The Model Line Project seeks to build the ‘perfect’ community team. A concept taken from industry, this project involves managers and clinicians being immersed in feedback from service users and carers, experts by experience, evidence-based practice and lean methodology. The aim of the model line programme is to provide a framework to underpin service delivery, ensuring a standardised approach to pathways that builds in mechanisms to allow clinicians to work with patients to meet their individual recovery goals.
What We Did
Tees, Esk and Wear Valley’s ambition is to become authentically recovery focused, involved embedding self-care and peer support as a cornerstone of our services. The key enabler in transforming our culture, from one of compassionate paternalism to genuine co-production, is the Model Line. The Model Line Project seeks to build the ‘perfect’ community team. A concept taken from industry, this project involves managers and clinicians being immersed in feedback from service users and carers, experts by experience, evidence-based practice and lean methodology.
The aim of the model line programme is to provide a framework to underpin service delivery, ensuring a standardised approach to pathways that builds in mechanisms to allow clinicians to work with patients to meet their individual recovery goals. The model line prototype of both corporate and clinical staff, considered both what a ‘perfect’ community team should do and how it should do it.
After deep listening to patients, families and experts, the team was able to define its areas of focus: co-production; service user defined goals; family interventions and involvement; evidence-based psychological treatments; and providing high quality physical health care and health promotion services such as smoking cessation, weight and alcohol reduction.
A model line looks at the entire pathway, from onset of symptoms to meaningful recovery, through the patient’s perspective and ensures that each step adds value to the patient experience and outcome. The overarching aim is for every patient to receive a high quality service every time. The key elements in achieving this are: clear evidence based standards; clear and standardised ways of delivering evidence based practice; effective team processes to enable delivery of evidence based services.
This allows teams to ensure that the service is: Effective i.e. we are doing the right things; Efficient i.e. we are doing things right and not doing things that do not add value; Improving i.e. we are doing things better. The model line incorporates methods of visual control that support patient care.
The new way of working has ensured staff can maximise the time they have available to work with patients, their families and carers. Teams of six to seven staff meet daily for a 15 minute stand up ‘huddle’ attended by clinical leaders. Staff report on every patient they have seen in the last 24 hours, confirming the patient and their family’s goals and, importantly, the next steps planned. Staff can ask for help if there is a blockage in the process or if they feel progress to recovery has slowed.
The introduction of ‘œcell’ working and daily huddles has brought about a number of improvements: staff are supported in their decision making: staff have increased access to the leadership team; ad hoc and duplicated conversations have reduced, making communication both safer and more efficient; coordination has improved, helping ensure that all service users have a clear plan of action towards recovery; evidence-based practice has increased • multi-disciplinary working has improved.
Wider Active Support
A number of our community mental health teams are integrated teams ie teams comprising of both nurses and social workers, some of which are employed direct by the local authority. Working in partnership with the relevant local authorities has ensured that the benefits to patients and their carers was achieved.
Service users and their carers were involved from the outset the project. Using a range of methods eg focus groups, questionnaires and experts by experience we were able to shape the new way of working around the feedback we received. Then throughout the roll out to all EI and psychosis teams across the organisation, we utilised the experts by experience to tell their stories and co-facilitate DROP
(Developing Recovery Orientated Practice) sessions with each of the 13 teams. The evaluations of the sessions that were led by the experts by experience, evaluated extremely well with the staff in the community teams as the stories were very powerful.
Looking Back/ Challenges Faced
As this is a large scale change project, we underestimated the gravity of the changes required, therefore the pace of change was probably too quick. We slowed down as the project progressed. So even though the quantity of teams slowed, we feel the quality increased. This is borne out by the sustainability survey we did.
We would have liked to get the steering groups members out on the ‘shop floor’ to see the process in action a little more. I felt they were a little detached from all the good work that was going on and with a deeper knowledge we could have unblocked some of the issues sooner than we did.
The importance of engaging with staff hearts and minds at the earliest opportunity cannot be overstated and we learned this early on. Having key senior staff (e.g. psychiatrist, psychologist and manager) in the prototype team is essential. Not to underestimate the profound impact this work has on the pilot teams during implementation, in terms of time and resources, again we went too fast. Developing a realistic and achievable roll out plan is important. No two teams are the same, so approach each team with a fresh pair of eyes. Challenge from middle managers to release cost savings and demonstrate more tangible outcomes.
However, we are fully supported by the Chief Executive and he has publicly stated that he doesn’t expect to see any major outcomes until much further down the line. Measuring success has been a challenge. The measures that were agreed at the start of the project were quite difficult to gather and possibly not representative of the improvements that were made. Equally, getting the steering group to agree the measures was a challenge as they all had different views. Also, by the very nature of this patient group, improvements in their outcomes would take a while to become evident.
We used the NHS sustainability tool to measure the position of the 3 pilot teams, 6 months after implementation. The aggregate score across all three domains of Staff, Process and Organisation was 71.6 and, according to the supporting information for the tool which states that, a score of 55 or more offers reasonable optimism. We are currently in the process of re-measuring all the teams to see if this has been maintained as, anecdotally, feedback from the teams suggests it has.
A mid project evaluation was completed in July 2015 which showed real improvements in team processes eg: The % of completed recovery stars has almost doubled; Just under 90% of patients are receiving a physical wellbeing appointment within 8 weeks; The offer of family therapy dramatically improved from a baseline of 0% to 75%; Patients with a staying well plan also significantly increased from a baseline of 0% to 59%; Twice as many patients are seeing a medic within 5 days of referral compared to pre-model line
The ability to get real time feedback from patients, with a reasonable return rate, has been a challenge. One of the teams tested a feedback mechanism which comprises of a simple token system and a box situated in the reception area of the team base. Patients are asked to respond to the question “Was your experience of our service today good”? The options for the response is either ‘yes’ or ‘no’ and the patient or carer drop the token in the relevant section of the box. This commenced in January 2015 and the results are as follows:
- Month Total responses Yes No • January 2015 13 13 (100%) 0 (0%) • February 2015 46 45 (98%) 1 (2%) • March 2015 38 36 (95%) 2 (5%) • April 2015 42 42 (100%) 0 (0%)
Equally, we have had some excellent feedback from staff who have said they feel much less stressed in their day to day work due to the changes in configuration of the teams as well as daily, scheduled access to their leadership team.
This project focused exclusively on the early intervention and community psychosis teams. However, so much of the learning and benefits of the new way of working was generic enough to share with all other community mental health teams. A case study on this project has also just been published on the NHS Providers online resources.