Healthcare change is messy but we are going in the right direction

In the latest of a series of blogs on the Person-Centred Care programme, a GP from Islington looks at the role of Collaborative Care and Support Planning (CCSP) as an enabler for system transformation:

Implementing wholescale change isn’t easy.

In Islington we have been working to support general practice to offer proactive CCSP to people with Long-Term Conditions (LTCs) since 2013.

Having drawn up a Patient and Public Participation strategy for Islington CCG in 2011 that put supporting people to engage in their own self-care firmly at the heart of all our commissioning activities, we then needed to put theory into practice.

After several months we had read all the literature available on supporting people with LTCs to improve their health and wellbeing, including the salient paper ‘Thanks for the Petunias’. Following this the CCG embarked with local patients and providers, on co-producing a logic model that identified desired short, medium and long-term outcomes for people with COPD and diabetes.

From our work with patients and providers we formed a steering group that developed a new patient pathway that would be offered to all patients with Type 2 diabetes who were registered with an Islington GP. The service, developed in partnership with the Year of Care, aimed to deliver a two-stage approach that looked to ensure that people with diabetes were provided with the information they needed to make informed decisions about how best to stay well with their condition. Central to this pathway was a CCSP consultation that enabled people to identify what was important to them and what support they needed to achieve their goals.

We then rolled this out as a locally commissioned service to all Islington GP practices and uptake was excellent with 100% sign up!

Like many new services, of course we encountered teething problems. The electronic data collecting templates didn’t work, results letters didn’t auto-populate and the searches to monitor performance and agree payments weren’t consistent. None of the problems were insurmountable however, and we rode high on our success of achieving such great coverage.

Our initial euphoria was, however, replaced by a sense that maybe things weren’t as rosy as they could be and, in 2015, two years after launching this new pathway we commissioned an evaluation.

Practices didn’t appear to be delivering as many CCSP consultations as we had anticipated and clinicians kept telling us that patients didn’t understand what was expected of them.

So the results of the evaluation weren’t a surprise. Even though there was an improvement in the Islington wide achievement against the National Diabetes Audit, the evaluation told us some practices had failed to implement the new pathway altogether.

While those practices that had embedded the new pathway demonstrated strong fidelity to the two stage approach, there was still a lack of consistency in regards to the centrality of the CCSP consultation, the importance of active listening and the need to work in partnership with informed and engaged patients.

So, what could we have done to have improved uptake and achieved greater buy-in to the cultural shift needed to take a proactive, holistic approach to the management of LTCs?

Reflecting on other programmes of change both locally and further afield, the initial ingredients of co-production were robust. A more organic, iterative process of continuous quality improvement with engagement of the willing may have achieved greater buy-in. This would have enabled us to have demonstrated improved outcomes for both patients and clinicians sooner, thereby encouraging other practices to get on board.

Change is messy and healthcare is complex. We may not have a perfect offer for patients with LTCs yet. The seeds of change have been planted and our local GPs recognise this and have started to ask for help to develop the services further at a practice level. We have started to offer in-practice diagnostics, supporting the willing to carry out their own cycles of continuous quality improvement and we will capture and share these learnings.

It’s still unclear which is the best way forward, but at least we are going in the right direction.

To find out more about NHS England’s campaign to support person-centred care and to share your commitment to ‘Our Declaration’.

Dr Katie Coleman

Dr Katie Coleman is a GP partner at The City Road Medical Centre. The practice was established in 1999 in collaboration with Dr Josephine Sauvage, Chair of Islington CCG and together they developed the organisation into a thriving inner-city training practice.

She is the Islington CCG Governing board GP lead for Patient and Public Participation and the Chief Clinical Information Officer, leading on the development of integrated care records for Islington residents in collaboration with other CCGs across North London Partners in health and social care.

She is the North London Partners clinical lead in Primary care and Care Closer to Home, providing strategic direction on the development of Care Closer to Home Integration networks and Quality improvement support teams (QISTs), Access to GP services and social prescribing.

Katie has recently taken up a GP Director role for the Islington GP federation.