Making Every Contact Count for Physical Activity in Musculoskeletal Outpatient Physiotherapy: A service improvement project to implement NICE public health guidance PH44

Project aim:

To establish a suitable targeted approach to identifying inactive people accessing MSK outpatient physiotherapy services at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust to facilitate brief interventions for physical activity in line with NICE guidance (PH44) and MECC guidance.

Our initial phase involved the review of local and national strategies relating to promotion of physical activity and reviewing results from previous audits and service improvement. A process of defining and scoping followed in which clear objectives and project plan were set. Driver diagrams were established to map potential areas for change and measures of success. Process measures were selected to evaluate staff confidence in the delivery of brief interventions, frequency of delivery, and frequency and consistency of documentation of brief interventions for physical activity.

These process measures reflected local need and recommendations from wider literature in order to support physiotherapists to comply with the following statements within NICE public health guidance PH44 recommendations 1 and 2;

• Identify adults who are not currently meeting UK physical activity guidelines.
• Do not rely on visual cues. Use validated tools to assess physical activity levels.
• For people who are not meeting UK guidelines, identify the most appropriate time to discuss physical activity.
• Ensure the person leaves the consultation with awareness of the health benefits of physical activity.
• Advise adults who have been assessed as being inactive to do more physical activity, with the aim of achieving the UK physical activity guidelines. Emphasise the benefits of physical activity.
• Provide information about local opportunities to be physical active.
• Record the outcomes of the physical activity assessment and any discussion.

Public health and disease prevention is a high priority for Doncaster and Bassetlaw Teaching Hospitals (DBTH) Foundation Trust due to the high levels of physical inactivity (48%) and proportions of overweight and obesity (73%) among adults residing in Doncaster raised by recent public health profiles (PHE, 2016).

There is also evidence to suggest that large proportions of adults accessing MSK outpatient physiotherapy are physically inactive and/or classified as overweight or obese (McPhail et al, 2014). It is recognised that healthcare providers have the opportunity to impact patients’ health every time they interact with a person visiting their service (PHE, HEE, 2016). DBTH had recently collaborated with Chartered Society of Physiotherapy Charitable Trust and National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber to deliver a co-production service improvement to support physiotherapists to implement evidence based guidelines relating to management of overweight and obesity and demonstrate commitment to ‘make every contact count’.

During this project it was recognised that physical activity, although frequently discussed in the context of routine physiotherapy assessments, was documented in only 25% cases. A finding that is reflected in the most current literature (Lowe et al, 2017). NICE provide evidence based guidance to support health professionals assess and manage overweight and obesity (CG189) and offer brief advice for physical activity (PH44) but it is acknowledged that there are many challenges to implementing guidance into practice. Staff, management and patient representatives had undergone a 6 month process of engagement to support previous co-production service improvement project in 2017.

The first phase of this project involved ongoing engagement with staff and managers through discussion and debate at team meetings and liaison with local research and development and service leads. Application of “plan, do, study, act” approach (Taylor et al, 2013) encouraged staff to engage in ongoing evaluation of change and measurement of success throughout the trial implementation period.

This project applied a service improvement framework approach inspired by strategies set out in NHS Innovation and Improvement Handbook of Quality and Service Improvements Tools (NHS Innovation and Improvement, 2010) with training, mentorship and support from the community of practice Allied Health Professions for Public Health (AHPs4PH).

Following engagement with stakeholders, drivers for change were established and process measures selected. Trust audit department were consulted to consider data collection options available. SurveyMonkey (Trust’s web based data collection tool) was selected as the most effective and resource efficient method to collect process data. The audit department developed the on-line survey and a link was shared with managers and team leads from MSK physiotherapy across all four hospital sites. They then disseminated to individual teams via staff email. This process presented challenges in terms of reliance on managers to distribute link to staff, staff accessing emails in a timely manner and choosing to participate in the survey but was considered the most time and resource efficient option.

Following initial survey completion, three phases of small scale change were implemented using Plan, Do, Study, Act (PDSA) cycles. In late July 2017, two validated physical activity screening tools were piloted by one physiotherapist in one clinic. The selected tools were the GPPAQ (DoH, 2013) and the Milton et al (2010) single item physical activity screening tool. Feedback from this pilot identified Milton’s single item question as a more appropriate tool for an outpatient setting for both ease of completion by patients and speed and ease of analysis by the clinician.

The second phase in August 2017 involved pilot with one small department (four clinicians) for one clinic. This pilot suggested the single item question would benefit from presentation alongside an ‘actions’ and ‘review’ section to aid documentation. The third PDSA cycle piloted the screening tool with all qualified MSK physiotherapy staff across all four hospital sites (50 staff in total) for a period of one week (5 days).

After the third PDSA cycle, this same survey was distributed once more and staff were encouraged to reflect on their experience over the implementation week so a comparison could be made. Both sets of data was exported into an excel spreadsheet and data from SurveyMonkey was analysed.

Process data collected to support PH44 suggested that a targeted approach to identifying inactive people accessing MSK physio supports physiotherapy staff to feel more confident to identify patients at risk due to inactivity (25% increase in staff feeling confident or very confident) and to document outcomes of these conversations more often (31% increase in staff documenting often or very often).

Following implementation of Milton et al’s (2010) single item physical activity screening tool, 100% of staff completing the surveys felt confident or very confident to identify adults not currently achieving physical activity guidelines. 85% staff completing the second survey felt confident to deliver brief interventions relating to physical activity and 69% delivered brief interventions often.

A smaller proportion (61%) of staff felt confident to signpost patients to local opportunities for physical activity. 47%of staff reported that they documented their patient’s physical activity level often or very often and 62% of staff documented outcomes of brief intervention often or very often.

This project recognised that physical activity screening could also be implemented as a component of wider musculoskeletal health outcome measurement offering further opportunity to measure and collate impact data. Further pilot tests are underway to evaluate implementation of the full Musculoskeletal Health Questionnaire (MSK-HQ) in DBTH’s MSK outpatient physiotherapy.

Further efforts are required to facilitate fast, simple and accurate signposting to local services, written information on health benefits to patients and support documentation. Developments are underway to implement a co-produced public health pathway ‘Way Forward Doncaster’ in which a specifically designed proforma will allow fast and simple documentation of physical activity level (taken from MSK-HQ) and actions from brief interventions.

Local sign-posting will be facilitated through interactive screen linking to local services and national guidance and branded patient information leaflets can be provided to patients to signpost to other local information points.

This project served to demonstrate that, when provided with the correct tools, allied health professionals can develop the skills and confidence to incorporate public health messages into routine practice. Training and mentorship delivered by the AHPs4PH team offered the opportunity to apply new skills in NHS service improvement.

Advice from allied health professionals experienced in designing and deliver public health interventions, online training delivered by NHS Improvement and peer support from other public health advocates were invaluable during this process but delivering the project required dedicated time away from direct clinical work which can prove challenging in many departments. The initial scoping phase of the project to review literature and consider local and national policies was essential to gain support from managers and service leads.

This particular project was delivered at a time when public health agendas were already at the forefront of many physiotherapists’ minds due to engagement with a previous public health project and awareness raised by our professional body. However, face-to-face contact from a motivated and enthusiastic lead was essential to ensure the smooth running of the project and gain valuable feedback throughout PDSA cycles.

Due to time constraints and project coinciding with peak holiday periods, One limitation of this project was that staff did not perhaps receive sufficient contact and opportunities to engage to ensure high participation rates plan for longer-term implementation. Earlier planning may also have allowed base-line time-series data collection to demonstrate impact after implementation. We are now considering options for how the learning from this project can be fully integrated into routine clinical practice and planning appropriate methods of data collection to ensure we can demonstrate the impact.