Connecting Q Locally

There is a growing number of healthcare professionals looking to make their practice more sustainable. One way to achieve transformation is through engaging in an active network of likeminded individuals.

The Health Foundation awarded funding to the sustainable healthcare special interest group in the Q community(link is external) (an online community of healthcare professionals involved in quality improvement, mostly in the UK) to enable us to grow the group and increase collaboration.

The focus of our work is to run a series of 4 virtual events addressing ‘hot topics’ in sustainable healthcare. These events will allow debate and discussion and a meeting place for all those interested in sustainable healthcare, especially those in the special interest group who will have the further opportunity to participate in further curated discussions on the Q community online platform and Twitter.

The series was launched on 25th November 2020 with a successful event posing the question ‘remote consultations; what is their role in sustainable healthcare?’. Speakers were from primary care, secondary care and NHS Digital.

Remote consultations

At the heart of healthcare are relationships; communication is foundational to good relationships and the work of healthcare. This communication in caring has predominantly been carried out face-to-face, though remote forms of communicating (e.g. telephone) are embedded in existing care pathways and an aspiration to increase digital care was set out in the NHS Long Term Plan.

The massive shift in practice this year towards remote communication and care, as a result of the coronavirus pandemic, has provoked fevered debate on the benefits, limitations, creative opportunities and pitfalls of running healthcare services remotely at scale.

On the 25 November 2020, we held the first of our Connecting Q Locally virtual event series which posed the question ‘Remote consultations: what is their role in sustainable healthcare?’

Our inspiring speakers weighed up the impact of remote consultations and care using a sustainable healthcare lens, focussing not only on clinical outcomes but also impacts on the environment (on which we all depend for our health), social wellbeing (of staff, patients and community) and cost.

We heard from:

Dr Andrew Appleton, Clinical Digital Lead & Chief Clinical Information Officer, Bristol, North Somerset and South Gloucestershire CCG, who discussed remote consultations and their role in primary care.
Dr Shanti Vijayaraghavan, Consultant Physician in Diabetes & Endocrinology, and Joanne Morris, Senior Project Manager at Barts Health NHS Trust, Newham University Hospital, who discussed the role of remote consultations in secondary care.
Ben Tongue, Head of Sustainability at NHS Digital, who discussed the main carbon footprint contributors of digital services.

Resources for learning and discussion

1) Watch the recording of the whole event [54.35 mins], here

2) Try this exercise with your team, organisation or at a regional meeting :

select some video clips from the event on different topics and watch these together. You can find the clips below in the ‘video clip library’ or on this playlist on YouTube(link is external). Each clip is accompanied by the key learning points.
After watching the clips use this prompt for discussion: “To make your service more sustainable what remote/digital solutions would you: a) add in b) optimise (and how) c) stop using?”
Depending on the size of the group you could have a whole group discussion or small group discussions in break-out rooms (for online groups).
You may like to try using virtual whiteboard softward like Jamboard, Miro, Mural or Padlet that allows the whole group to collaborate whever they are and also creates a colourful record of your discussion that can be saved and used later on to further your ideas. Here is a jamboard with example answers(link is external) and here is a master copy of the jamboard(link is external) that you can copy and use in your own session.

3) A series of conversation starters and video clips from the event were posted in the Sustainable Healthcare Special Interest Group(link is external) on the Q Community(link is external) platform that brings together healthcare professionals with an interest in quality improvement. Please do come and join in and contribute to the conversation! Apply to join the Q community(link is external) if you aren’t already a member, and for existing members do visit the Sustainable Healthcare Special Interest Group(link is external); we’d be delighted to welcome you!

4) Join the Centre for Sustainable Healthcare in piloting a new carbon calculator for remote consultations! With the support of the Health Foundation, The Centre for Sustainable Healthcare has developed a carbon calculator to assess the carbon emissions savings of avoided patient travel due to switching from in-person outpatient or GP appointments to remote consultations. The calculator is accompanied by a a step-by-step guide. Please contact Mrs Ingeborg Steinbach(link sends e-mail), Carbon Modelling Lead, if you’re interested in piloting this exciting new tool.

Video clip library

How do remote consulting and digital systems contribute to sustainable primary care? [8 mins]

Listen to Dr Andrew Appleton:

Key points:

The journey of introducing digital care systems in one practice.
Benefits for patients and staff of introducing digital systems.
How digital systems contribute to sustainable primary care through patient empowerment and lean systems of working.

How do remote consulting and digital systems contribute to sustainable secondary care? [ 6 mins]

Listen to Dr Shanti Vijayaraghavan & Jo Morris:

Key points:

Social sustainability was the main driver for introducing video consultations
The journey of introducing video-consultations in the diabetes service in Newham.
The impact of video-consultations on reducing patient travel and reduce emissions.

The benefits and impacts of digital systems in healthcare [20 minutes]

Listen to Ben Tongue, Head of Sustainability at NHS Digital:

Key points:

although digital healthcare often contributes to environmental and social sustainability, running the infrastucture of digital systems does have a environmental and social costs.
the 3 main contributing factors to the carbon footprint of digital services in healthcare are:
1. Data hosting (ie on the Cloud or servers)
2. Networks (require wiring)
3. End user devices e.g. phones, laptop, iPad
that the manufacturing phase accounts for 80% of the energy of the lifecycle use of digital devices and an important change needed is using fewer devices designed to be repaired and updated.

Q&A

Q1. Does travel required to pick up prescriptions increase the carbon footprint of video-consultations in primary and secondary care? [1:30 minutes]

Key points:

Many secondary care physicians do not prescribe in outpatients but ask primary care colleagues to prescribe.
In primary care nearly all prescriptions are transmitted to pharmacies electronically saving printing materials and travel between the practice and the pharmacy for patients and staff.

Q2. How does staff working from home effect the carbon footprint of healthcare organisations? [3:27 minutes]

Key points:

Staff working from home, rather than in the office has a lower carbon footprint.
In primary care where the number of staff are increasing and existing buildings are becoming too small for teams, homeworking could reduce the need for new building, which is important as the process of building has a high carbon footprint.

Q3. How reducing ‘did not attend’ rates through using video-consultations improves sustainability through creating a leaner process, making it easier to access services and through empowering patients. [3:02 minutes]

Key points:

reducing ‘did not attend’ rates through using video-consultations improves sustainability through creating a leaner process, making it easier to access services and through empowering patients.
‘did not attend rates’ in the diabetes clinic reduced from 33-50% (depending on age group) at baseline to 26% once remote working introduced. This dropped further to 13% when user-initiated contact was introduced. At the same time glycaemic control improved, probably due to better self-management. Similar results have been replicated in other services.
Technology needs to be easy to access and use.
The whole pathway needs to be redesigned (through co-design with patients) when introducing video-consultations, including patient-clinician interaction, booking, feedback of results.

Q4. Limiting digital exclusion for socially sustainable remote consulting [3:27 minutes]

Key points:

Volunteers, family members and receptions have been deployed to help patients to access remote healthcare consultations.
Don’t make assumptions about different groups accespting and being able to use remote consultations. It is often assumed that digital solutions do not work for elderly people but often it works better for patients and families, especially given the inconvenience and risk of travel (especially during COVID).

Q5. If you are redesigning a pathway around digital solutions how are face-to-face options included? [3:45 minutes]

Key points:

In both primary and secondary care both digital and face-to-face/in-person are offered to allow for the need to examine patients and for patient preference.
There are different methods of achieving a mix of remote and face-to-face appointments discussed further in this clip.

Q6. What do patients feel about having sensitive conversations online? [2:45 minutes]

Key points:

Many people prefer having sensitive conversations bad news online when they can be at home in a supportive and familiar environment, evidenced by the VOCAL study carried out in the tertiary cancer care centre at Barts.

Q7. Co-production for social sustainability when introducing digital care and video consultations in primary and secondary care [2:12 minutes]

Key points:

Working with the patient participation group in primary care is important and helpful at the early design stage and in giving feedback as plans take shape. The video discusses various examples of co-production in practice.

Green Social Prescribing for sustainable healthcare

Good relationships with others, ourselves and the natural environment as well as a sense of purpose are fundamental elements of good health.

The pandemic has led to many discovering the health and wellbeing benefits of being in nature, noticing, connecting with, and stewarding/caring for, the natural world and there is a strong evidence base to support this lived experience of millions of people.

How can we capture the power of the natural world to support the physical, mental, emotional, social and spiritual health of each person and the population as a whole, helping us all to keep well, stay well and prevent illness? And how can we steward and care for the ecosystems that we rely on so that they are sustained as they sustain us?

The concept of ‘green social prescribing’ has been offered as a solution and a national policy published in the last 12 months has set the agenda in this area.

On the 22nd June, we held the second of our Connecting Q Locally virtual event series where we discussed translating green social prescribing from policy to practice.

We heard from:

Nicola Gitsham, Head of Social Prescribing and Community Approaches, NHS England and Improvement on ‘What is Green Soical Prescribing? Why does it matter & how does it fit with social prescribing?’:
Jacob Krzanowski, Specialist Registrar in General Adult Psychiatry at the South London and Maudsley (SLaM) NHS Foundation Trust, and Jenny King, Wild at Heart Project Officer, Sheffield and Rotherham Wildlife Trust who shared their experiences of green social prescribing for mental health & long term conditions:
Sam Alford, Senior Manager, Green Social Prescribing programme, NHS England and Improvement who spoke about how green prescribing is being scaled up in the UK and why this is important to do now:
Jane Soothill, Communities and Prevention Officer, Surrey County Council who shared the strategy in the Surrey Heartlands area for systems change to facilitate nature connection, green space use and green prescribing.

Green Prescribing resources for learning and discussion

Watch the recording of the whole event [54.35 mins] here
Try this exercise with your team, organisation or at a regional meeting :
- select some video clips from the event on different topics and watch these together. You can find the clips below in the ‘video clip library’ or on this playlist on Youtube(link is external). Each clip is accompanied by the key learning points.
- After watching the clips use these prompts for discussion:
  - What might the benefits be of making green social prescribing available in your area and integrating it into your clinical pathways?
  - What 1 action will you take to help make this happen?
- Depending on the size of the group you could have a whole group discussion or small group discussions in break-out rooms (for online groups).
- You may like to try using virtual whiteboard like Jamboard, Miro, Mural or Padlet that allows the whole group to collaborate wherever they are and also creates a colourful record of your discussion that can be saved and used later on to further your ideas. Here is a master copy of the jamboard(link is external). Please make a copy to use in your own session by clicking on the 3 dots in the top right of the jamboard page.
From the 24th August – 2nd September a series of conversation starters and video clips from the event will be posted each day in the Sustainable Healthcare Special Interest Group(link is external) on the Q Community platform(link is external) that brings together healthcare professionals with an interest in quality improvement. Please do come and join in and contribute to the conversation! Apply to join the Q community(link is external) if you aren’t already a member, and for existing members do visit the Sustainable Healthcare Special Interest Group(link is external); we’d be delighted to welcome you!

Video clip library

These clips are also available as a playlist on YouTube

Overview of series

Dr Olivia Bush sets the scene of how green social prescribing fits with the principles of sustainable clinical practice & introduces this series of virtual events on sustainable healthcare in practice.

What is green social prescribing?

Hear from Nicola Gitsham, Head of Social Prescribing and Community Approaches, NHS England and Improvement. Key points include:

Social prescribing is a way for health professionals, including link workers based at GP surgeries, to connect people to community activities for practical, social and emotional support.
Green social prescribing specifically supports people to connect with nature-based activities.
All social prescribing is a way for the health service to implement a wholistic approach to health & care and address the social and ecological determinants of health.
Social prescribing starts with what matters to the person and is part of ‘personalised care’.
Personalised care is one of the five themes of practical changes that all health & care systems have to implement by 2023/24 as part of the NHS Long Term Plan. One of the targets is for GP surgeries to employ link workers.

‘Wild at Heart’; an example of a community green social prescribing project

Hear from Jenny King, Wild at Heart Project Officer, Sheffield and Rotherham Wildlife Trust. Key points include:

‘Wild at Heart’ is a social group for adults, where members can choose from a broad range of seasonal nature-based activities cooking, gardening and nature walks.
The group provides the opportunity for staff to get to know participants in a relaxed atmosphere and to encourage participants to explore what they enjoy and what they need for a full and satisfying life. The starting point is pleasure rather than problems.
The approach helps participants to gain confidence in their skills and abilities as well as the opportunity to meet and form friendships with other group members. Many go on to use their new skills at home and build a healthier lifestyle for themselves as part of the wider community.

‘The Green Walking Initiative’; an example of nature-based therapy in secondary care

Hear from Jacob Krzanowski, Specialist Registrar in General Adult Psychiatry at the South London and Maudsley (SLaM) NHS Foundation Trust. Key points include:

The Green Walking Initiative piloted the introduction of a weekly walk in a greenspace for psychiatric inpatients accompanied by members of staff, in units nationwide. A guide to setting up this project in your area and spread and scaling this work can be found in the resouces section below.
Why is this initiative important?
- This is a rare example of a nature-based therapy initiative in secondary care (rather than the community).
- Addresses inequalities in access to green spaces as patients often don’t have access to green spaces during their hospital stay despite the fact that many hospital sites are adjacent to and on green spaces.
The richness of the impact was best captured through accounts of how it felt for staff and patients’ to be off the ward and in nature. Staff described how patients were ‘transformed’ by the walks and how the effect was ‘unbelievable’.
Where the initiative flourished it had a ‘ripple effect’ with other green initiatives being seeded.
Embedding even a relatively simple intervention in a care pathway at sites required a huge amount of energy and long-term commitment. Key elements of success included selecting staff members at sites who would own and champion the project and pilot sites being one of a larger community of sites working on the initiative at the same time.

What is the Green Social Prescribing Programme?

Hear from Sam Alford, Senior Manager, Green Social Prescribing programme, NHS England and Improvement who speaks about how green prescribing is being scaled up in the UK and why this is important to do now. Key points include:

This 2-year initiative is exploring:
- how the use and connection to natural environment can be increased through green and blue social prescribing referrals.
- how green and blue social prescribing can be implemented at scale and embedded.
The programme focusses on mental health (although there is evidence for the benefit of green social prescribing in physical health as well).
The initiative is being carried out through collaborating with a wide range of partners including local integrated care systems, Public Health England, Sports England, DEFRA, NHS England, Natural England and the Natural Academy of Social Prescribing.
7 Pilot sites have been chosen. All sites are:
- focussing on communities that have been especially hard hit by the coronavirus pandemic & areas of high level of health inequalities.
- using a collaborative approach and co-designing work to make sure that services are delivered in a way that make sense to local people and set up so that prescribers feel confident to refer to the services.
The 7 sites are geographically diverse (coastal, rural and urban areas are all represented) and have different models for working with partners.
The initiative makes funding available for both project delivery and for exploring sustainable funding for the future that will allow green social prescribing to be embedded.

Interview from one of the Green Social Prescribing ‘test and learn’ pilot sites

Hear from Jane Soothill, Communities and Prevention Officer, Surrey County Council who shares the strategy in the Surrey Heartlands area for systems change to facilitate nature connection, green space use and green social prescribing. Key points:

Surry Heartlands have established a broad partnership to develop a vision of how they their health and social care system and clinical pathways to look different after this pilot. The partnership includes the clinical commissioning group, hospital trusts, primary care, local authority, councils, VCSE sector and green sector
Working groups have been established for a variety of workstreams including evaluation & training, community engagement. Each group is co-chaired by a representative from the health sector and another from the green/leisure sector.
To share learning the site has established their own local online network. They also share learning with other test and learn sites through a dedicated space on the NHS collaboration platform.
The site has found that green/blue social prescribing is an area that brings people together and to which large numbers of people are willing to dedicate their time and energy.

Q&A

Funding & stakeholder engagement

Key points:

Social prescribing requires a varied range activities in a local area. Delivering this range starts with finding out about the needs of the local population, mapping what is currently available (e.g. using the ‘Commonplace’ platform) and identifying gaps.
Where social prescribing works well local areas have a place-based strategy that involves cross-sector partnerships and a model of ‘share investment funding’ i.e. they are attracting different sources of funding rather than relying on statutory funding.

Staff training, policies and quality assurance

Key points include:

For existing programmes where staff work with vulnerable people the ‘Institute of Outdoor Learning’ have produced a best practice document providing guidance to support staff and organisations to offer responsible care. This includes practice advice on staff training and policies.
As part of the initiative quality standards will be developed so that organisations can go through a quality assurance process. This will help referers to be able to refer with confidence.

Will funding for providers go to large national organisations or local organisations?

Key points:

The initiative is about local engagement and working in local areas and that will be where funding is most likely to be allocated. Local groups usually have that local sensitivity and local need, are part of that community and know how to imnplement services in those communities.

Evaluation; how can the benefits be measured?

Key points:

The measure depends upon the change you want to see (and for whom e.g. patients, staff, community). There is an existing range of different measures.
Evaluation can detract from the patient experience so it is important to identify what is essential to capture and focus on that.
One of the objectives for test and learn pilot sites will be to identify what the useful outcomes are and what evaluation methods are best suited to green social prescribing. For example, Surrey Heartlands are looking at the benefits of storytelling methods.

Resources

Networks

Join the Q community and the ‘Sustainable Healthcare’ special interest group
Join the CSH networks including ‘Green Space and Health’ network
All-Party Parliamentary Group on Health and the Natural Environment The purpose of the group is to examine the physical health and mental wellbeing benefits to people of all ages that come from access to and connection with the natural environment.

Green social prescribing & why it matters

The Nature Prescription Handbook(link is external) (recently launched by Exeter University)
Prof. Miles Richardson blog: nature connectedness and wellbeing(link is external)
ONS Report(link is external) about the relationship between nature and Covid
MIND’s Mental Health and Physical Activity Toolkit

‘Wild at Heart’; an example of a community green social prescribing project

‘The Green Walking Initiative’; an example of nature-based therapy in an inpatient psychiatric hospital setting.

The Green Social Prescribing Programme

The original Green Social Prescribing Programme call for expressions of interest gives the background to the programme and all of the lings to the supporting evidence and research are at the end of the webpage.
Sam Alford, Senior Manager of Green Social Prescribing programme, NHS England and Improvement, can be contacted via the Green Social Prescribing Inbox, if you would like to find out more about the delivery and progress of the programme.
Commonplace platform for community stakeholder engagement

Quality assurance

‘Institute of Outdoor Learning’ have produced a best practice document(link is external) providing guidance to support staff and organisations to offer responsible care.

Evaluation

Connect with evaluation and impact team at NHE
Defra Green Social Prescribing Evaluation – PenARC
A guide for evaluating health and wellbeing outcomes for community growing programmes

Embedding Sustainability into Quality Improvement: a two-part shared learning forum

Embedding environmental and social sustainability into quality improvement education, training and practice can support healthcare professionals in contributing to the NHS’s commitment to a Net Zero health system. The Centre for Sustainable Healthcare’s ‘SusQI‘ framework provides a practical tool for reducing healthcare’s negative environmental impact while maximizing social value at every opportunity.

Listen to the recordings of the third and fourth webinars of the Connecting Q Locally virtual event series, in which our inspiring panelists discussed how to embed sustainability into quality improvement education, training, and practice.

Part I: Embedding sustainability into healthcare education; lessons learned from practice

This event highlighted the lessons learned from the SusQI Education Project, touching on newly published research findings. Our panel members explored the strategies taken to embed SusQI into QI education, the impact it has on learners, and how we are navigating the further spread of SusQI through the Beacon Site Programme and SusQI Academy.

Panel members:

Dr Heather Baid, University of Brighton: embedding SusQI into nursing postgraduate education
Dr Florence Wedmore, Barts Health NHS Trust and Queen Mary University London: teaching SusQI to medical students
Dr Kay Leedham-Green, Imperial College London Medical Education Research Unit: lessons learned from a multisite, multiprofessionals evaluation study of SusQI

Part II: Embedding sustainability into QI training and practice within NHS Trusts; barriers and strategies

NHS trusts and boards can integrate the SusQI framework as a way to meet the workforce development demands of NHS decarbonisation targets, and to set strategic goals which drive practical, systemic changes towards sustainability. During this event, we heard from pioneering NHS trusts who are already on their way to transforming their QI training and practice by embedding sustainability. You will learn about the support offered through the SusQI Education project at CSH, including the Beacon Site Programme, SusQI Academy and Green Ward Competition.

Panel members:

Stuart Lane, Sustainability and Carbon Manager,University Hospitals Dorset NHS Foundation Trust
Katy Morris, Associate Director of Continuous Improvement and Sustainability, Midlands Partnership NHS Foundation Trust
Laura Middlemass, Assistant Sustainability Manager Newcastle Upon Tyne Hospitals NHS Foundation Trust

Learning Resources & Support

30-minute SusQI elearning session(link is external): this free SusQI ‘taster’ session provides learners with insight into the value of embedding sustainable healthcare principles into each step of quality improvement
3-part courses:
- Sustainability in Quality Improvement: examines in-depth how the SusQI framework can be applied in practice to develop preventative, holistic, lean, and low-carbon care
- Teaching Sustainable Quality Improvement: uses the ‘SusQI’ framework to help health professions educators to integrate sustainability concepts into mainstream quality improvement teaching
SusQI.org open access resources
- Step-by-step guide(link is external): provides SusQI project resources, including driver diagrams, process maps, a carbon calculation guide and a project development template
- Educators pack(link is external): contains materials for teaching SusQI to a variety of learners, such as introductory materials, a slide set, interactive activities, and an assessment guide
The Q Community Sustainable Healthcare Special Interest Group(link is external): brings together healthcare professionals with an interest in quality improvement and sustainable healthcare
CSH Sustainable Specialty Networks(link is external): enable communities of like-minded people to collaborate internationally on sustainability in their clinical specialty or area of interest.

Support for healthcare and educational institutions

SusQI Academy: provides organisations with support to help them embed sustainability into their QI education and practice by training key staff to become SusQI leads
Course block booking: enables your organisation to equip staff with the motivation, skills, and resources necessary to develop low-carbon healthcare projects that align with your Green/Sustainability Plan
Green Ward Competition: an award-winning, tried & tested leadership and engagement programme to transform healthcare by cutting carbon, improving patient care & staff experience and saving money
Beacon Site Recognition: can be applied for by institutions and organisations and demonstrates their leadership in empowering faculty and/or students to design and implement sustainable quality improvement and transformation

Embedding Sustainability into Quality Improvement: a two-part shared learning forum

Part I: Embedding sustainability into healthcare education; lessons learned from practice

Panel members:

Dr Heather Baid, University of Brighton: embedding SusQI into nursing postgraduate education
Dr Florence Wedmore, Barts Health NHS Trust and Queen Mary University London: teaching SusQI to medical students
Dr Kay Leedham-Green, Imperial College London Medical Education Research Unit: lessons learned from a multisite, multiprofessionals evaluation study of SusQI

Part II: Embedding sustainability into QI training and practice within NHS Trusts; barriers and strategies

Panel members:

Stuart Lane, Sustainability and Carbon Manager,University Hospitals Dorset NHS Foundation Trust
Katy Morris, Associate Director of Continuous Improvement and Sustainability, Midlands Partnership NHS Foundation Trust
Laura Middlemass, Assistant Sustainability Manager Newcastle Upon Tyne Hospitals NHS Foundation Trust

Learning Resources & Support

30-minute SusQI elearning session: this free SusQI ‘taster’ session provides learners with insight into the value of embedding sustainable healthcare principles into each step of quality improvement
3-part courses:
- Sustainability in Quality Improvement: examines in-depth how the SusQI framework can be applied in practice to develop preventative, holistic, lean, and low-carbon care
- Teaching Sustainable Quality Improvement: uses the ‘SusQI’ framework to help health professions educators to integrate sustainability concepts into mainstream quality improvement teaching
SusQI.org open access resources
- Step-by-step guide: provides SusQI project resources, including driver diagrams, process maps, a carbon calculation guide and a project development template
- Educators pack: contains materials for teaching SusQI to a variety of learners, such as introductory materials, a slide set, interactive activities, and an assessment guide
The Q Community Sustainable Healthcare Special Interest Group: brings together healthcare professionals with an interest in quality improvement and sustainable healthcare
CSH Sustainable Specialty Networks: enable communities of like-minded people to collaborate internationally on sustainability in their clinical specialty or area of interest.

Support for healthcare and educational institutions

SusQI Academy: provides organisations with support to help them embed sustainability into their QI education and practice by training key staff to become SusQI leads
Course block booking: enables your organisation to equip staff with the motivation, skills, and resources necessary to develop low-carbon healthcare projects that align with your Green/Sustainability Plan
Green Ward Competition: an award-winning, tried & tested leadership and engagement programme to transform healthcare by cutting carbon, improving patient care & staff experience and saving money
Beacon Site Recognition: can be applied for by institutions and organisations and demonstrates their leadership in empowering faculty and/or students to design and implement sustainable quality improvement and transformation