Person Centred Care Programme in Sheffield End of Year Report 2016 -2017 Ollie Hart and Eileen Hall
Person Centred Care Programme in Sheffield 2016 – 2017 1
ContentsExecutive summary..........................................................................................................5 Background and Context.................................................................................................7
Local and national context............................................................................................7Evolution of the service specification across the 3 years..............................................8Project support..............................................................................................................9Examples of activities:...................................................................................................9Clinical lead.................................................................................................................10Locality Support Team (LST)......................................................................................10
Outcomes from year 3 (2016-17)...................................................................................12Engagement with specific development opportunities:...............................................13Level of overall engagement with the LCS as judged by the LST...............................14Patient Survey Results:...............................................................................................15
Learning..........................................................................................................................16Key themes seem to be emerging:.............................................................................161. Variation in grasping the ethos and concepts of PCC.............................................162. Variation in levels of practice engagement.............................................................173. Adoption of PCC approaches, tools and system changes:....................................194. Measurement of change in patient self-management.............................................215. Reflective learning...................................................................................................22
Future recommendations................................................................................................23Balancing Vision and pragmatic starting points..........................................................23Developing Practice Engagement...............................................................................24Directive v Flexible approaches towards Locally Commissioned Services.................24Practice Ownership.....................................................................................................24What’s in it for me?.....................................................................................................25‘Practice centred approach’.........................................................................................25Highlight ‘positive deviants’.........................................................................................26How to build ongoing engagement across Health system:.........................................26Developing patients that champion PCC....................................................................27Ongoing data collection to support the case for PCC.................................................27
Appendices....................................................................................................................30
Person Centred Care Programme in Sheffield 2016 – 2017 2
End of Year Report 2016 - 2017
Appendix 1 – Examples of positive changes in practice.............................................30Appendix 2 Share and Learn Event November 2016..................................................32Appendix 3 – Neighbourhood Report May 2017.........................................................33Appendix 4 – Information from Insignia: example of how data can be displayed........38Appendix 5 – Patient Survey Feedback......................................................................40Appendix 6 – Examples of what works well in Practices.............................................41
Person Centred Care Programme in Sheffield 2016 – 2017 3
Many thanks to everyone who has contributed to this report
To all our patients, carers and users of the services GP Practices and Staff Locality Support Team Sheffield Citizens Reference Group All colleagues across the Health and Social Care System in Sheffield Colleagues from Insignia and NHS England
For further information, please contact:
Ollie Hart, Clinical Lead for Person Centred Care Sheffield Clinical Commissioning Group GP Partner Sloan Medical Centre Sheffield Clinical Lead for RCGP Collaborative Care and Support [email protected],
Eileen Hall, Commissioning Manager Person Centred Care Sheffield Clinical Commissioning Group [email protected]
Person Centred Care Programme in Sheffield 2016 – 2017 4
Executive summary
80% of the city’s practices took part in the schemeThis report marks the end of year 3 of a 5 year programme. The Locally Commissioned Service (LCS) underpinning the programme aims to support practices in the difficult and complex paradigm shift towards person centred care (PCC). It aims to incentivise and encourage the range of activities that contribute to PCC, and build an ongoing local evidence base for what works in which circumstances.
We recognize the challenges in supporting practices at different levels of change across time, and the difficulties of sustaining and developing improvement in the context of significant time and resource pressure.
We describe the important roles of the Support Team for the programme - Project Coordinator, Clinical Lead, and Locality Support Team.
In year 3, 69 out of the city’s 86 practices took part in the scheme. They wrote their own plans for what they would do to fit their own populations best, and reported back on progress at 6 and 12 months. This covered a range of different patient cohorts, totaling 17,000 patients (3% cities population). 12,000 Patient activation measure tests where captured in the year.
Our assessment of practice returns suggested 44% of practices fully engaged in the aims of the LCS, 36% partially engaged, and 20% did the bear minimum to qualify for practice payments.
52 practices submitted additional case stories, of which 36 were judged to be high quality.
We describe and expand on some key learning and key themes emerging from the programme covering:
1. Variation in grasping the ethos and concepts of PCC2. Variation in levels of practice engagement3. Adoption of PCC approaches, tools and system changes4. Measurement of change in patient self-management5. Reflective learning
Person Centred Care Programme in Sheffield 2016 – 2017 5
As a result of our observations we make 12 key recommendations, for the future of this LCS and for other sites aspiring to replicate our aims of embedding PCC in primary care:
Person Centred Care Programme in Sheffield 2016 – 2017 6
Background and Context
The overall aim of this 5-year programme is to progressively introduce and embed PCC approaches into primary care, such that they become part of the usual way of practice. We recognise that this represents a significant culture change
This report is intended to reflect on the progress so far at the end of year 3 of this 5-year project. It aims to describe the evolving process that we have been following to achieve the aims of the service specification, report on lessons learnt so far, and indicate our views on how NHS Sheffield (and others) can gain best value from pursuing such locally commissioned services.
Drawing from a range of definitions we would say in our context PCC is about creating the conditions for people (primarily with long-term conditions) to be active partners in their health care, supporting people to be a resource to themselves and to the care systems. It involves a different approach on the part of commissioners, health and social care professionals and their patients. The Year of Care team describes this as the ‘house of care’1
We will not repeat the arguments for person centred care and the associated activities of collaborative care and support planning, shared decision making and supported self-management. The benefits of PCC in primary care, in terms of better health outcomes and more efficient services are now well established23
Local and national context
It is clear that developing self-management is seen as core part of NHS future plans, with a whole chapter (1 of 4) of the 5 Year Forward View dedicated to this. In Sheffield’s portion of the regional STP there is a strong commitment to person centred approaches. It articulates an aspiration across NHS, Local authority and all collaborating partners to develop a person centred city.
What is less clear is exactly how this is to be achieved. Potential funding models and delivery systems have been articulated by a range of bodies including NHS England, 1HTTP://WWW.YEAROFCARE.CO.UK 2HTTP://BJGP.ORG/CONTENT/66/642/12.SHORT 3HTTP://WWW.RCGP.ORG.UK/CLINICAL-AND-RESEARCH/OUR-PROGRAMMES/COLLABORATIVE-CARE-AND-SUPPORT- PLANNING.ASPX Person Centred Care Programme in Sheffield 2016 – 2017 7
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Kings Fund, The Health Foundation, Nesta, National voices. An excellent recent report from a 2-year scoping project involving many of these groups called ‘Realising the Value’4, reported on the range of activities likely to achieve more person centred care. They highlight 5 specific activities- Peer Support, Self-management education, Health Coaching, group health promotion, asset based approaches. These should be delivered across the broadest spectrum of the health settings, including community and social care settings.
It is also not clear what sort of measures of success we should be employing. The end outcomes of improved health metrics (such as BP, BMI, or Hba1c), or reduced utilisation of resources often require a significant amount time to be realised in a meaningful and robust may. This project has therefore searched for effective early objective makers of change. We have strongly encouraged the use of the Patient Activation Measure, as there is good evidence that it can be used as measure of change in patient self-management skills, knowledge and confidence. Evidence shows that improving PAM scores leads on to improvement in the end outcomes described above. It can be seen as an early marker of these longer-term changes. It also has the added validated utility of helping to improve the quality and effectiveness of PCC by tailoring approaches to different levels of activation.
This ambitious LCS sets out to support practices in establishing answers to some of these unknowns. It incentives them to trial new ways of working and to consider how to measure the effects of these changes, and reflect and learn from the results. The core project management team performs the role of supporting system changes, sharing learning, and helping the whole system to develop collaboratively.
Evolution of the service specification across the 3 years
The first year started with quite an output focused approach with a strong focus on producing a care plan for people with complex long-term conditions. Collaborative Care and support planning, is recognised as being one method to generate PCC. However, it requires a good understanding of a partnership approach to developing the plan, with as much value applied to the process as the output of the written plan. Feedback from clinicians and patients indicated that simply paying practices to produce a written care plan, does not actually achieve a meaningful shift in mindset, behaviour or culture.
In year 2 whilst that attention was still focused on care planning, more effort was paid to educating people about the overall aim of the care planning process, and how it fits into PCC as a whole. We also introduced the concept of patient activation (people’s skills, knowledge and confidence to self-manage), as an important factor in the success of PCC. After considering all available options the PAM was chosen as the best available measure of a patient’s capability to self-manage. The incentives for the 2nd year where designed to encourage the development of skills and capacity to embed the use of PAM into patient management.
Whilst the service specification for the first 2 years were quite directive, the natural progression for year 3, as practices were becoming more familiar with PCC and PAM, was
4HTTP://WWW.NESTA.ORG.UK/PUBLICATIONS/REALISING-VALUE-TEN-ACTIONS-PUT-PEOPLE-AND-COMMUNITIES-HEART-HEALTH- AND-CARE Person Centred Care Programme in Sheffield 2016 – 2017 8
to produce a much less directive specification. The aim being to allow more freedom for innovation and ownership; practices had more scope to select cohorts of patients that they felt most appropriate for PCC, and in who they felt most confident of success. We hoped that giving practices more autonomy in deciding their own plan for the year, would engender stronger engagement, and widen the opportunity for innovation and learning. Within this we still maintained the requirements for some measurement of change, with a recommendation that PAM is likely still the best tool. However we did not specify that PAM must be used if some other measure of change was felt more appropriate.
The intention for year 4 and 5 is to further evolve the specification to support the process of practice engagement. We recognise a balance between allowing autonomy and clarity of the ‘ask’ needed to achieve payment.
The CCG has maintained a commitment to fund the LCS at around £450k / year.
Project support
Project Coordinator
This is a full-time role and has been central to the smooth and sustained progress of the project. This person works closely with the Clinical Lead, and focuses on relationship building and interaction with practices. The Coordinator acts as a first point of contact for practices, providing feedback on returns, explaining the specification and negotiating timings and degrees of engagement to flex with practice pressures, and helping to facilitate practice engagement. They develop and maintain all the written and personal resources to support the project.
Examples of activities:
Coordination and Facilitation: Practice visits and development activities Learning Sessions Review “panels” Coordination of case study development Share and Learn events Evaluation and Learning and LST Meetings : updates and information Learning sessions to support PCC LCS development and monitoring processes
Development and sharing:
Production of Guidance to support the LCS, Practice Plans and Case Studies Contribution to and delivery of development sessions to support PCC
approaches including practice development meetings, Health Coaching and skills sessions
Production and updating of Intranet resources Working with practices to Identify and share "what works well”
Relationship building:
Person Centred Care Programme in Sheffield 2016 – 2017 9
Practices /Primary Care Sheffield (GP provider group)/LMC/Sheffield City Council
LST/ CCG governance Group Coordination of Share and Learn Events November 2015; April 2016;October
2017 Encouragement of practices to facilitate tables at Sharing Events in
November 2016 Liaison with external agencies re sharing and updating i.e. NHSE, Insignia
other organisations interested in our work Making links to include PCC at every opportunity in other city programs e.g.
Active Support and Recovery; IPC; EOLC; Primary Care; Neighbourhoods.
Clinical lead
A one session per week role for a lead GP, this role ensures clinical relevance and acceptability of the project. There is also a key role in leading specification review and design, training and education. The person in this role has held a range of national roles in the field of PCC which has helped inform local practice and maintain credibility of the project. The Clinical Lead has a key role in interacting with peers in GP practices to encourage engagement and sharing of learning, and to take account of practice feedback.
Locality Support Team (LST)
A group of practitioners who are offered backfill payment for their services and are available to support practices to embed PCC approaches. The LST are champions for person centred care within their day to day activities and have the opportunity of being at the forefront of developing person centred care. Throughout the project they have been offered, and generally taken up, additional training in a range of PCC skills. I.e. Health Coaching, Motivational Interviewing, problem solving, mentoring.
Typical members of the LST: Coordinator GPs x2 Practice Managers x2 Practice Nurse x1 Primary Care Development nurses (PCDN) x2 Community Matrons x4 South Yorkshire Housing Association x1 Service user x1
The LST have also played a key role in assessing and providing feedback on practice submissions (Plans and end of year reports). This enables a wide MDT perspective, and a richer range of comments.
Person Centred Care Programme in Sheffield 2016 – 2017 10
Examples of specific activities forming year 3 (2016-17):
November 2015 Share and Learn Event - all practices invitedSharing learning to date ; developing and guiding practices through LCS for 2016
April 2016 Share and Learn Event - all practices invitedTo share learning to date ; developing and guiding practices through LCS for 2016
May 2016 Practices submit a plan stating how the LCS would be achieved : identifying which cohorts of people this approach would work best with
October 2016 Review the plan, assessing progress against their targets ; identifying opportunities and challenges ;learning from using the PAM
November2016 Share and Learn Event - all practices invitedto share learning to date ; 6 practices facilitated table top sessions sharing their learning with others; keynote speakers from NHSE; guidance provided for case studies
January 2017 Case study "drop in sessions" to support practices with the development of case studies
February 2017 Review of the plan; sharing learning, areas of good practice; changes in PAM scores and their relevance to practice : changes in practices, development of new practices ;changes in patients and staff behaviours ;
March 2017 Option to produce case studies describing the learning from using a person centred approach : patients and staff
Outcomes from year 3 (2016-17)Person Centred Care Programme in Sheffield 2016 – 2017 11
Section 2
Practices chose a range of cohorts of new people they wish to work with to develop new care plans:
people with COPD
people with Diabetes
people with Palliative Care needs
older people living alone
people with multiple long-term conditions
people who are new immigrants to Sheffield who have long term conditions
people with mental health problems
people with dementia
people identified by the Avoiding unplanned Admissions DES
people identified by other risk stratification - e.g. frailty index, Combined risk prediction tool
people identified as high users of A+E
a number of practices combined the above and in addition used pcc in an opportunistic way
The total numbers of people included in practice cohorts was approximately 17,000, which equals approx. 3% of the city’s total population.
Total number of PAMs completed in year = circa 12000
Engagement with specific development opportunities:
Person Centred Care Programme in Sheffield 2016 – 2017 12
Activity Number of staff
PAM on Line 358
Motivational Interviewing 45
Share and LearnApril 2016November 2017
120 (representing 59 Practices)
Stop It, Do it Health Coaching
36
Lunchtime LearningSessions
30
Practice visitsSept 2015- April 2017
48
Hits on PCC pages on intranet (April 16-April17)
2449
Level of overall engagement with the LCS as judged by the LST
30 Practices Fully engaged with the Produced timely reports
Person Centred Care Programme in Sheffield 2016 – 2017 13
(43%) process Demonstrated learning and reflection on PCC approaches and the benefits it can bring to patients and staffHave actively sought support from the LSTHave engaged with development sessions and contributed to the processProduced reflective case studies and are open to new ideasCan provide examples of changes in systems, process and behavioursRemain challenged by the process
25 Practice(36%)
Engaged Fulfilling requirements of the LCSWorking toward PCC provide minimal belief in and evidence of changes and benefitsProduce case studies which provide minimal reflectionAre engaged with support on offerRemain Challenged by the processWilling to continue
14 Practices(20%)
Minimally engaged "Tick the box"Little evidence of changes in practice, thinking or behaviour
Practice plans and reviews were submitted to a panel of individuals in the CCG – mainly comprising of members of the LST in addition to other people who have an interest in PCC approaches e.g. Locality Support Managers, Public Health Principal, and Quality Team.Plans were rated as:☺ Examples of good practice, changes in behaviours, learning for using the PAM; qualitative and quantitative evidence; Minimal examples of any changes and learning ☹ No examples of any learning / quantitative evidence
Overall ratings: See Appendix 3
Submitting Case studies was an optional part of the LCS contract and was intended to enable practices to reflect on their learning to date. Guidance was provided to support the development of case studies – this together with key dates had been sent to practices twice and posted on the intranet, discussed at the Share and Learn events in April and November . Three dates had been outlined as “Case Study Drop In sessions” to support the process- these were not taken up. 2 practices asked for support visits prior to writing the case studies; 12 practices asked for feedback on their first submission; 10 practices decided to incorporate the feedback, 2 practices did not. 103 case Studies from 52 Practices within 15 Neighbourhoods were submitted; 38 Case Studies to be shared across the city.
Person Centred Care Programme in Sheffield 2016 – 2017 14
Patient Survey Results: These results are obtained from patient Surveys from July 2016 – June 2017
Comments from Patients:
Person Centred Care Programme in Sheffield 2016 – 2017 15
Learning
Key themes seem to be emerging:
1. Variation in grasping the ethos and concepts of PCC
It is clear from the evidence in practice reports and case studies that there is significant variation in how practice teams understand and conceptualise the theory of person centred care. As leaders of the project we are clear this is a new paradigm for interacting with people with long-term conditions. It is a personalised approach that seeks to develop a person’s capability to self-care, within the context of ongoing medical support (and the capability of their support networks, where relevant) This ethos is played out in certain activities such as the process of developing a collaborative careplan, proactively coaching people to develop their self-management, and involving people in shared decisions. Implicit in these activities is a different type of ‘conversation’, that recognise the value of that persons own resources, and seeks to build on these assets, however small. The end outcome is aimed at building skills, knowledge and confidence to self-care, improving self-efficacy, and overall wellbeing of the person living with the LTC. These activities are not the only way to achieve this, they are proposed as a way of making it easier to grasp ‘what to do’. We would hope that practices that fully grasp the concept of PCC would describe a range of approaches that fit for their context and demographics, and indeed we have observed this in practice.
Where practices have really grasped these concepts we have seen:
Evidence of how the person was involved in their own care; genuine enquiry into finding out what is important to the patient
Recognition of and reflection on the relationship between an individual’s knowledge skills and confidence and positive changes in their health and wellbeing, behaviour and biometrics
Demonstrable evidence of reflective learning on an individual and team level, describing how practice has changed as a result of adopting a person centred approach (e.g. Shared medical appointments; clinics for particular groups of people; patients triaged according in to their PAM score ,determining which practitioner they are seen by)
Person Centred Care Programme in Sheffield 2016 – 2017 16
Section 3
Involvement of a wider network of people other than practice staff ( including Community Support workers/ Age UK/ Community Nurse/Local Community input)
We have observed that practices that appear not to grasp the ethos and concepts of PCC focus purely on the delivery of isolated aspects of this approach, without considering the overall aims of PCC. This can lead to activities been seen in a negative light, as ‘bolt on’, or ‘irrelevant’ and detracting from the job of usual care rather than complementing it. It can also lead to the actual practices being far from collaborative.A common example of this is evidence where practices describe a management plan as opposed to a care plan. A care plan would reflect evidence of a much more collaborative approach; it is likely to reflect everyday language, with smaller steps and more specific outcomes.We would suggest a management plan is very much an expert led plan, where direction is proposed based on their knowledge of clinical risk factors. The language is usually very medicalised, the goals vague and nonspecific, and often out of proportion to what might be expected of someone’s level of activation:
Focus on patient compliance, not engagement
No evidence of shared decision making, joint goal setting and review
Little evidence of discussion of how the person was involved in their care. Little evidence of shared decision making “We’ve done care planning for years”
Little or no evidence of reflective learning or any attempt at changes in practice
Of course it maybe that for the purpose of reporting the details of a more collaborative approach has been lost in the reporting, however this reflection is backed up by conversations with practices, and reflections of observations from the LST.
2. Variation in levels of practice engagement
With the above variation being observed it is perhaps not surprising that we have seen significant variation in practice engagement. Some show high levels of ownership, with clear evidence of developing practices and approaches beyond the basic remit of the LCS. Others demonstrate minimal engagement, with a clear articulation of wanting to simply ‘tick the box’ to qualify for payment on the LCS.
We recognize that it was a common feature of fully engaged practices that they had a particular individual who championed their practice engagement and drove internal changes. This could be a GP, manager or nurse.
Person Centred Care Programme in Sheffield 2016 – 2017 17
Our assessment is that 43% of practices taking part in the scheme have demonstrated clear evidence of good engagement, 36% have partially engaged, and 20% practices in the ‘tick the box’ group.
Typically highly engaged practices demonstrated:- Examples of a MDT involvement across the practice team, as opposed to it being a
single practitioner focused process- Wider community team involvement utilising the voluntary sector (e.g. health trainers
and champions), local authority staff (community support workers), - Integration into ongoing regular systems of care rather than a bolt on service- Reports tended to be written by clinicians rather than the management team
Features of Engaged vs Less Engaged Practices:
Engaged Practices Less engaged Practices
Leadership Enthusiasm, strong clinical and managerial leadership for PCC ; MDT approach within and beyond the Practice Team
Little enthusiasm and thus less , Clinical and managerial leadership for PCC.PCC remains the responsibility of one member of staff - commonly the Practice Nurse
PracticeVision
Belief that working in a different way can make a positive difference to patients and staff ;acknowledgement that systems , processes and behaviours may need to alter to assert that change . Linking PCC with other priorities within the practiceAcknowledgement that cultural change takes time - transformational mindset
Belief that “we have been doing this for years”. “What do we have to do to tick the box” PCC is seen as just another thing to do and is not linked to other priorities.Transactional approach
Relationship with CCG
Have engaged with development activities on offer and have taken up LST resources and support ; assertively challenged the requirements of the LCS to make it relevant to their way of working
Less engaged with the CGG for a number of reasons e.g. historical experience ;some engagement with LST resource and support
Workload PCC incorporated into other systems, processes
"We are too busy to do this"
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PAM Understanding how PAM can support in tailoring approaches and be used as outcome measures“Even though the PAM has not increased, the patient feels she is now involved in her own care."
PAM is seen as a barrier" the questionnaire is difficult to understand" "patients don’t like it"
3. Adoption of PCC approaches, tools and system changes:
We observed evidence of a wide range in the demonstration of activities that underpin PCC.Those returns judged to be of higher quality showed evidence of training in, and application of: e.g. new clinical skills such as health coaching and Motivational Interviewing approaches; accessing the PAM online training tool; accessing the reporting / "Template Training" sessions
Examples: “The entire clinical team undertook a coaching session … to try to help us as
a team, to engage with our patients”
The PAM scores are useful, because it allows you to see how well the patient understands their own health, medication and in some cases, they even feel it is their responsibility.
Productive use of facilitating tools:The Project Coordinator and LST promoted access to supporting resources and tools on the CCG intranet. We describe above the use of these. However, it was really encouraging to see some practices developed their own tools and resources to support PCC in their context – see appendix 6 for examples
Valuing tailored approach to care - especially recognising small steps at lower activation levelsWe have specifically highlighted this point as it is clear that this is one of the key features that evidence successful adoption of PCC. We have observed that where practices evidence a strong personalised approach they recognise the need for a different approach to people with lower levels of activation
Examples from Practices:
"Just by focusing on one small area (she) has managed to succeed in improving her general health and wellbeing.”
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“It’s been recognised within the team that some patients need smaller scale improvements/targets and that there are just as valuable as larger targets.”
“The team recognises that some patients may need to firstly agree that they can take responsibility for their own health and can take small steps to improve their own health. ……there are frustrations that improvement is not seen quickly for some patients.”
“PAM scoring has enabled us to focus on patients with lack of understanding” “As this patient has a low activation level, we need to have regular follow up
appointments to review the patients goals on a regular basis” "Due to the activation level of 1 being identified our nurses were aware that she
needed to build her basic knowledge and our nurses needed to promote self-awareness"
When we observe more of a disease focused approach (more of a one size fit all management plan), we see descriptions of very ambitious goals and action plans that often aren’t achieved
Examples from Practices:
"To maintain blood sugar readings within a normal range" "Maintain own independence with the support of the surgery staff, warden at the
home and friends and family" "Goal to reduce weight and BMI"
System changes
It was encouraging to see some evidence of new pathways of care incorporating PCC approaches. Again this implies a much higher level of engagement.
Examples from Practices: Shared medical appointments, involving wider MDT at Hackenthorpe Development of “Virtual Ward “ at Dovercourt Development of “pre Desmond” Diabetes group programme at Sothall Using Ok To Stay Plans for a specific group of frail older people city wide
4. Measurement of change in patient self-management.
We know this is a challenging area to evidence change. We had actively proposed the use of PAM as a validated means of measuring change in the underpinning skills, knowledge and confidence to self-manage. We have seen a significant uptake in the use of PAM. We saw increasing evidence of baseline scores, but limited evidence of capture of follow up Person Centred Care Programme in Sheffield 2016 – 2017 20
scores, and even less reflections on reasons for any observed changes. We recognise that it may still be early in the process of change for these changes to be observed as often repeat scores are captured at 6 or 12 monthly intervals.
Never the less, it is encouraging to see so many practices proactively train their staff in the appropriate introduction of the PAM tool, and there is some early evidence of improvement in PAM scores in those more engaged practices that are starting to capture repeat PAM scores
This chart from one practice shows the distribution of patients second PAM score in relation to their first by starting level of PAM. It shows strong shift to improvement in levels 1 and 2, less so in level 3, and in level 4 a trend towards a lowering of PAM score. This is as might be expected as less activated patients become more engaged, and the most activated become more ‘realistic’
It is interesting to note that every practice plan choose PAM as their measure of change with no other suggestions for objective measurement of change in patient’s self-management capabilities.
5. Reflective learning We observed that this was the most challenging aspect of the LCS to demonstrate. We recognize that having both the willingness and capacity to engage in meaningful reflection on changes in approach is difficult in the current highly pressurized environment of primary
Person Centred Care Programme in Sheffield 2016 – 2017 21
care. There are multiple competing demands on time. Despite there being reasonable resource allocated to practices as part of the LCS, with the intention this would allow some backfill cover to free clinicians to reflect, we recognize that the practicalities of meeting day to day patient demand, make this very difficult to achieve.
Where there was evidence of reflection, this was a felt to be a good marker of engagement, as it indicates the value placed on new activities. Good returns showed high levels of deep thinking and reflection, with evidence that this had been discussed as a team, and even lead to changes in ongoing practice.
Examples from Practices: "By changing the way the nurses consult with the diabetic patients and pre-
diabetic patients and promoting DESMOND more, as well as the referral scheme to the Leisure Centre."
“We have an expert patient who is helping us with some of our work”
"Care plans can be useful in reminding patients to attend for routine bloods and chronic disease reviews with the Practice Nurses."
"We are considering PAM scheme for all diabetic patients as routine in the future as it shows how much a patient understands and where we need to focus discussions at reviews."
"Communication with patients: Self Care information station in the practice - to extend to the website. Quarterly newsletter"
"Where at all possible we would try and link in PCCP with the Diabetic reviews, so ideally patients that were up to date with their Diabetic bloods, preventing the patient having to come in multiple times."
"Greater understanding for all members of staff surrounding the role of the community support worker, referrals have increased across the practice, not only for PCCP patients but for all patients
Person Centred Care Programme in Sheffield 2016 – 2017 22
Q Future recommendations
Balancing Vision and pragmatic starting points.
It is clear that for many practices and practitioners this PCC approach is new. Many people will say ‘we always practice in a person centred way’, and we have little doubt that there is a strong common thread of wanting to do the best for patients, and consider their views. However as previously highlighted, Person Centred Care (PCC) is a very deliberate approach, with specific activities, and methods that develop patients to operate as equal partners in their care. The evidence base is strongest when using these specific approaches.
However we recognise when introducing a new approach there is a tension between developing the vision and associated mindset (the ‘why’), and actually pragmatically ‘doing’ new things on the ground (the ‘what’). Particularly when the capacity to adopt new practices is limited (e.g. time available for reading specifications, attending training and redesign of clinical pathways) It is crucial that people value the overall vision and can see how it is relevant to their context. But too much time spent developing the vision leaves people feeling nothing is changing, and impatient to get started. However if you jump straight in with new activities, such as measuring activation, without a good understanding of how it fits into the bigger picture of person centred care, you equally build discord. If people, HCPs and patients, don’t understand how the activities fit into the bigger vision of what they are trying to achieve with PCC the new activities are seen as an annoying diversion of scarce resources.As the project progresses it is important to check that the balance of ‘vision building’ and ‘doing’ is maintained.
We also recognise that new evidence and political imperatives emerge over time and influence the national and local priorities. The overall vision needs to be both sustainable and flexible to remain compelling and relevant despite these changes. Culture change takes time, and needs to weather shifting priorities.
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Developing Practice Engagement
Directive v Flexible approaches towards Locally Commissioned Services.
Our approach has evolved with the programme. Our reflections would be that initially in years 1 +2 as a commissioning team we were more directive. We tied incentive payments to specific activities like doing care plans, capturing PAMs and attending training, and specified specific groups of patients that we wanted people to work with.In year 3 we took a less directive approach giving practices more freedom to determine what they did to deliver on the LCS. We allowed them to select the cohort of patients they felt suited a person centred approach in their context, and gave them a much free remit for determining what they would do, and measureOur thinking behind this mirrors that of a coaching approach, where if you judge knowledge, confidence and skills are at an early stage, and then expecting small specific tangible steps is easier to deliver on.
Practice OwnershipOwnership of a project is certainly central to its success and this less directive approach has certainly worked well for some practices - with evidence of new and innovative approaches. These are led by the practice rather than directed by the CCG, and as such have a much better chance of becoming part of normal everyday practice, and being sustained after the project has finished.
We have tried to do this in an informal way by offering multidisciplinary support (clinical and managerial), using a coaching style. The advantages of having practices write and report on their own project plans is that we can use this as a basis for coaching. We are working on their own ideas and reflections, rather than pressuring them to follow a single approach.
It is clear that around 45% of practices are fully engaged. The options we might consider would be to focus on these most engaged practices to focus investment of resource in the most interested. This might make it easier for us to develop a local evidence base and business case, for other practices to follow in the future. However there is worry at CCG level that this might widen inequalities of service delivery. Another option might be to
Person Centred Care Programme in Sheffield 2016 – 2017 24
We recommend that significant effort is put into communicating the overall vision, with clarity of where starting activities fit into the bigger picture. This needs to be endorsed and championed at senior leadership level, with an appreciation of a stepwise approach to implementation.
We would recommend in the future we should put more effort into assessing practices ‘activation’ for person centred care, and offering a range of options for practices accord-ing to their specific needs, with a focus on building ownership, and peer support.
support most engaged practices to buddy the least engaged (see ‘Positive Deviants’ below)
What’s in it for me?It remains important to keep sight of the advantages to practices in pursuing this approach. Whilst improving patient care and building activation have a compelling case, this can seem distant from the day to day pressures of provision of primary care services.We have found it helpful to develop the case of how it can benefit day to day practice:
1. Identify what to stop doing. The PCC approach is a good way of identifying when patients are not appropriate for care. I.e. not over advising people with high activation, or overwhelming people at low activation. This ‘allows’ people to discharge the responsibility to feel they have to do everything for everyone all the time. Our experience has been that this is particularly refreshing for practice nurses delivering LTC reviews, where there is an often a perceived pressure to discuss all health issues
2. A more satisfying consultation. Our experience has been that adopting a PCC approach often leads to a more satisfying conversation that resonates more closely with patient’s priorities. This is often much more satisfying for staff, helps to build a stable happy workforce.
3. Achieving QoF outcomes, and sustaining them - We recognise that there is anxiety that focusing on PCC approaches, draws resource away from achieving QoF targets. However research suggests that improving activation has the opposite effect, and is more likely to be sustained.
4. Reducing pressure on appointments- Evidence suggests that more activated patients that practice self-management behaviours are less likely to attend for unnecessary practice appointments. Although this evidence base is still in development in the UK, experience of local pilot work supports evidence from outside UK primary care settings.
‘Practice centred approach’ Looking ahead to year 4 we plan to continue to allow practices to lead their engagement, and submit their own project plans again. We hope this will allow the stronger practices to build on work they are doing, and give us further opportunity to meet less engaged practices where they are, and design support. We will use the outputs from this year to inform this support.
Person Centred Care Programme in Sheffield 2016 – 2017 25
We recommend a strong focus on the practical advantages to practices of engaging with PCC. Consider workload, financial and job satisfaction factors
We would recommend in the future we should put more effort into assessing practices ‘activation’ for person centred care, and offering a range of options for practices accord-ing to their specific needs, with a focus on building ownership, and peer support.
We feel that this ‘practice centred approach’ to care is most likely to engage teams, and indeed matches the style we are trying to champion with the project!
We recognise that from a commissioning perspective there is anxiety about widening inequalities by teams being draw to the ‘easier’ patient groups. We recognise that this is important, however we also recognise that is hard to develop new skills by starting with the hardest groups.
Highlight ‘positive deviants’
A strong advantage of this practice centred approach is it allows us to develop local case stories of good practice. We feel there is much value in capturing these and sharing the learning. A feature of this year’s LCS was to further incentivise practices to submit in-depth case stories to describe activities and strategies that worked well for them. This allows us to share neighbouring practice stories and build a pool of local resources and examples.
We anticipate that as the project progresses this will allow us to buddy higher performing practices with those that are struggling. The City is already developing neighbourhood clusters of practices and this should create the ideal environment for practice to support each other.
How to build ongoing engagement across Health system:
The challenge we are facing over the next 2 years of this project is how to embed PCC into our local health system, such that it continues as part of usual care. The CCG has committed to 5 years of project funding but it is unlikely that this level of investment will continue, and there will be an expectation that the highest value aspects of PCC will become ‘business as usual’ without need for specific incentives.
We hope that having given practices opportunity to develop new skills and practices, by funding internal training and development time that the new skills and practices will be Person Centred Care Programme in Sheffield 2016 – 2017 26
We recommend that commissioners work closely with partner commissioning organisa-tions to describe the mutual benefits of integrated systems
We recommend that it is the role of a good project support team to recognise where teams are doing well and to support and encourage them to take on more challenging and ambitious activities, more likely to address inequality gaps.
We recommend that ongoing resource is reserved for development, and mentoring of the sup-porting team.
Recommendation - capture a wide range of local examples of good practice so these ex-periences and skills can be shared with other practices that may be earlier in their devel-opment of PCC.
maintained. In a lot of ways this will be the true test of valued PCC approaches are to patients and practitioners. Will people expect that this is the way interactions are practiced? Will patients demand this approach, will they continue to develop their role as equal partners. Will practitioners feel that this approach suits their ambitions of how they want to practice?
We also recognize that there is interdependence on the wider voluntary sector, and social care systems. Where PCC has worked well in practices it has often involved collaboration with health trainers, community support workers and community nursing teams. These teams are not directly funded by health care, and we worry that their funding is vulnerable.
We recognise that up to now much of this project has focused on developing HCP skills, knowledge and confidence, and that it is equally important that we develop an understanding in the patient body of the vision of PCC. The value of this was demonstrated in the Year of care approach and The Health Foundation’s Co-creating Health Programmes.
We plan to do this by asking each practice to identify at least 3 patient champions who are willing to contribute to developing this theme - we will offer support, listen to their views and develop a shared understanding to patient needs in this area. We will collaborative develop and deliver local training for patients, along a train the trainer model. We will use previous learning from programs such as the Expert Patient Programme. However we will engage patients in the specifics of how the local health care system wants to develop a whole system PCC approach. We will encourage them to work with their practices to co-design and implement system that work best to deliver PCC in that practice setting.
Person Centred Care Programme in Sheffield 2016 – 2017 27
We recommend that in year 4 we focus effort and resource on building an understanding of PCC in our patient body, and skill patients to assist in co-production of solutions
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Ongoing data collection to support the case for PCC
We recognise that building the case for PCC is an ongoing process. Early adopter sites such as Sheffield have an ongoing responsibility to continue to collect high quality data to contribute to local and national development of new models of care and supporting contracts.
We need to tune into the quantitative and qualitative measures of a high value system
We believe this involves proposing clear logic models that lead to desired end outcomes. This allows us to identify steps along the journey and to attribute measures to each stage of change.
To now we have recognised that the initial stages of change have been focused around building engagement, developing skills and tools to support PCC practice, and capturing early measures of change such as patient activation.
We must now aspire to translate new processes into impacts on outcomes that matter.Drawing on national (e.g. Realising the Value) and local evidence these are likely to be:
Patient perspective:- Creation of Health and Wellbeing- People feeling supported, in control, socially connected and independent- ‘Personalised Outcomes’ that are most important to people and their communities- Valuing peoples contributions- Working in partnership- Equity - targeting to those with greatest need
Practice:-Lower staff costs-Higher staff satisfaction and retention-Reduced (inappropriate) patient demand-new more efficient ways to achieve health outcomes
System:-Reduced costs -health-USC/ crisis usage, prescribing- Social - low value contacts-Improved overall wellbeing- staff and patients
A business case for PCC
This is our concluding and perhaps most important recommendation. It is our opinion that to properly embed PCC in to health systems we need to develop a clear business case for organisations involved, particularly GP practices themselves.Person Centred Care Programme in Sheffield 2016 – 2017 28
We recommend that significant effort is put into systems (ideally digital and automated), for collection of measures of change, to allow informed approach to quality improvement of PCC approaches.
There has been much written about new models of care for general practice. We would reflect that one of the key challenges for primary care is making an internal case for how it can deliver high value health care. This becomes especially important at a time when new organisations are seeking to enter the space currently occupied by primary care, be these current Acute or Mental Health Hospital trusts, private care providers, charities such as Age UK, or even housing agencies.
With 70 % of NHS resources consumed by provision of care for people living with LTCs, undoubtedly organisations that are able to deliver best value care in this area are likely to attract future contracts for care.
It is our belief that the practice of PCC allows the development of a strong business case for management of LTCs. We believe efficient and effective care can be achieved by:-A tailored approach to care, involving a wide range of skills and approaches to build patient activation and self-management capabilities-Reducing wasted clinical input and focusing efforts in situations most likely to improve outcomes-Rationalizing and optimising medication use
New ways of practice working need to be backed up by new contracts that place financial value on outcomes that matter most to patients. If we define high value care as outcomes/cost, we need to ensure that the outcomes that are central to new contracts are those that really matter to patients and society as a whole. Practices will only develop business cases and whole heartily transform their services according to PCC principles if their contracts demand it. The aspiration to do this is well articulated in the 5 Year Forward View for the NHS, however we reflect that these are yet to be translated into new contractual arrangements.
Person Centred Care Programme in Sheffield 2016 – 2017 29
We recommend that NHS Sheffield pro-actively contribute to the co-production (with prac-tices and patients) of new contracts that support provision of high value PCC
Appendices
Appendix 1 – Examples of positive changes in practice
Working with patients Using PAM to focus discussion during appointments Plans to create newsletter for patients Information provided in waiting areas and on line Utilising the PAM crib sheets with patients Including the PPG PAMS seem to show increased motivation with the people that are participating
fully in their care plan Self-management information provided for patients
Doing Different things Person Centred Care and PAMs will be used for all AUA Patients
Shared medical appointments
Pre appointment questionnaires Using PAM to determine which practitioner is best to offer support Links to the diabetes prevention and pulmonary rehab programme Providing transport to surgery for people with Long Term Conditions Holding “Care Planning Clinics” Extended appointments change patient’s perception to proactive rather than
reactive conversations
Admin Processes Developing spreadsheets for all patient information to be kept in one place – all
staff will have access to this Offering longer appointments All clinicians made aware of pts care planning status with onscreen “pop up”
box Monthly searches by managerial lead produces PAM report which allows
comparisons and information to be used at MDTsPerson Centred Care Programme in Sheffield 2016 – 2017 30
Section 5
Lead admin person monitors the process Streamlining the system : Embedding PCCP into annual review and recall
process for LTC Use the frailty index as a way of identifying people to support with a care plan
Use one care plan across the pathway – hospital and community
Multidisciplinary Team Working Community Pharmacist included in PCCP process and for asthma reviews Using HCA for social aspects of PCCP Using nurses to deliver the programme is proving more effective Using IAPT, Specialist Nurses, Smoke Cessation Providing bypass numbers to the surgery for MDT communication Health trainers administering the PAM before and after interventions Admin staff contacting patients the day before appointments has resulted in
fewer non attendances
Challenges: The PAM - its use and relevance : linking the PAM to the process : identifying
cohorts, informing the approach Ok to Stay Plan - this does have a place with a particular group of people -
confusing for practitioners One care plan - how can we make this a reality Linking the learning to self-management strategy
Person Centred Care Programme in Sheffield 2016 – 2017 31
Appendix 2 Share and Learn Event November 2016
Numbers: 81 people in total 35 Practices Represented 62 members of staff
Representation from: Citizens reference Group NHSE Age UK Sheffield City Council South Yorkshire Housing Authority Sheffield Teaching Hospitals ( Community Nursing Services, Renal and Diabetes
Services )
Table top discussions led by: Crookes Hackenthorpe Page Hall Porterbrook Sheffield Medical Centre The Hollies
Person Centred Care Programme in Sheffield 2016 – 2017 32
Appendix 3 – Neighbourhood Report May 2017
Person Centred Care – Practice Plan Reviews May 2017
What is working well across the city?
Weekly meetings with nursing staff to discuss PAM changes and how this affects Patient Care
All staff being involved has improved the process
Expanding MDT meetings to include Pharmacists
Informal MDT meetings as well as formal process improves communications
Joint home visits and longer appointments
Contacting patients by telephone 3 monthly to update on progress
Using IAPT and community team to help recognise health needs /signposting
Crib sheet has been developed as a reminder for the process
PAM easy guide for staff has been developed to help with explaining what PAM is and how it’s used
Including PAM questionnaire with the LTC review invite letter
Pop up box identifying who is eligible for a care plan
Working with community nursing helps to support housebound/hard to reach groups
Development of a “mini Desmond Programme” to fit in with evening appointments
Working with neighbouring practices to share skills
“You said we did” information for patients
Shared medical appointments promoting peer support -for people with Diabetes
Linking Person Centred Care planning with the national diabetes prevention pro-gramme
Learning needs questionnaire for people with diabetes
Developing recall systems for 6/12 follow ups
Person Centred Care Programme in Sheffield 2016 – 2017 33
Changes in the way we look after people with diabetes
Challenges:
Communicating the benefits of a person centred approach to staff and Patients – why are we doing this? (Process vs ethos)
Introducing the PAM
Linking the PAM to the conversation
Changes in PAM scores – how are they being used
Care Planning appointments being “declined “
Changing staff/staff vacancies – puts increased pressure on remaining team
Practicalities of working in this way – extra time needed
DESMOND in languages other than English
Using patient feedback to inform the process
Themes emerging:
Minds but not hearts
Little evidence of quick goal follow up
V little reflective behaviour/thinking
Still seen as an “add on”
Sustainability and spread within the practice if one member of staff is the lead
Using PAM results as a way of tailoring support (very sparse examples)
Sharing practice and outcomes
Person Centred Care Programme in Sheffield 2016 – 2017 34
Practice plans and reviews were submitted to a panel of individuals in the CCG – mainly comprising of members of the LST in addition to other people who have an interest in pcc approaches e.g. Locality Support Managers, Public Health Principal, and Quality Team.Plans were rated as:☺ Examples of good practice, changes in behaviours, learning for using the PAM; qualitative and quantitative evidence; Minimal examples of any changes and learning ☹ No examples of any learning quantitative evidence
Neighbourhood GPA1
Oct 20164 3
Feb 20174 3
North 2
Oct 20163 7
Feb20177 2
Townships 1
Oct 20161 4
Feb 20172 3
Townships 11Oct 2016 3 2Feb 2017 3 2
West 4
Oct 20162
Feb 20171 1
Darnall
Oct 20163 1
Feb20173 1
Oct 20163
Feb20171 2
Person Centred Care Programme in Sheffield 2016 – 2017 35
South West
Oct 20161 2
Feb20171 1 1
City Centre
Oct 20161 5
Feb 20174 2
SWAC
Oct 20163 2
Feb 20172 3
SAPA
Oct 20164
Feb 20173 1
High Green
Oct 20164 1
Feb 20175
Hillsborough
Oct 20163
Feb20172 1
Oughtibridge /Upper Don
October 20163
Feb 20173
Peakedge
Oct 2016 2Feb 2017 2
Porter Valley
Oct 20163
Person Centred Care Programme in Sheffield 2016 – 2017 36
Feb20172
Townships 2
Oct 20164 1
Feb20173 2
Person Centred Care Programme in Sheffield 2016 – 2017 37
Appendix 4 – Information from Insignia: example of how data can be displayed
This data represents a small proportion of the data entered and is for display pur-poses only
Person Centred Care Programme in Sheffield 2016 – 2017 38
Person Centred Care Programme in Sheffield 2016 – 2017 39
Appendix 5 – Patient Survey Feedback
Person Centred Care Programme in Sheffield 2016 – 2017 40
Appendix 6 – Examples of what works well in Practices As part of the reporting Practices were invited to share what works well for them – this information was then posted on the intranet and the practices facilitated tables at the Share and Learn even in November 2016.Examples included : Example 1: Invitation Letter
DATE
PATIENT NAMEPATIENT ADDRESS
Dear PATIENT NAME,
Person Centred Care – Managing and Preventing Diabetes
The Practice is currently running a new initiative to help patients with managing their own health and promoting ways to increase well-being through simple steps. Our GPs and nurses have chosen to invite those who have recently been diagnosed with, or may be at-risk of, diabetes.
How it works
The process is simple:
- You will find enclosed with this letter a booklet which we will use to ask you how you currently feel about your and manage your own health. This will be used through the process to help the clinical team address your personal needs and concerns.
- First, we will contact you to book an initial appointment with one of our Health Care Assistants. They will then take a small blood sample to help look for any important indicators.
- Once we have received the results, we contact you to book you in to see one of our Practice Nurses. They will then use this and the information you provide us to help you create a unique personal plan to help you manage your individual needs and concerns.
- A few months later to see how you are getting on. We will book you a final appointment with a Health Care Assistant to see if your results improved over time. If you still need help with your condition then they will arrange for you to see someone about this.
What happens next?
You will shortly receive a telephone call from a member of our administration team who will ar-range your first appointment. Whilst you await our call, please take a look at the ‘Patient Activation Measure’ section of the booklet enclosed. If you are able please answer the questions as truthfully as possible and we will ask you to bring this to you first appointment.We encourage all patients to bring a relative, friend or carer for support and who may also be in-volved with managing your health to your appointments.Person Centred Care Programme in Sheffield 2016 – 2017 41
If you have any questions please let us know and someone will ring you to answer any questions you may have.
Yours sincerely
Example 2: Crib Sheet for use with people with diabetes:
Patient Centred Care Planning Crib Sheet for the Process: Patient requests a blood appointmentReception to confirm if diabetic bloodReception book 20 mins appointment with HCAWhen patient attends for appointment PAM questionnaire given to patient to read whilst waitingHCA to do B/P, height, weightAny outstanding QOF e.g. smoking statusPAMPatient given card to return to reception, reception to book 40 mins Diabetic Care Planning Appointment with Practice Nurses HCA pass read code info to Admin to update S1Patient attends Diabetic Care Planning AppointmentNurses complete care plan using information from the PAM
Example 3: An Audit tool to record and track changes in a patients PAM scores and blood results; the information is then used in reviewing patients in MDT meetings:
PATIENT ID
PAM SCORE& LEVEL
GOALS SET BY PATIENT
HBA1C DATE PAM SCORE& LEVEL
HBA1C GOALS ACHIEVED BY PATIENT
Person Centred Care Programme in Sheffield 2016 – 2017 42
Example 4: A crib sheet to help in the Care Planning conversation. Having prompts on the crib sheet enables staff to focus on the patient, and the page references included in the prompts help in the subsequent completion of the PCC template:
What does PATIENT consider the MAIN PROBLEM? (pg5)
What does CARER consider the MAIN PROBLEM? (pg5)
GOAL (pg6, q2 click on the icon for the template)
Action plan for goal - (pg6, q2 click on the icon for the template)
Pick a category! Maintaining
wellbeing Disease
prevention/ Avoidance Early detection Physiological Maintenance
Symptom avoidance
Prevention / management of complications
CVD risk/ lifestyle Social Psychological
Other Anticipation / pre-
ventative care Assessment Maintenance Supportive Enabling rehabilitation
Clinical management plan (pg7, q3)
CRISIS plan – what to do if condition gets worse (pg7, q4)
Person Centred Care Programme in Sheffield 2016 – 2017 43
Person Centred Care Programme in Sheffield 2016 – 2017 44
