Why nursing makes such a difference for us all – Ruth Thompson

Posted on May 12, 2022

Ruth Thompson, Associate Director of Nursing & Midwifery at Healthcare Improvement Scotland, started her nursing career in coronary care, and today celebrates International Nurses Day.

I started my nursing career in Glasgow, training at the Victoria Infirmary. I loved my training, so many of the registered staff were generous of their time and invested in the development of the next generation of nurses, something I try to replicate and support. During my training my biggest struggle was sewing-up my starched lace cap!

As a registered nurse I worked within Coronary Care, where I developed my love of cardiac medicine, Acute and General Medicine, starting as a staff nurse progressing to senior charge nurse, directorate senior nurse manager and then to chief nurse of both Hairmyres Hospital and Monklands Hospital in Lanarkshire.

I then joined Scottish Government as a professional advisor working with the Scottish Executive Nurse Directors to maximise the impact of robust workforce planning on patient safety and quality of care, and to reduce the reliance on supplementary staffing. I joined Healthcare Improvement Scotland in 2019, transitioning the Healthcare Staffing Programme from Scottish Government, before successfully securing the Associate Director of Nursing and Midwifery post.

Caring

During the pandemic I supported several NHS boards. Every day I witnessed nurses going above and beyond, working in new roles, environments, delaying their retirement plans or indeed coming out of retirement to support colleagues and services. All done with a can-do attitude, humour and humility. I also required ED treatment myself, the staff were amazing, kind and caring. Whilst not a surprise to me, I was overwhelmed.

I have been truly blessed to work with many inspirational nurses, who work tirelessly to enhance their own skills and knowledge to improve the care, experience and outcomes for patients.

I don’t think I could have made a better career choice, my experiences whether they made me laugh or cry have been wonderful learning opportunities and shared with fabulous colleagues of many professions.

Unique

For me, nurses are in a unique position to provide the continuum of care across the age spectrum, supporting people to manage their own health and providing that additional support when people are unable to meet their own needs. As a nurse you see people, both patients and their families, at their most vulnerable and the trust placed in you is humbling.

I believe the greatest improvements are those challenges identified and owned by the team; they know their clinical area, the ideas for improvement and then prioritise their improvement programme. Undertaking leadership walk-rounds or “back to the floor days” was a great opportunity for teams to share their successes using the improvement boards and safety crosses and for me to see them in action. Their pride in the improvements made to patient safety and care was palpable.

As a chief nurse, embracing the work of the Scottish Patient Safety Programme (SPSP) we worked tirelessly to move from the traditional ‘bed meeting’ to the hospital safety huddle. Changing the focus from an ED wait for a bed to whole site responsibility for a patient safety issue, using data to understand the blockages in the system and testing new ways of working. This significantly improved the ED quality standard performance and reduced the number of lengthy waits for patients

Impact

The SPSP programme was the foundation stone to improving patient safety and care, this was then strengthened by the Excellence in Care programme which specifically identified the impact of nursing care. None of the quality improvement work can be delivered without having the right number of staff with the right skills at the right time and this is where our Healthcare Staffing Programme supports the delivery of safe, effective care.

Nurses are educated, knowledgeable and skilled practitioners, regulated by the NMC.

I hope that nursing continues to balance the art and the science, both are equally important to patients and their families. I hope to see more nurse-led services. The enhanced and advanced skills of nurses allows patients to be assessed, treated and discharged by nurses, allowing professional relationships to flourish.

Ruth Thompson is Associate Director of Nursing & Midwifery at Healthcare Improvement Scotland.

More information:

The NMAHP directorate (Nurses, Midwives and AHPs) provides professional support and leadership, stimulating improvement in care and collaboration with multidisciplinary teams in HIS and the wider health and care system.

Visit our website for more information.

Categories: Uncategorized

Quality improvement is continuing to support positive changes in maternal and newborn care in Scotland – Angela Cunningham

Posted on May 4, 2022

Angela Cunningham is our Midwifery Clinical Lead for our organisation. Angela has practised as a midwife for over 39 years in both Scotland and England. To mark International day of the Midwife, Angela explains how quality improvement continues to support real changes for mothers and babies in Scotland. Angela encourages all staff working in maternity services in Scotland to engage with quality improvement. Our organisation offers virtual visits, informal meetings and a range of webinars, all aimed at improving outcomes.

As a student midwife in the early 1980’s, and following that practicing as a midwife, we really did not have access to the levels of data immediately available to us now. By the time we had access, the data was often two to three years out of date. We all thought things had improved, we were doing it differently and doing it better. However, we had no up-to-date data to support these claims.

Now we have access to up-to-date data, we can track what is happening in the system and we can put in place systems and processes, tried and tested, by using the PDSA (Plan Do Study Act) methodology.

Safe and respectful childbirth should be the right of every woman. This is never more important than now, following the publication of the Ockenden report, which criticises the care delivered to women and families. We all need to hold up that mirror and ensure we are the best we can be and offer true informed consent to the users of the services.

Improved outcomes

In Scotland, through the Scottish Patient Safety Programme’s Maternity and Children’s Quality Improvement Collaborative (SPSP MCQIC), we continue to work hard to improve outcomes for babies, children and mothers. Our work in the area of stillbirth is recognised as world leading. From the inception of the programme in 2013, MCQIC has supported NHS boards to understand their local data and introduce changes to support efforts to reduce stillbirth rates. As always this is ongoing work. In the NHS boards, colleagues are passionate regarding our aim to further reduce the stillbirth rate in Scotland. As the Midwifery Clinical Lead for Healthcare Improvement Scotland, working with the multidisciplinary team, I am really proud to be part of a programme which has helped services make changes which mean more mothers taking their healthy babies home to start a new family. When all is said and done this is our purpose at Healthcare Improvement Scotland.

The introduction of the Scottish Patient Safety Programme gave maternity staff the opportunity to run small tests of change through the Model for Improvement and Plan Do Study Act (PDSA) process. These incremental changes have had a major impact on outcomes, giving staff permission to make changes which have improved outcomes for families across Scotland. Applying Quality Improvement (QI) methodology has helped to develop a consistent approach to service delivery at local and national level. It has improved communication between teams and more importantly improved the quality of the care and advice given to women and families. When I hear stories from frontline staff about the difference they have made to the families they work with it makes me very proud that in the background we in HIS are contributing to this through #SPSPMCQIC

Engaging with the clinical community

Everything we do is based on improving outcomes and we do this by engaging with frontline clinical staff. Safety is paramount in maternity services. Across the UK and the world, too many women and babies are still dying in pregnancy and childbirth. For some of those dying in pregnancy, experiencing a stillbirth, a neonatal death or a baby harmed at birth, it is due to systems and process failures and human error. We all have a responsibility to do everything we can to learn from things that go wrong, listen to the parents involved, as they are closest to the process and know the timelines of what happened to them, and support staff through the learning from adverse events process in a supportive environment.

Fast paced and making a difference

Working in Healthcare Improvement Scotland has been strange over the last two years. However, we have risen to the challenge, engaged without colleagues remotely and were involved in the implementation of the home monitoring and Near Me technology. It was amazing how quickly using the PDSA methodology that we could implement a change safely and rapidly. I’m part of the team that supports continuous improvement and the re-design of services for the better in healthcare settings. My training with patients and clinicians gave me transferable skills in negotiation and communication so I can engage in discussions with the same clinicians I am working with now. The training, coaching and mentoring support that I have received since I started has been invaluable and it has helped me become more confident in my role. If you want to work in a fast-paced and exciting team where you can make a huge difference in improving healthcare services, becoming an improvement advisor is the first step towards that goal.

I would recommend working in Healthcare Improvement Scotland to any colleagues. No matter what your background or previous experience, we can learn from you and you can learn from us.

‘All share, all learn’ really is our moto.

Angela Cunningham is our Midwifery Clinical Lead.

More information

More examples of the work of SPSP MCQIC and resources to help make maternity care as safe as possible are available on our website: www.ihub.scot.

Categories: ihub

Prison pilot scheme proves its worth during pandemic – Dr Steve Conroy

Posted on April 6, 2022

COVID-19 has created new challenges for the delivery of treatment and care to individuals with a drug problem within the prison population. Dr Steve Conroy tells us how the rapid rollout of a successful pilot scheme involving Healthcare Improvement Scotland has helped both prisoners recovering from addiction and the staff who are there to treat them.

Treating opiate addiction takes time. The most frequently prescribed treatments (opiate agonist therapy, or OAT) need to be taken every day, and it’s estimated that there are 1800 people in prison in Scotland who need it. Every day, each individual will be taken to and from a dispensing area by Scottish Prison Service staff and have their medication supervised by at least two NHS staff. That’s around 12,500 contacts between patients, the clinicians who treat them and the prison staff whose role is to facilitate that treatment every week.

In HMP Shotts where I work, over 170 of the 545 people in custody are prescribed OAT. That amounts to 63,145 interactions with them across the space of a year simply to administer their medicine. That’s a lot of time on the part of both staff and prisoners that might be better spent on work which can support them to recover from addiction in other ways. It’s also time that could be spent supporting other prisoners with other vital rehabilitation work. Throw a pandemic into the mix, where physical distance and constant cleaning of contact surfaces is vital, and those timeframes increase even further.

A vital decision

Generally, the OAT of choice is methadone, with far fewer patients on oral buprenorphine products. Buprenorphine, although a very valuable medicine in treating addictions, comes with many problems in the prisons, where it can be used as currency – creating problems with diversion, bullying and coercion. But it’s used because methadone is not a suitable treatment for all patients. Thanks to a decision taken by the Scottish Medicines Consortium in August 2019, there is now an alternative to daily treatment.

Buvidal is a form of buprenorphine which is a longer acting treatment and can be given monthly or weekly through a slow-release injection compared to daily doses of oral forms. When given within a framework of medical, social and psychological treatment, it may enable patients to focus on recovery and returning to normal daily routines without the daily visits to a pharmacy to receive treatment.

Time for change

Following the SMC’s decision, Healthcare Improvement Scotland’s Prisoner Healthcare team, with whom I work closely, began looking at a pilot scheme for the medicine in prisons. A business case was approved by Scottish Government in January 2020. But as the COVID-19 pandemic progressed, it became clear that the reasons to support the pilot became even more compelling and the team was asked to scale up their proposals.

Under our revised plan, all prisoners with at least six months left to serve of their sentence would be transferred to the new form of buprenorphine during the pandemic, provided patients gave consent to switch treatment.

As well as supporting social distancing measures, our proposals also meant, in theory, that staff and patients alike would have more time to spend on other activities which could support recovery from drug addiction – within the parameters afforded by COVID-19 restrictions. While it’s too early for data to confirm this, logic tells us that if we only see someone twice in 28 days rather than 28 times, staff and prisoners will have more time to spend on other things. In addition, the reduction in the quantity of controlled drugs being used prisons would help to reduce the potential for their use as currency, and improve overall safety.

To support the move to the prescription of this slow release form of buprenorphine in prisons, the team engaged with clinicians with experience of prescribing the medicine at local, national and international level in order to develop guidance. Crucially, given how the pandemic affected supply chains, we also worked closely with the pharmaceutical company to ensure there was sufficient stock of the product to meet requirements.

Game changer

The decision to move to slow-release buprenorphine has been widely welcomed by prison staff and those receiving treatment alike. People have described it to me as “a game changer”, “nothing but good” and “the way forward”. In HMP Shotts, we have only had two people choosing to come off the treatment and going back to their previous medication. Those I’ve prescribed it to have said they feel better generally, enjoy the clarity of thought and really appreciate not having to wait in the daily “methadone queue”. Prison staff, meanwhile, have said that they have noticed a marked improvement in the general condition of people prescribed this medication. It’s incredibly satisfying to have worked with colleagues at Healthcare Improvement Scotland to have delivered a simple and effective change that has made such a difference to people’s lives.

Dr Steve Conroy is Lead Medical Practitioner in NHS Lanarkshire’s Addictions Community Prescribing Service.

More information

Read our position statement on long-acting buprenorphine for opioid substitution therapy.

Categories: COVID-19 blogs

Life on the Board of Healthcare Improvement Scotland – Suzanne Dawson

Posted on March 17, 2022

_{In this video Suzanne Dawson explains the role of Board Member within Healthcare Improvement Scotland}

As Healthcare Improvement Scotland recruits for new Board members, Suzanne Dawson, a Non-Executive Director on our Board, explains the role, how she joined the Board and the importance of diversity and collaboration.

Healthcare Improvement Scotland (HIS) is currently looking to appoint three new Non-Executive Directors to our Board. To many, being on a board may seem like a mysterious role, but they may not be aware that they could be exactly what a board is looking for.

My own journey to the Board

I have been a member of the HIS Board for three years, three of the most turbulent years in the history of the NHS in Scotland.

Before I outline some of my reflections on my role, let me tell you just a little bit about how I got here. Although I had previous board experience, it certainly isn’t a necessary requirement for us, and each of us has to start somewhere. For me, it was as a member of a Further Education College Board.

My professional career was in marketing, primarily in economic development, promoting Scotland in key sectors such as the life sciences, tourism, and the creative industries. Following maternity leave I decided to take a different approach to my working life and set up my own marketing consultancy business. Around the same time, I saw the College Board position advertised and, thinking it would provide me with a great new opportunity to contribute to my local community while gaining new skills and experience which I could bring to my business, I took the jump and applied. I didn’t have any previous board experience and I wasn’t wrong about what I would get from the experience. By the time I left the College at the end of my two terms I recognised just what an important and influential role a board member plays. It certainly wasn’t always easy and with a major estates project happening during my time with the College, there was a whole lot of learning to do.

Board life before and during lockdown

I was appointed to the Board of Healthcare Improvement Scotland a full year before our first COVID-19 lockdown and so was lucky to be able to spend time getting to know my new colleagues face to face. Like now, there were three of us starting around the same time, which was a great support and helped create a collaborative induction process. Like everywhere else, we had to change ways of working in March 2020 and Board business was no different. We adapted very quickly to Board meetings by MS Teams, and it is our intention to take some of the learning from our experience into the future. It is likely that some Committee meetings will continue to be held online, and others will offer hybrid alternatives.

The role of governance committees

Each Board member sits on a couple of governance Committees. In my case I Chair the Committee which is responsible for ensuring public and community engagement across NHS boards and healthcare providers. I also sit on the Quality & Performance and Succession Planning Committees. As Board members it is our role to provide scrutiny, to seek assurance around decisions which are being made and to hold executives to account through effective challenge. Committee work provides a good opportunity to dig deep and ask questions: where’s the evidence for this and are there any gaps in the evidence; what actions are being taken to mitigate risk; how might this proposal impact on patients or local communities; how will we recognise, monitor and evaluate success. These are just some of the questions I have heard asked while I’ve been a Board member.

Diversity makes us stronger

In my experience a strong board is a diverse board. By that I am talking about diversity of thought which goes beyond protected characteristics. Life or community experience which brings a different perspective adds real value to decision making. As our organisation operates across Scotland it is also important for us to fully understand the impact of any proposal across diverse communities, including both rural and urban.

While we can be a diverse Board, with Non-Executive Directors coming from different backgrounds and with a wide range of skills and experience, the key to the Board’s effectiveness is around how we all work together as a team. We are not simply a group of individuals, but are at our best when we work collaboratively, building relationships based on a clear set of values around trust, openness, compassion, dignity, and respect.

Could this role be for you?

If any of what I have said here chimes with you. If you have a real desire to help shape the future of the NHS in Scotland, while broadening your own skills and experience, I would encourage you to apply. You don’t need years of board experience, you just need the commitment to make a difference, to challenge effectively and influence decision making based on your skills, knowledge and experience however that might have been acquired. You have nothing to lose by applying and you, our Board and the people of Scotland have plenty to gain.

Suzanne Dawson is a Non-Executive Director on the Board of Healthcare Improvement Scotland.

More information

Visit the Scottish Government website to apply for this role.

Categories: Uncategorized

The importance of having hope when living with an eating disorder – Ellen Maloney

Posted on January 27, 2022

Healthcare Improvement Scotland have published a new clinical guideline on Eating Disorders. Ellen Maloney, a patient representative on the guideline development group, explains her experience of living with anorexia nervosa and outlines the changes she hopes the new guideline will bring.

I was twelve years old when I first developed anorexia nervosa. I had just started high school and on the surface, everything in my life was going well. I had a group of close friends, I did well academically and had plans to study medicine at university, and I played the harp, performing and competing around the country. Yet I felt constantly overwhelmed and paralysed by anxiety that I had no words for. One day, I simply stopped eating and for the first time, the unbearable anxiety dissipated, and I felt calm.

Managing unbearable feelings

The thing about eating disorders is that they are not about food or eating or weight. Eating disorders are essentially, about managing unbearable feelings. It took years of prolonged hospital admissions before I was able to access therapy that helped me to understand this and find other ways to manage how I felt.

I now volunteer for Beat, the UK’s leading eating disorder charity. My story is not unique: I hear time and time again that access to appropriate treatment is delayed or obstructed because eating disorders are so misunderstood, and professionals focus too much on the symptoms, how much someone is eating or what they weigh. This barrier is highly problematic because we know that a predictor of recovery is early intervention. My hope is that the recommendation in the new guideline produced by SIGN – part of Healthcare Improvement Scotland – for early intervention is implemented as it is not only effective, but it saves lives.

Eating disorders are mental illnesses

A further barrier that many people experience when trying to access treatment, is the focus on symptoms and physical health. Once they reach a certain weight, they are considered “recovered” and support is taken away at a time when it is most needed.

What I hear all the time through my work with Beat and have experienced myself is that this is the hardest stage of recovery. All the coping strategies have been taken away but mentally things can feel very much unchanged. It is acknowledged – for the most part – that weight is only one measure of health in eating disorder treatment, and yet it is too often conflated with recovery. What we found when reviewing the literature for the new guideline is that weight gets conflated with recovery all the time because it is easy to measure, and so terms like recovery and relapse have started to lose meaning because recovery means “weight restored” and “relapse” means “weight loss after treatment”.

There is too little emphasis on the psychological change which is needed for things to be different for the quality of people’s lives to have improved by the time they finish treatment. This has proven to be problematic when writing a clinical guideline on eating disorders as there is no agreed upon definition of recovery. We need more research into this but also more conversations with patients. I had been in treatment for over 10 years before a psychiatrist asked me what I wanted out of my treatment. Maybe recovery would not be so hard to define if patients were engaged more collaboratively with their care.

Language matters

I also think the language used when talking to patients is important but it’s often overlooked. It’s not uncommon to hear stories of people being labelled “treatment resistant” or of being told by clinicians that they will never get better, that their inability to change is because they don’t want it enough – the implication of course being that “wanting to change” should somehow be enough to make that change happen. It doesn’t work like that – and I know that.

My own time in treatment was often a fraught process because the professionals involved in my care so openly expressed frustration as I struggled with change, and I felt blamed and isolated. As it transpired, I was not at all treatment resistant, I needed different treatment. Blaming patients for ineffective treatment must stop. What we know about eating disorders and the treatments we currently use is that not everybody responds in the same way. That should be a time to pause and reflect on the treatment, not a time to dismiss the patient as untreatable.

There is always hope

When I think about the patients I have met at focus groups during my time as an Ambassador for Beat, or through my own time in hospital, I think of people who have struck me as determined, thoughtful, selfless, and caring. Yet they all have stories of medical professionals labelling them as selfish, manipulative, controlling and somehow responsible for their difficulties. These are people who almost always want to get better and yet feel paralysed to a point where the fear of change outweighs the fear of staying the same. For me I began to get well when the balance tipped, and I was more afraid of staying the same than I was of making changes. What the evidence we have looked at shows, is that it doesn’t matter how long someone has been unwell or how many times they have been in and out of treatment, change is possible and there is hope of life beyond an eating disorder.

The guideline development group had long discussions around terminology and it was a deliberate decision to avoid using phrases like “treatment resistant” or language that blames patients in this guideline. My hope is that this will bring about much-needed change in practice and patient experience.

Click here to read the full guideline.

First diagnosed with anorexia at the age of 12, Ellen Maloney spent her teenage years and 20s in and out of treatment. Now in recovery, Ellen uses her platform as an Ambassador for Beat, the UK’s leading eating disorder charity, to channel her passion for both raising awareness and understanding of mental health difficulties and campaigning for easier access to treatment.

Ellen has also written articles about her experiences for Young Women Scotland, American Association for Suicide Prevention, Third Force News, and The Guardian.

Ellen is studying Philosophy and Psychology at the University of Edinburgh, and in her free time can be found translating TED talks or pole dancing.

Categories: SIGN, Uncategorized

Tagged: eating disorder, SIGN

Helping the COVID-19 vaccination effort for Scotland – Bernie McCulloch

Posted on December 20, 2021

When the call went out for vaccinators to aid the national effort to respond to the Omicron variant, many of our staff with clinical experience put their hands in the air to help. One of those volunteers is Bernie McCulloch, Portfolio Lead for Healthcare Improvement Scotland’s Community Care programme. In this blog, Bernie explains what’s involved in being a vaccinator, and how people and healthcare professionals alike are rising to the continued challenge of the pandemic.

When the call went out for volunteers, it made perfect sense to me to become a vaccinator.

Taking my teenage son to get vaccinated I saw at first hand the long queues of people keen to play their part to help themselves and others in the continued pandemic. As a trained nurse, who has worked away from the frontline for a number of years, I instantly felt the moral obligation to dust down my skills and answer the call.

For me, the issue at hand is clear: the more people we can support to get vaccinated – especially in the wake of the Omicron variant in the lead up to the festive period – the better for everyone in Scotland. So I jumped at the opportunity to use my clinical skills and experience in a way that can make a real difference.

Getting the right training to make the right decisions

In my role as a vaccinator, I screen individuals, obtain consent and administer first and second COVID-19 doses, boosters, as well as flu vaccines to those who are eligible. Similar to the COVID-19 vaccine, there are different types of flu vaccines depending on age and medical conditions.

The training to become a vaccinator takes place through extensive and comprehensive online courses and through physically shadowing of other vaccinators. As a trained nurse, I’m able to carry out assessments to determine the appropriate vaccine for people; to support this is the Green Book, which lays out all the side effects and contraindications for all vaccines. In addition, our training covers the legal aspects in relation to consent, how to fill in appropriate documentation and how to correctly handle people’s personal information.

Although the training is thorough, at the vaccination centres there is always support on hand: doctors, nurses, pharmacists and healthcare assistants – so, if you ever have any questions, there are other experts to call upon to help make the right decision for every patient. In addition, daily staff huddles, before the centres open to the public, help to ensure that any changes to national guidance are communicated effectively.

The spirit of togetherness

Aside from the feeling of helping to make a difference, it’s hugely satisfying to have patient contact again and reminds me of what it is that we do in the NHS: caring for people when they need it.

Those who turn up at the vaccination centres all want to be there, which is great to see. Sometimes people are spending hours queuing for the vaccine, but they are all grateful and appreciative to the healthcare workers, the volunteers and to the NHS. As a result, I try to make my interactions as person-centred as possible: thanking them for turning up, for doing the right thing for themselves and others, and for making the effort.

This feeling of us all being in it together also extends to those working at the vaccination centres. There’s a real appetite for everyone to help each other whenever it’s needed.

I’m also encountering people under 50, who are not eligible for the free vaccine, paying privately to get the flu vaccine from their local pharmacy. I think this shows how many people are seeing the benefits of vaccination programmes, and the important role they play in keeping them and other people safe.

The festive season and beyond

I continue to carry out my duties with Healthcare Improvement Scotland alongside shifts as a vaccinator. Over the festive period, I expect to undertake more shifts and in all likelihood into January also. But I’m looking forward to it. I hope that every vaccination that’s carried out takes us all one step closer to coming out of the pandemic, maybe saves a life, while at the same time bringing us all a little bit closer together as a society. If you haven’t been vaccinated yet, please come to one of the centres. We’d be delighted to see you. You’ll be helping yourself and helping everyone else around you too.

Bernie McCulloch is Portfolio Lead for Community Care in Healthcare Improvement Scotland’s ihub.

Categories: Uncategorized

Tagged: COVID-19

Long COVID: The importance of holistic care – Dr Tom Fardon

Posted on December 14, 2021

We have learned a lot about Long COVID and its effects over the past year. In our latest blog, Dr Tom Fardon, Consultant Physician of Respiratory Medicine at NHS Tayside, outlines his own experience with COVID-19 and explains the steps he takes to diagnose and treat patients who may be experiencing long-term effects from the syndrome.

COVID-19 is an unusual illness. The range of symptoms is broad, much more so than the original case definition of early 2020 that included only breathlessness, persistent cough, and fever. The range of severity of illness is equally as wide: some people suffer only mild symptoms of an upper respiratory tract infection; some have no symptoms at all; some develop a rapidly progressive pneumonitis requiring ventilatory support – in wave 1 of the pandemic 20% of people who were admitted to hospital with COVID-19 did not survive.

The unprecedented collaboration between scientists, clinicians, and pharma companies around the world has led to the discovery of a small number of treatments that can, and do, improve outcomes. But, most importantly, we now have safe and effective vaccines that protect against infection, reduce severity of disease, prevent admissions to strained NHS services, and reduce mortality.

The new ‘normal’

For most people COVID-19 affects two weeks of their lives, with a range of flu-like symptoms that are unpleasant, but don’t lead to hospital admission, and they will recover. Most people will take a few weeks to recover their fitness, get back to their normal level of activity, and feel “normal” again. People always ask: “How long until I get back to normal?” Everyone is different. Depending on your previous baseline, the severity of your illness, the length of time laid up resting, and your expectations of recovery, it can be a week, two, perhaps six.

For some people, recovery from the acute illness is only the start of the journey. What we have now come to term Long COVID affects somewhere between 5% and 20% of people who have had the COVID-19 infection. The severity of disease does not seem to predict progression to Long COVID. Indeed most of our critical care COVID-19 survivors have not gone on to develop Long COVID, though their rehabilitation has been long, simply due to the severity of their illness.

Offering a service to people with long lasting symptoms following COVID-19 infection is very challenging. Long COVID is a syndrome for which there is no clear clinical definition; no diagnostic test; large overlap with other diseases and syndromes, some of which are ‘diagnoses of exclusion’; and no mechanistic or pathophysiological pathway. Most hospitals do not have an existing team dedicated to the holistic care of people presenting with the symptoms of Long COVID. The symptoms cross speciality borders: cardiology, respiratory medicine, neurology, rheumatology, dermatology, endocrinology.

Emerging Patterns

In NHS Tayside we followed up our patients from COVID-19 critical care areas after wave 1, and we’ve seen a range of people in our outpatient clinics with Long-COVID symptoms. My experience of seeing people with protracted symptoms following COVID-19 infection has shown me a few emerging patterns.

Speaking to people who have protracted symptoms following COVID-19, there are commonalities in their concerns: is this Long COVID? will it get better? how long will these symptoms last? is there anything I can do to get better? will it get worse? and is this how it’s going to be forever?

Steps to diagnosis

Our first step is to rule out other causes of those symptoms. If someone is breathless following COVID-19, have they developed asthma? If someone has chest pain, is their ECG normal? Just because symptoms started after COVID-19 doesn’t always mean that COVID-19 is responsible. A detailed history often reveals mild symptoms prior to COVID-19, and new things can happen at any time.

Step 2 is to look for modifiable causes of symptoms – deconditioning and weight gain are very often implicated, so a gradual return to an exercise programme, with planned weight loss can be very effective. Addressing any psychological issues is also critical.

Aftercare

Holistic care is vital. There is no clear answer to most of the concerns these people have. We simply don’t understand enough about the Long COVID syndrome to give reliable information about the outlook. In my experience it is uncertainty that scares us: once we’re given the diagnosis, the prognosis, the clear plan, we then have a target, something to aim for, a route to take, and a team to support us.

For people with Long COVID we work in an area of extreme uncertainty. Development of multi-disciplinary teams to help people with this wide range of symptoms, and causes has to be a priority for the next 2 to 5 years.

In NHS Tayside the COVID-19 Assessment Rehabilitation Enablement and Support (CARES) service consists of highly specialised physiotherapists, occupational therapists, psychologists, and secondary care consultants, like me. Our approach is to ensure early screening to look for serious conditions known to complicate COVID-19, such as pulmonary embolus, atrial fibrillation, pericarditis; followed by a personalised patient-centred care plan delivered by the team; and early referral to secondary care if there are concerns over developing complications.

My own experience with Long COVID

I had COVID-19 in April 2020, just before I should have been running the Boston Marathon. I had a dramatic loss in fitness over the 2 weeks of illness, and suffered for over 12 months with daily headaches, earache, tinnitus, sore throat, dizziness. Those symptoms have, with time, settled. I have no explanation for why they happened, why they went away, and even whether they were definitely related to my COVID-19 infection. They certainly created a high level of uncertainty for me and my family, adding to what was already a stressful 2020. But it has helped me to have first-hand experience of the uncertainty that people can experience.

Hope for the future

As we approach 18 months of the pandemic we see more people who do recover and return to normality, but as the restrictions are relaxed and infection rates reach dizzying heights across the country, we will undoubtedly see more people with symptoms of Long COVID. It is therefore vitally important that we have clear guidance on the approach to people who present with symptoms suggestive of Long COVID. As the national guideline continues to develop, it will be a vital place for clinicians and the public to look for reassurance and guidance. Most importantly, it’s important that we don’t miss newly presenting illnesses, and equally important we don’t ignore or downplay the symptoms that people are now presenting with. As we wait for more studies that help us to diagnose and treat, this approach will be crucial.

Dr Tom Fardon is a Consultant Physician in Respiratory Medicine at Ninewells Hospital and Honorary Reader in the University of Dundee

More information

Read our SIGN Guideline: Managing the long-term effects of COVID-19.

Categories: Uncategorized

Tagged: COVID-19

Could you be the next Clinical Lead for our neonatal improvement programme? – Colin Peters

Posted on November 16, 2021

As Colin Peters leaves us as Clinical Lead for our organisation’s neonatal improvement work after five years, in this blog he describes the rewards of the role of clinical lead and how he made the role work alongside his day job.

Interesting, rewarding and enjoyable. After five years as the Neonatal Clinical Lead for Healthcare Improvement Scotland, that’s how I would describe the role. Now that I’ve moved on from the role and I reflect on the time with the organisation’s Scottish Patient Safety Programme, I feel grateful for the tremendous support of the team and the engagement of neonatal teams from around Scotland in order to deliver improvements.

There have been lots of highlights during the five years, but I particularly enjoyed the learning sessions where we had such engagement from everyone involved: nurses, midwives, doctors, improvement advisors and more. Post-it notes and marker pens were the order of the day with roaming microphones and ideas aplenty.

While I’ll miss being in the role, it does mean that there is a fantastic opportunity waiting for someone to take up the mantle of Neonatal Clinical Lead.

The role of the MCQIC Neonatal Clinical Lead

So what does the role of Neonatal Clinical Lead entail? First up, the role is essentially for one day a week, so you undertake the role alongside your clinical duties within your NHS board.

The key responsibility is to provide clinical direction to the neonatal improvement work of the organisation. This includes identifying new areas of work and ensuring that existing areas are up to date. Here it’s important to seek new ideas from around the UK and abroad, as well as draw on recent publications, national guidelines and evidence.

Within the role, you get to visit each NHS board to provide support, share ideas, motivate and inspire. I really enjoyed these as I inevitably came away with a new idea or reflection on something that could be developed.

The importance of collaboration and leadership

Working collaboratively with Midwifery and Obstetric Leads and NHS board teams on measures that sit across the whole MCQIC programme, is a vital part of what the clinical lead will do. In my view, improvement in neonatal outcomes depends on improvements in obstetrics and midwifery. The collaborative work on the Preterm Perinatal Wellbeing Package was a fine example of working across teams to come up with a message for everyone caring for a woman delivering prematurely and her baby.

Leadership is another key element of the role, for example, leading sessions at Scotland-wide meetings. These are really interesting sessions with a fair bit of work involved to put together an engaging presentation / session that leaves the delegates inspired to go back to their NHS boards with ideas and a motivation to improve.

You will also develop and participate in regular webinars. These are now more familiar to us all and although talking to your own screen, hoping that there are people out there, is strange, the responses and conversations are really rewarding.

The Clinical Lead for Neonatal will also contribute to national networks and groups. In my time I’ve worked with the Scottish Perinatal Network, the MANDALS group and Clevermed. Strengthening these relationships have ensured that we’ve been able to take consistent approaches across Scotland and avoided duplication of effort.

I’ve found the support from the project officers to be excellent, and I’ve put many of their ideas into practice. Moreover, the support from the Senior Improvement Advisor has been really helpful. I felt that I wanted to come out with more than just having worked one day a week, so I completed the Scottish Improvement Leader course. The new lead may have some particular area or skill that they want to develop.

Ways of working

I tended to work flexibly, especially in the virtual world which now exists on Teams. Before the pandemic I’d work in Delta House (Glasgow) or Gyle Square (Edinburgh) some days, site visits on other days and at home on some days. Sometimes I’d work whole days, on others it would be broken up across a week trying to average one day a week.

And what advice to my successor as Clinical Lead for Neonatal? There is lots of support from all teams within Healthcare Improvement Scotland, so don’t worry about the practical matters of the job. Enjoy, laugh, and don’t be afraid to voice your opinion. Make the role your own.

Colin Peters is Consultant Neonatologist in Greater Glasgow & Clyde and is the former Clinical Lead for Neonatal for Healthcare Improvement Scotland.

Visit NHSScotland to see the list of current job vacancies.

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Tagged: impact campaign

Long COVID: a new challenge in managing uncertainty – Scott Jamieson

Posted on November 11, 2021

Dundee-based GP Scott Jamieson explains his experience in diagnosing patients with Long COVID and his contributions toward the creation of the now updated Long COVID clinical guideline, which will play a key role in assisting doctors to diagnose and treat Long COVID.

In general practice we are very accustomed to managing uncertainty. We teach GP trainees that this is not only when we don’t know immediately know what a diagnosis is, nor how to define it, but also when we are unsure how to treat it.

The key to managing uncertainty is sharing decision making. Where there is uncertainty, there is nothing more important than to share management. Demonstrating empathy to understand the condition from the patient’s perspective is key. But, with COVID-19 disease, we were in new territory.

In the UK alone, the ONS reports 1.2 million people as of November 2021 who have reported symptoms of Long COVID ongoing for more than 4 weeks after COVID-19 infection. Of these, over 65% report it impacts on day-to-day activities with 55% reporting fatigue as their most common symptom.

As we come to have a better understanding of the symptoms ongoing after COVID-19 infection, it has become apparent that the new or continued symptoms is a separate condition all together. The term ‘Long COVID’ is commonly used to describe signs and symptoms that continue or develop after acute COVID-19.

The importance of the guideline

It is important in unknown waters to endeavour to chart a path and update that course as evidence emerges to inform the best route. In Long COVID, as with any severe illness, GPs will continue to have a critical role in navigating uncertainty and excluding other causes of symptoms.

Symptoms ongoing after COVID-19 disease are fairly indiscriminate in different patients I see. There are some groups more likely to be affected – females, more deprived backgrounds, even healthcare workers – but those differences are not great.

Any person getting COVID-19 be those with mild or with severe symptoms in hospital can develop ongoing symptoms thereafter. It is likely this isn’t a ‘syndrome’ per se with a unifying mechanism. Each symptom potentially has a different cause, and with a lack of clear direction in how to manage the symptoms, I utilise ‘the COVID-19 rapid guideline: managing the long-term effects of COVID-19’, to help navigate the challenges of each symptom. People have had to stop their usual work, reduced normal daily activities or struggled more with their mental health: it’s not easy but thankfully for most the recovery is progressive and steady.

A unified approach

Collaborating with my Royal College of General Practitioners (RCGP) counterparts in London, as the RCGP Scotland Executive Officer (Quality Improvement) and sitting on the Scottish Intercollegiate Guidelines Network (SIGN) Council, we were mindful that there were moves both north and south of the border to consider a guideline on managing the breadth of ongoing symptoms after COVID-19 infection.

However, with a lack of strong evidence on effective treatments, these guidelines were likely to heavily depend upon consensus for treatments.

In the UK, we are lucky to have both SIGN and the National Institute for Health and Care Excellence (NICE) as expert organisations in guideline development.

As such, with my RCGP counterpart in England approaching NICE, I reached out to SIGN and the Clinical Cell at Scottish Government to suggest it would be best to have a single guideline to work from.

All parties agreed and the guideline developed from there. I continue to work alongside RCGP and SIGN in reviewing the guideline and I’m particularly excited to see the patient booklet to go alongside, which I know will be welcomed by patients and their family and friends.

It has been a pleasure to be involved in the collaboration of SIGN, RCGP and NICE to create a unified ‘living’ guideline on Long COVID. Beyond this, an implementation note was developed by the Scottish Government to support NHS boards to introduce the guideline effectively. We have a long way to go to ensure that we manage the uncertainties and find an effective path forward for those with Long COVID, but the revised guideline, the implementation note and the patient booklet are important steps in the right direction.

Visit SIGN’s website to access the revised guideline and patient booklet.

Scott Jamieson is a GP within NHS Tayside and a member of RCGP Scotland’s Scottish Council

Categories: COVID-19 blogs

Improving death certification standards during the pandemic – George Fernie

Posted on October 19, 2021

Our Medical Reviewer, George Fernie, explains how our Death Certification Review Service (DCRS) has helped the national response to the pandemic by advising doctors on the accurate recording of deaths.

In many respects, this year’s annual report has been difficult to write. It has felt slightly uncomfortable to be looking to celebrate how the Death Certification Review Service (DCRS) has been supporting the pandemic, when the reality is that we’re helping to improve the accurate recording of deaths which we sincerely wished had never needed to be reported.

However, one thing that we shouldn’t shy away from is the importance of DCRS in being able to support the response to the pandemic in meaningful ways.

It has been vital that death certificates have been completed correctly and that doctors have been given the proper advice to know how to record COVID-19, especially when there can be a range of other co-morbidities that may have impacted on an individual’s death. The evidence tells us that we’ve risen to the challenge and carried out our task effectively for the service.

The importance of improvements

DCRS sits within Healthcare Improvement Scotland. As a consequence, it’s right that improvement is at the heart of what our service does.

I’m proud to say that DCRS has seen sustained year-on-year improvement in the quality and accuracy of Medical Certificates of Cause of Death (MCCDs), and the progress achieved appears to have been maintained as we start to exit the worst of this unpredicted virus.

We continue to meet our legislative requirements to improve the quality and accuracy of MCCDs, giving the public confidence in the death registration process in Scotland; to inform public health information about causes of death in Scotland, supporting consistency in recording that will help resources to be directed to the best areas in a more timely way. In addition, we’ve seen continued improvement in the number of ‘not in order’ certificates across all NHS boards – despite the significant additional pressures placed upon certifying doctors and the team of medical reviewers during the pandemic especially. Moreover, all advance registration applications have been undertaken within 2 hours, which minimises any additional stress that might be caused to loved ones as a consequence of knowing that a review of the paperwork was to be carried out.

These improvements are down to the hard work and dedication of the DCRS team, but also to the doctors across the breadth of the country to show commitment to making sure that death certificates are accurate and meaningful.

Fulfilling our commitments

Each year we set goals for key areas that we wish to improve. Last year was no different, even though we were in the midst of the pandemic.

On top of the goals we set, in July we took the opportunity to reflect on our response to the pandemic and carried out an After Action Review which helped us to be prepared and positively respond to the second wave. We responded well, indeed, we identified why there was a difference between death rates from COVID-19 diagnosed clinically and those where there was a positive polymerase chain reaction (PCR) swab, taking into account a known ‘false-negative’ rate. In addition, we highlighted nosocomial (hospital acquired) infections and successfully used the Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) framework to categorise these. Furthermore, we worked with Scottish Fatalities Injuries Unit (SFIU) and the COVID Death Investigation team (CDIT) to ensure accuracy and promote public reassurance.

Unexpected developments

Although we would not have planned to do so in a pandemic situation, through necessity the service migrated IT systems and relocated staff (although at the moment the full team continue to work from home). Within seven months we have successfully introduced a new electronic case management and telephony system which has allowed the service to work with greater efficiency, in a more focused manner and benefits all stakeholders in the death registration process.

The pandemic and our team

Like the rest of society, the staff of DCRS experienced all the varied consequences of COVID-19 where many of us were tested for the virus, a number contracted the virus and, some like myself, lost a frail family member, all whilst viewing real-time data of the deaths that were occurring in front of us. Whilst this was nothing like the impact on those in the frontline of the NHS, we have had to learn to live very differently in both our personal and professional lives. We were fortunate enough to come through this experience physically unscathed as a team, but are very much aware of the consequences due to our direct knowledge of what had happened.

I cannot thank my team enough for pulling together during an incredibly difficult time where I believe we made a meaningful contribution to the NHS in Scotland – their commitment and sensitivity at a time of national emergency was outstanding.

George Fernie is Senior Medical Reviewer with Healthcare Improvement Scotland.