Theory into practice: Development of Near Me

Identify

NHS Highland provides healthcare across a remote and rural area of Scotland. Many outpatient clinics are delivered in the main urban centre (Inverness) resulting in travel times for patients of up to 3 hours each way, often for brief appointments. The need for a different option for outpatient appointment was driven by public demand. Video consulting technology was available at the time but was rarely used as there were no processes to enable its effective use.

Understand

Extensive engagement was undertaken with patients, the public, action groups, and a wide range of staff (eg, clinicians, patient booking service, outpatient clinic staff, eHealth, estates, medical records, administrative staff, management). System mapping of outpatient services was completed to understand the processes and systems that a new video consulting service needed to interface with.

Develop and design

Development of the service was based on a co-design approach. This involved discussion and demonstrations with three key groups: service users (patients, carers, public), service providers (clinicians and clinic staff) and service enablers (staff from various supporting functions such as clinic booking and eHealth).

Prototype and test

An initial service model with an agreed standard process was created. This was moved into a second co-design phase involving real-time testing with the same three groups (service users, providers and enablers). Continuous improvement was undertaken using PDSA (Plan, Do, Study, Act) cycles with over 100 changes made: this was done at pace to ensure people could see the impact of their involvement in the design process.

Review for implementation

The feasibility, acceptability and advantages/disadvantage of the service were evaluated throughout the testing phase. Results from each PDSA cycle were recorded. Qualitative and quantitative data were captured and reviewed on a regular basis by a Near Me governance group established for the project.

Define and implement

A standard process manual for the Near Me service was co-developed so that it could be used by all clinical services across NHS Highland. This was overseen by the Near Me governance group which comprised senior operational directors, eHealth leads, clinical service heads and the head of the patient booking service. Having a standard process made running outpatient clinics straightforward and a key element was automating coding to avoid additional work for clinic staff.

Embed and sustain

Widespread awareness raising for staff and the public was undertaken with leadership from the Chief Executive. Training was delivered for clinical services and demonstrations were provided for the public. Specifically designed clinic rooms for Near Me consultations were constructed in 16 locations across NHS Highland. Quantitative and qualitative data continued to be monitored by the governance group to ensure continual focus on sustaining the service and to identify any potential improvements needed to the standard process.

Review for spread

Following successful use of Near Me in the 16 clinic locations, it was agreed to spread Near Me to patients in their own homes. This involved a second change cycle, beginning at the “understand” step and taking the same co-design approach. This was simpler because many of the technical processes such as clinic coding had been resolved in the initial change cycle but the involvement of patients, families and the public in designing the additional detail on home-access was key.  A further spread phase across NHS Scotland was undertaken in 2020, stimulated by the Covid-19 pandemic.

Clear vision and purpose

Patient demand for better access to outpatient services across remote and rural NHS Highland provided a clear purpose at the start of this project.

As the “understand” phase progressed, a slightly broader vision was defined with additional information gathered about the challenges to travelling to outpatient clinics. In addition to the expected challenge of rurality and distance, other challenges identified were lack of public transport, illness/pain during travel, time away from work, caring responsibilities, and neurodiversity/mental health barriers to attending in person.

The vision was therefore to develop and embed video consulting within outpatient services. It had to be easy to use and provide benefits for both patients and staff.

Leadership and culture

Senior leadership was provided by sponsorship of the work by the Chief Executive. This included awareness raising, making connections for the project lead to senior staff, and unblocking barriers. After signing off the vision for Near Me, the Chief Executive created the space and gave the permission for the project lead to experiment and test.

The project lead had significant experience in implementing change and was trained in multiple change methods (Scottish Quality & Safety Fellowship, Intermountain Advanced Training Programme in Healthcare Improvement, and Lean Leadership).

The project succeeded because of the extensive engagement and whole-system co-design approach undertaken. This created a culture of genuine collaboration, shared ownership and wide buy-in. Every concern raised was taken seriously and changes were made in response. Rapid cycles of improvement ensured people could see how their concerns had been responded to, and this further built a culture of collaboration.

People-led

Near Me was created by people. It was shaped through the engagement and co-design with people: patients, families, carers, public, local politicians, action groups and a wide range of staff. The project team listened to, acted on and amplified their voices.  Near Me could not have been developed by the project team in isolation, being people led was fundamental.

Over 30 meetings were held within the “understand” phase alone. Even the service name “Near Me” was created by the public at a meeting in Caithness in January 2018: they wanted it to be called something that represented the service belonging to them, rather than them being seen as “remote” from the urban centre where outpatient clinics were located.

Process rigour

The service development was underpinned by clear programme management which ensured a clear aim and timely progress. Each step of change was rigorous in the application of evidence-based methods in particular drawing on quality improvement, engagement and service design. Quantitative and qualitative data were reliably collated throughout the project, reported and acted on. A governance group was established to provide oversight of the project and to approve the output.

Process rigour was also applied in the creation of the standardised Near Me process manual which was a key output of the project. Video consulting technology had been available prior to this project but it was rarely used because there were no processes to enable its use. Therefore, rigour around developing a standardised process that covered every element of outpatient clinics was essential (e.g. booking appointments, coding appointment types, clinic building, equipment for clinicians, patient information, virtual receptionist, technical support).