.

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How we’re improving care and outcomes for people with sepsis in NHS Scotland – Calum McGregor

Posted on September 13, 2018

As a doctor in the Medical Receiving Unit at Wishaw General Hospital, I’ve seen first-hand the devastating impact sepsis can have, not only on the person who has sepsis but on their family and also on staff who are providing care. Sepsis is a life-threatening condition which arises when the body’s normal response to infection or injury overreacts and starts to harm organs and tissues. In the UK, it is estimated that there are 44,000 deaths from Sepsis each year. This is higher than deaths from heart attacks, and deaths from the three commonest cancers (lung, breast and colon) combined.

Over the last 10 years, the Scottish Patient Safety Programme (SPSP), has worked with NHS boards to reduce mortality and harm for people in a range of healthcare settings. In 2011, sepsis was identified as an important area for improvement that would support the aims of SPSP.

What we are doing

To do this, SPSP launched the Sepsis Collaborative in 2012 aiming to reduce deaths from sepsis by 10% by December 2014, by delivering earlier recognition and treatment for people with sepsis – this is important, as there is evidence that each hour’s delay in delivering antibiotics leads to the increasing likelihood of further harm and death.

“Over the last 10 years, the Scottish Patient Safety Programme (SPSP), has worked with NHS boards to reduce mortality and harm for people in a range of healthcare settings. In 2011, sepsis was identified as an important area for improvement that would support the aims of SPSP.”

Since the Sepsis Collaborative launched we have worked with clinical and improvement teams to:

Improve the recognition of sepsis through implementation of the National Early Warning Score (NEWS). NEWS is an evidence based tool that assists staff to recognise sepsis early, this has now been implemented in 14 NHS boards and the Scottish Ambulance Service. The widespread implementation of NEWS is a critical step in improving communication in patient care.
Improve the timely treatment for people with sepsis. Clinical teams have tested and implemented the Sepsis Six care bundle. Evidence tells us that reliable delivery of this care bundle can improve outcomes for people. Data shows that for patients identified as having sepsis across Scotland, antibiotic delivery within one hour increased during the Collaborative to around 80%.
Improve awareness and communication of sepsis. Sepsis has become common terminology and is a standard item on ward and hospital safety briefs and regularly highlighted in visual prompts such as ward whiteboards.
Improve education. We have developed the NEWS and Sepsis Screening App and an online training module for NEWS.

Our Impact

Since 2012, we’ve had fantastic engagement and support from NHS boards which has supported measurable benefits for patients:

Mortality rates from sepsis has fallen by 21%,
Hospital Standardised Mortality (HSMR) has fallen by 9.2% from August 2016, and
The cardiac arrest rate in general ward setting has fallen by 27% across 16 reporting hospitals.

Working on sepsis has been a lever for us to drive better recognition and timely response to people who deteriorate from causes other than sepsis. Our approach of early recognition and response has helped support NHS boards to make sepsis, and other causes of deterioration, an issue that everyone working in healthcare understands and feels empowered to improve.

“We will continue to collaborate to maintain our focus on prevention, recognition and response to deterioration across the pathway of care. I consider it a privilege to be at the centre of this work where I can not only work closely with the national SPSP team, but also with front line staff to test new ways to continually improve the care we give.”

But sepsis is not just a problem in acute hospitals. Across a range of settings, SPSP has been able to spread this work and are now supporting improvements in Maternity and Children and Primary Care and the Scottish Ambulance Service. Standardised screening tools have been developed for use in Maternity and Paediatrics, and NEWS is being widely tested and implemented in Primary and Community care settings. Primary Care and ambulance crews have started to pre-alert hospital teams when Sepsis is suspected, leading to even faster recognition and treatment of sepsis.

Over the last decade, we have made great progress, which is a tribute to the hard work, resilience and openness to improvement of staff in NHS Scotland. But there are still plenty of opportunities to reduce harm for people in health and social care. We will continue to collaborate to maintain our focus on prevention, recognition and response to deterioration across the pathway of care. I consider it a privilege to be at the centre of this work where I can not only work closely with the national SPSP team, but also with front line staff to test new ways to continually improve the care we give.

Dr Calum McGregor is Clinical Lead for the Acute Care portfolio of the Scottish Patient Safety Programme (SPSP)

More information

Visit the Sepsis Toolkit page of the ihub website

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Seeing the benefits of SIGN’s glaucoma guideline – Lisa Cowan

Posted on September 6, 2018

LC 2017.jpg Glaucoma was the third most common issue that resulted in a risk of sight loss or blindness in Scotland in 2015 and accounts for 20% of referrals from primary to secondary care. With an ageing population, those referral numbers were expected to increase.

Against that background, we produced a guideline for glaucoma referral and safe discharge in 2015. Two aims for this guideline were: to improve the accuracy of referrals of patients with suspected glaucoma from community to secondary-eye-care service, and to decrease false positive referrals to secondary-eye-care services.

Production of the guideline is in itself crucial, but just as important to the staff and clinicians who developed the guideline was to ensure that the guideline was effective, that it was used and that it made a real difference to the care that people received.

To better understand this, we looked at what had happened since the guideline was published.

Getting the message out

What we found was that over 66,800 copies of the guideline had been downloaded or distributed in the 21 months since publication. The guidelines were requested by services all over Scotland, including hospital out-patient departments, GP practices, high street optometrists, and specialist organisations such as NHS Education for Scotland and Optometry Scotland.

“Production of the guideline is in itself crucial, but just as important to the staff and clinicians who developed the guideline was to ensure that the guideline was effective, that it was used and that it made a real difference to the care that people received.”

In the guideline we outlined several suggestions that would support the implementation of it, including training and auditing of key points. The year after the guideline was published NHS Education for Scotland ran 15 training courses in 13 locations addressing the training needs identified in the guideline – 294 community optometrists attended the training events. We found that at least three secondary-eye-care services had undertaken audits relevant to the guideline. We also co-facilitated a workshop at the 2017 NES Annual Optometry Conference, focussed on the guideline and its impact.

The impact it made

Most importantly, we learned from all this work that accuracy of referrals from community optometrists had improved and that rates of false positive referrals from community optometrists have decreased since the introduction of the guideline. In addition, community optometrists reported an increased measurement and reporting of recommended parameters to ensure more accurate diagnosis, as well as reporting an increased confidence in their decision making and patient management.

Using knowledge to make improvements

Working to ensure that the right people make use of our guidelines is always a work in progress.

We found that better communication could lead to further success. For example, we found out via a survey that 92% of respondents reported they had had no communication with their local secondary care clinic.

It is clear that some aspects of the guideline have been implemented more universally than others –it’s possible that additional targeted training and education on the implementation of the guideline could lead to further improvements in referral accuracy and patient care, which would be welcomed by the optometry profession, and the wider eye care community.

“We learned from all this work that accuracy of referrals from community optometrists had improved and that rates of false positive referrals from community optometrists have decreased since the introduction of the guideline.”

Overall, the guideline appears to have been accepted as a positive move by the optometry profession, and has had a positive impact on patient care, and I know that SIGN look forward to taking this learning forward into the development of other guidelines.

Lisa Cowan is Senior Postgraduate Optometry Tutor with NES and co-author of ‘The impact of a SIGN guideline: SIGN 144 Glaucoma referral and safe discharge.

More information

To access the full guideline and impact report, visit the SIGN website.

Video: Megan Lanigan, impact report co-author, on the impact and implementation of the Glaucoma SIGN Guideline

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Why it’s time to get tough on those wilfully avoiding registration of their clinic – Tracy Birch

Posted on September 4, 2018

Independent clinics have been legally required to register their service with Healthcare Improvement Scotland for over a year. This registration process assures the public that the provider is fit for practice and provides clinics with the opportunity to demonstrate that they have met various stringent criteria. Regulation also helps to improve safety for customers and ensures that independent clinics continually ‘raise the bar’ by striving to improve the services that they provide. To date, nearly 300 clinics throughout Scotland have complied with the new legal requirement to register their business. “We have recently taken the step of writing to independent clinics to let them know that unregistered services who submit completed applications on or after 1 October 2018 must cease trading until the registration…

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