Andy Phillips
Director of Therapies and
Health Science
1
LEADERSHIP. LEARNING.TECHNOLOGY
Experience of Prudence,
Preventing Imprudence
and Rejection of
Impudence
Today, we would like you to share your creativity and
inspiration
Noun
impudence -an expression of lack of respect
-marked by contemptuous or cocky boldness or
disregard of others
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Asserting that all current practice is ‘bad’ or
‘wrong’
Instructing healthcare professionals how to
practise
Assuming that there is a single ‘solution’ that
will work in all contexts
Disregarding the views of any stakeholder
Assuming that, as a healthcare professional,
your job is to ‘know’ what people need and what
services you should deliver to them
Dictating ‘solutions’
Noun
imprudence - the quality or condition of being unwise
To act, plan, or conclude without adequate consideration
of significant factors or circumstances; to fail to take into
account the role of others, particularly those whose
position would make their input determinative
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‘Rationing’ based on arbitrary, set criteria
Failing to invest in improved outcomes valued
by patients
Having reduction of cost as the basic
organising principle of services
As a patient, assuming that services are
automatically designed around outcomes that
you would value
Noun
Prudence-careful good judgment
- the ability to govern and discipline oneself by the use of
reason
- sagacity or shrewdness in the management of affairs
- skill and good judgment in the use of resources
- caution or circumspection as to danger or risk
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Perception that many grommets,
tonsillectomy operations are carried out
across Wales not in accordance with NICE
criteria
Geographical variation in operation rates
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30 per cent year on year reduction in these
operations in ABMU
Limited scope for release of resources from
further reduction
But… you may well wish to provide
commentary in the ‘white paper’ eg on use of
option grids, day case tonsillectomy, risks in
reducing rates
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Strong potential to apply prudent principles
Large potential gains in outcomes that patients
value and in clinical outcomes
Large patient volumes, so large potential gains
in freeing up ENT capacity for inpatient and
outpatient work
Experience from elsewhere
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Equity based care, treating greatest need first
Do no harm
Do the minimum appropriate to achieve the
desired outcomes
Choose the most Prudent Care, openly together
with the patient
Consistently apply evidence based medicine in
practice
Co Create health with the public, patients &
partners
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Commissioners noted that a high volume of
patients referred into ENT with hearing loss,
balance disorder or tinnitus had no treatment
from ENT
Many patients gave feedback that after being
seen in ENT they did not have a result that
they valued ie better hearing, less dizziness
or reduced annoyance from tinnitus
High proportion of patients referred from ENT
to Audiology for treatment
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Agreed criteria with GP’s for e-referral of all adult
and child patients with hearing loss, balance
disorder and tinnitus direct to Audiology
Only conditions requiring medical or surgical
treatment were excluded
All referrals considered by Consultant or Principal
Clinical Scientist-small number (<2 %) to ENT
Agreed referral by Audiology for imaging
Agreed support from neuro-radiology
Agreed onward referral pathways
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Routine audit and discussion with ENT
All patients needing medical or surgical input
were seen in ENT
No adverse incidents reported from missed
pathology
Patients always seen in ENT if that was their
preference
Attention paid to minimising patient distress
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Significantly reduced cost of service by reducing
ENT outpatient clinics, surgical intervention,
diagnostic tests
Improved delivery of outcomes valued by the
patient, better hearing, less dizzy, reduced tinnitus
distress
Changed skill mix in Audiology, using more
Assistants and more Advanced Practitioners
Patients maintained Independent living
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Developed the Cocreating Health Framework
Small number of patients chose to have
medical or surgical intervention
Significant number of patients chose not to
have any intervention
Patients reviewed and reassessed at their
request
Prudent Service was financially very
successful for both the NHS Foundation Trust
and the Commissioner
Review and Further
Actions
Evaluation
. of
Outcomes
Co-creating Health – clinical
interactions
Patients and professionals
review
clinical and experience
outcomes
Implementation
Facilitation of agreed
action(s) and choice(s)
Patients and clinicians are clear
about the next steps and agree plan
Agreement of way
Forward
Professionals and patients work
closely to share decision making
Shared understanding
of options
Based on condition and
Preferences, use of decision support tools
Further information
May be needed to fully
Describe the patients
condition and preferences
Agenda Setting
Conversation between
Professional and patient
Patients need to be prepared to
Participate in setting agenda
Preparation
Patients need to have a level
of health literacy and be aware
of their own condition. Patient
and Clinician both understand
known information
Develop sustainable patient and clinician peer-support networks
Share the evidence and celebrate success
The co-creating health framework aims to
facilitate patient self management. It includes agenda
setting, use of decision support tools, clinical outcome
measurement, audit processes and continuous service
improvement
OPTION GRID-AGE RELATED HEARING LOSS
Understand
Condition
Speech in
Quiet
Speech in
Noise
Localise
Sound
Hear Both
Sides
Hear TV,
Doorbell,
alarms
Counselling
and Advice
Hearing Aid
in One Ear
Hearing Aid
in Both Ears
Assistive
Devices
√
-
-
-
X
X
√
√
X
X
√
X
X
X
√
X
X
X
√
X
X
√
√
√
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Counselling provided to each patient
Routine offer and acceptance of hearing aids for
each ear
Use of best technology including receiver in the
canal and in the ear hearing aids where appropriate
Offered range of ‘assistive listening aids’ including
TV, telephone, doorbell etc
Use of effective counselling strategies in tinnitus
Large number of patients seen for balance
rehabilitation and involvement in falls reduction
Mild and unilateral hearing losses treated
Offer of speech processing training if appropriate
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Capacity freed up in ENT for outpatient and
surgical work
Very low waiting times for both Audiology
and ENT including same day appointments if
required
Prioritisation based on urgency of clinical
condition
Service taken out into the community, with a
large number of satellite clinics and a mobile
unit to ensure good access for disadvantaged
communities
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Deliver outcomes valued by patients
Stop doing things where there’s evidence
they don’t work
Invest where this would provide better
outcomes
Improve quality and clinical outcomes
Investigate areas where evidence is not clear
Singleton Total ENT Included
referrals Number
rec’d
of Adult
Hearing
loss
referrals
Included Included
Number Number
of
of
Tinnitus Dizziness
referrals referrals
% of all 3
referral types
against total
referrals rec’d
January
445
90
26
15
29%
February
501
73
42
14
25%
March
456
72
32
12
25%
Total
1402
235
100
41
26%
16%
7%
3%
Average
%
referrals
types
rec’d per
NPT
Total ENT Included
referrals Number
rec’d
of Adult
Hearing
loss
referrals
Included Included
Number Number
of
of
Tinnitus Dizziness
referrals referrals
% of all 3
referral types
against total
referrals rec’d
January
212
46
11
13
33%
February
248
42
20
9
28%
March
204
32
5
6
28%
Total
664
120
36
28
26%
18%
5%
4%
Average
%
referrals
types
rec’d per
POW
Total ENT Included
referrals Number
rec’d
of Adult
Hearing
loss
referrals
Included Included
Number Number
of
of
Tinnitus Dizziness
referrals referrals
% of all 3
referral types
against total
referrals rec’d
January
402
91
26
20
33%
February
380
48
16
21
22%
March
390
42
20
16
22%
Total
1172
181
62
57
26%
15%
5%
5%
Average
%
referrals
types
rec’d per
ABMU
totals
Total ENT Included
referrals Number
rec’d
of Adult
Hearing
loss
referrals
Included Included
Number Number
of
of
Tinnitus Dizziness
referrals referrals
% of all 3
referral types
against total
referrals rec’d
January
1059
227
63
48
31%
February
1129
163
78
44
25%
March
1050
146
47
34
22%
Total
3238
536
188
126
26%
16%
6%
4%
Average
%
referrals
types
rec’d per
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Buy in to Prudent Principles
What is the idea that you would like to
develop in this workshop ?
Benefits
Dis-Benefits
Need to describe this idea in a way that would
make sense to patients
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Training Requirements
- Advanced Practice
- Assistant Practitioners
- Cocreating Health
Medico legal aspects
- Attitude to Risk
- Cover for Individuals
Workforce Capacity Requirements
Enabling Infrastructure