Author: Vanesther Hamer

My AHSN connection – Sandra Akintola

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Sandra Akintola, Clinical Project Lead for Bristol Community Health, writes about how her work with the AHSN helped her to hone her networking style, make valuable connections and see the bigger picture to her work.

I first connected with the AHSN when I attended a network meeting in place of my manager. Although I didn’t quite know how I fitted in, I knew I was amongst like-minded people. As I got to know people in the AHSN it helped me see beyond my immediate role and see how my workstream fits in a bigger picture. I’m a natural networker, but the richness of the organisations the AHSN works with has helped me hone my networking style, and has introduced me to clinicians who have become my role models.

My role involves introducing new clinical approaches and monitoring their implementation, so I’m always open to new ideas. Where I’ve found working with the AHSN to be especially helpful is introducing the clinicians and clinical directors I work with to others, maybe working in different settings, trying to make the same changes. I’ve heard phrases like “I didn’t realise so many other people out there are doing this – it makes it seem real.”

It is this sharing of knowledge and experience that is so vital, helping clinicians feel part of a wider process of change and improvement. It makes sense to share knowledge, as we share patients all the time as they move from community settings to hospital and then back again.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

My AHSN connection – Dr Damian Gardner-Thorpe

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Dr Damian Gardner-Thorpe is a practising GP and CEO of the digital healthcare solutions platform Digital Algorithms. One recent Digital Algorithms product is ROVA, a platform designed to deliver social prescribing and other self-care solutions through clinical commissioning groups (CCGs) and local authorities. Here Damian writes about how the West of England AHSN helped Digital Algorithms in their journey.

Designing and building a completely new platform to enable social prescribing has been challenging on many levels but the AHSN has helped us make a number of valuable connections. Initially they helped us gain grants to enable us to build the ROVA platform. Creating a new, fully secure system, that allows individuals to connect with a range of volunteering opportunities, guided by GPs and link workers, simply wouldn’t have happened without that funding.

Our initial funding brought together a group of 10 stakeholders, including Bath University, who now have a specialism in Social Prescribing within their Institute of Policy Research. For us, it has led to us working with Virgin Care to deliver the Wellbeing College to help residents of Bath and North East Somerset to access courses, activities and groups to support their wellbeing.

The AHSN has now helped us gain further funding to apply the technology we’ve developed to create VolHub. This application allows individuals to move through volunteering opportunities in a way that helps them develop skills and confidence and a CV of achievements and experiences.

Throughout our journey the AHSN has provided advice, helped us to access funding and provided key introductions. As a practising GP I recognise some of the barriers, but their support and backing has helped us understand and overcome them.

The team at Digital Algorithms are available to discuss any new software applications targeting community health and social care.  Please visit their website to get in touch.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

My AHSN connection – Elizabeth Beech

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Elizabeth Beech is National Project Lead for Healthcare Acquired Infections and Antimicrobial Resistance at NHS England, and a pharmacist for Bath and North East Somerset Clinical Commissioning Group (BANES CCG). Here Elizabeth writes about how her involvement with the AHSN and the Q community has helped her to make productive connections and improve local practice.

I’ve worked with the AHSN on a number of different projects over the past few years, but recently I’ve found being a member of the Q community really valuable. When I joined Q, I set myself the challenge of setting up a community of practice to improve the management of urinary tract infections (UTI). I tracked down some really useful advice from other Q members about the best technology to use, and now host a great network of 400+ improvers discussing UTI issues across a number of countries.

Another productive connection occurred at a national Q event where I met an experienced Q member who wanted to improve GP engagement with his local diabetic improvement programme. BANES CCG were planning a process mapping workshop as part of our programme to improve GP practice based management of hypertension in the diabetic population. This was a great opportunity to import some expert Quality Improvement (QI) facilitation skills for our local workshop and enable GP engagement – a very definite win-win for both organisations and the GP practices involved.

Facilitating the use of QI processes in GP practices has also started to change the local QI culture, with some practices using process mapping to start to improve other elements of practice activity.

The AHSN offers so much more than the Q community – I’m also a part of the Primary Care Collaborative (PCC). The AHSN pulls together organisations in the West of England and makes it easier to collaborate across healthcare systems.

The AHSN and Q Community have enabled me to develop direct, purposeful working relationships with a whole range of other people working in and around the health and care system. It’s a community that allows you to dive straight in and get to the productive discussions that lead to improvements in safe and effective patient care.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

 

My AHSN connection – Abby Sabey

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Abby Sabey, Senior Lecturer at the University of the West of England (UWE) and Senior Teaching Fellow for the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), talks about her work, and how the West of England AHSN helps her to join the dots.

My work centres on teaching and training health and social care professionals in research and evidence-based practice. Working with AHSN allowed me to access key audiences, such as the Clinical Commissioning Groups (CCGs), which really benefit from having access to the latest research and thinking in this area. By working with the AHSN, an organisation the commissioners already knew and trusted, the CLAHRC was able build productive relationships with commissioners.

From the work we did together, it became clear offering our training electronically would be very useful, both within our region and beyond. We developed an online training package together and also, when it became clear there was wider need, we created a train the trainer package, which we delivered to colleagues from CLAHRCs and AHSNs from across the country.

Through the AHSN I’ve also worked with GP Clinical Evidence Fellows for the past three years. We have been able to support their knowledge base as they developed into champions for evidence within the CCGs.

Working with the AHSN has helped me and my colleagues to share and spread our research and expertise so it can have the greatest positive impact, by being put into practice at the heart of clinical care and commissioning.  It has been great to work with an organisation that shares our drive to use sound evidence to improve services.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

Keeping the A in AHSN

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Lars Sundstrom, our Innovation and Growth Director reflects on the role of academia in encouraging innovation and experimentation, and the importance of this to AHSNs.

Last month we had our first get together as an AHSN Network. Around 200 fellow AHSNers, most of them considerably younger and much more energetic than me, got together to celebrate how fast and far we have come in our first five years. Bright eyed, bushy tailed and ready for the next challenge, how can an old-timer like me not be inspired by the next generation and their appetite for the future?

When I was a university professor, I always felt the best antidote to feeling blue or if things got a bit bogged down was to find some students and talk to them. You quickly realised that the world is driven by hope and belief in the art of the possible, but that over the years you accumulate fear and restraint to the extent that you focus more on the art of the impossible.

Anyway, at the AHSN gathering I felt like a milestone had been achieved, not just because we entered another five year licence, but because it completes a personal journey from invention to innovation that I have been on for the past 30 or so years.

Bench to bedside

As you have probably guessed, the path that led me into the AHSN was not via the NHS but through academia. I spent most of my career in translational medicine doing drug discovery and development both in universities and in industry. I tell the youngsters in the team that back in them olden days when I was young we didn’t have a word for translational medicine, and we didn’t even know how to do it. I tell them we didn’t have phase one, phase two and phase three clinical trials; we just gave people pills or injected them with stuff and saw what happened.

“No way man – how could you do something like that? That can’t have been safe!” Well it wasn’t, I say, but what else could we do? Somebody had to be brave enough to be the first!

Translational medicine was the buzz word at that time and the term ‘bench to bedside’ is often used to describe it. So what brought me to the AHSN was the next logical phase – to  scale up. Perhaps we could say bedside to bedsides. I was also attracted by a new buzz word ‘innovation’, which I believe is probably the most important word to ever impact the NHS, and I’ll explain why shortly.

So back to the AHSN conference. After reminding people how AHSNs came into being five or six years ago, the speaker asked, “Hands up how many of you were around when it all started?” Apart from me, a few hands went up. She described the amazing progress made and we looked into the future and it felt great – except a bit of me felt that as the endeavour grows, that original pioneering spirit of adventure was slowly slipping away a little; that leap into the dark, that fear of the unknown. It all felt a little too safe, a bit too much like the NHS.

In the coffee break I bumped into my colleague and friend Tony. “What did you think of that then?” I asked. “It was great”, he said, “but I guess I’m still trying to figure out when it was that I joined the NHS?” “Yeah,” I said, “it feels a bit more like we’re in the NHSN rather than the AHSN.”

The conference concluded with a fabulous talk by Michael Seres, a patient entrepreneur and someone I have admired for many years. We once ran a conference on what it’s like to be an entrepreneur and inventor developing products for your own health issues – a ‘chief patient officer’ as Michael describes it. His message to us was clear: “Dare to be brave.” What’s  great about people who have come to this journey by misfortune in life is their spirit of adventure. It feels like they have nothing to lose and everything to gain, so they just hurl themselves into the unknown with unswerving devotion and energy.

People like Michael, Kevin Mashford, David Constantine are amazing – people who dare to be brave and innovate against all odds are the ones who will change the world.

What is innovation?

So back to innovation, this new buzz word. What is it? Well, like translational medicine in the olden days, we actually don’t really know how to do it healthcare. In 10-20 years’ time I will be able to tell you. I can tell you what it isn’t though. It isn’t about continuous improvement; it is about doing something that hasn’t been done before. Therefore it is also not 100% safe. I could write a blog on just that but in the meantime have a look at this excellent blog post by Alex Ryan and Jerry Koh on the subject.

I strongly believe, as I have said many times before, without innovation the NHS will not transform and will not be sustainable and it won’t survive. But like translational medicine back in the day, if we don’t try and we don’t fail, we will never learn and it will never be safe. So my message to the young AHSNers is: dare to be brave, learn from failures and then improve it, and it will become safe.

In the questions and answer section, I asked the chief officers where they would like us to be in five years’ time. Charlie Davie, Managing Director of UCL Partners, gave a great answer. He said, “I want the NHS to be known for being the best place in the world to do innovation, and in future the Americans come over here to learn, instead of us going over there to learn how to do improvement.”

As an academic, I know that all improvement and impact starts with experimentation. So I say, let’s keep the A in AHSN – where it stands for Adventurous, Ambitious and Audacious. If we see ourselves just as a safe distribution channel for innovation into the NHS we will have become NHSNs, and from there it is a small step to becoming the NHS and we will have failed to change anything.

So let’s dare to be brave, keep the academic mentality in the AHSN, and keep in mind the words of George Bernard Shaw:

“There are those that look at things the way they are, and ask why? I dream of things that never were, and ask why not?”

My AHSN connection – Dr Seema Srivastava MBE

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Seema was awarded an MBE in the 2018 Queen’s New Year’s Honours list for her services to the NHS in Patient Safety. Here Seema writes about her involvement with the West of England AHSN right from the start, and how we help facilitate the work she’s involved in.

I’ve been involved with the AHSN right from the start; I was already involved in regional Quality Improvement (QI) work. One of the things I remember, right back at the early meetings in 2012 was the range of people I got to meet. I was particularly interested in meeting innovators and people using technology to tackle some of the issues we were facing.

For us at North Bristol NHS Trust (NBT), the National Early Warning Score (NEWS) was high on the priority list right from the start. Working with the AHSN meant we could work alongside others, at University Hospitals Bristol and then in the community. We learn from each other’s successes and failures and take a standardised approach that has rolled out across the region and is now being implemented across the country.

One of the things I value most in working with the AHSN is the way they remove barriers and get people working together. The face to face meetings are both productive and enjoyable. The team there are also great at facilitating remote teams and keeping complex projects with dispersed teams on track.

It’s this ability to bring people together and focus their efforts that has allowed us to progress NEWS with the pace and scale that we have. I’m also working with them on approaches to Learning from Deaths and the ReSPECT advanced care planning tool. These are sensitive areas but with the support of the AHSN we are gaining wide-ranging and senior support and buy-in that will really help the development and adoption of these projects.

This story is a highlight from our 2017/18 annual review: joining the dots to healthcare innovation. Check out the full review here.

The Usual Suspects: ways to widen involvement in service improvement

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Hildegard Dumper, West of England AHSN PPI Manager, reflects on ways to widen involvement and participation in service improvement.

This story is a composite drawn from real events with names and identifiable features changed.

Pamela came out of the COPD Steering Group meeting the other day feeling really upset, and determined to leave the project. One of the clinicians on the steering group had asked about increasing the number of public contributors on the group. He said that there was a need to make sure patient reps were more diverse and we needed to avoid ‘the usual suspects’. By this he indicated he meant ‘white, middle-aged and retired’ which of course is what Pamela is. Debbie, the project manager noticed she looked upset and asked her what was troubling her. When Pamela told her, Debbie tried to reassure her that she was still a valued member of the group.

However, the experience got Pamela thinking. She approached Debbie and asked her if she was willing for Pamela to look into this. They agreed that Pamela would draw up a plan for how they could engage with a more diverse group of people suffering from COPD. She would share it with Debbie and take this on in a voluntary capacity, claiming for expenses. The plan included the need to have a discussion with the advisory group about what was meant by being representative – the demographics of the population of the area served, or users of the services. Or was it just different voices they needed round the table. In which case they could promote the role amongst users of the service and encourage interested people to apply. It was felt that all three factors were of importance.

Drawing on information from public health, it was identified that COPD was something that affected the population they served in different ways. Communities from a number of different ethnic and socio-economic backgrounds were heavy smokers and at risk of COPD. Pamela identified visiting three different communities in the region that reflected this range (Somali, Polish, deprived white). She contacted someone who Debbie knew in public health and got the names of the health ambassadors (in different regions they are known by different names) who had contact with these different communities.

She contacted them and it was suggested she attended one of the team meetings that were held monthly. She could then explain to the team what she was trying to do and get their advice. The public heath ambassadors were very encouraging, but pointed out that the communities she was targeting were mainly people who were struggling with their own challenges related to language, surviving in a different culture and the day to day challenges of living with poverty. It would be difficult to find people with the practical wherewithal and emotional space to contribute what was needed at a strategic level to the development of a project. However, they told her about a number of community events and encouraged her to attend so that she could meet people and identify people who may be interested.

Some months later, Pamela went back to Debbie with a three point proposal. She suggested that an extra patient rep be identified from users of the service interested in becoming a member of the steering group. Having two lay reps is seen as good practice as it takes the pressure off one person having to speak for all lay people, and offers a different viewpoints being heard. Pamela has also got to know the health ambassadors. One of them has shown a particular interest in the service and has good access to inner city communities. Pamela suggests inviting her to be part of the steering group so she can act as a conduit to some of the affected communities. Lastly, Pamela suggests they run a series of road shows where members of the steering group attend local community events to talk to those attending about the service and how it can be improved. This would require a big time commitment which may not see any immediate impact, but would be the start of forming a relationship with the communities they want to reach.

It was a learning experience for all involved.

  • For the clinicians in the steering group, they realised that different methods were needed to communicate with different groups of people.
  • Another key point was that it takes time to build up the relationships needed to identify the right people.
  • For the health ambassadors, they appreciated the direct link with clinicians and the relationships that developed as a result.
  • The experience also enhanced their knowledge and understanding of the pressures on the services helping them to manage the expectations of the communities they worked with.
  • The communities valued the fact that people were listening to them and wanting to understand their experiences
  • They themselves had a deeper understanding of how things worked and were able to have a more realistic expectation of health services and their role in managing their condition

 

My life as a Medical Director – Dr Peter Brindle

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Dr Peter Brindle, a practicing GP and previous Lead for Commissioning Evidence Informed Care at the West of England AHSN talks about his new role as Medical Director (Clinical Effectiveness) for Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (CCG).

I’ve been in my new role for about seven months and it is a very different role for me, with an extremely steep learning curve – but I think I am beginning to get to grips with it!

What is my role?

My motivation in taking this role was to make a significant difference in improving the health of our population through looking for variation in performance and clinical practice across our healthcare system, to understand what optimum might look like and then to promote changes to reduce the unwarranted variation.

We have finite resources in terms of staff and money so on behalf of our population we need to make every effort we can to maximise value. This is exciting because this approach can both improve care and save money at the same time.

What have I actually been doing?

So far I haven’t yet done as much of this as I would have liked as I have responsibilities in a number of other specific areas, for example in cancer services, urgent care, medicines management, research and development as well as diabetes outcomes.

I have had to acquire a lot of new knowledge in these areas to that I can ask the right questions and make informed decisions. There have also been a lot of new people to get to know, both within the CCG and also our providers, and as a clinician, mastering the processes, governance and language around commissioning healthcare has been a challenge.

We have also been going through a reorganisation, with a merger of three CCGs. It takes a lot of time to design a new organisational structure, prepare job descriptions and interview many people, but we should be through that shortly.

This merger and associated restructuring is a crucial part of creating a new and functional healthcare system, but it is tremendously difficult for everyone involved. Despite this uncertainty, the staff have been amazing in the way they have kept on with the day job of planning and commissioning care for our population.

Soon the reorganisation will be complete, and I will lead a small clinical effectiveness team who will be using benchmarking tools and examples of great practice to find unwarranted variation. They will then work with clinicians and managers, using improvement techniques to promote positive changes that bring better and more efficient care to people.

Too much ‘re-invention of the wheel’ goes on, but we don’t have the time or money to waste on doing that, so it is crucial we learn from other CCGs and international health systems who have pioneered approaches and services, evaluated them and shown what ‘works’.

What are my main observations so far?

  1. The importance of working with all our providers to build a system-approach to our challenges. In the past there has been a tendency for services to be led by a provider perspective which has led to many fragmented services with variable standards. We need to plan and deliver services starting from the patient and population perspective leading to a standardised approach balanced where needed, with a strong locality emphasis sensitive to specific population needs.
  2. The constant requests and need for more investment in a range of different things. Balancing these demands is thought-provoking and challenging – every pound spent on one area is a pound less on something else. Once again, a population view is needed to prevent slipping into overspending on areas that are driven by strong and articulate interests. A relentless focus on getting value from our interventions will release resources from which all can benefit.
  3. From a personal perspective, there is a big demand for me to attend many meetings which, although they are useful, does mean I have less time to build effective relationships and to drive change arising from small group conversations. Getting the balance right is a work in progress…
  4. Sometimes the idea of ‘dedicated health service staff’ typically brings to mind the image of a nurse, doctor or someone in a clinical role, but I never cease to be impressed by the incredible efforts of the staff in the CCG who are totally committed to improving patient care, especially while going through some uncertain times. They are dedicated to the needs of patients every bit as much as their patient-facing health service colleagues.
  5. There is never a dull moment – well practically never! It’s fantastic to be in the heart of some really significant decision-making in a challenged healthcare system. There is so much potential and I’m excited about being part of the change which is already taking steps to improve healthcare for our population.

How has my time at the West of England AHSN helped me in my new role?

  • I learnt a lot about quality improvement tools and techniques from West of England AHSN colleagues which I continue to apply in my current role. I want to do everything possible to promote a strong culture of continuous improvement across BNSSG.
  • I remain a champion for the use of evidence. I have seen how through the use of the best available evidence, significant savings can be made and patient care improved. Read some examples here.
  • I have always been an advocate of evaluating our decision making and I am now better able to ensure evaluation is built into the processes of normal business, so we create our own evidence of whether our services are doing what we expect them to. Find out more about evaluation here.
  • I made some great contacts with like-minded people who are passionate about improving healthcare by looking at the evidence, learning from the experience of others and applying robust improvement techniques. Some of those have joined the clinical leadership team within BNSSG and the rest continue to be very important to me in achieving my goal of better care for patients.

If you want to get in touch, you can contact me on peter.brindle@nhs.net or @petbri on Twitter.

Your evaluation questions answered!

Posted on by Vanesther Hamer

Abby Sabey, Senior Lecturer at the University of the West of England (UWE)

Abbey is also a Senior Teaching Fellow at CLAHRC West and delivers training with the West of England AHSN. Here she reflects on the recent delivery of the ‘Introduction to Service Evaluation’ course and answers some key questions…

I ran the ‘Introduction to Service Evaluation’ course with my expert evaluation colleague Kathy Pollard from UWE, in early December. On this one day course for health service providers and commissioners, we share experience of successful evaluations and facilitate group work that gives participants the opportunity to develop their own evaluation ideas. Like every other occasion I was bowled over by the commitment, thoughtfulness and hard work of everyone who came along to join us at CLAHRC West.

Earlier this year we refreshed the course and built in a small element about using the principles of logic modelling to develop an evaluation plan. Logic modelling helps you tell the story of your project in a diagram and a few simple words, helping you test the logic of what you plan to do and how this will make a difference. It worked its magic again this time and everyone took away a completed plan on which to base their evaluation.

The group who joined us included people working in public health, medical physics and commissioning; highlighting the wide range of people who are getting involved in evaluation. There was a great communal feeling in the room during the course. We give lots of opportunity for people to interact and discuss their projects as a way to test out and develop ideas and this time in particular, it was noticeable how much support there was within the group.

Towards the end participants showed how far they had come by presenting a three minute summary of their plan; great evidence of a productive day. We were delighted to get an almost perfect four out of four in the course evaluations; a great morale boost at the end of another year of training!

If any of this has given you an appetite for evaluation, feast on these top tips and resources:

1. What is evaluation and why is it important?

Evaluation is a way of learning what works, why and how…and why things don’t work. It leads to change and improvement; enhances quality; and shows accountability and organisational learning. Evaluation also contributes to the evidence base. This short video explains more

2. I need to do an evaluation, where do I start?

The Evaluation Works toolkit! It provides a step by step approach to completing an evaluation through five steps of the evaluation cycle.

evaluation cycle for service evaluation

Only got five minutes? Watch this short video on the first step of the cycle and check out the quick start guide

Got half an hour? Watch the full collection of videos that make up key components of the ‘Getting Started with Service Evaluation’ course here www.nhsevaluationtoolkit.net/resources/training

Got more time? Work through the toolkit step by step or come along to the next training workshop.

3. Where can I find out more?

  • CLAHRC West offer a variety of training courses. Keep an eye out for the next ‘Introduction to Service Evaluation’ on their website
  • Learn from the experience of others. There are several case studies on the West of England AHSN website demonstrating the positive impact of service evaluation
  • You could also sign up to the evaluation online network; a virtual peer to peer support group for all things evaluation related
  • And of course, the Evaluation Works toolkit is full of advice and resources

The answers are out there

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Natasha Swinscoe, Interim Managing Director, explores some of the issues raised by the recent Nuffield Trust  paper ‘Falling Short: why the NHS is still struggling to make the most of new innovations’.

Many of the NHS staff I’ve worked with seem to be cut from the same piece of cloth. If you show them a problem needing a solution, they’ll either find the solution or work out how to. These people are proactive problem solvers, so if the thing they need isn’t on the market, they may well make one ‘Heath Robinson’ style.

At a recent conference I listened to clinicians from one of our local trusts outline some of the systems and solutions they’d been putting into practice to fix their problems. These ranged from different training methods to a sponge being used in an innovative way to stem internal bleeding. I was struck by their creativity and innovation. The question in my head was how we harness this creativity, recognise and celebrate it, and then spread the solutions to others in different hospitals to use. Professional networks often provide an adoption route, but even these don’t offer comprehensive coverage.

Shortly afterwards I read the Nuffield Trust briefing paper ‘Falling Short: why the NHS is still struggling to make the most of new innovations’. I knew it resonated with my experience when I kept underlining sentences in red, with a number of exclamation marks! Here are a few…

  • Innovation in the NHS relies on pushing products first and hoping people take them up!
  • Identifying problems and looking for solutions isn’t built into everyone’s day job!
  • Innovation needs Senior Exec level oversight and support!
  • Too often short term savings drive the need for innovation rather than transforming pathways!

These are all important points. We know clinical and non-clinical staff will always find solutions. What we can’t rely on is the culture within the NHS supporting innovation. If the culture doesn’t foster or support innovation then new solutions or ways of working will falter, stay hidden from others, or at worst fail to solve the problem.  A ‘let’s try’ environment is crucial.

In my role as a manager of Acute Services, I lost count of the number of times I had clinicians turn up at my door or stop me in the corridor with an ‘idea’ they wanted to try – frequently for little or no cost.  We often pursued these ideas with a positive ‘Ok, let’s give it a go’.  Out of this came some fascinating service and pathway changes benefiting patients and staff, and saving time or money that we could then re-invest.  There were many  win-win results,  but they relied on a team culture that encouraged and shared  ideas, kicked them around, and then had a go, without being sure if they’d be successful or not.

From April we’ll be working with Office for Life Sciences to support this innovation pathway ‘end to end process’. We will be looking for ways to strengthen and support trusts and commissioners to adopt tried and tested ‘oven ready’ innovations. We will be looking for ways to capture ideas from front line NHS staff to match with business sector innovators.

The answers are out there. The people working in the NHS every day, the ones facing the situations that need solving, embody a wealth of creativity. We should be asking them what they need to make their working lives easier, what they need to make services slicker, safer and cheaper. They know what’s needed. If we support them and pair them with innovators and creators in the commercial and business sector they will create the changes we need. Let’s all start by looking for our innovators, listening to them, and supporting them to give it a go.