Becoming the face of Community Rehabilitation

Karen Poole is the Consultant Therapist (Rehabilitation) for East Sussex Healthcare NHS Trust (ESHT) which is a large integrated acute and community trust and is also the Director of Trauma Rehabilitation at the Sussex Trauma Network and Co-Clinical Lead for Sussex ISDN and post covid services at Sussex Health & Care Partnership. Karen is about to embark on the transformation of community rehabilitation services in East Sussex.

This is the first in the series of blogs and vlogs on Karen’s journey, her insight and lessons learned. The aim of the blog series is to inspire other Members who are either going through a similar journey or are thinking about service transformation and wondering where to start.

Karen led the transformation of services within intermediate care and this blog post follows on the lessons learned from this project, useful advice for others and how Karen intends to take this learning forward to transformation of community rehabilitation.

Becoming the ‘go to’ person for rehabilitation

Karen reflects on how her AHP Lead role at ESHT gave her a seat at the executive table, giving her a platform to influence change – becoming ‘the face’ of the local system.

Prior to this position, Karen had worked in previous roles within the Trust over the past decade building up experience in unifying teams, harnessing the umbrella approach, working across MDT and developing a workforce that took a holistic approach to patient care. When she became the professional lead it gave her a different lens to look at services and an opportunity for rehabilitation to be developed in a much broader way.

As AHP Lead the ability to work across professions with a ‘helicopter view’ together with a profile at executive level enabled Karen to become the ‘go to’ person for rehab.

Becoming the face of rehabilitation is important as it is such a broad service and so far-reaching, with so many professions, providers and community groups involved. This makes it all the more challenging to affect change. In the shoes of a commissioner or a decision-maker on the ICS it is impossible to interface with all these groups, which is why the need for a person with that rehabilitation knowledge across the system is vital.

In Karen’s local ICS, rehabilitation impacts on the work of her 3 leadership roles, which is why collaboration and communication across all of these workstreams is an important aspect of Karen’s work.

The challenge of transforming rehabilitation

In embarking on a process of transformation, change has to be a collaborative and be an engaged approach with clinicians against the back-drop of a real operational and system push to do things differently and quickly. It is about finding a common language that supports the vision and brings all stakeholders with you on your journey, and finding a way to communicate the balance between action and pragmatism for those who need change to happen quickly, and those with the understanding of how it needs to be properly embedded. Rehabilitation, more than any other pathway, has got to be a ‘cheek by jowl’ partnership with our patients, clients and service users. It is an umbrella remit where you are trying to get it right for multiple patients with different needs – there just isn’t a one size fits all approach – it needs to be flexible.

Making a start – its all about the people

Karen’s first step in the transformation process was intermediate care, which was in urgent need of a raised profile within the Trust as to demonstrate what could really be achieved across the system.

At the start of this journey Karen’s attendance with colleagues to a training day on transformation really opened their eyes to the scale of the challenge that they faced. The capacity and time needed to step-back and get some headspace to look at the challenge and identify what they didn’t know as well as what they did couldn’t be underestimated.

To make change they had to bring the workforce with them, so Karen moved her office into the centre of the Intermediate Care team. This gave her the chance to really get to know the teams working there, their challenges and to give them an understanding of Karen’s role so that a partnership approach could be adopted rather than things ‘being done’ to them.

In her office Karen started writing her plans on wall charts marked according to these categories:

• Data
• Workforce
• Outcome
• Patient experience

She then looked at each heading to start to think about the mechanisms that needed to be put into place so that she could identify the voices that she needed to listen to and identify the key influencers.

In doing this exercise she was able to start asking questions to fill the gaps in knowledge:

• What is our USP? It became apparent in asking this question that not everyone was on the same page as to their purpose, so it was clear the aim needed to be centralised
• How do you know when a patient’s rehabilitation is complete? What does the data tell you?

Karen says the first step in any transformation is to identify who in your network is going to have the most influence and then investing in developing relationships with those individuals. She says it’s also about identifying the gaps in your own skills and sourcing those individuals who can help. So getting people involved like the communications director and the health and wellbeing strategy lead really helped.

For example, with communications it was about turning round the perception of intermediate care within the Trust to boost its profile and to highlight how effective it could be with patient flow across the system. It was also about winning over the hearts and minds of ‘naysayers’ to change – to bring about effective transformation. It was about having difficult conversations with staff and moving towards a ‘home-first’ mind-set for patient treatments. It was also about addressing some of the areas of friction within the system. The intermediate care team were passionate about rehabilitation but tired of being seen as a way of just releasing beds in acute.  

The communications aspect was well utilised to help colleagues in intermediate care see what they were contributing to, what they were there for and to promote a sense of pride in the service they were delivering for their patients and for the Trust. The team had their own Twitter profile to promote their work, patient booklets were produced on ‘your stay in rehab’, a virtual journey of the service was developed as well as regular rehabilitation bulletins updating on achievements which were sent direct to the Trust’s Chief Executive.

Equally important were the colleagues in health and wellbeing who advised on the risks to transformational change and the work required for particular groups of the workforce to accept that change needed to happen. 

Bringing in together the skills, experience and knowledge of people within different departments helped Karen to see the task at hand through different lenses and adapt plans accordingly.

Informal initiatives developed by the team, such as ‘Cuppa, Cake & Collaborate’ proposed by the intermediate care matron brought together the nursing and therapy teams who had become disconnected. Karen had previously spoken to nursing leadership about what would help engage the nursing team and they said tea and cake would help! It was clear that transformation wouldn’t be possible without the nursing team on-board so this informal get together helped these teams to see the valuable role they played in rehabilitation and how collaboration was vital.

Making sure you have the ‘right’ patients

In Karen’s data exercise, she looked at the types of patients entering the service and began to stratify them. This helped to identify the level of the system’s effectiveness and what needed to be done elsewhere in the system to reduce patient dependency. In analysing all this data and identifying opportunities for transformation it was important to put it in the language that a Chief Operating Officer (COO) would understand. Karen reflects that when making a case for system wide change, too often as clinicians we focus on clinical outcomes, which whilst important, needs to be re-packaged in a way that resonates with a COO.

Karen developed a ‘dashboard’ with infographics so people could see what was happening ‘under the skin’ of the intermediate care unit. In stratifying the patients it was easy to spot those that would benefit most from intermediate care in terms of complexity. In producing this easy to understand data interpretation of patients, Karen was able to then make the case for more funding. It also helped rejuvenate the service’s awareness of their core purpose and who they were there to help. This benefitted workforce retention and also led on to develop an ACP role for the service.

Creating the right physical environment for both staff and patients

Collaboration discussions with multi-disciplinary teams un-earthed some improvements that needed to be made in the physical space within the intermediate care service. A contribution from one of the housekeepers, who used to work in Poland in psychiatry, suggested that the atmosphere needed to be improved and reflected that those patients in bays did not have a suitable place to meet their visitors, friends and family.

As a result they began on an environmental enrichment exercise to cultivate the right setting for rehabilitation and recovery both for patients, staff and visitors. Changes that were made included:

• Improving the patient information on walls by involving the communications team to create eye-catching advice
• Encouraging local art groups to exhibit their pictures
• Re-purposing a space that had been previously used as storage to make the most of the atrium feature into a activity hub for patients, turning the patient area in the clinical atrium for dining with a ‘French bistro’ look and feel complete with storyboard table, enhancing the unloved reception and WRVS kiosk into a vibrant café complete with flowers, tablecloths and volunteers running the reception area to welcome visitors, carers and families into the unit. . A patient liaison member of staff helped to consult with the patients to understand the type of environment that would benefit their rehab journey and developing the welcome process to the unit. This included encouraging patients and staff to sit and eat together. This also enabled the staff to hear more about patient stories which were then later used as case studies about patients achieving their rehabilitation goals
• Working as an MDT to share skills in getting patients ready for the rehab day ahead benefits the effectiveness of the rehab team to be able to see patients earlier in the day and maximise the capacity to take part in all aspects of the rehab day, including the activities on offer within the unit as well as important time with friends and family. 

The changes weren’t just about the look and feel of the place, but also about encouraging patients to be more active too. The atrium area was also used by activity co-ordinators to run clubs. Patients were encouraged to get out of their pyjamas and wear normal clothing to attend groups that ranged from art and craft clubs through to gardening. This also provided other opportunities for therapists to signpost patients to so that they could become more active and engaged while in intermediate care.

Post pandemic – where next?

Karen and her colleagues are now embarking on phase 2 and phase 3 projects of rebuilding better after Covid which includes community rehabilitation transformation. Karen has a project officer who has been invaluable in bringing together all of the elements Karen describes to make transformation a reality. Through her work to date Karen is engaging with people at the top of the decision-making process, such as the Director of Operations. Post pandemic Karen really feels that the NHS is on the precipice of change. Covid has expedited where the system needs to be by about 3 or more years. The past 18 months has highlighted the big issue of inequity of access. A big part of the transformation that needs to happen is about making services more accessible.

Through Karen’s journey so far, she shares some helpful top tips and approaches she will continue to use through the transformation process:

Karen’s top tips

• Get in place some strategic rehabilitation leadership – not medical - to start to socialise and be the ‘face’ of rehab for your system- that’s your quick win! This post will then be able to support you in developing a strategy/ road map for your rehabilitation delivery. Chunk it up into palatable pies – it’s difficult to articulate a whole strategy clearly, as much of the next step depends on what you have found in the step before
• Importance of socialising the fact that Rehabilitation is the solution to patient flow. Post Covid pressure on systems has meant services haven’t got the headspace to deal with transformation right now but they need to understand that rehabilitation is the answer to the problem
• Provide a forum or platform to enable energy and engagement with colleagues across all pathways of rehab. Hold meetings with all clinical and operational leads to start to build a picture of what a proper programme of care looks like. Recognising that not any one person has all the solutions but many will contribute fantastic ideas you may not have thought of or had the insight to draw conclusions about. Develop facilitation skills or bring in people to help with facilitation to listen to objective views and those views that you might not want to hear, to flush out the naysayers and understand their point of view.  It takes a whole system approach for meaningful change – you have to put in the time to take everyone with you on the vision
• Avoid Silos where possible (the efficiency is in developing lifelong pathways irrespective of the diagnosis)
• Use a ground up approach (with strategic leadership) drawing on QI methodology
• Do some proper housekeeping – data/ mapping, understanding what works etc – can’t be emphasised enough. Weave this information into all interactions with the person you are trying to influence. It’s all about speaking the language of the person you are trying to influence and the type of data that will interest them and motivate them to support your approach. Also citing examples that you have found effective for example - number of lost bed days
• Develop dashboards (or similar) so that you can survey across the rehab landscape- what pathways or areas are doing well – where are the challenges?
• 'Live in it - be a credible part of the team' - the importance of basing your workplace in the department or service you need to influence so that you are best placed to have those 'soft conversations' with staff who recognise you as a part of the team rather than someone coming in to 'do things to them'
• Get back to community rehabilitation by enabling teams to do community rehabilitation! Its important that teams embrace the concept of self-supported management with other aspects of the workforce so that  bands 6 & 7 can focus on complex disability management
• Be bold! Embrace the attitude of 'what's the worse that can happen' be brave and fight for the autonomy to try new approaches. Don’t shy away from defending your position and approach – you may be required to do this multiple times!
• Maintain the focus across pathways and across departments and teams of what you are trying to achieve rather than how you are achieving it.  A whole system approach is needed if you want sustainable change. Regardless of the different ways of working by different departments if everyone is focused on the objectives and have bought in to the mindset of reducing disability legacy, improving patient experience and improving quality of life then you have achieved the first significant hurdle in service transformation – winning hearts and minds!
• Never lose sight of the end goal and your USP – what can you do and what do you not need to do to achieve this? The NHS can be criticised for being too paternalistic in its approach and this is something that we need to change for the benefit of patients and our future workforce. So it’s important to always maintain the focus on the patient and what is the most effective way of delivering patient-centred care that empowers populations