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Co-producing solutions to the outpatient challenge with patients

Large scale change is complex & often fails to deliver benefits. Public involvement in framing the challenge & making pragmatic, locally designed changes to ensure solutions meet citizen needs.

Read comments 11 Project updates 2
  • Winning idea
  • 2019

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

To reimagine the cardiac rehab pathway to enable flow, increase uptake and influence behavioural change.  Circulatory diseases cause nearly a quarter of early deaths and 90% of people with CHD have comorbidities. Demand is growing, yet the traditional outpatient model is unsustainable and often doesn’t meet need.  NHS systems are exploring alternative models. Locally we are cautious about implementing nationally endorsed solutions without understanding local needs. We propose taking a coproduction approach to designing a solution to the outpatient challenge, with a focus on Cardiac Rehab. People recovering from a heart or circulatory event should be offered support to help them live healthier lives, to protect against further harmful events. Such services reduce hospital readmissions and deliver better outcomes. We propose a project that brings together patients and clinicians to reimagine the pathway to enable flow, increase uptake and influence behavioural change.

What does your project aim to achieve?

  • Enable flow: Following a cardiac event patients are often transferred to a specialist centre but on discharge a referral to the local Cardiac Rehab team may not be made and patients can be ‘lost’. Using lean methodology the project will seek to eliminate this ‘defect’.
  • Increase uptake: Cardiac Rehab is mainly group-based, at a hospital setting. Certain groups are less likely to take up services like this. The project will explore the obstacles and reimagine the pathway to increase uptake. The BHF report that an increase of just 15% could lead to c.20,000 fewer deaths and c.50,000 fewer hospital admissions over 10 years in England.
  • Influence behavioural change: To manage their long term condition people must often make behavioural and lifestyle changes. E.g. reducing salt intake to 6 grams per day for adults by 2023, could prevent over 8,000 early deaths. Using these sorts of examples, we would identify common themes and develop a more holistic behavioural recovery programme.

How will the project be delivered?

There will be two key components:

1. A Rapid Process Improvement Workshop (RPIW): A 12-week research and evidence gathering exercise will culminate in a RPIW to review the current value stream, identify wastes and develop a new pathway, supported by standard work to sustain change. The RPIW team would include patients, carers, clinicians and managers working within the local Integrated Care Partnership and representatives from the three other ICPs that make up the Integrated Care System (ICS).

2. Using the Easy Attractive Social Timely (EAST) framework to apply behavioural insights to healthcare:  In the planning stage of the RPIW, a workshop to understand behavioural insights would be run to ensure that concepts, tools and techniques were understood by the participants prior to the RPIW event. The workshop would talk the RPIW team through how to define the behavioural change, how to apply science to understand it, how to develop solutions and how to test and learn, using PDSA cycles.

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

Testing and learning will be fundamental to success and a variety of mechanisms will be used:

  • Formal project structure: a project working group, to ensure strong governance, regular communication and day to day management
  • Web-based communication: a webpage, to post regular updates about the project, with social media used to share updates, particularly across industry relevant platforms such as the Future NHS Collaboration Network (and the Q community).
  • Systems learning: whilst the project will start in the G&W ICP there will be involvement across the ICS to ensure awareness across the system. The focus will be a sharing event at the end of the project to identify opportunities to sustain and spread the solutions
  • Interaction with existing networks: the plans and outcomes will be shared through existing networks e.g. Cardiac Rehab networks
  • National platforms: there is support for the project from the British Heart Foundation, who will be involved and can help share the learning nationally.

How you can contribute

  • We would appreciate help to promote our idea to help garner support. We would also welcome any members who wish to get involved with delivering and developing our idea. Finally, if anyone is in the Guildford and Waverley locality and can link us up with other support, such as offering a venue for engaging with our citizens within the pre-event workshop etc. that would be really valuable.

Plan timeline

26 Aug 2019 Rapid Improvement Event scoping workshop
2 Sep 2019 Begin the 12 weeks of research and evidence gathering
11 Nov 2019 Hold EAST framework for participants pre-RPIW
25 Nov 2019 Hold RPIW W/c: 25/11/19
2 Dec 2019 Evaluation and next step planning

Project updates

  • 16 Feb 2021

    6 months since we last posted – and it is change again! The further 2 national lockdowns and second COVID wave have had a significant impact on our system priorities and our resources have had to shift to support emergent pressures and priorities. Like many others, we have learnt so much from these shifts and gear changes but it has meant that we have been delayed in achieving other goals we had hoped to work on.

    We are now in a position where we feel able to refocus again and now we want to progress the coproduction element of our bid. A whole year behind schedule, but I guess that that is a reality of delivering health and care services during a pandemic!

    Our plan for the next few weeks is to assess the current state of how we use coproduction, codesign and public engagement in service change and improvement work. We will review all of our toolkit and guidance documents and then look back to see how these were used and applied in practice.

    So far our findings are pretty predictable – we have lots of information and resources available. There are pockets of really incredible practice and some highly skilled staff. But there is a variation in how well these toolkits are applied and quite often there is limited evidence of coproduction or codesign taking place throughout the change process.

    Our next step is going to be using this information to rethink and redesign our approaches to improve and increase our use of coproduction – we will then test the change in a few areas (maintaining a focus on Outpatients, this will be tested with services using virtual consultations, and will include Cardiac Rehab).

    Any ideas from members of their learning in this area are really welcomed. We want to know anything that could be relevant but in particular if there were any changes made in systems that really increased the use and application of coproduction tools and approaches and if there are any resources we might be able to review to help inform our next steps?

  • 25 Aug 2020

    In light of the post COVID pandemic, our cardiac rehab project has changed significantly since its initial conception. The original intention was to understand why individuals who have experienced a cardiac event refused the option to take up rehabilitation services to support healthier lifestyle choices.  The extract below is from the original brief:

    “Circulatory diseases cause nearly a quarter of early deaths and 90% of people with Coronary Heart Disease have one or more long term conditions. Demand is growing, yet the traditional model of outpatient services is unsustainable and often doesn’t meet patient need. We propose a project that takes a coproduction approach to designing a solution to the outpatient challenge, with a focus on Cardiac Rehab. People recovering from a heart or circulatory event should be offered support to help them live healthier lives and protect against further harmful events. Such services reduce hospital readmissions and deliver better outcomes but only half of those eligible take up these services. To understand this, we had aspired to bring together patients and clinicians across the system to improve the existing pathway using a rapid improvement event to review the current value stream, identify the wastes and develop a new pathway, supported by standard work to sustain the change.”

    During the Covid response and recovery phase, the Cardiac Rehab team made a number of significant and rapid changes to service delivery. Within this context, the original project remit no longer felt fit for purpose and on review, the project team wanted to re-scope the purpose of the quality improvement intervention.

    The cardiac rehab team evaluated the current service using the local Provider quality improvement tool, collective sense making approach, in order to understand the following:

    ·       What activities have been introduced to respond to the immediate demands specific to the pandemic crisis?

    ·       What new activities have we been able to try and have shown some promise of continuation in the future?

    ·       What activities have we been able to stop that is no longer fit for purpose in this new normal?

    ·       What activities have we had to stop in order to focus on the pandemic crisis but now need to be picked up in this new normal?

    Following this evaluation, we have revised our focus for quality improvement activity. The cardiac rehab team have strongly reflected that the virtual initial assessment process has improved accessibility although it has not been an approach for everyone. Whilst the new initial assessment approach is still at the learning phase, we have recognised the real benefit in applying Quality Improvement methodology such as Plan, Do, Study & Act (PDSA) in order to facilitate team learning in a live environment and to then codify a standard approach to this activity. Application of the PDSA approach in this project will replicate some of the benefits seen in the style used in the Covid response phase (whereby QI and Programme Management colleagues ‘lessons learned’ reflections strongly highlighted the value of implementing rapid test of change cycles). The project team is keen to build on this learning and apply the approach within this Cardiac Rehab project.

    In conclusion the ‘current state’ of services has completely changed over the Covid period. The increased range of service offered and accessibility that has emerged during Covid has certainly expanded opportunities. It feels like it is no longer relevant to undertake an end to end process redesign and improvement event however, patient engagement around the changes to delivery would be really valuable to understand what can be done to drive a new normal forward and there is significant opportunity to apply the PDSA approach to refine the virtual initial assessment model, and to codify an intervention that could be shared more globally across other services, to support service delivery and improved access into Covid recovery and beyond.


  1. Great to see the RPIW approach. Can confirm that it is very empowering for patients (based on own experience in North Cumbria Acute Trust) but hope that patients will have the time to understand the tools, and to just "feel their way".  It will need time.

    Great to improve the patent pathway in this field and that it is applicable to other areas.

    Good luck everyone


    1. Many thanks for your support Sue

  2. Hi Michelle,

    I really like your idea, particularly the mixing of theory bases to bring about better improvement.

    I think the lessons you learn in your project and the ones in our Outpatients Innovation Collaborative could compliment each other.




    1. Many thanks for your support Tony, your Outpatients Innovation Collaborative sound very interesting!

  3. I think it would be useful to say more about how you intend to recruit patients and members of the public into your project. I think it may be useful to explore with a PPI group why the uptake is so low.  I would be interested to know more about the Research and Evidence gathering step and the end product. Will there be a list of behavour recommendations on a piece of paper for patients or will ther be other practical tools for them to implement this 'new' behaviour? Also, I would be interested to know more about how you will overcome the barriers of working with a wide mix of patient demographics.

    1. Thanks for taking time to comment Michaela, you certainly have given us some food for thought!

  4. Hello


    I was wondering which social media platforms you intend to use to sign post participants to your website?

  5. This is a lovely idea. I find it somewhat frustrating that you talk about coproduction, but don't have any patients listed as team members.

    1. Unfortunately I can only add Q members to the team on here and also I wouldn’t want to name patient representatives without their consent, but we are of course working with patients. Thanks for the support!

  6. More wonderful ideas and work from Surrey.  Are you linked with the the wider work on this at STP level?

    Wondering if other Q applicants want to do any joining up on the co-production work?  What might we do at scale...  Have you spotted/engaged with the other co-production projects?

    1. Yes we are linked with the wider STP.  The project is being jointly designed by colleagues in the local CCG and the ICS.

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