With contributions from CSP members, we look at the digital response to Covid-19 by different physiotherapy sectors, through the lens of a plan-do-study-act cycle of service improvement
Covid-19 signalled the start of rapid transformation for many physiotherapy services, both within the NHS and in the private sector. In a bid to continue to provide physiotherapy input during an unprecedented period when routine face-to-face outpatient consultations were suspended, many CSP members quickly turned to digital modes of delivery. With the urgent need created by the pandemic, the transformation of physiotherapy services rapidly moved through the stages of service improvement.
A few months on, these digital options have become embedded and the new norm. As non-Covid-19 healthcare pathways slowly resume, questions are now being asked about what physiotherapists and patients want their services to look like with digital services front and centre of the discussion. Here we take you through the plan-do-study-act (PDSA) cycle of service improvement.
The need to plan for alternative delivery was clear to Ben Wanless, consultant physiotherapist at St George’s Hospitals NHS Trust, as he explains:
As soon as we were told we couldn’t see patients face-to-face, we knew we would have to ensure self-management was as robust as possible.
His team worked with getUBetter to quickly and safely reconfigure the existing digital-first self-management pathway. Developed by physiotherapist Carey McClellan, this platform provided in-app referral to urgent virtual assessment for MSK conditions, direct access for all patients to evidence-based digital self-management configured to the local pathway and - importantly - a patient-focused digital first MSK service.
Stuart Buchan, clinical lead at MSK NHS Ayrshire and Arran, feels his own service’s existing digital strategies were invaluable to manage the impact of staff redeployment. They used their established social media platforms such as Facebook to initially inform patients about suspended services and planned how to build their posts to support public health messaging by including links to government advice and other appropriate resources to help service users self-manage during lockdown.
In future, there may be different drivers for planning to maintain or further develop digital options. The ‘stay home’ message was very effective and there may be patient aversion to visiting clinical environments for fear of infection. Services may need to plan for training of redeployed or shielding staff who are returning to work in a context changed by Covid-19. Mr Buchan recognises this challenge and plans to train these returning staff members to understand how to use the digital platforms safely within new standard operating procedures, following a service-wide roll out of video consultations.
During Covid-19, this implementation phase happened at pace in many areas. Within a very short period of time, services were suddenly provided with the technology and software to offer virtual consultations and the digital tools to promote self-management.
The MSK Service at NHS Ayrshire and Arran rapidly adopted video consultations, using their website to signpost to self-management resources. In addition, the service used Microsoft Teams as a communication tool for various aspects of service provision and to provide ongoing support for staff who were isolating or shielding.
While services adopted their preferred existing platforms, developers also supported implementation by making additional software widely available. The iPrescribe Exercise App uses health data to prescribe a personalised physical activity programme that is appropriate for most, including patients with chronic disease. This data can be used by clinicians to monitor their patients’ physical activity and health outcomes remotely. Carron Manning, physiotherapist and co-founder of iPrescribe Exercise, describes how they rapidly increased the range of home exercise content across different intensities and ‘made the app directly available and free for both the users and clinicians in order to help keep rehab services going throughout the pandemic.’ [June issue of Frontline]
This evaluation phase is crucial to measure the impact of new or extended digital ways of working and key to this is data. Hannah Morley, an MSK physiotherapist in Gloucestershire, recently completed a Winston Churchill Fellowship in New Zealand. She draws comparisons with the disaster response to the Christchurch 2011 earthquake and the healthcare system response to Covid-19, in terms of short and long-term population impact. Christchurch had previously begun work on a data-driven health model prior to the crisis.
‘We would benefit from learning from Christchurch and how they were able to respond using an evidence-based approach due to their principles of data-driven healthcare which empowered clinicians and leaders to act on the data and encouraged innovation in technology,’ she says.
Ms Morley also reports the need for service transformation to be ‘citizen-focussed’ to ensure patients are provided with what they want rather than what they are perceived to need. This is particularly appropriate to review now to identify any changes to citizen preferences in technology as a result of increased or different utilisation throughout the pandemic.
Mr Buchan agrees, saying it is a mistake to assume that all digital solutions will be appropriate for all client groups. Physiotherapists must, he asserts, ‘know your audience and what they want from your service’.
Evidence of impact on safety, efficacy, equity and user/staff experience are among the areas that should be considered. The team in Ayrshire and Arran are collecting data on the use of Facebook, the local MSK website and virtual consultations to evaluate and determine where each digital solution will fit when the service returns to normal business. Early indications are that there is support from both staff and patients for these digital options.
Patient feedback for the i-Prescribe Exercise App is reportedly high and is to be formally evaluated as part of an existing Sport England grant.
A randomised controlled trial is planned for the getUBetter roll-out in south west London to build on previously published evidence that demonstrated a 12 per cent reduction in GP appointments and a 90 per cent rate of patient recommendation for friends and family. In addition, the CSP is planning an evaluation of remote service delivery in the coming months.
The exact action needed for further service improvement, or adoption as business as usual, will depend upon evaluation results but it is clear that integrating digital solutions will feature in many services moving forward.
Ben Wanless plans to extend the getUBetter offer in his service to include shoulder and ankle conditions, while the developers of the iPrescribe Exercise app will continue to support services across the country to allow patients consistency of access to rehab programmes regardless of geographical location.
As physiotherapy services look to the future, the continued integration or expansion of digital solutions into patient care should be planned and evaluated carefully, using improvement methodology. This also needs to consider how to best support the behaviour change required by both patients and staff to embrace digital innovation and technology.
While Covid-19 may have accelerated the implementation of digital options, as Mr Wanless says: ‘never underestimate the work needed to improve engagement and behaviour change’.
- Plan, Do, Study, Act (PDSA) cycles and the model for improvement
- Remote service delivery options
- Digital physiotherapy
PDSA cycles at scale
Royal National Orthopaedic Hospital (RNOH)
In response to the Covid-19 pandemic, the RNOH set a target of an 80 per cent reduction in face-to-face consultations. A multidisciplinary group of healthcare professionals, including physiotherapist Anthony Gilbert, was established to support the wide-scale implementation of virtual consultation across the hospital.
The team approached this with a quality improvement approach using a large number of repeated PDSA cycles, running simultaneously across five main areas:
- administrative processes
- Plan the next cycle Decide whether the change can be implemented
- Define the objective, questions and predictions.
- Plan to answer the questions (who? what? where? when?)
- Plan data collection to answer the questions
- Carry out the plan
- collect the data
- Begin analysis of the data
- Complete the analysis of the data
- Compare data to predictions
- Summarise what was learned
- clinician training and skills development
- installation of technical infrastructure
- design and implementation of clinical pathways
- patient and clinician experience
Using this approach, rapid implementation and evaluation of virtual consultations was achieved at RNOH with 87 per cent of consultations delivered remotely during the first six weeks.
The CSP’s Professional Advice Service gives advice and support to members on complex and specialist enquiries about physiotherapy practice, including professional practice issues, standards, values and behaviours, international working, service design and commissioning, and policy in practice.
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