‘Hard-wiring’ changes to how teams and individual health professionals work encourages consistency and enables more monitoring and sharing of information, but it can be hard to develop and embed new systems and ways of working.
Some of the ways that teams can develop the way they work include:
Sharing information within the team as it ensures that people are consistently supported to self-manage by the different health professionals involved in their care. Mechanisms for doing this might include:
- Routinely sharing individual goal setting information within multi-disciplinary team meetings.
- Sharing goal setting information through SystmOne templates, enabling the goals set with community teams to be seen by other clinical professionals.
For example, the stroke team in Cambridge meet every Friday for a ‘timetabling’ meeting to plan their patients’ therapies with input from patients. The stroke team is then able to pass on to the ward staff what is important to each individual patient to work and achieve. This has led to the whole multi-professional team being aware of the patients’ agenda and goals.
In Calderdale, SystmOne templates were developed to enable the goals set with community teams to be seen by other clinical professionals.
Refining IT systems to provide ‘prompts’ which can help to ensure that self-management support is implemented consistently by all team members. It also means that self-management support is embedded in the routine way that services and individuals work, and self-management support is linked with other team processes.
Several sites working with the Health Foundation’s Co-creating Health programme used templates within their clinical systems to increase reliable and consistent use of the self-management tools.
For example, in Ayrshire & Arran many GPs use the same system, so they have developed a ‘tag’ for the records of patients with COPD to prompt the GP to check if they have been offered the opportunity to attend a self-management programme.
“So that becomes a routine prompt to allow people to recognise that we are encouraging people to be supported to manage their own condition and that there are opportunities for them to refer people into that programme. It won’t just come up at diagnosis – it will be attached to the patient’s records and will flag up every time they are in the practice, so over the lifetime of their diagnosis, it should flag up.”
“As we spread to the different specialties, we’ll then be able to say to the IT people to add this on to the people who have a record of stroke, or whatever it might be. So that then becomes systematic and it’s not reliant on some people finding out and some not.”
Whittington Health have developed SystmOne templates to prompt the clinician to agenda set with their diabetic patients.
- Developing systems so that the goals that people set during their consultation are linked through to their annual review.
- Incorporating self-management support into job descriptions and recruitment processes, for example, by asking applicants about their approach to self-management support at their interview.