Co-Production - Experience based design - Patient led services
Asking patients how they would like the service I provide? – Get real!
A short review by Dr Alan Willson, Improvement Science Research Group, Swansea University
If you are allergic to buzzwords then all these terms will already have given you a rash. You might reject them in common with every wave of managerialism or political correctness. But, like most new ideas, it is most useful if we take control of it and use it purposefully. Here, we share some thoughts about why more participation could help us, some tools to make it easy and links to colleagues who can share experience. The aim is to move beyond jargon and make it real.
First – what is it?
I am going to use a wide definition of this topic. It can refer to work with whole communities about services in general or individual patients about their options and preferences. To save space, I will use the term Participation. Sherry Arnstein described a ladder of 8 levels with increasing amounts of participation.
Although written about town planning, her paper has transferrable messages to other fields: decide on the right level for the setting. The highest level isn’t appropriate for all settings (running an ITU as a people’s republic would be unwise!) but maybe a higher level of participation could deliver benefit. For example, hospitals that have developed effective partnership arrangements with former ITU patients have learned lessons about noise disturbance which has led units to reduce bin clatter and loud conversation: improving patient experience and, maybe, outcomes.
Ideas like co-production fit at levels 6 and 7: why not share the power of decision making to allow patients to make informed choices according to their priorities? (Ruth Dineen, founder of Co-Production Wales, has written a good explanation of coproduction with some more bibliography Ruth Dineen on Co-production). A wonderful video by Dr Alf Collins describes his use of co-production in transforming his practice as a consultant in chronic pain management. Dr Alf Collins video. (Send this link to your home or phone of your organisation blocks YouTube. )
If you want to read further, a wonderful annotated bibliography containing references has been shared with us by Paul Batalden (see page 9 onwards). In Wales, keep an eye out too for the Planned Care Programme where there are descriptions of how participation and a patient activation measure are being taken forward in Welsh healthcare.
Second – are health services good at it?
In short – No.There are some good examples of participation in health services but they are exceptions. A useful paper by Josephine Ocloo and Rachel Matthews (BMJ QualSafdoi:10.1136/bmjqs-2015-004839) reviews the reasons for our historical reluctance and some solutions. They show how we are particularly bad at involving some groups of service users. So, we should not be surprised if we find it difficult to do it properly or that some of our colleagues need a lot of persuasion. Ocloo and Matthews paper.
If this is your thing, have a look at a short and well written paper which seeks to apply this thinking to patient safety O'Hara at the crossroads. In short, if we learned how to accommodate patient knowledge, we would work a lot more safely. Being awash with data is no substitute for real knowledge of what happens.
At a recent Health Foundation workshop entitled ‘Coproduction more than just a word”, Professors Zoe Radnor and Paul Batalden presented a challenging and thought provoking account of how we might think about the design and management of public (health) services and the involvement of users. They argued product (manufacturing)-dominant logic has traditionally shaped the way we deliver and manage public (health) services, instead of a service-dominant logic (SDL) which aims to put the user at the heart of the service. Typically in manufacturing production and consumption are separated as discrete processes and the ‘customer’ occupies the role of purchaser and consumer. Whereas in services the user is also a co-producer of the service, making the distinction between consumerism and coproduction. Zoe and colleagues have developed a SERVICE framework in which sustainable business models for a range of public services can be situated, this is currently being tested in healthcare.
A comprehensive report published in 2013 as part of the World Innovation Summit for Health makes the case for patient involvement and provides case studies from across the globe WISH review of patient engagement.
Then there is the “Berwick Report” following the enquiry into Mid-Staffs. Berwick report on mid-Staffs. The authors recommend that “Patients and their carers should be present, powerful and involved at all levels of healthcareorganisations from wards to the boards of Trusts. In commenting on the report, Don Berwick says:
“If mid-Staffs had listened to the patients, listened to the carers or the staff, if someone had said ‘what are they telling us? Put it together’ they would have been on alert, they would have been worried, they would have begun to have some diagnostic work done. Instead the voice of the patient, the voice of the carer, the voice of the staff was muted and eventually more or less ignored.”
Mid-Staffs is not typical of the NHS but a higher level of participation would – in the view of this report – have provided a vital safeguard to avert the crisis developing.
Third - What tools are available?
Good news! There are many places you can find useful tools – many on line and all those listed below are free. Use them in your practice – don’t worry if they are not created locally. On line resources can be exploited to help us with our work.
Health foundation tools.Probably the richest online source of healthcare friendly tools and applications. The Health Foundation site includes theory, explanations, tools and blogs.
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1000 Live Co-pro tools.A description of resources and programmes available in NHS Wales and a link to support and expertise. 1000 Lives have also published three white papers relating to this subject. The most recent is 1000 Lives Listening White Paper.
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Co-creating health in ABMU. A short but inspiring video explains the principles: ABMU video
Training and support are available locally. See the attached poster for details or contact David Murphy, Assistant Director of Therapies and Health
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Kings Fund EBD Tools. This is one of two toolkits about Experience Based Design which are available online. It is based on practical work at Guys, St Thomas’ and Kings College. Everything is here to help you work with patients and staff, apply their knowledge and measure the results. More recently the Kings Fund has released Patients as partners. Don’t start any significant joint working until you have checked this out – maybe you may even consider their leadership programme in partnership with a patient leader.
NIII EBD tools. Similar to the Kings Fund tools but slightly harder to access given the demise of the Institute. Still worth a look.n.b. you seem to be able to get tools free from this address whereas they are chargeable if you use another site.
AHRQ tools includes a wealth of tools. They feel and sound quite US focussed but you may find just what you are looking for here – let us know!
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Finally – who is doing what in South West Wales?
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Experiences in Co Production- Plastic Surgery Physiotherapy
I started looking in to co-production a couple of years ago as part of my involvement with a physiotherapy health promotion group when I was interested in skilling our physiotherapy staff in behaviour change.
I subsequently organised a two day workshop for physiotherapists with Petrea Fagan attended by 25 of our staff. Since then several others have completed her workshops.
My own experience of using the principles of co production have been in my own clinical area of plastic surgery and here are a few examples
- Smoking cessation / Healthy lifestyle advice
I try when I can to use the principles of Making Every Contact Count to offer opportunistic advice for my patients who are smokers. Also many plastic surgery patients are instructed to give up smoking by their surgeons and so I try to follow this on when I can with using co production principles around behaviour change.
I also try to take a similar approach to people who are not as physically active as they should be and use principles of co production. This is usually opportunistic advice and helps people to work out for themselves how they might achieve better levels of physical activity
- Rehabilitation following Breast reconstruction
Patients who undergo breast reconstruction following treatment for breast cancer are all offered a six week post op physiotherapy follow up. The purpose of this appointment is to guide patients through the physical recovery from the surgery and help advice them on exercises and return to function, work and leisure.
Dealing with issues around cancer survivorship lends itself well to the principles of co production particularly around healthy lifestyle advice. The appointment may last for up to an hour and I have found that the time invested in this appointment often means they do not require or seek subsequent appointments.
Clare Ford
Physiotherapy Clinical Manager
MorristonHospital
Front of house redesign – Prince Philip Hospital
Work to redesign the flow of patients through Prince Philip Hospital in Llanelli has been based upon the need to ensure stable medical staffing and to achieve sustainable improved outcomes for patients within target performance levels. The work began with an understanding of the needs of the area and a review of the current patients attending the Accident and Emergency Unit and their needs. Based upon this analysis six broad patient groups were identified and consequently six clinically led workstreams established. Each workstream with was given the remit to design the optimal pathway for their particular patient group and to develop a plan to deliver that pathway. These individual elements were then brought together into an overall model. Partnership working both within the Health Board and wider health and social care community has been essential to the development of the model with engagement with wider stakeholders including the Community Health Council and local Pressure Groups running in parallel to ensure patients’ voices have been central to service development.
Evidence is now being to be gathered and although only recently adopted the model is showing significant early quantifiable benefits.
Nicola O'Sullivan Head of Public and Patient Engagement Hywel Dda University Health Board
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Patients First Programme 2015/16
Year 7
‘Let’s talk about miscarriage’
Background
The Foundation of Nursing studies (FoNs) and Burdett Trust are two London based institutions who support and fund nurse development and studies. Every year they invite nurse led teams to apply to the programme with ideas to improve practice with a focus on patients. The programme takes on 10 initiatives throughout the UK each year and this year Hywel Dda University Health Board has proudly gained two places one of which is the initiative ‘Let’s talk about miscarriage’. Successful projects receive a £5000 bursary and benefit from the support of experienced Practice Development Facilitators. For more information go to: FONS report
The initiative aims and goals
‘Let’s talk about miscarriage’ is an initiative idea developed by staff and patients who work with or have experienced a miscarriage. The aim of the initiative is to gather patient stories of miscarriage and staff beliefs and values held around delivering care and information to women who have experienced a miscarriage. The goal of the initiative is then to develop and improve the support given to women and their families during and after a miscarriage.
The programme develops skills in working with a person centred approach to care and work culture. Projects are invited to 6 study days held in London over an 18 month period, where FoNS Practice Development Facilitators introduce a wide variety of tools and creative ways of enabling teams and their wider health care areas to discover their values and beliefs. Overall the greatest value of being part of the project has been meeting and learning about the other projects from around the country. We have and continue to learn so much from each other purely from having the opportunity to share knowledge and experiences.
Project so far
The project team has collected staff values and beliefs through a free writing exercise, ran a three week person centred values and beliefs exercise inviting whole ward participation and gathered written patient stories from a range or sources including EPAU, Gynaecology ward and the local miscarriage support group. This information has been analysed and themed and will be feedback to interested parties at a stakeholder meeting in July. For further information please contact
Rachel Whittal-Williams
Professional and Practice Development Facilitator
Nursing Support Team
Prince Philip Hospital
Llanelli
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Coproduction in rehabilitation and recovery services for mental health
A group of staff, service users and carers across Rehabilitation and Recovery Services in ABMU have been meeting monthly over the last 2 years to develop a strategy for co-production within these services. We have worked together to develop and run focus groups to assess current levels of co-production within these services and developed a model and key guiding principles for moving this forward. We are currently in the process of developing an involvement handbook and associated role description which we intend to use to recruit new members shortly. We have co-produced 1 hour training modules which we intend to deliver to mixed groups of staff, service users and carers at each of our units. We have an associated payment policy to ensure people are appropriately reimbursed for their time and expenses when working with us. We have co-produced an article about our experiences that is due for publication shortly.
Dr Laura Freeman, Clinical Psychologist, Bridgend
Transforming Chronic Pain services in Hywel Dda University Health Board; the Ophelia approach
A review of the chronic pain service pathway found it to be inefficient, ineffective, not person centred, and heavily reliant on repeated medical interventions which lack standardisation. Subsequently, the waiting times were steadily increasing, the follow up to new ratio were high, with high reliance on interventions by secondary care medical staff. Recognising that the current model of service delivery and pathway were unsustainable, working in collaboration with 1000 lives i, the modernisation of the pathway is being undertaken at a service re-design level through the use of Ophelia to optimise the service and service users’ health literacy levels. The Ophelia (OPtimisingHEalthLIteracy and Access) process was developed to assist health services to understand the needs of their community and efficiently undertake co-production of service improvement. Ophelia supports the development of locally-relevant, fit-for-purpose service improvements based on deep patient engagement and collation of local wisdom from experienced, expert healthcare personnel. A series of co-production workshops have been hosted and joint interventional improvements to the pathway have been identified which are being taken forward through joint working of the staff and service users. For more information, please contact
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Using Co-production in Pain Services Empowers Patients
HDUHB has transformed its pain service as it was not fit for purpose for the huge number of people living with chronic pain. Patients, managers and clinicians have been working together, developing a new pathway where supported self-management is seen as key. Patients have been involved as experts, advising service planning, engaging with health literacy evaluation, and scrutinising the new assessment and patient management programme. There is ongoing work with staff to help them have different conversations with patients so that decisions are made collaboratively with the aim of shifting the relationship from the all-knowing/expert (health professional) with the passive recipient (patient) towards a more balanced, shared decision making process. The aim is to have supported self-management options across the healthcare system, from GP practices, community chronic pain services and secondary care pain clinics. For more information contact or go to:
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Coming Together to Improve Quality Together