S5E8 Mixdown 1
Intro - Welcome to Stoma and Continence Conversations from Coloplast Professional. I'm Hannah, Ostomy Care Associate Education Manager at Coloplast. Working in specialist care, I know that stoma, bowel and bladder issues impact the lives of those you care for. This podcast is here to support your educational needs and help you in supporting your patients. You'll hear from fellow healthcare professionals and experts by experience, discuss the latest hot topics in the world of stoma, continence care and specialist practice.
Paul: I am really, really pleased to be joined by everybody today and especially our guest speaker on today. So, but I'm gonna leave him to introduce himself in just a second. But for those of you that don't know me, my name's Paul Russell Roberts and I am Ostomy Care Education Manager here at Coloplast. Practicing stoma nurse, still a stoma nurse, and I love stoma nursing and I love Clinical Nurse Specialists. It is part of my passion is supporting clinical nurse specialists to prove, showing them how they prove their worth and prove how vital role we play within the NHS and patient pathways. So that's a little bit about me. I'm gonna ask my lovely colleague and friend, Hannah to introduce herself and then we'll hand it over to Scott to introduce himself as well. So Hannah, how are you?
Hannah: I'm good, thanks Paul. And hello everybody. As Paul already said, I'm Hannah, I’m Paul's right hand woman! I'm the Associate Education Manager at Coloplast. So I work very closely alongside Paul. Like Paul, I've had ostomy care experience. I was previously colorectal HCA within a local trust in Birmingham, and also a previous Ostomate myself as well. So very similar to as you said Paul… lots of passion from me when it comes to stomas, stoma care, stoma nursing, all things stoma! So really happy to be joining everyone on our very first Webinar Wednesday.
Paul: Brilliant. Thank you. And last but not least, Scott…
Scott: Hi guys, and Paul and Hannah. Thank you for inviting me to come and speak with you today. I'm really looking forward to this afternoon. So for those that don't know me, it seems a long time ago when you say it, 18 years, it sounds really quick. It's like the blink of an eye is how it feels. But, 18 years ago, I left my role in the pharmaceutical industry, funnily enough, and came to form my own independent management consultancy. And from that point forward, I've worked inside the NHS, so working with the general practice, with mental health trusts, with hospital trusts, community service providers, all around change in change management, redesigning pathways, shifting care, reshaping, the delivery. And fundamentally right now, that's the big issue. So a lot of my work just now is with general practice through GP federations and primary care networks. And the real issue is that the NHS as a whole right now has an agenda of having too much work. It doesn't have enough people to meet that demand, and it's driving us to innovate and work in different ways, and that's really where I spend the bulk of my time, working with the NHS right now. So really looking forward to sharing thoughts today.
Paul: Brilliant. Thank you, and again, thank you so much for joining us, Scott. And we were talking before the webinar, we were saying this isn't gonna be death by PowerPoint. For those out there, we've got no slides. There's gonna be no slides to show. Because as with all parts of nursing, it's a human science and you know when we talk about the true cost of care, you know, one of the things that people gotta want, you know, I would love people to understand more, is what is the true cost of care? How can we describe or discuss the cost of care? So really my first question to you, Scott, is whenever we're redesigning or initiating any aspect of care, how do you actually show that true cost of care?
Scott: I mean, it's a great question that you ask Paul. And the thing that I always try and frame in my mind before I set off down the trajectory with redesigning any particular pathway or aspect of clinical care is I kind of frame it in terms of what is the problem that I'm trying to solve? And it's usually as we've talked about before, related to pathways of care that don't work either to the benefit of the patient or the benefit of the healthcare professional. And that's usually because they're not really well-defined. In terms of either the funding flow or the patient flow. And that often means that in terms of how we then get the true cost of delivery, that's usually linked to the fact that we've not implemented the local guidelines or the local formulary, despite the fact they're really well intended, it's been left unimplemented, and that results in an overload of workload. Tied to that point, we've just made the lack of workforce, and then we fail to meet the demand and we need to innovate and we need to look for new approaches. And at that point, I absolutely do what you're asking. I spend time reviewing the pathways and trying to work out every step, what's the absolute cost of delivery and what's the next step in this pathway? Because we'll often get to a point where we can't actually identify what the next step is, or it doesn't make sense. So then of course when things either don't work or don't make sense, we're adding layers of cost because the true cost here really comes down to the contacts that we have with the NHS, whether that's in general practice, in community services and hospital, and A&E with the out of hours provider. All of that, absolutely drives cost. So I want to understand every single step, the people involved at every single step, any kit and equipment, any drugs, any care at all that happens, diagnostics and such like, I want to understand all of that so that when it's time to then implement the process for a redesign, which we'll talk about, the focus then becomes about how do I improve the patient outcomes, reduce unnecessary appointments, referrals, and admissions. I might look to tackle health inequalities, and of course all of that is gonna be wrapped up in a pathway redesign. But to really understand the true cost, you want to know and understand every single step, the people involved, the kit and equipment, anything that's going on, get a cost to it, and you can then identify the true cost of the care. And often that's horrifying when you do that!
Hannah: So is there a process that you use to demonstrate what happens within a pathway of care?
Scott: Yeah, Hannah, again, another really, I can see this is gonna be one of those days where I'm gonna get hard question after hard question! So yeah, that one, it's a case really of mapping and costing every single step in the current pathway. So what I tend to do is, again, there's another little bit that I kind of like to do when I'm redesigning the pathway is I like to get people to tell me, in an ideal world, what would this look like? So if you had the absolute ideal pathway from end to end, from the initial point of contact with the patient, right, to the point where hopefully we can safely discharge them having had full treatment, what would it look like? And then you get the clinicians involved in describing the ideal pathway. I also get the patients involved as well, because in reality, they're the only ones that walk every step in our pathway, we might think we know what it looks like, but in real terms, only the patient sees every step. So, we get the design of the ideal. What I then do is start to then map every single step, all the people, all the costs in our current pathway, and then you look and compare one to the other. And that's often where you then find the wastage steps, the avoidable duplication, the kind of, what I would describe as underuse, overuse, misuse of services. All of that becomes apparent cuz it tends to not look like what your ideal pathway would look like. So it really is that bit about mapping every single step, all the touch points, all the cost points so that you get an absolute picture before you then start going down the route of what are we gonna redesign and what's it gonna look like and what it really will show. As you already know, what this really shows is that it's the contact with people that drives the cost. It's often not the drugs, the devices, the technology, the apps. It's the fact that we need people on the other end seeing the patient. That's where our cost tends to get away from us. So understanding every step becomes absolutely key.
Hannah: So how do you then use all that information to build the case for making that judgment? I'm sorry, it's another, probably one of ‘those’ questions!
Scott: Oh, no, it's not, that actually builds on the last one, so I kind of touched on it there. What I tend to look for is, so what was previously commissioned? So we've got the pathway there and we look at kind of what we're doing, and we're starting to map every step and all the costs associated with the step. What I'm then looking for is what I described there as underuse, overuse and misuse of services. So what I mean by that is we've commissioned a thousand, but we're only doing 500 a year. What's gone wrong? Why is that? You know we've obviously, we've gone through a full commissioning cycle. We've looked at everything. We've looked at all aspects of care. We've commissioned on the basis that we think we need a thousand a year, and we're now doing 500. Why have we got such an underuse of this service? What's causing it? Then the other end of the scale, we've commissioned for a thousand, that we're doing 2000 a year. What went wrong? What went wrong in our forecasting that we’ve now got double the volume that we expected. And often when you get that one, you then find a little side effect to that, which is a misuse of a service. My best, which actually in brackets means worst example of this, I'll not tell you where it is cuz I don't wanna embarrass anybody. And it's not designed to. But at a piece of work, this goes back pre-pandemic quite a bit before the pandemic in reality where we had a hospital department that was commissioned to do about 600 patients a year. So this was two week cancer wait and over the 15 years that had existed at that point, they had run between 550 and 580 patients a year every year. It had bobbed up and down in that band, and suddenly it had doubled. It had literally gone through the roof and they were doing over 1200 patients a year. And it was by complete chance that I got involved with that. And to cut a very long and boring story short, my first question to them was, what's your normal 18 week referral pathway looking like? And they were like, ah, we're it kind of 26, 27 weeks. And I said, I’m willing to bet you that's what's driving this take-off in your two week wait. What did we do to solve it? We had a redesign and we actually brought the consultant out the hospital, and they did one afternoon a week, funnily enough, a Wednesday afternoon, and it still happens to this date where they were able to do 15 minute appointments for a three and a half hour session. So they were doing 14 patients per afternoon. If you multiply 14 by 48 weeks in the year, it comes out just over 600 patients. So everybody that was currently being stuck in that two week pathway, because basically primary care was saying it's beyond the level of the skill I've got to deal with this patient. I know it's probably not cancer, but if I put them in the two week wait, they'll get seen rather than waiting 26 weeks. So we sorted all of that out. It's the classic overuse of a service, and it was driven by the fact that the main service was clogged up and not working correctly. So that tends to be where I start. It's the process I look at. What did we commission? What are we doing currently and what's gone wrong in that pathway that is meaning that we need to now redesign it? So underuse, overuse and misuse of services is a really good place to kind of start that process.
Paul: It's a fantastic, I love how you're saying that cuz really it is all about gaining that understanding, isn't it? Cause if you don't have that understanding, if you don't know the nature of the beast that you're dealing with, then whatever outcome you get at the end, isn't gonna be fit for purpose if you haven't got that basic, essential understanding. And I know from previous conversations with lots and lots of clinical nurse specialists, cuz I do support them in business planning, speaking up for their service, things like service summaries. And if you have got any questions on service summaries or even you know, business planning, please, please, please, you can go on the Coloplast Professional website at coloplastprofessional.co.uk . There's a link there to the Apollo Nursing Resource and it talks about how to speak up for your service, writing business plans, service summaries, etc, etc. And without that basic, essential understanding of what you are trying to do you are never actually gonna get an appropriate outcome at the end. But I, again, one of the things that lots of nurses come back to me with is, I'm a nurse, I'm not a trained, I'm not a business person. That's a lot of the things they come from. And I know that from previous conversations with you, Scott, that we do need the input of other clinical teams, different individuals to help you possibly, you know, expand on what your vision is. So could you, and again, putting you on the spot, could you hopefully expand and explain a little bit more this involving other people into the process?
Scott: Oh, totally. Oh, I'm so glad that you've asked that as a question cuz it gives me a great opportunity to highlight… I'm not a nurse! Okay, so I get people coming at me all the time wanting help with their pathway redesign, but I'm not clinical, so I don't have the clinical skills to be able to do it. So that's where the real coming together can really benefit because clearly I, well, I'd like to think I've got the business skills having redesigned numerous pathways over many massive bank of redesigns, that I've got the business skills that they, the nurses will say, no, I lack the business skills to do, but that they've got the key ingredient for me, which is the clinical skill because I am not clinical. So, I need their input and their insight. And I said earlier, we always try and include the patients in that process too, because they bring an insight that only they can possibly have because they're the only ones that walk the full pathway. But this is where the clinical skills are so important in shaping the new service. And that's where I would pull on all of their insight and expertise in terms of what works, what needs to be included within the new pathway, what doesn't work when we look at that old pathway, what's causing them a problem? And we absolutely need to fix and address, is there new national guidelines? Are there new local guidelines that we need to include and make sure that we deliver that outcome that's absolutely envisaged by the redesign? So, yeah, whilst I did laugh when you said that the nurses are sat there thinking, oh, I haven't got the business skills. And I was immediately sat there thinking, yep, you know what, ladies and gentlemen, I haven't got the clinical skills! So that's where we get together and we can do something really remarkable. You know, I've got lots of really great pathway redesigns that when we first sat down on day one, it was a blank sheet of paper and it was then built from there. And then years on it's still running. One of my favourite ones just as an example, Paul won't mind me telling this lovely GP Paul Nets up in Newcastle. Way back, he approached me and said, Scott, could you help me redesign the Non-Mediated IGE Pediatric Allergy Pathway? And I was like, right, Paul, whoa, whoa, rewind going to explain to me what Non-Mediated IGE Pediatric Allergy is? And we laughed about it, but you know what? That contract now, seven years further on, has just been renewed again, to continue that particular pathway because it now works really, really well for them. So you can start with a completely blank sheet of paper and still end up with a brilliant outcome.
Paul: It's amazing hearing you say that, and I think it is… you know, I always talk about things with, you know, when it comes to business planning, when it comes to implementing change, implementing new innovations. Because a lot of the time it's not necessarily, you know, we talk about change, but a lot of the struggles that nurses can have, especially clinical nurse specialists, is the introduction of innovation. Because, and again, I know from listening to you previously and listening to people like our mutual friend Roy Lilly has also mentioned things in the past as well, that it's that fear of not moving, you know, the tried, the tested and sometimes you have to step out of that and go, no, if it's not working, having the, for want of better words, guts to say, look, this is changing! There is new things out there, there's new things coming through and you know, we've been on 18 minutes now and we haven't mentioned those lovely five letters and one number y COVID you know, COVID-19. Innovation that has happened. Yes, and again, I'm sure you can probably give hundreds of examples about how you know, COVID has exponentially increased how things have progressed, new innovations. We talk about the digital revolution and how the digital revolution has exponentially changed the face of care. More so than ever before. I always think of the NHS long-term plan. When I think about, you know, they always had digital revolution in the NHS long-term plan. And it was about you know, chapter three as it was then. But every time they did a review, it never seemed to go up the priorities, and it always seemed to get pushed out. Suddenly COVID hit, they had to make that change. But again, I am a nurse, I'm not a businessman. That's why we, you know we’re really pleased that you are here as well. But I know from nursing, one of the things I say to nurses is who I ask them a question, who loves data? And they'll say, No, don't understand data. But data is at the heart of nursing. A blood pressure, a pulse, respirations, oxygen saturations. That is data. And we can interpret that data in a heartbeat. You know, it's nursing 101, we're able to interpret that data. So if a nurse is wanting and they've worked out a pathway and they're going, right, this is how we want to do it. This is what we want to change. We've got our blue sky thinking. One of the things that I know I struggle with is appropriate outcome measurements. So what are the good things to measure to show the value of clinical input? Cause you know, as I said, unlike a TPR chart, we can see if we've given somebody fluids, urine output goes up, blood pressure goes up, pulse comes down. We know we've inputted a change, we've implemented something, we've made a measurement. Yes, it's worked. So from a change in implementation point of view, what is good to measure?
Scott: A great, an absolutely great question, and if you don't mind, I'll come back and I will answer it for you. But I want to go back and just pick up on one of the things that you said, because you jogged something in my mind listening to you Paul, particularly around reasons for change and, and COVID and the like. One of the things that I often cite is, unless you're gonna tell me you are 100% happy with your current outcomes, that's everything. That's your workload, the workforce, the number of appointments, referrals, admissions, all aspects of care, the team, the premises, the path, everything. Unless you're gonna tell me you're 100% happy, that's the time to step back and say, so what am I gonna change? Because more of the same input is only gonna drive more of the same outcome that you are unhappy with. So you have to keep that in mind. Unless you're 100% happy, that's the point that you should step back and say, what am I gonna change? Then coming back to the point that when you do implement, what am I going to measure? This is where I use NICE guidance. A lot of the time I use local guidelines if they've got them. What measurement were we expected to be able to deliver in implementing this guideline? I will use that. I use NICE guidelines and I use NICE quality standards as well, because ultimately what we really tend to be looking at are simple things. Can we improve the patient outcome? Does it reduce unnecessary appointments, referrals, and avoidable admissions? Is it something that's gonna tackle the health inequalities gap locally? So I'm always looking at those things, and then I have my own very simple set of tests for when people approach me with ideas, I tend to kind of filter them through four steps. Does this project significantly improve the patient outcome over where we are now? Because if we're only gonna tinker at the edges, what's the point? We're all drowning in work. So small changes, that don't really have a brilliant outcome from a patient perspective tend to not be massively worthwhile. There may be exceptions but tend not to be so, significant improvement over what we're doing now. Does it reduce GP practice or wider practice team or community service or hospital workload? Is the result from that improved outcome gonna reduce our workload? Let's assume it does. What impact then does it have on our income? You know, as a hospital, as a hospital department, as a community service team, as a general practice, is it putting our income up? Is it putting our income down? Does it have no impact on our income? Because you have to think about that because all our budgets are predicated on the income that we generate. So it has to be part of the consideration. And then probably the most important one, have I got a team of people to deliver this change? There's no point in creating a super pathway and then going, right, let's get… oh, there's nobody here that can actually implement that. So to me, it has to meet the four tests. It's gotta significantly improve the patient outcome. It's gotta reduce the workload. Shouldn't have a negative impact on our income. And we must have the team of people available to do it. And I think if you've got that, you're always gonna find either NICE guidance or local guidelines that can then be your benchmark on what you're showing that your pathway's gonna do. But just as simple as, does it reduce appointments, referrals, and admissions, would be more than enough currently in the NHS to say, if we can do those, we're on a winner. We should be implementing this.
Paul: Brilliant.
Hannah: I know this is probably really hard to do, but are you able to, Scott, in a nutshell, summarize the process for us?
Scott: You know what, I can actually do that because since starting, I said this at the beginning, 18 years ago, I have literally used the same process for every redesign. So the business case template is still the original one that was put together when I first started the consultancy. And I want to go right back to what I said at the beginning. What is the problem that this project will solve? So frame it, give us a background that says this is why you should want to read the rest of this business case. And then in simple terms, the business case will lay out step by step, what is this project designed to do? How is the project designed to deliver the required outcomes? So back to the previous question, these are the outcomes that we're gonna deliver. This is how we're going to do it. Who is responsible and for what? And this makes sure that you include every single person that needs to be involved in the project, in the project. So go back to Paul's point, I need data. So who's the data analyst that's gonna go alright..? Often we set off creating projects and we don't think about every single person that we're gonna need to engage. So the minute that you sit there and say what we're doing, how we're doing it, who's responsible and for what within this project, you'll get a nice long list of names of everybody you need to engage. Then you come back to, again, the previous question, how are we going to measure and evaluate? In other words, what outcomes are we expecting to deliver and achieve and how are we gonna measure and evaluate those. And then there's a last piece that I always include, which is what contingencies have we got? So when the things don't work the way that we expected them to work, when it doesn't quite fly the way we thought it was gonna fly. What's our contingency plan to get us back on track? And I think if you follow that process, you will not go far wrong and you'll end up with some great pathway redesigns that can very successfully be implemented and deliver that improved outcome and the reduced workload that really is the holy grail in the NHS right now.
Paul: It's amazing and you know, I know we are. I'm very, very conscious of time, Scott, and you know, I know from both Hannah and myself, you know, I really, really appreciate the time.
Scott: It's a pleasure. Absolute pleasure
Paul: And it's, you know, I'm, you know, from my kind of summary thinking about it, and again, from my personal experience and what I often talk to nurses about, it's be curious, cuz nursing is a curious profession. Nursing, you know, the reason we undertake blood tests, x-rays, CTs, everything we do is all about curiosity. And it's all about making the change, and I'm really, really pleased. One, you know, one of the things that you've said almost every time, every question we've asked you today, you've mentioned patient input. You know, you've included, and you know, we do and we should, whether it does always happen, put the patient at the center of everything that we do, which I'm really, really pleased that you know, you have said in every point that you've made, it's involve the person that is actually going to affect. Any innovation, any change that you're driving. At the end of it, the person that should be benefiting the most is the patient, is the person at the end of, the other person at the other side of that clinic desk. The other person, the person who's having that scan, the person, the end, who is on that pathway, and it's our responsibility to if there is innovation, if there is a change that's needed to improve the process for that individual, totally. That what we need to do, that's what we need to drive for.
Scott: If you think about it, Paul for a minute, every time a healthcare professional prescribes or refers, what they're actually doing is seeking an outcome on behalf of the patient. So I'm prescribing you A to try and get you to B. What I then do is say, so if B doesn't work, what is C to get to D? And if D doesn't work, what's E to get to F? In really simple terms, that's what we're looking at. What are the steps in the pathway that are gonna get the patient that outcome that the healthcare professional has in mind for them that first time they meet them and they then set them off on a course of action? And I think if you keep your pathways in mind like that… What's the next step? What's the next step? What's the next step? Actually, what you'll then deliver is a pathway that flows really, really well. The funding will flow, the patient flow will work for you as well to everyone's benefit. So yeah, I think it's a great point you make. We have to keep that in mind. There's always a patient on the end of every decision that gets made.
Paul: Yeah. Fantastic, fantastic. Thank you so much Scott.
Scott: You're very welcome.
Paul: My last thing I'm gonna do, I'm gonna do an open plug now as well because we did a couple, about 18 months ago, we did a podcast with the lovely Maddie White and it was about the journey of a Stoma Nurse. And what I can remember, one of the things she said was, cause we spoke about how to become, you know, if your thinking to becoming a Clinical Nurse Specialist, and again, it ties into what you said. She said, you have to understand your regional climate, understand the pathways, understand local policies, because unless you've got that understanding, You are not gonna be able to do anything. And so please, again, all the podcasts are available on the Coloplast Professional website, and they're available through all major podcast deliveries, however you get it. So please have a little look there on Coloplast Professional an excellent set of podcasts. It is one o'clock Scott, thank you so much. I know this is actually the first of three webinars on the topic of ‘true cost of care’ and that sort of thing. And I would hope beyond all hopes, Scott, that you'll join us for another webinar on another day,
Scott: It would be a pleasure.
Paul: Thank you. So, Hannah, any, any, any last points from you?
Hannah: No, just backing up what you've said. Thank you so much, Scott. Really fascinating to listen to you and the passion that you've got. And from a non-clinical background as well, cause Paul and I have both said, we come from clinical background, so to actually hear passion from somebody not from a clinical background is fantastic. It really, really is.
Paul: So brilliant, thank you. So for everybody, whether you're watching live, whether you're watching on demand and on catch up, you will get your, uh, certificate at the end of it for your 30 minutes of CPD, so that is there coming through there. So please, join us next month where we've got another webinar, which I'm really, really pleased about, and they are all on the Coloplast Professional website. So on behalf of Hannah, Scott and myself, I hope you have a brilliant rest of the week. Good luck. Take care, and we'll see you all very, very soon. Thank you.
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