A new report by the NIHR is a valuable resource for all physios.
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Cambridgeshire Community Services (CCS) NHS Trust shares how its DynamicHealth service integrated core principles from the Moving Forward review into clinically-led service redesign.
Drivers for change
DynamicHealth delivers musculoskeletal (MSK) services and pelvic health physiotherapy across Cambridgeshire and Peterborough. With 15% increases in referrals yearly and minimal increases in budget, mounting numbers of patients were waiting more than 18 weeks for specialist physiotherapy, leading to concerns from commissioners regarding RTT (referral to treatment) breaches. Patient complaints were multiplying and staff morale was plummeting, causing rising vacancy and sickness levels.
‘We were struggling to cope,’ explains Jenny van Maurik, Clinical Lead and MSK Physiotherapy Specialist.
‘Our waiting lists were four to six months long and we were constantly firefighting. On top of this, provision differed at each of our six hubs across the county due to the split of commissioning by geographical area, resulting in unequal service provision.’
With Public Health England data indicating further increases in demand and funding expected to remain static or even reduce, current service performance was unsustainable for both patients and the trust.
The service redesign process
In December 2016, we began an ambitious programme to review and redesign our DynamicHealth service in collaboration with other organisations and members of the Cambridgeshire and Peterborough MSK Sustainable Transformation Plan (STP). The objective was to develop a standardised, unified and equitable service for all Cambridgeshire patients, which was clinically and financially sustainable.
Our service redesign team visited each of our six hubs to identify what was working well, what wasn’t, and what the national drivers for change were. Two clinicians spent dedicated time each week on service redesign and time was allocated for clinicians across the service to be involved in specific work streams.
Using a variety of tools and techniques, including workshops to process map what the service currently looked like and our aspirations for the future, we engaged approximately 36% of our workforce in project groups, including the detailed development of new clinical pathways for the top five conditions (based on referral volumes) to reflect best practice and NICE guidance.
Using evidence at service level
We embedded core principles from the Moving Forward review into our service redesign programme. This included key evidence on matching treatment for back pain using the STarT Back tool, adopting a combined physical and psychological approach based on the Back Skills Training (BeST) programme, improving patient access to exercise and providing patients faster access to advice and exercises by expanding our telephone self-referral service.
‘We had started to use the STarT Back tool before the review was published, but we hadn’t fully embedded it across our service,’ explains Jenny.
‘Reading about the benefits the tool offered in terms of matching patients to the right treatment influenced our decision to implement it into our redesign programme, in particular to match the high risk group of patients identified using the STarT Back tool to the combined CBT and exercise classes.
This meant we were able to provide a low intensity pain intervention to patients who would otherwise have had one-to-one physiotherapy interventions’.
To help us adopt a stratified care approach, we introduced a number of initiatives to empower patients at low risk of persistent disabling pain to self-care in line with the national shift to supported self-management.
This included launching a new website as an online resource for staff, patients and health colleagues, which offers a leaflet library, animations and exercise videos to enable and encourage patients to manage their MSK conditions themselves (where clinically appropriate). Exercise and pain management programmes are also included for those at medium to higher risk of pain.
The website features a landing page with a body image that allows users to select where they’re experiencing MSK symptoms. Each body part has its own page containing information and exercise leaflets, and some pages include video playlists demonstrating exercises.
We also redesigned and expanded our telephone self-referral service ‘Physio Advice Line’ across Cambridgeshire and Peterborough to improve access to clinical expertise and advice.
Combined physical and psychological approach
Evidence from the BeST programme was integrated into our redesign and led to the introduction of understanding pain (UP) classes, which combine a cognitive behaviour approach with exercise, at all six community hubs. This means patients now have access to low intensity pain interventions closer to their homes.
Additionally, in light of overwhelming evidence that exercise is essential for health and should be a core treatment in MSK pain, our new service delivery model sought to improve access to exercise-based treatments.
‘We took on board patients’ feedback when designing and piloting improvements and created four new rehabilitation and exercise classes in line with this,’ explains Joe Piper, who was physiotherapy lead for the service redesign.
Almost all (90%) staff attended workshops, which helped to ensure everyone understood the new service model and its vision. Organisational change can be unsettling and we realised the importance of engaging staff early on and invested time to help them get on board to ensure the redesign was a success and so that they felt supported throughout.
‘The new service model saw a shift towards enabling patients to take an active role in self-management and using key research helped staff feel empowered to help promote this,’ adds Jenny.
Our service redesign team worked with the trust’s leadership team to help staff through the change process, and all clinicians attended health coach training to support patients to self-manage their conditions when clinically appropriate.
In addition, an educational package was created for our primary care colleagues and we presented and delivered training at numerous GP events and meetings to help spread the message about self-management. fl
Next time, we explore the benefits of implementing research into clinical practice at a service level
and explore the challenges involved.
Sarah Turner is Communications Officer (Corporate Services and Ambulatory Services) at Cambridgeshire Community Services NHS Trust.
With thanks to Sarah Saul, Joe Piper, Amy Edwards and all DynamicHealth staff
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