Using Insight Across Health Systems to Improve Care

Midlands & Lancashire Commissioning Support Unit

Midland and Lancashire Commissioning Support Unit employs over 900 people and provides commissioning support services to 24 CCGs, NHS England, some acute providers and other related organisations. There are regional offices in Staffordshire, Lancashire and in West Bromwich.

Rationale & Summary

  1. Create a single repository for patient experience feedback from so that themes and trends could be established to ensure that a future Mid Staffs scandal was avoided by using real time feedback via dashboards confirmed based on a personal portfolio of service provision.
  2. The project was extended to include clinical feedback and safety information this creating a safety system this was to ensure that all data could aggregated and themes via standardised data set. The project allowed, multiple organisations to feed information on quality into one system to provider themes and trends the users of the system are outlined in figure 2
  3. The data aggregation was set up to allow data to be aggregated at a provider level across multiple locations and organisations/CCGs to ensure that a true picture of provider performance could be seen.

This innovation is 5 years old, and has grown from a small patient experience project to a holistic quality approach to collecting, theming and trending date from patient-experience, clinical-effectiveness and safety data across organisations to provide real time feedback on provider services. It was developed by the MLCSU working in partnership with CCGs to develop insight from real data and has the potential to be used by providers too. Some of the CCGs are considering this part of the contracting arrangement with their providers to report data using standardised data-sets.


Figure 1

In 2009 standardised data-sets were developed and a single database to record commissioning patient-experience data from complaints, focus groups, social media/media, and online source (Figure 1). It developed into a quality system that currently covers 12 CCGs, over 440 GP practices, NHS England local area team in Staffordshire/Shropshire, condition support groups and out of hour’s providers.

All data is fed into the system and themed as below(Figure 2)


Figure 2

All data covers of the three pillars of quality to provide information in real time across multiple organisations and locations. This has been achieved through system wide leadership and a health economy approach to sharing data and managing contracts/performance of providers.

Figure 3

Figure 3

The project has been supported by senior leadership and via clinical engagement with GPs has been extended to cover multiple sites and sources of data. It has been led and implemented by people who truly want to see patients at the heart decision making within the commissioning process learning has been gained through the delivery of the project.

Figure 4

Figure 4

The system has been developed to incorporate multi-site reporting with bespoke data entry and reporting options that encompasses the three pillars of quality, by collating, aggregating and triangulating data to pinpoint areas of improvement.

Figure 5

Figure 5

What Was Done

The system was developed to use the five domains of patient-experience to theme and trend data, CCGs to develop new ways of providing, theming and trading data. Stoke-on-Trent and Fylde and Wyre CCGs have been instrumental in the development of the system to record safety and clinical effectiveness data through events (incidents) reporting at GP Level

The project is now 5 years old and has grown organically as outlined

4 2009 – 1 PCT
5 2010 – 2 PCTs
6 2011 – 6 CCGs
7 2012 – 9 CCGs
8 2013 – 10 CCGs and 54 practices
9 2014 – 12 CCGs, 228 GP practices and an out of hours provider
10 2015 in progress 1 CCG, 66 practices and NHS England Midlands

The project continues to grow with the advent of co commissioning, federation and integration of health/social care and the fact that the approach is now embedded into the culture of the organisations will ensure its sustainability. We have interest from other strategic partners in creating network of sub regional data and are exploring the possibilities of working with other CSUs across the country.

Impacts / Outcomes

A total of 21,715 individual records have been entered into the system and are available via real time dashboards

1. Complaints 1738
2. Compliments 213
3. Voluntary Sector 275
4. Media 1590
5. Social-media 231
6. MP Letters 620
7. PALS 5530
8. Patient Story 58
9. Clinical Feedback 680
10. Soft Intelligence 7659

Events – Safety and Clinical Effectiveness -3121


Death (Caused by the event)


Good Event


Low (Minimal harm)


Moderate (Short term harm)


None (No harm)


Severe (Permanent or long term harm)




1. 98% of events rated as severe and above have had follow up action taken on them.
2. All events and feedback are reviewed within 30 days
3. All data is shared across health economies figure 3
4. 1200 active users of the system
5. Over 600 hours per year reviewing the data and setting actions across the CCGs
6. Data is review at quality subcommittee and formally reported to the CCG board for primary and secondary care
7. 68% of cases that require action have an action formally recorded against them
8. 181 GP practices trained
9. Over 350 GP practice staff trained
10. Over 600 members of staff at CCGs trained
11. Over 150 CSU staff trained
12. Over 50 NHS England staff trained
13. Regular quarterly reporting for 12 CCGS by theme and trends
14. Over 300 individual real-time dashboards and reports
15. Top ten themes and trend identified

Changes initiated as result of the system

1. New system to inform practices in Blackpool when a patient dies in hospital
2. Changes to referral system for CAHMS
3. Contract review for WMAS to deal with suspected fractures
4. Use of locum radiographers to clear backlogs on imaging
5. Improved discharge reports and communications
6. Full clinical review of district nursing services
7. Review of the falls service
8. Themes and trends feeding into communications and engagement strategy
9. Review of coding in radiology and pathway
10. Improvements to the paediatric discharge pathway
11. Improvements to confidentiality and training on information governance
12. Plain film reporting has been improved
13. Standardised format for discharge summaries
14. Improvements to scripts for 111 service
15. Contract reviews of 111 and radiography service
16. Assurance measures for ophthalmology service
17. Adult protection and safeguarding referrals

Key Elements

1. Clinical leadership both initiating and sustaining sponsorship
2. Engagement with GPs and practice managers – linking into what important to them and what they are passionate about
3. Long project length and its organic growth based on what people can feel as the tangible benefits
4. Linking insight to involvement and giving the information about what patients experience to patients to ensure improvement, accountability and scrutiny.
5. Health system approach, data sharing and looking at themes and trends across primary scoriae and tertiary providers
6. Use of standardised data sets and pre designed forms to ensure data consistency and calibration
7. Use of real time data and the ability to set flags within the system – reposnvine4ss to patient and clinical feedback
8. The ability to have all data in one place so that smaller anecdotal feedback is turned into evidence
9. The use of clinical champions to encourage engagement with clinical staff and practices.
10. The CSUs ability to understand what CCGs need from the reporting in terms of quality and working in partnership to develop it
11. The cross health economy approach as outlined in figure 3 sharing data, comparing data at contract monitoring meetings and setting actions that have an audit trail.
12. Passion and commitment to the small team of people who have developed the system and have worked from a patient perspective to implement.

Learning Points

1. Taking a whole system approach
2. Developing standardised data sets
3. Calibrated data with clear entry instructions
4. Champions at local level
5. Clinical engagement about the things that practice value and find important
6. Tenacity in development
7. Vision about what the system could achieve rather than just a focus on what it does

This project has been the subject of national interest through the below accolades and through speaking at national conferences


HIV Peer Support Improving Well-Being – Positively UK

Positively UK is a patient-led charity founded over 25 years ago by two women living with HIV, putting up hand drawn posters in HIV clinics across London and gathering together in their living room to offer each other support. We are now a medium sized charity with 19 members of staff and 50 volunteers; with all front-line staff and volunteers trained and accredited in delivering peer mentoring and advocacy. Our aim is to improve the physical, emotional and social well-being of people living with HIV; we believe good health and quality of life is determined by all three, they are equally important and often over-lapping.

Based in London we support 1,000 people per annum through outreach at HIV clinics, prisons and our base in Islington encompassing one-to-one assessment, information, guidance, mentoring and advocacy; culturally specific group support and recently diagnosed workshops.

Across the UK we support agencies developing local peer-led workstreams, advocate with national bodies e.g. BHIVA, NICE and promote the greater involvement of people living with HIV in care through initiatives including our biennial conference of people living with HIV.

HIV is now considered a long-term medical condition and the treatments mean people living with HIV can have a comparable life-expectancy with the general population.

However HIV brings challenges in managing medications and their side effects, sexual health when living with a communicable condition, and the psychological impact of living with a disease that is still met with stigma. Research also indicates that people with HIV experience poorer mental health than the general population.

Positively UK’s peer support service was developed to address all of these issues and aims to help people feel more in control of their condition.

Access to good quality peer support is vital for people living with HIV. This project set out to demonstrate that, and how our work contributes to both the NHS Outcomes Framework in managing longterm conditions, and Public Health Outcomes Framework in improving well-being.

Peer led support is an undervalued and underfunded service. This initiative stands out because:

  • it is patient-led, with services developed and delivered by people living with HIV
  • in obtaining the statistical it gives credence to the value of peer support in long-term condition management and improving well-being.
  • it is a collaboration drawing on the strengths of the voluntary sector to support clinical care
  • it demonstrates peer support is transferable and can help many people with many different conditions, not just HIV,
  • and the Warwick-Edinburgh scale could be used to measure impact on well-being in any setting

Positively UK’s peer support service is innovative in helping people manage HIV as a long-term condition. It is uniquely integrated into clinical settings with the continual investment into the professional development of peer workers and volunteers. It has demonstrated leadership across the sector in developing standards which are now being recognised within the new NHS 5-year vision.

External evaluation found peer support contributed to the NHS Outcomes in managing long-term conditions with patients reporting increased understanding of HIV, medications and engagement with clinical teams. It contributed to the Public Health Outcomes Framework with a significant improvement in mental well-being (p=<0.01) using the validated Warwick-Edinburgh scale. The initiative is sustainable with commissioners committing to continued funding of peer support in London boroughs and NHS Trusts directly commissioning Positively UK to establish peer-led support within their patient cohorts.

Project findings were disseminated across the health and social care sector including a launch event; as a result we are working with HIV voluntary sector and NHS Trust partners across the UK to implement a national programme pf accredited peer mentoring; and, showing transferability, working with NHS England, NESTA and National Voices in a wider evaluation in the role of peer support in long-term condition management.

Positively UK’s peer support service is currently being commissioned by Local Authorities and CCGs and supplemented by Trust funding.

Staff and volunteers who deliver the service are integrated into 10 clinics across London working as part of interdisciplinary teams providing support, advice, information and advocacy. They are qualified to a minimum NVQ Level 3 Guidance or equivalent.

To extend our reach, a new volunteer programme was developed and recruited 50 volunteers over two years, all living with HIV, all trained and accredited to Level 2 in Peer Mentoring through the Open College Network, and to the Mentoring and Befriending Foundation’s required standards.

Our primary measure for the success of Positively UK’s peer support service was to demonstrate its role in achieving statutory outcomes set out by the NHS (in managing long term conditions) and Public Health (in improving well-being).

Secondary measures included studying the perception of peer support, how it complements clinical care and enables people to better manage their health. This involved conducting a survey which was distributed to people who have used, or are currently using Positively UK’s peer support service. Participants were recruited through internal local meetings and word of mouth. The questions included the validated Warwick-Edinburgh Mental Well-being scale (WEMWBS)

Results were collected, analysed and presented at a launch event in Jan 2014. We also conducted a short HIV clinician perception survey with the 10 clinics where we deliver outreach to identifying how and in what way peer supports complements clinical care.

Results showed a significant improvement in mental well-being (p=<0.01) using the validated Warwick Edinburgh scale for those who accessed Positively UK’s peer led support services and participated in the survey. Graph 1 below reports on the average scores for each parameter. case1

Patients also reported that peer support has a positive impact on other aspects of living with HIV shown in the graph below:

We also conducted a clinician survey which shows the HCP’s who offer this service within their clinics value it greatly, 100% stated that peer support complements clinical care and either significantly (60%) or considerably (40%) improves the understanding and management of HIV.

The impact of this research has been commissioners from Inner North West London confirming the continuation of the service with other commissioners committing to continued funding for peer support within required retendering. As a result of the launch event a large trust fund approached us and asked us to develop large scale proposal for a national roll out of accredited support.

The research was supported by a grant from MSD and the secondment of a researcher and employee of MSD

Peer support is now considered by the NHS as a key component of improving patient care within the 5-year review published in November 2014. Positively UK’s work has been identified by NESTA and NHS England as an example of best practice in the field. NESTA and NHS England are working with National Voices to undertake a wider evaluation of peer support across long-term chronic conditions, and Positively UK’s CEO will be involved in a steering group for this programme.

Positively UK’s peer support model could be used in any setting and in any therapeutic area. The service has humble beginnings, starting very small and growing to now supporting over 1000 patients a year with statutory funding in place. Other organisations could start with a small local peer-led service slowly establishing it in their therapeutic area and very quickly begin to see the significant results we report above.

We are currently working with agencies across the HIV sector in developing a framework for HIV support services seeking to influence the commissioning of effective services across the UK. Our evaluation is a key tool within this demonstrating the effectiveness of peer support.

The research has also been of relevance to others working in the HIV sector across the UK in demonstrating the role of peer support in long-term condition management and is easily transferrable to other areas, especially long term conditions. As member of National Voices, working with NEST and NHS England the work will have a wider impact and support the robust evaluation of peer support across other long-term conditions.

Peer led support services significantly improves the well-being of patients facing a long term condition and can be used in any healthcare setting in most therapeutic areas. Using validated questions to measure impact will definitely lead to more robust results and we would highly recommend using the Warwick-Edinburgh scale, it was easy (and free of charge) to obtain permission to use it.

Showcases the Overall Winner at this year’s PEN National Awards

Leicestershire Partnership NHS Trust (LPT) provides integrated community health, mental health and learning disability services for a population of a million people in Leicester, Leicestershire and Rutland. We have more than 5,000 staff and a passion for quality, integration and excellence. LPT’s division of Families, Young People and Children’s Services (FYPC) provides the School Nursing Service across the area.

ChatHealth is new texting software that safeguards vulnerable teenagers. It keeps messaging conversations safe/secure to provide timely, confidential access to help from qualified clinicians. Our initiative is improving experiences for patients and staff – who co-developed the system uniquely for the NHS.
Our ambition was to transform access to healthcare for young people. They are leading communications change – almost 100% own mobiles, 80% have advanced phones used to administrate every aspect life. If we fail to provide age-appropriate care in this landscape, they will disengage further.
Our ChatHealth school nurse messaging service is now available to 65,000 students aged 11-19 in 90 mainstream schools in Leicester, Leicestershire and Rutland. They no longer have to wait for a clinic appointment or ask a teacher’s permission to attend – they just send a discreet SMS text message at any time and get 1:1 support from a clinician.
Our software proves technology can have large scale, cost-effective impact on improving patient experience – whilst our team is influencing national best practice and actively promoting transfer/dissemination.

Teens are high risk. In the last 10 years depression/self-harming in this demographic has doubled. Texting provides them with timely, age-appropriate, confidential access to help. It’s widespread technology, offering a far-reaching solution for improving patient experience. Yet it’s rarely adopted in the frontline because staff/managers are risk adverse. The risk of messages going unanswered out-of-hours, losing audit trails and holding sensitive info on handsets, seems to outweigh vulnerable young people crying-out for help.
School nurses and young people solved this problem. They co-designed ChatHealth. They imagined pupils in school sending texts from phones as normal, but texts arriving with nurses in a computer-based risk management system that:

  • Ensures no message received ever goes un-answered
  • Sends automated safety bounce-backs out-of-hours signposting alternative help
  • Is fully auditable and reportable
  • Notifies staff when action is needed
  • Allows nurses to manage messages as a team without giving out numbers for personal handsets

No off-the-shelf product met this specification. So, the Trust employed a software developer to build ChatHealth.

The plan was supported from the outset by senior management, ensuring high quality leadership. This enabled tech development to begin – bringing to life the system patients and nurses had co-designed:

  • Chief Executive injected initial funding/created dedicated project lead post
  • Director of FYPC chaired project board to ensure robustly governed approach
  • Commissioners, impressed with initial achievements, contributed £150K funding to widen impact.


Project lead was appointed from marketing/communications background, to engage patients/staff and communicate objectives. Aims were clear:

  • Improve patient access to school nurses
  • Enable patients/staff to lead transformation
  • Pilot in 3 schools (4,500 students) until at least 10% contact was delivered by text messaging
  • Assess impact on patient/staff experience, with a view to rolling-out

Staff capacity’s stretched; sometimes students can’t get to see a school nurse. But, some choose not to see a school nurse. They feel more comfortable talking about sensitive issues without meeting face to face (F2F). Because of emotional/cultural stigma they feel more self-confident speaking remotely/anonymously from “behind the screen” (of their mobile device). ChatHealth gives patients a better experience on both fronts.

  • Increased reach/access – 100 additional monthly contacts
  • Overcomes stigma of F2F access – half of contacts begin anonymously
  • Reaches underserved teens, 1/5 male users compared to 1/10 in F2F clinics
  • More 1st time users, broader range of enquiries, earlier intervention compared with F2F clinics
  • Improved safety for staff and service users
  • Improved interagency working with police/social-care

To better understand the impact we examined/discussed patient/staff experiences in a number of ways:
Focus groups (30 students)

  • Student survey (2,000 respondents)
  • Staff reference group
  • “Mystery shopper” anonymous test by appointed service user
  • Patient/staff satisfaction video interviews
  • Peer review; 150 conversation transcripts reviewed by school nurses/managers
    Reviewers described a thorough, timely, instant, informative, succinct, safe, non-judgmental, sensitive and reassuring service.



See short exert from patient/staff satisfaction interviews: Young People and Staff Feedback
Read more feedback in “Additional Supporting Evidence”.

With 1,200 school nurses nationwide looking after 20,000 schools, there aren’t enough staff. ChatHealth is the kind of sustainable solution needed to improve experiences more young people with fewer resources.
School nurses can now provide an industrial-scale messaging enquiries service. We introduced a single point of access triage model, so just one duty nurse handles all enquiries from 65,000 patients across Leicestershire. If all Trusts adopted a similar model, as few as around 30 nurses could handle all messaging enquiries from all UK teens.
We’re delivering 100 additional monthly contacts within existing capacity. Achieving the same in a traditional F2F way would require two additional nurses costing £70K p.a. Low-cost messaging contacts eliminate unnecessary resource-intensive F2F contacts, saving taxpayers’ money. Furthermore, our duty nurse responds to two thirds of enquiries through messaging; only one third is escalated to F2F colleagues. This releases capacity so more F2F care can be delivered where it’s most needed.
The capacity for transferability is infinite – ChatHealth is configurable to multiple services/organizations. We’ve already engaged widely with other Trusts and identified a healthy appetite to adopt the culture/behaviour.
ChatHealth improves the patient experience for teenagers because it’s age-appropriate. Techy young people will become increasingly isolated if healthcare fails to keep up with them – ChatHealth turns that on its head by changing the primary way we interact with patients.
This would be impossible without our unique technology and guidance which ensures safety. Nurses say they speak with more new young people than ever before across a broader range of issues. We get more contact from vulnerable/underserved adolescents who might not otherwise engage with healthcare, particularly boys, for whom we are significantly improving outcomes.
ChatHealth is significantly scalable, which we are actively catalysing. This could benefit high numbers of patients.

  • Improves access – an open channel, available to patients 24/7
  • Innovative – more efficient, but simple and safer
  • Age appropriate – empowers patients
  • Earlier intervention – discreet and timely, removes barriers for patients


  • We learned software development takes much longer than expected, but results are outstanding if patients/staff are involved from the conceptualisation stage.

  • We haven’t set out to replace face to face care – but we learned some young people prefer an alternative. They say they feel more self-confident, less judged, less exposed speaking anonymously/remotely.

  • We learned young patients are interested in what we mean by “confidential”. We are clear – we won’t tell parents, teachers, etc. if a student makes contact, unless we have concerns about safety. If a message suggests a young person is at significant risk, we ask the police to help ensure they’re safe. Is this a breach of confidentiality? One patient told us they were just pleased someone cared.

  • Widening service access has improved our patients’ experiences. We were unsure what would be the impact of this on our already busy nurses, but they say messaging as quick, efficient and manageable. We learned messaging helps them reach more patients within existing capacity.

  • Our new single point of access improves timeliness for patients. We thought changing the traditional locality based service model would be challenging. We learned that it flourished. Young people value having direct access and duty nurses say it’s gratifying to support more patients from across the County.

  • Patients wanted messaging access and many staff were keen to pioneer it. These confident champions were critical to the success of the project, supporting less confident colleagues to engage. The champions approach was so valuable we made it central to the service roll-out.

Let the Children be heard

Let the Children be heard

Setting: NHS (National Health Service) Leicester City, Leicestershire County and Rutland (LLR) is a public organisation responsible for commissioning health services in the Leicestershire County Region including the Leicester City and Rutland areas. NHS LLR Commissions health services for 955,300 residents and has more than 700 staff. NHS LLR aims to improve the quality of life, health outcomes and the life expectancy of the residents (customers) it serves. The main focus for the organisation is to target the causes of premature death and reduce health inequalities between its residents and the national average.

Introduction: We believe that children and young people should be given a clear voice to help improve the health services they access and need. When NHS Leicester City needed to redesign its strategy for Child and Adolescent Mental Health Services (CAMHS), it turned to its Engagement team to discover how young people felt about the existing service and where improvements could be made. The engagement work that followed resulted in a new service specification that better meets patients’ expectations, based on young people’s feelings about using the service.

To design the most appropriate service, a public consultation took place over four months. The aim was to listen to what young people:

  • think of the service
  • want from the service
  • want to be prioritised regarding treatment
  • think are major issues that need addressing.

The engagement team then wrote a strategy to reflect the findings from the public consultation, reflecting the priorities and service changes that were fed back.

Summary of Outcomes

By carrying out such a robust process with the full involvement of children, young people, their families and carers alongside experienced and knowledgeable health professionals, From the results a new strategy was written, and service changes made, with principles chosen to reflect the children’s views. NHS Leicester City feels confident that the CAMHS strategy developed will ensure continuous involvement and service improvement. The young people involved have had their voices heard and their thoughts acted on, which has proved to be an overwhelmingly positive experience for them. And, as well as meeting the needs of patients, the efficiency of the service locally has improved dramatically.

Let the Children be heard

How Was It Achieved?

In order to design the most appropriate and effective consultation, we used the insight and knowledge of young people. The consultation was designed by a young person who joined the engagement team on the Takeover Leicester Day, with input from other young people and supported by YoungMinds, a charity for children’s and young person’s mental health promotion. The young people suggested who should be approached for comments, the style of language to be used and advised on incentives they would trigger the best response. This knowledge and information proved invaluable in creating a genuine engagement process. The resulting questionnaire design was simple to understand and complete, asking children for their thoughts on the rules of the service and what the priorities should be.

We then evaluated the existing service and developed the engagement plan with children and young people, identifying the priorities and guidelines by involving stakeholders at every key stage of the process.

There are two elements of this project which have been very unique; the integration and influence of patient feedback into the project and strategy as a whole, and the engagement design itself.

From project initiation to the strategy design through to the final documentation, the patient has been placed at the heart of the service and includes objectives that are viewed as real and will improve the patient experience. Throughout the process there has been real influence from patients, carers and local children and young people which has been a rewarding experience, creating a completely accessible strategy.

The engagement design used experience-based patient involvement from the very beginning. The look, feel, tone and method of engagement was all influenced by the end user – children and young people all played an integral role in the design, language, communication channels, questionnaire and presentation design which made it easier for communication and made the strategic process understandable for people involved. This allowed the engagement team to collect excellent, beneficial feedback that was meaningful to the organisation and the strategy design.

The strategy itself has outlined the future progression of CAMHS and has laid the foundations to continually improve patient experience. We ensured the plans developed were fed back to interested stakeholders and complied with the standards of engagement for all partnership organisations of CAMHS. An agreed priority was for CAMHS staff to continually gather patient feedback on service delivery. A real success is that there is now on-going engagement by the service itself as part of the delivery strategy. Taking a ‘whole family approach’ to treatment involves including carers and family members in future care and this approach was highly supported by the consultation and by CAMHS staff.

The feedback has also had an influence on the future action plan for CAMHS. This is to be fulfilled by 2014 when the strategy is to be reviewed. By this point the future GP lead Clinical Commissioning Groups – CCGs – will be responsible for the review, and they are being made aware of how successful this process has been.

Learning Points and Tools

There were many learning points from this particular project. They included very small factors and some overarching principles which our organisation has used on projects since the project debriefing.

The most valuable learning experiences which were key to the project’s success are:

  • Ask questions; do not be afraid to ask service users for advice on what they want.
  • Use best practice; the design phase was made easy and was quick and simple by using best practice materials such as artistic pathway design (NHS Leicester City), experience based design (Institute of Innovation), and easy read (LDICN).
  • Test and test again; using the questionnaire as an example, the first questionnaire was not the final one. We used practice questionnaires to develop a final questionnaire which could be delivered by people who may not have known CAMHS well.
  • Hear what people say; we didn’t just listen to what patients were saying, we heard what their problems were. Some issues raised were not necessarily the problem itself, but an underlying cause. We explored these using a focus group which proved successful.
  • Take time; this was a long process, allow the project time and remind people that it is happening. This removes the tokenistic approach and allows the organisation to gather meaningful feedback.

Living Our Values

Summary – A key aim of this programme is to nurture a values-led culture within teams: through team development sessions, facilitated by trained in house facilitators, to build the skills to deliver a great patient experience, and to be receptive to, and act on patient feedback. We wanted to inspire staff to want to make changes and improvements; in their behaviour, for their teams and for their patients.


Ashford and St. Peter’s Hospitals were authorised as a Foundation Trust (FT) in December 2010. The Trust is a medium sized district general hospital working across two sites, St Peter’s Hospital in Chertsey, Surrey and Ashford Hospital in Middlesex. The Trust employs over 3,200 staff, serving a population of 450,000 including a broad socio-economic and ethnic mix. The Trust provides a wide range of medical, surgical, diagnostic and emergency services as well as a full range of medical outpatient specialties. Ashford and St Peter’s have a combined bed allocation of over 600 beds.


Our values are:

  • We put patients first;
  • We take personal responsibility for our role and the responsibilities we have every working day;
  • We have a passion for excellence in everything that we do; and
  • We take pride in our team, looking out for each other and celebrating our successes and supporting each other through the challenges we may face.

We believe that to succeed in improving patient and staff experience a vital starting point is the alignment of core values to the patient and staff pathways around our core values. We have been and will continue to work closely with our employees to inspire and enable them to listen to what patients say and to make improvements to the clinical and non-clinical services they provide to them.

A key aim of this programme is to nurture a values-led culture within teams: through team development sessions, facilitated by trained in house facilitators, to build the skills to deliver a great patient experience, and to be receptive to, and act on patient feedback. We wanted to inspire staff to want to make changes and improvements; in their behaviour, for their teams and for their patients.

Our aim was that all Trust staff – from ward to Board would have the opportunity to attend a workshop within 6 months.


  1. Diagnostic review; programme plan and messaging
    Identify a plan to create a clear vision for improving patient and staff experience, based on a good understanding of what is already in place:
    • Diagnostic sessions were held to create a vision for aligning patient and staff experience pathways, we identified what was already in place and agreed improvement priorities with our Project Board.
    • Established objectives and measures of success.
    • Developed a plan for roll out of team sessions and feedback
  2. Team development

    The aim was that every team would take part in a workshop to raise awareness the importance of values and feedback in delivering a great patient experience, to practice service and communication skills and to put in place an improvement loop of listening to and acting on patient feedback by providing a:
    • Team workshops which included presentation materials and a facilitator guide
    • Tailored delegate workbook which was brought to life with real patient and staff feedback.
    • We trained 16 members of staff to deliver the training across the Trust

Before workshops staff were provided with “graffiti boards” in their areas to write comments, below with some examples:

The compliment I’d most like to hear from patients:

  • Knowledge & confidence/caring in their care.
  • Trust.
  • You seem cheerful.

Within our Team we can help each other to live our values by:

  • Team building.
  • Working as a team and all chip in!
  • Listening & supporting each other.

I’d like my colleagues to describe me as the kind of person who:

  • Is a good team player.
  • Listens and assists their concerns
  • Communicator and team worker – happy to help.

The organisation can support me to live our values everyday by:

  • More communication!
  • Listening to our concerns.
  • To show appreciation on a personal level & to understand the concerns we have!

The sessions in the workshop focused on:

  1. 1. “We get what we give” – the experience exchange cycle, helps us understand the impact of what we say and do on others and how this can in turn affect us.
  2. 2. Confident communication
  3. 3. Challenging behaviours
  4. 4. Patient stories – staff met with our patients, carers and relatives or watched a video of one of our patients. They then worked together to think about what they would want to differently.
  5. 5. Putting our values into action – inspired by the patient story and what they had learned from each other and the graffiti boards.
  6. 6. Listening and improving
  7. 7. Personal Commitments

This was a true ward to Board venture. Where possible staff attended in their team groups. Where this was not possible staff attended in specialty groups. All levels of staff took part including: Executive and Non-Executive Board members, consultants, nurses of all grades, administrative staff, allied health care professionals, managers, registrars, housekeeping staff. We achieved 86% attendance. The Project Team reported to a Steering Group, whose Executive members were the Director of Workforce and Organisational Development, the Chief Nurse and the Medical Director.

To support the involvement of Clinicians we set up a “Medical Advisory Group” who helped us design bespoke sessions for doctors, which were well attended.


The key measurement of success was attendance of staff at workshops. Early on in project delivery we found that levels of attendance were low, we explored this from feedback and a significant barrier to attendance was the level of time commitment. We therefore worked with April Strategy and our facilitator colleagues to redesign workshops, providing a high quality half day option. We then re-launched this and attendance dramatically increased.

There was also an initial resistance to attending workshops, or staff who did attend did so reluctantly. However word got out that the workshops were not only interesting and helpful – they were also fun! Bookings increased dramatically.

We wanted to see evidence that staff were engaging with patient stories:

Whether face to face, with one of our patient story videos and also with patient feedback and that they intended to make changes as a result.
Each team developed a set of Team Standards and these demonstrated that they had been inspired by the patient story and the workshop to think about what they and their teams could do differently to improve both staff and patient experience.

A suggestion was that we develop a patient diary and this has been commenced – it is currently under a second stage of development, following feedback from patients and following pilot a final version will be rolled out across the Trust.

We wanted to see more interest in patient feedback taken by senior staff:

One Matron responded to patient feedback about frustration they experienced in Out Patient Clinic where they did not receive timely updates about waiting times – the action was to introduce monitors, which give real time updates to patients and Matron is monitoring this.
Another Matron interrogated patient feedback to understand why the Net Promoter Score had dropped during a particular period and discovered that communication had been affected by a Ward move. This has been shared with the staff on the Wards, who were able to associate their behaviours with patient satisfaction – the NPS has improved.

The facilitators received excellent feedback from the majority of staff and often made inspiring comments:

“It’s not about the number of staff, it never will be. It’s about your individual attitude with that patient, at that time – you have a choice”.

“That moment you have with the patient is their moment – it’s not your moment to be stressed or huffy and cross – it’s your moment to be with them”.

Evidence that staff are living our values are reflected in The WOW! Awards submissions – the Trust introduced the national recognition scheme in July 2012 to capture positive staff and patient feedback relating to when staff get it right!

Derek Williams, Chief Executive of The WOW! Awards, said: “Running The WOW! Awards across a broad variety of sectors, we are truly surprised and delighted by the enthusiasm of patients for catching people doing things right. It’s clear to see the impact this has on employees and management are getting a whole new line of communication which will help to underpin their teams’ standards.”

Here are some examples of those award submissions:

Passion for Excellence

  • “At one stage I was seeing [the nurse] 3 times a week, and she has always been so kind, gentle and patient. She really goes that extra mile to put patients at ease, and shows that she enjoys her job. She is always there if I need her advice, and will always make time to see me if need be. [She] is a REAL nurse – kind and caring, something sadly missing in the world of today.”

  • Patients First

  • “The staff were very kind and considerate to all [my mum’s] needs”
  • “My daughter, who has multiple food allergies, has been admitted to Ash Ward 3 times in the past 2 months and on every admission [the Housekeeping Assistant] has gone above and beyond to ensure that she gets everything that she needs, pre ordering her allergy friendly meals ahead of time, and following up with us to make sure everything arrives as expected. This is a huge weight off our minds during a difficult time”
  • “[The physiotherapist] always has time to help you understand why you have pain and how you need to help yourself.”

Pride in our Team

  • “The day staff on [the Ward] are gentle, compassionate and thoughtful in every way. Their calm, gentle manner is most re-assuring. Also, attention to detail is outstanding; one significant example was cutting food without being asked (as, due to an injury, I am unable to do anything myself). This is just one example of the help that has meant so much to me. I could go on. The overall efficiency is exemplary.”
  • “All the staff are always jolly and willing to help her help herself! My mother can be very difficult at times, yet they manage to get her to improve on a daily basis. Nothing has been too much trouble when I have asked.”

Personal Responsibility

  • “[The nurse] showed so much dignity and supported me when I needed it most.”
  • “I was very nervous today, but [the nurse] was wonderfully reassuring, explaining every detail, and even holding my hand.”
  • “[The physiotherapist] has been so encouraging, helping me with my ongoing hip problem. He explains things so well, which helps with understanding why I need to do the exercises and overall has given me a new confidence, which has been lacking previously.
  • “[The doctor] is simply fabulous! She puts you at ease and has a very engaging nature. It is so easy to speak to her. I consider my visits a social call!”

“I am due to come in for an operation soon, which I am very nervous about. I came in today and was dreading just seeing someone asking *me* general questions and not actually reassuring me and answering *my* questions! [The nurse] was such a lovely lady – she could see I was upset and she took the time to explain exactly what I wanted to know, even without me asking.”

The Future

We have incorporated the Living our Values programme into Trust induction. In association with the Chief Executive’s welcome message about the organisation’s vision and values, inductees participate in a Living Our Values session when we explore the key elements of the original workshop (as outlined above): the communication model; a patient story via DVD; what patients tell us about their experience and inductees are invited to explore what they will contribute to the Trust and what associated support they require from the Trust. The Non-Clinical staff attend a further workshop during induction to explore that contribution as experience from the projects suggests it may be more difficult to appreciate one’s contribution if you do not care for patients directly every day. Feedback from these sessions has been very positive.

We have commenced our “Valuing Frontline Feedback” project, which we have started following a funding award from the NHS Institute’s Patient Feedback Challenge. This project will include activity with two other healthcare providers to share learning from the Living our Values programme. It will also build on what is already in place to develop a replicable approach to continuous engagement with patients and making improvements as a result of their feedback.

We will look at how we gather, report and act on frontline feedback; celebrating success and sharing good practice amongst teams.

Key Elements & Learning Points

The key contributor to success has been the engagement and involvement of staff at all levels as well as patients, carers and relatives.

Our Chaplain and a housekeeper were members of our fantastic team of facilitators. Our Chief Executive really inspired staff to attend after he attended a workshop and gave some positive feedback.

Above all, many patients took part in this programme and some even agreed to be filmed so that their experiences, both negative and positive, could be used to improve services and the experience of patients in the future.

Patients consistently told us how helpful the experience was for them and staff now ask patients to come and tell their story when they want to improve a service or respond to a complaint.

This programme has led to other values-based initiatives, including an invitation to the Tutu Foundation to look at the humanity aspects of the care we deliver. We were honoured by a visit by Archbishop Desmond Tutu to the Trust as part of his recent UK health and education tour.

  • Culture change does not happen overnight, so think about the pace. Be realistic, if it is possible to deliver a large programme over a longer period, you can then also focus on work to embed.
  • If you want to engage a particular staff group (e.g. doctors) make sure you involve them from the outset. It is important to consider how you might tailor workshops according to the audience.
  • Champions are really important –champions from all staff groups actively encouraged involvement in their areas/disciplines.
  • Be flexible! Listen continuously to feedback, adjust plans and comms accordingly.