Enhancing Quality of Services through Effective Collaborative Practice

Introduction

Throughout this piece of work, I will be considering and interspersing the 4 underpinning concepts and domains of collaborative practice using the Interprofessional Capability Framework. Using reflections and experiences I will consider the impact that these have on my role within the ambulance service.  I will be considering these concepts and domains in relation to my role as a future paramedic, student paramedic and also in my current role as an ambulance technician.

In the period of August 2018 to August 2019, 86,095 or 10% of overall emergency calls received were related to falls with 68% (approximately 58,544) of these being over the age of 65 (YAS.NHS.uk, 2019). Previously, Darnell, G., Mason, S., & Snooks, H. (2012) had suggested that clinical and cost-effective service models were yet to be developed in relation to this widespread issue. In their study less than 50% of overall elderly patients who were attended by an ambulance crew were able to be left at home although reasons for this weren’t provided.

Working collaboratively and considering OC3, L2 (Shu 2014), we could begin to interact and co-operate with others within and across organisations in providing person focused services by sending the appropriate help first time every time. By sending an appropriate vehicle, be that a civilian vehicle, ambulance car or double crewed ambulance, crewed with, for example a medical professional, an occupational therapist and a district nurse, acting as a falls team and an after care team in one vehicle could reduce the time spent making referrals and the possibility of patients ‘falling through the cracks’. This initiative would provide for improved assessment tools on scene which Halter et al., (2005) believes would significantly reduce conveyance rates to hospital.

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Gates et al., (2008) note that there have been few large scale and high quality trials on the effectiveness of assessment and intervention on falls in the community but that the trial by Snooks et al., (2010) allows for technology to work side by side with a new model of service delivery. Since these trials, numerous initiatives and trials have been completed with the London Ambulance Service (LAS) trialling a Falls Specialist Response Vehicle (FSRV) in 2017/18 with 768 bed days released and an approximate £173,760 saved on Emergency Department attendance. A fact that is queried by Darnell et al., (2012) who state that in their research only 5 years previous a crew of a paramedic and a social worker left between 7% and 65% of patients at home. Surely any percentage of patients left at home, safe and with a referral in place and not taken to hospital is a good thing.

I would like to believe that we can go further with a team such as the FSRV sent by LAS but with increased capabilities and personnel. In my experience referrals are made for a person who has fallen and once the patient is safe and seen to be mobile the crew leave scene without any follow up or information regarding the success or failure of their referral. Could a team with more capabilities and the ability to apply what the referral would’ve requested there and then on scene be a long-term cost saving idea and initiative that if successful could be rolled out nationwide.

Models of Leadership

Thistlethwaite, (2012), suggests that as a healthcare community we constantly value or devalue other professions using stereotypes and in the adjectives we use to describe them. My understanding and knowledge of other healthcare professions, even in my third year is sadly lacking and I have been guilty of the stereotyping of others. Working as part of the ambulance service already has both helped and hindered these thought processes by listening to the preconceptions of established ambulance workers and also highlighting the positives of other professions. I don’t believe that a leader who doesn’t believe in other healthcare professionals’ expertise is a leader I would like to follow.

At the core of the NHS leadership academy’s, Healthcare Leadership Model (NHS leadership academy, 2013), is ‘Inspiring Shared Purpose’ and ‘Connecting our service’, being curious about how to improve services and patient care and understanding where my team sits within a formal structure. In an ambulance service that is stretched and constantly busy it is difficult at times to find someone who has these beliefs or someone who will inspire me as a student/technician. With my idea for a service improvement the healthcare leadership model appears to have sections that encourage collaborative practice and encourages the working together of different sectors within the NHS, perfect for what I would be trying to achieve.

Within the NHS many different leadership models are used and these can change on a daily basis and even within the same team which confirms what Grimm, (2010) alludes to when saying that leadership is complex and has many definitions and qualities. The two leadership models that I believe best work for the ambulance service are Situational and Autocratic models. Situational due to the leader or the paramedic on the road knowing the skill set of the staff around them and being able to set realistic targets and know what they can expect from an individual. Autocratic would be used during a particular situation in which the leader or paramedic would give ‘top down’ instructions to their staff and is able to make immediate decisions with the final say. This model would work particularly well in a high-pressure situation such as a cardiac arrest where the model could go fluidly from situational to autocratic. Willis, (2015) notes though that although a leader may appear to be one style at one time, the leader would very rarely exhibit only one leadership style and it would be a mistake to label them as styles can be fluid as mentioned above. In my experience I tend to agree with Willis, (2015) in that paramedics I have been on the road with have, at times seemed to take control and barked orders as an autocratic leader but then for the next patient have changed completely.

A leader in an ambulance setting Gienapp (2008) and Parsons (2009) believe is integral to its success and should be someone who is willing to teach as Martin & Swinburn (2012) argue that pre-hospital is unplanned and complicated and that strong leadership in this environment needs to be greater than most other healthcare environments. Further to this, Sola et al., (2016) states that recent studies suggest that effective leadership promotes positive results and has a direct beneficial impact on patients. In relation to the idea of an interprofessional response vehicle, although an older article, Department for Health, (2005), ‘Taking Healthcare to the Patient’, notes that clinical leadership from a range of areas will be able to better utilise resources and will drive improvements and change in the healthcare environment and lends itself perfectly to OC3 L2 (SHU, 2014) by beginning the process of interaction and co-operation with others within and across organisations and enable them as a team to provide person focused services.

In one of my greatest experiences of collaborative practice the team work and collaboration between ambulance, a GP, end of life care and a hospice, the situational teamwork and leadership showed that day made an upsetting and seemingly impossible situation bearable. Autocratic leadership wouldn’t have worked on that day as an elderly gentleman was sadly in his final days, but the family were unaware and didn’t need anyone giving orders or taking control but understanding and appreciating the situation. Although an emotive situation I believe that the decision not to take the patient to the emergency department and instead look for alternative pathways collaborating with the family and external agencies was the best option. The paramedic on scene from the outset allowed those around him to express their feelings and to make decisions without pressure or especially in this situation, guilt. Feather, (2009) believes that the actions shown by the paramedic show an emotionally intelligent leader although Cavazotte, Moreno & Hickmann, (2012) argue that this trait is difficult to measure but Sterud et al., (2011) argue that attending terminally or chronically ill patients creates different emotional demands to those of a ‘regular’ emergency patient.

The opinion of the ambulance staff in this case were mirrored in the actions of the GP, end of life carer and the hospice in which the patient was taken to and most importantly the family were left to spend some time with the patient in his final days. Although argued as difficult to measure the leadership taken by all parties. A situation such as this one adds weight to the idea of a multi-faceted response team as although a positive outcome it meant the ambulance crew being on scene for around 3 hours.

Approaches to Service Delivery

Whilst out on the road it has become apparent that as the Shu 2014, Inter- Professional Capability Framework suggests, OC3 (Shu 2014, L2), healthcare professionals need to improve the communication between the members of the community of practice to enable change and improve person focused services.

For an elderly/geriatric SU their environment in many cases is all they know and can become a place of safety and Means, Richards & Smith, (2008) suggest that this is a key factor in the improvement of their personal health and wellbeing. Kelly, (2012) goes on to say that the environment in which these people live can make a healthy lifestyle easier to adhere to. Conversely to this advice I recently attended a geriatric patient who had become scared in their own home and also scared of his own son who lived with them. Due to this the patient had deteriorated from being self-sufficient and able to mobilise even to the shops 100 metres up the road to being almost bed bound, non-compliant with his medications and reliant on those around him. This enhances Kelly, (2012) argument that if this patient felt safer and more comfortable in his own home then this would translate to a healthier patient.

During previous inter collaborative weeks it became clear that not enough is done collaboratively and that the opportunities are there for us to work together as a wider healthcare workforce. With this thought process previous jobs that I have attended began to resonate and the impact this collaboration could have on our SU and how empowered we could make them to make their own decisions. In these jobs, allowing the SU to be part of his decision making and treatment plan would’ve been beneficial as quite often they do not want to go to hospital and in the policy document ‘No Decision about me, without me’, (Department of Health, 2010), SUs should be put at the heart of any decision and allowed to collaborate with healthcare professionals in decisions about their care.

As an autonomous practitioner it is going to be my responsibility to enable these SU’s to make their own decisions and using CAEP2 L1 (SHU, 2014) and along with Department of Health, (2010) policy, the SU should be able to recognise where it is appropriate for the SU to participate in a decision about their own treatment. NICE, (2015) states that the healthcare professional dealing with the SU has to power to decide the current mental state of the SU and decide if they are fit to participate in decisions regarding their own care.

It is also going to be a challenge when allowing this involvement to ensure that the decisions being made are in their own best interest and that the SU, by making these decisions, aren’t preventing an improvement in their own health and putting constraints on the improvement of healthcare services (Flottorp et al., 2013). McKeown, Malihi-Shoja & Downe, (2010) state that our job as a healthcare professional is to empower the service user (SU) to make their own decisions and empower them to decide their own welfare.

In my experience not enough is done on scene with a patient in terms of referrals and working collaboratively with other healthcare professionals to what I believe is the detriment of the patient. By making a ‘falls referral’ and making sure that the patient is mobile we as an ambulance service believe that we have done our job and that the detail is complete. I believe that there should be a collaborative effort for every patient in this situation and that access to all pathways and treatment plans should be available to confer and refer to. I have been to numerous patients where this isn’t the case and although patient care isn’t lacking, the aftercare for the patient left alone with the memories of a recent fall is.

I believe that as an ambulance service we should be striving to evolve and improve and that along with the Inter- Professional Capability Framework, R1 L2 (SHU, 2014) we should be reflecting on our performance in promoting person focused and integrated service provision whilst also self-reflecting. Improvements such as a collaborative response car would take a level of buy in from all sides but would eventually lead to an integrated service in which our soul focus was the patient. In terms of delivery and collaboration as Wankhade, (2017) states, emergency services and different areas of healthcare are moving at differing rates and speeds causing confusion as to the roles and responsibilities across organisations.

A study by Wankhade, (2016) points to the belief in the ambulance service that they are being inappropriately dispatched Wankhade believes doesn’t instill confidence in the staff responding and then that same clinician is under pressure when leaving the patient at home. Due to this, responsibility is growing with what Wankhade, (2016) describes as inconclusive evidence regarding the safety of patients not transported to hospital. This study is backed by significant evidence from McCann et al., (2013), Fisher et al., (2015), O’Hara et al., (2015), Newton and Harris, (2015) and Evans et al., (2014) who confirm that the service delivery currently being offered by the ambulance service, including that of paramedic decision making and patient safety in relation to this is sadly lacking.

For the delivery of the new collaborative response vehicle to work these barriers to successful service delivery would need to be overcome and clinicians from all areas of healthcare on scene should feel empowered to make safe and clinically backed decisions. In Wankhade’s, (2016) study the situations described are true to those of my personal experience where initial call coding has been incorrect, and the clinician is then on scene making a judgement regarding the correct pathway for the patient with minimal input. If this decision could be made collaboratively and with the input of leaders from other healthcare agencies on scene. Perceptions of the ambulance service being a transportation service to these other healthcare providers as described by McCann et al., (2013), Wankhade, (2011) and Heath and Wankhade, (2014). This is something that at times I have witnessed with patients calling an emergency response and waiting outside of a house with bag in hand knowing where they want to go and who they want to see there. Could this be made into a historic view with a future of collaboration, on scene decision making and care pathways that increase patient safety, reduce the individual stress on the clinician as described.

Conclusion

It is clear from the research and from my personal experiences that not enough is done on scene in my area to provide the elderly/geriatric patients, of which they are an increasing number, with a plan of action once an ambulance crew has been on scene. These patients are a prime example of CAEP2 L1, (SHU, 2014) in which they are, along with the clinicians on scene, able to collaborate and participate in the decisions made about them (if deemed to have capacity by the clinician) to improve their overall outcome. Within my idea for a new initiative in the ambulance service OC3 L2 and CW3 L3, (SHU, 2014) can be adjoined in the collaboration and co-operation of a multi-agency response to these particular details, leading to savings not only in the time of the ambulance service to be able to respond to the more life threatening calls but savings in A+E time, hospital bed costs and after care time that referrals create.

A collaborative picture is a picture in which one call from a patient to the ambulance service, triaged correctly at point of contact, leads to a quicker multi-agency response in which all aspects and areas of a patient’s treatment arrive in one vehicle. As mentioned in the main body of this piece of work the ambulance service is stretched and ambulance personnel are struggling with the weight put on them to keep the patient safe and also to make a decision of hospital or home. A collaborative approach to patient care would remove a lot of this individual stress and allow for interprofessional working and shared/joint decision making. The issues in service delivery stated above would therefore be alleviated and the issue of leadership would and could be shared. I have witnessed whilst on placement the stress of a clinician on scene trying to find an alternative pathway for a patient without knowing the full picture of what is available. Currently and from personal experience not enough is known about alternative pathways and therefore patients are incorrectly or inappropriately taken to hospital when they would be better served staying in their own homes. A joint approach to their care and treatment would allow a quicker time on scene and a more appropriate service delivery and journey for the patient.

I have however recognised the limitations in my role as a student paramedic and eventually a paramedic in that I would be asking for a significant change in process and initial investment, but I will endeavour to personally made a change as and when I deem possible on scene. When I am out on placement or in my regular role with the service I will constantly review jobs of this nature and lead my colleagues in making better referrals and considering all pathways available to me across the healthcare organisations thus developing as a clinician and creating a more integrated and patient focused environment (R1 L2, SHU, 2014).

References

Department of Health (2005) Taking Healthcare to the Patient. Department of Health, London

Department of Health. (2010). Equity and Excellence: Liberating the NHS. Retrieved from https://www.gov.uk/government/publications/liberating-the-nhs-white-paper

Healthcare Leadership Model, The nine dimensions of leadership behaviour, (2013), (www.leadershipacademy.nhs.uk) Accessed on 10^th January 2020.

Heath, Geoffery and Paresh Wankhade. 2014. “A Balanced Judgement? Performance Indicators, Quality and the English Ambulance Service; Some Issues, Developments and a Research Agenda.” The Journal of Finance and Management in Public Services 13 (1): 1–17

NHS Improvement. (2018). Falls Specialist Response Vehicle. Retrieved from https://improvement.nhs.uk/resources/falls-specialist-response-vehicle/

Newton, A. and Harris, G. (2015), “Leadership and system thinking in the modern ambulance service”, in Wankhade, P. and Mackway-Jones, K. (Eds), Ambulance Services: Leadership and Management Perspectives, Springer, New York, NY, pp. 81-94.

O'Hara, Rachel; Johnson, Maxine; Siriwardena, A Niroshan; Weyman, Andrew; Turner, Janette; et al. (2015). A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety, (2015), Journal of health services research and policy, Volume. 20, Issue 1

Parsons J (2009) Small ‘I’ in Leadership. Aust Fam Physician 38(5): 277

Yorkshire Ambulance Service Promotes Falls Awareness Week (2019), (https://www.yas.nhs.uk/news/media-releases/media-releases-2019/yorkshire-ambulance-service-promotes-falls-awareness-week/) Accessed on 10^th January 2020.