A practical initiative responding to drivers for change and transformation in Digital and Technology Enabled Health and Social Care.
This is a true story about transformation in the NHS in Staffordshire. It’s a tale of how project innovation alongside a desire to deliver a challenging vision resulted in “something happening on December 19th 2018” that looks set to secure a foundation for Technology Enabled Care Services and Digitally Enabled Care becoming an everyday reality for local people. Why should this be interesting? Put simply Technology Enabled and Digitally Enabled Care offers a new way to maintain person centred health and social care while making potentially one of the biggest contributions to the future sustainability of our health and social care system. NHS England said of TECS in 2015 “Technologies such as telehealth, telecare, telemedicine, telecoaching and self-care apps have the potential to transform the way people engage in and control their own healthcare, empowering them to manage it in a way that is right for them”.
So the advent of Technology Enabled Care Services (TECS) is not new but the promise of widespread and sustained application of TECS has not yet been realised in Staffordshire. That doesn’t mean there hasn’t been progress, there have been some terrific Staffordshire initiatives and projects which have had national and even international recognition, it’s more that where there is implementation in health (including General Practice) and social care settings it has been hard won and the commonplace application of TECS is not yet a reality. The rapid development in “Digital” has created a new environment for the introduction of TECS in health and social care simply because becoming digital opens up access to more and more of the population and importantly more and more practitioners.
So how did the “Something that happened” start? There are two key players in this story ……
One of those nationally recognised projects mentioned above is an NHS Pathfinder project managed by The Good Things Foundation through Stoke on Trent CCG which set out to explore the attitudes of local people towards Digital Health. Led by Dr Ruth Chambers OBE, Staffordshire STPs Clinical Lead for TECS programme, Digital Workstream and Visiting Professor Staffordshire University and honorary Professor Keele University, the “GTF Project” ran in 2018 which concluded that by and large local people were receptive to the introduction of Technology and Digitally Enabled Care and wanted if not demanded to know more about what was available and supported by the NHS and Social Care – and here is an important bit, in many more cases than expected local people were already utilising Health and self-help Apps without any involvement of the NHS or Social Care so outside of any Health and Social Care plan. Ruth and the small project team were doing what all good projects do – trying their hardest to get the findings disseminated and learning applied.
Then there was a conversation with Dr Ann Ewens, Dean of the School of Health and Social Care at Staffordshire University.
Ann had a challenge. The University aim to be a leading Digital organisation and Ann is committed to ensuring the School of Health and Social Care plays its part in securing that aim. Alongside this University aim, Ann and her team are important University contributors to the Staffordshire Deal which is a partnership and plan for a connected and digital county. It that has a principal objective to “Improve Health and Social Care, reducing health inequalities and improve the health and wellbeing of local communities through applied research to enable innovation in service delivery’’ While it needed a couple of conversations over a couple of hours, Ann and Ruth came to a shared position that working together – and doing so quickly – they could support each other’s ambitions to see learning applied and real change secured. Ruth and her team were to bring their experiences and findings from the GTF project and their wider experiences in the TECS area to the lecturer team at the School of Health and Social Care.
In truth for the importance and scale of what was attempted Ann and Ruth got there quickly with a minimum of fuss and at a minimum cost – and it is worth outlining why. They started with understanding Ruth’s desire to cascade and share the findings of the GTF Pathfinder project and Ann’s imperative to drive the ambitions of the University. They found real complementarity in the experiences of Ruth’s team and the needs of Ann’s team in meeting the future needs of the School of Health and Social Care graduates that suggested they must work together. They picked out where there was convergence in their aims around which they could explore the possible, rather than trying to create an idealistic common aim. In transformation work there is often a focus on differences that need to be overcome rather than on complimentary areas that can be built on.
Their approach was truly opportunistic as rather than create a specific new initiative they chose to build on what was happening and planned already and set out to add measurable value by sharing learning and what it means for future practice. In that lies the shared ambition. Ann has commented that from the outset she and Ruth set out to do the right thing which to onlookers at the time might not have seemed to be doing it right! Yes there was risk.
For Ruth and the team the risk was that the value in the learning gained from working with the public and practitioners about technology and digital applications in health and social care would not be recognised as having relevance in the context of the pressure to successfully deliver for learners a complex curriculum. Failing to show the relevance and importance of technology and digital applications would hold back bringing innovation into everyday health and social care practice. For Ann and her team the risk was considerable as a double jeopardy applied. If the opportunity was missed to secure a common and shared understanding of the technology and digital imperative in health and social care the School might fall behind the emerging needs of the sector.
The scene was set. It was late November, Ann had arranged already a team away day on the 19th December and she decided to give 3 hours of that event over to a workshop to be led and delivered by Ruth’s team. To put this into context Ann has only two team “away days” a year so to put half the day aside for this “transformational” element reflected Ann’s confidence in Ruth and her team and the messages they intended to share.
Ruth and Ann quickly established a partnership approach committing members of their teams to pull the workshop together. Invitations to support the design of the event and its delivery went to the Local Authorities and the CCG clinical team – invitations that were accepted. The team:
Dr Ann Ewens Dean, Staffordshire University
Dr Ruth Chambers Clinical Lead, Stoke on Trent CCG, Staffordshire STP and GTF lead
Mike Phillips Associate Dean, Staffordshire University
Teresa McGougan Strategic Improvement Lead Nursing and Patient Care, Stoke on Trent CCG
Peter Ball Telecare and Physical Disability Services Manager, Stoke on Trent City Council
Lisa Morgan Administrator, Staffordshire University
Chris Chambers Telehealthcare Facilitator, Stoke on Trent CCG
Dave Sanzeri GTF team and Event Facilitator
The brief was clear – 3 hours, lots to get through so keep on topic, make it interesting and engaging and, because of the constraints of the venue, no Powerpoint. Ruth and Ann intended there would be shared ownership of what they saw by then as a flagship initiative with a clear shared understanding of the design of the event and what the expected outcomes would be. The workshop aim and 4 objectives were agreed as:
- To update the School of Health & Social Care academic teams to the importance of including digital delivery of care as an essential element in every undergraduate and postgraduate course or degree.
- To appreciate Staffordshire’s strategic imperative for digital health and care to contribute to clinical and financial sustainability of the future NHS and the scale and pace of social drivers for development
- To explore and prepare for the impact of digital delivery on healthcare pathways, models of care and Practice
- To develop an understanding of the expectation for quality assurance in technology enabled and assisted care
The School of Health and Social Care identified the workshop outcome was to be:
Commitment to action and the creation of a digitally ready workforce in the NHS and social care who embrace technology enabled care services and develop an understanding and positive approach to digital inclusion of patients/carers and the public in relation to health conditions and adverse lifestyle habits.
There wasn’t an undue focus on structure and content beyond managing time constraints and would what was planned get the delegates to shared understanding and deliver the outcome anticipated. The workshop team put together a 3 hour programme based on 5 sessions each with a short introduction to set the scene and put a challenge to the delegates where their responses and conclusions influenced how long each session lasted and how the next or following session would need to adapt to what had already been contributed by the delegates – an unbelievably flexible and intuitive approach to doing things only possible because of the openness Ann and Ruth engendered and the trust they developed between their teams. A lot of thought was given to the facilitation of the event, it was agreed a member of Ruth’s team would act as single facilitator with a key responsibility to make the transitions between sessions seamless bringing together the contributions made by the delegates as the sessions progressed. This might sound a bit twee – but think of all the initiatives where event planning has been the focus of endeavour, with sweat and indeed tears being shed and where stake holding has got in the way as the design of the event and managing for every eventually has been important rather than successful inclusive delivery being the measure of success.
To deliver, while there had to be clarity and certainty about the nature and significance of the learning under the GTF understanding the delegates to the event and their needs in introducing any technology or digital themes into the curriculum was paramount. Colleagues at The School of Health and Social Care at Staffordshire University were described as having a rich and diverse variety of professional backgrounds. Those teaching on health-related programmes having clinical experience as nurses, midwives, paramedics and Operating Department practitioners. The academics in the Social Work and Social Welfare team represent the professions working to improve the welfare of local and indeed regional citizens and beyond – many of them are Social Workers or Welfare Advisors in the voluntary sector by background. Academic colleagues were described as responsible for delivering the most contemporaneous knowledge, clinical skills and practices in order to equip graduates with the ability to perform safely and effectively in their professional roles upon graduation. They design and bring together the component parts of the curricula against which students are taught and assessed. To be effective it is essential, therefore, that this wide and diverse workforce themselves feel confident in their knowledge of evolving trends in practice including technology and digital assisted practice. The planned initiative involving Ruth and her team was timely as colleagues with the School had begun to discuss how they could ensure that they could respond to the increasing demand from their students about the utilisation of digital technologies. Ruth and Ann understood that the School of Health and Social Care team were ideally placed given their rich mix of interactions and involvement with not just students but NHS and healthcare partners, service users and carers and other key stake holders to bring forward the introduction and integration of TECS and digital into planning and practice. The strategic place the University team holds in Staffordshire was clear including this talented team of academics and experienced tutors have influence over the skill-set that graduates will have on entering into the workplace of a modern NHS and Social Care system.
Making Something Happen in Staffordshire was to prove timely. To help set the context and to provide a frame of reference illustrating the relevance and pertinence of “Making Something Happen” it is worth referring to the latest review in this field published in February 2019 “The Topol Review” – Eric Topol MD, in a letter to the Secretary of State for Health and Social Care on release of The Topol Review says:
“We (the review) offer a number of recommendations for you to consider. These will require early implementation by education providers, as well as by arm’s-length bodies and employers on behalf of the NHS, if we are to gain the benefits these digital healthcare technologies offer.” (page 7)
The review goes onto to say:
“Our review of the evidence leads us to suggest that these technologies will not replace healthcare professionals, but will enhance them (‘augment them’), giving them more time to care for patients. Some professions will be more affected than others, but the impact on patient outcomes should in all cases be
positive. Patients will be empowered to participate more fully in their own care”. (Page 9)
“With patients placed firmly at the centre of our discussions, this report is the culmination of an extensive literature review, interviews, expert meetings and round tables. We had an overwhelming response to the call for evidence from individuals and organisations, with responses from hundreds of patient representatives, professional groups, industry, education, regulators and national bodies. ……… Within 20 years, 90% of all jobs in the NHS will require some element of digital skills. Staff will need to be able to navigate a data-rich healthcare environment. All staff will need digital and genomics literacy.” (Page 9).
Section 9.3 of the review (Supporting Educators) seems apposite to this local initiative to Make Something Happen reflecting the foresight of Ann and her team and referencing the experience of Ruth and her team:
“Educational leaders and educators, including quality improvement experts, are critical to driving a new learning culture. For these leaders to be truly transformational and deliver on their responsibilities, the NHS needs to support them to embrace culture change. This may include specific experiential learning within external companies who are engendering the culture the NHS is aiming to achieve. Given the pace of change, educators must be reflective in their approach, not only engaging in ongoing learning, but developing and adapting their educative practice through innovative ways to meet new and future challenges. ……….
Champions should be encouraged to share their knowledge and experience. Evidence highlights the
benefits of networks within and across organisations that enable collaborative and guided learning. The primary care ‘digital nurse champions’ is a good example [R. Chambers et al., ‘You too can be a digital practice nurse champion’, Practice Nurse, June 2018.] (Page77)
In the review section 5.0 “Digital Medicine”, there are statements that mirror the conclusions Ruth and her team have drawn in driving TECS within Staffordshire and regionally / nationally:
“New digital technologies have the potential to transform how the NHS delivers care in the decades to come, for example, through faster and more reliable diagnosis of infectious diseases, empowerment of patients to monitor and manage their long-term conditions, promotion of health and wellbeing through personalised apps, and the delivery of care outside of traditional healthcare settings through remote monitoring………….. To realise the full benefits of digital medicine, the NHS will need to develop senior managers capable of leading on the digital agenda. Time and opportunity to increase the digital skills of the current workforce will be required, as will the ability to attract much needed up-to-date digital expertise. Equally, citizens, patients and families will have a pivotal role to play. Patient activism………. exemplifies a growing trend in empowered patients demanding and taking greater control over their own care. Tackling digital exclusion while supporting the workforce to develop new skills and practices will be essential to ensure access and adoption across all socio-economic groups. Increased patient and public education programmes, as well as practical facilitation, will be needed to ensure that digital technologies do not increase health inequalities”. (Page 47).
“The Topol Review, Preparing the healthcare workforce to deliver the digital future, An independent report on behalf of the Secretary of State for Health and Social Care.” February 2019.
The workshop design (Delivery time 3 hours):
Session development objective
Facilitator role / contribution
Participant activity / contribution
Introduction – Ann’s team
Transition to workshop – thanks to CCG and GTF – Ruth’s team
Challenge during feedback “Will it take till 2030”
Table exercise (self selected groups)
What will your home look like in 2030?
Table feedback – by addition / challenge to prior feedback
Participants will be able to identify and discuss the place and potential of digitally enabled and / or technology enabled services in the delivery of modern and sustainable health and social care.
2 x presentations to introduce:
NHS imperative and public driven demand
Social Care challenge and need for change
Facilitator roaming. Facilitator (& table leads) encourage participation
“Consequence mapping and visioning”
Table exercise: (self selected groups)
Odd groups – what if we embrace TECS / Digital?
Even groups – what if we do nothing?
Table feedback – summarise a case for change?
Participants will be able to discuss and scope the introduction of TECS and Digital into health and social care pathways including the adoption of technology enabled services into care planning and commissioning
2 x presentations to introduce TECS / Digital
… in self management and prevention
… in diagnosis, treatment and monitoring and rehab, recovery and maintaining independence
Facilitator roaming. Facilitator (& table leads) encourage participation
“Elderly Care Pathway mapping” (STP example)
Table exercise (constructed cross discipline groups)
Identify points in pathway to introduce TECS
List changes in practice – practice enhancements
Risks to be managed with mitigation actions
Groups present pathway, challenges, risks and mitigations (as team)
Participants will be state the issues for organisations and individual practitioners in quality assurance, continuous professional development and the realisation of patient and client expectations with the assimilation of TECS / Digital into health and social care.
1 x presentation to introduce:
IT skills are not digital competences and knowledge requirements reflect this
Facilitator roaming. Facilitator (& table leads) encourage participation
“Quality in a digital age”
Table exercise (Mixed discipline groups)
(1) Support the statement “Our graduates are fully prepared” or “Our graduates are not at all prepared” to integrate TECS and digitally enabled care into their practice
(2) How should course content develop to ensure that graduates are prepared for and can work to quality measures appropriate for a digital age.
(3) How can the University develop graduates and support post graduates in TECS / Digital in their CPD strategies.
Group feedback – emphasis to be placed on action?
Open Forum (10 – 15 minutes)
END OF WORKSHOP
Panel of all presenters and facilitator
Transition to rest of development day
Q & A on next steps:
Engagement of organisations?
Engagement of students / learners / practitioners?
It is always difficult to report on a workshop or similar event as, when they are run well, the value for participants is in “being there” with the benefit coming from the interactions with colleagues while they share the experience of learning together with secondary value and benefit arising from the content of presentations or a copy of any slides.
This workshop in “Making Something Happen” stimulated an energy in the delegates and grabbed their attention to a such a degree that far outweighed anything expected or hoped for during the design and planning of the event. This energy and attention was reflected in the level of participation and the quality of delegate exercises that built on short but high quality scene setting introductions. The format throughout relied on posing questions and challenges to the delegates encouraging open and unrestrained dialogue that was tightly facilitated so that table groups reached conclusions – yet committed to continue the debate in later university forums.
The level of participation was noteworthy, with competition on and between tables as delegates made their contributions and this high level of participation was sustained throughout the event. There was a vibrancy and energy which in part came from the way the event was designed – and so its relevance to the participants was evident to them. In this they were completely engaged, the level of challenge was excellent and thoughtful, the contributions coming back in the exercises was in some cases visionary and the quality of the table conversations was at a level of sophistication greater than anything imagined when the workshop was designed. This doesn’t mean there weren’t objections – of course there were but through the flexible and intuitive way the event was delivered they were handled and contributed to the quality of the day rather than detracted from it. There is a challenge in sharing the session conclusions and discussion contents as “you really had to be there” and the nature of the transformation secured was in the attitudes and intentions of a key University team and what this means for the training and development of the Health and Social Care graduates.
In addition to the core of the workshop, Ruth arranged an opportunity for delegates to share their views and understanding from participating in the workshop. A simple form asked delegates “Just tell us, in one or two sentences, how you feel technology enabled care could make a difference to the health of service users with long term conditions”. Before the Open Forum session, one form was drawn from those submitted that won an Amazon Fire 7 tablet. The comments coming from the delegates can be grouped into key themes:
- introducing skype or face time techniques in improving patient care and service user benefits
- communications and digital technology allowing real time feedback and wellbeing updates from patients and service users and carers and could be harnessed for wider social interactions
- enabling independence, self-reliance and personal responsibility within patient care and service user plans supporting an enhanced role from health and social care professionals
- technology enabled and digitally enabled services will address exclusion while driving inclusion (addressing loneliness and isolation) and will create opportunities for a different, fairer resource allocation
- the single personal record should become a reality directly improving integrated person-centred health and social care which is not limited to the role of professionals
- distance techniques for monitoring (including biometrics and wellbeing indicators) would seriously improve quality and standards in care particularly in safety
- the contribution of carers and the community and voluntary sector and private providers can be better utilised under an integrated care plan for health and social care driving a better more consistent use of resources with less in terms of crisis management and
- be positive and life changing (breaking the links with and focus on illness and need).
There was, from the table conversations, session feedback and form entries, real time evidence that thinking was developing, knowledge was being acquired and applied and post event actions were intended.
So did “Something Happen”? By the design and the path that led to the workshop taking place there is no pre workshop baseline to refer to or against which any changes can be assessed. It is possible though to reflect on the outcomes seen at the event:
Recognition that TECS and digital enhanced care is an inclusive methodology and is not about separate TECS or Digital pathways;
Ruth and her team have made some progress with commissioners and NHS organisations in recognising TECS and Digital must be integrated and mainstream. Consistent with the Topol Review findings and recommendations this workshop outcome should be significant in driving the understanding and perceptions of Health and Social Care graduates.
Inclusion in care plans is the key so it should be focussed on the needs of the individual “by design” and so be appropriate to their care – so there is an important role for those who establish the care plans with patients and users – an area of practitioner confidence and competence identified;
This is a strategically important outcome as it proves the necessity to mainstream TECS and Digital based on servicing or meeting the health and social care needs of the individual as opposed to creating TECS or Digital programmes that individuals might or might not benefit from.
There should be positive social inclusion because of utilising TECS and digital in health and social care being mindful / alert / careful that the enthusiasm for TECS and digital doesn’t inadvertently leave people behind (this social inclusion idea being counter intuitive for the delegates);
Consistent with the learning from the GTF Pathfinder Project and earlier TECS implementation projects and now the Topol Review local people are more digitally active than thought but they are not necessarily using their digital capacity and capability to support their health and social care wants and needs. This outcome recognises that while much more could be done to include health and social care in existing digital activity as TECS and Digital mainstream it will be important to ensure the limits of the infrastructure available to individuals are understood and that no patient or service user / carer gets left behind.
Who resources TECS / digital has to be confronted and clarified if practitioners are going to integrate TECS / digital into care plans? It was recognised that commissioners, providers and users all have a part to play and the scope for things like Personal Health Budgets (PHB) hasn’t really been explored in health; and
An outcome that captures a key issue and the quandary that if TECS and Digital must be integrated, and mainstream health and social care methodology how are the resources needed to make the transition going to be released? During the workshop options including efficiency incentives and PHBs were mentioned while the consensus was that it is in this area that there is the greatest need for change and transformation.
In conclusion this event consolidated the School’s leadership view that the timing was right to start a serious conversation amongst its academics regarding the role of technology enhanced care in the delivery of future health and social care services. The learning from the event was that there is a positive appetite and enthusiasm within the academic team for embracing a new approach to embedding the development of digital literacy into the student body through a new and refreshed curriculum.
In terms of the School’s commitment to action following the workshop the following is already in process:
- Addressing a digital theme in every future School away day
- All new curriculum to embrace digital literacy skills development in students
- The renewing of the focus of the School’s ‘Digital Champions’ ensuring the School now moves at pace regarding embracing a new pedagogy where digital is embedded
- Collaborating with University colleagues and external stakeholders to support the goals of the Staffordshire Deal in terms of improving health and social care services through digitally enhanced care
- A cross University ideation event to explore the role of the University in digital health education