Transforming healthcare through marginal changes

At the moment there is lots of talk about transformation, systems thinking and strategy across health and social care.

Recently I was helping a friend who was preparing for a job interview. My friend was anxious because the role was to provide strategic direction to a big transformation programme in social care. Although they had already done a very similar role they doubted their ability to think strategically. The conversation went something like this:

Friend – I’m not sure that I can show that I am strategic

Me – Why do you say that?

Friend- Well, I am good at bringing people together, identifying problems and finding practical solutions but not at having big ideas

Me – So do you have a clear sense of where you want to organisation to get to?

Friend – Yes

Me – Do you have a sense of how to get there?

Friend – Yes, but it is about getting our people to make lots of smaller changes which move us in that direction, not one big change

Me – Do you have a sense of how you can get them to do that?

Friend – Yes, it is change management and using their knowledge and enthusiasm to improve things for their service users

Me – That sounds like a strategy to me.

This is not a unique conversation. I have met many bright and articulate people who feel daunted by either the strategy word or transformation. Sometimes this is because they have seen their organisations parachute in experts who say their strategy of one big change will revolutionise things. Certainly for some services or organisations a big strategic shift, for example from face to face to online services, can be transformative. However, in most organisations there isn’t going to be a single big game changer, or the big project will only deliver part of the strategic shift needed.

At its simplest strategic change is “just” setting clear ambitions, and inviting appropriate actions to move the organisation in that direction. I am great advocate for the Dave Brailsford strategy of making multiple small improvements across a business as or system.

Brailsford https://en.wikipedia.org/wiki/Dave_Brailsford is the man credited with transforming the performance of British cycling. Under his direction the GB and now Team SKY have become dominant in the world of cycling. His approach is to look for many marginal improvements which add up to a big improvement overall. A 1% improvement on 100 things can be the equivalent to 100% improvement in one.

It is not surprising that some of our top leaders in the world of health (Simon Stevens and Jim Mackey for example) are talking about system transformation coming through local actions. Enabling change at team, ward or service level is going to be the key to change in the NHS and social care. Who better than frontline staff and their patients to say what can be done better, faster or more cheaply?

However, just as having a big idea does not guarantee change nor does exalting people to make local changes. Marginal gains will only make system level change if they are supported with wider change, which is where they become strategic in my view. So what is needed to achieve change through marginal improvement?

* Cultural change – For marginal improvement to flourish there needs to be a shift in culture. Too often health and care are characterised by professional hierarchies and approvals mechanisms. We need to empower the frontline to self-manage change in their own area.

* Better communication – We need to share new ideas more quickly between and across organisations. It is no good a great but simple idea being used in one team in one trust in one town. Sharing simple ideas needs to be as common as sharing the results of large scale clinical research. The Vanguards are trying to encourage this as are initiatives such as http://www.fabnhsstuff.net/ and social media communities such as @Physiotalk.

* Time – In all organisations there can be a tendency to see time spent thinking about change as “not proper work”. This is particularly true in healthcare where patient contact is seen by most clinicians as their main role. Unfortunately this is reinforced by some of the initiatives intended to transform the NHS. Productivity schemes which classify non-patient contact time as non-productive won’t help harness the knowledge of frontline staff to make change. So we need to build time to develop improvements and evaluate new activities into the concept of productive time.

Talking to my friend many of these are issues sound common to social care too. They have a pretty clear vision for how she can engage colleagues to make their own service changes. So I had no qualms in reassuring her she is a strategic thinker. Oh, and they got the job.

What do you think we need to do to harness the power of marginal improvements in health and social care?

Advertisements

#BackingRehab – London

What is the CSP interest in the GLA?

The CSP is the professional body and union for physiotherapists and support staff. We have over 7000 members in London.

What is rehab?

Rehabilitation is an essential part of healthcare, following surgery, illness or injury, and aims to optimise function and wellbeing. Rehabilitation works by helping people get back to daily activities, return to work and enjoy their leisure. Community rehabilitation when provided leads to:

✔   shorter length of stay in hospital (good for the patient and taxpayer)

✔   improved mobility

✔   increased activity levels

✔   significantly improved quality of life.

Physio rehab helps treat a wide range of conditions:

Musculoskeletal disorders (MSDs) -Rapid access to musculoskeletal physiotherapists can reduce the amount of time people are off sick and is vital in preventing a new acute problem becoming chronic and long lasting.

Cardiovascular disease (CVD) – CVD includes conditions such as angina, heart attack and stroke. Up to 90 per cent of the risk of a first heart attack is due to nine lifestyle factors that can be changed. Physiotherapy-led cardiac rehab programmes are clinically effective in reducing mortality, improving health and quality of life, reducing length of hospital stays and reducing the number of hospital readmissions.

Chronic obstructive pulmonary disease (COPD) – COPD is an umbrella term for a group of lung diseases that include chronic bronchitis, emphysema and small airways disease. Pulmonary rehab programmes are clinically effective and cost effective in improving health and quality of life, reducing length of hospital stay and reducing the number of hospital readmissions for people with COPD.

Stroke – Approximately one-third of stroke survivors are left with disability and rehabilitation needs. Emerging evidence shows that physio rehab very early after stroke (ie, mobilisation within 24 hours) and at high intensity leads to better outcomes and is cost effective. A minimum of 45 minutes of physiotherapy for five days a week is recommended.

Falls – One in three people aged over 65 will fall every year equating to more than three million falls per year. Half of people who fall will fall again in the next 12 months. In the UK physio-led group exercise programmes have been shown to be effective and to reduce falls by 29 per cent and the risk of falling by 15 per cent – and individual exercise programmes by 32 per cent and 22 per cent respectively.

As more people survive serious accidents there is a growing need for rehabilitation physiotherapy. London’s NHS may already be struggling to cope with increased rehabilitation demands as a result of the success of major trauma centres. Robert Bentley, director of trauma at King’s College Hospital has expressed concern that there are insufficient community rehabilitation facilities in London.

Be part of the campaign

The CSP is encouraging candidates to get behind local rehabilitation services. There are a number of ways that the Mayor and Assembly can act to support quality rehab. In supporting the #backingrehab campaign, candidates are committing to take action if elected such as:

  • Visiting a local service and meeting staff and patients
  • Meeting with patient groups
  • Asking London’s health commissioners to ensure adequate rehab services.

All candidates who sign up to support #backingrehab will receive further information on the value of rehabilitation.

Candidates on twitter will receive a retweet for tweeting ‘I’m #backingrehab’ in support.

 

#BackingRehab – Guernsey

Thanks to the candidates in the States election who replied via Twitter to the invitation to support the #backingrehab initiative. This post is intended to answer some of the queries raised.

What is the CSP interest in Guernsey?

The CSP is the professional body for physiotherapists in Guernsey. We have well over 100 members in the Bailiwick.

What is the situation in Guernsey?

HSSD’s Future 2020 Vision states that plans are to be developed in the following areas where physiothepy can help rehabilitate people:

  • Stroke
  • Disability
  • Respiratory disorders.

However, the Vision does not cover other areas where rehabilitation would be beneficial and has only one reference to rehabilitation, and that is in the context of providing  health services to non-residents. It also highlights that in 2017 funding agreements with physiotherapy providers are to be renegotiated.

It is therefore an appropriate time for those wishing to seek election to ask questions about rehab in Guernsey.

What is rehab?

Rehabilitation is an essential part of healthcare, following surgery, illness or injury, and aims to optimise function and wellbeing. Rehabilitation works by helping people get back to daily activities, return to work and enjoy their leisure. Community rehabilitation when provided leads to:

✔   shorter length of stay in hospital (good for the patient and taxpayer)

✔   improved mobility

✔   increased activity levels

✔   significantly improved quality of life.

Physio rehab helps treat a wide range of conditions:

Musculoskeletal disorders (MSDs) -Rapid access to musculoskeletal physiotherapists can reduce the amount of time people are off sick and is vital in preventing a new acute problem becoming chronic and long lasting.

Cardiovascular disease (CVD) – CVD includes conditions such as angina, heart attack and stroke. Up to 90 per cent of the risk of a first heart attack is due to nine lifestyle factors that can be changed. Physiotherapy-led cardiac rehab programmes are clinically effective in reducing mortality, improving health and quality of life, reducing length of hospital stays and reducing the number of hospital readmissions.

Chronic obstructive pulmonary disease (COPD) – COPD is an umbrella term for a group of lung diseases that include chronic bronchitis, emphysema and small airways disease. Pulmonary rehab programmes are clinically effective and cost effective in improving health and quality of life, reducing length of hospital stay and reducing the number of hospital readmissions for people with COPD.

Stroke – Approximately one-third of stroke survivors are left with disability and rehabilitation needs. Emerging evidence shows that physio rehab very early after stroke (ie, mobilisation within 24 hours) and at high intensity leads to better outcomes and is cost effective. A minimum of 45 minutes of physiotherapy for five days a week is recommended.

Falls – One in three people aged over 65 will fall every year equating to more than three million falls per year. Half of people who fall will fall again in the next 12 months. In the UK physio-led group exercise programmes have been shown to be effective and to reduce falls by 29 per cent and the risk of falling by 15 per cent – and individual exercise programmes by 32 per cent and 22 per cent respectively.

Note: figures are based on UK studies but are likely to be similar in Guernsey.

Be part of the campaign

The CSP is encouraging candidates to get behind local rehabilitation services. There are a number of ways that Deputies can act to support quality rehab. In supporting the #backingrehab campaign, candidates are committing to take action if elected such as:

  • Visiting a local service and meeting staff and patients
  • Meeting with patient groups
  • Asking the HSSD to clarify intentions with regard to rehab services
  • Speaking up for quality rehabilitation in the States.

All candidates who sign up to support #backingrehab will receive further information on the value of rehabilitation.

Candidates on twitter will receive a retweet for tweeting ‘I’m #backingrehab’ in support.

Isn’t this an English initiative?

#BackignRehab is an initiative running in Guernsey, England, Scotland, Wales and Northern Ireland in advance of elections this year.

We are not running the initiative in Jersey or the Isle of Man (which are also covered by the CSP) because there are no elections in Jersey and those on the Isle of Man are for bodies without a health remit.

Why isn’t there a CSP press campaign on rehab in Guernsey?

Our focus is engaging with candidates, as those of you elected will be key decision makers after the election. We have a range of public facing promotions and campaigns which we will be engaging the media in Guernsey on later this year.

If you’d like further information please contact yeldhamr@csp.org.uk

Should CPD providers be vetted by the CSP?

 

Some Chartered Society of Physiotherapy (CSP) members have asked about our approach to accreditation of continuous professional development (CPD) and to advertising short courses.

Some people believe that the CSP should formally review and accredit short courses and other CPD for physiotherapists. Others believe that accepting advertising in CSP publications amounts to an endorsement, so advertisers should be subject to more scrutiny before ads are accepted.

Validation of an individual course or provider would not mean that the CPD offered is right for every individual. The model of CPD we endorse is a reflective one. This places the onus on the individual to consider their developmental needs and learn from a variety of situations and experiences. It is therefore the responsibility of each physiotherapist to ensure that any training or other CPD they undertake is appropriate to their specific needs.

The CSP has looked at developing short course recognition in the past. This was rejected as other activities were judged higher priorities. Charging was considered to bring in additional resources for an accreditation scheme. However, we would expect charges to providers to be passed on to members undertaking courses. We don’t think it is in the best interests of the profession to increase the costs associated with CPD.

Were the HCPC to move to a system of revalidation this could create a need for the quality of CPD provision to be formally assured. There is no suggestion such a change will be made. Even if it did it would be more likely that the focus would shift to appropriate arrangements for assuring individuals’ on-going fitness to practise (which is fundamentally different from assuring the quality of learning experiences accessed).

Although the CSP does not have a validation programme for CPD courses, we do have a process for considering requests for the formal endorsement of any service or product. To date no CPD provider has sought endorsement. If they did the process would involve an independent professional assessment, which the potential endorsee would have to fund.

We believe that most members understand that the advertising of courses, or other CPD opportunities, within CSP publications does not represent an endorsement. This is made clear in the advice we routinely run in Frontline magazine:

Course – Guidance for members

 Members have a responsibility to limit their practice to those areas in which they have established and maintained their competence. Completing a course may not be sufficient to establish personal competence in a new area, while members are responsible for undertaking CPD to maintain their competence in all areas of their current practice.

 Members should explore individual courses’ suitability and value (including their quality, intended outcomes and whether they include formal assessment of learning) for meeting and demonstrating fulfilment of their personal learning needs. Members should also think about the broader ways in which they can address their learning needs. These include day-to-day practice, self-directed and mentored learning, and professional networking and peer review.

 It is important that members evidence their learning: maintaining a record of CPD is a regulatory requirement of the Health and Care Professions Council (HCPC), while recording the education and training undertaken to support progression into a new area of personal practice is a condition of CSP professional liability insurance (PLI) cover.

 A course being advertised in Frontline does not necessarily mean that it is relevant to all members, has gone through a quality assurance process (courses advertised in the magazine are not formally recognised by the CSP unless explicitly stated), or that its topic area falls within the scope of UK physiotherapy. In addition to issues of competence, including an area within personal and collective scope of practice depends on the context in which it is practised, how it is integrated into physiotherapy activity, how it is promoted as a service delivered by a physiotherapist and how its physiotherapeutic value is demonstrated.

 

Some areas ordinarily sit outside the scope of UK physiotherapy. However, they may be undertaken by CSP members as part of extended activity. Members should ensure that this is with the agreement of their employer and/or explicitly as a service delivered outside their activity as a physiotherapist; is supported by appropriate education and training; and is covered by insurance from a source other than the CSP. Courses advertised in Frontline may be relevant to members extending their activity in this way.

 Further guidance and support:

 CSP ePortfolio: http://www.csp.org.uk/ePortfolio

CSP Code of Professional Values and Behaviour: http://www.csp.org.uk/code

HCPC CPD requirements: http://www.hpc-uk.org/aboutregistration/standards/cpd.

 

 

Nudge – clever or basic common sense?

Dan Berry from the English Department of Health presented on behavioural insight to the CIPR Health Group last night. The underlying basis of behavioural insight, or nudge as it is also known, is that people are not rational. If you want to change behaviours you therefore need to understand how people respond to a stimulus, not assume they will behave rationally.

We are all hard wired with cognitive biases e.g. to feel a loss more deeply than a gain. If we are seeking to change behaviours, whether we call it public health, policy making or communications, we will be more successful if we work with the biases people, rather than try to convince them with logic.

Some key nudge insights include:

  • Framing the message is key – which all communicators know already.
  • Keep it simple – keeping comms short and simple, even directive, can be effective in changing behaviours, no surprise to a professional copywriter or marketeer.
  • Normative messaging works – people can be influenced by the sense that others like them are doing something.
  • Fear of loss is usually a better motivator than the promise of a gain.
  • Reciprocity can be a powerful motivator – music to my ears as a social anthropology graduate.
  • Timely feedback can nudge people – promoting thoughts with information at a key point in a process can influence behaviours positively, for example cost information at the point of prescribing.
  • Get people to make an easy commitment – getting people to say they will do something easy is the first step to behaviour change.
  • Use trusted messengers –something any good PR advisor will tell you.

The exact mix of factors can be more complex which is why testing different approaches is so important. For example, nudging is not good at cutting demand for A&E services. If you think you have an urgent health problem your overriding bias is to seek help. What nudge can help with is to influence where you might seek that help.

Most of the examples shared by Dan are essentially communications interventions; changing the messaging in patient information, direct mail campaigns, redesigning forms or providing information at the point of decision making.

The Department of Health are using randomised control trials (RCTs) to test different patient or clinical nudges. RCTs are the gold standard for medical research. They involve testing a specific intervention with one group against a similar control sample who do not receive the intervention.

Using this approach to testing and evaluation is not a new idea in comms, however it is rarely used in my experience because of lack of resources / expertise and the reluctance of senior decision makers to allow something which might work not to be used with the control group. So it is great that DH are doing this work.

Dan ended his presentation with the disarming admission that many people find this “just commons sense”, although some find it hard. I am firmly in the commons sense camp, but with the caveat that commons sense is surprisingly uncommon.

So how could we apply this at the CSP?

Member retention – We could test different messaging in our renewals and lapsing processes to see what messages help retain members? e.g. would highlighting the loss of PLI have a great impact than emphasising that 9 out of 10 physios are members?

Primary care – We could help providers/trusts and commissioners/boards develop nudges to help get patients to use physiotherapy services to relieve pressure on GPs.

Professional practice – We could prompt an invitation to register for PUK after a member accesses CPD resources online.

Member engagement – We could test different “asks” to see which encourages members to take the first steps into activism.

What do you think we could use nudge insights to refine?

Of course you may feel we are doing these things anyway, but are we routinely managing them in a way which allows us to gather evidence and work out what works and what does not?

Further reading:

EAST (simplified behavioural insight guide) – http://38r8om2xjhhl25mw24492dir.wpengine.netdna-cdn.com/wp-content/uploads/2015/07/BIT-Publication-EAST_FA_WEB.pdf

Behavioural insights in healthcare –

http://www.health.org.uk/sites/default/files/BehaviouralInsightsInHealthCare.pdf

Social norms in public administration –

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2514536

 

Local engagement

Physiotherapy and the CSP are facing a number of challenges which mean that how we engage members, decision makers and the public needs to change to reflect the local and regional dimension more. The key drivers are:

  • The changing nature of health economies with local decisions made by CCGs /health boards and local councils increasing shaping the pattern of provision
  • Further devolution of powers to Scotland, Wales, Northern Ireland and to English regions and cities.
  • The need to change a perception amongst a sizable minority of CSP members that we are London centric.

We have therefore embarked on a countries, regions and localities (CRL)work stream to develop new ways of working. This includes projects to:

  • Pilot local trade union organising
  • Pilot having a professional adviser based in Scotland
  • Recognise the regional dimension within a Leadership Development Programme
  • Creating a refocused, and slightly larger, regional campaigns and engagement team.

Engaging members  is a key element of each of these projects. We think the future model for staff and members to work together on local concerns is likely to be based on a how clinicians ideally work with patients.  We listen to members, interpret their need, give expert advice and then seek to agree an approach.

Regional Networks

Our ten regional networks (ERNs) enable members in England, the Channel Islands and Isle of Man to meet with peers to learn, network and influence. They are member led and member run. Scotland, Northern Ireland and Wales have country boards which are representative of member groups in each country.

We are committed to supporting the ERNs as part of the countries, regions and localities work. We are aware that there will be different views amongst members about the ERNs based on their own experiences and preferences. However, the CSP remains keen to develop the role of ERNs and the support we offer to the work of ERNs.

There are no changes proposed to the role or structure of ERNs. What we are aiming to do is; spread best practice between networks, develop the ability of members to act for themselves and reduce the amount of `red tape’ for volunteers.

We will also continue to encourage more local initiative and action, and see this as complimenting ERN involvement in profession wide priorities and campaigns. Our regional networks have themselves identified supporting more local action as a priority for their work.

ERNs have always been asked to contribute to delivering the CSP objectives, which are set by our member Council. In response to feedback from networks we want to offer more opportunities to participate in local delivery of UK-wide campaigns. These will be modelled on the successful Workout at Work Day campaign, with staff developing resources for members to use locally as they wish.

If you have any other questions please feel free to contact: yeldhamr@csp.org.uk

Should “house” magazines still have a place in the comms mix?

During my career I’ve effectively been the publisher of a range of magazines; Lewisham Life for Lewisham residents, Frontier for UKBA staff and Frontline for physiotherapists and physiotherapy support staff. Over the years there has been regular pressure to junk the magazine format. The decline in print advertising challenged commercial models for magazines. The rise of digital and then social media presaged doom laden reports of the death of print. So why does the house magazine format endure in the 21st century?

Portability – Having ways to consume content on the move did not arrive with the smart phone, tablet and e-reader. Magazines are an intrinsically portable channel of communication. They fit with modern lifestyles. They allow us to consume content without needing power or a mobile signal and in settings where it isn’t appropriate or sensible to use an expensive mobile device. Have you ever heard of anyone being mugged for their magazine?

“Me time” value – For some readers magazines have an intrinsic value. I learnt this when we carried out extensive market research before relaunching Lewisham Life. For some key demographics a magazine was seen as a luxury item – something to be consumed at your leisure with a cuppa and a biscuit. I’ve never heard anyone describe an e-bulletin in this way. Now it is possible that this was a unique set of readers and this was some year ago now, but I sense that this still the case. High end consumer magazines and celebrity publications both emphasise the luxury of “me time” embodied in flicking through a magazine.

Depth and breadth of coverage –140 characters is not enough to give any depth of coverage. Whilst blogs and longer online pieces can cover more ground than social media, the traditional magazine format provides a pre-packaged set of content in a way which, whilst possible with the best online channels, is often beyond the scope of many smaller organisations to do in any other way. (I can sense some sales pitches coming from the online world already…).

Standing out – As more and more content is only delivered via digital channels, it seems likely that hard copy formats will have more stand out in some circumstances. My email inboxes are full of ezines. I rarely read them, even where they are from organisations I’ve chosen to join and whose work I am interested in. I do read the very well written and designed magazine I receive from a leading chain of estate agents which lands through my letter box. The tangible product sat there entices me in. Similarly, having Frontline drop through doors 21 times a year means CSP members are reminded that they belong to the Society and that there is a wealth of content available to them if they want it.

Value for money – Print isn’t cheap but it can give a good return on investment. In some circumstances magazines save money. In many businesses or organisations there is a tendency to want to market every service or product or to update staff on every department. How many organisations do you know where individual departments are commissioning their own promotional materials and are effectively competing with themselves?

Regular magazines can be a key means of having a more strategic and cost effective approach. When I worked in Lewisham we expanded the frequency of the Council magazine paid for by stopping printing a wide range of service specific publications. Instead we built promoting services, in a more audience focussed way, into content planning for the house magazine. This saved money and the evidence was that it improved the impact of Council communications.

So there are some good reason why a house magazine might stay as part of an effective comms mix. But, magazines which don’t evolve quickly become ineffective. So how can magazines develop?  The answer depends on the title, its audience and its purpose but here are some things to think about:

Understand your audience – As with any form of communication, insight into the way your channels and content are received is critical to developing them. In each organisation where I’ve overseen magazines I’ve insisted on research amongst the target audience to understand what they need and how they consume the medium. Market research should not just focus on your loyal readers but also understand why some of your target audience choose other channels and how you can make subtle changes to bring in a wider audience.

Blend the on and offline – Print isn’t for everyone so sharing the print content online is important. To be effective this means reediting and designing the content not just putting a pdf on your website.  It is also important to recognise that a hard copy publication can’t compete with the speed of social media, online coverage and broadcast media. Our Frontline team at the CSP routinely post news stories online and broadcast them via social media before the magazine is published. This meets a need for digital news but also frees space for what a magazine can do best – features, analysis, comment and other non-news content.

Maintain mobility – Although I have argued that magazine formats are inherently mobile, keeping them so is important. Mobile friendly online versions is one way of doing this but so too is reformatting the hard copy. This won’t be relevant for every publication but thinking about keeping the hard copy format usable on the move can be as important.  For example, we reformatted Lewisham Life from A4 to “handbag size” in response to feedback from women who wanted to read it on the commute to work. Print quality, pagination and size can all impact on when and where people ae able to read their magazine.

Build the “me time” – Unless your magazine is intended to be an academic journal recognising the “me time” element will be important. Some house magazines come across as little more than Pravda – explaining the corporate line in jargon. You don’t need to turn your magazine into Hello! however. Even if your objective is to promote your corporate messages the smart thing to do is to tell your story through the people your audience wants to read about, and in an approachable style. A less corporate feel and a more consumer style may help you get the attention of your readers.

So these are my thoughts on house magazines, but I am a bit of a fraud. Although I’ve managed comms functions producing magazines I’ve never edited one directly. So I have learnt a huge amount from some key people – Michelle who led the relaunch of Lewisham Life, James who turned Frontier from a corporate desert into an engaging staff comms vehicle and Lynn the Editor of Frontline who champions her readers so well. Thanks to you and all!