Examples from practice, annex C

Situation and Background

The pandemic had a significant and long-lasting effect on the delivery of planned care across Hywel Dda University Health Board. More than 4,000 orthopaedic patients had their treatment delayed and this had a significant impact both on their physical and psychological wellbeing. There was no prehabilitation service available to support optimisation for patients across a large geographical rural area.

Aspiration

To offer a tiered virtual prehabilitation service to all patients awaiting elective hip and knee arthroplasties across Hywel Dda University Health Board, providing advice on the:

• self-management of symptoms
• physical exercise sessions
• healthy lifestyle
• nutrition
• home safety
• psychological wellbeing.

Solution

Hywel Dda University Health Board developed and implemented a virtual, tiered, multi-disciplinary orthopaedic prehabilitation service with partners in industry.

Patients are assessed and stratified onto one of three different virtual patient centred tiers of prehabilitation based on their clinical, physical and psychological needs utilising digital platforms.

• Tier 1: 8-week online prehabilitation programme using a digital personal held health record (Patients Know Best).
• Tier 2: Tier 1 plus “live” virtual group home based prehabilitation (12 sessions over 12 weeks) utilising Attend Anywhere group functionality using a virtual group consultation concept and remote monitoring through technology enabled care (blood pressure/ weight/ heart rate/ oxygen saturation) supported by Delta Wellbeing and Tunstall’s “MyMobile” app.
• Tier 3: Tier 1 plus supported one to one virtual prehabilitation sessions for patients with more complex needs or digital accessibility challenges (hearing, eyesight etc) utilising Attend Anywhere video consultations and remote monitoring (default virtual, flexibility for face-to-face if required).

Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) data capture through the DrDoctor platform.

Impact

• Improved patient clinical outcomes (weight management, improved mood and wellbeing).
• 60% of patients reporting PROM via DrDoctor.
• 100% of consultations have been virtual.
• Improved patient experience.
• Increased uptake of virtual group consultations (100% of tier 2 consultations are delivered through virtual group consultations).
• Increased virtual appointments (100% of tier 2 and 3 consultations virtual, over 600 consultations).
• Increased digital inclusion and access.
• 100% of patients have been offered prehabilitation as part of their pathway using a tiered approach.
• Increased use of personal held health records – over 400 patients signed up to the online 8-week programme.

Situation and Background

NHS Grampian's Public Health Healthpoint which launched a test of change to support elective patients awaiting procedures amidst rising waiting lists exacerbated by the pandemic. Collaborating with the Acute Sector, they targeted Orthopaedic patients, the largest cohort, based on prior surveys.

Aspiration and Solution

To offer a ‘wellbeing’ conversation where they listened to the patient and looked at practical ways to support the patients to ‘wait well’, providing advice and support such as:

• supporting a patient to swim again by finding local swimming pools with hoists
• finding a local ‘knit and natter’ group for a patient who was still feeling isolated after Covid19
• took the opportunity to update the patient’s details held on Trak and inform clinical colleagues of patients who wished to be removed from the list or had periods of unavailability for their procedure.

For patients who disclosed that their symptoms had significantly deteriorated, a Tier 2 service was provided where a Nurse contacted the patient to provide support and escalate to the clinical teams if necessary. For each patient, an In-Patient Waiting List (IPWL) Surveillance form was completed by the Healthpoint team and uploaded on to Trak. This allowed clinical colleagues to view the details of the Waiting Well conversations including advice given and signposting to services. Patient were given their free healthline number and encouraged to call back at any time if they needed additional support.

The delivery of the service commenced on 20 June 2022, with the first cohort of patients being completed by 14 November. Planning started early May.

Throughout the delivery of the Waiting Well Service, the Healthpoint Advisors recorded information on the Waiting Well conversations. The team were also encouraged to provide feedback on the test of change. This information was used to shape the service and identify trends in requests or gaps in information provision e.g. mental health and suicide training organised with Penumbra, appointment letters amended to include Healthline number, improvements in MS form for recording etc.

Impact

The Waiting Well service supports 8000 patients per year, garnering overwhelmingly positive feedback:

• 85% found the information useful
• 22% implemented health-related changes
• 27% planned or contemplated improvements
• 9% reported significant life improvements. Minimal barriers to accessing services were reported, with clear contact information facilitating engagement. This highlights patients' openness to conversations and guidance while waiting for elective procedures.

Situation and Background

As we remobilise services post pandemic it is recognised that there remains an ongoing backlog in surgical waiting lists with potential for patients to decondition whilst waiting for surgery: 7697 - 86% routine. Long Waits 69%>3months, 48%>6months, 21%>1year.

We know that fitter patients who are able to improve their health and activity levels recover from surgery more quickly and reduce their risk of suffering major complications. Locally in NHS Ayrshire & Arran we have introduced Active Clinical Surveillance (ACS) which offers health screening to identify those individuals who might benefit from earlier intervention in the pre-operative patient journey.  

Aspiration and Solution

This innovation will allocate the Period-Operative Assessment (POA) service based on the need of the individual at a time when demand on the service is at a peak, maximising its benefit and helping people to ‘wait well’ for surgery. It will provide a system for active clinical surveillance of patients on waiting lists, particularly those who have been waiting for longer than 3 months.

• Orthopaedic, General Surgery & Gynaecology waits at 42 weeks.
• The patient will attend a 45 minute face-to-face appointment at the Preoperative Assessment Facility. Commences with Royal College of Anaesthetists ‘Fitter, Better, Sooner’ audio-visual (if not watched at home).
• Active Clinical Surveillance Screen: Lifestyle, Nutrition and Psychological screening utilising evidence-based patient rated outcome measures.
• Referral to prehabilitation resources, signposting to community resources, offer of myOp (digital self-management app).
• Targeted prehabilitation face to face or hospital based supported by AHP colleagues.
• Expedited to perioperative nurse led assessment.
• Ongoing 3-month reviews via ACS until surgery date is issued.

Impact

Since May 2023 there has been 599 appointments offered via ACS. On average three quarter of appointments were attended. Recruitment gap November 2023 to January 2024 impacting on appointments cancelled and rescheduled.

• Reduced cancellations for not fit for surgery (zero for last 7 months for these specialties).
• 225 patients were expedited to perioperative nurse led assessment, with 144 of these patients being within SIMD 1&2 (the most socially deprived postcodes).
• 152 patients were ‘on-boarded’ onto myOp with an average of 71% user activation rate. Educational views: 1708 by 255 patients. 487 Activity diary information entries by 23 patients.
• Random sample of patients from ACS (baseline) to 3-month review by POA Nurse indicated moderate levels of stability in lifestyle and psychological screening and notable improvements in nutrition.
• Positive qualitative feedback received from patient cohort with 83% of respondents finding the questions being asked at ACS to be relevant. Thematic analysis of feedback that in general patients felt more informed of their role in recovery and felt more confident about the next steps before surgery.

Joint Venture: how an NHS physio waiting list was shrunk in just two days

Link to the article in New Local by clicking here .

Situation and Background

Allied Health Professionals (AHPs) in Sussex had overwhelming waiting lists, but also knew that many people on lists might be there incorrectly i.e. they could have been signposted to other community services, given online resources to use etc. They also knew that these people may wait a long time, only to eventually be seen and told advice they could have had from other routes much earlier on. There was also frustration among community members who found it challenging to secure appointments with public services due to inefficiencies in the booking system.

Aspiration and Solution

Teams decided to have establish a weekend Community Appointment Day (CAD). The primary aim of the Community Appointment Day was to provide a platform for locals to directly engage with service providers, reducing the barriers to booking appointments and ensuring that community members receive timely and effective assistance. Additionally, the initiative aimed to foster a sense of community solidarity and empowerment by collectively addressing common challenges.

Impact

The results were helped to reduce waiting lists but more importantly, led to an improvement in people’s health and wellbeing outcomes.

The positive impact of the Community Appointment Day includes the local community coming together to address the inefficiencies in the appointment booking process. As a result of the initiative, wait times for appointments were reduced by a third, demonstrating tangible improvements in accessing public services for community members.

To note, NHS Lanarkshire have also just undertaken a similar CAD. Click here  to view the website.