North Tees and Hartlepool NHS Foundation Trust serves a population of approximately 330,000 people across Stockton, Hartlepool and parts of east Durham. Locally the population has some of the highest levels of deprivation in the country, compounding poor health. This is demonstrated through significantly shorter life expectancies than the national average and, importantly some of the lowest healthy life expectancies in the country.
Physical activity is an important factor in the development and management of long term health conditions and to support good health and wellbeing. Local data shows a great opportunity to make improvements through this project. Levels of physical activity are low amongst our population: they are significantly below the national average and often below the North-East average.
Chosen Pathway
One of the four pathways North Tees and Hartlepool chose to implement as part of the Active Hospitals pilot was Musculoskeletal (MSK) Outpatients. Integrated MSK (iMSK) service includes MSK (Extended scope practitioners in Physiotherapy and MSK Podiatry) Physiotherapy outpatients, hand therapy, Hand and Wrist MSK, Podiatric surgery and Community Pain Management. However Podiatric surgery and Community pain management were not a part of the pathway.
The aim was to increase the number of health promotion conversations specifically about physical activity and the use of signposting to encourage long term behaviour change in relation to improving the physical activity levels of our local population. The data collected was used to work collaboratively with local authority partners in identifying areas of low physical activity that could support a more targeted approach.
Pathway
Pre-appointment questionnaire to patient from MSK service (electronic or paper)
Appointment with iMSK team
Follow-up appointment if appropriate
Direct
Physical Activity Questionnaire
Active Conversation
Provide:
Referral to MisM
Referral to LA programmes
Leaflets
Signposting – Live Well website or MECC Gateway website
Indirect
Active Hospital Physical Activity Dashboard
Staff training – PACC and MECC – regional training
Governance Framework
Environmental changes
Communications/Promotion
Prevention Group Terms of Reference
Intervention Overview
A Physical Activity Questionnaire was embedded within assessments for all patients presenting to the iMSK team, including FCP (First contact practitioner) appointments within primary care. Patients also receive this questionnaire electronically (or a paper version if required) to complete prior to their appointment. This links back to the patients record, saving the clinician time and allowing them to use this information to have a health promotion conversation, provide advice, signposting or onwards referrals to support an increase in physical activity where appropriate. Data from this pathway is collected into an Active Hospital Dashboard and used to provide feedback to the teams as well as support evaluation. The dashboard also includes data on Physical Activity levels broken down into postcode area which has been shared with Local Authority partners. This provides opportunities to design local initiatives for at risk populations. There was no need for data sharing agreements as the data shared included only first half postcode (eg TS19) and the percentages of people within those areas meeting/not meeting the guidelines as well as percentages of those inactive i.e. less than 30 minutes PA. No patient identifiable information was used.
A ‘Movement is Medicine’ patient education session was created in collaboration with Local Authority partners and patient reps, to provide patients who felt they wanted more support, with knowledge and confidence about Physical Activity, as well as information on local opportunities for Physical Activity. This initially sat within the MSK pathway but has since opened up to other services including social prescribing to allow self-referral into the session.
Click on the boxes below to find out more information about the interventions used in this pathway
Pre-appointment Physical Activity questionnaire
A physical activity questionnaire was sent to the patient before the appointment to calculate PA undertaken by the patient during the week and to guide the conversation with the physiotherapist at the appointment. It is based on the Vital Signs questionnaire/or the PA calculator which can be found on the Moving Medicine website.
The team are aware it is un-validated and therefore has limitations however the team felt that framing it this way helped during assessments to more quickly identify those meeting/ not meeting guidelines and the most inactive patients without having to do any additional calculations. It also fit better with the questionnaire functionality on the system used for patient records. Not all questionnaires were completed prior to appointment and in these cases the clinician was then expected to complete with the patient. ‘Time’ within appointments was the biggest barrier to engagement with our staff so the idea was to make the questionnaire as easy as possible for them to encourage more to complete it. Questions 2 and 3 were felt to be very important, if not more important than the patients actual activity levels. Taking a behavioural change and MECC approach these questions allows the clinician to identify the patients readiness for change and provide an opportunity to support them with any barriers identified as the reasons for so
A conversation between the physiotherapist and patient took place to establish current levels of physical activity and guide what advice, signposting or referrals were appropriate for that patient. This was based on the 5 minute conversation Moving Medicine format.
Referrals and signposting
Signposting
Referral to Movement is Medicine sessions
‘Movement is Medicine’ patient education session was created in collaboration with Local Authority partners and patient reps, to provide patients who felt they wanted more support, with knowledge and confidence about Physical Activity, as well as information on local opportunities for Physical Activity.
Sessions are run once per month in each borough (Stockton and Hartlepool). Face to face for 1 hour delivered collaboratively by a staff member (physiotherapist), local authority representative (who presented about all the local opportunities to be active) and a patient representative who volunteered her time to share her physical activity journey with many long term conditions. They were delivered out of local council run leisure centres which added the opportunity of introducing people to these venues.
Signposting to Live Well
Patients may be signposted to Live Well on the North Tees and Hartlepool NHS website. Here they can find a wealth of information and links to external organisations which can provide advice and guidance to help them Live Well.
Referral to Local Authority sessions
The Local Authority provides sessions for those with a variety of health conditions including MSK and patients may be referred to these sessions if appropriate.
Stockton is Active Health
Hartlepool is a more general referral to Hartlepool community hubs where they will undertake an assessment and offer support for many aspects of health and well being (not just PA) and they can support people to access these.
The Active Hospital project strengthened these specifically to Physical activity. They were a part of our main steering group right from the start and came to monthly active hospital meetings. Sharing of patient details for the purpose of the LA schemes was via a referral process with the patients consent.
Patients may be given the Keep Moving leaflet from Versus Arthritis which contain information on the benefits of movement, hints and tips, goal settings and links to additional information.
Active Hospitals Dashboard
Physical activity data was recorded on a Dashboard created for Active Hospitals. In addition to providing a record of conversations and interventions it also introduced an element of competition between clinicians from different departments.
The trust use SystmOne for their patient records and through the questionnaire functionality it enables them to pull reports out. This included the number of times the questionnaire was completed within each SystmOne unit as well as the breakdown of the answers selected within the questionnaire and the plan/actions following the conversation. This was being pulled out manually initially (with support from our BI team) and fed into the dashboard on YellowFin however we were working on securing a live data feed.
The data collected provided a really useful source of feedback to the teams. Just knowing that over 50% of our patients wanted to be more active (from Question number 2) was very powerful and was a reminder that highlighted the need for us to make every contact count considering the patients general health and wellbeing and not just the ‘sore knee’ that they are presenting with.
The questionnaires were also able to be linked back to individual clinicians so we had data on how each clinician was performing in relation to completion of questionnaires. This data was displayed on the dashboard anonymously (each clinician had a code so they could identify themselves within the data) and so it provided a source of personal performance feedback too that could be discussed at 1:1’s etc.
Physical Activity Clinical Champions training was given to all staff within this pathway. This is peer to peer face to face or online interactive training delivered by a healthcare professional. It is designed to increase knowledge, skills and confidence in healthcare professionals around the benefits of physical activity to improve the quantity and quality of conversations with patients.
Making Every Contact Count (MECC) training
MECC training is given to all staff in the Trust. It is an approach to behaviour change which utilises the day to day interactions that organisations and people have with other people to encourage changes in behaviour that will have a positive effect on the health and wellbeing of individuals, communities and populations.
Relationships with providers/LA/social prescribers
Relationships have been built with a number of organisations, including leisure providers, such as Tees Active, the local authority, social prescribers and the voluntary and community sector. These improve the ability of healthcare professionals to refer and signpost patients to suitable activities which will support them during and after their treatment at the Trust.
Each organisation has its own PA agenda, the key was working out how they all link together and can support each other.
Governance – feeds into Prevention Board/Steering Group
The Active hospital project group met monthly and progress was reported to the Trust Prevention group alongside other preventative programmes of work that aim to achieve one of the Trusts strategic priorities – ‘improving population health and wellbeing’, and are in line with the North East and Northu Cumbria ICS population health priorities (TOR attached)
Outcomes
In this section you will find some of the outcomes from the pathway.
Data Collected
The data collected from these appointments included:
– The number of specific physical activity conversations which took place
– The physical activity levels of the patients
– The desire of the patients to be more active
– The number of interventions offered
The data was recorded on a Dashboard created for Active Hospitals and in addition to providing a record of conversations and interventions it also introduced an element of competition between clinicians and departments.
Outcomes and Evaluation *
Healthcare Professionals
– Number trained to deliver Active Hospital interventions – 62
-An increase in awareness about the UK CMO’s guidelines and confidence to discuss physical activity
– Staff awareness of community opportunities for PA has improved
Patients
-Spoken to about physical activity – over 7000
-Physical activity levels assessed and recorded – over 7000
-Physical activity levels reviewed at follow-up appointments – over 1200
-Reporting a desire to be more physically active – almost 4000
-Signposted to resources or support services – 2800
-Referred to additional support services – over 600
76 people attended a movement is medicine group. Patient feedback was positive and mostly focused around the increased knowledge about what was available locally to support them to be more active that they weren’t aware of previously. We also had a case where 3 ladies from one group continued to meet up for walks together afterwards. We attempted to gather long term data on activity levels post group but were unsuccessful.
328 patients were referred to a local authority ran physical activity programme. Unfortunately we do not have the data on how many followed this through
*Evaluation undertaken between April 2021 and July 2022
Formal evaluation of the MHPP Active Hospitals workstream was undertaken and the report can be found here.
Next Steps/Sustainability
-Have formally incorporated AH responsibilities into four job roles (Quality, Safety and Innovation Leads) – this will be central to supporting the spread of Active Hospital pathways into new areas
-Amends to electronic data management systems: the physical activity assessment questionnaire has been integrated into SystmOne at North Tees and Hartlepool
-Engaging in design talks with the LA regarding the build of a new leisure centre in Hartlepool (c.2024) to jointly co-produce the space and co-locate services there
-Will continue with Movement is Medicine sessions and to train more physios to deliver these and local partners will continue to support these groups
-A proposal for AH Phase two for N Tees and Hartlepool has been put forward for acute wards
Top tips
1
Build pathways from the ground up and involve the staff who will be delivering the intervention
2
Identify measures and a means of collecting data early and get support from Business Intelligence and IT teams
3
Adopt a whole team approach to delivery to ensure sustainability
4
Link anything new, e.g. PA questionnaire, to what is already established in clinical practice to give it more chance of success
6
Be willing to make mistakes and learn as you go
Resources
Pre appointment questionnaire
Movement is Medicine Poster
Movement is Medicine session aims
Prevention Group Terms of Reference