Gloucestershire working as One

Navigating the COVID-19 pandemic has been a huge challenge for all our partners. It’s been essential to adapt quickly to a fast-moving situation and everyone has pulled together to support our communities during this unprecedented time. Here we reflect on how we’ve responded – from adapting the way we supported patients to supporting the biggest vaccination programme in NHS history – to keep thousands of people safe and well.

The vaccination programme

Protecting the community

It was evident early in the pandemic that vaccination would play a big part in the response and plans were already underway on how to implement a mass vaccination programme even before vaccine authorisation was granted in December 2020.
Gloucestershire was leading the way during the rollout, delivering well over one million doses in the twelve months to December 2021. As 2022 gets underway, 90% of the county’s residents over the age of 16 have had at least one dose of the vaccine and more than 87% of eligible people over 18 have been boosted.
GP Dr Cameron Jackson, St Pauls PCN Clinical Director, was one of those involved in the collaborative response to organise community vaccinations across the county. Thanks to a good relationship already in place the three PCNs in Cheltenham worked together across 16 practices to deliver vaccines at scale.

He said: “We were ahead of the game and PCNs in communities across the county started engaging people early on as it was apparent we would need a lot of volunteers to pull this off. It was a massive team effort supported well by the CCG, community NHS services, volunteers, local councils, fire service, doctors and nurses with everyone coming together for one cause.”

The good will of volunteers as well as NHS staff who were often helping with the vaccine programme in addition to their day job was essential for success. In our patch, the roll-out involved:

  • Recruiting volunteers through local businesses to help run the dedicated booking service set up by practice staff.
  • Setting up the Cheltenham East Fire Station as a vaccination centre with many firefighters also supporting the effort as marshals.
  • Practice staff giving up their days off to vaccinate house-bound patients.
  • Establishing a drop-in site at a practice in a deprived area to reach those who perhaps would otherwise not have been vaccinated such as drug users, the homeless and asylum seekers.

In addition, Gloucestershire was part of a care home pilot by NHS England and NHS Improvement to establish how to safely transport the Pfizer vaccine, which must be kept below a certain temperature, to be delivered to staff and residents.

Dr Jackson said: “The care home residents really bore the brunt of the pandemic and seeing patients you’ve looked after for years dying of COVID gave us a strong incentive.”
The team came up with a novel way of transporting it to the Faithfull House care home using cool bags, temperature gauges and ice packs. The trial was a success and soon rolled out across the UK.
“It’s mindboggling looking back now at the pace it progressed. The vaccine was a ray of hope and it was easy to get people to give up their time to volunteer to administer it. The commitment and enthusiasm of everyone involved will always stay with me. There are learnings we can take from this too – it’s clear there are certain things that can be done at scale easier than at practice level and volunteers are an invaluable asset.”.

Ensuring staff get the jab

Professor Steve Hams, Chief Nurse at Gloucestershire Hospitals NHS Foundation Trust was the Senior Responsible Officer for the Gloucestershire COVID-19 Vaccination programme.
Bringing the vaccine to staff throughout One Gloucestershire was a mammoth undertaking particularly in light of rapidly changing national guidance, but as Steve says:

“The team and I knew that protecting staff would be key to protecting our patients and we are immensely proud that we have contributed to protecting each other and saving lives.”

Given the pace of the rollout and the importance of making sure frontline staff were protected as early as possible it was imperative to bring together different individuals and organisations early so everyone was working together.
When it came to encouraging uptake communication was key. Steve says:

“We provided as much information as possible to members of staff through as many routes as possible and as often as we could. Providing information sensitively and clearly helped staff make choices about receiving the vaccination.”
“Our vaccination programme has been characterised by working in partnership, this has been a truly joint effort and we are immensely proud of everyone that has been involved.”.

The virtual ward

With pressure rising on hospitals and the need to socially distance to limit the spread of the virus, a virtual ward provided the perfect solution to keep patients safe and ensure the sickest got the treatment they needed. In Gloucestershire, the COVID virtual ward was up and running in June 2020 and by the end of November that year it was live countywide.
Dr Charles Sharp, Respiratory Consultant at Gloucestershire Hospitals NHS Foundation Trust, and colleagues put forward the idea after learning of the model elsewhere and primary and secondary care partners worked together to implement it.
COVID patients who fit criteria to potentially become seriously unwell are equipped with oximeters to record their daily levels which are then checked by clinicians who make sure recovery is on track or decide if intervention is needed.
Senior Programme Manager, Megan Isaac who leads on Respiratory and COVID pathway development across Gloucestershire is on the project team. She said it was very much a collaborative approach to get the virtual ward up and running and feedback from patients has been excellent.

She says: “We spent a lot of time on Teams talking to each other and there’s no way we would have had as much facetime pre-COVID. It was ground-breaking the way we worked together – everyone rolled up their sleeves. After we started, this it came out as a national directive. COVID has certainly galvanised the need to innovate. It’s been a big way of reducing anxiety for patients who at that time were scared to have a COVID diagnosis and unsure what would happen to them. The knowledge they were being checked on by medical professionals was really reassuring.”

The virtual ward made sure hospital resources were kept for those who needed that higher level of care and avoided the need for unnecessary hospital visits.
The pathway is adapted depending on latest guidance or learning and following the success of this model of care it has the potential to be used for other health conditions.

Post COVID syndrome support

Our understanding of COVID-19 and the impact it can have on the body long after the initial symptoms have faded is developing all the time. It is thought that around one in 50 people who have had COVID may develop long COVID and there appears to be no direct correlation with how severe the initial infection is.
To support patients who are affected by long COVID, a community-based service has been set up provided by Gloucestershire Health and Care NHS Foundation Trust and supported by the wider One Gloucestershire health and care family.
The Post-COVID Syndrome Assessment Service provides support for both the physical and psychological symptoms associated with long COVID with a multidisciplinary team of healthcare professionals on hand to help patients’ recovery. The team includes a psychologist, respiratory consultant and occupational therapist and has expanded to accommodate the growing number of patients who need help.
The service is available to those who experience symptoms for more than 12 weeks and they don’t have to have been admitted to hospital to have a referral. After a discussion with their GP, the patient will have an initial appointment with one of the team who will signpost them to the most appropriate support for their needs.
There are understandably many worries for those affected by long COVID and being able to provide this ongoing support has been well received by people who appreciate the reassurance that having continuity of care brings.

Caring for the severely unwell

Dr Charles Sharp, Respiratory Consultant at Gloucestershire Hospitals NHS Foundation Trust and many of his colleagues at the Trust were integral to the response towards COVID-19 given coronavirus is primarily a respiratory illness. His team coordinated treatment guidelines and worked very closely with ITU to ensure they  were specifically responsible for  the patients most likely to benefit from their care.
During the first wave both Cheltenham General Hospital and Gloucestershire Royal Hospital operated High Dependency Units (HDU) where patients could be treated with continuous positive airway pressure (CPAP) and high-flow nasal oxygen therapy and would hopefully avoid the need for mechanical ventilation in ITU.
The respiratory critical care team which includes Consultant in Thoracic Medicine, Dr Henry Steer and Consultant in Intensive Care and Anaesthesia, Dr David Windsor, could see what was happening elsewhere in Italy and London so read widely and spoke to people who were living it to plan the approach. Additionally, Gloucestershire got involved in the international RECOVERY trial at a very early stage.

Dr Sharp said: “It was a real team effort to decide how we would manage resources and tackle questions around treatment plans. Communication was key and we spoke with ITU colleagues daily on who to look after where, and how to make decisions on who would benefit from certain treatments. As we are well used to giving CPAP in respiratory, so we didn’t need to send these patients to intensive care freeing up those beds for the very sickest patients.”

The mental toll on those treating COVID-19 patients can not be underestimated so to help spread the pressure, decisions were always discussed between colleagues.

“It was really hard emotionally and cognitive fatigue is a hazard so teamwork is invaluable in helping people to never feel isolated.” Says Dr Sharp. “We shared responsibility and learned a huge amount in that first wave so we got very good, very quickly. Nurses did the bulk of the hard graft working hard to look after patients.”

Nurses were redeployed to respiratory care from other areas and a special squad was set up, distinguished by yellow lanyards, who would go to where they were needed.
Throughout the pandemic, ITU and HDU functioned as one team and linked closely into what was happening in the community too as Dr Sharp explains:

“We got patients into hospital earlier than we would have done through the virtual ward and got them out earlier because of the supported discharge which ensured that if they did get sicker we could get them back in again quickly. We kept ourselves abreast of all of the evidence so if anything new came up we were rapidly adapting.”

For those patients that do need a stay in ITU, they have follow-up appointments involving a multidisciplinary team from social prescribers to pharmacists, and nurses have been at these clinics to see the improvement and recovery of patients they treated when they were at their sickest and the outcome was uncertain.

Looking ahead

The learnings from our response to the pandemic will be helpful for One Gloucestershire going forward as it’s been made abundantly clear we are stronger together. We can look at what’s worked during our COVID response, particularly integrating community and acute care, and apply these learnings elsewhere for the benefit of our communities.