Musculoskeletal services represent the largest community service commissioned by NHS Sussex, with more than 100,000 patients using the services each year. The services are delivered across five provider organisations comprising a large NHS community foundation trust, an integrated acute and community NHS trust, a social enterprise, a healthcare charity, and an NHS mental health foundation trust.
12 months ago, NHS Sussex embarked on a journey to establish their first unified outcomes data set to better understand and improve the value provided to patients across community MSK services. The programme brought NHS Sussex’ five providers together under the leadership of NHS Sussex Clinical Director, Matthew Carr.
Since then, he’s been at the forefront of a project designed to navigate the challenges of collaboration and incorporate patient-reported outcomes to drive positive change.
What came out of this project was an unexpected yet powerful insight into the inequity of patient outcomes across NHS Sussex, sparking a new project designed to address these equity issues through seamless integration within and beyond the healthcare setting.
The need for consistency
For Carr, positive change starts with a consistent view on what good looks like. In MSK, there is little agreement around exactly how to demonstrate the value of the clinical services that are provided. While the wider healthcare setting is generally fixated on mortality rates – keeping people alive – in the MSK setting quality of life outcomes are far more relevant.
Carr realised that the healthcare system should not only be about preventing negative outcomes but should also actively work to enhance patient well-being and quality of life. He believed that by focusing on what was important to patients, and building a robust data set around that, he could lift service levels across NHS Sussex’ five sites:
“If we could find a way to benchmark good quality and good positive impact for our patients, we could start to pull up the quality and the standards that our patients experience and we could start to tackle some of that poor practice across our profession.”
Getting those impact measures into a consistent data set that could unlock genuine insight meant forging a new path within NHS Sussex. This data simply didn’t exist, and there was no previously agreed framework to use as the foundations. To architect a robust systems-level view required robust systems-level thinking.
Designing for success
For Carr, there were three key factors that helped drive success for NHS Sussex’ programme:
1. Importance of leadership and governance
Carr was supported in his quest to lead this initiative by the creation of his role in the first place. Many healthcare organisations overlook the importance of having roles single-mindedly focussed on the delivery of integrated care and on raising the levels of care across a broad healthcare system. Empowering Carr with this role reflected on an organisation that was genuinely invested in this space.
“Our ICS invested quite early on in system leadership. My role is a system leadership role, which doesn’t always exist in other healthcare systems.”
2. Passion and drive
For Carr, passion is the ultimate fuel for driving something new like the integration of Patient Reported Outcome Measures (PROMs) in MSK. Without the unwavering belief that this was important, and that it was worth fighting for, Carr doesn’t think the programme would have overcome the numerous challenges involved in pushing forward change.
“You really need a level of passion and to find or influence similar passion in like-minded colleagues. Enthusiasm in seeing the benefit and the long term value in this programme has been so powerful. There’s been a lot of times where we’ve been told no, or we’ve been told you can’t do that and without passion to push forward it would have been easy to give up.”
3. Building trust and effective teamwork amongst providers
To ensure collaboration and break down resistance, Carr adopts a systematic approach to bringing the various teams involved in the delivery of community MSK care together. For him, effective leadership plays a crucial role in building trust and safety, fostering open communication and collaboration, and shifting the perception of feedback from a means of competition to a valuable tool for improvement.
“It’s been my role to create that sort of space and build those foundations of effective team working. You start by building trust and then build the ability to embrace conflict and embrace critical inquiry. Once you’ve got that in place, then you build on the attention to results and pull people in. For me, that’s when you have a high-functioning team.”
Return on investment
completion rate (start of journey)
completion rate (during and beyond intervention)
Carr’s first priority in launching PROMs within NHS Sussex’ MSK setting was to give patients a user-friendly route to ensure their experiences and outcomes were heard by the clinical teams delivering their care. So creating a system that moved on from “a lot of paper collection” which was “taking up valuable consultation time” was critical.
In the first 12 months of using Cemplicity’s digital solution to collect patient-reported data the programme has collected over 24,113 unique survey responses. This was garnered from an unprecedented 54% completion rate from patients at the start of their healthcare journey and 35% completion rate during and beyond their intervention. That’s in comparison to a response rate of just 5% for some of the previous paper-based PROMs and PREMs surveys.
Service efficiencies have been realised by taking administrative tasks off clinicians; patient feedback response rates have increased exponentially; and these high-volume responses are providing valuable insights to assist service improvement planning.
The clinical teams have reported the PROMs programme has saved 2-3 minutes per patient interaction per clinician when compared to the previous system in place, equating to around 1 follow up appointment per full time clinician, per day.
saved per patient interaction per clinician.
With waiting lists a critical focus for the NHS, the capacity to get through extra follow ups is of enormous benefit to the organisations.
Despite having the right structures in place, and bringing limitless passion to the project, Carr still faced numerous challenges in getting PROMs fully integrated across the MSK team. For Carr, the biggest of these was the lack of agreed-upon standards for measurement. Without the right data it isn’t impossible to create benchmarks, but without the benchmarks, it’s hard to know what to measure. This was the conundrum that Carr set out to address.
While NHS commissioners do ask for providers to demonstrate measures from both an experience and outcomes point of view, the commissioners often aren’t the experts in what those measures should be. This left the providers themselves in a position where they could essentially mark their own homework. Carr rallied against this as this encouraged the providers to take the path of least resistance rather than push for the best possible measurement frameworks.
“I’d seen what they were trying to do in Canada with value-based commissioning where they were changing the way they commissioned services to incentivise the delivery of more healthcare services that could demonstrate their positive impact.”
Carr is passionate about the need for an industry-wide measurement framework that would enable everyone, including patients, to understand what constitutes excellent outcomes.
“If you look at the hotel industry, most of us will know what a 3 star hotel is and most of us know that a 5 star hotel is only for a very special treat. We don’t have similar consistent understanding in MSK healthcare.”
Agreeing these standards, and creating a consistency of measurement, became a core goal of Carr’s efforts.
Healthcare isn’t the full picture
Another challenge for Carr was the realisation that the healthcare setting alone isn’t in control of patient outcomes. Carr emphasises:
Direct clinical care has been cited to contribute to around only 20% of a patient’s total wellbeing.
The importance of also acknowledging and addressing broader socio-economic issues, such as health confidence, literacy, financial concerns, stress etc, is so important to helping someone live well. By bridging the gap between MSK clinical care and population health and social systems, NHS Sussex aims to drive greater integration of care and provide more comprehensive support to patients.
“You know, they might struggle with money worries, they might be struggling with stress and anxiety. It might be all of those things that are compounding their MSK problem. Those issues need to be addressed just as much as the clinical issue itself for someone to live well. So we’re building a tool that identifies those people and then we are linking with our population health programmes to try to make sure we can offer patients”
Foundations for future initiatives
One unexpected outcome of gathering and sharing patient-reported outcomes is the discovery of inequalities within NHS Sussex’s MSK patient communities.
The patient reported data has played a crucial role in identifying at-risk populations, something that Carr plans to use to empower fairer health delivery as he transitions into phase two of his patient reported data work. This insight has enabled bidding for health inequaility funding.
“We’re now using funding to build a stratification approach to identify people at high risk of these poor outcomes earlier in their journey. We then link them to broader programmes within Sussex that are focussed on helping people with their broader health and wellbeing.”
For Carr, the fact that the right measures are now in place is critical in evaluating the success of future improvement initiatives.
NHS Sussex’s journey towards a culture of improvement started with creating a consistent set of outcome data that enables benchmarking, analysis and insight to drive future improvement initiatives. By focusing on what matters to the patient, NHS Sussex has aligned its team behind a single view of what good looks like, in the meantime fostering collaboration between its clinicians through strong, passionate leadership.
But the journey has only just begun. These foundations are empowering a move towards leveraging data to build an integrated care approach that spans across the healthcare and social setting. It enables a shift towards more value-based commissioning models, founded on effective proof of the value that NHS Sussex’ MSK teams deliver to their patients.
In thinking bigger than the individual patient and taking a systems-wide approach to addressing healthcare and socio-economic challenges, NHS Sussex has made significant strides in delivering more effective and equitable care for its communities.