Linking improved governance to innovation
Air Ambulance Kent Surrey Sussex (AAKSS) is a helicopter emergency medical service which operates out of Redhill, Surrey and Rochester, Kent. We serve a population of 4.7m people plus those who travel through the area. Our crews of pilots/co-pilots operate three helicopters and fly 2,500 missions a year with on-board medical assistance provided by doctors and paramedics. Of the more than £11m needed to sustain the service each year, 92% is raised by public donation and fundraising with the remaining 8% provided by the NHS.
As an independent charity delivering pre-hospital emergency medicine, AAKSS is accountable to five principal regulators including the Charity Commission, Care Quality Commission and, perhaps less predictably, the Gambling Commission. A successful lottery accounts for over 50% of our income and a CQC inspection conducted last year provides a glowing account of outstanding patient care.
A governance review could appear – and perhaps has appeared - as an attempt to fix what isn’t broken given that we are considered a leader in our field and have benefited from a relatively secure financial position. However, for the current board of trustees, the imperative to diversify our income streams and standardise safeguarding across the charity has become increasingly urgent, not only from the perspective of risk but also of values.
Caring is one of our core values and a considered approach to what this means in the context of pre-hospital emergency medicine raises some important ethical and organisational implications.
Potential income
Our staff care deeply about patient outcomes. However, the clinical involvement of doctors and paramedics with the patient is an intense and relatively brief one and often they will never know what happened following handover at the receiving hospital. It is clear that a significant number of patients want to express gratitude to the people and organisation that, in their view, saved their lives. This gratitude represents considerable potential income.
Strong evidence from the United States suggests that, when appropriately stewarded, this expression is beneficial to both the patient and to those who provide care. Sadly, not all patients survive and bereaved relatives care that all that could have been done was done, and some feel the need to meet those present in their deceased relative’s final moments.
One of the challenges of pre-hospital emergency medicine delivered by a charity such as AAKSS is that normally there is no formal mechanism for maintaining a dialogue with patients and relatives. A relatively small proportion find their way back to us and the “base visits” which feature prominently on our website tell moving stories of patient and crew reunions. In light of the evidence of the emotional benefits of maintaining this connection, our digital strategy including our website design, will optimise opportunities for former patients and relatives to get in touch.
A newly created patient liaison role is intended to provide specialist expertise to manage these important relationships. It takes into consideration both the nature of care in this context and the nature of risk, and reinforces the need for specialist skills and for a holistic approach. This extends to the safeguarding and care for our own staff in relating to people who have experienced major trauma, including life changing injuries, and bereavement.
Emotional reunions
Reunions with former patients or relatives can be emotional for the crews and, given that they take place at an airfield where the helicopters are based rather than in a hospital, appropriate boundaries and safeguards need to be in place. As one highly experienced paramedic pointed out, the reunion can close a loop for them too and reunite them with people they feared would not survive.
The patients themselves may be unconscious but the crew members are acutely aware of what have often been harrowing events. They need to make judgments about how much they should share and how involved they want to be in a visit, if at all.
In a culture of continuous improvement in which our teams take enormous pride in delivering outstanding patient care, the creation of the patient liaison role represents an incremental step in further developing the nature of care provided. In this we have taken notice of the approach of our peers, notably the London Air Ambulance, in not limiting the caring relationship to the pre hospital period but to think much more holistically about what it means.
This could include signposting former patients to other services or establishing peer relationships with others who have experienced major trauma.
Of primary concern in all of this is our commitment to ensuring the physical and emotional safety of people who have been through a major trauma and may have suffered life changing injuries or bereavement. Given that our crews are treating the most sick and seriously injured people, patients themselves often have no recollection of events but may feel a need to know what happened.
Meaningful way
Significantly, the patient liaison role needs to respect their desire to give back to the charity in a meaningful way and to ensure a sense of belonging, assuming that it is part of our duty of care to do so. Many people are unaware that air ambulance services are delivered by charities and a very common response is a strongly felt desire to raise money, both by donating directly but also by using networks to achieve greater effect.
Over the years many of our volunteers have come forward because they have been touched personally by the charity and are given roles within our offices, helping with the administration of our fundraising or going out into the community to give talks.
However, the increased scrutiny of fundraising practices within the charity sector with safeguarding as its dominant theme has necessitated a hard look at freedoms that, in the past, have been taken for granted.
Our safeguarding review of fundraising has resulted in much tighter recruitment processes for volunteers including consideration of DBS checks and placing restrictions on public facing roles which may include entering schools. It has also prompted consideration of how we create meaningful engagement for former patients and relatives who may not necessarily fit existing volunteer role profiles.
Two important additions to our board of trustees are providing further enlightenment for our considerations of the relationship of care. In an open recruitment process, one of them began his application with the words “this charity saved my life”. Once recovered he insisted on paying for the cost of the mission that saved him and took the opportunity to join the board as soon as it became available.
Patient advocacy
The other new trustee is a very senior clinician who has been a leader in the Surviving Sepsis campaign and has first hand knowledge of the power of patient advocacy following trauma, as well as a strong commitment to ensuring emotional safety in acute medical situations.
These improvements to our governance and consequent organisational changes have required balance and real thought about what it means to be caring. Recognition of the need of former patients and relatives to express gratitude takes into account the concern of staff not to appear to be “ambulance chasing” or to take advantage of people at a time of vulnerability.
Care for their emotional safety needs to be balanced against the welfare and emotions of our staff, including of course the clinical and operational crews. Current anxieties about safeguarding in the charity sector need to be balanced against the good will and trust that former patients and relatives feel for our charity and that we wish to honour in return. It is not always an easy balance to achieve but our governance review has produced new opportunities for meaningful engagement and for philanthropy.
