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Building on Success - Future Directions for the Allied Health Professions in Scotland

Shaping the Future
6. Service Redesign

Modern clinical care is increasingly evidence-based. Services and systems, however, often operate from a historical 'custom and practice' perspective. Practitioners frequently live with the frustrations this creates, without knowing how to influence the solutions. Service redesign offers the opportunity to look at the contribution of all those involved in the patient journey from beginning to end and find creative solutions to problems. This chapter sets out AHPs' contribution to the process.

6. Service Redesign

Service redesign aims to improve the experience and quality of care for service-users. It calls for fundamental rethinking and radical redesign of care processes to achieve dramatic improvements in the speed and quality of care delivered. It can lead to services being delivered in a completely different way.

Service redesign involves multi-professional teams adopting an inclusive approach to service review. By adopting this 'whole systems' approach, the complexity of the care journey from beginning to end can be outlined in full. Multi-professional teams are then tasked with streamlining the care process, removing duplications, delays and unproductive work, and offering a better overall service.

AHPs have an important, and often essential, role to play in a variety of care pathways and are therefore crucial to the redesign process. So far, nearly 100 AHPs have participated in training on service redesign and many others have already contributed to local redesign projects.

>> The North East Glasgow Acute Lower Back Pain service is led by specialist physiotherapists and has impacted on the successful management of this condition, which affects 60-80% of the population. Ninety per cent of patients felt their treatment had reduced their symptoms and allowed them to return to their social activities sooner, with 60% achieving a full recovery and 95% returning to work post discharge. <<

>> In Lothian University Hospitals NHS Trust, the Therapy Services Director has developed a structure that supports the integration of the professions into directorates and facilitates their development planning. This ensures that AHPs are maximising their impact on Trust priorities such as waiting lists, discharge planning, service redesign and modernisation and care pathways that support extended scope of practice. <<

Reviewing professional pathways and systems

Reviewing service provision can also offer opportunities to consider the existing and future roles of clinical and support staff. Many AHPs have already developed specialist practitioner roles or extended the scope of practice of existing qualified and support staff to improve services, reduce waiting times and improve outcomes. The King's Fund report on the ENRiP (Exploring New Roles in Practice) study, Developing New Roles In Practice: an Evidence Based Guide, offers useful guidance on the process of developing these new roles.

>> In North Glasgow University Hospitals NHS Trust, patients are able to self-refer to the open access diabetic foot ulcer clinic run by Podiatrists. Rapid assessment and treatment of foot lesions is provided to improve the clinical care for these patients and avoid hospital administration or the need for surgical intervention. <<

>> In Midlothian, Occupational Therapists from Local Authorities and health services have worked together to redesign the management of equipment and minor adaptations. This has resulted in more responsive services to support patients being discharged from hospital and a more efficient use of staff time in both agencies. <<

Reconfiguring the skill mix within a service can also ensure that practitioners are making best use of clinical time, and that Support Workers are enabled to enhance their role appropriately through additional training and support. The new Workforce Centres outlined in the Scottish Executive Health Department (SEHD) response to the report of the Scottish Integrated Workforce Planning Group, Planning Together, will be key to supporting and developing such new ways of working, founded on clinical and professional competencies. It will be essential to include key stakeholders in this process including employers, NHS Education for Scotland, and the professional bodies.

>> The Society of Radiographers and the Royal College of Radiologists are working together on clinical career development and progression for staff in radiography. The work promotes widening access to the profession, flexible career pathways and the development of new roles which have the potential of allowing some highly skilled radiographers to undertake more complex procedures and to have greater influence over the management of their patients. This may in some cases free up consultant radiologist time. Therapeutic Radiographers in Scotland have developed extended roles in review and management of palliative radiotherapy patients and Diagnostic Radiographers are undertaking barium and ultrasound investigations, IVU examinations and injections of contrast media. <<

The introduction of AHP prescribing in the future is an example of changes in roles and clinical pathways. The Review of Prescribing, Supply and Administration of Medicines, which reported in 1999, recommended that systems be put in place to extend the prescribing of medicines beyond doctors, dentists and certain nurses to include other competent health professionals.

The Health and Social Care Act, 2001, allows for the introduction of independent and supplementary prescribing. It has been decided that supplementary prescribing will be introduced initially for Nurses and Pharmacists. This is currently under consultation with a view to implementation in late 2002/early 2003. Extending this to other healthcare professions will be considered in the light of this experience.

Wherever possible, and where it is in the interests of patients, AHPs should be enabled to undertake extended scope of practice that contributes to reducing waiting times, improving access to the right healthcare practitioner, and encouraging seamless care and health improvement.

Supporting the contribution of AHPs to strategic and local planning

AHPs are core members of the multi-professional and multiagency teams that deliver services to all of the national priority groups and the growing numbers of people with chronic diseases and disability living in the community. It is therefore essential that local planning processes reflect this through the involvement of AHPs in all levels of planning.

Better information locally and centrally is also required to support and inform the planning process, both in terms of individual professions and within the localities or context in which those services are provided, such as stroke, cancer, and older adults' services.

>> Podiatrists and Dietitians in Glasgow Primary Care Trust worked within a GP practice to develop a self-management approach for patients with Type II Diabetes. This service has been well received by patients and has enhanced both awareness and improvement of diabetes control for these patients. <<

>> A 'model pharmacy' has been developed in Possilpark, Glasgow, providing a resource centre where other staff such as Podiatrists can work and the local community can access a range of services from one convenient location. <<

Managing changing priorities

Managing and prioritising workload is an ongoing challenge for AHPs, particularly as a result of growing demand for their 'needs-led' services and the impact of workforce changes in other professions. This has been further compounded by recruitment and retention difficulties and the impact of planned leave without established 'backfill' (or locum replacement) arrangements, which has been a long-standing problem.

Many AHP professional bodies provide guidance for staff on caseload management. This should be reviewed by AHP leaders to inform integrated workforce planning arrangements. The work of the national and local Workforce Centres will be vital in influencing the workforce planning of the individual professions. The professions will need to supply accurate data to support this initiative. Further work will also be required to evaluate the specific impact of workload.

Future developments, however, must be based on appropriate arrangements for service continuity. They should also reflect the impact of planned leave on increasing workload pressure and jeopardising the retention of existing staff. And consideration needs to be given to the impact of the Working Times Directive for those staff who provide out-of-hours services, such as Radiographers, Physiotherapists and, most recently, Occupational Therapists.

AHP participation and involvement in new NHS systems

Several NHS Boards now have AHPs as Board members, either in the capacity of corporate employee representative or as chair of the clinical advisory committee. AHPs need support to develop these new roles and responsibilities within the context of new multi-professional and multi-agency structures.

It is vital that management systems and structures within Trusts, Local Authorities and LHCCs should support AHPs in making a full contribution to the service. They should be well informed and involved in planning and delivering on priorities for action at local level. Appropriate leadership for AHPs is also critical to delivering the required improvements in the care journey. AHPs must actively work together in teams to address their shared clinical and organisational priorities, in partnership with colleagues from other professions.

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