WHO Bulletin: Improving the quality of health care across the health system (4) Large scale change (2)

5 December, 2018

Hi Neil

You asked for examples of applying the messages from the NHS Leading Large Scale change. Here are three examples that I've been involved with:

Example 1. From London (population 8 million): Helping Smokers Quit in London http://www.londonsenate.nhs.uk/helping-smokers-quit/ We reframed smoking as tobacco dependence, and therefore, in contrast to many NCDs actively chose to medicalise it - ie, there are effective and cost effective treatments so it’s a clinical re (not just doctor) responsibility to diagnose and treat; reframed smoking cessation workers as “specialists”; worked across networks eg maternity, surgery, mental health, respiratory, public health etc. Did nice graphics and clear messages for all to make it easy to do the right thing from putting tobacco dependence as cause of death (only South Africa mandates this we believe) to expecting everyone to be trained in Very Brief Advice and to use it every time. Summarised by CO4 that we asked all London’s health organisations to commit to:

The ‘right’ COnversation for every patient and staff member who smokes that gives him or her a chance to quit, referring if necessary/possible.

Make routine near-patient (i.e. desk-top, bed-side and home) exhaled carbon monoxide (CO) monitoring by clinicians possible: as a motivational tool: “Would you like to know your level?”

COde smoking status and the intervention so we can evaluate effectiveness - including death certification.COmmission the system to do this right: so the right behaviours are incentivised systematically.

The treating tobacco dependence framing has definitely taken hold. There are more and more respiratory leaders/champions. The maternity community is using exhaled CO monitoring to support its efforts to protect women and their unborn child. Coding remains mixed. Commissioners are not investing sufficiently, so the work continues.

Example 2

Another London example, of bridging networks: the idea that to achieve large-scale change you need to connect different networks. We ran a 6 year programme engaging physio, nurse, GP, respiratory physician networks, as well as framing interventions with a value framework. For example, we designed a very widely shown "COPD value pyramid" - a visual that tried to show the relative value of non-pharmacological and pharmacological interventions and e-health in COPD. It is widely shown as it was what people wanted to hear. There's a more sophisticated and better analysis that didn't get the same traction. See LRN final report 2017-05-05.pdf

Example 3

Internationally, we are using a social movement and network approach to create a discussion about a problem that we've known about for decades but which previous interventions haven't shifted. That is, the over-reliance on short-acting beta agonists/reliever medication for asthma, rather than guideline based anti-inflammatory medication (inhaled corticosteroids). We're at the first phase of this, having tested in four countries. The programme is based on a value principle again, "right care" (see Lancet 2017 series). It's called Asthma Right Care. We've developed tools to get the conversation started about asthma, to raise the discomfort with the present state, so that people (practitioners, patients) want to know what could be better. Pharmacists are really engaging, so are patients. We co-created the materials with them. It's not a top down approach. It's involving new people - because it's all about the followers, not the leaders. See www.ipcrg.org/asthmarightcare for more information. Let me know if you'd like to get involved. Or on Twitter search for asthmarightcare for who's getting involved. www.ipcrg.org/asthmarightcare Following the large-scale change model, we are now going to more geographies, more parts of the healthcare system, and going deeper - to achieve a paradigm shift. This involves developing an implementation pack to enable others to follow, and, using case vignettes, starting to move those who are now interested and talking about the problem of over-reliance on symptom relief to a discussion about better options.

Hope that helps illustrate.


HIFA profile: Sian Williams is Executive Officer at the International Primary Care Respiratory Group in the UK. Professional interests: Implementation science, NCDs, primary care, respiratory health, education, evaluation, value, breaking down silos. sian.health AT gmail.com