Time to reprioritise rehabilitation

By Sara Hazzard

This historically under-funded service could be key to reducing pressure on acute NHS services, and pave the way for a healthier, happier workforce, writes Sara Hazzard, Assistant Director Strategic Communications and Co-Chair Community Rehabilitation Alliance at The Chartered Society of Physiotherapy (CSP).

Transformation doesn’t always need to be complicated, expensive or even that radical. Sometimes, it can be achieved by simply prioritising an existing, under-utilised asset. Rehabilitation services are a case in point and if the NHS is to have any hope of tackling some of its biggest challenges, it is exactly that kind of transformation that will be required.

At its best, rehab makes lives worth living. It adds life to years and years to life, enabling people to recover from major trauma or serious events like stroke and cancer, while supporting others to live with long-term conditions, such as COPD or arthritis. Rehab gives people the mobility and function to maintain independence and reduce the need for other NHS and social care services.

At its best, rehab keeps the NHS moving. It reduces the number of people being admitted to hospital by helping people to manage their conditions in the community.

This means greater system capacity for anyone who needs to arrive at the front door of a hospital, while inpatient rehab ensures they recover promptly and are ready for discharge, often to those much-needed community services, in a timely manner.

All of this allows for greater flow throughout the system, unblocking some of the most pressurised parts of the NHS.

Finally, at its best, rehab also yields benefits for wider society, reducing health inequities and sustaining a healthy, productive workforce by reducing sickness absence. Unfortunately, too many people do not find rehab at its best.

It has been under-funded for decades and shown a chronic lack of prioritisation, sometimes derided as a Cinderella service of lower importance than surgical treatment and medication. Historically, the problems were most significant in the community, with patients often discharged and then waiting weeks, if not months, to be picked up by outpatient services.

During the pandemic, however, hospital gyms and other spaces were lost to make way for overspill wards and to allow social distancing, making high-quality rehab harder to access for inpatients too. This has been further exacerbated by the most recent winter crisis when further rehab space was lost to create room for extra beds.

The irony of investing in beds rather than the rehab that could prevent so many needing one has not been lost on the profession. The impact of this loss of space is taking a toll on patients, staff and the system alike.

Six in ten physiotherapy staff in a recent survey said they are seeing increased levels of disability and 50 per cent report depression and anxiety among patients as they struggle to cope with long-term pain and immobility.

The survey also reveals that the issue is having a further impact on the NHS workforce crisis, with 32 per cent saying it means they struggled to recruit staff and four in ten citing retention problems. What is more, 60 per cent of respondents say they are considering quitting the profession altogether because of the issue.

The lack of rehab is also increasing the need for readmission to hospital and more intensive treatment, the survey shows. Clearly that situation cannot continue. Services need to be given the appropriate space, staff and resources to provide high-quality rehab.

That’s just the minimum required, however, to meet the enormous patient demand that has built up in recent years and continues to grow every month, according to NHS figures. To truly transform how we deliver healthcare in this country, we must break free of the outdated mode of thinking and place a far higher priority on the value of rehab.

That shift appears to be happening – and not a moment too soon. In a letter to the Community Rehabilitation Alliance, which the CSP co-chairs and convenes, Health Minister Will Quince said he agreed that “rehabilitation is as essential to good health outcomes as medicines and surgery”. With millions on waiting lists and large parts of the system falling down, rehab’s time has come.

Now’s the time to invest in rehabilitation and the workforce to deliver it, recognising the ripple effect these vital services have through the system. But this requires leadership, and it is vital that there are accountable leaders whose focus is on the effective commissioning and delivery of personalised rehab.There is much work to do, but this shift of emphasis could unleash the enormous potential of rehab and have a transformative impact on the NHS at a time when it’s needed most.

The Chartered Society of Physiotherapy will be joining ICJ and Public Policy Projects at the Integrated Care Delivery Forum in Leeds, on Wednesday 28 June. The event is free to attend for relevant healthcare professionals, so come and say hello!

West Midlands Academic Health Science Network annual report reveals transformative impact

By Integrated Care Journal

10 years after being formed by NHS England, the organisation has helped improve standards of care and facilitated millions in inward investment into the West Midlands.

The West Midlands Academic Health Science Network (WMAHSN) has released its 2022/23 Impact Report, highlighting its work and innovations contributing to improved health and generate income growth across the West Midlands.

Key achievements outlined in the report include a reduction of 745 emergency 999 calls – just over two per day – as a result of West Midlands care homes adopting deterioration management tools. This resulted in a reduction of 11,633 hospital bed stays, in cases where patients could receive alternative treatment.

As well as reducing pressures on the NHS and encouraging young people to get involved with healthcare innovations, the WMAHSN has also created 16 new jobs, supported 448 businesses and achieved over £9million of inward investment into the region.

April 2023 marked 10 years since the AHSN Network was established by NHS England and, in this time, the WMAHSN has undergone significant growth and transformation. In the past year alone, the organisation has grown to support the delivery of its programmes, which focus on improving Implementation and Adoption, Patient Safety and Improvement, and Innovation and Commercial.

Key highlights from the WMAHSN Impact Report include:

The launch of the Junior Innovation and Skills Incubator, which aims to address the UK skills shortage by unlocking untapped potential and accelerating training among young professionals. Three workshops were held to introduce innovators to a range of real-life health and social care challenges, helping to shape the minds of the future.
The introduction of Thopaz+ to the MedTech Funding Mandate. Thopaz+ is a portable digital chest drainage and monitoring system used for patients who have air or fluid around the lung, due to chest trauma or lung disease. Thopaz+ supports clinical decision-making and assists patients’ recovery and, in 2022/23, national reporting metrics demonstrated an increase from 28 per cent to 46 per cent of trusts implementing or adopting this innovation.
The West Midlands Managing Deterioration Programme worked with 1,679 care homes across the region to support the training, adoption and sustainability of deterioration management tools, helping professionals to better spot and respond to deteriorating patients. As a result, between January 2021 and September 2022, there were 3,232 fewer emergency admissions, resulting in a saving of £13,590 per care home.
The West Midlands region was chosen as one of the pilot areas to trial the Child-Parent-Screening programme a method of identifying children and their parents who have familial hypercholesterolemia (FH). FH is an inherited condition passed through families caused by a faulty gene making the liver less able to remove ‘bad’ (LDL) cholesterol. A total of 99 children have been screened to date, across three West Midlands sites, with a further three sites due to go live in 2023 which will have a combined potential of 247 annual immunisations.

Professor Michael Sheppard, Chair of the WMAHSN, said: “Our purpose is to lead, catalyse and drive cooperation, collaboration and productivity to accelerate the adoption of healthcare innovation across the region. With this in mind, it is inspiring to see the positive impact our work has had over the past year, generating continuous improvement in the region’s health and wealth and making a real difference to patients.

“The healthcare sector continues to be a highly dynamic and evolving environment, and we’ve seen several changes across the landscape during 2022/23. Despite this, we intend to keep strengthening our ability to work nationally, regionally and locally, maintaining the environment we have helped create.”

To read the full Impact Report, visit the WMAHSN website.

Pharmacies could free up more than 30m GP appointments, Company Chemists’ Association says

By Gabriel Blaazer

Report calls on government to “go further and faster” in giving more capability to pharmacy to prescribe prescription-only medicines and reduce pressure on general practice.

A new report from the Company Chemists’ Association (CCA), whose members include Asda, Boots, LloydsPharmacy, Morrisons, Rowlands Pharmacy and Superdrug, has urged the government to be bolder in its plans to expand pharmacy services, announced in May as part of its Delivery plan for recovering access to primary care.

Included within the Department of Health and Social Care’s (DHSC) plans is £645m to enable the expansion of pharmacy services in England over two years, intended to help relieve pressure on GPs – including an approach it dubs Pharmacy First.

This includes ambitions for community pharmacies to be able to supply prescription-only medicines for seven minor health conditions (Pharmacy First), increase their provision of the oral contraception and blood pressure testing services, and the delivery of improved IT system connectivity between general practice and community pharmacy in England.

The measures are expected to free up an additional 10 million GP appointments per year once scaled – equivalent to around 3 per cent of all appointments – but the CCA have urged the government to move faster and be “bolder” in their plans and accelerate plans to train pharmacists in England to act as ‘independent prescribers.

By their own estimates, the CCA expect the plans for Pharmacy First will free up around 6m appointments annually. They estimate that a more ambitious Pharmacy First service could free up 30m+ GP appointments per year, five times as many as in the government’s current plans.

In their new report, Pharmacy first and independent prescribing, the CCA argue that giving community pharmacy additional capability to supply non-prescription medicines and additional prescription-only medicines is a necessary and urgent step.

“There are an estimated 23,000 pharmacists currently in England without independent prescriber qualifications. A simple extrapolation of the plans currently in place indicate that it will take until 2040 to train the entire workforce. We need 95 per cent of community pharmacists to be trained as independent prescribers by 2030,” said Malcolm Harrison, Chief Executive of the CCA.

The CCA argue that their recommendations would effectively create 11,000 urgent care centres in England. With an estimated 90 per cent of the population located within a 20-minute walk of a local pharmacy, they believe that a “Pharmacy First” approach could transform access to care and help address under-provision of clinical services in certain areas. They say, for example, that “ambitious commissioning could position pharmacies as the ‘go-to’ place for urgent and emergency care”.

Alongside the expansion of prescribing capabilities and certain clinical services, the CCA are also calling for:

A fairer funding framework for community pharmacies. Community pharmacy is chronically underfunded. The current annual funding shortfall equates to more than £67,000 per pharmacy in England. The funding announced in the recent Delivery Plan is new money for new activity and does not address the historic underfunding of the sector.
A bold approach to harnessing Pharmacist Independent Prescribing. All pharmacists registering after 2026 will be independent prescribers (IP). There are an estimated 23,000 pharmacists currently in England without IP qualifications. Under current plans, it will take until 2040 to train the entire workforce.
A flexible and future-looking legal and regulatory framework that enables pharmacists and pharmacies to deliver and safe and effectively of medicines and to provide appropriate clinical care directly to patients.

Malcolm Harrison added: “Government plans to rollout Pharmacy First are welcome, but are only a drop in the ocean. Under current plans, pharmacies are expected to free up 6m GP appointments annually – but our analysis shows pharmacies could do five times this number.

“Action to address the historic underfunding of pharmacies and a roadmap to utilise the clinical skills of pharmacists are essential to achieving this. The Covid-19 vaccination programme showed what pharmacies can do when the Government places its faith and investment in pharmacies. An investment in community pharmacy is an investment in greater capacity for the NHS, enhanced resilience in primary care and better patient outcomes.”

A spokesperson for DHSC said: “Community pharmacies play a vital role in the NHS and we are providing them with an additional £645m investment that could free up as many as 10m GP appointments a year. This is on top of the agreed annual £2.6bn of funding set out in the pharmacy framework.

“We are also taking a range of actions to modernise and enable better use of resources and automation, allowing pharmacists to provide more care for patients.

“We are working closely with NHSE and Community Pharmacy England to launch Pharmacy First by the end of 2023 and will share an update on timings shortly.”

“Time for health and care to face the right way” – Stephen Dorrell

By Stephen Dorrell

In his foreword to Public Policy Projects’ (PPP) latest ICS Delivery Forum report, Chair, Stephen Dorrell, argues that now is the moment to reorientate the health and care system and seize upon cross-party support for integrated care systems.

It is an old truth that our system of health and care services faces the wrong way. Success obviously requires the ability to respond in a timely way to demand for high quality care and treatment, but the objective should be to support people to enjoy healthy, happy years of life rather than simply to treat disease. Delivery of this objective is the focus of our work at Public Policy Projects.

To borrow a word chosen by Coventry and Warwickshire ICS Chair Danielle Oum, integrated care has the potential to ‘subvert’ our system of health and care. Resources and effort can finally be rebalanced to better target health prevention, early intervention and reducing health inequality.

This thought process underpins the development of ICSs; furthermore, it is a thought process which, crucially, is the subject of bipartisan support between the Labour and the Conservative Party.

“National government has created the structures and can coordinate their development, but it cannot micro-manage delivery.”

This is vital. As we go into the pre-election period, the framework of health policy for the next decade is not the subject of party-political debate. There will of course be intense arguments about the health service in the run-up to the election, focused in particular on funding levels which do represent a political choice, but the principle of integrated care is now a shared ambition across the political divide.

But, although the aspiration has been articulated many times, the ICS programme is still in its very early stages. Despite the predictable journalistic desire to declare the system “broken” and call for headline-grabbing “reforms”, it is important to remind ourselves that the current structure is only 12 months old.

The policy challenge centres on the development of properly integrated care systems at local level. National government has created the structures and can coordinate their development, but it cannot micro-manage delivery. Any attempt to do so is not only certain to fail; worse than that, attempts to over-centralise will ensure that valuable local initiatives will fail too.

This is not a prediction; it is a history lesson. The NHS has always struggled to create a healthy balance between local initiative and central accountability; the requirement to create more integrated local systems makes that balance more urgent and more difficult.

The ICS Delivery Forum is a series of events designed to address these challenges. Our focus is on developing ICSs and helping them to deliver integrated care for citizens and populations.

Our inaugural Delivery Forum convened leaders from across the West Midlands at the City Library of Birmingham. This centre for local excellence epitomises the ambition of integrated care – an anchor institution that creates space for creativity, employment and learning while bringing communities together and fostering close ties between public services and the public themselves.

We believe these events help create the space to allow ICSs to deliver on their promise. We also believe that the successful delivery of that promise is what will ensure that the NHS maintains the position it established 75 years ago as a global role model for universal healthcare.

The full version of the West Midlands ICS Delivery Forum Key Insights report can be found here.

Stephen Dorrell is Executive Chair of Public Policy Projects, and was a Member of Parliament from 1979 to 2015. He served as Secretary of State for Health from 1995 to 1997, and was Chair of the NHS Confederation from November 2015 until 2019.

Majority of public would use health tech to avoid hospital, research finds

By Integrated Care Journal

Survey highlights increasing public acceptance of healthcare technology to self-manage care and take greater individual responsibility for health.

The majority of people would use health technology if it meant they could avoid going into hospital, new research carried out by Ipsos on behalf of the NHS Confederation, supported by Google Health, shows.

The same proportion – more than 7 in 10 people (72 per cent) – would also use technology including wearable and health monitoring devices to help better manage and monitor their health and would also be willing to share the information and data gathered with their doctors and other medical professionals.

The survey of 1,037 members of the public highlights people’s increasing appetite for using technology to self-manage their care, and more broadly, to take greater responsibility for their health and that of their families.

Nearly 4 in 5 people (78 per cent) also said they would be happy to use different types of health monitoring equipment to help manage their health if an NHS professional recommended it to them, with nearly 9 in 10 (89 per cent) people aged over 75 willing to do so.

The results have also found that just over half (53 per cent) of the 92 people included in the survey who have been diagnosed with a long-term condition resulting in them interacting with the health service four or more times a year, are already using the NHS App to access personal health information, compared with one third (33 per cent) of the general population.

The government recently announced a target for patients at more than 90 per cent of general practices across the country to be able to use the app to see their records, book appointments and order repeat prescriptions by March 2024.

Commenting on the findings, Matthew Taylor, chief executive of the NHS Confederation said: “This research shows the potential of technology in empowering patients to better manage and monitor their own health, especially if it means they can avoid being admitted to hospital.

“There is clearly an appetite amongst the public to use technology to self-manage their long-term conditions, and more broadly, to take greater responsibility for their health and that of their families.

“The government’s recent commitment to accelerate and widen the use of the NHS App should also help to strengthen the public’s understanding of the benefits of digital engagement.

“However, the decisions we make now as a society will determine whether technological change means we can make continuous improvement in the offer we make to everyone through the NHS, or whether it will divide ever more widely the ‘healthy haves’ from the ‘unhealthy have nots’. We must always deliver greater digitisation with equity in mind.”

Elsewhere, the survey findings showed that just over 8 in 10 (83 per cent) adults already use some form of technology to manage their health, and this increases to nearly 9 in 10 (89 per cent) people living with one or more long-term condition. However, only just over half of those surveyed were currently satisfied with the technologies and tools available for them at present.

The research also showed that that nearly three-quarters (73 per cent) of patients want their doctors to provide them with the “best technology available”, with three-fifths (58 per cent) wishing “their doctor provided them with technology to monitor their health”.

Ease of appointment booking and the ability to communicate via messaging services with healthcare teams are also high on the list of priorities. The research also found that more than two thirds (68 per cent) of people believe that healthcare in the future will include more technology and less reliance on healthcare professionals, although this comes with the concern that without access to the right technologies, access to healthcare could be limited.

Susan Thomas, UK Director, Google Health added: “Google Health has been privileged to partner with NHS Confederation and Ipsos to drive this piece of research; the findings have resonated with our mission to help everyone, everywhere be healthier through products and services that connect and bring meaning to health information.”

One in five people in the UK say fear of wasting doctor’s time would stop them getting tested

By Integrated Care Journal

Widespread publicity of NHS woes likely contributor to hesitancy over seeking medical attention.

One in five people in the UK (22 per cent) would put off getting health tests for fear of wasting their doctor’s time, new research from Roche Diagnostics has revealed – a barrier that is not reported by the general public in any of the other countries surveyed.

The finding comes after a Roche survey of the public and healthcare professionals in the UK, USA, Germany, Switzerland, India, Taiwan and Thailand showed that this fear of time wasting was unique to people in Britain.

The survey, designed to understand attitudes to diagnostic testing and the barriers to timely diagnosis of illness, also found that nearly half (49 per cent) of those surveyed in the UK said they received no explanation, or an inadequate explanation, on the role of or reason for testing.

This is despite the fact that the UK public demonstrated a high awareness of how valuable diagnostic testing is with just over half (51 per cent) of respondents saying they thought that the most important role of testing was in helping them to avoid more invasive treatments later down the line.

Lynsey Gate, pre-eclampsia patient, said: “When I first started experiencing symptoms like hand swelling, I phoned triage and told them about it and my concerns. I was about to travel, and they said to come in when I got back. But by the time I got home the swelling had gone down so I phoned them again and they agreed I didn’t need to go in to be checked. I felt like I was being a burden and worrying about potentially nothing. I regret it in hindsight because it could have changed things for me had they caught it earlier.”

Rachel Power, Chief Executive of the Patients Association, said: “We would always encourage people who are concerned about their health to seek advice. That doesn’t have to be from your GP – there are other health professionals who can help. None of them will think you’re wasting their time. A conversation with a pharmacist, for example, could put your mind at rest or point you in the direction of another healthcare professional who can support your health.”

NHS pressures

Also unique to the UK, was the finding that more than a quarter of those surveyed cited “cancelled appointments” as a reason for missing a diagnostic test – a further symptom of the challenges the NHS is facing.

However, despite these challenges, trust in healthcare professionals was high among members of the UK public and globally doctors emerged as the most trusted and widely consulted information source for diagnostics. Even in countries where the general public are dissatisfied with the information they are given on diagnostics – such as the UK and Switzerland – they continue to believe that their doctor is their best source of information.

Emergency Medicine Consultant, Professor Rob Galloway said: “I understand when people are bombarded with messages about long waiting lists and how much pressure the NHS is under they might be reluctant to seek medical help. But that’s exactly why you should come forward if you feel something is wrong. The sooner you are diagnosed, the quicker you can be treated and the better your outcome is likely to be.

“Too often in A&E we see patients who have ignored or lived with their symptoms for so long that their condition becomes an emergency – and this might have been avoided if they had come forward sooner. There is no doubt the NHS is currently under a huge amount of pressure and we do want people to use healthcare services wisely. But we definitely don’t want people who are experiencing symptoms to avoid seeking help for fear of wasting our time.”

Improvements to access

The survey also revealed some reasons for optimism. Fewer people cited a fear of catching COVID-19 as a reason to stay away from seeing the doctor, when compared to results from previous years. As well as this, more respondents said they were eager to prioritise testing appointments in their diaries over other commitments when compared to the same question last year.

Roche is always looking for ways to help the NHS improve access to testing and overcome the barriers that exist for some patients and the insights provided by this survey, about how public attitudes to diagnostic testing vary or overlap in different countries, will inform that work.

Geoff Twist, Managing Director of Roche Diagnostics UK and Ireland said: “The enormous pressure the NHS is currently facing has been widely reported so it is not entirely surprising that people in the UK are conscious of not wanting to waste the time of doctors. However, I would urge people not to delay talking to a healthcare professional if they feel something isn’t right.

“The right diagnostic test, done at the right time, can actually help to reduce pressure on the NHS by ruling out serious conditions in some patients and ensuring those who are unwell receive the treatment they need sooner rather than later. In many serious or life-limiting diseases or conditions, such as cancer, cardiovascular disease, sepsis and pre-eclampsia, early diagnosis can result in more targeted treatment and fewer healthcare appointments, as well as better quality of life and outcomes for patients.”

New drug combination twice as effective for some ovarian cancer patients as next best treatment

By Integrated Care Journal

Findings suggest new hope for patients suffering with disease that has a poor response rate to current treatments.

A targeted drug combination for patients with a type of ovarian cancer could be nearly twice as effective as the next best treatment, according to interim results from a Phase 2 study.

The international RAMP-201 study, has been led by researchers from The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, and sponsored by Verastem Oncology. The study has tested avutometinib alone and in combination with defactinib in 29 patients with low-grade serous ovarian cancer (LGSOC). Both drugs are designed to block signals that encourage cancer cells to grow.

Researchers hope these results, which are being presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, will lead to a new option for patients with advanced LGSOC, a rare form of the disease that has a poor response rate to current treatments.

Approved treatment options available for patients with advanced LGSOC in the UK are currently limited to chemotherapy and hormone therapy, with response rates typically ranging from 0-14 per cent. Alongside standard treatment, LGSOC patients in England can access trametinib, a targeted treatment, via the Cancer Drug Fund, which has a response rate of 26 per cent.

Improvement on current treatments

According to the study’s interim results, nearly half (45 per cent) of patients treated with avutometinib in combination with defactinib saw their tumours shrink significantly, suggesting the new combination could be almost twice as effective as the next best treatment.

Responses to the drug combination were particularly promising in those with a mutation in a gene called KRAS, with six in 10 (60 per cent) patients experiencing significant tumour shrinkage. However, nearly a third (29 per cent) of patients without the mutation also had an encouraging response, which is also an improvement on standard treatment.

Patients previously treated with other types of targeted therapies, including MEK inhibitors, also saw their tumours shrink following treatment with the drug combination.

Avutometinib is a dual RAF and MEK inhibitor, a type of targeted drug that blocks certain proteins that help control cancer growth and survival. Studies have shown the drug can become ineffective over time as tumours develop resistance to treatment.

However, when combined with defactinib – which is designed to combat a protein that encourages drug resistance – researchers believe avutometinib works more efficiently. This is confirmed by these results, which demonstrate that the drug combination is over four times more effective than avutometinib alone.

RAMP-201 follows the phase 1 FRAME trial, which tested avutometinib (then known as VS-6766) and defactinib on a slightly smaller cohort of patients with advanced LGSOC and was led by researchers from the Oak Foundation Drug Development Unit at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London. While survival data is not yet available from RAMP-201, results from FRAME indicate that this patient group lives an average of 23 months following treatment with this drug combination before their cancer progresses.

LGSOC accounts for about one in 10 cases of ovarian cancer, with around 700 women in the UK and 80,000 worldwide diagnosed each year. Compared with other forms of the disease, LGSOC tends to affect younger women.

Global lead investigator of the study, Dr Susana Banerjee, Consultant Medical Oncologist and Research Lead for The Royal Marsden NHS Foundation Trust Gynaecology Unit and Team Leader in Women’s Cancers at The Institute of Cancer Research, London, said: “These initial results could be fantastic news for women with low grade serous ovarian cancer, indicating a far more effective option than current treatments may be on the horizon.

“It’s wonderful to see so many patients experience a meaningful response to this innovative drug combination and I’m so grateful to all who joined the trial, making this research possible. Low grade serous ovarian cancer does not respond well to currently approved treatments, so these results could represent a significant breakthrough in treating the disease.

“We are hopeful this drug combination will one day become a standard of care for women with low grade serous ovarian cancer.”

The reality of the world: anticipating failures to achieve success

By Emil Bernal

Emil is a former British Army officer who now specialises in change and transformation in complex environments, including the NHS. He is currently Head of Transformational Programmes and Projects at NHS Shared Business Services.

I recently walked into my local high street bookshop. I counted dozens of books telling me how to succeed at project delivery. There was no shortage of people offering their tips for success. I couldn’t find any books about how to avoid failure.

This is odd but not surprising. From childhood, we’re conditioned to be uncomfortable with the thought of things going wrong. No-one likes making mistakes. Our education system is built on telling us ‘how to do things’, and punishes us for getting things wrong. The world is filled with motivational speakers talking about the sunny uplands. Can you think of a single modern motivational speaker who talks about avoiding the dark abyss?

Emil Bernal, Head of Transformational Programmes and Projects, NHS Shared Business Services

Programmes and projects are no different. We start with optimism and marvel at the promise of a brighter tomorrow. And, for sure, optimism is needed to motivate a team to take on challenging goal. But excessive optimism in our ability to shape and influence the future has led to spectacular failures.

Things can and do go wrong. The NHS has the dubious honour of hosting one of the most expensive failures – the world’s largest civil IT programme, the £12.4 billion National Programme for IT.

In their book, “How big things get done”, Bent Flyvbjerg and Dan Gardner researched the outcomes of over 16,000 projects in 136 countries. Their data shows that 92 per cent of projects overrun on time, cost or both. And cost overruns can be dramatic.

The average cost over-run for every Olympic Games since 1960 is 157 per cent. NASA’s James Webb Space Telescope was 450 per cent over budget. Scotland’s Parliament building was 978 per cent over budget.

The private sector doesn’t do any better. In 2000, Kmart launched two IT projects. Costs exploded, contributing to the company going bankrupt in 2002. Even families get it wrong: you only have to watch Grand Designs to see people’s home renovations go over budget and run late.

We need to learn what went well with previous projects. And we need to understand what went wrong – “how not to” repeat the same mistakes. So, when wide-ranging reports are published – like Patricia Hewitt’s recent review of Integrated Care Systems – I start, as many people do, by thinking “how are we going to get this done”? The next thought is perhaps less common. How do we avoid things going wrong?

Here, then, are five ways to stop things going wrong:

1. Go to the cinema. Or, rather, think about projects in the same way as the film industry: get the balance right between planning and delivery. There’s often a push to start “doing something”. This misses the point that planning is doing something. The film industry understands this, and gives film producers time to plan. During planning, costs are relatively low while film producers explore ideas, produce storyboards, and redraft scripts. Costs explode when production starts and Hollywood stars and crews are working. The work that producers put in upfront means that filming follows a well thought-through plan and avoids costly delays.

2. Find experience and expertise. Very few projects are genuinely unique. There will always be something that makes a project different from others. But, in many ways, your project will be “another one of those”. People who worked on “one of those” will have valuable experience and expertise. Find those people.

3. Listen to that experience. Having found your experts, listen to them even if – especially if – it’s something you don’t want to hear. Listen when they tell you that the project will cost more than the figure you have in mind. Listen when they tell you the project is likely to be more complex and take longer that you ideally wanted. Listen when they tell you about the issues and risks you’re likely to face. It’s better to be told a painful truth early, rather than push ahead in comfortable ignorance.

4. Ask four questions. There is a cultural tendency to shy away from disagreement. So, be explicit and ask for alternative views. As we start to form an outline solution to a problem, I’ll often ask four interrelated questions: what’s good about our solution that we should keep? What needs to be changed? What’s not needed? And – probably the hardest question to answer – what’s missing?

5. Get hindsight in advance. Lessons learnt – or after-action reviews – are standard practice. Flipping this on its head is a useful way of identifying where things could wrong. This approach was popularised by psychologist Gary Klein and Nobel laureate Daniel Kahneman and is often called a ‘pre-mortem’. It’s simple but powerful. Get the team to imagine that their project has already failed. What caused the failure? Work backwards to figure out the causes. Run through a few scenarios. The time spent visualising different outcomes will bring to life the future for the team. And, after the pre-mortem session, make sure that you re-energise the team’s belief in the project.

By taking these steps, you can give yourself the best chances for success. But even the best planning won’t stop issues from cropping up. A supplier lets you down. A team member falls ill. A pandemic. A ship getting stuck in the Suez canal. You’ll have to be ready to manage issues and find practical solutions. But, by getting the planning right, the window of time when risks can come crashing into your world will be smaller – like the film industry which spends time in planning so that the costly production phase can zip along from start to finish.

Learning from your mistakes is called experience. Learning from other people’s mistakes is called wisdom. I wonder how long it will be before I start to see the shelves of my local bookshop filling up with stories about things that went wrong and how to avoid making the same mistakes?

Poor work/life balance driving NHS exodus

By Integrated Care Journal

As vacancies hit record levels, doctors and nurses want more flexible work arrangements to carry on working in healthcare, study from Deloitte finds.

Poor work-life balance is a key driver of job dissatisfaction for healthcare workers, and improvements are within the power of employers, according to new research from Deloitte’s Centre for Health Solutions.

The findings come from the report, Time to Change: Sustaining the UK’s clinical workforce, which looked at the experience and resilience of front-line clinicians, based on a survey of 1,286 UK public healthcare workers. The study examines how attitudes within the profession have changed since 2017, when a similar piece of research was conducted, and includes input from doctors, nurses and other clinical staff working in primary, community and secondary care.

Having a ‘sense of fulfilment/making a difference’ (42 per cent) and a good ‘work-life balance’ (41 per cent) are the top two drivers of job satisfaction for healthcare workers, the study found. By contrast, pay (60 per cent) and having a poor work-life balance (42 per cent) were found be the two main drivers of job dissatisfaction within the professions.

The high ranking of work-life balance for job satisfaction and dissatisfaction is in stark contrast to five years ago, when work-life balance was the fifth-biggest driver of job satisfaction, according to Deloitte’s 2017 study.

When asked how their feelings on job satisfaction and dissatisfaction has affected career intentions, the most common response, among 53 per cent of all respondents and 59 per cent of doctors, was to reduce hours and move to part-time working in healthcare. In addition, 40 per cent of clinicians overall, including 35 per cent of doctors and half of nurses and midwives had considered leaving the profession and changing career.

The study follows a slew of unwelcome news in recent days, including (now-confirmed) speculation that the government’s long-awaited NHS workforce plan (due to be published Tuesday 30th May) is to be delayed as it is considered too costly and the admission from the Health Secretary, Steve Barclay, that the 40 new hospitals will now not be built by 2030 – in contravention of the Conservative government’s flagship pledge.

Additionally, NHS vacancies remain at record levels as the health service continues to struggle to attract and retain staff. One-fifth of all nursing posts in England are estimated as vacant, and NHS trusts fear that the situation will not change until the government sets out a fully-costed workforce plan.

Karen Taylor, Director and Head of Research at Deloitte Centre for Health Solutions, said: “The problem has worsened over the past few years and our findings mirror recent staff surveys from the industry. There is a clear need to address the physical and mental health needs of staff if employers are to build a resilient workforce.

“Many solutions are in the hands of local health organisations to address and several have implemented effective solutions, just not at the scale needed.”

Sara Siegel, Partner and UK and Global Head of Health at Deloitte, said: “The most vital asset in healthcare is its workforce. Our study shows that the availability, accessibility and quality of care available to patients depend on having the right professionals, with the right skills, in the right place, at the right time.

“Healthcare leaders have a real opportunity to make a long-lasting impact in this crucial area. Those that have adopted new ways of working and technologies, have already realised the benefits to empower their workers. Not only will this help patients, but it will have a positive impact on job satisfaction that supports individuals to build rewarding, long-term careers in healthcare.”

Implications for physical and mental health

The study also revealed that 87 per cent of clinicians had experienced an increase in their workloads since March 2020, including 90 per cent of nurses and midwives and 84 per cent of doctors, with serious mental health and wellbeing implications for those staff affected; 46 per cent of clinical staff reported experiencing a negative impact on their physical health, including 50 per cent of hospital doctors and 45 per cent of hospital nurses. The study also found 57 per cent disclose a negative impact on their mental health, including 58 per cent of hospital doctors and 59 per cent of hospital nurses.

This contrasts with the 2017 study, in which 30 per cent of hospital doctors and 32 per cent of hospital nurses said that their workload had a negative effect on their physical health; and 23 per cent of hospital doctors and 33 per cent of hospital nurses said that it affected their mental health.

Digitisation will help – eventually

Numerous policy documents and reports, including the NHS Long Term plan, have identified the importance of adopting technology across healthcare. Deloitte’s study therefore asked healthcare workers which technologies they think are helping to improve the quality of patient care. The top five technologies included Electronic Health Records (EHR) (87 per cent), e-prescribing (78 per cent), patient apps (73 per cent), at-home diagnostics (70 per cent) and remote consultations (70 per cent).

Adoption remains low, however, and only 64 per cent of clinicians said they are using EHRs, while fewer than half of respondents have adopted e-prescribing (46 per cent), patient apps (33 per cent), at-home diagnostics (22 per cent) and remote consultations (39 per cent). Likewise, automation of human resource and occupational development services is lagging behind other industries and the study points out the crucial need to modernise these areas.

Dr Karen Kirkham, partner and Chief Medical Officer at Deloitte added: “While healthcare workers know that technology-enabled care models, systems and processes can improve outcomes and safety for patients, simplify tasks and reduce the significant administrative burden for clinicians, adoption remains fragmented.

“Healthcare leaders need to modernise and unlock better ways of working that improve the employee – and employer – experience. More efficient HR and people policies that focus on equality, diversity and inclusion, investing in leadership and professional development, and accelerating the digitalisation of healthcare infrastructure, will go a long way towards developing new ways of working that release time to care.”

News, Workforce May 23, 2023

NHS must seize upon growth in physiotherapist numbers

By The Chartered Society of Physiotherapy

Growth in the physiotherapy workforce should be the solution to the workforce crises in the NHS community rehabilitation services.

The physiotherapy workforce is ripe for expansion, which is good news for the public, policy makers and service providers. But this good news is not resulting in a high-quality rehabilitation service for all with a well-resourced physiotherapy workforce.

Many people do not know what good quality rehabilitation should look like, and there exists a growing unmet population need, combined with historic understaffing of community services, particularly of rehabilitation services.

At present, nearly a third of people in England has a long-term health condition. People with long-term conditions are being pushed into the most expensive and overburdened parts of health and care because they are not being supported in the community to manage their conditions effectively.

The needs of people with long-term physical conditions account for half of all GP consultations, 70 per cent of bed days in hospital and 70 per cent of total health and social care spending, while more than 60 per cent of patients admitted to hospital as an emergency have one or more long-term conditions.

Lack of access to high quality rehabilitation services

Narrowing the gap in healthy life expectancy will only happen with better access to quality community and primary care services for people with long-term conditions and for these services to be integrated around their needs.

NHS community rehabilitation services have been developed in a piecemeal way, often siloed by medical condition, with varying criteria for access. Furthermore, poor access to rehabilitation is particularly concentrated in areas of deprivation and among marginalised groups, resulting in more demand for GP appointments, increased A&E attendance and admissions.

Delivery plans for NHS policies have been also undermined by the lack of calculations on the additional staff capacity needed. For example, policies on urgent community response and discharge to assess have been implemented at the expense of rehabilitation, because they are delivered by the same group of staff. This has meant the policies have failed to reduce emergency admissions or the harm from delayed discharge.

However, for the last five years, additional roles in primary care have improved access to expert advice and diagnosis within primary care.

The value of Musculoskeletal first contact physiotherapist roles

An example of this is the establishment of the role of the Musculoskeletal first contact physiotherapist (MSK FCPs). MSK FCPs are improving patient outcomes, reducing demands on GPs, cutting medicine prescribing and reducing unnecessary onward referrals and tests.

The initial target provided in the Interim People Plan 2019 was stated as 5000 MSK FCPs, but currently there are only 1376 posts covering many GP surgeries and population sizes several times more than originally modelled. Due to these issues, GPs report that they don’t feel the impact of MSK FCPs, and issues of MSK FCPs retention are emerging.

This dynamic undermines implementation and has slowed down the evolution of the MSK FCP role which would support integration with community services.

How can we expand the physiotherapy workforce?

Community rehabilitation services are experiencing difficulties with recruitment and retention, but even greater issues are a lack of established posts and gaps in provision. 15 per cent of physiotherapy staff are leaving the NHS each year and almost half of them are leaving within the first five years of qualifying.

Many are moving to the private sector, but some newly qualified physiotherapists are seeking positions in low-skilled roles in the commercial sector citing less stress, flexible working hours and better pay. There is also the worrying issue of support workers retiring; a 2019 CSP survey of support workers shows that approximately 24 per cent of the current physiotherapy support worker workforce are over 55 years of age.

To compound this, a recent CSP staffing survey, showed that 93 per cent of physiotherapy managers reported that there were insufficient staffing numbers to meet patient needs and 39 per cent of physiotherapy staff reported that this was something they were very concerned about. CSP members also reported having less time to spend with patients, longer waiting times and a lack of available time to improve services, while issues around staff retention and an inability to fill vacant posts were also highlighted by members as contributing factors to insufficient staffing levels.

In the UK, there are currently nine registered physiotherapists for every 10,000 people compared to Denmark, where there are 26.8 physiotherapists for every 10,000 people and Norway, where there are 25.3 physiotherapists for every 10,000 people.

What are the solutions?

Over the years, the NHS has not grasped that, if done well, an increase in physiotherapy provision can help to meet patient needs and reduce pressures on the most overstretched parts of the system.

Insufficient staffing levels are contributing to recruitment and retention problems, which has led to a vicious cycle of high workloads and too few staff.

Change can happen but this requires increased staffing as well as doing more to attract and retain the physiotherapy workforce. The growth in the numbers of registered physiotherapists is increasing, but a sustainable and long-term workforce solution is urgently needed.

The NHSE Long Term Plan must support integrated workforce planning, with targets across primary and community sectors based not on the status quo but on Government and system policy objectives to improve provision to meet population need.

Support workers also have a vital role to play – they need expanding in number and should be upskilled through Rehab Assistant Practitioner apprenticeships to take on greater responsibility, making it possible to safely expand the support worker workforce as a proportion of the workforce overall.

As well as addressing under-staffing, community services also need more strategic leadership, consistency of provision and visibility within the NHS. The lack of leadership in community services is worrying; where Trusts have Chief AHPs at a senior level, community service leadership is strengthened, improving visibility. As well as ensuring this is the case within all Trusts, there need to be more clinical therapy roles within the community working at an advanced practice or consultant level to drive up consistency in standards, lead integration across pathways and partnership working with primary care.

The good news is that the number of registered physiotherapists is growing, alongside a supply of students. Now is the time for the NHS to utilise this rise in numbers. Doing so will go a great way towards tackling the current workforce crisis in NHS community rehabilitation services.

The Chartered Society of Physiotherapy will be joining ICJ and Public Policy Projects at the Integrated Care Delivery Forum in Manchester, this Thursday 25th May. The event is free to attend for relevant healthcare professionals, so come and say hello!

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