Making sense of systems

By Mark Cole, Director, Radical OD Ltd

Thinking afresh as to how to support new ways of thinking and working

The NHS in the UK faces many challenges and at the same time, is guided by an ambition to reform itself to become more geared towards – and responsive to – the needs of the population.

However, there is limited time and space for those who work in the NHS to think creatively about how to respond to these circumstances. The service is extremely busy and it feels as though staff – particularly those responsible for managing and leading – are caught up in a permacrisis, which limits their capacity to think differently and to test out new ways of doing things.

This has led to a fresh corporate imperative for people to embrace systems thinking – and, in practice, to apply the precepts of systems leadership. However, this raises a crucial issue: there are myriad approaches to business leadership these days, as a cursory glance at the groaning shelves of the Airport Academy demonstrates, which can sometimes make systems leadership feel like yet another fad.

As with all fashions, of course, people are sucked into it, partly out of a personal fear of missing out and partly because everyone around them seems to be saying that it’s a trend into which they need to buy.

Current systems thinking

However, approaching the challenges and ambitions of health and social care systemically makes absolute sense. It is a perspective that acknowledges that the whole is greater than the sum of its parts and that a system relies upon meaningful connectivity between agencies – and individual agents – to maximise that effect.

All of which has led to a busy market of workshops, courses, and programmes that aim to induct people into systems thinking. However, these tend to take place at a distance from the practicalities of what it is like to make sense of systemic working in practice and to navigate it in a positive fashion.

There is a paradox at the heart of this. The busyness that managers and leaders in the NHS face at this time denies them the headspace to think systemically in the context of their systems. They are frantically doggy paddling in order to keep their heads above water, which prevents them from learning in the pool the swimming strokes that would make the situation smoother and easier.

On the other hand, there is an effort to teach people about systems – but this is taking place away from the practicalities of work in a quite abstract fashion. It’s as if people are stepping out of the pool to sit in a classroom to be shown the theory behind other swim strokes that might support them better in the water.

Crisis and leadership

Why is proximity to practice so important in this instance? Primarily because our organisational focus in most instances is on structure: we focus constantly on the scaffolding that envelops the work that we are asked to do. Yet the latter occurs systemically, with a passing relationship to the structure but in many ways independently of it.

Importantly, it is arguable that recent experience shows us that systems become apparent, and we are better able to acknowledge their presence, at times when we face crisis. There are examples cited by Rhiannon Firth in her book Disaster Anarchy – for instance, the aftermath of Hurricane Sandy in the US – where disasters outstripped the state’s capacity to respond, due to its structural emphasis, but out of which arose mutual aid arrangements, which were systemic responses.

A clinician with whom I spoke at the peak of the Covid 19 pandemic explained that it used to take her at least three days to organise a patient transfer. Invariably, to action it, she would need to involve people above her in the hierarchy. However, with the arrival of coronavirus, she found it necessary to step into leadership – and she quickly found that she could network with opposite numbers in other agencies at a grassroots level…and suddenly transfers could be achieved in around half a day.

This is important learning about how structures can often constrain innovative approaches to getting things done – and that an experience of crisis can create a tendency for systemic working to come to the fore. The challenge, however, is to preserve that learning about systems that arises out of difficult practice, when organisational elasticity tends to see things snap back into place, with bureaucratic structure reasserting itself.

Learning about systems from systems

Over the course of the past six months, I have been in conversation with my colleague and co-thinker Eitan Reich as to how best to help people with systems thinking and practice. This piece is a summary of a longer and more detailed white paper, which can be accessed HERE.

We have generated several foundational precepts in terms of thinking about this challenge:

Crises tend to cause structures to buckle, which has the positive effect of allowing the systemic underpinning of the workplace to become more apparent – and hence more widely applicable.
Seeking to “teach” people about systems at a distance from the systems is too abstract an approach – which will make it feel like an imposition for many leaders.
A useful starting point is to explore people’s recent experiences of crisis, in terms of what they saw happen; what they initially considered doing, and what eventually emerged as a way forward, which may well have been wholly unexpected but needs now to be acknowledged as a different way of working.
Knowingly engaging with the experience of working systemically that arises inadvertently out of extreme circumstances will give people the permission to unlearn traditional leadership thought and practice and to allow a new way of being and doing at work to emerge. For example, the structural mindset requires us to think about directing: to embrace a systemic perspective means that we focus instead of finding ways of connecting.

Next steps?

Eitan and I are now extremely eager to identify a couple of partners who are interested to work alongside us in collaboration to continue this exploration and development of a way of helping people to think and practice more systemically in the public sector. If this is something that you might be interested to discuss with us, please drop us a line at radicalod@colefellows.co.uk and we’ll schedule an exploratory call.

Email: radicalod@colefellows.co.uk
Website: www.markcole.org
Blog: www.radicalod.org
X: @reflectservices

News, Thought Leadership May 28, 2024

Professor Mahendra Patel OBE: Reimagining the role of community pharmacy

By Samantha Semmeling

ICJ recently spoke to Professor Mahendra Patel OBE, leading pharmacy expert and Director for the Centre for Research Equity at the University of Oxford, about his vision for community pharmacy, and how multi-professional collaboration can help the underutilised sector play a key role in the fight against health inequalities.

Public Policy Projects (PPP) is hosting its inaugural Medicines and Care Pathways theatre as part of the Integrated Care Delivery Forum in 2024. The first iteration of the event took place in Birmingham on 9 May where pharmacy professionals joined wider ICS leadership to discuss pharmacy’s contribution to the integrated care agenda.

Professor Mahendra Patel OBE, Director for the Centre for Research Equity at the University of Oxford, and a recently appointed Independent Expert Member to the UK Professional Pharmacy Leadership Advisory Board (UK PPLAB), joined the theatre and highlighted the untapped potential of pharmacy to further contribute to system priorities.

PPP spoke to Mahendra about the current developments in UK pharmacy leadership, multi-professional collaboration, and the role pharmacy professionals can play in reducing health inequalities.

The evolving landscape of pharmacy leadership

In 2023, Mahendra brought his expertise to the UK Commission on Pharmacy Professional Leadership acting as Vice Chair of the Leadership, Policy and Professionalism working group. The Commission’s report concluded that there is ‘insufficient collective leadership’ for pharmacy in the UK, and that pharmacy professionals are generally disengaged from professional leadership bodies (PLBs).

The findings prompted the Commission to recommend the formation by the Department of Health and Social Care of the UK PPLAB, as an independent public body. The board has since appointed its chair and independent expert members, involving representatives from both PLBs and specialist professional groups (SPGs). The board will be implementing the Commission’s recommendations over the next 3 years, including the development of new arrangements for pharmacy leadership in the UK.

On the formation of the UK PPLAB, Mahendra says: “The new leadership board, through its broad-based range of independent experts from across the four nations, provides a robust and meaningful structure to steer the line of professional pharmacy leadership moving forward. Whether that is a royal college with different faculties, or two or three professional bodies under one umbrella – that’s for the UK PPLAB to decide.”

Equally, it’s an exciting time for community pharmacy with emerging new services and the increasingly advanced roles of pharmacists and pharmacy technicians. However, Mahendra warns of potential hurdles when it comes to determining new leadership structures. “There are going to be challenges when uniting all pertinent groups under one umbrella, as they are all resourced differently and to varying extents,” he adds.

Despite this, Mahendra remains excited and optimistic that “representation in this new setting will inspire and instil a breath of fresh air, so that those often disengaged, including a significant number from the community pharmacy sector, will come to believe that there is something in it for everyone across the pharmacy spectrum. The board creates a whole new arena of expertise, voice, and experience, including the patient and public opinion, making it a unique place to strengthen the present and shape the future.”

Multi-professional collaboration – bringing community pharmacy to the table

Beyond the Commission and implementing its recommendations, Mahendra seeks to help further elevate the role of community pharmacy. Using the Sigma conference in South Africa as a platform, he brought together pharmacy, nursing, medical and dentistry leaders from across the four UK nations to discuss the opportunity for multi-professional collaboration in the newly integrated NHS.

Using the implementation of the Pharmacy First service in England as an example, the session underscored the potential for pharmacy to engage in multi-professional collaboration. The service involves collaborative working across pharmacy and general practice to free up GP appointments and demonstrates untapped value in cross-sector working within primary care.

For example, the NHS Chief Dental Officer speaking at the event outlined exciting possibilities for the role of community pharmacy in preventative dental care, especially in reducing the levels of tooth decay in children – an increasingly pressing issue in the UK over recent years.

Mahendra feels that “community pharmacy can play a huge role in the prevention agenda. If we have the prevention agenda better resourced while we are coping with a shortage of dentists, at least we are considering longer-term perspectives.”

He concludes that the professions within healthcare are “united by providing the highest standards of health and care. They are all talking about the same problems but shout about them separately.” He calls for multi-professional collaboration for the benefit of patients and the public to ensure that health and care professionals are communicating to government with one clear voice.

Addressing health inequalities through research equity – the role of pharmacy

Throughout a diverse portfolio career, working to reduce health inequalities, especially in cardiovascular disease and type 2 diabetes, has been an underpinning focus for Mahendra. As Director for the Centre for Research Equity (CfRE), his work aims to target underserved communities and black and ethnic minorities through championing inclusivity and community engagement in health research.

Decades of work have exposed deep inequalities in the health of the UK population. As Mahendra explains, “we have seen the same results time and time again, as far back as the Black Report, two consecutive ten-year Marmot reviews, and most recently with Public Health England’s COVID-19 Report”. The Health Foundation has also pointed out that health inequalities in England are some of the worst among developed countries and are likely to persist without sufficient intervention.

Mahendra argues that engaging communities who are most impacted is essential if we want to prevent this projected widening of inequality. He stresses the role of research equity is a key piece of the puzzle and the role of pharmacy within this is crucially important.

He uses the case of the drug Clopidogrel, an anti-platelet medication used to prevent heart attacks, as an example. “One study showed that those from Bangladeshi or Pakistani origin were 30 per cent less likely to activate the drug once taken. These populations are those more likely to die of heart attacks compared to the white population.”

Garnering evidence which is generalisable across all populations is essential for reducing health inequality. The CfRE aims to achieve this by ensuring representative and more equitable health research.

Where does pharmacy come in?

Nearly 90 per cent of the population in England can access a community pharmacy within a 20-minute walk, and importantly, the ‘Positive Pharmacy Care Law’ exists, mandating that access to pharmacies increases to 100 per cent in areas of greatest deprivation. This makes community pharmacy a uniquely placed asset to engage with communities where health inequalities are most stark.

NHS England is supporting pharmacy to leverage this position. The recently published Report of a UK survey of pharmacy professional’s involvement in research has spearheaded the formation of a Pharmacy Research Advisory Group to implement the report’s recommendations. These include aims to “embed a research culture in pharmacy careers, develop a clinical academic pathway for pharmacy and provide a pipeline of pharmacy research leaders”.

This, in addition to the recognition provided to pharmacy in supporting inclusive research by the CfRE at Oxford University, a world class academic research institution, and the formation of the UK PPLAB, provides a huge boost for the sector.

Mahendra concludes that this recognition “demonstrates the ability of pharmacy to shift the dial of healthcare in many directions, inspiring the next generation of pharmacy professionals as well as those who may not have previously considered it as a career”.

PPP will be hosting the Medicines and Care Pathways theatre at the Integrated Care Delivery Forum in London on 5 November.

The Integrated Care Delivery Forum connects system leaders with on the ground innovators and industry experts to highlight exactly how ICSs are making place based, personalised care a reality. Rather than discuss issues such as health inequalities in broad framing and terminology, the Forum asks local systems leaders and stakeholders to demonstrate exactly how integrated care systems can affect change in key health and care challenges.

For further information about the Delivery Forum theatres, please contact:

Medicines and Care Pathways – Samantha Semmeling (samantha.semmeling@publicpolicyprojects.com)

Systems Transformation – David Duffy (david.duffy@pppinsight.com)

Data-driven Transformation – Gabriel Blaazer (gabriel.blaazer@publicpolicyprojects.com)

All news

EHR roll-outs need strategies to mitigate clinician overload

By Dr Dominic Pimenta, Jasmine Balloch, Dr Ellie Asgari; TORTUS

Clinicians are increasingly subject to cognitive overload, and recent studies suggest that without mitigation strategies in place, poor implementation of EHR systems can exacerbate the problem.

In April, a narrative review paper was published in the JMIR Medical Informatics titled Impact of Electronic Health Record Use on Cognitive Loads and Burnout Among Clinicians. My fellow authors and I applied cognitive load theory to explore the impact that routine EHR use has on clinicians and to suggest how the risk of negative effects could be minimised.

It’s important to preface the discussion of our conclusions by acknowledging that EHR systems are essential for the delivery of efficient, joined-up patient care: they allow for improved communication between clinicians, remote access to clinical records and to a high volume of clinician data for research and audit purposes. Rightly, years of effort and significant investment have led to widespread EHR implementation across the NHS: 87 per cent of primary, secondary and community care staff surveyed by the Health Foundation reported using EHRs as part of their work, and in the 2024 Spring Budget, the Chancellor pledged that they would be rolled out across all NHS Trusts by 2026.

However, only 57 per cent of respondents in the same Health Foundation survey chose EHRs as the technology saving them the most time, and their rapid review of 72 studies about EHRs and related tools identified that 44 per cent found no time savings delivered. This indicates that the potential of EHRs is not yet being fully realised.

As our new review concludes, taking a considered, evidence-informed approach to the design and implementation of EHRs makes all the difference when it comes to unlocking their full potential, while mitigating significant potential risk. Importantly, by acknowledging and proactively addressing the relationship between EHRs and cognitive burden, organisations can successfully reduce rates of clinician burnout and minimise risks to patient safety.

EHRs and cognitive overload: examining the evidence

Cognitive load theory explains that human capacity to process information is limited to a few elements in working memory at any given time. When this capacity is overwhelmed by an excessive quantity of information, the resulting cognitive overload can impair decision making, interfere with mental performance and elevate stress levels. Clinicians are typically at high risk of cognitive overload, as they must navigate complex patient data, integrate new information rapidly, and make critical decisions under pressure on a daily basis. The transition to digital records has compounded this challenge by significantly increasing the volume and complexity of data clinicians must handle during patient care.

Recent studies indicate that poorly designed EHR systems can exacerbate cognitive load. The factors contributing to this include inefficient user interfaces, excessive documentation requirements, and the need to navigate through cumbersome electronic systems to access relevant patient information. In addition, dealing with overly-frequent pop-up notifications has been shown to cause distraction and alert fatigue, both of which can lead to clinicians missing important information and result in poor patient outcomes.

Experiencing regular cognitive overload is a major risk factor for burnout. In 2023, 55 per cent of surveyed NHS workers had experienced burnout in recent years, a condition characterised by emotional exhaustion, demoralisation, and a reduced sense of personal accomplishment, which not only affects individual health professionals but also the quality of care they provide. Although burnout has multiple root causes, addressing the design and implementation of EHRs to reduce the cognitive load they place on clinicians is a necessary and important step towards tackling the rise in burnout cases.

Practical recommendations:

Improving EHR user interfaces: Simplifying the user interface of EHR systems can reduce unnecessary cognitive effort. This involves designing more intuitive menus, reducing the number of steps to complete tasks, and organising patient data more logically.
Streamlining information presentation: Tailoring the presentation of information to minimise extraneous load is crucial. This could mean displaying critical patient data in a summarised form, with the option to expand details as needed, thus preventing information overload.
Reducing documentation burdens: Automating routine data entry and employing natural language processing can decrease the time clinicians spend on documentation. This not only frees up cognitive resources but also allows clinicians to devote more attention to patient care.
Incorporating decision support tools: Advanced decision support tools can aid clinicians by providing contextually relevant information at the point of care, reducing the need for extensive data retrieval and analysis.
Training and support: Continuous training and real-time support can enhance EHR proficiency among clinicians. Tailored training programs that address the specific needs of users can alleviate stress and improve their interaction with the technology.

Importantly, emerging artificial intelligence and machine learning technologies offer promising avenues to manage cognitive load by automating routine tasks and predicting patient risks through advanced analytics. However, the integration of these technologies must be handled carefully to avoid adding to the cognitive burden – evidencing a need for user-friendly design and time-saving clinical integration.

In summary, clinician burnout is complex and has multiple causes – such as overall workload, inflexibility of rostering and organisational culture – which is why it could never be fully eliminated even by the ‘perfect’ design and implementation of an EHR. However, by scientifically assessing the impact of different EHR technologies and models, it becomes possible to paint a more complete picture of how they alleviate or exacerbate burnout. In turn, this understanding can be used to ensure that clinicians are equipped with the best EHR systems –and the best integrated technologies – that improve their efficiency and improve patient outcomes.

Study highlights prison cancer inequalities

By Gabriel Blaazer

Those diagnosed while in prison face several barriers to treatment and receive worse experiences of care, according to a study led by King’s College London.

Researchers from King’s College London (KCL), University of Surrey and University College London (UCL), funded by the National Institute for Health and Care Research (NIHR), have found that inequalities in cancer outcomes are persistent across English prisons, with those diagnosed while in prison 9 per cent more likely to die from the disease.

The study analysed cancer data from the National Disease Registration Service, which is part of NHS England, and conducted interviews with cancer patients in prison, and prison and healthcare professionals. It finds that cancer patients in prison are 28 per cent less likely to receive curative treatment than the general population, particularly surgery to remove tumours. Only half of the 9 per cent higher mortality rate can be explained by treatment differences.

Prisoners with cancer also have fewer hospital admissions than the general population, meaning that the cost of NHS hospital care is lower in the first six months due to fewer outpatient visits and planned inpatient stays. However, once emergency care and security escort costs are factored in, overall hospital care costs are higher.

Accordingly, the study emphasises the need to improve cancer care for people in prisons, to ensure that it is equivalent to that received by the general population.

Commenting on the study’s findings, Dr Elizabeth Davies, Clinical Reader in Cancer and Public Health in the School of Cancer & Pharmaceutical Sciences at KCL, said: “There are a number of structural factors that influence how healthcare is organised within the prison system, including the way in which prisons interact with NHS cancer services.

“Unfortunately, these factors can mean the route to diagnosis for people in prison is different to that of the general population, and they may not always receive the same level of treatment and support. People in prison with cancer have so far been a hidden and under-researched population. They should not be impacted by such health inequalities and should receive the same standard of care as they would in the community.”

To improve cancer care for people in prison, Dr Davies suggested, the NHS, HM Prisons and the Ministry of Justice should make better use of existing data to identify and reduce variations in care, as well as to better co-ordinate care pathways between these organisations.

Barriers to care

While finding that cancer patients in prison follow similar diagnostic pathways to the general population, the study shows that those in prison are disproportionately affected by barriers to care. These include lower levels of health literacy among those in prison, which impacts the ability to obtain and understand the information needed to make informed health or treatment decisions. Alongside this, the process for booking GP appointments in prisons is complex and time-consuming, and persistent communication issues between prison staff and NHS clinicians make co-ordinating care difficult.

Prison healthcare professionals interviewed commented that, prior to diagnosis, it can be difficult to distinguish between those with genuine healthcare concerns and those wishing to leave prison for other reasons.

Cancer patients in prison are also at risk of missing appointments if transport to hospital is not available. Persistent staff shortages in prisons also present another barrier. It was reported last year that many prisons are increasingly running more restrictive regimes, where a lack of staff can lead to prisoners being locked down for extended periods. The most restrictive of these, known as “red regimes”, were put into effect at least 22 times across English prisons in 2023. Prisoners have cited being locked up for 23.5 hours a day with no access to showers when under a “red regime”.

The study also highlights the use of handcuffs as a barrier to accessing care and a reason for prisoners to refuse hospital appointments. Further, prisoners are found to be reluctant to answer certain medical questions or raise concerns during appointments when healthcare professionals are present, and the study is the first to highlight discomfort among healthcare professionals and prison officers due to this practice.

After diagnosis, patients reported feeling unable to follow the advice of oncology professionals for managing and reporting side effects, which is especially challenging as they cannot directly communicate with their consultants from prison.
NHS oncology services often advice patients to bring friends or family members to appointments to offer psychological support and assist them with information gathering and retention, yet most of those diagnosed in prison attend appointments without this support, and their families often have little interaction with oncology teams.

“Prisons are designed to take away elements of control and choice for prisoners, however, this should not apply to their healthcare,” said Professor Jo Arnes, Professor of Cancer Care and Lead for Digital Health in the School of Health Sciences at the University of Surrey. “Our findings show that patients experience a number of barriers during diagnosis and similarly, once treatment started, they struggled to follow the advice of oncology professionals for reporting and managing any side effects.”

“Instead, they were reliant on prison officers and prison health professionals to respond appropriately, which undoubtedly impacts on their overall physical and emotional wellbeing. With a growing and ageing prison population there is an increasing need for patients with cancer within the prison system to access equivalent care to those in the community,” Professor Arnes added.

Professor Rachael Hunter, Professor of Health Economics at UCL, commented: “Although the cost of clinical cancer-related care for people in prison is less than in the general population, this does not reflect cost savings or efficiency, but worse access to care. More evidence is needed on cost-effective ways to improve access to curative cancer care for people in prison that is appropriate for the prison service.”

The study was coproduced by peer researchers with lived experience of the criminal justice system, supported by Revolving Doors – a charity dedicated to improving services for people in contact with the criminal justice system. It was presented in three collaborative papers published by The Lancet Oncology and eClinical Medicine.

New data reveals mental health toll on NHS staff

By Integrated Care Journal

Despite challenges facing the service, the NHS remains one of the UK’s most loved institutions, says survey data, as NHS Charities Together launches new campaign urging public to continue supporting NHS and its staff.

More than three quarters (76 per cent) of NHS staff surveyed said they have experienced a mental health condition in the last year, according to new data collected by NHS Charities Together. Conducted by YouGov on behalf of the charity, the survey of more than 1000* NHS professionals also found that 52 per cent reported experiencing anxiety and 51 per cent reported struggling with low mood.

More than two-fifths of respondents (42 per cent) said they had experienced exhaustion in the last year, while three in five (60 per cent) reported feeling concerned for the mental health of colleagues.

Despite these challenges, however, 79 per cent of respondents said they feel proud to work for the NHS and 68 per cent said that they are unlikely to leave within the next 12 months.

The survey reveals the impact of increasing pressure on NHS staff, who are now subject to ‘winter pressures’ throughout the year, and are increasingly facing high workloads, long and unsociable hours and exposure to traumatic, stressful events. 96 per cent of those surveyed said they believe that overall pressure on NHS services is growing, and 69 per cent said that morale is the lowest they have ever experienced. A similar number (70 per cent) said that work-related stress has negatively impacted their mental health in the last year.

The release of these findings comes alongside the launch of a new campaign from NHS Charities Together called Support Goes Both Ways, which aims to raise awareness of need to continue to support NHS staff, so that they can best support the public.

Commenting on the findings, Ellie Orton OBE, CEO of NHS Charities Together, said: “Staff working within the NHS do a hugely challenging job every day, often dealing with traumatic events most of us would never encounter. The majority of NHS staff love doing the job they do, and both NHS staff and the general public feel proud of our NHS. But the nature of the work can have a detrimental impact on their mental health, and stigma can prevent them talking about it.

“Many NHS Trusts are already doing what they can to prioritise the mental health and wellbeing of our NHS staff, but it doesn’t go far enough. We will continue to work closely with NHS England and across the UK to ensure the additional support we provide for NHS staff has the most impact.”

In a separate survey, also carried out by YouGov on behalf of NHS Charities Together, more than 2,000 members of the public were invited to give their opinion on the NHS. Despite the challenges facing the NHS, the 2024 survey revealed that almost four in five (78 per cent) agreed that the NHS is one of the UK’s most loved institutions, compared to three in five (60 per cent) of the 2,000 respondents surveyed in 2022 who stated that the NHS is the best thing about the UK.

The proportion of respondents saying that they would consider a role working for the NHS if they were starting their career again, has risen slightly, from just over one in four (28 per cent) in 2021 to three in 10 (30 per cent) in 2024**.

Author, comedian and former doctor, Adam Kay, whose number-one bestselling book and multi-BAFTA-winning TV show, This is Going to Hurt, provided an insight into the often funny but harrowing daily life of a junior doctor, said: “These figures sadly come as no surprise at all. I know from my own experience just how hard NHS staff work, day-in, day-out, and the mental toll that routinely takes. We are uniquely privileged to have the NHS and should be proud of the wonderful people who sacrifice so much and go so far beyond the call of duty to look after us when we need it. But they desperately need support too, which is why I’m very proud to get behind NHS Charities Together’s Support Goes Both Ways campaign.”

Pat Chambers, Charity Development Manager, County Durham and Darlington NHS Trust Charity, said: “During the pandemic, many staff were affected mentally and emotionally. The extra support from NHS Charities Together enabled us to fund wellbeing spaces, equipment and food and drink for staff, who were working exhausting shifts in the constraints of PPE.

“We also received funding for the Trauma Risk Management (TRiM) project. TRiM is a trauma-focused peer support system helping to prevent extreme trauma and PTSD – similar to interventions delivered for service personnel returning from conflict zones. Funding enabled us to recruit 53 staff volunteers to be trained in providing peer support and interventions. We also funded a staff choir, which was a great outlet for staff and even saw us recording a single during lockdown, which hugely boosted morale.

“The unique challenges of the job means many NHS staff still face mental health challenges today, and the extra support is still needed, allowing us to promote wellbeing across our workforce and therefore ultimately continue to support the delivery of safe, compassionate and quality patient care.”

Hannah Canning is the Health and Wellbeing Coordinator at North West Anglia NHS Foundation Trust. Her role is fully funded by NHS Charities Together, through the North West Anglia Hospitals’ Charity, and was created to support frontline workers in the hospital. She said: “Thanks to the funding from NHS Charities Together, I’m able to support the wellbeing and mental health of staff in the hospital. I’m focusing on individual and team wellbeing and encouraging breaks and rest – considering all things that affect staff while they are on shift. Using this funding, we are able to go ‘over and above’ to support our staff.”

Ellie Orton OBE, CEO of NHS Charities Together, added: “NHS Charities Together already funds extra support such as counselling, green spaces, helplines and wellbeing zones and we’re launching Our Support Goes Both Ways campaign to raise awareness that while those who work for the NHS have a duty to care and protect us all, we all have a responsibility to make sure those who work for the NHS are looked after too.”

Steph Gorman is an intensive care nurse at Guys and St Thomas’s Hospital in London. She said: “I’m passionate about my work as a nurse. It’s hard, and I’ve had my struggles, but despite everything, it’s still one of the best jobs in the world. In the past, I’ve needed to seek help and started one-to-one counselling sessions at the hospital, which was really beneficial.

“Working as a nurse is still incredibly challenging. It’s so vital that we continue to invest in NHS staff mental health. NHS Charities Together have funded wellbeing zones at the hospital, just one example of the types of measures that really help make a difference.”

*Healthcare Professional sample: Total sample size was 1078 NHS staff. Fieldwork was undertaken between 13th – 19th February 2024. The survey was carried out online. The figures have been weighted and are representative of all NHS staff by occupational group.

**GB/UK Omnibus: Total sample size was 2068 adults. Fieldwork was undertaken between 16th – 18th February 2024. In 2022, total sample size was 2132 adults. Fieldwork was undertaken between 13th – 14th January 2022. For the 2021 survey, total sample size was 2120 adults and fieldwork was undertaken between 11th – 12th March 2021. The surveys were carried out online. The figures have been weighted and are representative of all UK adults (aged 18+) while for the 2022 survey, the figures are representative of all GB adults (aged 18+).

Supporting care companies in the digital switchover

By Kristian Torode

As many industries embrace the changes the Public Switched Telephone Network (PSTN) switch-off will bring, there are others that have cause for concern. Vital care devices such as telecare systems will be impacted by the switch off — so how can care companies ensure a smooth transition for their customers? Here, Kristian Torode, Director and Co-Founder of PSTN switch-off specialist, Crystaline, investigates.

Around 1.8 million UK residents use telecare devices, which enable vulnerable people to live independently by providing assistance in the case of accidents. These wearable devices alert family, carers or emergency services when pressed and can also connect to other safety equipment such as fall detectors, smoke alarms and door sensors.

However, the PSTN switch-off in December 2025 means that the copper wire phonelines that have historically connected these systems will be turned off, threatening their functionality.

In recent months, a number of stories of serious incidents that occurred when telecare devices no longer worked after users were switched from analogue to digital phonelines have hit the headlines. In February 2024, it was reported that Ofcom is investigating Virgin Media over its compliance with rules to protect vulnerable customers during the digital switchover. Consequently, Technology Secretary Michele Donelan met with telecoms providers to determine how best to safeguard vulnerable users during the switchover, which resulted in a commitment not to migrate customers if the functionality of a telecare system is at risk.

However, this poses challenges for vulnerable telecare users, telecoms operators and care providers alike.

Digital divide

Telecare systems are most beneficial to people who have communication, mobility or visual impairments, meaning many users are elderly or disabled.

While vulnerable users are likely to be more heavily impacted by changes to their phone service, it is difficult for them to access information relating to the switchover and how it affects them. According to Good Things Foundation data, non-internet users are twice as likely to have a disability or health condition than extensive users, and six times more likely to be over 65 years of age. As a result, many of those who rely on telecare lack the digital skills to find online information relating to switchover dates and to set up routers for digital phoneline services.

Although telecoms providers have put protections in place for those with disabilities and additional needs, many customers are unaware that they should give these details to providers, meaning existing lists are likely inaccurate.

Tackling telecare issues

So, what can telecare providers do to safeguard elderly and disabled residents? Firstly, telecare companies and local authorities offering these services should share data on who has a device with telecoms providers, allowing them to support vulnerable customers during the switch off.

The next step is to ensure that the right technology is in place before the switch off date. On the care provider’s end, upgrading to a PSTN alternative such as Voice over Internet Protocol (VoIP) now will make sure that there is time to perform checks on existing telecare devices before December 2025. As a result, non-compatible analogue systems can be replaced in advance of the switch off.

Finally, care companies and local authorities must make sure that customers are aware of how the PSTN being turned off will affect their telecare systems. This allows clients to test their personal alarm after their phoneline has been upgraded to ensure it is still fully functional.

As the PSTN switch off draws closer, elderly and disabled telecare customers stand to be one of the groups most heavily impacted but least informed about the effects of the digital switchover. Getting the systems in place in advance and performing thorough testing means telecare companies can guarantee a smooth switchover that safeguards vulnerable people.

To learn more about Crystaline’s PSTN switch off support services for SMEs, including those in the care sector, and to explore digital telephony alternatives, visit the website.

Is the push for collaboration causing a retention crisis?

By Rob McDonald

Rob McDonald, NHS Retention Services Manager at NHS Shared Business Services, asks whether exit interviews could hold the key to boosting NHS retention – a key goal of the NHS Long Term Workforce Plan.

Collaboration has been an NHS mantra for years now. According to all sources, no matter what the problem, collaboration (oh, and technology) will solve it.

But is that true? Intriguingly, my experience is that – far from being a panacea – the move towards collaboration might be exacerbating the NHS’s staffing problems.

Don’t get me wrong. I’m a fan of collaboration. It helps to spread good practice. It reduces or eliminates inconsistencies. It enables organisations to pool their resources and benefit from economies of scale. So it’s perhaps not surprising that the entire NHS has been reorganised to encourage (or mandate) partnerships, exemplified by system-wide reorganisations like the establishment of ICSs two years ago.

The drive for productivity is resulting in mergers as services are scaled. The changes affect all organisations – from acute providers to community, mental health and learning disability services and Community Interest Companies. These TUPE transfers (Transfers of Undertakings (Protection of Employment), affecting many thousands of front-line staff every year, are frequently seen by senior managers as routine or benign. After all, the individual’s terms of employment are protected – so what is there to worry about?

The reality is that the changes are often poorly managed, can be unsettling and – I believe – are contributing so much to staff turnover that they’re having a significant impact on patient care.

What does it feel like if you’re one of those staff?

Thankfully, that’s a question we can answer. NHS Shared Business Services provides an exit interview service, which I am privileged to run. We’ve done more exit interviews in the past three years than most people do in a lifetime. I say that as a statement of fact, not a boast!

One of the questions we’ve started to ask leavers is whether uncertainty around, or the impact of, mergers has influenced their decision.

The answer is yes. We’re finding that nurses in particular often cite service mergers as contributing to their desire to leave, frequently in combination with other factors, such as general stresses of the job.

It goes without saying that this is a problem. The NHS’s long-term workforce plan highlights the need for up to 190,000 additional nurses by 2037, requiring retention rates to improve by around 15 per cent over the course of the plan. Losing nurses has knock-on effects way beyond the immediate impact on patient care. The cost of recruitment to backfill; the cost and time of additional training; the stress on team members who have to provide cover and the cost of overtime – all of these erode both money and goodwill.

The recently published NHS staff survey confirms this. Although most of the People Promise indicators showed a modest improvement, many of the numbers are still concerning. Some 30 per cent of respondents said that they felt burnt out by their work, and 34 per cent found it emotionally exhausting, yet only around half said they felt able to make improvements happen or be involved in change.

The good news is that this can be fixed. Mergers and reorganisations do not need to make staff feel disempowered and uncertain. In fact, when handled well, they can have the opposite effect.

To do this takes time, care, and skill – I’ve provided a few hints below, based on the feedback we’ve been getting.

Uncertainty about a merger is often more damaging than the merger itself, so communication really is key. People subconsciously “triangulate” information – that is, they won’t absorb or believe it until they’ve heard it from three different sources. So think about what level of communication you might need, then triple it.

Identify flight risks. This is something we’ve done for years at NHS SBS; we even have an algorithm that predicts people at risk of leaving. Then take proactive action to address their concerns and bring them further into the fold. Leavers often tell us their manager knew they were thinking of leaving; managers, by contrast, tell us the resignation came as a surprise.

Conduct exit interviews – and use the data you collect. I may be biased, but I think exit interviews are possibly the most important conversation you can ever have – more important even than recruitment interviews. Yet, remarkably, the standard approach is for an automated tick box survey to be sent to leavers upon resignation. The response rate is usually around 30 per cent and the greatest reason for leaving is ‘unknown’ – in other words, the path of least resistance to complete the survey without discussing any real issues.

Finally, remember – a resignation doesn’t have to result in a leaver. Is there a feeling that once resignation is given, the horse has already bolted? I think there is. Yet when I ask leavers whether they would have stayed if somebody had done something differently, the answer is often yes.

Resignations can be withdrawn. And sometimes, a conversation is all it takes to retain a valued and valuable member of staff.

Given that the magic roundabout of change in the NHS is unlikely to slow down any time soon, learning to support and empower staff through periods of uncertainty is critical.

I’d love to hear from readers about their experiences of change – particularly the impact of service mergers on retention and how you use exit interviews. Contact me at Rob.McDonald1@nhs.net.

Rob McDonald, NHS Retention Services manager, NHS Shared Business Services

Prioritise nutrition and hydration to boost broader health outcomes, says new report

By Integrated Care Journal

New report from PPP finds that efforts to implement a multidisciplinary approach to nutrition and hydration are needed to help address the dysphagia burden across the NHS.

A new report from Public Policy Projects (PPP) finds that with the UK becoming a ‘super-aged’ society, declining nutritional and hydrational status among elderly and frail populations will place increasing strain on health and care services.

The report, Prioritising nutrition, hydration and dysphagia in an integrated care context, states that while considerable work and investment has been allocated to reduce the incidence of obesity and the diet-related diabetes, malnutrition and hydration are not given the same focus, despite their significant impact on health outcomes and its role in the management of other conditions.

The report is the culmination of two roundtables held by PPP in 2023, which convened stakeholders to discuss how ICSs embed nutritional and hydrational health into integrated care strategies. The discussions focused on specific elements of the debate, including improving the management of dysphagia and care provided for frail populations in different care settings. Attendees included NHS England clinical leadership, allied health professionals (AHPs), including speech and language therapists (SLTs), social care providers, primary care representation nurses and other key health and care stakeholders.

*Graphic showing levels of elderly population at ICS level in 2021. Source: Census 2021*

According to the report, recent reforms to the health and care sector (most notably, the introduction of ICSs) present new opportunities to develop comprehensive approaches to nutrition and hydration, in a way that improves holistic patient care and saves valuable resource for the NHS.

However, among its recommendations, the report calls on the Department of Health and Social Care to launch a national review into food and drink provided across the care sector, to help improve the nutritional and hydrational status of frail citizens in social care. This review should follow the structure and ethos of the NHS Hospital Food programme, the report argues.

It adds that addressing dysphagia should be central to broader NHS goals of enhancing the quality of life for the elderly population, and that by prioritising the management and screening of dysphagia, the NHS could prevent avoidable hospital admissions and promote more efficient use of resources across the health and care sector.

Download the report here

To address the complex and multifaceted challenge of dysphagia, with various medical, neurological, and anatomical elements potentially contributing, will require systems to adopt a multidisciplinary approach, says the report. This will necessitate close collaboration between diverse teams of healthcare professionals, each with specialised expertise.

It finds that a multidisciplinary approach that includes speech and language therapists, dietitians, and physicians, is essential for managing dysphagia and addressing the complex healthcare needs of the elderly in a holistic fashion. To help enable this multidisciplinary approach, the report argues that the model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.

The report also recommends an expansion of the speech and language therapy workforce, with ring-fenced funding for broader allied health professionals – in line with ambitions set out in the NHS Workforce Plan.

“The nutritional and hydrational needs of our elderly and frail citizens has been neglected for far too long. As the UK moves towards a ‘super-aged’ society, NHS organisations, care providers and integrated care systems must increasingly focus efforts on improving nutritional and hydrational health,” said report author and Group Editor at PPP, David Duffy. “It is vital that resources are orientated to support allied health professionals, particularly speech and language therapists, who play a vital role in maintaining nutritional health for elderly and frail citizens.

“Nobody in the UK should suffer from malnutrition or dehydration in this day and age, especially not our frailest and most vulnerable citizens. We hope that this report will help shine a light, not just on the scale of the problem, but also on achieveable solutions that we believe will help address the terrible burden of dysphagia.”

Recommendations:

NHS England must prioritise nutrition, hydration and dysphagia as part of its drive to improve system performance and broader health outcomes. Nutrition and hydration management are underdeveloped areas which can help enable success in key national strategies, such as the elective care backlog plan, workforce strategy, the urgent and emergency care plan and the delivery plan for recovering access to primary care.
Integrated care systems should consider dysphagia and wider nutritional and hydrational health as key parts of preventative health policies that can help future proof local health systems.
The Department of Health and Social Care (DHSC) should commission a national review into food and drink provided across the care sector. This review should follow the structure and ethos of the NHS Hospital Food programme. The review should be led by a range of stakeholders from within the NHS and social care, as well as representatives from industry and the private sector.
As the population becomes a ‘super-aged’ society, an integrated strategy is required to manage the health of the elderly and frail population. This should draw upon global and international frameworks provided by the WHO’s ICOPE framework.
ICSs should ensure that maximising the ‘intrinsic capacity’ of citizens is a key priority within integrated care strategies, to prevent deterioration of health and supplement preventative health policies.
ICSs should work to prioritise evidence-based nutritional and hydrational approaches within the social care sector, harnessing tools such as nutritional supplements where necessary, to assist those who have difficulty eating, drinking and swallowing.
The model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.
NHS England should undertake a national dysphagia screening drive to identify individuals as early as possible. Social care staff and AHPs should be trained to conduct dysphagia screenings for all elderly and frail patients in their care, and much like falls, dysphagia should be considered among the primary risks in any risk assessment of elderly and frail patients.
The speech and language therapy workforce should be expanded with long-term ring-fenced funding for broader allied health professionals.

Download the report here.

Will the disposable vape ban save the NHS from another health epidemic?

By Sienne Amer

As the government confirms its plans to ban the sale of disposable vapes, Sienne Amer examines the impact of vaping on the NHS so far, and to what extent the ban will help avert another health epidemic.

The UK government recently announced its plan to ban disposable vapes to protect children’s health and tackle the significant rise of vaping among young people. While we have not yet seen the full health impact of the younger generation using vapes, this ban may be a welcome first step in limiting the impact of what could have become the next health crisis.

The devices have appeared on the market recently and rapidly risen in popularity, which is why there is still little research available on the extent to which vaping harms our health. Introducing this ban has the potential to limit the impact vaping has on the NHS, which is already stretched responding to other health crises caused by tobacco smoking, alcohol abuse, obesity, and an ageing population.

There are 4.7 million people in Great Britain who use e-cigarettes, 31 per cent of whom are disposable vape users. Disposable vape brands are targeting children, using bright colours for packaging and a variety of interesting flavours, with the fruit flavours making them far more likely to appeal to children. A shocking 21 per cent of secondary school children have tried vaping and 57 per cent of disposable vape users are aged between 18 and 24. The most popular brand of disposable vapes, Elf Bars, were removed from supermarket shelves last year after the nicotine levels were found to be at least 50 per cent higher than the legal limit. The lack of regulation of these products is an issue, regardless of the effects of use.

Disposable vapes contain nicotine, and inflict similar impacts to any other nicotine product, including heart disease and other cardiovascular disorders, along with respiratory and gastrointestinal disorders. Children are especially susceptible to the toxicity of nicotine, which can impact brain development, leading to shorter attention spans, anxiety, depression and reduced cognitive function.

It has also been shown that when the coils in the e-cigarette are heated, toxic metals, including aluminium, chromium, iron, lead, manganese, nickel and tin leak into the e-liquid, which are then aerosolised, inhaled and absorbed by the lungs. E-liquids have been shown to contain ingredients that generate pulmonary irritants and carcinogenic carbonyl compounds, all of which can lead to respiratory, gastrointestinal, and constitutional symptoms, in addition to an increased risk of early onset strokes.

Although vaping is still recognised as a safer alternative to smoking by the NHS, there has not been sufficient investigation into the long-term impacts on health. Other countries, such as the United States, have recognised the impacts of vaping; in 2019, the US Center for Disease Control and Prevention announced an outbreak of e-cigarette/vaping product use-associated lung injury (EVALI) after it caused the deaths of several young people.

While there have not been any recorded e-cigarette related deaths reported in the UK, in 2023, the NHS recorded 420 vaping related hospital admissions, 15 of which were for children aged under 9, demonstrating the severe risk to health young children are exposed to.

When compared to just under half a million hospital admissions caused by cigarette smoking-related illnesses, the health impacts of disposable vapes appear to be minor. However, conventional cigarettes were only recognised as a significant health hazard in 1964, more than 40 years after the introduction of cigarette manufacture, showing the time it can take to fully understand the long-term effects a product can have on human health.

The NHS is already dealing with several other health epidemics, with smoking costing the NHS in England £2.6 billion per year, approximately 2 per cent of the NHS budget. Obesity costs around £6.5 billion a year and is the second biggest cause of preventable cancer. Alcohol abuse costs £3.2 billion a year in England. This is a total of £12.3 billion of the yearly NHS budget going towards preventable illnesses, and the cost of vaping would be an additional burden on NHS.

To what extent is vaping impacting the NHS?

At present, there is no record of the health-related costs associated with vaping. But modelling the cost to the NHS using smoking data could provide an estimation of the impacts vaping will have. The UK smoking population is equal to 6.4 million people, causing 474,000 hospital admissions a year at a cost of £2.6 billion. The model assumes that 7 per cent of the population requires hospital admissions, with each admission costing approximately £400.

The 420 admissions related to vape use last year would have cost the NHS approximately £168,000. However, vape-related hospital admissions only started to be recorded in 2019 and since then, there has been a 237 per cent increase in admissions. An annual growth of 10 per cent in the vaping population is also expected to cause an increase in admissions. This means that, if only 7 per cent of the vaping population is admitted, the cost to the NHS would be £132 million per year, excluding any impact of an uptake in the number of young people seeking mental health services as a result of the toxic effects of vaping.

The ban on disposable vapes is estimated to affect 2.6 million people in Great Britain – including 316,000 18-to-24-year-olds, who other than vaping, have never regularly used tobacco products – saving a large proportion of young people from the risks caused by nicotine dependence and vaping. As disposable vapes were initially introduced to the market as an alternative to cigarettes, there is a high risk that 75 per cent of people will revert to traditional tobacco products.

Since the focus of the ban is solely on disposable vapes, alternative e-cigarette products will continue to be available for people trying to quit smoking. It is crucial that information should continue to be collected and published, through platforms such as NHS Digital, to monitor and understand the health impacts of the current vaping generation, even post-ban. Hospitals should be advised to continue to use the ICD-10 code to improve data on vaping-related admissions, along with adjusting advisory information to support the disposable vape ban.

Sienne Amer is a Net Zero Graduate at Lexica.

Study developing AI to spot lung cancer risk from patient data

By Integrated Care Journal

Researchers are developing artificial intelligence which they hope will help to identify patients most at risk of lung cancer before symptoms have even appeared.

A team from Nottingham Trent University and Nottingham University Hospitals NHS Trust aims to create an AI-driven model which can autonomously piece together subtle clues and signs in patients’ data to identify those at risk so that they can be investigated further.

There are about 48,500 new cases of lung cancer in the UK alone each year with almost 35,000 people dying from the disease.

The team wants to address the current challenge of European health systems manually identifying people at risk of certain diseases and also help to reduce the financial burden by ensuring services are used by those who need them the most.

It will involve developing a system to recognise factors which might make an individual high risk and then creating ‘synthetic’ data in order to train it to pick up even the weakest signals that there could be an issue.

The aim is to help save lives by identifying people before the disease becomes symptomatic because that can be too late for patients with lung cancer.

The Nottingham team are the UK partners in PHASE-IV-AI, a much larger €7.6m project funded by the European Union’s Horizon Europe research and innovation program.

The project involves 20 partners from ten European countries and aims to unlock the full potential of AI and data analytics in health care in a secure and privacy-compliant way.

As well as lung cancer, the developments of PHASE-IV-AI project will also be validated by other partners in prostate cancer and ischemic stroke. Lung cancer and prostate cancer are among the top three priorities in tackling cancer in Europe, while neurodegenerative diseases are one of the most relevant issues with the EU’s ageing population.

If successful, it is hoped that the Nottingham team’s model could be trained to identify risk for other serious diseases and rolled out to hospitals and organisations across Europe willing to utilise AI-driven diagnostics.

It is thought that AI can enable real innovations in health care, and that AI systems which can process vast amounts of data quickly and in detail can be harnessed as a tool for preventative health care and clinical decision-making.

Despite this, the way in which information is currently stored across European countries and the limited access to health data can form a barrier to innovation, as developing trustworthy and responsible AI systems often requires large datasets for training and validation.

“The hope is that we could develop an AI-driven model for hospitals which they can then utilise and run to help find those most at risk,” said Dr Mufti Mahmud, an Associate Professor of Cognitive Computing in Nottingham Trent University’s School of Science and Technology.

He said: “Countries have huge amounts of clinical practice data, and we want to understand how we might harness this to identify the right people, so they can be invited for more focused diagnostics. We need the system to be able to find people before they start showing symptoms, and ultimately to help save lives.”

“Health care data storing is very sensitive, very private, so by developing synthetic data we can train the model to function responsibly and to provide the reasons why it selected an individual.”

Nottingham University Hospitals NHS Trust lung cancer consultant Professor David Baldwin said: “Identifying the right people for cancer screening is vital to ensure that the most people benefit whilst not harming people who have a low risk of developing lung cancer.

“AI offers the opportunity to improve the way we target screening programmes to make them more clinically and cost effective. AI is also changing practice in many other areas of lung cancer care. AI tools can help reduce the workload of specialists like radiographers and radiologists, as well as treatment costs, and improve outcomes for patients.”