Clinical engagement (2): Community Resuscitation Development Officers

Valerie Billingham — Fri, 04 Sep 2009 11:17:00 GMT

Following on from my last post, I should like to highlight the contribution of BHF-supported paramedics and others who are involved in delivering emergency life support to the health and wellbeing of local populations, and the perspective they can bring to outcomes-based commissioning for children. Once again, this post represents a first shot at writing up a chunk of material for eventual inclusion in our commissioning e-book chapter. It represents a personal view, not a considered BHF view, although the intention is that the final version of the e-book paper will be signed off by the organisation.

This time, I am indebted to EdComs, particularly Louise Dartnall, whose evaluations supply much of the material in this post. Several evaluation reports on BHF work to develop emergency life support programmes within local communities are uploaded at the end of the post. The final version of the e-book paper will contain full references.

Community Resuscitation Development Officers (CRDOs)

The BHF established a new post within the emergency services, that of the Community Defibrillation Officers (CDOs), originally thirty-one paramedics based in Ambulance Services in England, as part of the Lottery-funded National Defibrillator Programme (NDP) which we undertook jointly with the Department of Health between 2003 and 2006. Since then, the role has grown and evolved, so that the post-holders have been renamed Community Resuscitation Development Officers (CRDOs - twenty-seven currently) or Responder Managers.

The aim of the NDP was to enable people to receive resuscitation more quickly than before, by placing public access defibrillators in areas of high footfall, and developing a network of trained lay people, known as Community First Responders (CFRs), who are able to bring a defibrillator quickly to the scene of an emergency, in areas of high cardiac risk where ambulance provision is challenging. The programme in general, and the CDOs/CRDOs in particular, have enabled the integration of more resources under ambulance control, which is fundamental to improving outcome after cardiac arrest. CDOs/CRDOs went beyond their original remit of placing equipment and securing training in the community, to undertake extensive, well considered mapping and gapping exercises of community capacity for resuscitation. They have developed a much more strategic approach to community resuscitation capacity in their areas, hence the evolution and renaming of the role.

Independent evaluation has shown that CRDOs are dynamic and enthusiastic developers of community capacity, recruiting more volunteers, boosting initiatives such as emergency life support (ELS) training, organising previously scattered local voluntary societies, groups and resources into effective local networks and integrating them with wider organisations including other emergency services, above and beyond the call of their NDP duty. This in turn has benefited the wider wellbeing of local people, including children, young people, families and teachers.

Ambulance Services acknowledge that, in the CRDOs, the NDP has created “experts” in community resuscitation who are now recognised as a major resource to their service. All the pump-primed posts have been incorporated into the permanent structures of ambulance services and many post-holders have been promoted in recognition of the value of their work. I would go further and maintain that CRDOs are major resources for the health and wellbeing of their communities, who should be engaged in the whole commissioning cycle.

Work with children and young people

CRDOs have a good overview of local voluntary organisations’ work to equip children and young people to respond in an emergency, and are active supporters of it. The following paragraphs summarise the main ways in which the BHF develops the skills of children and young people in emergency life support, give a flavour of the perspective which CRDOs can bring to commissioning for children, and highlight some of the other professionals and volunteers involved.

Heartstart UK

The BHF recognises the importance of equipping members of the public with Emergency Life Support (ELS) skills so that they know what to do in a life-threatening emergency. This is the purpose of the Heartstart programme for children and adults across the UK, which has been running since 1995. The course incorporates dealing with life threatening emergencies such as someone who is choking, suffering from serious bleeding or may be experiencing a heart attack, or ultimately performing cardiopulmonary resuscitation (CPR). Almost two million people (adults and children) have been trained through the Heartstart UK initiative, and there are currently 2,749 schools delivering the course. .

The programme is available to primary and secondary schools and can be delivered to students via a staged or a standalone approach, using the Heartstart training pack for schools. It is usually delivered as part of the Personal Social and Health Education or Citizenship curricula, or sometimes as an after school activity. Different levels can be taught at different ages. In primary schools, the programme is usually delivered to children aged 9-11; in secondary schools, to the upper year groups. However, a very simple version (eg, how to make a 999 call) can be taught to children as young as four or five. The training has also been adapted very successfully for children with learning difficulties.

The programme is delivered by teachers and other school staff, who are trained as Heartstart UK instructors. Teachers are trained by Heartstart UK Training Supervisors, volunteers with an appropriate clinical background, on occasion supported by external partners including voluntary aid societies, emergency services and PCTs. (Teachers consistently rate the quality of the training and support as “excellent” or “good”.) Training supervisors spend only part of their time in the role. When the programme began, there were only a few training schemes to cover in each area. Now that the programme has mushroomed, demand is exceeding supply. Training supervisors often cover large geographical areas with fifty to a hundred widely dispersed school schemes and may incur significant out-of-pocket expenses. Lack of volunteers is a persistent problem.

Schools Training Officers (STOs)

In response to the growth in the Heartstart UK programme for schools, the BHF appointed three Schools Training Officers (STOs), based in Cumbria, Wales and Scotland, as a pilot project. The role of the STO is to recruit and train teachers to deliver the programme. All have succeeded in increasing awareness and uptake of the programme and in increasing the supply of volunteer training supervisors.

Mini-Anne project

The effectiveness of traditional CPR training has been questioned in a number of research projects which indicate many people are not able to perform effective CPR immediately following instructor-led CPR training. The BHF Mini-Anne project, currently being evaluated by the Pre-Hospital Research Unit in Cardiff, involved providing a self-directed learning package (an inflatable miniature resuscitation manikin (Mini-Anne), a self-instruction DVD and questionnaires). The package was targeted at children in schools and their family members, and hard-to-reach groups in the community. The objectives of the study were to find out how effective the kits were at providing a CPR learning experience that was enjoyable and which delivered the required training. The study also evaluated the multiplier effect – in the case of children, how many more people in their families used each individual kit to learn CPR when the children took them home.

Since 2007 we have distributed 6,000 Mini-Anne Kits to schools. The multiplier ratio for the kits given to school children was 2.03 – higher than that of cardiac rehabilitation groups or other community groups in the study. The comments received about the kits were overwhelmingly positive.

Heartstart grants

We provide short-term start-up grants and other support to pump prime the establishment of schemes locally, to increase uptake and widen the resuscitation capacity of local communities. Since 2003 we have awarded around 50 grants of £10,000 for one or two years. An evaluation of our grants programme is in progress.

CRDOs map, co-ordinate and support all these initiatives and resources within their areas, working across the boundaries of health and education, and supporting extensive networks of paid employees and volunteers.

Results

Direct results

A direct result of the CRDOs and the BHF investment in ELS training has been to consolidate and maximise the capacity of communities to respond immediately to life-threatening emergencies, thus saving lives and, where life is lost, assuring families that everything possible was done to try to save their loved one.

Most teachers say they feel that the programme has taught pupils how to cope better in an emergency. Around 1 in 5 teachers report that their students have used ELS skills in a real life situation. Several community partners and teachers report that students receiving training at school are keen to share the knowledge with their parents. Some parents who attend other ELS courses do so because they are aware of the programme at their children’s school.

Indirect results

An indirect result for children and young people is the beneficial impact which involvement in ELS training has on their wider wellbeing.

Many teachers report that the STOs’ training, as well as making them more enthusiastic and knowledgeable about the programme, has also given them another means of engaging with their pupils, particularly the less academic ones. Even pupils who were normally disruptive participated fully in classes and emerged with a sense of pride in their achievement – an all too rare occurrence for some.

The pupils themselves realise that they are able to help someone in an emergency, and they say that this makes them feel “grown up”. Teachers report that pupils increase in self-esteem and confidence.

The training also offers pupils the opportunity of going on and being a teacher themselves, which does not happen often: Older students can be nominated as mentors and trained to help deliver Heartstart for younger ones. This helps to improve inter-year group relationships between children and young people.

Some CRDOs are also now beginning to explore the potential of ELS training programmes in reducing anti-social behaviour by young people, through Local Strategic Partnerships.

The benefits of community resuscitation initiatives involving children and young people therefore go well beyond the saving of others’ lives and have a significant positive impact on the wellbeing of the children themselves and on the cohesion of local communities.

Clinical engagement in commissioning

CRDOs are committed, inspiring people who think creatively, take the initiative and know their communities inside out. They should be major assets to the commissioning cycle. BHF has been working with CRDOs and Ambulance Services throughout the NDP to ensure the sustainability of their posts. All the CRDO posts have now been incorporated into Ambulance Services and there is a great deal of senior-level buy-in to their work.

Nevertheless, as with the nurses who were the subject of the previous post, CRDOs’ lack of engagement with commissioning is notable.

Reasons for disengagement

BHF

The reasons for this disengagement for commissioning are similar to those of the nurses: BHF has primarily looked to the acute sector to set up and pilot our new models of service delivery; we have not looked to commissioners as a primary audience for our evaluations, and so not always captured the evidence which appeals to them, concentrating instead on extending knowledge and improving patient access, with the professional development and impact on service delivery. Again, we need to get better at capturing the difference our CRDOs and others make to population health, particularly to the wider wellbeing of children and young people, and to community cohesion, in a way which commissioners find easy to assimilate. As Ambulance Services apply for Foundation Trust status, they are already placing more emphasis on community engagement, as the application process requires this. We are collaborating with partners to build a strong evidence base tied to a strategic approach so that we can demonstrate value in these areas.

CRDOs

CRDOs are experienced health care professionals, technicians and educators, with a strong and distinctive professional culture which is very much rooted in reacting to emergencies. It has not so far brought them into much contact with commissioning. Just like the nurses, CRDOs are familiar with the internal budgeting requirements of their employing organisation (although it is usually their line managers who undertake responsibility for budgeting), but are inexperienced in drawing their work to the attention of commissioners so that it is specified and commissioned explicitly, as part of the contract with the Ambulance Service. Just like the nurses, this leaves CRDOs trying to squeeze funding for their sterling work on community development from the margins of the allocation after it has been made, thus putting the stability of the community resuscitation service at risk. In London, fifty schools who took part in Heartstart UK training were left without a training supervisor to offer continued support when London Ambulance Trust were unable to reinvest in the role.

It is to CRDOs’ credit that, coming from a culture of emergency response, they have demonstrated such breadth of vision and such a strategic grasp of community resuscitation and its wider benefits for their communities. Possibly because of this cultural background, there is a particular perception on the part of CRDOs that, as far as ambulance services are concerned, commissioners are almost exclusively interested in ambulance response times, that some commissioners are only just beginning to look beyond response times to clinical outcomes, but that none of them is even considering the wider beneficial effects of their community resuscitation work as population health outcomes worth commissioning. This may also be because, as the population ages, demand for emergency response is increasing. Another factor may be the existence of a lead commissioner in each area where numerous PCTs contract with a single Ambulance Service, thus limiting the visibility of the other PCTs to the CRDO.

We are (we hope) about to open up some conversations with commissioners to test this assumption. We would be interested in your views.

Making it happen

As with nurses, commissioners and the CRDOs serving their areas need to seek each other out and be as proactive as CRDOs are with their communities in engaging them in the commissioning cycle and developing their ability to engage in it effectively. Again, BHF can help commissioners across health, education and social care find out how to reach them.

CRDOs participate in the same BHF professional support and development programme as BHF nurses and all our supported health professionals. There are therefore the same opportunities for commissioners to begin a dialogue with them as a group.

Similarly, the evaluation reports of our community resuscitation pilot projects are available to commissioners; those published to date are uploaded at the end of this post. We encourage you to read them and consider how you might wish to tap in to our networks to inform the commissioning process. We welcome feedback from commissioners, as we continue to try to develop our ability to engage with them.

Val Billingham at the BHF : anti-social behaviour

Clinical engagement (2): Community Resuscitation Development Officers