Sustainability and spread across multiple pathways in Community and Mental health services

Caroline Poole Clinical Improvement Lead, Service Development and Sustainability

Date

A bit about us…

• Community and mental health provider organisation• Commissioned to deliver into 6 of the 10 boroughs across

Greater Manchester• Covering a population of 1.3 million• Approximately 5,500 staff• Delivering 263 different services• Almost 2.5 million patient contacts last year

About our strategy

‘To embed self-care and self-management into every service we deliver’

Challenges we needed to address:• Understand the elements

• Get a baseline measure – where are we now? • How big is the gap and what do we need to change?• How do we make this an authentic change in culture, not a tick box

exercise?

How do we bring people to the table when generally they think they are doing it well anyway?

Our experience shows that:

• Flo is one of the SYSTEMS we’ve adopted to enable the culture change

• Flo supports CLINICIANS to think differently about patient capability and opportunities for service redesign

• Flo supports PATIENTS to feel confident and capable

Why text messaging and why Flo?• Uses familiar technology; • No significant requirement for up-front cost whilst

building local evidence base for ROI• Evidenced to supporting self-management and

improve outcomes • Flexibility of product to meet locally identified need• Tried and tested in NHS provider organisations –

credibility and safety

Our initial approach to service redesign

• Clinically-led by front-line teams• Opportunistic, working with the willing• Simple evaluation of impact

Gave us these outcomes:• Huge initial enthusiasm from teams who could easily see

pathways that could be enhanced• High drop-off rate• “popcorn” go-lives• Challenges with sustainability• No spread of adoption despite positive outcomes

Frustration….missed opportunities…..ongoing challenges with sub-optimal outcomes and demand/capacity challenges

Why was this happening?

The COM-B model (Michie et al 2011)

Capability• Who are the

innovators?

• Service improvement methods

• Technical capability

• Cultural barriers – shifting from parent to coach

Opportunity

• Whose priority is this?

• Time and head space to innovate and improve

• What is the “day job”?

• ‘finding the good people and filling them with work’

Motivation• Getting it on the ‘important’ list

through strategy, CQUIN etc

• Intrinsic reward from success

• Managing the barriers in adopting others’ work

• Using clinical networking

• Award nominations, publications, and research funding bids

Building behaviour change through local leadership resource

• Local programme managers have adopted Flo into their porfolio

Challenges

Changing staff mind-set:• “We only keep patients that are unable to self manage”• “How can I fit Flo in to an already busy consultation”• Embedding in to the team – some times only 1 or 2 clinicians

using it

But…..do these challenges relate to:• Use of Flo itself? • Delivering the supporting self-management agenda? • Instigating change and improvement?

Local learning• Need to have a champion in the team

• Local lead needs to maintain the momentum, regular contact with the team with details of activity by team member

• Patient feedback on the content and volume of the texts and adapt and change as required; co-production reaps rewards

Where are we now?

• Technology programme managers providing local support for development, implementation and delivery (in 3/6 divisions)

• Mechanism for working across geographical boundaries• Central directory of Flo improvement projects• Peer assist being actively developed and encouraged• Results are coming in!

Moreover…..lessons learned feeding into strategic review of our improvement infrastructure

Showcasing some of our pathways

Psychological therapies: reducing stress and improving mood Reduction in DNA (50%), improving clinical outcomes (22%)

OT/Physiotherapy: upper limb rehabilitation post-stroke80% increase in achieving goals through group intervention

Community Nursing: supporting self-management of woundsPositive staff/patient experience and outcomes; 50% reduction in appointments for eligible patients/wounds

Speech & Language Therapy: supporting dysfluency group impactPositive parent feedback; ongoing evaluation of outcomes

Learning DisabilitiesEarly identification of mental health deterioration for people on Care Programme Approach

Child and Adolescent Mental Health: eating disorders pathwayImproving outcomes for young people on intensive treatment programme

Podiatry: supporting self-care in high risk foot pathwayPatient story: empowerment to act at early signs of deterioration

The patient stories are so powerful…. This letter….- Previously had toes amputated- Chronic ulceration of feet- Now: no ulceration due to supported self-management

My key messages:• The technology isn’t the change; the pathway redesign is the

change

• Without a strategic approach, it is difficult to get anything other than popcorn delivery from self-selecting enthusiasts

• Local ownership and leadership is invaluable – clinical, managerial, project and technical

My key messages (2)

• Spread doesn’t happen without effort – using “peer assist” and professional networks for recent adoption

• The power of patient stories….collect and use them!

• Apply robust service improvement methodology to demonstrate impacts (patient experience, patient outcomes, staff experience and service utilisation)

caroline.poole@nhs.net