Having gone through this process, the service is now seeing about 25% more patients per month, but is saving £200,000 per year despite this. We thought this was a great opportunity to ask Myra what her tips would be for colleagues thinking about making changes to a service, whether on a small or large scale.
Clinical Leadership Programme (CLP): What prompted you to look at redesigning the containment product service?
Myra Robson (MR): About a year before I started the role, someone asked me how to recruit to the leadership role in the community continence team. I suggested combining the two pelvic health physiotherapy teams and the community team into one big team. She thought that was a good idea, so I ended up applying for and then getting that job.
I came to the service as a physiotherapist – physios don't use catheters and rarely work with products. At that time the community continence team was just two nurses and it was a completely different service. The difference in the way in which the clinicians were viewed was quite striking.
The work being done in the physiotherapy services was very much: a patient comes with a symptom, you work out what's causing the symptom, make a diagnosis, make a plan, and fix or improve it. The community continence team was dealing with an older population with much more complex needs, but the expectation was that if someone had incontinence, you supplied pads and offered some help or advice. Everybody had the view that this was normal, but coming into it completely new, I found this astonishing.
One of the managers had asked the nurses to see if they could persuade everybody who was on one pad a day to come off pads, because she thought that if you're on one pad a day, you probably don't need pads. That was seen as quite radical thinking, whereas I wondered why we weren’t trying to fix them?
Then I got the budget – we're one London borough and we were spending £750,000 a year on products that were all going straight to landfill.
I didn’t make a plan – I just thought, where on earth do I start with this? It was a bit like going around a maze – I'd start with something and unpick a bit and there would be 10 black holes behind it. So then I had to figure out which black hole to work on next. Combined with that, I had some resistance from staff. Ultimately, there were so many problems in front of me, I just had to choose one, so I started with the one that was either the nearest or the smallest.
I don't think I realised how much I was changing, because we were looking at so much, like how the care homes worked, how the nurses operated and how the clinics ran. Looking back, I wish I'd kept a diary of where we were, but I was just overwhelmed. I was still overseeing the two pelvic health physiotherapy services and trying to align everything.
We had patients who weren't getting the opportunity to have their problems fixed, staff who were not getting the opportunity to be fully valued for their clinical skills, not being sufficiently trained, supported or supervised, and we're spending a fortune on stuff going to landfill. There was no connection between those things. And I just thought, there's got to be a different way.
CLP: What were the key parts of the redesign process?
MR: I knew nothing about most of the things that I was managing, so I had to pay really close attention to the detail to understand it. The service had a different medical record system, a different way of running a diary, did assessments differently. I'd never prescribed products and I wasn't familiar with care home work. That meant that I couldn't make assumptions about anything – I had to go down to the tiny details.
When it came to the products, I spent hours going through all the caseloads trying to make sense of who was on which products. As I started to understand it, I could see the little things that were wrong. I made a list of things I was going to fix now and things that I wanted to think about, and then I just picked something.
It wasn’t straightforward – the staff didn't really like what I was doing, and my manager was keen for me to get people through the system. So I picked one thing after another, whatever seemed to be the most interesting or the most ripe for change.
I'd contact a service and see what they did, and then get the appropriate NICE (National Institute for Health and Care Excellence) or national guidelines to benchmark ourselves against. Often we were so far away from the guidelines. Then I’d break the guidance down – for example, there's 15 key points, so let’s take this point and fix that first. Little by little, you work your way through that list, and then you move on to the next area.
CLP: Are there any aspects of the service that you didn't include that you wish you had?
MR: I was slow to get onto the catheters – for a while I had a job share partner who had a nursing background, so they focused on catheters as a key nursing skill. That colleague left and wasn’t replaced, and then I realised that I would have to look at catheters. We used the same process to look at that service, and we've just won another award for our catheter work, but I wish I'd got to that earlier because we've had a lot of wasted money, time and a less than perfect service under my name.
CLP: Were there any unexpected benefits from the process?
MR: With hindsight, yes. We now have a really motivated team, with some fantastic clinicians that really love what they do. A number of people have had their eyes opened, have developed a role that they love and have been instrumental in the team's success.
We’ve had 12 award nominations or awards, started publishing articles and people have come to meet us to find out what we've done and how we've done it. We won Team of the Year at the Trust awards a couple of years ago, which was really good. It's been because what we've done has been right, and there's real satisfaction in actually doing the right thing.
There's no doubt that trying to change a product service is a hornet's nest. We’ve had more challenging discussions and complaints than I've seen in my entire career just from trying to change people from using inappropriate incontinence pads to more appropriate containment products or to treatment.
On the other hand, we have patients who think this is fantastic. We've got a focus group of five patients who work with us – the aim is that they will review our patient handouts, come to our training days and tell their stories to staff, they're fundraising to help support staff with expenses when they go on courses. The interesting thing is that three out of the five members came to us with complaints about the product service, but when we explained why we're doing what we're doing, they've changed and become our biggest advocates because they've seen what we can do. That's really satisfying. When patients say: ‘you've made a massive difference to me because you've got the pads or the catheters right. You've changed my life because I've now got something I can go out in and wear and I'm confident’, those things really help.
CLP: If you were starting this process now, is there anything you would do differently?
MR: I would document more and plan better. I was so overwhelmed that I just got on and moved things on. Ideally you'd have somebody going into this who knows how to analyse the service and change it. When I took the job, I didn't realise that I was effectively going in to change a service. I don't think I was necessarily skilled for that, but I've learnt the skills and I think I've done a good job.
CLP: What are your top tips for colleagues considering a service redesign?
MR: Do your classic project management. Be really clear what it is that you're aiming for and then break that down into manageable tasks. It might be financial savings – that's a huge driver these days, but it can still work in the patient's favour.
Understanding the detail is vital. There are really good NHS guidelines and you need to read them many times to really understand them. I can quote chunks of Excellence in Continence Care from NHS England (2018) or the Association for Continence Professionals (2023) guidelines that are updated every two years. Those are really solid and well-thought out by experts in the field. It really helps you to be confident in decisions you're making, and gives you back up, particularly if you’re making decisions that might be unpopular.
The other thing is having the backup of your seniors. Of course, it was the money saving that got people excited. Then I had to get a group of stakeholders together, including someone from the ICB (integrated care board), a care home manager and a local GP, and present everything I was doing. I basically said ‘this is how I intend to run the service and this is why’ and asked them to sign it off. It was an informal sign off, but they could see that it makes perfect sense – it's guideline led, it's saving money and it's better for patients – you can't argue against that. That helped give us confidence when we started getting complaints to say ‘this is how the Trust does it’.
Then it's the detail. Don't be afraid to go down that rabbit hole, get to the final point and be confident that you know everything about that particular aspect. A classic example of this is ‘inco pads’ or procedure pads, which are used a lot as continence pads, for people to lie or sit on. We had at least 100 people using these. So I investigated. In research done by NHS Business Authority (2017) some continence experts concluded that these pads are not safe to be used as continence products. They're plastic backed and they're not absorbent, which can increase the risk of pressure damage. We've got such amazing containment products that if you've got the right product and use it properly, you shouldn't be getting leaks. We should be sorting out the leaks and getting that right, not just mopping up the leaks. So we took everybody off the inco pads and there was a lot of pushback, but now we don't prescribe those, we explain why and offer alternative options. That was a huge piece of work for something that was not a huge thing. But those little things together join up to become a really effective service. So getting the detail right is really important.
CLP: Do you have any tips for readers on dealing with complaints in this situation?
MR: Know what you're doing and why, and be really clear. When you make a decision, for example, stopping inco pads, know that if you stick to it, somebody else will back you up with it. As clinicians we want the best for our patients, we want to make sure we are safe and legally compliant, and we have to manage money as that is a part of the responsibility of NHS services. As long as you're making decisions for the right reasons that support these needs, you're in a really robust place.
Something slightly different, but when we were going through all the big transition stages, occasionally we would get to a point where we'd say ‘let's just have a rest. Let's just park that battle there and have a month off that particular project.’ We’d spend some time doing something where people say thank you rather than complain. Sometimes you’ve just got to accept that. Taking a break from it helps you start back with a bit more focus and purpose.
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