Q Exchange

Co-design to innovate in Respiratory Outpatients in Gloucestershire

This project will use Experience Based Co-design to develop and evaluate alternatives to traditional, physician led, hospital scheduled consultations as part of a wider Integrated Respiratory Pathway

Read comments 29

Shortlisted idea
2019

Meet the team

Also:

Kelly Matthews - Gloucestershire CCG
Andrew White - GHNHSFT
Adam Usher - GHNHSFT
Kathy Campbell - GCS

What is the challenge your project is going to address and how does it connect to your chosen theme?

Within Gloucestershire there has been an inexorable rise in both new referrals and follow-up attendances within secondary care outpatient clinics. From 2017/18 to 2018/19 referrals rose by 17.8% (1213 additional referrals) and follow-up attendances rose by 4.4% (656 additional attendances). As indicated within these data, a large proportion of the new referrals do not result in subsequent follow-up attendances. Likewise, a significant portion of patients who do require to be under secondary care review, do not require scheduled face-to-face review, but rather a responsive service which can see them at the point of need.

We are exploring alternatives to face-to-face review for both follow-up and new referrals, in order to improve capacity, and also to better support primary care colleagues in managing these patients in the community. In order to assess this, we need to ensure that stakeholders, both from primary care and patient groups, are involved in development of new pathways.

What does your project aim to achieve?

To design an innovative service which is fit for purpose, we will engage both patients and referring clinicians. We will use their experience to co-design a new model for respiratory outpatient services. This must be a responsive service, suiting the needs of the patient, rather than the convenience of the hospital.

Funding will facilitate co-design of a new respiratory model to be piloted for a defined group of respiratory patients. Funding is required for EBCD workshops with stakeholders and patients and project development.

Funding is required time for formal evaluation of this pilot, using Patient Activation Measures (including MyCAW) and Patient Reported Experience Measures, conventional metrics and qualitative assessment to ensure the new model is acceptable to patients and clinicians.

Possible models may include:

– Hybrid telephone/face-to-face clinics

– Group consultations

– Primary Care MDT

– Symptom based diagnostic clinics

– Vulnerable patient primary care “board rounds”

How will the project be delivered?

This project encompasses patients, the secondary care respiratory team (consultants and specialist nurses), community respiratory team (respiratory practitioners) and CCG (GPs and commissioners). Funding will enable project management support and qualitative/engagement expertise to ensure the service is appropriately designed and delivered, including expertise in experience based co-design (EBCD). We will also require funding for formal evaluation of the new model.

An EBCD approach will be used to develop a new model, using both process and emotional mapping to agree an area and model to pilot. We will also make use of the QuIPPs panels to draw on independent patient comment and expertise.

This approach will mitigate the risk that models are not acceptable to stakeholders. This is an area we have explored for some time as part of a new the integrated service, in a new ICS, with particular strengths in Quality Improvement and integrated working between secondary and primary care.

What and how is your project going to share learning throughout?

This project will give valuable learning to share with other specialties within Gloucestershire, and also outside the area about what alternative models of outpatient care are acceptable to patients and community clinicians, and also which methodologies work (and which are more problematic) for evaluation of such services.

This learning will be shared with local services, but also within the Q community to help others develop innovative services to address a common need. We will seek to present our experience at regional meetings to share this learning and also to invite comment to allow further development.

We will develop resources for other local specialty services to facilitate development of similar models in other areas within the ICS. We have been identified as a model which may be employed, in the wider Outpatient Transformation in OneGloucestershire ICS; the project will sit within the wider scope of the “Attend Anywhere” outpatient improvement programme in Gloucestershire.

How you can contribute

We have been very grateful for all of the valuable comments from the Q Community on this proposal. As a result of comments we have been able to refine our proposal to include:
- QuIPPs panels as part of the development process
- EBCD as a central methodology; we also now have PPI and EBCD expertise as part of the team
- Local and specialty specific experience of use of patient activation measures
We will also explore segmenting patients based on their activation. Some patients may need more intense and potentially face to face type consultations where as those who are more activated might benefit from less traditional approaches.
We would still welcome:
- Experience of evaluation of new models of outpatient care; what time commitment, skills and tools have been needed
- What models of care have others in the community explored and piloted? What pros and cons have they experienced?
- What potential pitfalls to our approach do members of the Q community foresee?

Plan timeline

10 Jan 2020	Co-design workshops; patients, community and primary care
2 Mar 2020	Agreement and refining of model to pilot
1 May 2020	Start of pilot
1 Sep 2020	End of pilot and evaluation
19 Oct 2020	Conclusions, experience sharing and onward plan

Comments

Thomas John Rose 9 Oct 2019

Ad hoc process mapping is a great development tool. How you do it makes a difference. I'm sure that and final process mapping will help this project. Please let me know if I can help. Regards Tom
Bethan Page 4 Oct 2019

Great to see another product with co-production are the heart of it. I'd be interested to discuss how you going to ensure you get the views of a cross-section of patients. Do you have specific plans on how you're going to do that yet? Co-production is central to our project on supporting parents to care for kids with complex medical needs https://q.health.org.uk/idea/2019/supporting-parents-to-care-for-children-with-medical-complexity/ . We've got a couple of very engaged parents but keen to ensure we get input from a cross-section, and not just the most engaged parents! It would be good to keep in touch and share experiences.
1. Hein le Roux 13 Oct 2019
  
  Thank you Bethan, involving patients with chronic or complex challenges (often both) will be crucial in both your and our project's quest to improve care for these people. From my current 'Churchdown Connections' Q Exchange project, I have learned a lot about patient activation. As professionals, we can see patients as a homogenous group for which to position services when in fact, like all people, they are a more complex heterogeneous group who do respond to a much more personalised service.
2. Charlie Sharp 4 Oct 2019
  
  Thanks - I agree, sharing experience would be really valuable.
  
  Our initial approach is going to be to establish EBCD groups through local patient networks, such as Inclusion Gloucestershire, in addition to existing networks of patients already involved in PPI within the hospital. We are also making use of the QuIPPS panels, with a session booked in November to discuss the project and invite comments.
  
  Engaging respiratory patients is always challenging and we will be inviting involvement from existing groups, such as patients undergoing pulmonary rehabilitation or participating in support groups.
  
  I don't think there is a right or easy solution however.
Charlie Sharp 24 Sep 2019

We are really excited to be shortlisted with this proposal.

Since the original draught, we have refined things further and within Gloucestershire are now aligned to the wider transformation programme for outpatients. This proposal is going to act as a test-bed for the methodology which will be applied to further specialties (4 further in the first instance). As such the learning that can be gained is already being built in.

The acute trust has also recently appointed a Patient and Public Engagement lead with experience of EBCD who is going to be involved in this project.

Comments or suggestions remain welcome as we aim to make this as productive as possible.
Hein le Roux 28 Jul 2019

Good point and I like your process map Charlie that you developed out of the suggestion.
Thomas John Rose 19 Jul 2019

I'm sure you will have seen this toolkit but here is a link anyway:

https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/
1. Charlie Sharp 22 Jul 2019
  
  Thanks - as you say a very valuable resource which has guided our thinking.
Thomas John Rose 15 Jul 2019

Have you mapped the service design or re-design process so that all can understand and contribute to the process particularly co-design participants. I can help with the visualization of any process mapping if required.
1. Charlie Sharp 15 Jul 2019
  
  This is a great idea; I will work on a graphical depiction, but may well be in touch!
Thomas John Rose 15 Jul 2019

Do you have a list of possible alternatives to face-to-face review? If you could publish such a list you may get some views from people that have tried these in the past. Good luck with your idea.
1. Hein le Roux 28 Jul 2019
  
  Thanks, good to think about alternatives to face to face, but also to segment patients in who might best fit those groups based on their activation. Some patients may need more intense and potentially face to face type consultations where as those who are more activated might benefit from less traditional models of consultation. As part of the project we could look at this psychological aspect of human behaviour linking it to outpatient alternatives.
2. Charlie Sharp 15 Jul 2019
  
  Thanks for your comment. A short list of possible models we are considering (not exhaustive):
  
  - Hybrid clinic model; a mix of traditional, routine scheduled face-to-face review, routine telephone f/up, emergent/urgent telephone f/up and responsive face-to-face f/up as a result of patient contact at the point of need
  
  - Group consultations for COPD
  
  - PCN/Primary Care based MDT as part of an enhanced Advice and Guidance model. We already have a very mature A&G service in Gloucestershire, with Respiratory ambulatory care (SDEC) clinics, telephone and electronic A&G, so this would be MDT discussion in addition to these services
  
  - One-stop symptom based, multi-specialty and multi-professional clinics (eg. Breathlessness model)
  
  The key element to our proposal is that patients are central to the selection and design of a model to pilot, which fits to their needs.
Hein le Roux 9 Jul 2019

A thought provoking project Charlie & Sally. I am a GP and often wonder why patients need to go to hospital to have their care reviewed often in a regularly planned way which does not always fit with their symptoms. Then when they have an exacerbation, services can't always respond quickly increasing the risk of an emergency admission. Also, the care pathways often treat patients as one size fits all. I think the opportunity you have here is to include patients in 'what matters to them' rather then the traditional 'what is the matter with you' approach. I am sure patients will welcome alternatives to paying for hospital parking and waiting in outpatients for face to face opinions and advice that could so easily be delivered in other ways.You also mentioned being more bespoke in the offer to patients and I am sure this would help break down the traditional medical model and improve patient involvement in how they respond to their conditions.
1. Charlie Sharp 10 Jul 2019
  
  Thanks Hein
  
  Working on an updated version of this, but I agree with your points.
  
  Should prioritize a responsive service which suits the patients needs, not the hospital's convenience. As such co-design with patients (maybe through a workshop model) is going to be at the centre of this proposal.
  
  There are various models I can come up with, but what I think is a good idea and what patients would value may be different things!
Elizabeth Angier 25 Jun 2019

Hi Charlie and Sally,

I've just posted an alternative to outpatients for allergy with the possibility of Skype as a triage tool. Looks like there is some possible cross-learning from both our ideas so will look out for any comments you might have for us as well.

Liz.
1. Charlie Sharp 1 Jul 2019
  
  Thanks - will have a look at what you are doing. Skype is certainly a future model we are thinking about, but we won't have the technology in the near future!
Helen Davies-cox 25 Jun 2019

HI Charlie and Sally,

this is excellent, it appears that we are planning to similarly co-design redesign. We are looking at having an event covering 5 specialities and respiratory is one of the 5. We'd be keen to collaborate and share learning with you.

Just a thought, have you considered using the Patient Activation Measure (PAM) as an outcome metric, tailoring or risk stratification tool. It is a validated tool and I know a colleague in Gloucestershire who can gt you the free licences (if you are interested). When we have used PAM in respiratory follow-up patients, it demonstrated that the patient cohort had a lower level of activation than some other LTC specialities. We wondered whether this was due to a high level of elderly COPD patients, but did not come up with a clear answer.

Good luck on your project, please let me know how you get on.
1. Charlie Sharp 10 Jul 2019
  
  That's really helpful as another metric to consider in our evaluation. I'd be interested to hear your experience in more detail.
2. Hein le Roux 9 Jul 2019
  
  This also links to our wider Gloucestershire system work with social prescribing and health coaching. From my experience with our 'Churchdown Connections' Q Exchange project, PAM has helped us segment our target population and work out who might benefit from health coaching. We are also using MY CAW which we find is less medical model. There are a lot of potential patient and system benefits to a more targeted approach rather then the traditional one size fits all medical model. Good luck.
3. Charlie Sharp 1 Jul 2019
  
  PAM scores are central to a large amount of what we are doing in Integrated Care in Gloucestershire and are hugely valuable. The real struggle is getting the scores from the hidden majority; those patients who haven't engaged, but are the most vulnerable (and probably most in need of service)!
Sarah Campbell 24 Jun 2019

Wonderful focus on engagement. Would be great to get the insight and expertise of colleagues from last year's Q Exchange and their great work on engaging patients with QI: www.swahsn.com/quipps
1. Charlie Sharp 1 Jul 2019
  
  Thanks - that's really helpful. I've sent them an email!!
Jo Murray 21 Jun 2019

Hi Charlie

The Oxford work had only been running a couple of months - I'm sure they will have been evaluating this. I will contact the leads to put you in touch. I've sent you a private message through Q to get your contact details.

Thanks Jo
Jo Murray 20 Jun 2019

Great to see you exploring alternative models. Have you included physiotherapists in this work? Suggest linking with the Association of Chartered Physiotherapists in Respiratory Care (ACPRC) https://www.acprc.org.uk/

There are a couple of models in my region that may be of interest:

Oxford University Hospitals https://www.ouh.nhs.uk/news/article.aspx?id=980

AIR team East Berkshire https://www.berkshirehealthcare.nhs.uk/our-services/adult-healthcare/respiratory-service/
1. Charlie Sharp 20 Jun 2019
  
  Thanks Jo
  
  We have services like those highlighted from Berkshire already within the county, run by a multidisciplinary team of respiratory practitioners. This project is focused very much on moving care currently delivered by secondary care out into the community and preventing a need for patients to come up to the hospital.
  
  I don't know if your local experience in North Oxfordshire has been positive/helpful? Do you know whether any evaluation work was conducted?
  
  Thanks for your comments.
  
  Charlie
Anna Burhouse 20 Jun 2019

Hi Charlie, May be best to contact Professor Sarah Purdy and Dr Peter Goyder, Directors of the Integration to Avoid Hospital Admissions Health Integration Team (ITHAcA HIT).

best wishes

Anna
Anna Burhouse 19 Jun 2019

Great to see your idea here, Sally and Charlie. Is the pilot just for adults or for children too? I'm asking as I seem to remember that Bristol Health Partners did some really interesting work about paediatric attendances and information for parents.

Good luck and if I can help, just shout.

best wishes

Anna
1. Charlie Sharp 19 Jun 2019
  
  Thanks for your comment - currently only adults. Do you know who within BHP might be able to give me an outline of what they did in paediatrics? There may be some learning to share.
  
  C