Rewriting the rules for outstanding care

Salford Health Matters, a social enterprise providing primary care to 15,000 patients, has been rated ‘outstanding’ by the CQC. Its excellence is rooted in the value it places on its nurses, its willingness to listen to staff and patients, and openness to innovation.

From left to right: Moira Ogunsakin, Liz Reilly, Alison Senior, Katie Barnes and Kate Jones

Picture credit: Neil O’Connor

You might expect a national report from the Care Quality Commission to focus on the failings it has found in healthcare organisations, but a March publication breaks the mould.

Celebrating Good Care, Championing Outstanding Care (tinyurl.com/CQC-CGCCOC) is the first CQC report to highlight inspiring examples of good and outstanding care, revealed by its in-depth inspections regime (see box), which it launched in September 2013 and began rolling out last year. From now on, such reports will be published quarterly to share good practice and show other providers how to achieve excellence.

CQC inspections:

Include hospitals, GP surgeries, dental practices, community health care, mental health, adult social care and hospices.

Assess whether services are safe, caring, effective, responsive to people’s needs and well led.

Award ratings of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’.

Among the services showcased in the report is Salford Health Matters (SHM), a social enterprise providing primary care to a registered population of 15,000. The organisation has a team of around 55, with three practices handling up to 1,000 patient calls a day. It was rated outstanding in every area of inspection in November 2014.

SHM chief executive Neil Turton says: ‘If we are talking about quality of care then that is down to the interaction between patients and our trained and motivated staff. To provide great care you need a great place for people to work.’

Here is how SHM ensures it is ‘great’ for its staff and patients.

Left: healthcare assistant Sara Bradbury; center: advanced clinician and nursing director Kate Jones; and right: lead practice nurse Moira Ogunsakin

1 Value nursing

‘We have a brilliant team of nurses,’ says Kate Jones, an advanced clinician and nursing director, who has been with SHM since it began in November 2007.

‘To begin with, we respect them,’ says Ms Jones. ‘We value their person-centred skills and we also invest in their training. Their opinions are sought and valued. They are encouraged to participate in changes and drive them forwards.’

A non-hierarchical approach with a relatively flat managerial structure helps to create a culture of open exchange, she says. ‘Our nursing staff are in a powerful position to influence their own day and that of their colleagues.’

The growing nursing team includes six practice nurses and eight advanced nurse practitioners. There are also five healthcare assistants (HCAs) and an assistant practitioner. HCAs have a structured three-month induction for their job and keep a competency folder, so they can collate evidence of what they have achieved.

All nursing staff attend an afternoon training session every six to eight weeks, run by lead practice nurse Moira Ogunsakin, who has worked at SHM for seven years. Topics covered include long-term conditions such as diabetes. ‘We take two subjects each time, suggested by staff,’ she says. ‘Managers are supportive of training and they recognise it empowers us to deliver better care.’

Ms Ogunsakin visits each of the three sites once a week to check that everyone is happy. There are also short staff surveys every two weeks and a more comprehensive questionnaire every quarter, with results passed on to managers for discussion.

This asks questions such as: do you understand your role?; what learning opportunities have you had?; is the organisation friendly?

‘If something is slipping, we can address it quickly,’ says Ms Ogunsakin. ‘You feel good working here; you know that you are appreciated.’

2 Be open to ideas

Salford offers patients who are living with a chronic illness and those aged 40 and over an annual health review. In the past this was likely to have been based on test results that might be up to 12 months old, but that has changed thanks to an idea suggested by a nurse.

Now tests including bloods, weight and blood pressure, and questions about diet, alcohol, smoking and exercise are handled by a HCA a couple of weeks before a consultation with the nurse. Patients are also asked about any memory problems, as the service is trying to catch signs of dementia at an early stage.

‘It has improved the service so much and we are getting a more accurate picture for patients now, who appreciate the results,’ says Ms Ogunsakin.

People from outside the service are regularly invited to present to the nursing staff. ‘Someone new brings different ideas,’ says Ms Ogunsakin. ‘You may only take one or two things away from a session, but those titbits can make a huge difference for your patients. Otherwise you can get stale and miss out on new ideas.’

3 Look beyond health to social needs

‘Our client group is challenging and life is hard for many of them,’ says Ms Jones. ‘What we began to realise was that no matter how brilliant we were with their health problems, their lives would not improve unless we helped them tackle other issues too.’ To that end, SHM created ‘social prescribing’.

‘As nurses we are in fabulous position,’ says Ms Jones. ‘Patients tell us things and we can do so much to help them, but we need to spend time to find out what they need. Some of our patients feel they have never achieved anything.’

Once a patient’s health concerns have been dealt with, an hour-long appointment can be made with the social prescribing team, which includes nurses, HCAs and social work students. The team builds up a picture of the patient and then recommends activities, organisations or courses aimed at helping them improve their life.

‘It might be signing up to a gym, literacy classes or cooking lessons,’ says Ms Jones. ‘But we get them started on something, even going with them the first couple of times if that is what they want. From there, they start making friends and bringing others with them. It is a big community and we are a small organisation, so we cannot do it all ourselves, but the model starts here.’

Housing is a big issue locally and SHM has forged links with a housing trust, which owns and manages almost 15,000 homes in West Salford. SHM runs the Salford Homeless GP project, providing healthcare to more than 120 registered homeless people through its drop-in sessions, held three times a week.

SHM also has its own allotment, which is now managed by two patients who originally began working there to combat their mental health problems. Gardening is one of the activities that can be prescribed, and better understanding of food and where it comes from is an important aspect of patient education.

‘We have a lot of young mums and many of their children had no idea what some vegetables looked like,’ says Ms Jones.

‘Of course you can treat their child’s constipation with medication, but teaching them how to cook using fresh vegetables is so much better in the longer term.’

We are small so we cannot do it all ourselves, but the model starts here

4 Learn from mistakes

When things go wrong at SHM, staff listen and respond – something that the CQC highlights as particularly important in its report: ‘Among the best care we have found is in services that acknowledge there is always room for improvement – they are proactive about seeking feedback and learning from concerns and complaints.’

Advanced practitioner Liz Reilly, whose background is in physiotherapy, supports the clinical lead in managing patient complaints. ‘We view complaints as a gift,’ says Ms Reilly. ‘We see it as a barometer, or a window. It is the way we learn from what has been happening and how we can improve our services.’

Information for patients on how to complain is available at each of the three sites. Although a GP at each site is responsible for investigating incidents, the entire staff is geared towards handling complaints properly. Significant events are discussed at a monthly meeting, where all staff are invited to suggest solutions.

‘There is no blame attached,’ says Ms Reilly. ‘Patients appreciate the time we spend investigating what has happened. It can be hard to complain and our approach makes them feel it was worthwhile. Often they want to make sure that the same thing does not happen to others. If we handle their complaint well, the person feels less anxious and their trust in what we do is improved.’

5 Change how care is delivered

With a disproportionately large number of parents opting to take their sick children to A&E rather than their local GP, SHM was keen to make some radical changes in this area.

Advanced practice in action (starting on opposite page): advanced paediatric nurse practitioner Alison Senior; advanced clinician and nursing director Kate Jones; advanced practitioner in long-term conditions Liz Reilly; and advanced paediatric nurse practitioner Katie Barnes

Picture credit: Neil O’Connor

Staff did not hesitate when the opportunity arose to be part of a groundbreaking project spearheaded by advanced paediatric nurse practitioner, Katie Barnes. In 2010 Salford joined with her small social enterprise, Kids Health Matters, and fellow community interest company Hope Street Centre to apply for a Department of Health innovation grant. They were awarded more than £400,000 over three years to set up the Salford children’s community partnership – the only project like it in the country.

The service is run by four advanced paediatric nurse practitioners, who treat children with anything from fever and asthma flare-ups to vomiting and diarrhoea. Sometimes children can be seen straightaway.

‘We’re changing the model of how we deliver care,’ says Ms Barnes. ‘We sit in a middle space between seeing the GP and going to A&E for something complex. In the past, the only time acutely unwell children ever saw paediatric experts was in a hospital, but now it is local.

‘We do the same as a hospital. We have a range of medications and can start treatment immediately. We then have space here to observe the child for an hour or so and if we do not feel they are progressing, we may refer them to A&E.’

Evaluation carried out by the Hope Street Centre shows that the project is working. Over its first three years, the acute admission rate for children attending A&E dropped by 4%, with spending reduced by a similar amount. Figures from the year before the project began showed that almost 1,400 children in Salford had been admitted to hospital, at a cost of almost £1 million, although the vast majority could have been treated locally and sent home. The service has been such a success it is expanding into four more practices.

‘Change is hard and it took a while to embed, but my view was always build it and they will come,’ says Ms Barnes. ‘It has expanded by word of mouth. Parents know it is a good service and easy for them to access.

‘When I started out, I knew that I had to push on an open door – and that open door was Salford Health Matters. Innovation is what they have for breakfast’.

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