Improving Patient Experience Quality Committee deep dive July 2016 Sasha Bhat head of engagement and experience NHS Bradford City and Districts Clinical Commissioning Groups sasha.bhat@bradford.nhs.uk
Improving Patient Experience Introduction NHS Bradford City and Districts Clinical Commissioning Groups (CCGs) identified improving patient experience as a strategic priority and integral to the ambition to commission high quality services, to reduce health inequalities and have better health for the people of Bradford. Patient Experience is a vital part of the quality framework. A simple description of high quality services was defined by Lord Darzi (2008) and by Keogh (2013) as services that are: effective in their care intervention deliver good patient experience and provide safe delivery of healthcare The ambition set by each CCG is to improve patient experience through meaningful engagement with our communities, providers and partners in the planning, commissioning and delivery of healthcare services. What do our patients mean by patient experience? Our patients tell us that for them patient experience refers to how we think and feel about what happens when we use health services. They want good services that support, listen and keep them informed so that they can make meaningful decisions and choices about their care. This resonates with the definition provided by Dr Foster (2010) which defines patient experience as feedback from patients on what actually happened in the course of receiving care or treatment, both the objective facts and their subjective views of it. A person s experience starts from their very first contact with the health and care system, right through to their last, which may be years after their first treatment and can include end-of-life care. We know that some people use different ways to describe the quality of care they receive and so it is essential that we have the ability to listen and reach our population to understand their experiences. Quality deep dive: Patient experience July 2016 Page 2 of 22
Importance of patient experience Good engagement More responsive services Improved experience Beter health outcomes A bedrock of good engagement is particularly relevant in Bradford where we have a diverse population in age, ethnicity, ability and access opportunities. Effective public engagement leads to collection of intelligence and insight from people to support the decisions, delivery and evaluation of services that have been shaped together by clinicians and relevant people and communities. Our approach to engagement will be described later on this paper. Patient experience positively correlates to processes of care for both prevention and disease management at both provider and individual level. For example, people with diabetes demonstrate greater self-management skills and quality of life when they report positive interactions with health care services and professionals. Patients experiences with care, particularly communication with providers, correlate with adherence to health care advice and treatment plans. This is especially true among patients with long term and chronic conditions, where a strong commitment from patients to work with their health care provider is essential for achieving positive results. Ultimately, people with better health care experiences have better health outcomes. For example, studies of patients hospitalized for heart attack showed that patients with more positive reports about their experiences with care had better health outcomes a year after discharge. Collecting and more so measuring patient experience is therefore important not only to inform service improvements but also because it can be used to measure the outcome and costs of treatment. Measures of patient experience also can reveal important system problems, such as long waiting times, delays in discharge and gaps in communication that may have broad implications for clinical quality, safety, and efficiency. Only by understanding what people want from their services and continually focusing on their experiences will we truly be sure we are delivering value for money. Our legal duties Improving Patient Experience is a strategic objective that the CCGs feel passionately about achieving. It is important to note that there are clear duties on CCGs set by the Department of Health to secure continuous improvement in the quality of health services and promote the NHS Constitution. The NHS Constitution places a statutory duty on CCGs and explains the shared purpose, principles, values of the NHS and the patient rights of users, public and staff. One of these principles is that the NHS aspires to the highest standards of excellence and professionalism in the provision of high quality care that is safe, effective and focused on patient experience. The constitution also states that respect, dignity, compassion should be at the core of how patients and staff are treated. Quality deep dive: Patient experience July 2016 Page 3 of 22
The Health and Social Care Act 2012 places statutory duties on the NHS to demonstrate continuous improvements in the quality of health services, with regard patient experience. The Act places a further duty on CCGs to deliver the following (summarised): Duty to involve and consult with the patients, carers, the public and the Local Authority S.242 & S.244 Enable choice for people in the services available and providedfor them S.13I Reduduce inequalities between patients and promote their ability to access health services, improve quality and outcomes through coordinated services S.14T Involve and consult patients, public and carers in developing, considering, planning and deciding of commissioning of services S.14Z2 Legal responsibilities Experience Promote the involvement of each patient and their carers in the decision making for their care or treatment and in the prevention and diagnosis of illness S.14U The Equality Act 2010 unifies and extends previous equality legislation. Nine characteristics are protected by the Act, which are age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation. We have additional local chosen priorities for carers, people living in rural areas, people on low wage or income support and for refugee and asylum seekers. Section 149 of the Equality Act 2010 states that all public authorities must give due regard in the course of their duties to the need to: Eliminate discrimination, harassment and victimisation Advance Equality of Opportunity Foster good relations with the public Inequalities in access to and the responsiveness of care and outcomes achieved between patients groups, and the degree of involvement and patient choice, are known determinants that impact on the experience of care. Key drivers for patient experience In addition to the above legal duties, there are local and national drivers for improving patient experience. NHS Bradford City & Districts CCG strategic priorities Both CCG members have stated that improving patient experience is a key strategic objective and is linked to improving health outcomes for our population. High Quality Care for All (2008) confirms quality as the organising principle behind everything that we do. Quality deep dive: Patient experience July 2016 Page 4 of 22
NHS England described the ambition of the NHS in the Five Year Forward View, to introduce a transformational approach to healthcare including strengthening primary care, joint NHS commissioning with local government and introducing entirely new models of care. In relation to patient experience and commissioner / providers - plans must include ambitions to: Reduce poor experience of inpatient care and general practice. Assess the quality of care experienced by vulnerable groups of patients and how and where experiences will be improved for those patients. Demonstrate improvements from Friends and Family Test (FFT), complaints and other feedback. Deliver all the NHS Constitution patient rights and commitments. Increase transparency of patient outcomes data to promote choice over where and how patients receive care. Our local five year forward view supports the above ambitions and has been further developed through our Sustainability and Transformation plans (STP) which outline our plans to ensure we achieve our vision for patient experience and health outcomes. A set of six principles set out the basis of good person centred, community focused health and care and require that: 1. Care and support is person-centred: personalised, coordinated, and empowering 2. Services are created in partnership with citizens and communities 3. Focus is on equality and narrowing inequalities 4. Carers are identified, supported and involved 5. Voluntary, community and social enterprise and housing sectors are involved as key partners and enablers 6. Volunteering and social action are recognised as key enablers The NHS Outcomes Framework 2016 was developed in December 2010, and is updated each year. It provides the outcome indicators to be delivered at CCG level, which are grouped in five domains and focus on health improvement and reducing health inequalities. Domain four of the framework relates to ensuring people have a positive experience of care and detailed indicators are below: Patient experience of primary care (GP/ GP out-of-hours//nhs dental services) Patient experience of hospital care Friends and Family Test Patient experience characterised as poor or worse (primary care and hospital care). The quality of commissioning will be directly assessed by the achievement of these health outcomes and they are meant to act as the catalyst for driving improvement - shifting focus from process to outcomes measurement in commissioning. Alongside the Framework sit the Care Quality Commission s Essential Standards which outline how the NHS can provide the services and experience that patients expect. Local Commissioning for Quality and Innovation (CQUIN) Schemes must include at least one goal covering patient experience. Quality deep dive: Patient experience July 2016 Page 5 of 22
CCGs are mandated to use the NHS Standard Contract for all healthcare contracts. The contract includes two service conditions to improve the experience of users. Service Condition 12 - Service User involvement stipulates that: Providers engage, liaise and communicate with service users, their carers and legal guardians in an open and clear manner in accordance with the Law and Good Practice. Providers must co-operate with any surveys that the Commissioners carry out. Providers must review and provide a written report to CCGs on the results of each survey identifying any actions reasonably required to be taken by the provider, in response to the survey. Providers must implement those actions as soon as practicable and publish the outcomes of and actions taken in relation to all surveys. Service Condition 17 Complaints stipulates that CCGs and providers must each: Publish, maintain and operate a complaints procedure complying with the Law & Guidance; Ensure that Service Users are made aware of the complaints procedure and how to use it. For smaller provider contracts, participation in the National Survey Programme is typically stipulated in the service specification. The NHS Patient Experience Framework - In 2011, NHS England agreed a working definition of good patient experience to guide measurement and a framework to outline those elements which are considered critical to a patient's experience of NHS Services: Respect for patient-centred values, preferences, and expressed needs Coordination and integration of care Information, communication, and education Physical comfort Emotional support Welcoming the involvement of family and friends Transition and continuity Access to care Quality deep dive: Patient experience July 2016 Page 6 of 22
NICE Guidance and Quality Standards for patient experience (CG138) were updated in 2014 and released detailed, evidenced based guidance and 14 quality standards (QS) building on the NHS Patience Experience framework. The standards are mapped against five key areas of care: Knowing the patient as an individual Essential requirements of care: respect for the patient, patient concerns, nutrition, pain management & patient independence, consent & capacity Tailoring healthcare services for each patient Continuity of care and relationships Enabling patients to actively participate in their care There are currently two standards developed in relation to patient experience, one for adult patients (QS 15) and the second for adult mental health service users (QS 14). NICE Guidance on community engagement (NG44) provides guidance which covers community engagement approaches to reduce health inequalities, ensure health and wellbeing initiatives are effective. The guideline covers five recommendations on: Principles of good practice Developing collaborations and partnerships to meet local needs and priorities Involving people in peer and lay roles to represent local needs and priorities Local approach to community engagement as integral part of health & wellbeing initiatives Making it as easy as possible for people to get involved The guidance reflects on the importance of reciprocal relationships, particularly in areas of high deprivation. It aims to strengthen collaborations and partnerships and establish better links between statutory organisations and local communities. The aim is to ensure they can work together to deliver health and wellbeing initiatives that improve health outcomes. Friends and Family Test (FFT) is a continuous feedback tool that supports the fundamental principle that people who use NHS Services should have the opportunity to provide feedback on their experience that can be used to improve services. FFT requires all patients to be asked, at periodic points or following discharge: How likely are you to recommend our ward/ service/ organisation to friends and family if they needed similar care or treatment? Services have the option to add in optional patient experience questions. Learning lessons from National Reviews In recent years there have been failures within NHS organisations, which have resulted in a number of national reviews. The recommendations from three serious reviews have had implications for patient experience. David Bennett Serious case review (2005) David Rocky Bennett died at a medium secure mental health unit. An independent inquiry found that he died as a direct result of prolonged face down physical restraint and the amount of force used by members of staff during the incident. The inquiry made recommendations about the use of physical restraint but related to experience, there were specific recommendations about engaging people, the use of intelligence and insight, the involvement of people, family, carers and Quality deep dive: Patient experience July 2016 Page 7 of 22
communities in care planning, shared decision making and supported discharge to community. It also recommended that Trusts ensure their staff reflected the communities they served in to ensure they had the capacity to understand and engage effectively. This review was particularly focussed on the inequalities to access and treatment by people from Black and minority ethnic communities. Bradford previously was an implementation site for the recommendations from the review. The mental health task force report by NHS England highlighted the lack of progress in achieving recommendations since this review was published. Winterbourne View Serious case review (2012) This review highlighted the criminal abuse experienced by service users at Winterbourne hospital. CCGs, regulators and adult safeguarding partnerships had a number of opportunities to identify and act on concerns, but failed to do so. For patient experience, the review recommended that CCG s: need to actively solicit and act on the voice of vulnerable people must ensure that providers meet proper training standards. Staff who are effective communicators can significantly influence patient experience should receive information via websites that allow those who use services, their family or carers, to give feedback. The Francis Inquiry (2013) The Francis Public Inquiry looked into the events that led to patient harm and unnecessary deaths at Mid Staffordshire NHS Foundation Trust. The government response detailed in Hard Truths (2013) including action for improving patient experience arising from the public inquiry and further six commissioned independent reviews, including the Berwick Report (2013) and the Keogh Mortality review (2013). From these reviews were recommendations for CCG s and providers that made clear that patient feedback was essential. Recommendations include: Preventing problems and detecting problems early: This includes using diverse means to gather patient feedback and taking action; making sure the complaints process is robust and complaints are heard at Trust Board and action is taken to improve services. Taking action promptly: Results and analysis of patient feedback needs to be made available to CCGs, regulators and the public, in as near real time as possible. Also to make sure FFT results are published for every ward within a maximum timescale of five weeks. This also includes having systems to comply with the Duty of Candour Ensuring robust accountability: To develop robust processes for understanding the experiences of patients with other quality related information. To use FFT as a catalyst for improvement and to use patient stories alongside quantitative data to make the data real. Ensuring staff are trained and motivated: Understanding the positive impact that happy and engaged staff has on patient outcomes using the NHS Staff Survey and Staff FFT to measure staff experience. A framework for patient experience The National Quality Board (2015) has agreed a framework to describe elements of patient experience that are perceived to be critical for Commissioners to deliver for patients or carers experience of NHS services. This frame work is based on 4 key structures: 1. Meaningful involvement and engagement 2. Data and intelligence on experiences 3. Strong, committed senior leadership 4. Focus on the workforce Quality deep dive: Patient experience July 2016 Page 8 of 22
1. Meaningful involvement and engagement with those that use health and care services, their families and the public throughout the process of designing, running, monitoring and reviewing services. Our approach: To ensure that we are listening, engaging and involving patients in the planning and design of their local NHS, we have the following methods of engaging and collecting the information based on individual, public participation and the use of insight. Individual participation Insight & feedback Public participation Individual stories Patient stories and case studies: Each Governing Body hears a personal experience of a patient or carer who has used our services. The importance of hearing patient stories has been evident from the outcomes we ve seen following presentations at Governing Body. In the past year, we have heard about the importance of information being accessible and these resulted in resources for staff training. The experience of carers has fed into our CQUIN development and community chest projects. Feedback from the patient networks and engagement events has led to the development of the People s Board. The development work around the Accountable Care System has involved people whose experiences provide a great deal of insight and expertise to shaping plans. This enables us to address some of the systematic barriers that patients and carers have shared with us. Self-management courses: We fund suites of self-management through the Self-Care programme, Diabetes, Healthy hearts, mental health work streams and through the voluntary and community sector. These courses are great ways to hear about local and individual initiatives of self-care. Establishing CQUINS and local improvement schemes: We currently have a CQUIN for patient experience focussed on dementia and carers (John s Campaign). The Local Improvement Scheme for engagement led to patient engagement leads being identified in all City member practices and have fully supported reaching out to our communities to understand experience and get more people involved. A great example of this has been the work at Valley View Practice to empower women who do not speak English to engage with their GP health service on issues around anti-biotics, immunisation, asthma, diabetes and blood pressure. The main themes that emerge from all patient stories and individual participation are around: Importance of empathy and caring staff Emphasis on individual being heard Support from services and mechanisms to support self-care, Good information both for access and during health care interventions Good communication and involvement in shared decision making and Coordination and integration of the system. Quality deep dive: Patient experience July 2016 Page 9 of 22
Public participation We have built a network infrastructure based on ensuring we have the reach and involvement of key areas of our population. Our aim is to ensure we listen to our communities and build open and transparent involvement and co-production on a bedrock of great engagement. The diagram below shows how we strive to achieve this and all our CCG programmes and strategic work streams use this infrastructure. This work is routinely presented to our quality committee, clinical board and Governing Body. Local groups providing essential social support and meaningful activities Charities and volunteers Grass roots engagement groups Patient participation groups A contractual requirement for every GP practice Young people's health network Community chest funds to support activity Patient networks Brings together groups to share good practice and strengthen engagement Local groups engaged with specific groups of interest such as young people, migrants, people with disabilities, service users, BME, LGBT groups, maternity partnership, faith groups, older people, carers etc. Local forum and groups Interest groups Engagement practitioners Women s health network A vibrant network of women, women s groups and services to build dialogue Includes health champions, engagement leads & trained practitioners to engage on our behalf Engaging our communities Our engagement with local people developed the following set of objectives which were presented to Clinical Board in 2015 and approved: Building voice and influence on a solid bedrock of great engagement. To ensure that involvement has demonstrable outcomes on CCG work. To increase and acknowledge the time, skills, expertise and resources that patients and the public give to achieve authentic influence. To support and develop strong, representative and sustainable patient, public and carer groups that support best practice engagement and community development. To strengthen our intelligence of current patient experience that shapes CCG priorities. To ensure that patient and public experiences are at the heart of our commissioning. Quality deep dive: Patient experience July 2016 Page 10 of 22
2. Strong, committed senior leadership (chief executives, boards and senior leaders), including: setting out a clear strategic vision on quality; consistent communication of vision & strategy which frame experience as an integral & equal part of the quality framework (alongside clinical effectiveness & safety); modelling behaviours, promoting a culture of continual improvement and learning; empowering people at all levels of the organisation to drive change; adequately resourcing service redesign that improves experiences. Our approach: Our CCG strategy for quality has a fundamental principle to ensure that care is consistently patient focused, clinically effective and safe at all times and this will be achieved by making quality the primary driver of every aspect of the CCGs work (Bradford CCG strategy for Quality 2015/16) Senior leadership has been key to driving our work on experience. The importance of good experience is resourced and promoted by all levels of seniority in our organisation. Governing body lay membership for patient and public involvement this has ensured that patient experience has been at the forefront of quality work and raised the profile throughout the organisation. Clinical leadership from the GP leads on our Clinical Board has embedded work in strategy and supported innovation. Clinical champions have ensured the engagement infrastructure has been co-designed. A robust governance structure ensures and assures the CCG of fulfilling its vision to improve patient experience. Quality performanc e groups Reference groups Quality committee Governing Body Public Governance Structures A number of staff teams are responsible for patient experience including the communications and engagement team, quality team members, Programme management officers, Equality and diversity lead, contracting performance and strategy. We have actively promoted patients and public members to be involved in promoting patient experience, demonstrating confidence and partnership working, and in the past year they have: Attended and presented at Patient Experience Network conference in Wakefield (Feb 2016) Participated in the Systems Leadership events hosted by Health Education England Attended and participated in the NHS Citizens Assembly and workshops Delivered presentations at local events (Equalities together conference, Diabetes Roadshow, Creating an Accountable Care System, our Annual General Meetings and many more). Quality deep dive: Patient experience July 2016 Page 11 of 22
The patient experience and engagement work is resourced according to NHS England guidance. This includes the resource to support and sustain the above engagement structures as well as resourcing a healthy community chest fund which is available to communities to identify good ideas for engagement, promoting good experience and raising awareness about health. To date we have funded 13 projects ranging on topics from mental health, young people s engagement, working with families, reaching the homeless and women refugees, healthcare support for children, initiatives to support long term condition management, reduce social isolation and social prescribing pilots. Each project provides an evaluation report and the outcomes are reported through the quality improvement groups on a quarterly basis. 3. An emphasis on data and intelligence on experiences gathered from continual feedback from those who use services, their carers, families and the public to measure and manage performance on experience. Our Grass Roots brings together intelligence from a variety of sources to provide the CCG with an understanding of what local patients, carers and stakeholders are saying about their experiences of the local NHS services. This is reported monthly to our Quality Committee and bi-monthly to the Governing Body. The Grass Roots report includes FFT feedback and compliments, concerns and complaints recorded by the CCG. Our aim with Grass Roots insight is to: see what people are saying about the services the CCG are responsible for commissioning understand what people s experiences are of local health service provision highlight areas for further exploration and understanding identify areas for improvement and/or development in planning and buying health services to enable the active participation of patients and public in decisions about the health services they use ensure that action is taken on the feedback We have collected Grass Roots insight since April 2013, during this period we have received feedback from over 3,853 sources of data reaching 21,281 individuals. The data has increased year on year as our engagement and involvement has widened and dived deeper to understand people s experiences. 2013 2014 2015 2016 (1 qtr) Sources of data 780 1,536 1,110 427 Individuals 1,560 7,837 9,548 2,336 Quality deep dive: Patient experience July 2016 Page 12 of 22
Our ambition for 2016/2017 is to broaden our reach and sources of data to include more detailed information from our providers. With the implementation of an improved and more sophisticated system, we hope to increase the reach to 400 per month to build our capacity to understand themes and trends across our health system. Deep dive on Grass Roots: Sources of feedback (April 2013 March 2016). 3% 11% 7% 26% Patients, public, carers Healthwatch Correspondence 19% 13% 21% NHS choices/patient opinion Complaints VCS Other Positive feedback (April 2013 March 2016) 250 200 150 100 50 2013/4 2014/15 2015/16 0 BTHFT BDCFT BD CCG BC CCG BCBD CCG VCS Other Negative feedback (April 2013 March 2016) 250 200 150 100 50 2013/4 2014/15 2015/16 0 BTHFT BDCFT BD CCG BC CCG BCBD CCG VCS Other Quality deep dive: Patient experience July 2016 Page 13 of 22
Key themes and activity from Grass Roots: Grass Roots insight collects experience of a wide range of issues and we have presented a deep dive on experiences with regards to: Psychological well-being services (November 2015) Care homes (December 2015) Maternity services (January 2016) Urgent and emergency care services (February 2016) Domiciliary and residential care (March 2016) Primary care services (March 2016) Our key themes across the system 1. Easy awareness and access about the services we offer (good communication, information and provision of services that are local and accessible). 2. Eliminate system and process barriers and provide a joined up service (people share their need once and can get the help they need from all services and inequalities are addressed) 3. Information is provided at all levels of service provision that supports people, carers and families to be informed and make choices and decisions, including how to self-care and prevent using services in the first place. 4. We provide a culture and environment of respect, dignity, high skilled staff and high quality services. 5. We are creative and innovative in developing effective services that provide choice and different approaches (involve people in coproduction and be brave about change) Provider patient experience These broad issues reported for our major providers as well as the clinical priority areas are highlighted throughout our Grass Roots reporting: Car parking facilities at the hospital impact of this is experienced as lateness or missed appointments, frustration from patients and carers, burden on carers and disadvantage for patients. Staff levels and workforce issues this is the second most reported issue and is experienced as perceived lack of staffing levels, poor attention to patient needs, delayed discharge and longer stays, dissatisfaction, stress, witnessing situations which add to poor experience, stressful environments, lack of communication and understanding of care plans, low involvement of patients and carers in decision making. High expertise and care of clinical staff was particularly commended. Quality deep dive: Patient experience July 2016 Page 14 of 22
Respect, dignity and empathy There are positive experiences reported by people about their interactions with staff at the hospital and in community services. There are however, many reports of people and their carers not feeling heard, being in situations of discomfort and experiencing indifference. Acknowledgement and respect for diverse and different needs is also reported. Food and hygiene Feedback about the food and environmental factors at the hospital have improved in Grass Roots, however, in the past few months, more negative experiences and reports have been made in Grass Roots. Communication and coordination Understanding and information about their treatment especially during waiting periods, knowledge about expectations and communication between staff and between staff and patients are the main issues that cause patients to report poor experiences of care at the hospital. This links to the coordination and joining up of services and facilities and delays/unsupported discharges. Clinical priority areas: We have 6 clinical priority areas as identified by NHS England. These are dementia, cancer, learning disabilities, maternity, mental health and diabetes. The main areas of feedback collected from our Grass Roots insight is presented below: Dementia Overall experiences of patients are positive Experiences for carers highlight areas needing improvement. Access to services is inconsistent while there are many good examples of good practice, there is also variation across the City for people and from different communities. There needs to be better education and awareness about dementia. Dementia services need to be more culturally sensitive and have an awareness of how wider social determinants impact on people s health Those who care for people with dementia need to be better looked after and supported and need more facilities and resources. Communication and information between services and about services needs to be made more widely accessible. Learning Disabilities having a written record of a consultation, so people can remember the key points of a GP appointment or other health check discharging people from hospital with the right support, so staff understand an individual patient s needs when they go home, so they get the right help and care support for people to find their way around hospitals and other healthcare settings asking if someone is on the learning disability register; most are happy to be asked this as it gives them access to more appropriate support. Quality deep dive: Patient experience July 2016 Page 15 of 22
need for hospital passports which have spaces to write down information about people such as their likes, dislikes and fears a simple template for GPs and practice nurses with prompts such as what s stayed the same?, what s different? and what do we need to do now? flagging patient notes and issues with accessible information (letters, referrals, reasonable adjustments needed) more choices for people and their families, and greater say in their care need for increased support and care in the community with easy access to professional support and advice more innovative services to give people a range of care options providing early, more intensive support for those who need it. different neds for women and young people with learning disabilities to promote positive health and self-care Cancer Overall experiences of care are positive Patient involvement in decisions about treatment and care Good feedback about family being involved in care planning, Negative feedback in relation to identifying risk, access to appointments for diagnosis and delays in diagnosis. More involvement and support wanted by carers and families to support shared decision making and involvement in care. Information about self-help groups and their support is positive. Excellent feedback about our cancer support services and their efforts to engage and raise the profile of cancer support. Positive feedback about the specialism, professionalism of staff on wards but mixed levels of feedback about capacity and responsiveness of staff to patient s needs. Patient and staff interaction respect and dignity The provision of information about what patients should do or should not do after leaving hospital and discharge equipment and information is an area highlighted for improvement by Grass Roots. The provision of care and help from health or social services after leaving hospital Positive and negative feedback about patient and staff interaction aim to focus on whole-person care. Maternity Planning for pregnancy and first contact with health services in pregnancy Accessing services through the GP and practice nurse Peri-natal mental health and safeguarding awareness Language support and cultural awareness and understanding of impact on practice Information and communication Contact with midwives throughout the pregnancy Antenatal service support and information Birth and delivery environmental, staffing, involvement, support in decision making Follow up support including breastfeeding and contact with services. Quality deep dive: Patient experience July 2016 Page 16 of 22
Information and communication about all maternity pathways are good: Involvement of different groups varies: Physical environment of the wards mixed responses Emotional environment is very positive Choice of and perceived control of choice is reported as positive Clinical care, including access to care when needed is positive Mental health Support during waiting times (both before and during referral) Expectations about treatments and support available to people (there is an overreliance on medication as a means of treating mental health problems and more focus needed to look at non-medical, community and spiritual ways of support). Access and communication about services and support available and providing quick access to referral. Inclusion of electronic / web based information Issues around stigma and understanding of mental health support and problems even for mental health staff. Difficulties to access mental health care outside of times of crisis and access and use of emergency services including service and peer support (in and out of hours) Informed choices and shared decision making and planning can be lacking Issues around language, accessible information and translation Women and mental health services poor experiences and access to support Support for carers and involvement of families Reducing fear and barriers to accessing support Particular experience of ethnic minority and protected characteristic groups Discharge planning and support including personalised control of budgets Suicide, self-harm and specialist support needed Parity of esteem and greater support for people with long term conditions and their mental health. Young people and transition support, continuity and improvements to service Increased capacity through changes in approaches and ways of working Flexibility in access and options for service provision Environment (improved buildings, facilities, community spaces) Choice of services, approaches and support with focus on recovery and hope Diabetes Information and communication, Clarity and understanding Service quality Continuation and integration of service provision Involvement of carers and care for carers Shared decision making in care plans Services reaching out Wider range of allied health and well-being services provided alongside Focus on well-being and whole person Quality deep dive: Patient experience July 2016 Page 17 of 22
Some overarching themes to consider are: What services are delivered: The quality and accessibility of services provided Variation in access to care and treatment The choice of services available How they are delivered: Integration and coordination Early intervention, prevention and self-care Control, empowerment and shared decision making Person-centeredness, co-production and cultural competence Close to home and in positive, well maintained environments The context of delivery: Education, awareness and attitude change Empowered staff Evidence and expert based approaches Focus on co-design and co-production The role of the private and voluntary sectors, and of wider society This feedback will feed into our strategic plans to drive improvements in these clinical areas. Outcomes Grass Roots insight has played a key role in all of the above programmes of work. Outcomes include: Identifying areas of improvement: Community midwifery, post-natal pathways, mental health support, access to information for psychological therapies both before referral and while waiting for treatment, pharmacy information, access to primary care and range of facilities in primary care. Focussing engagement such that we target our approach and we are making use of intelligence to guide our activity hence we are working closer with community groups to ensure we have heard their voice and reaching out to people where we have gaps in our existing engagement. We ve held specific events such as the Youth Health Summit, Accessible Information events, Learning & Sharing events, Citizens panels and workshops on promoting coproduction. Setting the direction of future engagement and identifying areas of further exploration such as screening in primary care, minor ailment support for parents with young children, working with migrant communities with regards to access to urgent care. Our Grass Roots and FFT data tell a different story to the feedback received from CQC and the HAWDR and so this could an area for future exploration. Quality deep dive: Patient experience July 2016 Page 18 of 22
Changes to services as a result of feedback can be tracked with services, for example, within maternity services in particular to facilities and support on the labour ward. Simple changes with large impacts were identified by making changes to how Colposcopy letters were addressed following feedback from people. This led to a reduction in missed appointments. Feedback from service users of a community service about barriers to joint working with our statutory providers led to changes and improvements to joint working and sharing of information protocols put in place. Other examples of CCG work where patient experience has made a difference and influence work include: Primary care access: The Grass Roots insight and further engagement work on primary care access has helped to springboard key innovations to improve primary care access. These were reported to our Primary care and GP quality improvement groups and have led to some key patient led initiatives: GP Access action plans: This summer all our GP practices will submit action plans to improve access. They themes and issues collected from Grass Roots engagement have been provided to make the case. Each practice will work together with their patient participation group to jointly develop plans and ensure they are addressing patient experience issues. Patient networks: We have two patient networks The focus of meetings are to share good practice and learning. Attendance has increased at network meetings and patients are getting much more involved than previous. Key aspect to this improvement has been the growing confidence of staff, tangible ideas and resources to engage on, sharing ideas and recognition and acknowledgment of good practice. Ownership of the network has also largely passed to practices with engagement leads taking a lead role in steering and planning the network. Bradford healthier communities chest: Community Chest is a non-recurrent allocation of money that encourages groups with good ideas the opportunity to bid or small pots of funding to get their ideas off the ground and to help make the city a healthier place. The chest fund was started as direct result of patients viewing feedback and having simple yet effective ideas to address or further understand the issues. People s Board: The People s Board grew out of our engagement work and patients and members of the public wanting to have a greater voice in the work of the CCG. The Board is made up of 18 individuals from a diverse range of backgrounds and experiences. The group is viewing engagement and experience data and applying this knowledge to support decision making around QIPP and other areas of strategic planning. Patient flagging of records: A project steering group consisting of 4 GP practices in City and Districts (Peel, Horton Park, Wibsey, The Ridge and Bingley), with CCG staff and patient groups are looking at addressing issues highlighted in Grass Roots about experiences of accessing health services by patients with accessible information needs. These included, for example, appointment letters being sent to people with visual impairments, translators for language or BSL not being arranged at clinics or information not provided in a way that can be used. The group has identified a way of flagging disabled patients access needs in SystmOne, the patient record system used by all local GP practices. Quality deep dive: Patient experience July 2016 Page 19 of 22
Women s health network: The CCGs agreed to support the development of a Women s network to enable key messages to be shared and develop a better understanding of health issues and experience by women who fed back their poor experiences and access to health care. Over 70 women have been involved in designing a network that will look to address key areas of concern around access to services, uptake of screening, immunisation and child health and obesity and health. Thrive: The CCGs working together with Barnardo s and BDCT launched a website to help young people navigate through their teenage years it is called Thrive Bradford www.thrivebradford.org.uk. The site was developed with the support and input of a group of young people who raised the issue of the transition between Child and Adolescent Mental Health Services (CAMHS) and adult mental health services when they attended a City CCG Governing Body meeting. This will enable young people to make a difference, tackle stigma around mental health and improve how services view their users. The group helped develop the content and design of the site, reflecting on experiences of young people and undertaking further engagement as well as taking part in the Beta testing to test out the accessibility of the tool. Youth engagement and volunteering: A project focussed on increasing volunteering of young people in health services with a focus on primary and community services has been commissioned following feedback from young people. The aim of the project is to encourage GP and community services to use the NHS toolkit for volunteering, support young people to understand and gain access to work in the NHS and promote a culture of volunteering and inclusion for young people. 4. A focus on the workforce: embedding experiences into HR processes such as induction and appraisal, and prioritising and improving staff engagement, which is strongly linked to improving people s experiences of care. Our approach: Grass Roots feedback has directly influenced work around workforce development and patient experience features as a key theme in our organisational development plans. Some key areas that have benefitted from patient experience focus on staff development are: Accessible information training we worked in partnership with Bradford Talking Media to develop training for all primary care staff to raise the profile of meeting patient and carers Accessible information needs. This training has been adapted for secondary care staff at our provider Trusts. Quality deep dive: Patient experience July 2016 Page 20 of 22
Customer care training the primary care team, as a part of a wider drive to improve access and patient experience, trained receptionists in customer care, to help staff make each patient feel valued and at ease. Training is vital to what staff do on the front line and this course recognised the important role every member of the practice team plays in making sure that all patients receive the best quality of care possible. Volunteering Workforce capacity has been an issue reported through Grass Roots and the CCG are working with the voluntary sector and BDCT to promote the workforce volunteering tool and encourage staff and NHS providers to take on more volunteers and upskill existing staff to retain staff and expertise. This will launch formally in the autumn but patient experiences and involvement of local people have driven the work plans. Measuring Patient experience There are a wide range of feedback tools available to measure people s experience, none of which alone offer a complete picture of the experience. Measures can be divided into two groups, both of which are necessary for service improvement: The DH and NHSE mandated measures for CCGs and providers are: The surveys that form part of the NHS National Patient Survey Programme: Adult Inpatients; Accident & Emergency Department; Community Mental Health; Outpatient Department and Paediatric Inpatient surveys. The Friends and Family Test see Appendix 2. Compliments, complaints, concerns (from CCGs, providers, CQC, Healthwatch) As specified in the NHSE Standard Contract for local insertions, any other surveys reasonably required by the Commissioners in relation to the services. Patient Reported Outcome Measures (PROMs), clinical outcomes relating to health gain. Patient experience data has the advantage that while the above measure may alert us to what issues there are in the system, our Grass Roots information has the ability to pinpoint why there are issues and start to answer how we can approach resolving them. To date, we have collected information and reported data in the above manner. Moving forward, we aim to improve our system for collecting Grass Roots so that we can map themes and trends in a way that allows us to identify indicators for improvement and measure progress in improving patient experience data. Appendix 1 dives further into how we intend to improve our current system and really put patient experience at the heart of commissioning decisions. Quality deep dive: Patient experience July 2016 Page 21 of 22
Next steps The work to improve experience is continual and a series of ongoing actions have been identified: Implement the new Grass Roots insight tool and share with each clinical and strategic programme Developmental session with all teams involved in Improving Patient Experience to look at closer and focussed working and develop an action plan going forward Identify key performance indicators for each programme and ensure our reporting is aligned with our internal and external requirements Appoint new clinical leads (as current post will become vacant in July). Review and improve current reporting mechanisms from our providers to input to Grass Roots and provide robust patient experience intelligence and outcomes in line with our assurance requirements, duties and drivers as described above Build stronger partnerships and shared working agreements with our providers and stakeholders Secure ongoing resource to support innovation and work to continue Continue to promote and raise the profile of the CCGs achievements in improving patient experience Quality deep dive: Patient experience July 2016 Page 22 of 22