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!

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!

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!

Blog - The Importance of Person Centred Care

Person Centred Care is about ensuring patients are at the centre of all aspects of their health and care, and that their individual needs, wishes and circumstances are listened to, considered and respected.

In the first of our new series of blogs exploring this approach, our Programme Manager Brook Howells looks at the case of why it's important for the NHS to achieve genuine Person Centred Care.

Over the next instalments, both AQuA staff and our members will be sharing their own thoughts and experiences of different aspects of Person Centred Care, so stay tuned to our News Page for more updates!

Brook Howells, AQuA Programme Manager

NHS policy has been driving the person-centred care (PCC) agenda for over 20 years, but the system has been slow to respond. With current austerity, there is an increased imperative to achieve the paradigm shift, away from traditional paternalistic models of care towards a more enabling, facilitative culture of healthcare delivery that supports PCC. This has been described as clinicians shifting from “parent to coach”.

Supporting self-management was the number one priority identified for commissioners of NHS healthcare services (The King’s Fund, 2015). Coulter et al (2008) state that: “too often, the way in which clinicians and patients interact tends to promote passivity and dependence, instead of self-reliance, thus sapping patients’ self-confidence and undermining their ability to cope” (p.5).

Despite these policy drivers, the system has been slow to respond at scale. Whilst evidence of improvements can be seen in pockets, for example in chronic kidney disease, the whole-scale change is difficult to evidence, and it appears that the shift is dependent on groups of individuals having sufficient motivation to drive the change within their locus of control.

The Advancing Quality Alliance (AQuA) has been working with clinicians and healthcare organisations since 2011, supporting a change in culture through quality improvement methodology and coaching techniques. The transformation is relatively easy for individuals and small teams or services to complete successfully, but achieving systemic change remains a major challenge, despite the obvious benefits.

We know that there are a lot of competing priorities vying for attention across healthcare right now and often PCC is, erroneously, seen as a “nice to have”; the cherry that will top the cake once the rest is successfully baked, rather than as a fundamental and necessary part of the solution.

There are clear indicators that many see the opportunities though since influential documents and policies like the Five Year Forward View point towards PCC as an essential element of modern healthcare. So why are we still so far away from achieving the goal of truly person-centred care embedded across all we do?

Trying to answer this question, a small group of people passionate about person-centred care has formed a community of interest, to share ideas, challenge each other and provide mutual support.

In recognition that a lot of this thinking would be of interest to a much wider audience, AQuA is launching a series of blogs by the group members about some of the key successes and challenges noted to date.

We hope this will inspire others, whether they be clinicians, patients or system leaders, to consider what more they can do to support PCC, and we welcome comments, queries and requests to join the party!

Next time...Brook takes a look at why the NHS has historically struggled with Person Centred Care, and how this is changing.

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

AQuA Lived Experience Affiliate Starts Nursing Training

The Advancing Quality Alliance (AQuA) is delighted to share news that Carl O’Loughlin, one of our Lived Experience Affiliates, will be taking his first step into nursing as he begins his training to become a Mental Health nurse at the University of Chester in February 2018.

Carl O'Loughlin, Lived Experience Affiliate

Carl, who started his career training to be a Chartered Accountant, has worked alongside our staff and members for a number of years, to help design our programmes and offers, and ensure patient experience is at the heart of our work. To support him during his studies, Carl has also been awarded one of the prestigious Margaret Parkinson Scholarship’s from the Royal College of Nursing Foundation.

Speaking on the news, Carl said:

“I am absolutely delighted to have been offered a place to begin my Mental Health Nursing degree. I am passionate about mental health care and I want to use my own personal lived experience of severe mental illness to try and make a difference to others suffering similar problems.

“My 'lived experience' roles at the Advancing Quality Alliance, Cheshire and Wirral Partnership NHS Foundation Trust and CLARCH North West Coast have provided me with invaluable experience and have certainly been the driving force behind me wanting to become a mental health nurse.

“I am also extremely proud and honoured to have been awarded a Margaret Parkinson Scholarship from the Royal College of Nursing Foundation which will support me throughout the 3 years of the course.”

Paul Greenwood, Mental Health Improvement Advisor, said:

“We’re really pleased for Carl and wish him all the best as he takes his first step into nursing. It is a pleasure to work alongside him as part of our Lived Experience Panel as he brings such a wealth of experience to our work, both from his previous career as an accountant and through his own personal experience of mental health.

“We’re delighted that the work with us inspired him to take this decision, and I know he’ll have a lot to offer when he qualifies in the years to come.”

Carl will continue to work with us through the Lived Experience Panel throughout his training. To find out more about the panel, please visit our website, or contact Paul.Greenwood@srft.nhs.uk.

Blog – International Inspiration for Person Centred Care – Cathryn Sloan

Cathryn Sloan is AQuA’s Head of System Transformation. Here she shares some exciting examples of how person centred care looks like in practice from around the globe, following her recent visit to the International Conference for Integrated Care in Dublin.

Cathryn Sloan

I was really pleased to be selected by the International Foundation for Integrated Care (IFIC) to deliver an oral poster presentation as part of the International Conference on Integrated Care (ICIC) held in Dublin earlier in May.

The title of the poster was ‘Putting Person Centred Pathways into Practice’ and it described the really powerful work AQuA’s Lived Experience Panel does with our members.

It became really apparent over the three days of the conference that IFIC (and its partners, Health Service Executive, Ireland and the National Clinical and Integrated Care Programmes) had taken the principle of person centred care very seriously and it formed a really strong thread through all of the plenary and workshop sessions.

The conference itself was awarded ‘Patients Included’ Charter status, as it had been co-designed and planned with patients and caregivers. Patients, caregivers and advocates were very much a key part of the programme, and we heard from many about their experiences of care and how integration of health and care services had benefitted them.

There are just too many examples of how people receiving care actively participated in the conference but here a couple that really stood out for me:

Thriving in New York City

During his plenary session, Gary Belkin from New York described the ‘Thrive’ programme which is the mental health plan for New York.

The programme aims to train 250,000 New Yorkers to provide mental health first aid to their communities, empowering all citizens to take action on Mental Health and addiction and shift the focus from punishment to public health awareness.

It was an incredibly powerful example of how people with a lived experience of Mental Health can help build systems of care.

The Dutch Touch to Training

The second example that really resonated with me was the WeLearn programme from the Netherlands; this a pilot programme where patients and clinical students learn together, undertaking training in Shared Decision Making, communication skills amongst other things.

The pilot has demonstrated that medical students gain a far greater understanding of how they can work in partnership with their patients to deliver care more effectively. The programme is about to be rolled out across all medical training.

Often, patients, carers, families and people with a lived experience of care are seen as bystanders in the health process, so it was really heartening to see how the international health and care community is embracing working in partnership!

I am looking forward to next year’s conference in the Netherlands to see how some of the programmes have progressed.

You can share your thoughts with Cathryn on Twitter via @Catieranger or @AQuA_NHS. You can also find out more about AQuA work around Person Centred Care on our website.