Learning from real life: How the pandemic can help workforce planning in future – Karen Mackenzie

Posted on August 24, 2021

Having the right people in the right place at the right time lies at the heart of workforce planning. But how does that work when the NHS is faced with a pandemic? Karen Mackenzie, Assistant Programme Advisor with Healthcare Improvement Scotland’s Healthcare Staffing Programme, tells us how colleagues in one territorial boards have coped – and how the experience of COVID-19 can help shape future workforce planning ahead of legislation due to be enacted next year.

The COVID-19 pandemic has been transformative for all of us. Many of us have found ourselves in situations we’d never imagined, doing things we’d never dreamed of. Nowhere is this truer than in the NHS, where staff who may not have worked on the frontline for years have suddenly found themselves volunteering to be front and centre when it comes to tackling COVID – and helping to prevent its spread.

When I started my new role as an Assistant Programme Advisor with the Healthcare Staffing Programme (HSP) in August 2020, our team had started to re-group after being redeployed to work in the first phase of the pandemic. It was an exciting time to join my nursing and midwifery colleagues as they worked to support territorial boards with remobilisation and recovery. Reconnecting with our NHS colleagues to learn from the challenges they faced was going to inform our objectives for the year ahead. But then the second phase of the pandemic descended on us and it was once again “all hands on deck”. Health and care services were faced with the parallel demands of COVID-19 care and the urgent roll out of the vaccination programme. Having heard about these challenges from frontline colleagues, I volunteered to provide enhanced support to vaccination programme staffing with NHS Western Isles.

All hands on deck

My clinical background is as an Allied Health Professional (AHP), but even with my knowledge of workload and workforce planning, I was anxious about whether I would be able to offer the right level of support to nursing colleagues given the pressures of vaccination targets.

Working with clinical staff, senior nurses, Public Health Scotland colleagues, clinic schedule coordinators, health intelligence colleagues and the local Quality Improvement coordinator, I began to learn about the landscape in which we were having to plan vaccinations. Something that immediately jumped out at me was the multiprofessional nature of the vaccination staffing effort, and the importance of professional judgement and clinical voice when staffing new services. I saw so many AHPs, from paramedics and podiatrists to dietitians and speech and language therapists, working to support the vaccination effort while also trying to maintain their own services.

Nationally, the pandemic response has highlighted how staffing affects healthcare quality and staff wellbeing across health and social care. In keeping with the principles of the Health and Care Staffing (Scotland) Act 2019, and ahead of its enactment, NHS Boards have to have systems in place to ensure professional advice has been provided at the right level in relation to staffing. Where decisions are made contrary to such advice, associated risks should be identified, recorded and any required mitigation put in place.

With this principle in mind, I worked with my vaccination programme colleagues to map out the current vaccination clinic process, highlighting key staffing risks to allow us to prioritise staffing and workload improvements. For example, observing workflow at vaccination clinics and joining the morning safety huddle helped me to understand the key staffing issues that were impacting patient safety and staff wellbeing. The mapping process helped to identify simple changes to rostering processes that helped to improve the skill mix and effective use of staff during their allocated shift times. Overall the changes were well received by the vaccination staff on the ground as they felt more engaged in staffing discussions and their concerns about patient safety and staff wellbeing were heard. The increased governance and flexibility gave the staff more ownership of their workload and helped to make the best use of their time. Importantly, the changes also protected rest break times and safe working hours to maintain staff wellbeing.

What we can learn

My experience and that of many of my colleagues is that the pandemic has demonstrated that multi-professional collaboration and improvement are possible in the most challenging of circumstances. However, as we move towards what is, hopefully, the beginning of the end, it has also highlighted the need for AHPs to have a consistent way to capture their workloads and to use reliable workload information to plan their services and workforce. This is where my team at Healthcare Improvement Scotland comes in. We support the upskilling of a range of professions in workload measurement to help ensure that their services are safely staffed for high quality care. Now we want to use the learning from COVID-19 to help AHPs prepare for the delayed enactment of the Health and Care Staffing (Scotland) Act 2019. We want to help AHPs understand the importance of knowing their available workforce and identifying gaps in their required workforce, and to explore practical, low data burden solutions to workload and workforce measurement.

Taking a closer look at staffing beyond the nursing and midwifery workforce helps to put health and social Care services in a stronger position for the new legislation, ensuring that services are “safe to start” each day. It also helps them prepare, post-COVID, for whatever happens next.

Karen Mackenzie is an Assistant Programme Advisor with Healthcare Improvement Scotland’s Healthcare Staffing Programme.

More information

Visit our website for more information on the Healthcare Staffing Programme.

Categories: COVID-19 blogs, ihub

Reflections of a Caldicott Guardian – George Fernie

Posted on July 28, 2021

Many people will know the term Caldicott Guardian but perhaps not quite know what it means. In our latest blog, George Fernie, Senior Medical Reviewer with our organisation, outlines the role and what it means for respecting the rights of patients.

The term Caldicott Guardian is one that many people will have heard of, but perhaps not entirely know what it means or where it comes from. Even within my own organisation, Healthcare Improvement Scotland, I’m likely known as our Senior Medical Reviewer, working largely on our Death Certification responsibilities, but many may not know how the role of Caldicott Guardian is vital in protecting the rights of patients.

What the role is and where it came from

So, let’s answer that question right up front. The generally accepted definition of what constitutes the role of the Caldicott Guardian is set out within the UK Caldicott Guardian’s Manual. It describes the role as:

“… a senior person within a health or social care organisation who makes sure that the personal information about those who use its services is used legally, ethically and appropriately, and that confidentiality is maintained. Caldicott Guardians should be able to provide leadership and informed guidance on complex matters involving confidentiality and information sharing”. Caldicott Guardians

The term is named after Dame Fiona Caldicott who died earlier this year having worked with some distinction as an NHS psychiatrist. The Government Review of Patient-Identifiable Information, chaired by Dame Fiona Caldicott, which reported in December 1997, recommended that “a senior person, preferably a health professional, should be nominated in each health organisation to act as a guardian, responsible for safeguarding the confidentiality of patient information.” At that time, the report also set out principles for determining when confidential information might be used and when it should not. These six Caldicott principles have since helped Caldicott Guardians to make balanced judgements for their organisations, with a seventh being added in 2013 and an eighth in 2020.

From law graduate to legal guardian

Describing the role of Caldicott Guardian is easier to explain, however, than the journey I took to become one!

In Healthcare Improvement Scotland, the role of Caldicott Guardian has been devolved to me because of my long-term interest in medical law and ethics. Although I started my professional career as a ‘proper doctor’ by being a general practitioner, I discovered something even better in forensic and legal medicine. Having commenced work as a medicolegal adviser in 1996, I then had a complete mental aberration by going to law school where I graduated Bachelor of Laws at the University of Strathclyde, in addition to already having a Masters in Law & Ethics in Medicine from the University of Glasgow.

A further opportunity to combine law, ethics and healthcare arose when I was appointed the first Senior Medical Reviewer for Scotland in 2013, which is a statutory role conferred by the Certification of Death (Scotland) Act 2011. The reform of death certification had been a long-term aim of mine when I was the inaugural Registrar and third President of the Faculty of Forensic and Legal Medicine. Scottish Government took the enlightened decision to base the Death Certification Review Service in an independent NHS quality improvement organisation, Healthcare Improvement Scotland. This has allowed me to provide an additional contribution to other organisational workstreams, making use of my knowledge in information governance and the 17 years of practical skills I had gained in supporting doctors in the UK, South Africa and the Republic of Ireland as a medicolegal adviser.

The role of guardian at Healthcare Improvement Scotland

At Healthcare Improvement Scotland, the Caldicott Guardian works as part of a team within the Information Governance Group. In 2021, I was nominated as the Scottish representative on the United Kingdom’s Caldicott Guardian Council (UKCGC). The areas in which the Caldicott Guardian is expected to influence include: strategy and governance; confidentiality and data protection expertise; internal information processing, and information sharing.

It is quite a responsibility to be a Caldicott Guardian, as well as being a great honour. I’m fortunate to work within an organisation that places significant value on the role and its importance for protecting the rights of patients. When I’m asked what I enjoy most about being a Caldicott Guardian, the answers are actually pretty straightforward. It is facilitating the access of people to records to which they are entitled, helping avoid the release of information which is considered confidential and utilising the immense amount of data we possess within our diverse organisation to improve the health and social care of the patients of Scotland.

George Fernie is Senior Medical Reviewer with Healthcare Improvement Scotland.

Categories: COVID-19 blogs, ihub

Clinical guideline is a crucial stage in treating Long COVID – Professor Tom Evans

Posted on July 6, 2021

Professor Tom Evans is an infectious disease specialist working with Glasgow University and a member of the development group responsible for the Long COVID guideline. Tom reflects on the year that’s been and the importance of sharing knowledge in diagnosing and treating Long COVID.

We have been living with COVID-19 for over a year, and it has affected everyone world-wide in at least one way or another. For some of us, this means the loss of a loved one. Now there is finally real hope for a reduction in deaths and severe disease caused by the infection with the introduction of effective vaccines and better treatment.

However, for some who experience even relatively mild COVID-19, their recovery can be very prolonged and they continue to experience a wide variety of symptoms – including a new condition of post-COVID-19 syndrome, also known as Long COVID.

My own experiences of managing patients with post-COVID-19 syndrome reflects very much the published studies of this condition. They all have experienced a range of persistent symptoms – fatigue is almost universal, as well as intermittent fast heart rates and an inability to focus, often referred to as ‘brain fog’. Many of these patients are still unable to work many months after their initial acute illness. They are frustrated by poor appreciation by some medical staff of the nature of the ongoing symptoms after acute COVID-19, of having multiple referrals to emergency departments or individual specialists, and in a lack of effective therapy.

When do you know you have Long COVID?

But what exactly is Long COVID?

Long COVID is when a patient continues to experience or develops new disabling symptoms for months after the initial infection. These can involve just about any organ system of the human body. Extreme fatigue is commonly reported in addition to:

breathlessness
an intermittent racing pulse
loss of concentration (brain fog)
fevers, and
abdominal pain.

Many patients also report that these symptoms can come and go. Such a diverse range of symptoms for Long COVID presents a real challenge to general practitioners: is this continuing infection? what investigations are required? who is the best specialist to whom I should refer?

Post-COVID-19 syndrome – what’s in a name?

Because of the growing realisation that these persistent symptoms were proving quite common, it was clear there was a need for a national guideline to set out a definition of the condition, to identify the evidence base for any investigations and treatment, and to develop a framework for services that might be required.

A unique collaboration was formed between Healthcare Improvement Scotland, the National Institute for Health and care Excellence (NICE) and the Royal College of General Practitioners, to develop a guideline that could be used across the UK. As an infectious disease specialist, I was asked to be a member of the oversight committee, to provide a definition of the condition, and to set out the questions that the guideline needed to address. This was a real challenge – the knowledge base for Long COVID was very limited and there was no accepted definition or indeed name for the syndrome. Given the large range of symptoms reported and that we wished to make clear this was quite distinct from the symptoms from the acute phase of the infection, we settled on ‘Post-COVID-19 Syndrome’, with a definite diagnosis at 12 weeks after the initial infection.

Patient groups and the media have continued to use Long COVID – I don’t feel there is any problem with this. We are used to there being ‘medical’ names for conditions as well as more common terms used by the public – doctors will call glandular fever ‘infectious mononucleosis’, but the important point is that we are talking about the same thing. Having a definition is incredibly important – this will allow every consultation with patients who have Post-COVID-19 syndrome to be captured by computerised data systems so that we can build up an accurate picture of its prevalence, the spectrum of symptoms experienced and risk factors for its development.

The guideline development team worked incredibly hard and at a fast pace to gather all available evidence in order to produce a document that could be used as quickly as possible. Specialists from across the UK were involved, as well as patients who had experienced the condition. A real challenge for developing the Long COVID guideline was the dearth of good evidence – this is such a recent illness that there was not much high quality research available. However, the final guideline incorporated all that was known at this time and sets out some concrete advice on diagnosis, investigations and management.

A “Living” Guideline

The developers very much realised that the guideline will continue to be modified over time as more evidence accrues – what we refer to as a ‘living’ guideline. But it is a welcome beginning that provides a solid start in recognising and defining the condition, and providing valuable evidence-based recommendations for clinicians caring for Long COVID patients.

As we continue to look at the new evidence in order to help guide future versions of the guideline, it’s important that healthcare professionals and those affected by Long COVID are familiar with what we currently know about the guideline and the best way to diagnose and treat it. Knowledge and the sharing of that knowledge will be crucial to improving the lives of those with the condition.

Professor Tom Evans is an infectious disease specialist working with Glasgow University and a member of the development group responsible for the Long COVID guideline.

More information

Visit the SIGN website to read our Long COVID guideline.

Categories: COVID-19 blogs, ihub

Let’s continue the conversation on health inequalities and improvement – James Battye

Posted on June 8, 2021

Equality is important. As a publicly funded organisation, Healthcare Improvement Scotland has legal duties to take action to address the inequalities that exist in Scotland. We must also be able evidence how we have met our duties in everything that we do. So how do we make sure it underlies our work? Associate Improvement Advisor James Battye give us his thoughts.

Since joining Healthcare Improvement Scotland’s ihub, health inequalities and what to do about them has been a key theme of my work. Given what we know about health inequalities in Scotland, keeping a constant focus on this is absolutely essential.

I won’t pretend that weaving this into my own day to day role as an Associate Improvement Advisor has been easy. I’ve spent a good chunk of my time doing a bit of head scratching and wondering whether I am on the right track.

For example – did I get that Equality Impact Assessment (EQIA) right? What will I do with it now?

Sessions like the equity knowledge café session organised by our Evidence and Evaluation for Improvement (EEvIT) team have been really helpful in clarifying my thinking, and left me keen to keep exploring the question of what we can do to address health inequalities in our work.

Health inequality and quality improvement

Towards the end of 2020, with the help of Zoom/Teams I had the opportunity to attend the Institute for Healthcare Improvement (IHI) Forum.

Health inequality was a key theme of the forum. Keynote speakers included Roseanne Haggerty, CEO of Community Solutions, a charity whose mission is to end chronic homelessness in the US and Patrisse Cullors, a social activist and co-creator of Black Lives Matter. In addition, among the sixty or so breakout sessions there were a good few dedicated to improvement and inequalities.

For me, two questions stand out when I think about health inequalities and quality improvement: firstly, what can health and social care systems do to support and sustain a culture of improvement and redesign around health inequality? And secondly, how do we measure the effect improvement or redesign has had on health inequalities themselves?

Supporting a culture of improvement and redesign around health inequalities

One theme emerged early on during presentations and this was the importance of a strong values base along staff at all levels which incorporated addressing inequality.

This was particularly evident in the United States in relation to Black Lives Matter. The movement has prompted health and social care professionals to examine their practice and consider whether they were doing all they could to end the racial disparities which exist within the U.S.

In the examples shared during the forum, health and social care professionals said they felt empowered to take action as tackling inequality was part of their job. They also said they felt supported by their leadership teams to take action. On the face of it this seemed be a key factor in mobilising a health and social care system to introduce changes which aim to reduce inequalities.

Considering Scotland, I think we have some of the right building blocks in place. For example there’s our own work on Quality Management Systems in which leadership and shared values are a key part. We also have the NHS Scotland’s 2020 workforce vision which includes a focus on providing more equitable access to healthcare.

However, I’m sure we’ll all agree that there’s much more to do.

Measuring the impact of initiatives to address health inequalities

When it came to how health and social care professionals measured the impact of initiatives which sought to tackle health inequalities things were a little less clear cut. Presenters admitted that often they just didn’t have the data – e.g. on demographics, income or something else – and they needed to put their efforts into improving what data they could gather. In fact, the content of the presentations was similar to many of the conversations we had as part of EEvIT’s knowledge café on equity.

Initially I was left a little disappointed by the Forum. I didn’t get that golden nugget that I was hoping might show me the way in relation to my own day job. But on reflection I actually found this encouraging: many improvers across health and social care are at the same point as us. We want to collectively address health inequalities, but we are not always sure what we can do and we are not sure how to measure it.

What can Healthcare Improvement Scotland do to address inequalities?

For me the IHI Forum helped underline why internal initiatives like the inequalities and equity knowledge café session organised by EEvIT are so important. They provide the space for us to share what we know and what we don’t.

It has also prompted me to more actively consider inequalities throughout the entirety of an improvement programme. Not only am I going to ensure that the EQIA is as thorough as possible but I am also going to revisit it frequently – meaning that if I didn’t get it right the first time I can always change and adapt it.

James Battye is an Associate Improvement Advisor in ihub’s Maternity and Children Collaborative

More information

Find out more about the work of our Evidence and Evaluation for Improvement Team.

Categories: COVID-19 blogs, ihub

Pandemic puts person-centred care at the heart of dementia care – Marie Innes

Posted on June 1, 2021

Restrictions imposed as a result of the COVID-19 pandemic brought to light the importance of person-centredness in dementia care. As part of Dementia Awareness Week, Marie Innes of our Focus on Dementia team, explains why delivering care to people in the way that matters most to them is at the heart of Healthcare Improvement Scotland’s relaunched Dementia in Hospitals Collaborative.

The COVID-19 pandemic put many thing on hold for many people, including the range of improvements that health and care professionals across the country were focused on for people with dementia through our organisation’s Dementia in Hospitals Collaborative. As Healthcare Improvement Scotland focuses on restarting this important programme of work, the pandemic has brought lessons that will be important to how the collaborative moves forward – most importantly, the importance of person-centred care.

The collaborative started late in 2019 and was originally scheduled to run until September 2021. The aim was to bring together hospital teams from across Scotland to work on improvements to hospital care for people with dementia, with an overall focus on the prevention and management of stress and distress, plus four other areas of focus.

Along came COVID-19, and the collaborative was paused, not once but twice, during 2020.

But the last year has brought important knowledge that will help aid the next stage of the programme.

Supporting people in the way that matters most to them

Even before the pandemic, Person-Centred Care Planning had been an area that had consistently been highlighted as an area for improvement both by hospital teams themselves, as well as through the findings of our inspections into the care of older people in hospitals.

During the pause, we engaged with a range of stakeholders to find out their key issues around hospital care for people with dementia during the pandemic. One issue that came out consistently was that the restrictions to hospital visiting had caused issues in the way hospital staff were able to engage with families and carers of people with dementia. This made it difficult to find out what was really important to individuals to support a meaningful, person-centred approach to care. In addition, the necessary, stricter, infection control measures that had been put in place, often made it difficult or impossible to support people in the way that mattered most to them. These issues meant that a person-centred approach to care planning for individuals has proved more challenging and was therefore identified as a key focus area for improvement.

The aim of the collaborative in this area is that the hospital care of people with dementia will be informed by a personalised care plan which reflects their strengths, needs, wishes and choices. Moreover, the person-centred approach will support the prevention and management of stress and distress.

Another key feature of the collaborative is that we are working in partnership with the Alzheimer Scotland Dementia Nurse and AHP consultants who are providing local leadership for collaborative teams in their NHS board areas.

Building on the learning from the past

The best programmes focus on learning from the past and building on what we know works well. The Dementia in Hospitals Collaborative does the same, by building on the Specialist Dementia Unit Improvement Programme (SDUIP), a three-year programme that supported four sites to improve the quality of care for people with dementia within Specialist Dementia Units.

The learning from the SDUIP programme also helped inform an online toolkit to support improvements in dementia care in hospital settings. The toolkit is due to be launched on our organisation’s ihub website in summer 2021 to coincide with the restarting of the Dementia in Hospitals programme of work.

Hopes for the future

We are currently identifying new and existing teams who are able to re-engage, with a restart planned for June 2021 and the first Learning Session arranged for late June. We hope that teams will be not only sharing their learning with other collaborative teams through the collaborative activities, but will also be developing plans for scaling up and spreading their improvements within their own NHS board, as well as sharing their learning with the wider hospital communities through the Focus on Dementia Learning System.

The collaborative is a really exciting piece of work with huge potential to make a difference to Person-Centred Care Planning. Through testing new approaches to care planning and sharing with each other, the teams involved in this programme can really help to pull together all of the great work and learning that has been happening over the last few years. I believe that this will make a real difference to the experience of people with dementia and their families.

Marie Innes is an Improvement Advisor with the Focus on Dementia Team at Healthcare Improvement Scotland.

More information

Find out more about our Focus on Dementia work.

Categories: COVID-19 blogs, ihub

Vaccine queen – Tracy Hunter

Posted on May 11, 2021

Although Tracy Hunter trained as a nurse and knows how to give injections, she never imagined when she joined Healthcare Improvement Scotland that she would be supporting a mass vaccination programme – and administering to patients herself. As we celebrate International Day of the Nurse, Tracy, an Assistant Programme Advisor for NMAHP’s Healthcare Staffing Programme tells us the challenges of setting up and running a vaccination programme for NHS Fife – and proves that nurses can turn their hand to just about anything.

When I was first asked to help support the set up and roll out of the COVID vaccination programme for NHS Fife, my first thought was “This is a mammoth task – how on earth am I going to do this?”

Now, over 200,000 vaccinations later, over 62% of Fife’s population have had the vaccine – quite an achievement, and one I’m very proud to have been involved with, given everything we’ve all gone through in the past year. And certainly not bad for someone who started out wanting to be a teacher!

Learning to fly

Nursing wasn’t how I originally saw my life panning out. When I left school, I trained as a teacher, but my heart was always in nursing and wanting to help people. There’s no greater feeling than knowing you have provided the highest quality care to an individual and their families. I feel very privileged to be a nurse and have met and worked alongside so many amazing people.

When the reality of the pandemic began to kick in in March last year, I was on secondment to Healthcare Improvement Scotland’s Healthcare Staffing Programme from my role as a senior charge nurse in adult inpatient services in NHS Fife. Like so many of my colleagues, I was deployed back to my home board to lend a hand to tackling COVID-19, firstly in a senior charge nurse role on a palliative care ward and later through joint care assurance visits with social work colleagues to nursing and care homes.

Seeing the impact the pandemic had, like most people I was delighted when a vaccine finally came in to use. Supporting its set up was quite another thing. In many ways it’s been like flying a plane when you are still trying to build it. That’s a phrase we’ve been using on a daily basis, and it really has been a huge task for everyone involved.

In the wee small hours of the morning…

One of the biggest challenges has been recruitment and management of rosters. Logistically, it was a bit of a headache to start with, and my knowledge of rostering and workforce planning was certainly a benefit in helping set up clinics.

We started out by building a rostering team, and in the early days we were building rosters in the wee small hours – my office actually became my bedroom for a couple of weeks. All the staff have been phenomenal, working excess hours at the drop of a hat to establish clinics. Along the way I’ve tried to be open and honest with the team as we worked alongside all the required agencies to bring the clinics together. I’ve asked the ‘daft lassie’ questions where I needed to, and not been afraid to do so.

Focusing on people, not processing

One of the things that I and the team were determined about when we were setting up clinics is not allowing them to be conveyor belts. I’m passionate about delivering person-centred care, and was keen to make sure every patient was welcomed and time was taken to discuss the vaccine procedure with them. To ensure this approach was being delivered, I’ve taken part in vaccinating people myself a number of times, helping out when teams are busy and need an extra pair of hands. It’s been great chatting to members of the public who in some cases have not been out of their homes for months. I will never forget one elderly gentleman who came in wearing his best suit. He was thrilled to receive his vaccine, so much so we both shared a tear or two. He was so grateful and appreciative of our NHS – you don’t forget things like that.

It’s a feeling shared by staff across the board – the feedback is that they love working in the clinics. So many members of the team work in their own jobs all day then support clinics in the evenings and weekends. I am in constant awe of them.

We’ve been supported in all this by teams from the army, who have helped us in so many ways. Their medical teams have taken part in vaccinating, they’ve helped facilities teams by adapting community clinics and empty shops into vaccination clinics, and they’ve supported the logistics of setting up and running clinics. They have been phenomenal, always sharing what they’ve learned – they’ve become part of the team. And like us, they have particularly enjoyed the regular donations of cakes and steak pies from local bakeries!

Typical day

A typical day for me at the moment is manic – it starts at the crack of dawn and then the day just flies by. It usually consists of rostering workforce (right people, right skills, right place), clinical updates, and educating and training of new recruits, particularly Band 3 healthcare support worker vaccinators – a brand new role developed for the pandemic. There are never two days the same and always some curve ball or other you’re not expecting. On the odd occasion where the clinics have been a little quieter, we’ve been able to offer support to GP practices which is always gratefully welcomed.

There’s still a lot of work to be done, and always room to improve and develop, as with everything, but I am so proud of what we have achieved, 19 vaccination clinics open across Fife and another four mass vaccination clinics. No mean feat given all the sleepless nights! I try to visit each of the clinics on a weekly basis, but it’s becoming harder with there being so many of them. For me personally, this has been a huge learning experience, and as I look forward to returning to work with colleagues in the Healthcare Staffing Programme, I hope we can make real use of everything we’ve all learned during this past year.

Tracy Hunter is an Assistant Programme Advisor for NMAHP’s Healthcare Staffing Programme, part of Healthcare Improvement Scotland

More information

Find out more about the work of our Healthcare Staffing Programme.

Categories: Mental Health

Sticks, stones and stigma – Lauren Redpath

Posted on May 10, 2021

As part of Mental Health Awareness Week, Communications Officer, Lauren Redpath, reflects on the importance of language in how we approach the topic of mental health – and explains what Healthcare Improvement Scotland is doing to deliver improvements to mental health care services.

“Sticks and stones may break my bones but names will never hurt me.”

When I was little, I used to chant this saying in the playground when other kids would poke fun at my curly hair. I remember one of my primary school teachers proudly teaching us the saying as if she believed she was providing us with a fool-proof coping mechanism against name-calling. It wasn’t until I got a bit older – and perhaps less resilient – that it dawned on me that names and labels do hurt and they have an unwelcome way of sticking too.

Bill Clinton once said: “Mental illness is nothing to be ashamed of, but stigma and bias shame us all.” This quote resonates with me on so many levels, but it’s a stark reminder that although we have made significant progress in reducing the stigma surrounding mental health and mental ill-health, we still have a very long way to go in ensuring it has no place in our society. Mental health stigma has existed for decades and the hurtful, inaccurate labels often given to people living with mental health issues are still swirling around – they’ve found a way of sticking.

Progress – but still a way to go

Over the past 10 years, mental health has become less of a taboo subject – we’ve seen more stories in the media and heard more conversations about mental health than ever before. Governments are also making it a priority. Mental health is a key theme in our organisation’s work and we have a broad portfolio of mental health redesign and improvement programmes, plus clinical guidelines to support diagnosis and care. For example, Early Intervention in Psychosis (EIP) is highlighted as a priority in the Scottish Government’s Mental Health Strategy (2017-2027) and Mental Health Transition and Recovery Plan (2020). As a result, they commissioned us to undertake a detailed exploration of current EIP services across Scotland, the findings of which were published in March. Engaging with people with lived experience of psychosis was a key part of this work, with the findings highlighting that stigma prevents people from seeking help early. Stigma doesn’t only present itself as hurtful labels, it’s also a barrier to people seeking help when they need it most.

According to research carried out by See Me in 2019, 79% of people in Scotland think that public perception of mental health problems has improved over the past 10 years. However, 56% of people with a mental health condition have experienced stigma and discrimination and only 55% of us would feel confident challenging mental health stigma if we saw it. Being a glass half-full kind of girl, I like to think the other 45% perhaps don’t feel confident in challenging mental health stigma because they don’t know what it looks like – and not because they’re willing to turn a blind eye as it’s not their problem.

The view from Down Under

Before joining Healthcare Improvement Scotland at the start of 2021, I lived and worked in Melbourne for six years – making the most of that big, round, yellow hot thing in the sky that us Scots only get to experience for one week of the year – if we’re lucky. Ok, ok, maybe that’s a glass half-empty statement but I’m sure you wouldn’t disagree.

I worked for an organisation called SANE Australia – a national mental health charity providing support and advocacy for Australians affected by complex mental health issues such as schizophrenia, bipolar, eating disorders, OCD, complex PTSD and trauma. I managed their StigmaWatch programme which promotes responsible reporting of mental ill-health and suicide in the Australian media. The programme team monitors and responds to reports of inaccurate or inappropriate stigmatising media portrayal of mental ill-health and suicide. They also work with the media to provide constructive feedback and advice on how to responsibly report stories touching on these issues.

Mind your language

Studying journalism at university and choosing a career in communications, it’s no surprise that language and how we communicate with each other fascinates me. Add to that my passion for raising awareness of mental health and breaking down the stereotypes and myths associated with it, working on the StigmaWatch programme couldn’t have been a better fit.

I’m hoping I can now use what I learned in Australia to help our vital communications work around mental health in Healthcare Improvement Scotland. I’m passionate about educating and supporting people and organisations on how to talk about mental health safely and responsibly. The language we use when talking about mental ill-health often plays a big role in keeping stereotypes, myths and stigma alive. But what does stigmatising language look like when talking about mental ill-health? Well, terms you might hear every day such as ‘nutter’, ‘crazy’ ‘lunatic’, ‘psycho’, ‘schizo’ and ‘mental patient’ are not only offensive and hurtful, they’re problematic and sensationalise mental ill-health. The preferred language would be a person is ‘living with’ or ‘has a diagnosis of’ a mental illness. It is also stigmatising to label a person by their mental illness. We shouldn’t refer to someone as a ‘schizophrenic’ – instead we should say, ‘a person has a diagnosis of’ or ‘is living with schizophrenia.’ Think about it this way – we wouldn’t label someone by the type of cancer they have so why should it be any different when someone is living with mental ill-health?

A weapon that keeps people apart

During my time at SANE Australia, I worked closely with many of our peer ambassadors who had lived experience of mental ill-health. While filming a promotional video to explain what StigmaWatch is and does, we asked one of them to tell their story. He turned to look in to the camera and said:

“Stigma is a permanent part of my life. After my diagnosis, many people just left. The negativity just came from decades of misunderstanding – in the media, in medicine. People were afraid. When I was given my diagnosis, it was stigma that told me that I was never going to have a home, I was never going to have a job, I was never going to have a family and I was never going to have a life. It took me 15 years to realise that that is all completely wrong.

“Stigma is a weapon that keeps people apart.” I think if I’d asked him about the sticks and stones saying from my childhood, he would simply have said “the sticks and stones and words just never stop coming – or hurting.”

Lauren Redpath is a Communications Officer for Healthcare Improvement Scotland. In her spare time she sits on the Advisory Group for See Me, Scotland’s programme for tackling mental health stigma and discrimination.

More information

Find out more about our mental health improvement portfolio

For anyone looking for support in a crisis, the Samaritans helpline is 0116 123 and is open 24 hours, 7 days a week.

Rethink Mental Illness offers support and advice for people living with mental illness.
Phone 0300 5000 927 (Monday – Friday, 9.30am to 4pm)

Categories: Mental Health

The four steps to the right Anticipatory Care Plan – Paul Baughan

Posted on April 21, 2021

We’ve launched a new section of our ihub website with information, tools and resources to support Anticipatory Care Planning (ACP), a crucial process which ensures that the right things are done in the future for each person, should their health change. Dr Paul Baughan, clinical lead with our Primary Care team explains why this ACP is so important and the various stages to enable the right outcome for patients.

The longer I work in general practice, the more I realise that there are many different ways to treat people who have exactly the same medical condition. Priorities for care vary considerably between individuals, and if we do not stop to ask “What matters to you?” then we can actually cause harm – even when following the latest evidence-based guideline.

Spending time with someone to explore treatment and care options that are right for them – in the context of their current state of health, their social situation, and the various priorities in their life – is critically important. It can ensure that the right things are done in the future for that person, should their health change. Things such as the type of medicines to use during an exacerbation or sudden deterioration, the people who should be contacted to help with decision making, and how the person would like to receive care if staying at home is becoming more difficult. These preferences can be written down, kept with the person, documented in their clinical notes, and shared with other people who need to know. Many people call this approach ‘Anticipatory Care Planning’.

***Diagram: The 4 steps of successful Anticipatory Care Planning***

There are four crucial steps to a successful ACP, which forms the basis of the new Healthcare Improvement Scotland ACP toolkit. Each of these steps is important to ensure that we do the right thing for the person we are caring for. We know that harm can be caused if we jump straight in at Step 3 (documenting a care plan), without the important preparation and planning, or having first engaged in meaningful conversations with the right people.

As a GP, as well as the Clinical Lead for Primary Care with Healthcare Improvement Scotland, let me explain how I’ve been using the four stages and how they help me to ensure that the right care plan is created for everyone.

Step 1: Preparation and Planning

The first step, Preparation and Planning, involves identifying who you will be having an ACP discussion with, then preparing yourself and the person for that conversation.

I do this by finding out as much as I can about the person before meeting with them. I ask myself the following questions: What is their current state of health? What have other professionals and specialists said or written in their notes? Is there anyone who normally supports this person with decision-making? What is their social situation? What realistic options are there for future treatment and care?

It is also important that I prepare the person with whom I will be speaking, check that they are happy to have this type of conversation, and ask whether there is anyone else who should be involved in these discussions (For example, a family member or power of attorney).

Step 2: Meaningful Conversations

The conversation between the health or care professional and the individual, as well as those important to them, is at the heart of ACP.

I find the REDMAP framework, developed by Dr Kirsty Boyd, Reader in Palliative Care at University of Edinburgh, a helpful structure to follow.

It’s important to allow appropriate time for these discussions, and this can be a challenge in general practice. I will often hold these important conversations over a number of different appointments over several weeks. This allows the person and their family time to think about things before we agree an action plan that is right for them.

Step 3: Documentation and Sharing

Once a plan has been made, it is important that it is shared with all those who need to know. After all, it might be needed in the middle of the night when the practice is closed. The best way that we have to share this information between health professionals is through the Key Information Summary (KIS). However, information can only be added to KIS through GP practice clinical systems. For those unable to access this, there is now a web-based Essential ACP Online Tool to document aspects of the ACP. This can be securely shared with the individual or the GP practice. Work is progressing with a digital version of ReSPECT, and ultimately I look forward to a time when we have a single citizen-held electronic health and care record. One within which my patients can enter their own information about ‘What matters to me’, and that can be supplemented with information from all the health or social care staff who are involved in providing care.

Step 4: Regular Review

People may change their mind about their priorities for care as their health or social situation changes. What matters to someone in six months’ time may be very different from now. That is why it’s important that ACP information is regularly reviewed and kept up to date.

33% of the Scottish population have something entered within their KIS. Not all of these will incorporate an anticipatory care plan, however it does present me and my primary care colleagues with a logistical challenge to keep them up to date. Healthcare Improvement Scotland with RCGP and Scottish Government has recently published pragmatic guidance and top tips for reviewing and updating KIS. An important aspect of this guidance is exploring the resources (people and time) that are available and ensuring that the extended multidisciplinary team is involved in these reviews. This requires preparation and planning, which of course brings us back to Step 1.

So whether, like me, you are working in general practice, or are based in another part of our health and social care system, anticipatory care planning is important. It is not a one-off activity to be ticked-off and completed, but instead is a process that requires preparation and planning, meaningful conversations, documentation and sharing and regular review.

Paul Baughan is a GP and the Clinical lead with Healthcare Improvement Scotland’s Primary Care Team.

More information

Visit http://ihub.scot/acp for all the resources mentioned here and share with us your learning about ACP by emailing: his.pcpteam@nhs.scot.

Categories: COVID-19 blogs

Getting on board – what it’s like to be a non-executive director – Rhona Hotchkiss

Posted on April 9, 2021

What’s it like being a non-executive director on the board of Healthcare Improvement Scotland? As we recruit for a new board member, Rhona Hotchkiss explains the route she took to becoming a non-executive director and the qualities you need for the role.

Sometimes life takes unusual turns that you can’t possibly foresee. Way back in 2004, after I spent a year as an Interim Director of NHS Quality Improvement Scotland (NHS QIS) – the predecessor organisation to Healthcare Improvement Scotland (HIS) – I left the NHS, seemingly for good, and went into management consultancy. I had no notion then that I would be back 15 years later as a non-executive director, nor of the path my career would take to get me here!

Scotland to Australia and then back again

But it all started way before HIS and way before QIS! I started my working life as a nurse, training with Argyll & Clyde Health Board, as it was then, and after qualifying went on to train and work in ITU. I went to Australia for 6 months on a working holiday visa, during which time I did agency nursing to keep myself fed and clothed, and the rest of the time generally scrounged off some Australian midwives that I’d become friendly with when they had previously come to Scotland to train.

Fast forward many years after my return from Australia, and life has taken more twists. It’s 1998 and I’m an advisor in Nursing and Quality at Scottish Government going on to become the first Director of the new Nursing and Midwifery Practice Development Unit for Scotland, NMPDU or ‘NUMPTY’ as it was affectionately known. After 2 years, NMPDU was one of the organisations that came together to form NHS QIS and then eventually became HIS. In a way, change and development was becoming quite normal.

Time for more change

By then I’d been working in the NHS for 25 years and it was time to try something entirely different, so I opted to join a consultancy firm. It was comprised of good people working to a very high standard, but, although I stayed for almost 5 years, it wasn’t for me. I missed the sense of unity and purpose, the feeling of service that the public sector had brought and, in a move that surprised many who knew me, I joined the Scottish Prison Service as a Deputy Governor. After being Deputy Governor at Barlinnie and then Shotts, I went on to be Governor of Dumfries (just the prison, not the entire town!) then to Cornton Vale, where I also project managed the reprovision of the women’s prison estate and finally to HMP Greenock, from where I retired in 2019. I could write a book! Well actually, I have, but I can’t get anyone to publish it.

One week after retiring and I was back in the NHS as a Non-Executive Director at Healthcare Improvement Scotland – saying ‘hello’ to at least 15 very familiar – and much aged – faces, while my own of course had barely changed!

The volume of evolution

As someone who had worked for QIS, HIS does and doesn’t feel like the same organisation. The volume of evolution and outright change has been huge. The direction the organisation has taken, and the size it has grown to, are sometimes surprising to me and at other times feel more organic. Having at least a passing familiarity with the organisation pre-HIS has been useful, as has retaining some understanding of the environment it operates within – but much more useful has been the whole 40 years I’ve spent working in or close to the public sector – at all levels – from very junior to very senior. Of course, running a prison is very different to being with HIS, but people are the same wherever you work: their concerns, their issues, their brilliant and their not so brilliant moments, and I feel every step of my 40-year working life has contributed in some way to the person I am and what I bring to the non-exec director role.

Being a non-executive Director is never dull. I’m as prone as the next person to letting my concentration wander during long meetings and, of course, some things interest me more than others – but that’s true wherever you work. I think there is both a qualitative and quantitative difference between a national public board like HIS and a territorial NHS board. Different issues, different pressures, and yes a different workload. I’ve been surprised by how well the non-executive team of directors get on and how our backgrounds and skills complement each other.

The main qualities required to be a board member

I think the main qualities a non-executive director requires are curiosity and a willingness to learn. If you’re already feeling jaded, then this isn’t for you, because the political machinations that determine how the NHS runs can feel a bit ‘groundhog day’ at times, particularly when you’ve been around the public sector as long as I have. But seeing real progress being made more than compensates for that.

You have to be able to probe and ask questions in a constructive way and you have to be brave enough – or stupid enough – to do that when no-one around you seems to have any issue with what is being said or presented. Everyone wants to operate in a supportive environment, and you have to play your part in creating that at board level – that means valuing the contribution of others, even when you don’t agree or can’t see their point; understanding that the process by which a governing board will reach a collective stance may not always result in what would be seen as a perfect outcome in your book.

Finally, I think being able to read critically is a vital skill. There’s a lot of material to plough through at times and having the wisdom to realise what can be skimmed, what has to be looked at forensically and what just doesn’t hang together properly and needs to be questioned further, is vital.

If you want to contribute to the NHS, if you have a broad base of experience, and if you can operate in a collegiate way, being a non-executive director might just be right for you.

Rhona Hotchkiss is a non-executive director on the Board of Healthcare Improvement Scotland.

More information

Find out more about this role and apply online now.

Categories: COVID-19 blogs

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

Posted on April 7, 2021

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.

Categories: COVID-19 blogs