Context to the System Intelligence Report

In order to give some background to my recent blog post on the five recommendations to Kent, Surrey & Sussex on improving the physical health of those with serious mental illness (SMI), I agreed, and felt it necessary to, post the context and additional findings here as well. As I stated before, the information came from numerous open discussions with people from a variety of sources including (but not limited to); service users, third sector, frontline staff, national arms-length bodies and a swathe of clinicians, leaders and managers at various strata in the healthcare system.

I appreciate that the content of this may only be of interest for those with a strong stomach for minutiae, but I believe that without this, some of the deeper reasoning for the recommendations may not be clear. As always, the inferences in the text are broad so as to ensure privacy to sources

Challenges

 The presence of Sustainability and Transformation Partnerships (STP’s) has little noticeable influence on day-to-day practice of clinical and frontline staff.

 Some clinical teams feel physical health assessment and interventions are not considered a high priority or part of the core functions of a team. This has been attributed to: availability of staff, recruitment issues, lack of time to spend on physical health and lack of availability of material resources with which to carry out specific physical health checks. Whether this has any correlation with clinicians’ own physical health status or wellbeing at work has yet to be evaluated.

 There remains a lack of communication between primary and secondary care providers as to a correct method of communicating and recording completed physical health checks so that a full record can be established by NHS Digital.

 Whilst the physical health of patients with SMI is considered a high priority by many within the system, approaches of teams to address the physical health of clients vary considerably, especially with regards to the availability or understanding of existing physical health related training from providers.

 There is little evidence that large scale providers within the regions communicate regarding the wider needs for training and education of staff on physical health; whether there are joint needs, pre-existing training or how teams investigate need.

 Where previous initiatives have been introduced and established within a team, commitment to maintaining its inclusion on on-going practice has diminished once the initiator has left the team. Similarly, when projects or initiatives are passed to colleagues or persons leave a role, significant delays can arise in implementation.

 Service Users have experience and opinions of the annual physical health check that may vary from the anticipated viewpoint in a negative manner. They are also varied in content and subjective in nature.

 The completion of the bloods-related elements of the PHC remain a challenge. This has been attributed to many factors including; varying skill sets in teams, reduced phlebotomy training and verification, patients handed blood test forms repeatedly but not attending phlebotomy clinics at other locations.

Information of note

 The figure of 280,000 more physical health checks  (PHCs) in the Five Year Forward View for Mental Health (FYFVMH) equates very closely to the number of service users currently under secondary care in England

 NHS England’s Mental Health Programme uses data from NHS Digital on the Sustainability and Transformation Partnership (STP) commitments to increasing numbers of required PHCs over the timescale indicated (30% in 2017/18 to 60% in 2018/19 of those on the SMI register, Office of National Statistics (2016))

o Kent & Medway STP: 4,342 in 2017/18 to 8,765 in 2018/19

o Surrey Heartlands STP: 1,901 in 2017/18 to 3,835 in 2018/19

o Sussex & East Surrey STP: 5,561 in 2017/18 to 11,213 in 2018/19

o Data is also available for each Clinical Commissioning Group (CCG) in England

 Data is yet to be established regarding PHCs carried out, reported or recorded, in the year 2016-17.

 Early Intervention in Psychosis (EIP) Teams in Kent, Surrey and Sussex will conduct an initial staff attitudes survey with regards to physical health interventions, to be completed by November 2017.

 There may be a significant number of physical health checks performed in secondary care that are not recorded in a way that can be recognised by National bodies charged with reporting overall figures. The scale of this discrepancy requires investigation.

 There has been previous work on a similar topic by a previous Darzi Fellow in London, where one outcome was a Physical Health Leads’ Forum for the five Mental Health trusts in the region.

 ‘Physical Health Check’ contains the six elements of the Lester Tool (NHS England, 2016b) but there is consensus that the remit of ‘physical health’ can extend beyond this to include (not exhaustively) eyesight, mouth-care, foot health, environmental situation and economic considerations, amongst others for various patient demographics as well.

 Both service users and some clinician groups have appreciated the dual-accountability for physical health when users are ‘out-of-service’ or under primary care. There is acknowledgement of the boundaries between ‘places of health and care’ where communication between providers can be improved.

 Some teams report an inability to locate, or a lack of, equipment to complete the six elements of the Lester Tool

Opportunities

 To explore a method to allow access for, and encourage, clinical and frontline staff to engage in the design and implementation of STP’s.

 Scope to develop a method of passing information from secondary to primary care in an appropriate way that ensures correct coding and submission to Quality Outcome Frameworks (QOF) data which contribute to the overall sum of PHCs accounted for by NHS England.

 To explore what a regional ‘Physical Health Leads’ Forum’ may include and what the needs are to establish communication around this topic. This may include visiting the London Forum as a prototype for the KSS equivalent.

 To explore a new model of training delivery around a ‘modular’ scheme for role-specific training in physical health. Teams in different disciplines may draw on certain elements to comprise a baseline ‘essentials’ package with additional, more in-depth sessions and competency as indicated, or requested by staff. This has been supplemented by ideas around a basic introduction of modules, followed by refresher sessions at an appropriate interval.

 There have been other initiatives outside the region that have addressed the physical health of this patient group that may yield pertinent information, solutions or ideas in addressing is in KSS (RAMPPS (HEE Yorkshire & Humber, 2016), Central & North West London NHS Foundation Trust, 2017)

 Both service users and clinician groups have welcomed the idea of promoting an ‘entitlement’ to a PHC for those on the SMI register. Ways to access those under primary care or those that have fallen out of both services for a multitude of reasons (cultural, language, accommodation, etc) might include places where service users convene as sites for promotion, engaging peer support in areas such as Recovery Colleges, social groups and drop-in cafés.

 The effect, perceived or measurable, of a clinician’s own physical health and its effect on their view of a patient’s physical health might be a possible topic for study in the future.

I hope this gives a little more clarity to the initial ‘recommendations’ blog and, as always, I welcome feedback and constructive dialogue around all aspects of this topic.

References

1. NHS England (2016a) Implementing the Five Year forward View for Mental Health https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf [Accessed 1/9/17]

2. NHS England (2017) Commissioning for Quality and Innovation: Guidance for 2017-19 https://www.england.nhs.uk/wp-content/uploads/2016/11/cquin-2017-19-guidance.pdf [Accessed 1/9/17]

3. Sussex Partnership NHS Foundation Trust (2017) New mental health research published today (29/7/17) https://www.sussexpartnership.nhs.uk/whats-new/new-mental-health-research-published-today [Accessed: 1/9/17]

4. Office of National Statistics (2016) Dataset: Subnational Population Projections for Clinical Commissioning groups in England: Table 3 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/clinicalcommissioninggroupsinenglandtable3 [Accessed: 26/9/17]

5. NHS England (2016b) Improving the Physical Health of People with Serious Mental Illness: A Practical Toolkit https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/05/serious-mental-hlth-toolkit-may16.pdf [Accessed 28/9/17]

6. Health Education England Yorkshire & Humber (2016) Recognising and Assessing Medical Problems in Psychiatric Settings (RAMMPS) https://hee.nhs.uk/hee-your-area/yorkshire-humber/education-training/multi-professional-workforce/clinical-skills-simulation/recognising-assessing-medical-problems [Accessed 28/9/17]

7. Central & North West London NHS Foundation Trust (2017) Improving physical healthcare in mental health settings http://www.cnwl.nhs.uk/news/improving-physical-healthcare-in-mental-health-settings/ [Accessed 28/9/17]

 

Five Recommendations for Kent, Surrey & Sussex in improving the physical health of those with serious mental illness

A long title, but hard to shorten without losing a significant understanding. It could be considered the ‘Berliner’ size heading; a little unwieldy in terms of size but suitable for the content. As for the Berliner reference; The Guardian changed its print size on Monday 15th January 2018 to a tabloid from an oft-unused size of newsprint known as the Berliner. In a similar effort, This blog post will break down my recent report back to the health system in Kent, Surrey & Sussex (regarding how one moves forward in the current struggle to meaningfully improve physical health for those with serious mental illness) to the five resulting recommendations.

As a bit of background, and if you are a reader of this blog, then you are likely to be aware of my recent work as a Darzi Fellow in this field and as such, I am in a privileged position to be able to speak to a wide variety of people from almost as many organisations across Kent, Surrey and Sussex who have an influence over the physical health of those with serious mental illness. Also from previous entries, you may have also gathered that I have highlighted some issues with regards to the ‘accounting’ for the number of physical health checks tallied up in relation to the Five Year Forward View for Mental Health. Given the chance to ‘connect the dots’ in the system across the region, I was able to report back to numerous stakeholders about the information of note, challenges and opportunities that arose as themes throughout the discussions I had.

Stopping short of turning this post into my Opus and making it an unreadable length, here are the five recommendations I made to the system to build on the already-existing good work being done and to allow us to slowly rectify the damning disparity in the health status and life expectancy between those with serious mental illness and those without. The recommendations are deliberately broad as they are intended to be interpreted by the points in the system in a way that is applicable to them. I hope this initiates a discussion around what is possible in the region, but of course a wider understanding of the connectedness and co-operation needed to progress:

1. Improved communication between secondary and primary care to ensure that all PHCs completed in any setting are recordable under National data collection practices. (GP QOF reported by NHS Digital against CQUIN deliverable figures reported to NHS Improvement). Agreement between primary and secondary care on best process.

2. A new, sustainable method to share best practice for physical health in those with SMI across the Kent, Surrey and Sussex region. Prototyping of a platform / forum for those with an interest and authority in promoting physical health of those with SMI to meet and exchange clinical experience, explore good / best practice at a National level and identifying specific regional and local needs.

3. A new model of training and education for staff around physical health needs of patients. To include, but not limited to, the elements of the Lester Tool; ‘physical health’ of the patients will include other parameters (e.g. dental care, mouth care, foot health, economic and environmental factors).

4. A wider regional and National initiative to engage service users in the design of a PHC programme; to include those in both primary and secondary care, as well as examining the scale of those not falling within either provider and ways to access vulnerable groups.

a. Informing and educating service users in a good understanding of the short, medium and long term benefits of a regular health check, ways to access information, interventions sought or required and the easiest and most appropriate access method for them.

b. Alternative delivery methods for PHC: ‘health visitor’ or ‘pop-up clinic’ models dependent on provider capability and service user need, with consideration of language, culture and additional barriers to engagement

5. An integration of practice between acute, community and mental health trusts for an approach to understanding the benefits of the PHC and collaborating with initiatives such as ‘Making Every Contact Count’ from Public Health England. All frontline NHS staff member who has contact with a patient with SMI to understand the entitlement to an annual PHC, to whom it applies and offer a brief intervention as to how to access if appropriate.

As with all things, context is key. I am happy to share the other contents of my report including the information of note, challenges and opportunities if there is enough call for it. In fact, I will do that anyway very soon (I have done: IT’S HERE) . As I was always told in maths lessons at school; ‘if you don’t show your working, how can we know if you truly understand the problem’. Never a truer word said.

Is 280,00 a big number?

What defines a big number? Is it length? Number of digits? The combination of elements that make the whole? Or its implications – immediate or long term? To put it in context 92,955,807 is a big number, 33 is relatively small. 92,955,807 is the number of miles from Earth to the sun (give or take) and 33 is the number of different sports in the Tokyo Olympics in 2020, the highest number ever. Vastly different, but with alternate implications. The distance to the sun may vary on the Earth’s orbit by a few hundred miles or so, but the distance means little. Our days and years are fairly predictable in temperature and length. But 33 different sports to coordinate in the World’s largest mass participation event in one locality has huge implications for the organisers, volunteers, competitors, etc. The impact is huge and far reaching.

So what about 280,000? About middling, right? But in relation to the Implementation of the Five Year Forward View for Mental Health, the significance is great. It represents the number of annual physical health checks needed to move from 30% to 60% of those on the serious mental illness (SMI) GP register. What is worth mentioning is that this is a national figure  for England and specifies a change from the years 2017 to 2021 (pp21).

But why is this important?

Sometimes it can be hard to acknowledge the longer term effects of a simple intervention such as a physical health check. To clarify, the National CQUIN outlines the intervention should be based on the Lester Tool including brief interventions for smoking and alcohol use (if indicated), height and weight measurement to calculate Body Mass Index and the blood tests to measure both blood glucose (as an indicator of possible diabetes) and blood lipids (as an indicator of possible raised cholesterol). But if we mention the discrepancies in physical health for those with SMI, it all starts to come together a bit.

Recent figures released by Sussex Partnership NHS Foundation trust indicate that the mortality gap for those with SMI remains at 15.5 years for females and 20.5 years for males compared to those without SMI. Add to that a greater incidence of Chronic Obstructive Pulmonary Disease (COPD) Type 2 Diabetes and Cardiovascular disease, an attendance rate at A&E three times higher than those without SMI and twice the likelihood of admission to hospital. Not a particularly positive set of numbers there, large or otherwise.

So who’s counting?

Now there’s the interesting question. Numbers are only relevant if they mean something and if we are not quite counting everything, or the numbers are not available to us, then how do we know the scale of our inquiry captures everything we want it to? Case in point; on Saturday 11^th November, I watched England play Argentina at rugby at Twickenham (I know this because it was on the television) and I also know my team lost their rugby game as well, despite my not playing (I saw two of my teammates later that day). So my direct experience tells me there were two rugby matches in England that day. Of course, I could explore further and check the league tables and fixtures and see what other games were played, but I would need to check several resources for that. So if every rugby match that was played in England on Saturday was recorded in one place; that would make my job of counting them significantly easier, right?

Well, again, this is a tricky one. Because if we are counting important data, and that data is used to report, inform deliverables and ultimately improve the long-term status of something related, then we’d be well informed to count the correct things. Second case in point; NHS Digital take data on physical health checks of SMI patients from the GP submitted Quality Outcomes Framework (QOF). They do this at practice, CCG and STP level. But nothing from any secondary care providers (as yet). So if PHC’s are carried out while a patient is under secondary care and the information doesn’t find its way on to the GP’s SMI register, then it can’t be counted by NHS Digital. So this could be quite a considerable number of unreported data, the scale of which is as yet unidentified, that might positively inform the accounting of the number of PHC’s those with SMI as the numbers approach NHS Digital and NHS England.

The crux of this piece is not in any way to criticise existing practice from any quarter, more to highlight an important consideration when dealing with numbers. In this case, if the sole target is to increase the number of PHC’s for those with SMI in the hope of reversing the health discrepancies for this patient group (a very brief précis, granted), then it may only need some simple reporting practices to achieve it. But of course, if those PHC’s are being done and simply counting them is all that needs to change, then there may be little long-term effect on the health outcomes for that group as the number of clinical assessments and interventions hasn’t actually changed. Or to put it another way, you may well hit the target, but you may also miss the point.

The enthusiasm to improve the physical health of patients extends throughout the healthcare system and is positively evolving, but we must ensure that the data we collect is meaningful and used wisely or we risk failing to address the genuine issues and impacting the health of the patient group in the way intended. A report I have recently written highlights some recommendations for the system in Kent, Surrey & Sussex that might help address the discrepancies in the long term and are deliberately broad in nature so as to ensure that local changes are appropriate for the patients. But the recommendations may also have implications for other regions if similar issues are encountered. Given that there may now be some cases of acronym fatigue after a piece like this, I will make the recommendations available on this blog shortly. If you’ve made it this far, many thanks for reading.

Prototyping and up-scaling at a personal level

So what to do with that niggling little idea at the back of your mind? The ‘what if?’ The ‘what if not?’ The ‘how might I do that?’ I’m going to assume that the majority of people might have had a feeling like that at some point in time about a small plan, concept, idea that might, in some way, be beneficial to you or others if it were allowed to flourish. But what did you do with it? Did you suppress it? Ignore it? Fight it, even? Or did you quietly let the thought grow in it’s own way, let it develop, feed it, foster it, give it space to stretch its legs?

If you did the former, do you regret not doing the latter?

I had a moment a bit like this recently. I have no idea where the thought of turning what might have been a simple flipchart paper and pen exercise with my fellow Darzi cohort at a workshop into a little bit of a personal test of that prickly idea came from. I’d witnessed, on numerous occasions, the skills of graphic recorders when listening to group discussions and developing vast and complicated murals capturing thoughts, themes and outcomes without breaking a sweat. In the dim and distant past of my schooldays I had a bit of an affinity with pen-to-paper through GCSE and A-Level Design and Technology and I’ll admit I was rather taken with the skill of the graphic recorders. And recently the thought of ‘what if?’ just bubbled to the surface. So I ran with it.

The first attempt wasn’t during a discussion, it was a bit of a forced one where I filled out the blank spaces for some words after doodling some pictures to fulfil a group presentation requirement. But it was what we currently refer to as a ‘prototype’ in change management: a micro-scale test of an idea that will have minimal impact If there is failure but enough scope to see if there is a future in it.

Exhibit A:

Even if I do say so myself, not a bad start. Satisfied that there was no lasting damage to my reputation. I went for the up-scaling. We were joined by Sarah Billiald, CEO of First Community Health & Care for a discussion about her career and I decided to try out some real-time graphic recording.

Exhibit B:

Whilst it may not exactly be as detailed, refined, colourful or accomplished as the professionals, it was an interesting experience and well received. But the artistry wasn’t the point for me. I’d had an idea, tried it out, it was agreed to try a bit of an up-scale and the result wasn’t disastrous, positive even. And what it had encouraged me to do is break out the pens, pencils and paper to have a try of a few other ideas in the comfort of my own home.

For me, this is what prototyping ideas is about; small trials, growth, feedback and the possibilities that occur. Because when you’ve let one idea out of the cage, there may be another one or two taking its place. And that can be an infectious feeling to let your ideas out when so often our lives dictate that it is either discouraged or time runs away with us. Make the time and space. You might be amazed at the result.

 

“You can’t start a fire without a SPARK…”

I will have to apologise to The Boss himself, Mr Bruce Springsteen, in person for the hijacking of his song lyric, if our paths ever cross in the future. However, the sentiment is true and will definitely need a spot of contextualising in this forum.

As Darzi Fellows, we are privileged to be able to have some structured teaching in our time away from or previous roles and responsibilities and this takes the form of regular workshops at London South Bank University under the tutelage of Becky Malby and Murray Anderson-Wallace (among a cast of many more). These workshops are intensive immersion in subjects related to the fellowship and, for those of us who might have been out of the formal academic world for a number of years, can be a bit more intense than perhaps anticipated.

A format that was suggested to us was using the creative programme, Adobe SPARK, to bring together thoughts, images, sentiments, quotes, etc. from each workshop when we are all together. The pages are brought together by two volunteer Fellows and then disseminated among the cohort for feedback before ‘publishing’. These are then visible to sponsors, colleagues, employers and, as they are free access pages, anyone else interested in the content of the teaching element of the Darzi Fellowship. One caveat is that it is the content is generated by the Fellows and is our interpretation and reflection on the time spent in the workshops. However, the process is democratic and inclusive, so gives, as far as we can tell, a representative view of the group experience.

Having put together the SPARK page for the second workshop, our first on ‘Core Concepts of Quality’, Daniel Dodd (Paramedic, Darzi Fellow and all round good guy) and I put authored the following report. You can read the Workshop 2 page here.

Perhaps the most interesting part of the process was the ability to reflect upon absolutely every point of the workshop process in a collaborative manner. Ours also had the interesting addition of the first day being off site carrying out an ‘organisational raid’, a process none of the cohort had experienced before.

The other excellent workshop SPARK pages were created by Mark Gregson and Helene McCarthy (Workshop 1) and Shirmilla Datta and Jen Palfrey (Workshop 3). I’m sure I will post the others as we progress throughout the year.

So, in closing, these useful pages are an aide memoire for us, a useful insight for our sponsors (hopefully) as to the time we spend at London South Bank University and possibly also a spark of interest to those who might consider applying for future programmes; be they in London, KSS (Kent, Surrey & Sussex) or perhaps even further afield should they catch on in a wider NHS context.

So, what exactly is a Darzi Fellow?

Invariably the most common question I get asked at the moment is the above. It follows either ‘Who are you?’ or ‘What do you do?’. It reminds me of the film Moneyball in which Brad Pitt, as Billy Beane, approaches Michael Cera’s Peter Brandt after their cautious interaction in a meeting and interrogates him: ‘Who are you?’ – Brandt gives his name. ‘What do you do?’ – Brandt gives his job title. Beane leans in closer – ‘What do you do?’. Beane isn’t interested in job titles, he’s only interested in what Brandt does.

Okay, so, the film isn’t a true representation of Michael Lewis’ original book of the same name (slight aside – brilliant book for those interested in improvement science and working towards quality under tight financial pressure – ring any bells?), but it highlights an interesting point for me. I’ve always wrestled with the explanation of the Darzi Fellowship because, for me at least, there isn’t one particular answer; the meaning to the person asking can be different depending on their standpoint. But as far as a general explanation, I can be fairly broad.

Initially, the Darzi Fellowships started in London in 2009 following Lord Darzi’s report on the NHS in 2008, formulated as a healthcare leadership programme over the course of a year for medics to work on a specific project either in or out of their specific clinical specialty or department. This grew to later accept non-medics and has recently finished the eighth cohort in London. I was very privileged to be selected (after application) as one of the first 26 KSS (Kent, Surrey & Sussex) Darzi Fellows in February 2017 and started with my sponsor organisation (Health Education KSS hosted by Sussex Partnership NHS Foundation Trust) in May 2017.

Fellows are matched with a sponsor organisation on a project they put forward with the aim of immersing themselves in an experience that includes systems leadership, multiple stakeholder engagement opportunities and the academic element of a Postgraduate Certificate in Leadership in Healthcare at London South Bank University. This also includes some elements of coaching from experienced facilitators, external site visits and direct project work in leading change in the healthcare system.

Personally, I was drawn to the opportunity for a number of reasons; learning from a pan-experiential peer group, a feeling I could do better at something I will freely admit to making a hash of in the past, academic input which I had been considering for a while and, ultimately, perfect timing. Out of choice, I am working on a project completely away from my musculoskeletal physiotherapy background: initiatives in the region to improve the physical health of those with serious mental illness (SMI). This is a topic gaining significant publicity at present, especially given the reduction in life expectancy of between 15 and 20 years for those with SMI compared to those without. Which, I’m sure you agree, should not be the case in 2017. And I am very proud and energised to be a small part of the workforce that is striving to reverse that disparity.

And that, at least from a personal perspective, is what a Darzi Fellow is. However, the relationship between two elements is absolutely key; it’s who I’m talking to that puts everything I do into context. Their needs, wants, expectations and experience are unique every time. So that’s why my answer may be different depending on who’s asking the question. And the invitation to a conversation is the most exciting and rewarding part.

Next steps: physiotherapist to Darzi Fellow

Thank you for visiting this website. This will be a (possibly) regular, (most likely) brief and (probably intentional) diversion from the day-to-day rigours of work where I will blog things of interest in a reflective way and highlight work I am involved with that might well spark an interest in the reader. All views my own unless stated. more about me in the ‘About Me’ section.