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The future comes rapidly down the tracks

14 February 2020

To ‘shoot the rapids’ the dictionary says is to move quickly in a river where the water flows very fast, usually over rocks and it’s the striking image I come away with from a meeting with Hillingdon Rapid Response team – the largest of CNWL’s six Rapids Teams in Milton Keynes, Camden, Westminster, Kensington & Chelsea and Hammersmith & Fulham. Their mission? Admission avoidance.

Two of the teams – Hillingdon and MK – are organised around a single hospital, and the other four have a number of hospitals over multi-boroughs.

They are a vital part of acute care, seeing around 11,400 patients in the last year.

Not insignificantly either, their work has probably saved about £10.2 million for the NHS by avoiding unnecessary hospital admissions and bringing highly skilled services into people’s homes – actually a defining feature of the modern NHS. The NHS Long Term Plan calls for an expansion of these types of services and we are well placed to help integrate care.

We are very experienced: the Hillingdon services started about 19 years ago, Camden eight years ago and Community Independence Service (CIS, partnering with West London NHS Trust and local GPs) for about three and half years. This is a lot of experience.

The public often don’t understand what this is. “Admission avoidance” sounds like an obstacle course to complicate entry to A&E but in fact it is a highly skilled team that provide hospital-level care, but in the community.

They are very successful at what they do, but they also make sure that those who need to go back to hospital do so, as well as providing a skilled intervention that keeps people cared-for safely and therapeutically, at home.

Nash Bageni (a nurse by background) and Fred Nxumalo (a physiotherapist) (pictured) are the team leaders for Hillingdon Rapid Response. Both joined the team over 10 years ago and have worked their way up. They love the team and are very proud of what they do.

To listen to them talk about this work and their knowledge that complements the local system, they also exude an ‘integration spirit’, a determination to make it work, that has produced a large degree of clinical trust between GPs, the hospital and the ambulance service.

They are very proud that they can trust each other’s assessments; “Being a multi-disciplinary team means that staff know enough about what’s needed – even if outside their professional boundary, so instead of referring on, they can make an assessment and start the process rolling – and keep it moving”, says Nash.

“Our band three and four Healthcare Assistants are also trained phlebotomists and that makes a huge difference to patients and to those staff who have gained a new and important skill. We’ve also just started an emergency blood test service for GPs, needed within 24 hours.”

They are skilled at recognising when things need to be escalated. All staff carry the National Early Warning Score (NEWS2) cards which standardise the assessment of and response to acute illness; these show the ranges of monitored indicators and when to escalate.

Hillingdon Rapids operates over fifteen hours a day; 9am to 12:30am – two staff from 4:30pm and 12:30pm who are attached to the Twilight Team of around 20 District Nurses and HCAs, who make late night visits – often for catheters, or insulin or IV anti-biotics.

Nash says, “We also work with Harlington Hospice who can provide a limited night sitting service but that’s never guaranteed and others in the voluntary sector (Age UK) provide a hospital-based take-home and settle service  that make a difference to patients who are often without basics such as milk and we could use more like it.”

There is no such thing as a typical patient but they will tend to be those who may be housebound, often with frailty (with multimorbidity and complex medication regimes), they may have already or need a social care package.

Medical conditions are usually around acute infection e.g. urinary tract infections, the exacerbation of a long term condition e.g. COPD, and even perhaps people at the end of Life (possibly unrecognised).

The Hillingdon Team see by far the most patients of all the teams and have around half of the 91 staff who works in Rapids across CNWL. Typically they have 40 to 50 cases but at times, especially in winter, it will be 65 to 70, with an average length of stay with the team of five days.

Nash said, “There’s lots of Trust amongst partners; more collaboration not friction, but flexible; we’re sort of submissive partners and that makes things work better; we don’t over-promise and we always do what we say we will.”

They don’t take self-referrals as their work comes from GPs, London Ambulance Service, other community services like District Nurses, Care Homes and the Community Rehabilitation service.

  • Acute sector: working at A&E for people who don’t require admission (at that point), usually around frailty and Rapid Response can treat them at home
  • Discharge to assess: after someone is medically optimised, that is when there is no longer a medical reason to remain in hospital Rapids can treat at home (perhaps eight a day). In conjunction with Social services are now piloting weekends too.
  • Home Safe: is slightly different; goals will be set in hospital and Rapids follow them through.
  • Intra Venous (IV) antibiotics there’s a cohort of people with cellulitis, or urine infections, who following initial assessment by consultants in hospital over three to five days can be treated intensively with anti-biotics at home.

Fred says, “We don’t do Palliative Care but we will help make it work by looking at the micro environment in a patient’s home and some basic adaptations around the house and we provide a bridging care package for 48 hours until social services provides a more optimal care package

What’s also impressive is they understand the pressures on staff in other areas – like the very busy staff in A&E – so that their processes are made easier to use the resource Rapids offers, like on Discharge to Assess.

People are complimentary. One said, "The two ladies that visited today were really lovely and made me feel very comfortable. I am very grateful for their visit today and was upset that they had to leave. I look forward to seeing them again on Friday. We're always quick to complain, so I thought I would be quick to praise!"

Another said, “A gentleman following a total hip replacement and discharged from Mount Vernon Hospital. He was complementing about the care he received from Rapid Response. How lovely everyone involved in his care. He felt like he was listen to and consulted throughout.  Equipment was put in place very quickly. He was praising staff regarding the way they helped with his rehabilitation. He managed the stairs first time today and is looking forward to sleep in his own bed tonight. He praised about the difference the team made in his recovery.”

Staff member also said, “Management support you in difficult times, recognise there is life after work, pushed to grow in your career, people agree to disagree. So I want to appreciate you all starting from receptionist, HCA, clinicians and managers.”

Samara Hammond (pictured) is CNWL’s Clinical Practice Lead on Rapid Response.

She’s a very interesting person. She’s been here about three years now and used to work with Amref Health Africa– also known as the flying doctors of East Africa; today they “use e-learning, telemedicine and mobile phones to spread health knowledge, training and care”. For three years, she ‘commuted’ once a month to Nairobi working in Kenya, Somalia, Uganda, Sudan and other areas in east Africa.

“Rapid Response is an exciting place to work. The new NHS 10 year strategy- the long term plan- put the community and rapid response solutions in the spotlight. With six teams in CNWL, and an absence of a recognised best practice model nationally- we were presented with an opportunity to look at what we currently do and to start a process of defining a model of practice “NICE (2018) defines rapid response as a part of intermediate care, it is a crisis response service which supports an individual to stay at home and avoid admission in the event of the acute episode”

“Our Community Services Board commissioned a piece of work to look at the six teams, The teams have all evolved over time under different influences, most notably but not exclusively commissioning arrangements led by local CCGs. This piece of work has the opportunity to identify areas of good practice against a backdrop of available evidence.” The ethos that underpins the work going forward, is the right care is provided at the right time, in the right place by the right person- and while the team is distinct, it can’t work in isolation- its effectiveness is enhanced by its integration in the wider health economy.

Samara says, “This is the model all teams agree best represents the core of what they do. There is a stage that has been added – planning- all the teams agreed and I concurred. A lot of what they do once the patient has been stabilised at home is working out what network of care needs to be provided around them, to strengthen the infrastructure around them. As the patients are undifferentiated, the staff need the appropriate skills to diagnose and treat across the physical, functional and social care spectrum.”

And as Fred and Nash would undoubtedly say, they do.