National Review of Primary Care Out-of-Hours Services

The Cabinet Secretary for Health and Sport, Shona Robinson MSP, launched the Report of the National Review of Primary Care Out-of-Hours Services on November 30, 2015. Professor Sir Lewis Ritchie OBE (the Review Chair) led this work with the following aims to review the current delivery landscape and recommend action to ensure that primary care out of hours services:

• Are person-centred, sustainable, high quality, safe and effective
• Provide access to relevant urgent care when needed
• Deliver the right skill mix of professional support for patients during the out-of-hours period.

In March 2017 four members of the Patient Public Panel, Margo Biggs, Evelyn Crosbie, Mary Miller and Helen Russell were invited to give the patient’s perspective at one of the afternoon sessions chaired by NHS Forth Valley’s Medical Director Andrew Murray and facilitated  by Deirdre Anderson from NHS FV Out of Hours Service.

The discussion took place around the present role of GPs in Scotland and the plans for alternative ways of health provision.  PPP members were invited to give examples of using the Out of Hours service either directly or from the experience of friends and family.  Mary Miller was able to give examples from her own treatment and that of patients in Clackmannanshire while Evelyn Crosbie described some delays surrounding a blood test for a family member.

There was wider discussion on other sources of Out of Hours Care such as MECS and ALFY and about signposting the public to the best appropriate service for their needs. Evolving roles were discussed and this included the use of pharmacies and Nurse Practitioners.

Members who attended felt that the session went well and that they were able to relate the points of view of patients and fill in some gaps in the knowledge base for Forth Valley.  Some members did comment afterwards that they felt they could have contributed better with more information on what had been covered at earlier sessions, more notice and opportunity for preparation.

The expectation was that the results of review programme would inform the National Delivery Plan for the Transformation of Urgent Care, for which £10m was set aside in 2016/17 to deliver both national and local initiatives towards enabling improvements in urgent care services. On 6^th July 2017, NHS Forth Valley’s Chief Executive announced an update on interim changes to Primary Care Out of Hours services, to be followed by a wider review of Out-of-Hours activity across Forth Valley and undertaken in partnership with the Integration Joint Boards to identify how sustainable Out-of-Hours services can best be delivered in the future.

Simulation Centre Actors

Patient Public Panel members were given the opportunity to assist with training doctors between November 2016 and May 2017 when they took part as “actors” simulating patient roles as part of medical training scenarios in the Forth Valley Royal Hospital’s Simulation Centre.  Members who took part were Margo Biggs, Sheila McGhee, Helen Macguire, Mary Miller and Eileen Wallace.  Medical staff were either being trained and assessed, in the case of Foundation Year 2 medical students, or as a preparatory exercise for doctors about to take the last part of their A&E Consultant Exams.

The simulated sessions took place as half-day periods of 3 to 4 hours or a full day of 6 hours

and for the scenarios, each patient-actor was given the background to a condition and facts surrounding the symptoms so that they could answer questions associated with a hospital visit. These included their name and date of birth, past medical history, medication, social history, family history and what the patient’s concerns and expectations were. Medical staff taking part were given a fixed time slot to ask questions and plan their next steps in order to arrive at a diagnosis.  At the end of each case study the clinical lead and coaches delivered their comments and feedback to the candidates. The process was repeated with all of the medical candidates being seen during each session. PPP members commented that, “… it was amazing the different approaches candidates took to the “patient”, given all had the same scenarios”.

Examples of the roles that members had to play included:

• A patient facing end of life care
• Grandparent of 3 year old with suspected child abuse; the sensitivity of how the doctor dealt with this scenario was monitored
• A 71 year old woman recovering from a broken hip at home but developed a bed sore in her heel and was admitted with MRSA and raised levels of antibiotics; this scenario used a ‘painted on’ ulcer using make-up artist material
• A 72 year old woman with dementia who was concerned about a family member gaining her property, and staff feared the patient was at risk of being taken advantage of.

A further session involved working with Emergency Department doctors as part of the Objective Structured Clinical Examination (OSCE) process organised by external staff. This involved around 12 stations that the candidates had to complete in an allotted time.  One simulated patient scenario was that of a patient with a fractured wrist which required local anaesthetic to allow for manipulation to reduce the fracture. The doctor undertaking the OSCE had also a “medical student” to instruct on how to assess the dose and injection of local anaesthetic. A prosthetic arm was used for the purpose of the ‘medical student’ administering the injection.

Members taking part reported finding their roles challenging. Margo found it difficult not to provide more information than required in her role as a patient returning from a trip abroad, while Helen Macguire found she needed to focus on the part she was playing and only reveal some information if asked. Sheila said she had to remember to, “… keep my mouth closed when things were missed”.

Members said they enjoyed the acting.  They found the students and doctors took the role play seriously and were professional in their approach.  All staff were welcoming, inclusive and  treated the PPP volunteers as team members . Comments from members included … Very relaxed and welcomed; … Nothing was too much trouble and every effort made to help our experience be a positive one; … The staff appreciated our commitment; … On the whole very interesting and another learning opportunity.  All members said they would take part again if asked.

Dr Michael Stallard, Simulation Fellow at Forth Valley Royal Hospital sent the following note, … Just wanted to say a very big thank you to you all for coming yesterday and your crucial help with our course. The feedback was very good from the trainees and a few of them specifically mentioned the quality of the patients in their feedback. I know that Olly was very impressed too so thank you for all your work in memorising the roles. The Oscars are just around the corner! Thanks again.

This was certainly a successful series of engagements for the Patient Public Panel, providing practical involvement of members who felt they had contributed meaningfully to the training process, and of positive significance to the working of the hospital and beyond.

Selection of Medical Directorate, Head of Nursing

Patient Public Panel members Margo Biggs, Carol Alardyce and Lee Campbell were the PPP representatives for the initial part of the process to select NHS Forth Valley’s new Head of Nursing for the Medical Directorate in December 2016.  They participated in the morning session, which started with a briefing session, followed by presentations by the candidates and then questions from the panel.  PPP members were pleased to be given the opportunity to ask questions as on the same basis as NHS staff.

Candidates came from 5 other Health Board Areas with one candidate from NHS FV.

The candidates were given a question, to focus on in their 10 minute presentations, about the approach they would use to engage with staff in the Medical Directorate. They were also given the opportunity to present their previous experience in areas relevant to the prospective role at NHS Forth Valley. After each presentation there was discussion on the strengths and weakness of each candidate. Again PPP members were able to contribute their opinions, and after all the presentations were complete there was a grading of candidates after a collective discussion. There was general agreement on the strongest candidates and the interview stage took place in the in the afternoon without PPP members present.

The PPP members who took part felt that they were made welcome to the proceedings and didn’t feel that their presence inhibited the process in any way.  Opportunities to ask questions of the candidates were welcomed and were certainly taken up.  The involvement of the PPP in such an important process demonstrates a genuine commitment by NHS Forth Valley to person-centred care.

Ward Support Roles

Beginning early in 2016, PPP member James Greenaway has been the PPP’s representative supporting Ward B23.  James attends the ward one day a week for 3 – 5 hours each visit and helps patients to complete Patient Experience and Catering Control surveys.  Ward B23 takes orthopaedic patients with ages ranging from around 30 to 80.  Patient Experience surveys cover how patients are admitted and welcomed, how they are treated by staff during their stay, whether they are addressed by their preferred name, attention given by staff, plus any other comments the patient wishes to record.

James also completes Infection Control surveys with patients who have PVC or PIC devices fitted, covering whether the site is inspected regularly and the device replaced if necessary, and if staff carry out hand hygiene procedures before treating patients.

James takes a relaxed and chatty approach to his role and helps patients to get their comments across constructively. He enjoys his role and works as one of the team on the ward. He is welcomed by the Senior Staff Nurse and other ward staff and describes his relationship there as “excellent”.

Benefits for the patients are evident and many welcome the opportunity to have someone to talk to. The PPP volunteers provide, reassurance that the hospital is listening and recording their comments independently; someone to talk about concerns unrelated to medical condition; a break in the routine with a new face; someone with the time to listen the patients’ life experiences.  Most simply have praise for the staff and their treatment.  Beyond these is the potential for an impact on wider patient community from some of the issues being addressed.

The role has been so successful that other wards asked for similar help.  Karen Maclure, Person Centred and Patients Relations Manager, commented that “Everyone wants a Jim”.  PPP members Lee Campbell started similar work in Ward B11,  Lee says, “The Senior Charge Nurse has made me very welcome as have the other staff. This makes it a pleasure to visit once a week.   Patients tell me they appreciate someone taking the time to sit with them as they complete surveys as opposed to being handed them for them to fill in, especially when the person is not NHS staff. They appreciate the confidentiality and the fact that anonymity is ensured. They find it easy to talk with me and voice any concerns.”

Carol Alardyce and Evelyn Crosbie volunteer in the Cardiology ward.  A benefit they have noted is that patients sometimes share a problem which the survey does not address.  This can then be passed on to the charge nurse who always finds a way to help.

Carol describes what she gets out of the role as …

• A sense of structure and purpose to my time in retirement
• A sense of satisfaction on those occasions when I make a difference for someone
• A sense of usefulness in practically supporting one of the NHSFV’s initiatives 
• A warm welcome from the ward staff
• Improving my social skills and helping me to approach people
• An appreciation of my own situation as I usually leave feeling better than when I arrived

Evelyn says …  The time spent talking and listening to the patients seems to help break up their day and that has got to be worthwhile.  I have gained confidence I can now take on the HAI and the Catering Surveys.

Hospital Catering Surveys

For some time PPP members have been assisting with Hospital Catering Surveys. The purpose of the surveys is to identify areas for improvement in the FVRH Catering Services delivery of food & refreshments to patients, covering Breakfast, Lunch and Dinner.

The surveys cover the following areas:

About the Food: Appearance, taste, temperature, portion size, choice available, and whether it suits dietary patients’ needs.

Patients are asked … 

Food Choices:  

• Are you given a choice of food?
• Do you receive the meals you order?
• If you missed a meal, was a replacement offered?
• Are you aware that you can choose either small or standard portion?
• Do you require assistance with eating or drinking?
• Are you given the opportunity to wash your hands before eating?

Snacks & Drinks:

• Are you offered snacks & drinks between meals?
• Are you satisfied with the choice available?

Food Service Staff:

• Are staff friendly and welcoming, smart and professional; are they efficient?
• Overall how satisfied are you with the Catering Service?

The survey also asks patient’s gender, age and length of stay in hospital.  It normally takes between 5 and 15 minutes depending on the type of patient. The range of possible responses can be Very Satisfied to Not at all Satisfied, but are usually between Very Satisfied and Fairly Satisfied. On occasion where the responses are not favourable, this is fed back to Sandra West, Business Support Manager for Serco Healthcare Enabling Services at Forth Valley Royal Hospital.

PPP members aim to cover one ward per week each and say they find it rewarding, meeting and chatting to some very interesting people.

Domestic Monitoring Audits – Christina McNeill

Being part of the Patient Panel offers members many varied and interesting opportunities.  One of these is taking part in Domestic Monitoring Audits. Accompanied by a member of staff from Serco who provide facilities management for Forth Valley Royal Hospital, Patient Panel members carry out audits of domestic and housekeeping services on the wards and other clinical areas.

Amongst other things, we inspect kitchen areas, patient rooms and bathrooms, treatment rooms, floors, curtain rails and so much more. If we find any issues requiring attention these are noted, reported and, more importantly, rectified.

Visits to the wards allow the Patient Panel member to build up a rapport with staff and raise the profile of the Panel. They also allow us to speak to patients and visitors and gain their views on the standards of the services provided.

As Panel members we offer an independent approach to the monitoring process. We are, in addition, a “ fresh pair of eyes “.  Hopefully we provide reassurance to patients and the public that service provision is a priority for NHS Forth Valley and that it is carried out to the highest of standards.

Influencing Change – Helen Macguire

A Patient Public Partner Member’s story prompted 2 other members to take action, which has influenced the way the possessions of deceased patients are returned by staff to those who come to collect them.

It all started with Helen Russell, a PPP member, approaching Helen Macguire and Margo Biggs, PPP members on the Bereavement Steering Group with her story.  The last memory Helen had of Stirling hospital when her mother died was being handed what looked like a plastic bin liner with her mother’s possessions.

The staff could not have been kinder or more caring to her mother during the last stages of her life, but this experience has had a lasting effect on Helen.

Helen and Margo took this story to the Bereavement Steering Group and asked if something could be done to change the way possessions of deceased patients could be handed back to relatives with more dignity and respect.

This request was sympathetically listened to by the NHSFV staff on the Bereavement Steering Group and the Chair, Sandra Campbell, Nurse Consultant for Cancer and Palliative Care said she would see what could be done. Various samples of holdalls were sourced by Sheena McCorrie who facilitates the meetings. The members were asked for their opinions before a suitable holdall was selected.  Finally, it was decided to have a pack consisting of a linen holdall, a mesh bag for jewellery and a sympathy card. These were piloted before being distributed throughout the wards at Forth Valley Royal and the 4 community hospitals.

Another member of the PPP, Christina McNeill, then became involved by assisting the staff in the PPI Cancer Involvement Group  to make up the packs for distribution.

At a  National Bereavement Stakeholder event at the Park Hotel in December, the pack was on display and Sandra said that they would now be used in all the FV hospitals, Care Homes and Strathcarron Hospice.  She added that interest had also been shown by other Health Boards in Scotland.   Since then there has been really positive feedback from the ward staff saying that some families also comment and are appreciative of the bags and cards.

This work is fully supported by Professor Angela Wallace as the executive lead for Bereavement in Forth Valley.

It is one of the PPP’s roles to influence change within NHSFV and this is a prime example of how this can be achieved when working together with staff.’