Realistic Medicine – Leads Away Day 12-13 March 2019 – write up

 

DRIVER DIAGRAM POSTS

• What support/resources are needed?
• Clearer structure in Boards
• Performance

Management

• Scale up – bigger – faster
• Rigour and criticism in implementing “new” projects in a Board

Data to be analysed

• ISD atlas will get big, quickly – do we know how to monitor?
• Website

Resources already in place?

• Atlas
• VDH training
• (some) people – Leads
• We need a repository for all the work that’s going on with RM to share good practice
• Electronic patient record
• Videos on SDM
• What is value? – need greater driver pressure to be effective
• Supporting resources to allow for productive atlas discussions – people? – governance?
• Tableau
• Clusters – quality in GP
• SDM – training in locum skills/attitudes
• Presentation/media and publicity – making it look professional
• How to scale up/spread small projects
• Aligning existing projects with RM = easy wins

How to improve public awareness of RM and change culture and expectations

• Engagement of non-clinical staff – HR policies etc. National event, patient literature/campaign
• Resource needed to inform/engage the public/media

Systems

• Resources already in place – local data
• Support needed – got data, but need data analysed eg cancer data
• Support; within marketing department – engaging the public in RM
• Special measures impact on RM? Seeing value -vs- cost saving opportunity
• Needed – HR involvement
• Needed – useful data – easy for clinicians to see
• Needed – public awareness – national information needed
• Needed – public champions – need more health economic support to model options
• Atlas variation – clinical support, PM support
• Support from ISD and data analysis
• Case studies for the Atlas – supporting discussions around the data
• Staff awareness – MD etc buy in

WHAT WILL YOU TAKE AWAY?

• Do differently: need a RM team
• Learning – relationship aspect around important of precision in structure so that people can flourish and do their job well and feel valued
• Learning take away/do differently:
  • there are opportunities everywhere to make small changes
  • better ways of sharing what’s going on more widely
• Will get some of the work we have done written up for the website!
• Better comms around RM work
• Public health on RM group
• Different approach for collaboration
• Improved network for sharing opportunities to spread RM vision
• Find a champion for staff wellbeing as part of RM
• More developed vision of a RM project team (learning from today)

 WHAT ARE YOU MOST PROUD OF? 

• RM conference was fantastic
• I have set up a group to implement hospital ACPs (via culture change)
• Who I work with and what they are already doing that relates to RM
• Inspiring others to start their projects which they have had for years but now have a reason to do under the “RM” hat (especially my AHP colleagues)
• The RM team and its achievements so far!
• Survived – people embrace the idea of RM
• People I work with and learning – always go and find out what’s happening
• Collaborative working with another RM lead to use their methodology ie CollaboRATE
• We launched the Atlas!
• Some of our marketing/newsletters have been well received and covered large area
• Developing work to periop lead
• Completing VBHC work
• Clinicians’ enthusiasm for better value
• RM afternoon for medical staff engagement
• How well RM is being received and the levels of engagement
• Presentation to the Board well received
• Sitting at same table and working with my finance lead!
• Collaborate patient decisions and training videos direct to patient letters
• Rebecca should be very proud of her RM video
• Getting through the on-line training
• ISD Atlas team’s progress on products to date
• Been great to feel part of something bigger than my local patch
• Local RM “educational symposium” being held next week!
• Colleagues getting IT and wanting to deliver a valuable service
• Starting conversations within senior leadership teams and hearing RM being discussed as a result in other groups

 HOW CAN WE ENSURE THAT THE 5 QUESTIONS – STYLE APPROACH WE USE IS WELL EVIDENCED? 

• Benchmarking exercises
• Data collection
• Evaluations
• Is one Board’s or services evidence good for another’s?
• Patient response
  • Clinician engagement
  • Appraisal training

WHAT KIND OF EVALUATION COULD TAKE PLACE TO ENSURE WE FIND THE BEST VERSION OF THE 5 QUESTIONS FOR SCOTLAND

• Tool/approach/attitudes
• Context and vision – “why?”
• Gather other places
  • 3 Welsh ones
  • 5 Qs wordy
  • It’s Ok to Ask
• Maybe more about permission than actual questions
• About engagement and attitude

Patient Reported Outcomes please

• Test pre and post in several localities and several services

 TACTICS

 How ? Methods 

THINK!	·       Pause ·       Rewind and summarise ·       Slow it down ·       “Balcony”
REFLECT	·       Listen ·       Acknowledge their point ·       Acknowledge their feelings
REFRAME	·       Yes and ask for their advice ·       Problem solving questions ·       What if?

 

• Bridge the gap
• Careful how you react
• Flexibility? – best 2^nd option?

WHAT EVIDENCE IS AVAILABLE ON SDM?

• Medical regret?
• Evidence via studies which video or audio record consultations
• Cochrane reviews (2014) – it is there – why do we need evidence when it is ethically and morally the right thing to do – we agree
• Hideous over-medicalisation and over diagnosis as a result of what we we’ve used for decades
• Current recommendations:
  • Citizens jury outcomes
  • Research – what there is is quite old and not relevant to current practice which has changed over time
  • Legal precedents – court ruling Montgomery etc
  • GMC guidance “duties of a Dr” decision making and consent
  • Anecdotal evidence from patients and staff “the right thing to do”
  • Scottish Health Council
  • National care experience survey
  • Initiatives in other places eg choosing wisely and similar

RM LEAD CHART – see PDF chart contained in hyperlink at top of page

Encouraging – Discouraging – see full graph contained in hyperlink at top of page

	ENCOURAGING
Cosy Superficial		Reward Learning
Avoiding		Directing
Disengaged		Stressful Anxious
	Discouraging

 

LACK OF CONFIDENCE

• Finance – no money
• Investment – time, people
• Fatigue
• Competing with other initiatives
• Mood of the day
• Seen as a disruptor
• Not a priority
• Not required – already doing
• Hostility
• “un”realistic expectations

WHAT WORK IS GOING ON TO SUPPORT SDM? 

• CLO support
• Asha
• Press release – covering CW5Qs
• Collaborate survey outputs to get the baseline/+formic
• CPD sessions – ANPs, GP
• Q1 approach
• Health literacy information better
• Palliative care and anaesthetic operation reviews
• Orkney:
  • 3Q OK to ask
  • Involved in fellow – R&R work
  • Posters – business cards
  • Plan more and media
• We need accessible education – TURAS?
• Education eg GP & BSGL
• In Fife orthopaedic conversations (GP run knee clinic)
• Argyll psyche discussion to care plans when we’ll be expressing wishes for when ill
• Palliative care letters – patient
• Copying referral letters – patient in Argyll – SHARING LETTERS
• Letters re diabetes Shetland – options – SHARING LETTERS
• Chasing options not usually patient initiated response
• Development of Scottish decision aids
• Advocacy – (formal/informal) – comms training – (targeted?) (mandatory?)

WHAT ARE SOME OF THE BARRIERS TO PRACTISING SHARED DECISION MAKING AND HOW MIGHT THEY BE OVERCOME? (barriers: patient/system/clinician) 

• Clinician uncertainty – is it quantifiable? – is it possible? – is it funded? (honesty) – clinician knows best
  • Encourage questions
  • Ask about concerns
  • Ask what matters to you
  • Culture of questions
• Perception of time – (information processing time) – this appointment versus the whole journey)
• Time to change/lead change and effect on service – clinician delivery – including others 3^rd sector AHPs, peers etc
• Process mapping/timing
• Evidence (don’t speak for first 2 minutes)
• Internet fake therapy
• Staff confidence through support, training and mentoring and decision support
• Health Literacy
  • Plain English
  • Decision aids
  • Core navigators/advocates
• Patient confidence
  • Culture – to question
  • Greet and response
  • Literacy
• “Well you’re the expert – you tell me”