Buurtzorg Diaries - A Brief Buurtzorg Reflection - Wirral

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

This final blog in our Buurtzorg Diaries series comes from our Wirral locality members, who share some brief thoughts from their visit.

"Motivated and positive staff"

"Clients feedback positive experiences and enjoyed time spent with nurses"

"Client and nurse empowerment and ownership"

"Nurse-driven principles"

"Self-organised teams allows staff innovation"

"Care plans tailored to patients needs" 

"The team and patient is the most important in the organisation, not the hierarchy"

"Align actions to visions"

"Nurses allowed to nurse and care to deliver person centered care"

"Lots of different solutions to issues/conflicts"

"Simplicity in nursing model and organisation of teams"

"Coffee first…then care (the conversation and relationship with patient as important as the hands on care)"

"Vitality of nurses – wellbeing of staff important (visits on bikes very much promotes staff well-being)"

"Like-minded people working together" 

"If a consensus cannot be reached the team have to ‘live with it’ i.e. not dwell on the issue and to accept differences"

"Better outcomes for clients and nurses"

"Bring in additional support when needed, family and community support"

"Importance of coach role and back office"

Buurtzorg Diaries - Integrated Care, Not Integrated Teams - Manchester

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

In our latest blog blog from our Buurtzorg Diaries series, members from the Manchester locality share their thoughts from the trip. 

“Buurtzorg feels right and fits well’ – SC, district nurse, Manchester

This blog is not an attempt to present a complete picture of either Buurtzorg or Amstelring as organisations – but rather to share a few ‘take home’ messages of a group of clinicians and managers who went to see Buurtzorg self-managed teams in action (March 2018), and to learn from Amstelring (who changed into an organisation with self-managed teams). 

By sharing our learning and thoughts we hope to build a collaboration of the willing who are prepared to lead by example and work in a way that really values people, trusts them to ‘do the right thing’ and enables them to build trust with the clients with whom they work – so here goes!

Be under no illusion – the client really is front and centre in both organisation and all they do – as Buurtzorg’s model makes clear.

The person needing support

The focus is on continuity of care and developing the strong bond between patient and member of staff.  Total patient holistic care was highly valued and the clients we met were clearly impressed with the staff working with them who knew them all well. W

We were also impressed that the staff made choices, sometimes, not to complete tasks but to simply listen / talk when it was more appropriate to do so; which built a culture of trust. The only protocols in the organisations were clinical; all others were removed in favour of simple goals and simplicity itself. 

Informal networks

Teams are based, and often live, in the community in which they work. Highly visible, they are often based in previous shop premises on the high street and people walk in from the street to seek access to the team. With small areas to cover, the team are also seen out and about on their bicycles; spending very little time commuting between visits.

Clients had access to all their care records via iPads in the home, as did their carers where they wanted them to.  All clients / carers could message staff via this route, as well as phone their team out of hours if necessary; although calls to teams were extremely rare – teams citing rates of one or two calls at night a year.

Buurtzorg team

Our reflection is that the current system in which we work in the UK is based on distrust rather than trust - rules are made for the 3% who don't do a good job rather than the 97% who do.

The small teams in Buurtzorg who share responsibility for management / planning roles within their team, seem to encourage people to ‘step up’ and hold both themselves, and each other, to account; whereas in the UK it feels more as though by making many people responsible, no one is responsible.

In Buurtzorg teams spring into life when a group of nurses collectively decide that they want to work together. Within the organisational infrastructure that Buurzorg provides, they operate as self-managed teams (almost individual ‘franchises’) with high levels of individual and mutual accountability. Teams rotate roles, operating with a framework of activities that prioritise the quality of the relationship with the customer, productive client facing time and longer term prevention.

The clinicians within our team saw true autonomy for the nurses who they felt were both personally and professionally more enriched and had more job satisfaction. Simplicity was key to their approach but this didn’t prevent a clear, open and safe approach to governance.

The willingness of the organisations to cede control of the teams stood out, as did the complete lack of traditional management structures and the simple systems for enabling the teams themselves to manage poor performance amongst themselves.  

The access to coaching support seems to be highly valued if infrequently required. Interesting to note that, of four coaches originally appointed by Amstelring, only two were ultimately successful in their roles; 2 of the 3 managers were unable to make the transition to coaches.

All staff reported that team size was crucial; 5 staff minimum to provide safe capacity but no more than 12 in total, with 8-12 cited as the ‘magic number’.  Any attempt to go over 12 had led to a breakdown in team functionality.

Staff as customers and client

Experienced staff were highly valued. Working on the assumption that in fact the staff are also customers of Amstelring (since happy staff provide safe and efficient care), the focus of the ‘back office’ function comes to be ‘delighting’ employees.

Support services should be just that - a back office function - and not an industry in itself. The net effect of this is that the back office teams constantly focus on ‘keeping it simple’ when providing support, removing obstacles, acting as a firewall to prevent bureaucracy creeping into the work of the clinical teams, and always, always, taking steps out of processes and working to simplify.

The single IT system helps, as does an approach which, for example, allows staff to notify the office of contract hours changes by email, text, letter or phone; whatever is easiest.  Teams work in a flexible way which was valued as a two way deal; good for clients, good for staff.

Leadership was pivotal in ensuring that the organisations took actions which embodied their visions; demonstrating to the workforce, through action, their commitment.  For example, the teams at Amstelring were charged with interviewing and appointing the coaches from the existing managers that applied. Even allowing for this, only 2 of the 4 coaches ended up being right for the job (2 previous managers could not make the transition).

Amstelring were demonstrating the value they place on good coaching ("we would rather have no coach than a bad coach") and interesting that the decision to delegate this process to the self-managed teams was considered deeply symbolic and consistent with their vision.

There was a sustained and deliberate focus on the future – where you want to be / get to – rather than dwelling on the past, as well as a belief in the power of shaping the wider system / world to be better - "this is our alternative to what you think you need” rather than just saying that what existed wasn’t good enough.

Formal network

Referral processes were simple and referrals to other teams appeared minimal. The principle of the team was to act as generalists, recruiting specialist help if and when needed.  Integrated care, not integrated teams, was the order of the day.

Conclusion

Inspiring, motivating, challenging and ‘do-able’, the lessons from Buurtzorg and Amstelring are timely for systems who really want to make a difference to the quality of peoples’ lives – clients, staff and communities.  If these ideas are of interest to you and / or you would like to find out more or become involved in work in Manchester please contact one of the team via peta.stross@mft.nhs.uk or siobhan.reading@srft.nhs.uk 

Blog - Adopting Systems for Quality Improvement in Health & Care - David Fillingham

Following the recent launch our paper A Sense of Urgency, A Sense of Hope at a joint event with The King’s Fund, our Chief Executive David Fillingham takes a further look at the need for health and care organisations to adopt systems for quality improvement.

David Fillingham

It has been a long, difficult Winter for the NHS. Staff have worked incredibly hard to care for increasing numbers of patients at a time of tightening finances. Sadly, despite these great efforts, we have inevitably seen too many stories of long waiting times and a worsening experience in many places. Whilst the NHS has a marvellous ability to cope in adversity, the sense of it being in crisis is growing.

On one of the snowiest days of the year, the 1 March (allegedly the first day of Spring!) over a hundred hardy NHS folk battled their way through blizzards to a King’s Fund / AQuA event in Manchester where we launched AQuA's framework on building a system and culture of improvement, entitled A Sense of Urgency, A Sense of Hope.

By a show of hands delegates indicated that they were very familiar with the extreme pressures facing the NHS. They also recognised that the current political and economic context is such that, the sustained and large-scale investment needed in health and social care is unlikely to happen anytime soon.

The 'hope' rests in the fact that there is a strong evidence base, in other sectors and in healthcare, that the strategic application of improvement methods can improve both quality and productivity. This is not to say that more spending isn't needed, it is, but until the day it arrives there is a great deal that the NHS can do for itself to tackle the waste, delays and duplication in the system that are such a source of frustration for staff and patients alike.

The problem is that our improvement efforts are too often small-scale, piecemeal and not sustained. Organisations which have achieved transformational results, such as Jonkoping in Sweden, Virginia Mason in the US or Salford Royal and East London Foundation Trust here in the UK, have adopted a long-term approach to building their respective improvement systems.

AQuA's publication is based both on a review of the published evidence about how they have done that and on reflections on leading and supporting improvement efforts on the ground.

Our framework has five interdependent elements:

• Vision and Strategy - developing a plan that inspires and engages everyone. It should have bold aims, measurable goals and commit the organisation to building improvement capability at every level.
• Leadership and Culture - in an improvement culture patients and families are full partners in their care. Staff are empowered and supported to use their energy and creativity to solve problems, and leaders are positive role models who coach others in their chosen improvement approach
• Building Capability - there is a commitment to train all staff in improvement method and to give them the time and encouragement to use those skills. Leaders and coaches will have more advanced know how and there will be a small number of genuine experts. The Board will itself commit to receiving development to carry out its own improvement leadership role effectively
• Developing an Operating System - improvement methods will become 'hard wired' into the organisation with goals being cascaded via a process of 'catchball' and expertise focussed onto the biggest challenges. Over time an improvement approach will become "the way we do things around here" and an accepted part of daily work
• Aligning Support Services - staff working in HR, Finance, IT/Information and Estates have a great contribution to make. They will be fully engaged and these functions redesigned to support an improvement culture.

Last year NHS Improvement, alongside other national NHS bodies, published their strategy Developing People,Improving Care. This exhorts NHS organisations to make just these kind of investments in their own improvement capability.

The newly revised CQC inspection framework asks questions as to what progress is being made on the ground. Not only do organisations need to adopt such an approach if they want to emulate the best, now they are actively being encouraged to do so by inspectors and regulators.

This kind of work takes time and is a difficult path. It's all too easy to become overwhelmed by day to day pressures. Succeeding requires courage, curiosity, persistence and optimism.

But the prize is a great one...that of seeing staff glow with the pride using their own experience, energy and ideas to transform the care that patients receive.

Feel free to share your thoughts with us via Twitter @AQuA_NHS or get in touch via AQuA@srft.nhs.uk to request a hard copy of our paper.

Buurtzorg Diaries - Bringing Buurtzorg Home - Wendy Lewis, Whole System Flow Lead

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes from Wendy Lewis, AQuA’s Whole System Flow Lead.

Well reflecting on a great three days where we really got under the skin of this Buurtzorg thing - it really is as good as the hype, in fact it might be better!

From the welcome we received, the honest responses and challenges to our questions to the bikes, strange contraptions for putting TED stockings on and the inspirational speakers, this has been a really stimulating and heart-warming learning experience.

As the final group discussion took place this morning, I noted the key issues we’re really wrestling with:

1. What's the compelling narrative we need to create that will get this work across the start line? WE get it now, how do we help THEM get it?
2. How do we create the space for self-led teams without actively seeking the obstacles and obstructors that we foresee we’ll have to overcome?
3. Can we achieve our organisations' expectations of Buurtzorg by using a too tentative approach to testing or implementing? 
4. Matthias van Alphen talked about how ridiculous it would be to describe someone as 'a little bit pregnant', or a little bit autonomous... Can we agree to approach this properly where self-led means self-led?

Finally, a perspective from Brendan from his experience, instead of the usual discussion if how we adapt the Buurtzorg way to our systems, we need to approach it differently:

1. How do we change the context to fit the Buurtzorg model?
2. Can we adopt the principles within the context we work without compromising the model?

Some questions to ponder as we return home and prepare for module three in May!

Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Wendy Lewis (@ERPwend) on Twitter for the latest.

Buurtzorg Diaries - Buurtzorg Life Poem - Jacqueline Williams, East Cheshire NHS Trust

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes as a poem from member Jacqui Williams, Associate Director for Service Transformation at East Cheshire NHS Trust.

This is our reflection of our time in the Hague,
We’ll try to give detail - and not be vague
Monday - the day our adventure began...
7 nurses let loose across Amsterdam
We’ve tried all modes of transport - car, foot, tram and bike
All thirsty for knowledge about the ‘Buurtzorg life’.

Nursing teams in neighbourhoods - where lives are laid bare
Early intervention, practice prevention and promoting self care
Really ‘knowing’ your patients - that's how it should be
Therapeutic relationships with continuity
Goals and solutions that are owned and are shared,
Everyone’s equal, with time given to care.

So, what has struck us about this philosophy?
A return to core nursing values ‘create simplicity’
Systems and support that don’t hinder or burden
A ‘no blame’ culture - and commitment to learning

Nurses self managing - committed to their job
Accountable, responsible, professional Buurtzorg!
All of this is what we can see
With a feeling that this was ‘how it used to be’

So, what next? We challenged our brains
Thinking about what, when and how we might change

Jos de Blok’s words echoing in our minds
‘Coalitions of the willing’ - we need to find
Review what we have - trade in ‘process and tools’
Reduce the bureaucracy - ‘relationships not rules’

Take the best of our past, our present practice too
There’s lots to celebrate in what we currently do

Give our nurses confidence, freedom and competency
For safe effective care that brings real quality
Nursing in different countries, different cultures, but we share the same aim

Great patient care - Buurtzorg?
The clues in the name.

Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.

Blog - Early Adopters & Spreading the Message - Norah Flood

In part four of our Person Centred Care blog series, Norah Flood, AQuA member and Assistant Director of Clinical Networks at North West Boroughs Healthcare NHS Foundation Trust, discusses the Trust’s implementation of Person Centred approaches and the importance of early adopters.

Noah Flood

‘We already do that’ and ‘I will not allow my patients to make a bad decision’ were the two stand out responses received when introducing the concept of Shared Decision Making (SDM) into a recently merged Community Physical Health and Mental Health organisation.

Fortunately, there were also plenty of open doors to be knocked on that welcomed the structure of tools to support the practitioner and patient to reach a decision together.

Initially, these doors belonged to the high volume services, possibly surprising, as a common concern among practitioners was the perceived extra time it would take in engaging in SDM conversations with patients. However, the case for enhanced compliance, reduced DNAs and increased patient satisfaction soon overcame those concerns.

Even better was the tangible evidence produced; demonstrating that patients did want to share in the decision, actually did know what their preferences were, and so did engage fully in their treatment plans.

Leaders in the field are essential but more crucial are the fast followers. What we found was that spread and adoption in Community Physical Health Services was both rapid and successful. Possibly because services were proactive in seeking out support to engage in SDM and adopted, or created, patient information to assist patients in determining what was best for them.

Equipment Services, Dietetics and Weight Management, Podiatry, and MSK became self-sufficient in utilising SDM and developing tools to support patients. Furthermore our Intermediate Care services introduced SDM and achieved a cultural shift in how risk was assessed and managed. This is best demonstrated by Jim's story.

An early advocate of SDM came from our Secure Care Services, who utilised this approach to support the introduction of the Trust’s smoke free policy. Tools to support service users to stop smoking were co-produced with service users, ward staff and pharmacy.

The response was both positive and immediate and the concept of Shared Decision Making was soon transferred to the unit’s multi-disciplinary team meetings; now the service user has the opportunity to fully participate if not lead their MDT.                                                                  

News travelled fast and on the back of one success came enquiries and suggestions for where else Shared Decision Making could be applied.

Another early adopter was our CAMHS services, where it was always felt that continuity of practitioner was of the upmost importance and while no-one denied that, it was realised that not all practitioners are skilled to offer the full range of interventions.

Therefore, tools were developed to assist families in deciding which therapeutic intervention they preferred to receive, and how that decision was affected if it meant moving to a different therapist.

This approach was spread to other services by the ‘share and adopt’ method, and Shared Decision Making has become something we already do across the organisation.

You can share your thoughts with Norah on Twitter via @NorahFlood1  or @AQuA_NHS, or feel free to leave a comment below.

In our next blog we hear from another of our members, Caroline Poole, Clinical Improvement Lead at Pennine Care NHS Foundation Trust; who explores a systems approach to measuring person centred care.

Stay tuned to our news page for more updates!

Buurtzorg Diaries - A Self-Led Start to our Trip – Emma Walker & Siobhan Reading

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Starting off the series, our Strategic Portfolio Lead Emma Walker and Programme Support Officer Siobhan Reading bring us up to speed after landing in The Hague…

Emma Walker

Siobhan Reading and Emma Walker

AQuA and member colleagues excitedly arrived in The Hague for our Buurtzog study visit to see how self-led teams work in the Netherlands.

It was quickly apparent from the initial welcome meeting with our Buurtzorg hosts that we were not just going to observe self-led teams, but the programme itself for us was going to be very self-led.

Teams were given their programme for the next 3 days and then we all had to work out how to get to various points across the city - some by 7.30am the following morning!

Initially, folk talked about getting taxis, but it didn’t take long for their adventurous spirit to creep forth and you could see why these folk had been chosen as they quickly embodied self-led ‘ness’ and a can-do approach; working in small groups (with good old Google) to work out which tram, from where and when they needed to get to by when (how did we manage before the wonders of smartphones?)

So, we are off with our phones, clutching maps on bikes, trams and foot to explore the 3rd city of the Netherlands to see how Buurtzorg works in practice - not only observing nurses with patients today, but also visiting a Buurtzorg office, seeing how the very streamlined back-office function works and how social and health care provision in the community functions together.

Siobhan Reading

Today I was surprised to learn that setting up a Buurtzorg team requires an entrepreneurial streak!

You have to be prepared for the challenges of business planning, budgets and watching your overheads.  You also need to have identified if the model will work within your neighbourhood by reaching out to GPs and other community organisations.

AQuA staff and members alongside Buurtzorg colleagues

It’s not enough to just have a team of nurses. With no formal support the team has to be prepared to make all their own decisions regarding staffing and working practices.

For anyone who's had a desire to set up their own business or be free of line management maybe the Buurtzorg model can apply to more than just healthcare.

However, taking on that responsibility might not be for everyone…

Teams from localities across East Cheshire, Manchester, and Wirral will also be sharing their experiences from the trip, so stay tuned to our news page for more.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.

A Sense of Urgency, A Sense of Hope – Our Latest Paper on Continuous Improvement for Health & Care

We’re delighted to announce the publication of A Sense of Urgency, A Sense of Hope; our latest paper by our Chief Executive David Fillingham CBE and Director Lesley Massey exploring how organisations can develop and support a culture and system for continuous improvement.

In the paper, David and Lesley take a look at recent best practise, changes to the health and care landscape, and distil over eight years’ experience of working with members as the North West’s quality improvement body, into five key domains where organisations can support and invest in a quality improvement system:

• Vision
• Leadership & Culture
• Capability
• Developing an Operating System
• Aligning Support Services

Download your copy here

Speaking on its publication, David said:

“We’re really excited to share our new paper, and hope it offers our colleagues across health and care an in-depth framework to help support their aims for continuous improvement.”

“Whilst we recognise the extreme pressure the NHS and wider care sector continues to face, we feel it’s important to still look for a light at the end of the tunnel. Therefore it is vital organisations invest in improvement, if we are to meet the demands of better, more efficient care and improved outcomes for patients.”

“We really believe this is possible and as we highlight throughout the text, there are a number of organisations we can look to for inspiration to achieve this together.”

Throughout the paper, the pair also look at case studies from our work with members, including from: Aintree Hospital NHS Foundation Trust, Manchester University NHS Foundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, North West Boroughs Healthcare NHS Foundation Trust.

Other examples also point to leading improvement organisations from other industries and sectors outside of health and care.

The paper was recently launched to over 100 delegates at a joint event with The King’s Fund; exploring successful approaches to quality improvement. Following the event, co-author Lesley Massey said:

“At the event delegates gave us some fantastic feedback on the framework and each of its five domains.

“We’re now developing a self-assessment diagnostic to support the framework, and would welcome interest from colleagues across the country who would be interested in testing this.”

If you would like to request a hard copy of the paper, or are interested in testing the self-assessment diagnostic, please get in touch via AQuA@srft.nhs.uk. Alternatively, feel free to share your thoughts with us via Twitter @AQuA_NHS.

Blog – From Patient to Practitioner – My Lived Experience of Working with AQuA – Carl O’Loughlin

Carl O’Loughlin has been a member of AQuA’s Lived Experience Panel since 2015. As he starts his training to become a qualified mental health nurse, he shares his experience of working with us for the past three years.

Carl O'Loughlin

I first came into contact with AQuA in June 2015, when I was working as an involvement representative on a peer support project in the Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Through this project I met Paul Greenwood, AQuA’s Mental Health Improvement Advisor; who was running a Restraint Reduction initiative on one of the CWP inpatient wards.

During our meeting, I shared with him my work with CWP, together with my own lived experience of using mental health services and my professional background; where I had experience of quality improvement.

Paul also told me that AQuA was forming a Lived Experience panel and after applying to join this and an interview, I was pleased to be offered the role as one of five Lived Experience Affiliates on this panel.

At my first Panel meeting, it was evident each of us on the panel had a significant and varied range of lived experience of healthcare services. Since then, we’ve all been welcomed by AQuA staff as a fundamental and key part of the organisation.

We’ve also had quarterly meetings with either the Chief Executive or Directors, to update them on the work we do with programmes and AQuA members; which demonstrates how important AQuA value the work the panel does.

Since joining, I’ve received significant training on everything from Human Factors, Introduction to Improvement, Shared Decision Making, Dementia Awareness, Safety and Mortality and Motivational Interviewing. AQuA has also facilitated my Experience Based Design Coaches training.

My presentation and report writing skills have also improved significantly, together with my knowledge of health and social care services and how they are organised and operate.  All of this training, skills development and knowledge will prove invaluable to my nursing studies and any future nursing roles.

During this time I’ve had the privilege to work on a range of programmes, including Whole System Flow, Mental Health, Restraint Reduction, Safety, Academy and Shared Decision Making.

There’s a range of work that I’m proud of from my time with AQuA.  The most prominent of these is our work with three systems as part of the 2017/18 Whole System Flow programme. Together as a Panel, we’ve spent the last six months visiting and interviewing service users and carers from each of the three systems.

This work has given us a deep insight into what it is really like to be a service user or carer using each system, and allowed us to produce a detailed lived experience report for each system.

Each of their project teams have fed back that these ‘real’ experiences gathered by the Panel has been the most important part of each project. It’s been clear that diagnosing issues and problems in each of these systems wouldn’t have been possible without these insights.

This piece of work has been incredibly rewarding and enjoyable personally; with the patients really valuing the opportunity to share their experiences with us.

All in all, it’s been an absolute pleasure to work with AQuA as a Lived Experience Affiliate for the last three years.  I’ve found AQuA to be a highly forward-thinking organisation at all times, especially with regard to quality improvement and co-production.

Staff have really welcomed all members of the Panel, and have actively worked to co-produce and embed lived experience into their programme design and delivery. They practice ‘real’ co-production, are happy to receive challenges and feedback from panel members, and use this to actively improve their work.

I’m certainly going to miss working for AQuA and everyone that I work with there, but I’m also excited to be starting a new chapter in my life with my nursing studies about to commence.

Feel free to share your thoughts and comments with Carl, or wish him good luck with his nursing training, via Twitter @Carloloughlin1 or @AQuA_NHS. 

Blog – Person Centred Care – Walking the Tightrope – Rachel Bryers

In the third blog of our Person Centred Care series, our other Programme Manager Rachel Bryers discusses the fine balancing act between supporting patients to be autonomous in their decisions on care, with protecting their health and reducing harm.

Rachel Bryers

‘Professional training provides a foundation for understanding the importance of Person Centred Care but it does not prepare you for the reality of managing complex decision making with patients; supporting their right to autonomy and choice, against balancing risk and fear of litigation.’

This is often the response we hear from health professionals when exploring how they can embed Person Centred Care within their practice.

As a team manager of an intermediate care service, we explored these ethical dilemmas; reflecting on our attitudes and practice when managing the complexities of risk, safety and wellbeing but most importantly ensuring that what mattered to the patient was the principal factor in decision making. This was paramount in getting to the crux of how we delivered Person Centred Care.

Tensions between autonomy and protection can be seen across all aspects of healthcare and more must be done to guide and support health care professionals with these challenging and testing conversations.

Recognising our paternalistic approach, albeit with our best intentions for the patient, is fundamental. When a patient makes a decision that we are not comfortable with it is difficult to support their wishes; more so when we feel it isn’t the option that will most optimise their health and reduce the risk of harm.

Health professionals want to be able to provide the care that responds to patient’s priorities but tell us they feel stifled, disempowered and scared by a system where governance and risk does not support this.

We all have different attitudes to risk, values and preferences, and should be supported to choose the option which matters to us. For health professionals, the fear of litigation and being held accountable for a decision which may prove to be unwise often results in labelling patients as ‘non-compliant’, or prompting them to sign a disclaimer form for ‘going against advice’.

How can we move away from this culture, to one which gives us ‘permission’ to support the patient’s choice by standing alongside the patient, listening and understanding what matters to them and feeling confident to act on it; with the support of our organisation? 

Clinicians who have a better understanding of The Mental Capacity Act and how it underpins clinical practice can feel more protected and equipped to support complex decision making.

When a patient chooses a course of action that the clinician would feel uncomfortable with, it enables them to take a Person Centred approach; leading to better outcomes for patients, as defined by the patient.

An example of this can be seen in our work with North West Boroughs Healthcare NHS Foundation Trust (previously Five Boroughs Partnership NHS FT). Professionals involved in the decision making must ensure they have the knowledge and expertise to understand the implications of the Mental Capacity Act in clinical practice, as not adhering to the legal framework of the Mental Capacity Act could be regarded as wilful neglect.

In my current role as an Improvement Facilitator working with health professionals to support Person Centred Care in practice, it is clear that more support and guidance is needed to understand their role in decision making.

You can share your thoughts with Rachel on Twitter via @Rachel_Bryers  or @AQuA_NHS, or feel free to leave a comment below.

In our next blog we hear from one of our members, Norah Flood, Assistant Director Clinical Networks, North West Boroughs Healthcare NHS Foundation Trust, on the importance of early adopters of Person Centred Care.

Stay tuned to our news page for more updates!

Joanna Bircher Joins the AQuA Board

We’re delighted to welcome Dr Joanna Bircher, GP and Clinical Director for the Greater Manchester GP Excellence Programme as a new member of our Board.

Dr Joanna Bircher

Our Board plays a vital role in helping to set our overall vision for our work with members and customers, and Joanna joins as the sixth of our Directors taken from our member organisations across the North West; alongside four external independent Directors.

Speaking on the announcement, Chief Executive David Fillingham said:
“We’re delighted to welcome Joanna to the Board. She has wealth of experience not just as a GP in Tameside, but also as a clinical leader across the region and on a number of national projects.

“Our Board have a real range of experience across health and care, which we benefit from massively in terms of our work with our members and customers. We’re really looking forward to working with her in the coming weeks and months, and adding her knowledge and skills to the team.”

Adding to this, Joanna said:

“I am so pleased to be joining the AQuA board at a time when it is being increasingly recognised that supporting UK General Practice to develop Quality Improvement capability may help the NHS to respond to the current challenges.

"I hope to bring with me the ‘eyes and ears’ of a working GP, with experience in applying QI methods at the front line to support AQuA in its mission to improve health and care quality.”

In addition to her role with Greater Manchester Health and Social Care Partnership, Joanna is a fellow for The Health Foundation’s prestigious Generation Q, and Quality Improvement Clinical lead for NHS Tameside and Glossop Clinical Commissioning Group.

She has also been a GP partner at Lockside Medical Centre, Stalybridge, since qualifying as a GP in 1998, and combines her clinical duties with GP training for the North West Deanery.

In addition, she has also been a Clinical Support Fellow for Quality Improvement at the Royal College of GPs since 2014, as well as their joint clinical lead for the college’s work on the National Diabetes Audit.

Joanna is highly passionate about quality improvement in general practice, and used her Generation Q fellowship to explore ways to support frontline staff across GP practices to deliver improvements.

Joanna regularly shares her thoughts and updates on Twitter via @JoannaBircherQI. For more information on our Board, please visit our website.

Blog – Person Centred Care - A Risky Business – Brook Howells

Following on from her last blog on the importance of Person Centred Care, our Programme Manager Brook Howells continues the series by looking at how we’ve been working with members to implement this approach, and why the NHS has struggled with it in the past.

Brook Howells, AQuA
Programme Manager

AQuA has been working with clinical teams across the North West to support improved Person-Centred Care (PCC) for a number of years and, has seen a subtle but significant change in the challenges we face.

Previously, we focused on helping people know what choices were available and giving them opportunity to be involved in that decision. We now recognise that in the majority of cases, where there is a simple choice between two comparatively similar options, clinicians are very good at providing the detail and making sure the right treatment for that individual is selected. The challenges arise when risk becomes a more significant part of the equation.

The prevailing culture in the NHS of ‘do no harm’ and to some extent the attitude of always-put-a-brave-face-on-it, often combine to make us shy away from conversations about potential problems; be they painful side effects or the possibility that a cure cannot be found.

This reluctance to discuss the negative aspects of healthcare, or ill-health in general, make it difficult to have an honest conversation about choice; one in which we talk about both the risks and benefits of each option available.

Risk is a tricky concept in itself to discuss; we can only give an idea of the probability of something occurring, and we cannot know how significant that probability is to each different individual.

Where one person might be quite happy to take a chance on a treatment that has a 25% risk of a side effect, another may opt against even a 1% risk of harm. It is all personal and relative to the situation; and that is exactly why we need to get better at talking it through with the very people who will be affected; the patients.

What makes this task harder is the sense that governance structures can sometimes prevent us from allowing any sort of risk to be taken. Governance exists to help us achieve our primary aim (to get people better and keep them safe), but we need to bear in mind that to deny someone their autonomy – their right to decide what happens to their body – is just as much a cause of harm as the more obvious problems like not preventing a fall or the spread of infection.

To this end, much of the work AQuA does with teams now focuses on helping them to see where their responsibilities lie, and how Shared Decision Making can actually help them fit within governance; whilst still giving patients autonomy and personalised care.

We help people to understand the Mental Capacity Act and how it supports people to make decisions, as well as giving healthcare professionals confidence, to allow people to take risks and to offer up all the options, not just the safest ones.

This is no easy feat and it requires a much greater shift in mindset than just remembering to tell people about each option, or to hand out an Ask Three Questions postcard. We still advocate both those things; we just appreciate that there is a lot more to supporting Shared Decision Making and therefore a lot more work to be done.

You can share your thoughts with Brook on Twitter via @BrookH_AQuA or @AQuA_NHS, or feel free to leave a comment below.

In our next blog, our other Programme Manager Rachel Bryers looks at implementing Person Centred Care in practice, and its implications around the Mental Health Capacity Act.

Stay tuned to our news page for more updates!