Health Service Focus

People Powered Health

People Powered Health, a practical approach to involving patients with long term health conditions in their own care, run by innovation charity Nesta, the Innovation Unit, and management consultancy Private Public (PPL), supported projects in six areas across England helping more than 200,000 patients. It recently won the top prize for Innovation at the Management Consultancies Awards. NHE spoke to director in Nesta’s Public Services Lab and lead on the PPH programme, Halima Khan, and PPL co-founder Simon Morioka.

Involving patients and service users in their own care is a theme across a number of different health and care agendas, thanks to the growing evidence base showing improved outcomes, reduced costs and greater engagement.

People Powered Health (PPH) was an 18-month programme designed to draw together and build on the work done in these areas, from shared decision-making to the Year of Care model. Although the formal funded elements of the project finished at the end of 2012, its overall aims are being carried forward.

Nesta, the independent charity formed from the former National Endowment for Science, Technology and the Arts non-departmental body, was keen to build on innovations in health co-production made by professionals and patients and extend them so they became ‘a normal part of life’. It did this via £100,000 grants to six winning teams (from 106 bidders) to develop projects.

These were in Leeds (Care Planning in Practice), Stockport (Crafty Needles: Peer Support), Newcastle (Health Trainers), Calderdale (Group Consultations In A Pain Clinic), Earl’s Court (Setting Up A Timebank) and Lambeth (Living Well Collaborative). More information on each can be found in the paper referenced at the end of this article.

Halima Khan, director in Nesta’s Public Services Lab and lead on the PPH programme, told NHE: “PPH builds on lots of existing agendas, brings them together, consolidates them and extends them. Because we’ve got a bird’s eye view from outside the health system, we can take a few steps back and see the connections between lots of different agendas.

“For example, we all know that it’s possible for a perfectly well-meaning clinician to do something like a care plan or shared decision-making through a tool, but for it to end up being quite superficial. It’s the deeper end of collaboration we’re interested in – the most transformational aspects.”

Simon Morioka, co-founder of PPL, the consultancy that helped deliver PPH, said the idea was to “mobilise” the latent assets of patients and service users – their “knowledge, experience, capability” – to improve care.

Making the case for change

Morioka said: “There is a very compelling case for change – you can get better quality outcomes and you can reduce demands in the system by better engaging patients and service users. But actually what we know is that the cost benefits accrue in different places in different times.

“At the moment, when resources are scarce and there’s competing demands on the system, if you’re going to secure and sustain the investment required to make PPH a reality, that case for change has to then be brought down to a level where it’s possible to get stakeholders to buy in and make investment decisions that will enable these schemes to happen and the benefits to be realised and to scale.”

Achieving that buy-in often depended on the enthusiasm and drive of senior clinicians interested in this agenda, Khan explained.

“We feel like we’ve tapped into an existing network of pioneering clinicians who have been using this approach for many years.

“They’ve been doing it somewhat against the grain of their colleagues.

“Clinicians have been very important and very visible in all of the projects we’ve been working with, and often it’s the projects where they have the most visibility, and which involve the most senior clinicians, where a real difference has been made more quickly. It’s different if it’s managers asking for it.

“You get leading practitioners, in effect, working a few steps in front of the formal evidence base. They’re just getting on and doing this stuff, and they can see the difference it’s making with the people they’re working with. “Those are the kinds of practitioners we worked with for PPH. The challenge then is to formalise the impact they’re having.”

Barriers

PPH is designed to be transformational – so radical change is inherent.

That can be disconcerting and troubling for some staff used to a certain way of working, unlikely to stand to benefit from the change (those benefits accrue instead to the individual patient and the healthcare economy as a whole), and to patients less willing to engage.

Khan explained: “There are significant barriers in terms of workforce culture. This is a challenge to the way we’ve got used to healthcare being delivered, both as clinical professionals but also as patients.

“It’s easier to focus, sometimes, on the challenge to professional workforce culture. But we shouldn’t lose sight of the fact that patients need to behave differently for this stuff to work. They need to take on more responsibility.

“On the professional side, at its core it requires clinicians to apply their expertise differently. It requires them to be very confident about their expertise, but be able to combine it with different kinds of insight – the patient perspective, for example. For some, it comes very naturally, and for others – well, clinicians are just like any other group of humans, and they all have different attributes.

“Some find it potentially more threatening to them as the ‘expert’, holding the knowledge. Some hear about this and it immediately resonates with them and they understand what it’s about; others, when they find it challenging, just challenge back by asking about the hard evidence for this. You often get into those sorts of conversations.”

Morioka said: “In honesty, the evidence base is still evolving. PPH is a contribution to that evidence base both in terms the work that’s done, but also in terms of synthesising work done elsewhere, and providing it to commissioners in a very accessible way.”

He added: “There will always be a desire for more evidence before people necessarily feel comfortable embarking on major change. This is a major change; clinicians and patients talking about whole system behaviours, it’s very different to how they’ve traditionally behaved. While the individual ideas may seem simple, self management and time banking and group consultation, actually for a consultant conducting their first group consultation and for patients being invited to their first one, that is a very different experience to anything they have previously experienced.

“We have to recognise that many people with long-term physical and mental health conditions have fought very hard to get the support and treatment that they receive. Anything perceived to be in any way giving up some of that professional support will need their full confidence that what they’re going to get ‘in return’ is as good as or better than what they’ve been able to secure historically.”

Savings

Asked about the ultimate aim of People Powered Health – or whether it was to some extent an end in itself – Khan told us: “It’s definitely a means to something else. It’s all about, ultimately, health outcomes, and if it can’t demonstrate that it improves health outcomes, then it’s basically just a ‘nice to have’ and will never be taken terribly seriously. Health outcomes are absolutely key, but they need to be thought about as much in terms of patient reported outcomes as well as professionallydefined clinical outcomes. Both are important. But then it gets into patient experience, which we know is a really important dimension, and then we think the cost dimension is central.

“Sometimes though it’s better to go in with the health outcomes argument – as that’s ultimately what this is all about – but we knew we couldn’t be promoting models of care that are more expensive, because there’s just no possibility they’d get taken up.”

The business case, she said, was “very practical” and “focused on real cashable savings”. “We didn’t think commissioners, in this financial climate, were particularly interested in hypothetical social return values.”

Khan concluded: “We’re very convinced that this is the overall direction of travel that the NHS needs to take to adapt, in terms of living well with long-term conditions, and the evidence base needs to catch up.”

The award

People Powered Health took home the ‘Award for Innovation’ at the Management Consultancies Association (MCA) Awards in London on April 18.

PPL, despite being one of the newest members of the MCA, won for its work with Nesta. In a joint statement, Simon Morioka and his co-founder Claire Kennedy said: “It’s an honour to have the innovative work we’ve been doing with Nesta and the Innovation Unit recognised by our peers at the MCA. This is a really exciting time for us at PPL, and it’s brilliant to see the hard work and commitment of our staff paying off with this win.”

Alan Leaman, CEO of the MCA, said: “This project really impressed the judges. It is at the leading edge of new thinking and practice in the health service and is clearly set to deliver great results.”

Halima Khan told us: “We were absolutely delighted. PPL were a real pleasure to work with: creative and pragmatic, a very good combination!”

She said she thought one of the reasons the project won the award was the “differentiated approach” taken to the existing evidence base. She said: “We wanted to be very transparent about its strengths and weaknesses. We didn’t want to over-claim or under-claim, so we differentiated through a scenario approach, where we said the strongest evidence base points to these sorts of savings, but if you’re prepared to relax the evidence base, the potential savings go up.”

What People Powered Health looks like

The April 2013 paper on PPH advocates three core changes:

1) Changing consultations to create purposeful, structured conversations that combine clinical expertise with patient-driven goals of wellbeing and which connect to interventions that change behaviour and build networks of support.

2) Commissioning new services that provide ‘more than medicine’ to complement clinical care by supporting long–term behaviour change, improving wellbeing and building social networks of support. Services are co-designed to configure and commission services around patients’ needs.

3) Co–designing pathways between patients and professionals to focus on long–term outcomes, recovery and prevention. These pathways include services commissioned from a range of providers including the voluntary and community sector.

For More Information

An April 2013 paper on PPH, ‘Health for people, by people and with people’, by Matthew Horne, Halima Khan and Paul Corrigan, is available at: www.nesta.org.uk/ library/documents/PPHforpplbyppl2.pdf