Jul 31, 2016 - technical complexities of posting on the NHS Networks hosted forum ranging from .... rehabilitation needs
Improving Rehabilitation Service Community of Practice Report – July 2016
Networking for sustainable improvement in rehabilitation
NHS Clinical Soft Intelligence Service Hosted by NHS Warrington CCG
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Improving Rehabilitation Service Community of Practice: Networking for sustainable improvement in rehabilitation
“A person-centred approach within rehabilitation is key to achieving the vision for future healthcare as set out in the Five Year Forward View. The development/implementation of Sustainability and Transformation Plans will ensure that health and care services are built around the needs of local populations. Networking across health and care, independent and voluntary sectors and including community resources (such as housing associations) can contribute to achieving these goals. Networking enables sharing of innovation, influencing strategically and focusing on meeting population needs to improve outcomes for individuals.” Suzanne Rastrick, Chief Allied Health Professions Officer, NHS England, 2016
Background and Introduction The development and support of the Improving Rehabilitation Services Community of Practice (IRSCOP) was originally commissioned from the NHS Clinical Soft Intelligence Service (NHSCSI) in 2012 by NHS England to support its Improving Rehabilitation Services Programme. As NHS England now focuses on embedding rehabilitation into its overall clinical priority programmes; this report proposes that it is vital that people continue to network within and across regions to capture the contribution of rehabilitation and inform regional and local strategic priorities and Sustainable Transformation Plans.
‘A modern healthcare system must do more than just stop people dying. It needs to equip them to live their lives, fulfil their maximum potential and optimise their contribution to family life, their community and society as a whole… It is increasingly acknowledged that effective rehabilitation delivers better outcomes and improved quality of life and has the potential to reduce health inequalities and make significant cost savings across the health and care system.’ NHS England, Commissioning Guidance for Rehabilitation, March 2016 https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf
The purpose of this report is to support readers who wish to continue to harness a diversity of expertise and advice to support local and regional improvement and strategic planning. It describes what has been learned, achieved and produced by the IRSCOP that can be taken forward or built upon.
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Sections include:
the impact to date of networking for improvement in rehabilitation (page 4) the experience and learning about building a community that networks across boundaries of condition, profession, organisation and sector (page 5) lessons learned regarding the barriers and enablers to networking for improvement for this community of participants (page 9) the aspirations of regional stakeholders for networking to support sustainable improvement of rehabilitation (page 12) links to resources developed by the IRSCOP that are available to initiate and support further networking within and across regions (page 14) tools that may be helpful to support regional networkers (page 17) information about how to connect with known stakeholders offering a source of diverse expertise and advice (page 18) Food for thought for the next steps (page 20)
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1. The impact of networking for improvement in rehabilitation to date
‘Rehabilitation is a personalised, interactive and collaborative process, reflecting the whole person. It enables an individual to maximise their potential to live a full and active life within their family, social networks, education/training and the workplace where appropriate. Rehabilitation can take place at any time across a life course or in a continuum and may include habilitation1, reablement2 and recovery3’ NHS England, Commissioning Guidance for Rehabilitation, March 2016 https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf
Rehabilitation is often characterised as complex and also underpins many healthcare solutions. Consequently an individual’s rehabilitation journey may touch on a variety of different services across the health and care system. Developing networks with a shared focus on improving rehabilitation can both confront challenges and find solutions, in part because collaboration can take place across boundaries of condition, profession and organisation: making use of innovative contributions from diverse participants. A strength of the community of practice lies in its positioning outside of one hierarchical structure: acting as a tool to link across the health and social care environment. Over the course of the programme, NHSCSI has developed and nurtured a diverse community of practice comprising service users, their families, service providers and commissioners from across the health and social care landscape. This multi-sector, multi professional group has been used to share intelligence and learning concerning the challenges of providing and commissioning rehabilitation. ‘I think the main impact in terms of the network to date has been the ability to shape the programme and has been the ability for us to have an independent credible voice that we can use to challenge our thinking. But also that’s been a powerful lever within the organisation in terms of us being able to set the priorities around rehabilitation.’ Lindsey Hughes, Rehabilitation Programme Lead, NHS England, ‘Networking to improve rehabilitation: why bother?’, NHSCSI Vodcast 2016
IRSCOP networkers have had an impact nationally, sharing their experiences with NHS England through, for instance, the development of a vision of what ‘good rehabilitation’ looks like [http://bit.ly/195tHpf].
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The process of assisting an individual with achieving developmental skills when impairments have caused a delay or blocking of initial acquisition of these skills. 2 The active process of an individual regaining the skills, confidence and independence to enable them to do things for themselves, rather than having things done for them 3 A deeply personal, unique process of changing one’s attitudes, values, feelings, goals skills and roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness For sources see https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf
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Networkers have influenced a range of national products that can be used to inform provision and commissioning of good rehabilitation. These include:
Rehabilitation is everyone’s business: Principles and expectations for good adult rehabilitation [http://bit.ly/1KVPcKs]
NHS England’s Commissioning Guidance for Rehabilitation [https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-1617.pdf]
2. Building a community that networks across boundaries of condition, profession, organisation and sector This particular network has been influential because of its ability to speak with a single common voice around the priority of improving rehabilitation, and it’s been influential because of the diversity of the membership Lindsey Hughes, Rehabilitation Programme Lead, NHS England, ‘Networking to improve rehabilitation: why bother?’, NHSCSI Vodcast 2016
Readers who wish to develop their existing networks or to build new networks to learn from each other and share the impact, value and contribution of rehabilitation may either recognise or find it useful to draw from the experience of NHSCSI as it worked to establish and build the IRSCOP. Over the years the community has grown from 135 (end 2012) to currently 584 known participants (end July 2016) (Figure 1). Figure 1
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Whilst it may seem a statement of the obvious to say it takes time for a community of networkers to grow and establish critical mass, more specifically, NHSCSI’s experience was that: a. Face to face dialogue with a specific focus appears to be a key enabler to engagement and seems particularly beneficial: - to support the engagement of people who use services - in engaging commitment of participants to adopt more active networking roles and behaviours - in reaching-out to draw-in participants from specific backgrounds or who may appear to be under-represented b. However, offering a range of modalities for engagement also appears to enhance the diversity of participation. For example, online engagement through webinars can also draw-in new participants or increase the activity of participants. c. Numbers of new joiners have generally peaked around the time of specific activities such as webinars and regional events focused around specific subjects of shared interests. d. It is clear that while there will be core networkers who remain committed to any network, others engage for variable amounts of time and this is to be expected and appropriate. In this community, a core of participants has remained engaged from its inception and the size of this group, who are still involved today (July 2016), grew steadily over the course of the programme. Other temporary participants were involved for variable amounts of time, according to role, enthusiasm and capacity to engage. Their total number at any point has been roughly constant (once peaks at the time of events are accounted for) and consists of different people at different times. (Figure 2) Figure 2
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e. Willingness to be a named contact4 has grown over the course of this programme from an initial 15% of 55 core participants to 45% of the core group of 429 identified in 2015 (47% of the 584 participants in today’s IRSCOP). This may be related to individual’s increasing confidence in being visible to others - ’putting their head above the parapet’, and also finding that the network proved to be of value as it became established. f.
Meeting individuals and having conversations at face to face networking events appears to reassure individuals about the purpose of a network and encouraged more visible engagement. Inviting participants directly to become named contacts at these events led to a related sharp increase in named contacts post event. This contrasted with a much slower but increasing trend in numbers when most of the networking was conducted online.
g. Diversity is always healthy in networking and it is worth reaching out to other groups and networks to achieve this. The range of participants illustrated in Table 1 below, helped enrich debate and learning at networking events and during the series of webinars produced with and for the IRSCOP. Table 1 Breakdown of participants according to role from 2012 to 2016 A. Participant numbers per role Total numbers of participants
Participant role Academic/ Education Charity Commissioning health, health & care, social care Community representative Membership Organisation Public Body (e.g. NICE, NHSIQ, NHS England) NHS Network Professional Body/ Trade Union Service Provider Service User Student Other TOTAL
2012/13
2013/14
31/03/15
18/07/16
3
14
18
26
3
0
0
5
21
66
61
63
0
5
6
8
0
0
2
2
4
7
10
17
4
10
10
16
0
9
12
13
64
271
351
417
31*
0
1
2
0
1
2
2
5
10
13
13
135
393
486
584
4
Named contacts have given NHSCSI permission to share their contact details with NHS England and other related work programmes as someone with a local interest in improving rehabilitation services
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B. Participants - percentage per role Percentage
Participant role Academic/ Education Charity Commissioning health, health & care, social care Community representative Membership Organisation Public Body (e.g. NICE, NHSIQ, NHS England) NHS Network Professional Body/ Trade Union Service Provider Service User Student Other TOTAL
2012/13
2013/14
31/03/15
18/07/16
2.2
3.6
3.7
4.5
2.2
0.0
0.0
0.9
15.6
16.8
12.6
10.8
0.0
1.3
1.2
1.4
0.0
0.0
0.4
0.3
3.0
1.8
2.1
2.9
3.0
2.5
2.1
2.7
0.0
2.3
2.5
2.2
47.4
69.0
72.2
71.4
23.0*
0.0
0.2
0.3
0.0
0.3
0.4
0.3
3.7
2.5
2.7
2.2
100
100
100
100
* Service User Reference Group
h. Service user involvement in networks has to be facilitated and supported. The Service User Group that is identified in the data for 2012/13 above was brought together with the express purpose of taking part in the development of an understanding of what rehabilitation really meant to people receiving services. Support was offered in many forms including training and ongoing interaction with others in the network. However, once service users perceived their purpose to have been fulfilled, numbers immediately dropped away. Networkers should actively consider how they involve service users and maintain their involvement i.
Despite explicitly welcoming all participants with an interest in improving rehabilitation and actively reaching out to groups with an assumed interest in rehabilitation some individuals and some groups chose not to engage. This is only to be expected given participation in networking is always a choice.
j.
Allowing the option for unattributed/anonymous participation in online forums appeared to support diverse engagement. Over the initial period of the IRSCOP it became clear that supporting people to post items that mattered to them encouraged engagement. At other times these same participants would become part of the greater number who chose to observe, absorb discussion and use the forum to find useful products. However it is important that there are ‘active’ visible networkers engaged to keep the network vibrant.
k. The use of social media alongside face-to-face dialogue, email and engagement through other digital platforms allows for a range of levels of engagement which networkers can opt-into or withdraw from according to preference. Twitter, for example provided an additional route for networking attracting some already known participants; others who then made themselves known to the IRSCOP and those who remained ‘unknown’ (not providing contact details to the IRSCOP) but who engaged via social media in an equally active and relevant way.
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3. Barriers and enablers to networking for improvement for this community of participants Over the course of supporting the IRSCOP, NHSCSI has identified and reflected upon issues that appear to have enabled or constrained networking activity. These are offered below for readers as they consider the suitability of their current networks or the steps they wish to take in developing networks or networking behaviours to both improve rehabilitation and to contribute to regional and local strategic priorities and Sustainable Transformation Plans. a. The importance of developing and sustaining open dialogue across roles and organisations has been emphasised by participants: firstly in the theme of ‘Communicate’ generated from their ‘soft intelligence’5 (Appendix I, page 22) and subsequently as a strong theme arising from regional stakeholders’ aspirations for future networking (see page 13) b. Face to face events with identified objectives have provided forums where individuals share experiences and information openly. However meetings have to be part of a mixed economy of networking modalities to allow for a range of preferred methods of interaction and to accommodate practical restrictions such as taking time out to travel to meetings or accessing internet sites at work to participate in webinars, for example. c. Whilst participants express a desire for access to online networking opportunities, many also express concern or lack of confidence in making use of these. NHSCSI has maintained and serviced the independent IRSCOP online forum [http://bit.ly/1QEeBfO] hosted on NHS networks. This particular platform was chosen for pragmatic reasons: - Anyone can access the site (access does not require an NHS email account) - There is good administrative and technical support - It is free to set up and use However, using online forums is not always that intuitive and it has frequently been necessary to support new networkers in navigating the website. d. Provision of ‘customer support’ (a known, named and helpful contact) has proved vital in both developing and enabling this community to network online: I. Participants have been more likely to become involved online when invitations are delivered directly by a named, known contact than when a general request is posted on a website. II. A role taking a ‘helicopter view’ and posting regular messages on the forum that reflect national, regional and local issues has helped stimulate discussion and debate in the community.
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‘Soft intelligence’ is the kind of information such as observations, experiences (both good and bad) and ideas that can be so useful to making a difference, but is rarely captured or shared. NHSCSI gathered soft intelligence concerning improving rehabilitation from networkers in the IRSCOP. The resulting analysis of data was offered back to participants for their use to inform and influence rehabilitation improvement, both nationally and locally.
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e. As the community grew, NHSCSI became aware that participants appeared to be reluctant to share information online that they had been observed to freely discuss in face-to-face events. The reluctance to make postings online may have been due to:
technical complexities of posting on the NHS Networks hosted forum ranging from individual online skills to NHS IT systems which may bar access to some sites reticence to enter debate or post information online that the authors may feel are subject to organisational approval or perceived as sensitive volume of work.
Participation on digital platforms was somewhat enhanced by: I. II.
invitations to participate in a debate being delivered directly by email from the known contact in addition to being posted on a web-page. an offer to post submissions on behalf of the participant.
Some participants took-up the offer to provide submissions by email to the named contact who would post onto the network’s forum for them. This was done either anonymously or under their name if given permission. However, the online forum continued to be primarily used as a repository for information and for signposting of resources as opposed to hosting open debate and dialogue. This contrasted with debate taking place on social media. f.
Formal and informal updates help. Updates delivered to participants via a group mail server enabled NHSCSI to keep participants informed of activity on the forum and to alert them to new information available, such as events in which they could participate; publications from events that have taken place or opportunities to influence future activities.
g. Invitations to contribute were initially formal, but reminders and nudges addressed more personally and in a brief and friendly style often yielded a positive response. h. It is the social networks of Twitter and to a lesser degree Linkedin where more open dialogue has taken place between both participants of the IRSCOP who have identified themselves to the project team and others perhaps unknown to the community. Using the hashtags, #rehabimprovers and #rehab, the number of social media followers has grown rapidly (Figure 3) and appears to span a wide range of different groups and experiences. However there continues to be some reported discomfort in engaging with and a lack of experience in managing the use of social media for some members of the community of practice.
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Figure 3
i.
Connecting with professional bodies appeared to enable the dissemination of information and to attract new participants. However, not all connections resulted in an increased flow of open dialogue as some established networks tended to focus communications predominantly upon the dissemination of information to a body of members as opposed to entering open, formative dialogue.
j.
Online products such as vodcasts and webinars (see page 1714) enabled audiences to access others’ learning and experiences: raising awareness of issues, barriers, innovations, tools and resources. Viewing numbers have been positive with, (at 31st July 2016) up to 500 viewings dependent upon the length of time each recording has been available online.
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4. Regional stakeholders’ aspirations for networking to support sustainable improvement of rehabilitation Stakeholders have expressed an appetite to both continue and build upon the achievements of the IRSCOP and have created a vision for rehabilitation networking (Figure 4). This was created by attendees at four regional rehabilitation stakeholder events held by NHS England in April 2016 (see Appendix II, page 27 for details of the method used to generate the themes contained in this vision. Initially, NHSCSI associates expected to produce a different set of themes for each regional group. However general consensus across all four regions plus a national group resulted in one common vision. The purpose in presenting Figure 4 is not to set-out a definitive ‘prescription’ or definitive guidance: rather it sets out the views expressed by and the appetite and aspirations of participants who took part in the networking workshops. Readers may use this as a discussion document to explore and/or take action upon as they build regional networks or develop the networking function of existing networks. This document is also available online [http://bit.ly/28IPuXo]. Pledges for action were initiated at a National Rehabilitation Networking event held in June 2016 when, as part of the day, the vision was given back to a smaller group of stakeholders from all areas. The group discussed this as part of their consideration of actions they choose to take to develop or build upon networking within and across their areas. The actions attendees committed to included:
Linking and brokering introductions between existing networks nationally and regionally Connecting with local stakeholders and leaders to champion and develop regional networks Sharing examples of good practice/ knowledge/ research/ evidence Working to make networks multi-sector and to include a broad range of stakeholders Sustaining learning from the national IRSCOP and avoiding the loss of useful information, resources and links Finding ways of gaining support to use digital resources and social media
The names and contact details of those who pledged to take action at the national event are included, with their agreement, in the regional databases of named rehabilitation networkers (see ‘How to find named rehabilitation networkers’, Page 19) Stakeholders need to make the shift towards networking that is embedded within and across regions. It has to be effective in informing and being informed by local commissioning and Sustainable Transformation Plans. In order to achieve this, stakeholders should:
develop and connect existing and new networks and networkers for the benefit of improving rehabilitation make themselves known and develop effective routes to engage with regional NHS England leadership teams
Many will offer action for the first, but few step forward for the second: issues of culture and confidence needing to be supported as this community affects the transition to the autonomy that characterises effective networking
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Figure 4 Rehabilitation regional stakeholders’ networking aspirations, April 2016 1.
The network has focus and purpose
2.
The network provides a regional focus on rehabilitation It is focused upon patient need and experience across a patient pathway The network assembles around shared purpose/ interest. It is active and outcomes-focused and is able to evidence that outcomes are being achieved There is a focus on sharing and expanding up to date knowledge/ ideas/ experiences There is a focus on sustained improvement, innovation and being creative The network can act as a platform for benchmarking, reviewing and feedback on local services The network can be a repository of information for local providers, service users and commissioners National, regional and local policies and priorities provide/ support the network focus The network supports generation of research Network structure
The structure of the network makes participation easy Names and contact information of those active/ interested in networking are openly shared It models and enables participants to perform within good practice guidelines and policies for networking The network is properly led/ facilitated by someone/ an organisation that both provides back-office support and has a ‘helicopter view’- not top down but can see bigger picture Participants feel that they are part of a well-established network that has the resources to sustain itself
3.
The network connects
4.
The network connects regionally, locally and nationally It is an informal ‘open’, autonomous network which also connects with other formal and informal networks The network models/ encourages collaboration to break through boundaries The network has influence
The network both attracts participants holding positional influence and enables others to become influential either as individuals or as a collective voice It has credibility and profile and therefore supports participants in their networking The network encourages fluid and inclusive participation The network has open, inclusive and diverse participation across all stakeholders including all sectors, professions and service users Participants are active in connecting / facilitating connections across diverse individuals / groups The network allows and enables participants to engage, disengage and re-engage according to capacity, energy, motivation, enthusiasm and choice People are free to choose different roles within the network according to knowledge, skills and preferences Smaller groups may emerge from the wider network to cluster around specific themes/ projects (eg locality/ condition/ profession…) Behaviour and values of the network
5. 6.
The network values and enables open and honest dialogue between participants who are supportive towards one another People demonstrate that they value and offer active feedback to contributions including frustrations, opinion and challenges People are willing to share how they have overcome barriers to change Networking is valued as an enabler for clinical professional and organisational responsibilities and becomes integral to individuals/ people’s roles Individuals take responsibility for their networking The network gives confidence/ validates services, ideas, approaches or innovations People use the network for information, problem solving, feedback and learning Participants are inspired to collaborate with energy and enthusiasm
7.
Networking benefits participants
People observe/ experience outcomes from their participation People experience greater support, collaboration and connectivity from involvement in the network People have greater understanding of others in the system including individuals, patient groups, professions, commissioners or services The network offers opportunities/opportunity-seeking to participants Participating brings professional, personal and job satisfaction
8.
The network provides a choice of networking modalities
The network offers a variety of easy and cost-effective ways to engage* and people are free to choose *(eg social media, apps, online site, tele/video-conferencing, face to face, named/non-attributable) Any on line platform should offer options for: service-only access service-user only access joint service provider-user access to discussions The network offers timely and accessible opportunities to meet face to face People can access learning/resources to increase their IT and social media skills and/or to facilitate their interaction within the network
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5. Resources developed by the IRSCOP that are available to initiate and support further networking within and across regions For those considering taking forward discussions, here are some resources to use for starting a conversation. Resource
Why this resource?
Content
Link
Vodcast: ‘Networking to improve rehabilitation: why bother?’ (July 2016) Storify and slide set from the National Rehabilitation Networking Event (8 June 2016)
This vodcast offers ideas and tools for building your network locally
Key national speakers talk about networking and its impact on the national programme and local priorities. It also signposts tools and offers practical advice about using social media.
View the vodcast: https://www.youtube.com /watch?v=uasKe6N8BJY&f eature=youtu.be
You may wish to consider what aspirations some networkers in your region have already expressed. This suite of resources will help your discussions about building your networking with others in your region.
View the Storify: http://bit.ly/28Zwd62
Webinar: ‘The transition from child to adult services with rehabilitation needs – what does it take to get it right?’ (May 2016)
You may wish to develop your network across the whole rehabilitation pathway and in particular, ensure there is a shared focus on making the transition between young people and adult services work for these service users
This day built on the aspirations for networking (Page 13) expressed by participants at the earlier NHS England’s regional rehabilitation networking events. A group of the IRSCOP met to consider how networking for the improvement of rehabilitation might become embedded within and across NHS regions and the agencies working with them. Linked resources including the regional networking aspirations, the Storify, and complete slide set are available. This webinar highlights the importance of providing support and guidance to young people with rehabilitation needs moving into adult services. It focuses on the real experiences of young people and service providers to reflect upon lessons learned and the transferable principles and knowledge that may apply across physical or mental health rehabilitation settings in child or adult health.
Vodcast: 'But I don't speak finance, I'm a clinician' (February 2016)
When considering your networking, it is important to engage widely. This vodcast will help inform building relationships between clinicians and finance teams to quantify the value of improved rehabilitation
A clinician provides their perspective of the imperative for clinicians and finance working together to enable the commissioning, delivery and demonstration of 'best possible value'.
https://www.youtube.com /watch?v=-VIlcLvy5dE
Webinar: ‘What is the value of rehabilitation and how to quantify this’ (January 2016)
Networkers frequently told us that articulating the value of rehabilitation is difficult. This webinar offers ideas for discussion within your network
The webinar illustrates the economic value of rehabilitation, using a local case study, from a provider and commissioner perspective. It also provides an overview of what ‘Best possible value’ means in the context of rehabilitation and describes resources and support available to help providers and commissioners quantify value
youtu.be/fxmW21zH_fs
Vodcast: ‘You want to commission rehab? We say know, know, know!’ (December 2015)
If you wish to influence or undertake commissioning that results in good rehabilitation services, this vodcast could help your networking between commissioners and providers to achieve this.
A commissioner gives their perspective of rehabilitation, the challenges surrounding its commissioning and the impact that good rehabilitation can have in delivering commissioning objectives and value.
https://youtu.be/FFoYK8Y MwHY
View the slide set http://bit.ly/28INnqY
https://youtu.be/oIvnVSJ MmuA
Issues such as ways to engage with your finance department, making meetings productive and where to find support to achieve the best value from your service improvement are addressed.
A broad overview of the NHS England Rehabilitation Programme is included and ‘Rehabilitation is everyone’s business: Principles and expectations for good adult rehabilitation’ highlighted
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Resource
Why this resource?
Content
Link
Webinar: ‘Managing Relationships for Transition’ (March 2015)
An individual’s rehabilitation pathway may extend across a range of services and providers. These two webinars support networkers linking across organisations and pathways
This webinar explores two examples of how rehabilitation service providers carried out service improvements across a pathway. In particular the webinar discusses how they are improving transition for people who use the service including enablers and barriers, working in partnership and sharing skills and expertise across providers to ensure effective transition. This webinar explored two examples of how providers have carried out service improvements across health, social care and the voluntary sector: achieving collaboration across organisational boundaries, maintaining momentum when undertaking service improvement and the leadership required.
https://www.youtube.com /watch?v=ynGG0_TP7q4& feature=youtu.be
Webinar: ‘Integration in Action: Breaking Down Boundaries’ (February 2015)
https://www.youtube.com /watch?v=72-SpTMV_YI
Webinar: ‘Unlocking Evidence of Best Practice’ (January 2015)
Rehabilitation networkers are often required to articulate their evidence of best practice. This webinar offers support for using and sharing evidence across a network to implement ideas and best practice.
This webinar focuses on evidence and what it is. It looks at the equally valuable but different roles of numerical and ‘softer’ data to describe effective rehabilitation to others. The barriers that prevent the sharing of evidence of best practice that would lead to the scaling up of ideas are discussed along with ways of overcoming these barriers
http://youtu.be/k1jA5h2z GL0
Webinar: ‘Making Rehabilitation Work Better for People’ (December 2014)
Including the service user’s perspective in networking to improve rehabilitation services is essential. This may help consideration of a shared focus for all stakeholders in a network
A service user, a charity representative and a national leader considered how changes could be made that better support people to return to meaningful occupation, including education and work.
https://www.youtube.com /watch?v=8m7b3U3AcVA &feature=youtu.be
Webinar: ‘Who cares about my outcomes?’ (March 2014)
Networkers may wish to focus on the use of outcomes and their relevance to local priorities. This webinar can support those discussions
This webinar discussed the broad use of outcome measures that have relevance for all stakeholders and their place in aligning outcomes, indicators and measures locally and regionally
https://www.youtube.com /watch?v=48M-oYqKJ0k
Webinar: ‘Everyone has a leadership role in commissioning and providing integrated care’ (March 2014)
Good rehabilitation relies upon integration and integration relies upon relationships: This webinar can stimulate your network’s thinking about leadership and building relationships in improving rehabilitation services
Speakers offer top tips around leadership in commissioning and providing rehabilitation services. An experience of leading change to improve rehabilitation services was explained including the rationale for change and outcomes. The webinar also discussed ways of influencing using a range of data
https://vimeo.com/89110 147 (Please use the password ‘webex’ to view this video)
Snapshots of redesign/ improvement/ innovation 2013-15
These examples of IRSCOP networkers’ rehabilitation service improvements may stimulate ideas and debate within your network.
Examples of service redesign, improvement and innovations range from ideas yet to be executed through to evaluation of their impact.
Snapshots 2014/15 Snapshots 2013
Soft Intelligence Summary Bulletins 2014-16 (See page 16)
These summaries contain themes that may trigger conversations in your network about the focus of improvement in rehabilitation
The profile of local service improvements has been raised by their inclusion in this on-line resource. These bulletins contain themes that represent hypotheses regarding the critical factors for the dissemination and adoption of good practice in the field of rehabilitation.
Bulletin April 2016 Bulletin March 2015 Bulletin December 2015 Bulletin December 2014
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Soft Intelligence NHSCSI describes ‘soft intelligence’ as information drawn from observations, experiences (both good and bad) and ideas that can be so useful to making a difference, but that is rarely captured or shared. NHSCSI gathered soft intelligence concerning improving rehabilitation from networkers in the IRSCOP between October 2014 and April 2016. The resulting thematic analysis of data produced fourteen overarching themes (Figure 5) representing hypotheses regarding critical features for the dissemination and adoption of good practice in the field of rehabilitation. Figure 5
Hypotheses regarding critical features for the dissemination and adoption of good practice in the field of rehabilitation 1.
COMMUNICATE
2.
WORK TOGETHER
3.
DEVELOP THE EVIDENCE BASE
4.
ALIGN OBJECTIVES FOR IMPROVEMENT
5.
CREATE A CULTURE FOR CHANGE
6.
BE ACTIVE IN NETWORKS
7.
INFLUENCE STRATEGICALLY
8.
DEVELOP AND IMPLEMENT COMMISSIONING SOLUTIONS
9.
SHARE EVIDENCE
10. ADOPT NEW MODELS & BEHAVIOURS 11. APPLY THE EVIDENCE 12. MAKE THE EVIDENCE ACCESSIBLE 13. USE TECHNOLOGY TO SUPPORT SERVICE IMPROVEMENT 14. WORKFORCE SKILLS & CAPACITY
The detailed case features underlying these themes and information about the questions and method used to gather and analyse the intelligence is provided in Appendix I (page 22). These are not presented in any sequential order and do not represent definitive guidance, but lines of enquiry that networks may choose to use as triggers for reflection or conversations about their focus for improvement in rehabilitation
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6. Tools to support regional networking The following nationally produced resources are just some of many available, but offer developing networks/networkers a focus, information and help to draw-in new stakeholders to congregate around a shared purpose. Improving Rehabilitation Services Community of Practice (IRSCOP) web pages and discussion forum hosted on NHS Networks NHSCSI have used this free and open platform for networking around health and care to create a safe place to host all the IRSCOP products described in this report.
IRSCOP web page(s) IRSCOP discussion forum
NHS England’s commissioning guidance for rehabilitation This interactive, online guidance supports the commissioning of effective, high https://www.england.nhs.uk/wpquality rehabilitation services, covering the whole life course and the full range of content/uploads/2016/04/rehabilitationrehabilitation for both mental and physical health comms-guid-16-17.pdf Readers will find: What rehabilitation is, i.e. scope, breadth and depth. The components of good quality rehabilitation. How to know whether the services that are being commissioned are of good quality. How to compare rehabilitation services locally, regionally and nationally. The guidance also provides access to a great many resources within its reference list, hyperlinks and comprehensive appendices. Rehabilitation is everyone’s business: Principles and expectations for good adult rehabilitation This document outlines principles and expectations of improved adult rehabilitation services that were derived from extensive discussions with a variety of stakeholders including many of the IRSCOP and additional data provided through a compilation of the case studies and ‘snapshots’, of rehabilitation redesign/ improvement/innovation.
http://bit.ly/1KVPcKs
NHSIQ networking toolkit – stronger networks, better outcomes NHS England, Sustainable Improvement Team are building the movement for improvement and safety across the country, enthusing and exciting people to engage in change and transformation. This on line resource supports networks to go further, faster together.
http://www.networksdiagnostic.org.uk
A vision of what ‘good rehabilitation’ looks like Seventy three service users and carers produced data that was thematically analysed. The themes were tested and refined with a stakeholder group of 104 commissioners and providers from across the health and social care spectrum including the voluntary sector. The vision that resulted was used in an open forum event to identify stakeholders’ views on the barriers and enablers to good rehabilitation services.
http://bit.ly/195tHpf
NHS Networks NHS Networks is one of many digital platforms available to support networking. Anyone can access the site (access does not require an NHS email account), there is good administrative and technical support and it is free to set up and use. Networkers without existing access to open digital platforms could, should they wish, set up an online network or open a discussion forum without cost using NHS Networks
www.networks.nhs.uk
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7. Finding a diversity of expertise and advice to support local and regional strategic plans:
"I would really encourage people that share a passion around rehabilitation to build on their networking because they will have discovered so far that it really brings benefits to learn, share and connect with others. And if that networking activity stops then they will be restricted and confined to their organisations, the silos that they work in and the hierarchal ceilings and therefore opportunity to innovate and make improvement could become restricted and stifled and their energy and passion may not be as strong as it was and is when they network with others." Liz Maddocks-Brown, Senior Manager – Networks and Faculty, Sustainable Improvement Team, NHS England ‘Networking to improve rehabilitation: why bother?’, NHSCSI Vodcast 2016
Following the four regional rehabilitation stakeholder events held by NHS England in April 2016, NHS England Regional Medical Directors expressed support for the connection and engagement of rehabilitation networkers into strategic planning. These offers have the potential to maximise the value, impact and benefit of rehabilitation for people who need these services, but will also fade if they receive no response. Participants of the IRSCOP must now consider whether to take up these offers or to leave them on the table. Taking up the offers will require rehabilitation networkers to be proactive in coming forward to offer helpful solutions as to how this engagement can be achieved. At the same time leaders at all levels must recognise that individuals with an interest and expertise in rehabilitation may be difficult to recognise. They are often embedded within organisations and structures that do not label their role or expertise as being in ‘rehabilitation’. They may not sit at the interface at which strategic planning discussions normally take place; may be dispersed across service areas and may not have clear and identifiable structures or hierarchies through which communications and points of contact can be established. If the opportunity to harness rehabilitation in support of the development of strategy and the meeting of priorities is to be exploited, it is important that: individual stakeholders empower themselves to act upon their aspirations; connect with each other and identify themselves to strategic leaders even if their starting point is ‘thinking big and starting small’ system leaders support the cultural change that may be required to liberate rehabilitation leadership at all levels to meet, connect and enter dialogue in a way that may be, even if only through perception, judged as ‘beyond their pay grade’. A starting point will be for networkers and leaders alike to identify and access people in their local and regional communities who have already declared themselves as passionate about rehabilitation. Over the lifetime of the IRSCOP, NHSCSI has built a large database of around 584 (at end July 2016) participants across the country. This database is arranged in regions, plus a national group. 47% of these rehabilitation networkers have given their consent to be named contacts for this community as at the end of July 2016. This means that they have given permission for their contact details to be shared with other networkers and aligned projects or work-streams. 18
These regional databases are provided as a resource to support the continuation of regional and local networking by identifying individuals who:
can offer rehabilitation experience and knowledge may support one another as they develop their regional networking communities. may act as a conduit to engage other local and regional networks, thereby building upon what already exists and avoiding reinventing systems and networks.
Equally importantly, a regional focus for rehabilitation improvement must not be allowed to encourage regional ‘silos’. Instead every effort should be made to maintain networking with others across the country and with those in national roles. The value of the national IRSCOP has been in the flow of ideas and experience across and between regions and other networks. Networks facilitate dialogue and collaborations across traditional organisational boundaries. Many participants in the current community of practice hold national roles and have expertise that may not be replicated in each region. How to find named rehabilitation networkers Details of named rehabilitation networkers in your region, other regions or of national networkers can be obtained from Joyce McKenzie
[email protected]
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8. Food for thought… a working note In the closing paragraphs of this document, NHSCSI does not wish to draw conclusions or make recommendations, but rather to offer some reflections gathered over the course of a journey alongside a community of people who are passionate about rehabilitation and getting it right for people. There will not be definitive answers to the opportunities, dilemmas and challenges that readers will face if they choose to put their energy into networking for the benefit of improved rehabilitation: readers will encounter these within their own specific organisational, social and human contexts. There are also many tools and much guidance available, some of which has been captured here, but much of which the reader will know more about than the authors of this document. The following points offer some reflections and other possibly provocative questions that we give back to the reader to reflect upon and, perhaps, use to create a shared understanding with colleagues and partners as they build effective networks: a. NHSCSI has observed a great passion and enthusiasm for uniting to get it right for people who need rehabilitation. There is also a strongly espoused value of openness and sharing for ‘the good of all’. At the same time there can be reticence to open sharing, being noticed and taking action that might, somehow, be ‘beyond one’s remit’. b. What might you do to enable yourself and others to become more active in participating? What will enable you and others to feel safe and confident in contributing to open debate? What activities engage people’s enthusiasm? What friendly, named points of contact, support and mentoring can you find/provide within or outside your organisation? c. Messages that NHSCSI has heard along the way are, ‘there needs to be guidance for commissioners’, ‘rehabilitationists need to be recognised and made visible’, ‘rehabilitation could offer so many solutions if it were commissioned to do so’. In the context that nothing is ever perfect, it would seem that some gains in these areas have been made. Networking undertaken by this community of practice has contributed to NHS England’s online guidance to support the commissioning of effective, high quality rehabilitation services [https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-1617.pdf] NHS England Regional Leaders’ expressions of support for the connection and engagement of rehabilitation networkers into strategic planning present exciting opportunities and offers, but these could fade if not taken up in good time
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d. If it is important to you that networking for improving rehabilitation contributes to regional, strategic planning Are you assuming that someone else is making the connection between the ‘front-line’ and the key leadership or strategic players? What is the risk of that assumption? If there is no obvious individual to take the first step, what will you do to support and enable any individual who steps-up regardless of their role? Whatever actions readers’ choose to take, it is hoped that the body of work built by the IRSCOP provides help and that the connections made will be built upon as those passionate about rehabilitation continue to exercise their potential to make a difference.
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Appendix I Soft Intelligence Figure I.1 Questions used to elicit soft intelligence (SI) from the IRSCOP SI Question 1 (Oct – Dec 20146): What is critical in the dissemination and adoption of good practice in the field of rehabilitation services? SI Question 2 (Dec 14 – Feb 2015): What is key to getting successful face to face meetings across professions, services and agencies to improve rehabilitation services? What barriers have to be overcome in order to get ‘the right people’ in the room? What barriers have to be overcome in order to get value from face to face meetings once people are together? What hints and tips can you share to get the best from face to face meetings once the necessary participants from different professions, services and agencies are together? SI Question 3 (Oct- Nov 2015): Are there forms of technology that you think could help in providing good rehabilitation as set out in ‘Rehabilitation is everyone’s business: Principles and expectations for good adult rehabilitation’ What helps you make use of or commission technology for rehabilitation? Are there any barriers to you using or commissioning appropriate technology? Do you have any local evidence of technology delivering solutions for commissioner i.e. delivering commissioning outcomes in terms of patient benefit and/or economic value? SI Question 4 (Jan 2016): What data you are gathering that satisfies both clinical and commissioning drivers for improvement? If this is not happening, what do you see are the barriers? SI trigger sentences used pre-webinar ‘The transition from child to adult services with rehabilitation needs – what does it take to get it right?’ (13 May 20167) Some of the things that service users tell us gives them a good experience are… The things that help most are… If there is one thing I could stop providers/commissioners doing / saying / believing it would be... The most helpful things that providers/commissioners do / say / believe are... The most unhelpful things that providers/commissioners do / say / believe are… If I could have three magic wishes about how moving from children's into adult services will look in the future, these would be... NHSCSI used a variety of methods to gain responses to these questions including postings on the online forum and a webinar pre-questionnaire for the webinar ‘The transition from child to adult services with rehabilitation needs – what does it take to get it right?’ However the most successful techniques used were direct emails and informal reminders combined with an offer to post networkers responses anonymously. The resulting analysis of data was offered back to participants for their use to inform and influence rehabilitation improvement, both nationally and locally. 6 7
Dates in brackets indicate when data was collected for each question Date of webinar
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Figure I .2 Summary of emergent themes (hypotheses) and case features regarding factors critical for the dissemination and adoption of good practice in the field of rehabilitation services 1. COMMUNICATE a. b. c. d. e. f. g. h.
Using a range of materials and multi-media routes to disseminate evidence of good practice both within and across professions and agencies Developing understanding and recognition of the breadth of rehabilitation activity; the range of roles delivering rehabilitation and building confidence for providers to promote those roles and services Developing trust and understanding across professions, services, organisations and service users through contact, communication and feedback at all levels Using plain language and an accessible format to set out the evidence for practitioners and service users Developing shared language between ‘rehabilitationists’ across the system Leaders, bodies and associations helping dissemination and adoption by communicating with individuals across fields Including people using services in making decisions about their outcomes Identifying and agreeing a focus for effective discussion and outcomes for meetings
2. WORK TOGETHER a.
Developing local partnership working, training and support for improvement: Both across professions/agencies (including third sector) across the pathway and across individuals within the same professions from different services i. Professions, providers, service users and commissioners working together at all levels (from individual practitioners through local, regional and national, strategic leadership) to improve access to good quality coordinated rehabilitation services, supported by appropriate data and cost-effective technology j. Services innovating to recognise people who use services and those who are important to them, including carers, as a critical part of the interdisciplinary team k. Ensuring engagement of the right people including patients, carers, commissioners and health and social care professionals for a successful outcome l. Advocating and modelling collaboration to address financial constraints rather than competition across professions and agencies m. Collaborating across the system including with service users to focus on meeting the needs of a community
3. DEVELOP THE EVIDENCE BASE a.
Being active in sharing tools techniques and approaches for putting evidence into practice and sharing learning on how to navigate barriers b. Valuing and promoting the role of all types of data (numbers and stories) in contributing to evidence c. Local services developing tools/using standardised tools to gather evidence of cost savings as an outcome of effective rehabilitation d. Professional bodies encouraging the collection of multi-professional evidence e. Supporting and advancing research across professional boundaries f. Committing to building competencies and capacity to develop the evidence base in ‘rehabilitationists’ at the level of the department, organisation and professional body g. Establishing relationships with higher education institutions/academic partners to support the building of competencies and capacity to develop the evidence base h. Influencing research funding and priorities towards the collection of multi-professional evidence focused on the service users’ needs i. Commissioning for research capacity within rehabilitation services j. Developing patient focused outcome measures across all sectors k. Engaging patients, their voices and experiences in developing evidence l. Signposting funding sources for rehabilitation research m. Improving access to research opportunities through effective processes to support a wider range of researchers n. Ensuring that appropriate outcome measures are used to build evidence for rehabilitation for individuals, groups and populations o. Searching for and using international evidence p. Uptake and use of technology requires both feedback to manufacturers/designers and collection of evidence to develop and spread understanding of how it can be used effectively and reduce its cost q. Sharing evidence and providing experience of using technology to promote uptake r. Data collection and the systems used should be sophisticated enough to record and identify outcomes from different service elements working in an integrated model of service delivery
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4. ALIGN OBJECTIVES FOR IMPROVEMENT a. b. c. d.
Uniting clinical, managerial and commissioning objectives (national and local) to embed good rehabilitation into priorities Gathering evidence through agreed/ co-designed metrics, data systems and analysis that satisfies commissioning, management and clinical drivers for improvement Uniting disciplines in change driven by patient-centred action Commissioning and using technology to support clinical and commissioning objectives
5. a. b. c. d.
6. a. b. c. d.
b. c. d. e. f. g. h.
h. i.
INFLUENCE STRATEGICALLY
Developing and mobilising a breadth of clinical leadership across medical and psychosocial models of rehabilitation Leaders helping dissemination and adoption by focussing on large projects which can spread easily Identifying key stakeholders to influence Thinking widely to identify enablers and barriers Using others' experience to develop and achieve objectives Seeking out mentors to give feedback and challenge Using effective communication approaches to influence strategically against shared priorities Having resilience to pioneer use of new technology/ new ways of working, sometimes in the face of organisational reluctance
8. a. b. c. d. e. f. g.
BE ACTIVE IN NETWORKS
Providing contact details and putting active people in touch with each other Taking responsibility to regularly make contact and engage with other active individuals Using interdisciplinary networks, including service users, to raise awareness, discuss, educate and share learning Discussing implications of implementing patient-centred outcomes upon practice across professional boundaries
7. a.
CREATE A CULTURE FOR CHANGE
Committing to action and seeing change happen to promote confidence to change Taking individual action to lead change Develop, support and protect time for clinical innovators Sharing knowledge to identify and attain grants and other funding to disseminate new ways of working beyond organisational boundaries
DEVELOP AND IMPLEMENT COMMISSIONING SOLUTIONS
Developing tariffs/unbundling tariffs to reflect rehabilitation pathways Building consensus and agreement when commissioning for innovative rehabilitation models across agencies Developing commissioning outcomes guidance for rehabilitation Commissioning appropriate services based on evidence for effective rehabilitation Using appropriate outcome measures to articulate value and inform commissioning Gathering data from across a patient pathway to inform clinical and commissioning drivers for improvement Develop commissioning and procurement of rehabilitation to reflect guidance on best practice (both clinical and commissioning) and to deliver best possible value Commissioning that uses outcome data to support and enable quality improvement Flexibility to commission/contract for and run new models of care in order to gather data which both tests and informs potential outcomes for patients
9. SHARE EVIDENCE a. b. c. d. e. f. g. h. i. j. k. l.
Professional bodies, AHP leaders, specialist networks and providers sharing evidence of potential cost savings as an outcome of effective rehabilitation Professional bodies their members and leaders disseminating evidence within and across professional boundaries to inform commissioning and adoption of best practice Local services using multidisciplinary outcome measures to communicate evidence effectively across a range of audiences Professional bodies publishing evidence in journals with a wide readership Spreading evidence through appropriate blogs and networks with a wide readership Academic institutions sharing evidence held on research sites Ensuring the patient experience informs the developing evidence base Making evidence accessible and sharing with service users Rehabilitationists sharing and using the relevant evidence relevant to an individual’s care Sharing and using evidence collected to benchmark services and support service improvement National data set systems providing appropriate tools and sharing evidence to support service improvement and assure commissioners of those improvements Routinely collecting well established outcome measures to demonstrate rehabilitation value to others
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10. ADOPT NEW MODELS & BEHAVIOURS a. b. c.
Services innovating to support self-management through education and information to maintain health and wellbeing to achieve maximum potential Adopting effective, person centred care, including use of technology, where this facilitates delivery of good outcomes, including good patient experience Encouraging development of the workforce to embrace new ways of working including the use of technology
11. APPLY THE EVIDENCE a. b. c. d. e. f. g.
Using the evidence to set standards at all levels against which to adopt best practice and improve quality Using the evidence to inform commissioning tool/s incorporating standards, outcomes and cost Using data and evidence to discuss and inform staff competencies and maximise effectiveness of rehabilitation practice and models Using the evidence to generate patient-specific outcomes and target intervention and resources Including action research methodologies to apply evidence incrementally to inform care and practice Using evidence to shape effective models of rehabilitation that meet the needs of individuals Using data and evidence to inform design and commissioning of improved services and pathways
12. MAKE THE EVIDENCE ACCESSIBLE a. b.
Establishing consistent use of repositories for rehabilitation evidence regardless of agency, profession or specialism and which protects ‘business sensitive’ evidence Developing interdisciplinary evidence-based guidance
13. USE TECHNOLOGY TO SUPPORT SERVICE IMPROVEMENT a. b. c. d. e. f. g. h. i. j.
Technology can facilitate transition planning and discharge Technology should enhance improvement/manage risk in the patient pathway Selected technology should be cost-effective for all (commissioners, providers and people using services) Technology can increase effectiveness and safety of intervention Use of technology supports development of skills and sharing of expertise across staff and organisations Service providers and people using technology collaborating with product designers/IT experts to co-design patient-centred solutions Taking local action to find technology that matches the specific needs of the service/system of participants Technology can increase the cost effectiveness of service delivery Making best use of existing technology Service users can be early adopters of technology to support rehabilitation
Themes derived from responses associated with the webinar: ‘The Transition from Child to Adult Services with Rehabilitation Needs – What Does it Take to Get it Right?’ COMMUNICATE a. b. c. d. e.
Time taken to support timely 2-way communication to clarify expectations, needs and plan transition from one service to another with the young person and family at the centre. Planning that involves communication between all service providers across health and social care. Holistic formulation of needs prepared and communicated by children’s service to adult service in advance of transition. Communicating across services and with young people to time transfer to adult services according to individual needs rather than just age. Paediatric clinicians have knowledge of available adult resources in order to plan and communicate effectively.
WORK TOGETHER a. b. c. d.
Young people and their families working in partnership with clinicians have an agreed transition plan in advance of moving to adult health and social care services The agreed and documented plan includes the handover of clinical information and clear lines of accountability. Child and adult services should meet together to plan transition in advance, and this should include arranging a meeting between the young person and the adult service. Services for young people and for adults work together so there are no gaps in services provided during and following transition.
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CREATE A CULTURE FOR CHANGE a.
A culture that considers and plans for the breadth of needs of the individual so that young people can transfer to integrated models of care rather than a series of specialist areas.
BE ACTIVE IN NETWORKS a. b.
Having a key contact in children’s service beyond transition who can be contacted if required. Use networks to ensure that children’s services are well informed of the services for adults that are available to inform the expectations of young people and their family regarding future care.
DEVELOP AND IMPLEMENT COMMISSIONING SOLUTIONS a. b. c. d. e.
Commission rehabilitation packages of care which follow the young person from child to adult services Commission rehabilitation according to need, with understanding that some individuals will required extended intervention to support transition into more independent life. Commissioning support for service development and quality of care. Child and adult services working together with commissioners to inform commissioned resources and processes. Ensure equity of transition experience for all young people through documented pathways and standards of practice
ADOPT NEW MODELS & BEHAVIOURS a. b. c. d. e. f. g. h. i.
An understanding by all involved that transition requires two-way communication and planning. Rehabilitation transition coordinator/case managers in children’s services to support communication and planning with adult services and transition between hospital and community services. A friendly and welcoming environment in adult services that listens to young people Rehabilitation provision is provided according to need not age. Recognition that some young people have high level needs requiring intensive input. Commissioners are informed of the needs of young people with chronic health conditions moving into adult services. Therapy services build the capacity to monitor young people as they grow into adulthood to proactively support changing needs. Clinical services offer the informal opportunity for young people to be together (e.g. young person clinics) Adult services use young-person centred styles of communication and flexibly deliver services according to need. Proactive culture of care focused on possibilities not limitations in care
USE TECHNOLOGY TO SUPPORT SERVICE IMPROVEMENT a.
Capture and share data between child and adult services to alert them to young people approaching transition age
WORKFORCE SKILLS & CAPACITY a. b.
Workforce in adult services with skills and capacity to differentiate their approaches to meet the needs of young people. Specialist training for adult services treating young people with conditions associated with high rehabilitation needs.
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Appendix II Method used to generate a vision for rehabilitation networking and access to the raw data Seventy-four people in total provided data as part of attending workshops facilitated by NHSCSI across the four stakeholder events. Attendees at each workshop were given the following trigger questions: It is April 2017. I am part of an effective network that supports the development of rehabilitation services… What does the network look like/do? What am I doing – feeling? What am I getting out of it? What will enable participation? Responses given by participants were then collated by region for thematic analysis. These analyses were then used to draw out emergent themes representing hypotheses regarding a vision for the future of networking for the improvement of rehabilitation (Figure 4, page 13).
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