Aligning Interdisciplinary Education and Quality Improvement Through the Cycle of Learning April 2016
Healthcare Professional Education: The Future Dr Kieran Walsh Presentation title
Road map The future of healthcare The future of healthcare professional education
The future of healthcare - change More primary care More accessible care Chronic disease management New and emerging infectious diseases Ageing population Interprofessional teamwork and care Patient safety Quality Cost control Knowledge explosion Technology explosion Era of continuous change
Healthcare professional education Needs to change also Is it changing fast enough? Is it - Tertiary care or primary care? - Ivory tower or on the ground? - Uniprofessional or interdisciplinary? Is it aligned with medical workforce and population needs?
How will healthcare professional education change? Frenk et al - in the future all health professionals should be educated to mobilise knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams
How close are we to this? Or are we trying to meet need by doing what we have always done? Just more of it?
Changes Online learning Clinical decision support - self-directed learning - learning at the point-of-care Delegation and supervision Quality improvement
Programme Overview: Urgent, Acute and Emergency Medicine Workforce Transformation Matt Aiello Programme Lead, Health Education England April 2016
Why do we need to transform? House of Commons Emergency Admissions to Hospital Forty-Sixth Report (2013-14): The health sector does not consistently work together in a cohesive way to secure savings, better value and a better service for patients. Royal College of Emergency Medicine: Up to 500 patients died in 2014 as a direct result of EDs becoming overcrowded and almost 350 of the deaths were among patients who had not been diagnosed or given medical treatment quickly enough. Time for a change? CQC State of Care report (2013-14): More than half a million people aged 65 and over are admitted as an emergency with avoidable conditions that potentially could have been managed, treated or prevented in the community.
Health Education England supporting change Backing diverse solutions and local leadership Create aligned national NHS Leadership Supporting the modern workforce Exploiting the information revolution Accelerating useful health innovation Driving efficiency and productive investment The health service needs to change over the next five years if it is to improve quality of care and the health of the population. HEE 15 Year Strategic Framework: Levers to support change: Workforce planning Attracting and recruiting the right people into training HEE Corporate enablers to support the above Using commissioning levers to best effect Encouraging employers to invest in their people
How can a Transformation Theme support system change? Communication A Joined-up, system wide approach Avoid replication of work-streams by sharing learning across the healthcare economy encourage collaborative working. Understand and respond to the needs of local workforces, through focussed engagement One HEE discourage silo working; promote shared learning; The transformation theme can provide a regional basis for national project scaling. Overcoming traditional divides Between primary, community and secondary care strategic, cultural and attitudinal Talking to stakeholders and user groups; encouraging cross-organisation, cross-geography engagement. Use innovative new models to break through organisational and traditional boundaries. Demonstrate through pilot work, new ways of working avoid its not grown here attitudes by scaling local projects. Multi-Specialty Community Providers / Urgent and Emergency Care Networks right care at the right time in the right place. Creation / identification of relevant networks and key decision makers
How do we know it will work? Example Evidence Base: The EM Taskforce Department of Health officials and members of the Royal College of Emergency Medicine established the Emergency Medicine Taskforce in September 2011. AIM: To address national workforce challenges in Emergency Medicine at a local level. Group membership included a cross-section of clinical workforce decision makers. Developed and delivered a successful portfolio of strategies, to address local and national EM and Urgent / Acute workforce challenges. In order to achieve an understanding of how different health care services can work collectively, new models of training are needed to prepare healthcare professionals for a career in a more joined-up workforce, with the knowledge and skills that span the management of acute health needs across community and secondary care environments. Examples of local transformation projects? Changing the world, one project at a time
Urgent and Acute Care (including Emergency Medicine) Workforce Transformation Vision In conjunction with regional and national stakeholders and sponsors, to address medical and non-medical workforce challenges in Emergency Medicine and Urgent and Acute secondary care; collaborating with primary and community care on shared solutions Examples of Ongoing Transformation Projects Post CCT GP Fellowship Pilot from January 2014 November 2015 1 st West Midlands cohort from September 2015. Scale & Spread across three London LETBs and KSS from January 2016. ED Pharmacy HEWM led (scaled up) National ED Pharmacy project, involving 53 Trust EDs in 12 out of 13 LETBs nationally, from March 2015. Evaluation results to inform further development. Physician Associates Supporting training across three West Midlands course providers, from September 2014. Developing a Midlands & East PA Steering Group from August 2015. Supporting cross-letb development of local funding models. 2015: Secretary of State for Health: A New Deal for General Practice Building on the success of a Health Education England pilot in the West Midlands, we will incentivise a number of newly qualified GPs with an extra year of training and support to develop specific skills needed in areas such as paediatrics, mental health and emergency medicine 2015: Royal Pharmaceutical Society (RPS): The RPS believes that pharmacists could make a significant impact on patient care by adding both capacity and capability to Emergency Departments...We are fully supportive of the work being undertaken by Health Education England to further evidence the value of pharmacists within Emergency Departments and will be doing everything we can to support those taking part. 2015: General Medical Council (GMC): We warmly welcome the launch of the new faculty to support this exciting development. Physician associates look set to play an increasingly important role in supporting the delivery of safe medical care and we are clear that in the interests of patient safety and to maximise their value, they should be subject to statutory regulation if the four Governments within the UK felt we should do so, we would of course seriously consider that option. Physician Associates Advanced Practice Delivery of a regional, multidisciplinary, Advanced Practice training programme pilot; concluded July 2015 Results demonstrate viability and value of a single training programme, suitable to train a multi-disciplinary, non-medical cohort. Future Work Steering Group Influences Steering Group Projects Mental Health Risk
Summary Transformation Themes should: Break new ground in training and career development pathways, through innovative pilot and test-of-concept projects Support development of multi-disciplinary training pathways, with a joined-up approach across community, primary and secondary care Propose and introduce new medical and non-medical pathways, to complement the multi-professional clinical workforce. Identify and retain workforce leaders, to assist in proposing and progressing workforce change Create and maintain effective communication networks, to overcome traditional cultural and geographical boundaries and allow for shared learning.
Thank you for your time
Case Study 1: Developing a New Workforce in the 21 st Century A program using simple QI methodology Prof V Wilkie Health Education England (WM) Academic Lead Urgent and Acute Care project Professor of Primary Care University of Worcester
Background UK healthcare is changing Demographics Shift to community care Change in health provision Economic change in funding (11% -8.5% GDP)
Overview Post CCT GP Fellowship in Urgent and Acute Care Key points to consider: What do we need to practice in 21 st century healthcare? Urgent care and frailty What works well now? What could we do better for the future? Where are the gaps in the service? How can primary care physicians integrate and add value to urgent care and care of the frail / elderly?
New models of care? Urgent care centres avoiding hospital admissions An increase in development and deployment of multi-professional teams Need to prevent acute ill health when possible Improve care of acute illness in the community Evidence and future aims of UK Government Department of Health (Five Year Forward View)
Current provision of workforce training needs to be reviewed. GP skills last reviewed in 2007 Based on office based consulting Similar curriculum to 1990 s Community Nurses Developing assessment and treatment skills Able to prescribe Developing new clinical roles Expanding the function of existing roles Eg. Development of Clinical Pharmacists
Integrated Curriculum Development Look at future need Develop and educational curriculum Try out the curriculum developing knowledge and skills across all urgent care sectors
Fellowship Aims The 21 st Century GP 12 month academic training post Comprehensive training approach to Urgent and Acute care for GPs To up-skill & enhance the function of GPs within: A&E Acute Medical Unit Ambulance Service and General Practice New career pathway for GPs in Urgent care Integrating primary & secondary care joined-up care, spanning GPs, social care, and A&E departments - overseen by a named GP. NHS England 5 Year Forward View (2015) RCGP The 2022 GP
Academic Day Action Learning Set (leadership, evidence based practice) Project Support: Quality Improvement using BMJ Quality as template Post Graduate Certificate in Urgent and Acute Primary Care: Tested with GPs, Advance Nurse Practitioners, Paramedics, Clinical Pharmacists
Project team and funding strategy: 4 days clinical + 1 academic day Evaluation significant increase in skills, and understanding of whole healthcare system. Graduates enabled to take on leadership positions at completion of training remain in urgent primary care Funding limitations and expectations are a potential block to future roll out London, Cambridge and East Midlands - alternative pilots West Midlands considering different models of care (shifting the balance between learning and service provision
If you do what you have always done.. Paucity of GPs and the need to develop multi-professional and integrated training Financial instability and service providers understanding of the need for new training You get what you have always got.. Solutions? Benefit of small pilots and a team to evaluate learning, career progression and funding strategies Test strategy, and delivery financial and educational as a continuous learning cycle Class of 2014 HEE Post-CCT GP Fellowship in Urgent and Acute Care Significant benefit of networking and feed back from other sites
Prof Veronica Wilkie (Academic and Clinical Lead) V.wilkie@worc.ac.uk Thank you
Case Study 2: A brave new world Pharmacist Development in Urgent & Acute Care Matt Aiello Programme Lead, Health Education England April 2016
2013-2015: Health Education England Urgent, Acute and EM Pharmacy Programme Aims: To test and justify development of clinical pharmacist roles within the ED and across primary and community urgent and acute health economies. To provide an evidence base for further Health Education England-led project work Investigating the potential for cross-region / national scale and spread potential. Guiding questions: 1. To what extent can pharmacists manage patients in the ED? 2. What extra training is needed to create an advanced clinical ED pharmacist? 3. What can a pharmacist uniquely contribute to the joined up, multi-disciplinary, multiskilled urgent and acute / emergency care workforce of the future?
2014 West Midlands ED Pharmacy Pilot: Study Findings 3.2% 5.1% Patients suitable for management Community Pharmacy (3.2%) Independent Prescriber (5.1%) Advanced Clinical Pharmacist (39.9%) Medical Team Only (51.8%) 51.8% 39.9% Of the 782 patients surveyed over the three sites, 48.1% of patients could be managed by a pharmacist as part of a multiprofessional team and under the overall supervision of a doctor. Of these, 39.9% could be managed by a pharmacist with 12 months focussed Advanced Practice training, aligned to the HEE National Advanced Practice framework
Advanced Practice Training Identified training needs included: Clinical examination and assessment (including diagnostic skills) Medical management and treatment Training course component 12 month (Level 7) double module (60 credit pgcert) West Midlands and National ED project categorisations based on this curriculum Module 1: Clinical Examination Skills for Healthcare Professionals (40 CATS points at Masters level) Aim: To provide the theoretical underpinning and practice base to enable the health care professional to deliver safe and effective autonomous care. This will include patients presenting with undifferentiated and undiagnosed primary and secondary care conditions across the age and acuity spectrum Assessment: Assessed Essay/course work 4000 words Four objective structured clinical examinations (OSCE) Portfolio of evidence from own clinical practice Module 2: Clinical Investigations & Diagnostics for Healthcare Professionals (20 CATS points at Masters level) Aim: to complement the clinical examination module to provide the student with the theoretical underpinning for the acquisition of a range of skills and knowledge to support safe autonomous practice when requesting and interpreting clinical investigations for a wide clinical spectrum of conditions. Assessment: Assessed Essay/course work 2000 words Two objective structured clinical examinations (OSCE) Portfolio of evidence from own clinical practice
April-May 2015 National ED Pharmacy Project: Service Improvement Audit March - April 2015: HEWM team led for HEE: Delivered a national version of the West Midlands project. 49 Acute Trusts engaged nationally, each categorising up to 400 sets of patient data against the West Midlands pilot methodology. The 49 Hospital Trusts were drawn from 12 of the 13 national Local Office Areas Project Trusts representative of a national cross-section. Data would demonstrate variance in patient presentations at UK EDs, during winter pressures period. 18,613 sets of patient data received from 49 Trusts. Aim: To expand upon West Midlands project and demonstrate evidence base for national consideration of a near-patient clinical pharmacist in the Emergency Department, as part of a multi-skilled, multidisciplinary workforce.
2015 PIED-Eng Study: Findings 3.9% 3.9% Primary categorisation Community Pharmacy (3.9%) Independent Prescriber (3.9%) Advanced Clinical Pharmacist (27.9%) Medical Team Only (64.3%) 64.3% 27.9% Of the 18,613 patients surveyed over the 49 sites, 35.7% of patients (n=6,647) could be managed by a pharmacist, as part of a multiprofessional team and under the overall supervision of a doctor. Of these, there is potential for 27.9% to be managed by a pharmacist with Advanced Practice training aligned to the three year (MSc) national framework. If training is targeted at the 2 highest impact clinical groupings (general medicine and orthopaedics), this figure becomes c.19%.
Outcomes HEE-WM Pharmacy Programme developed an evidence base for potential new 3.2% roles for clinical pharmacists, 5.1% as part of multi-professional, multi-skilled clinical teams in Urgent and Acute Care / EM, including: Undertaking medicines-focussed duties; eg: pre-discharge medicines optimisation, medicines reconciliation, TTO preparation, Optimising the use of medicines on admission to emergency and acute care, Provision of confident and competent clinical care to patients presenting in urgent and 51.8% acute settings, 39.9% Pre-discharge of acutely ill patients, Freeing up doctors to conduct clinical work, Reducing patient waiting times and delivery of safe patient care, Duties often undertaken (unnecessarily) by junior medical staff, consultant grades and GPs, who face significant demands on their time. The 2013-16 West Midlands Programme evidenced the potential for enhanced clinical pharmacy roles in urgent and acute care. Next Steps?
Next Steps? Clinically Enhanced Pharmacist Independent Prescribing (CEPIP): 1 st Non-Pilot Cohort of the HEE-WM CEPIP programme: January 2016 100 pharmacists joined programme Even split between primary, community and secondary care Future Programme Development to include: Strategies to support pharmacist access to DMP Mapping pharmacist training needs and competencies against national Advanced Clinical Practice (MSc) syllabus. Evaluating CEPIP programme to understand workforce impact and return on investment. Working with national stakeholders to prepare a model curriculum and competency framework for clinical pharmacy training for national consultation. Aim: To demonstrate capability of advanced clinical pharmacists to practice competently and confidently as part of a multi-professional Urgent and Acute clinical workforce. Using service improvement study data to inform workplace-based development.
Supporting Development Supporting Trainees: HEE-WM CEPIP Programme (2015-16): With the enhanced clinical content of this programme and the lack of educational / clinical support resources to assist pharmacists, identified need for a standardised support E-learning resource. BMJ Best Practice and Learning provide pharmacists the most appropriate support for clinically enhanced training. HEE licensed Learning and Best Practice for all programme pharmacists Early Indications? An excellent resource. I would be very keen to get this implemented and look at optimising use. Mrs Parbir Jagpal, Programme Director, Practice Certificate in Independent Prescribing School of Pharmacy, University of Birmingham I have personally used both over the years and regard the resources as being high quality and potentially quite useful in the context of quality improvement. Dr Sanjiv Ahluwalia, Postgraduate Dean, Health Education London Central and Southeast The teaching session at Aston went well, and I'm confident that our students have had a good introduction to BP and how it can help them in both their studies and their future practice I'm confident that this is an essential tool for students enhancing their clinical <skills>. Dr David Terry PhD MRPharmS, Director, Pharmacy Academic Practice Unit, Aston University
Near Patient Clinical Pharmacist: Possible Career Development Pathway MPharm & Registration Existing Clinical Diploma (2yrs) Pharmacist undertakes (60 credit) Clinically Enhanced Independent Prescribing Module (CEPIP) Supporting clinical training BMJ Best Practice and Learning Fit for purpose? Evaluation from CEPIP, ED Pharmacy programme and ACP pilots mapping exercise Map identified learning needs against existing training pathways (eg. national Advanced Clinical Practice / Physician Associate etc Informing CEPIP development: IP + Clinical Health Assessment and Diagnostics (aligned to workforce needs) Multi-professional Advanced Clinical Practice (ACP) Training (3 year, 180 credit MSc) Pharmacist practices as (MSc) Mid-Level clinician Transfer of credit (RPL / APL) Pharmacist achieves GPhC accredited Independent Prescriber Status (IP) Step-off point pharmacist prescriber with enhanced clinical skills Future Roles? Evaluating Workforce deployment models. Addressing Clinical Skills Gaps in Urgent and Acute and Emergency Care Cash in MSc credit toward Further Clinical Skills Development Bespoke Clinical Doctorate As the professional basis for Consultant level Pharmacist?
The Future? The HEE Pharmacy programme provided an evidence base to inform workforce development in EM and Urgent and Acute Care. The programme will further develop the evidence base in cooperation with regional and national stakeholders The end result? Evidencing the potential for a multi-specialty clinical practitioner A Generalist Specialist Pharmacist Health Education England will continue to investigate the potential for pharmacist clinicians in the joined up, multi-skilled, multi-professional Urgent, Acute and Emergency Medicine workforce of the future.
The RPS believes that pharmacists could make a significant impact on patient care by adding both capacity and capability to emergency departments. Hospital pharmacy has been at the forefront of advanced clinical practice for some time and I have no doubt chief pharmacists and their teams will respond positively to this opportunity. We are fully supportive of the work being undertaken by HEE to further evidence the value of pharmacists within emergency departments. Dr David Branford, Royal Pharmaceutical Society (RPS) English Pharmacy Board chair Professor Sir Bruce Keogh, National Medical Director (NHSE), confirmed that key outcomes from the ED Pharmacy work would include a positive impact on patient safety, improved patient experience and throughput, expediting safe discharge of patients from hospital and increased capacity in the acute care pathway. Stakeholder Engagement? We are pleased with how the pilot went here and are very keen to take this work forward. We are now looking at putting a pharmacist in the emergency department, who can be part of the team there and support with the triaging of patients. Neil Fletcher, clinical director of pharmacy at East Lancashire Hospitals NHS Trust
45 Thank you for listening
Case Study 3: Pharmacist clinicians & clinical delegation Evidence and delivery Dr David Terry Director Academic Practice Unit Aston University and Birmingham Children s Hospital
Pharmacists - background Clinical pharmacy movement of the 1980s in hospitals Pharmacy came out of the dispensary Pharmaceutical care (Hepler & Strand, 1990) Medicines Management. Medicines Optimisation Community pharmacy (sometimes called retail pharmacy) took longer to change, but change has come Millennium first EHC service without prescription Independent prescribers 2006 1,400 excess pharmacist graduates each year
Pharmacists - background Over 270,600 patient visits every year 361 beds 43,151 inpatient admissions each year Birmingham Children s Hospital: Pharmacy 85 staff 30 pharmacists Clinical services
Clinical delegation pharmacists - evidence The PIED Study Prof Liz Hughes Matt Aiello Chi Huynh Kostas Petridis Louis Mazard Alex Terry Anthony Sinclair Hirminder Ubhi And contributors from around England
Clinical delegation pharmacists - evidence PIED National Study Commissioned by HEE March July 2015. Aim: To determine the potential of pharmacists to manage patients within Emergency Departments
Clinical delegation pharmacists - evidence Manage? 49 sites 18,613 cases 4 categories Community Pharmacy IP-Pharmacy IPT Medical Team
Clinical delegation pharmacists - evidence Findings CP = 3.9% IP = 3.9% IPT = 27.9% MT = 64.3% 64% 4% 4% 28% CP IP IPT MT achievable?
Pharmacists - training Impact index? general medicine = 13.18 orthopaedics = 9.69. Training? CEPIP 60 credits L7 masters Adv Health Assessment 60 credits L7
Pharmacists - training Clinical training IPL Diagnostics Support Best Practice
Pharmacists future studies Post training PIED study (WM2) Curriculum mapping Supervision vs contribution
Delegate discussion 10 mins. Delegates to discuss in 2s / 3s 5 min What we need to do is transform the workforce. This needs to be Inter-professional. We need a more flexible workforce What can you do and how can you enable this? What are the three biggest problems and what are the three biggest risks in doing this?
Evaluation 10-15 mins
Panel Q&A 25 mins
Sum up and close. Task. Make a pledge of what you are going to do at your own workplace. Write it down on a piece of paper and give it to us. If you do this we will give you Guest access to BP for one month We will email you in 4 weeks to see if you have done it
Dr David Terry, Aston University d.terry@aston.ac.uk (David works for Aston University and Birmingham Children's Hospital. Recent research projects have been supported by HEE, NIHR / CLARHC, Sanofi, PRUK, and BCH Charities) Prof Veronica Wilkie, University of Worcester v.wilkie@worc.ac.uk (Veronica is seconded to HEE from the University of Worcester. She researches and has received grants to evaluate the NHS from NHS bodies) Matt Aiello Health Education England (HEE) matthew.aiello@wm.hee.nhs.uk (Matt works for HEE, a non-departmental UK government body, responsible for planning and buying education and training for NHS and public health organisations in England) (Kieran and Mitali work for BMJ, which produces resources in clinical decision support, healthcare professional education and quality improvement) Mitali Wroczynski BMJ mwroczynski@bmj.com Dr Kieran Walsh BMJ kmwalsh@bmj.com