Context; how where we work impacts on what we do

6.3.3.1 A receptive context

A receptive context, where healthcare professionals are open to change, for example the introduction of new ways of working, was noted as an important factor in the

154 and healthcare disciplines. Whilst disparities relating to the uptake of new initiatives or guidelines were identified between departments they were also noted within departments too, making it challenging to implement change. Reasons for the reluctance to change were stated as being the lack of desire to change old ways and concerns that the new way of working would result in more work. The latter was felt so strongly that it was reported as resulting in healthcare professionals contacting their Union as a reaction to the change, as the following quote indicates;

“… it takes a long time to convince people that by using this guideline things will be improved. So first, because they are always used to using the same methods… and if the guideline means more work for example, we’ve had instance for example where for example we did some guidelines and we have Unions coming up because of more work for example or because a major change needs to be implemented.” (IB04)

Comment was however made that one may start out reluctant to implement change but after it has been illustrated that the change has a positive effect, then engagement is achieved.

“If enough people subscribe to them and they are shown to be useful, then I think they will be taken up.” (IA03)

6.3.3.2 Receptive context and the role of the patient

Reluctance to change as outlined was not just attributed to healthcare professionals. Respondents indicated that a receptive context is also influenced and reliant on the role of the patient and their attitude. It was identified that patients can sometimes be unwilling to change their health behaviour or accept an alteration in their healthcare management, thus causing a barrier to change. These behaviours not only were regarded as affecting the patient, but the ability of the healthcare professional to manage the patient in a preferred or new way. The subsequent quote summarises the different influences of reluctance and the difficulties that can arise;

“Which is, certain nurses, certain people are reluctant to that change, which will cause others that will really need or really want to move to this desire change to be very difficult. It could be from the nurses side it could be from the patients side to change their routines … and from the medical side as well. Sort of sometimes we get stuck in what we know best sort of … and we are afraid to move further.” (FG205)

155 6.3.3.3 Implementation of new initiatives

Regardless of the recognition that a disinclination for change may exist, findings indicated an appetite for the implementation of new initiatives and ways of working. This was not only expressed through the interviews and focus groups but observed during the

discussions of the guideline and the potential for change. Efforts to implement new ways of working or engage with change were reported as being on an individual level or as a department, for example an individual might put together a guideline and lead on its implementation within a specific department. Participants reported that these types of activities and behaviours were often dependent on the individual and have a strong element of being personality driven. This was linked to harnessing the enthusiasm of others and ensuring the right stakeholders are involved (see section 6.3.5.3).

6.3.3.4 Sensitivity to context

The importance of the necessity to contextualise guidelines was a strong theme. Consideration of the context, the macro and micro healthcare environment, in which healthcare is delivered as having its own nuances, was recognised by participants who proffered that the content of guidelines should be modified to reflect the local context. Participants advocated this to be the case particularly when related to specifics such as diet, antibiotic resistance, the availability of items such as pharmaceuticals and services. Concern was expressed that without contextualisation the guidelines would not succeed. Observations were made particularly in the guideline discussion group of the importance of the contextualisation of the guideline. A good example of this was the discussion regarding BMI and how the current level recommended in the UK would not be possible in Malta as there were too many people with a BMI of that level. Thus the recommendations made were with this salient point in mind (these can be seen in Appendix T).

“Putting them in a local setting is one of the basic requirements of good guidelines.”

(FG202)

“So if there is a different prevalence, if people are susceptible to something different, if the environment is different, that will change. I mean it depends what the guideline is but in general it’s always important to adapt guideline to local use.” (IB02)

156 6.3.3.5 The need for a coordinated approach

Participants reported that even though there was a coordinated approach in the hospital towards the development of guidelines, through the existence of a guideline group, this did not prevent individuals, within departments or wards from creating their own guidelines. It was acknowledged that this was changing as was the reluctance to adopt the guidelines from the medical department in the hospital. Although the group is from the medical department they were keen to state that a multidisciplinary approach was taken to developing guidelines as there is an acute awareness that for any guideline to be used, collaboration is needed. This supported the role of having a multidisciplinary group for developing this guidelines. However, it was observed that within the group, not all

participants were accepting of the development. Change was seen as being facilitated by multidisciplinary involvement and was identified as being important to the development of guidelines or policies and their implementation. It was revealed that this way of working and inclusion in particular of allied health at all levels, could be and needed to be improved.

“By being involved, you actually have your say how you want these guidelines to be.” (IA09) “I personally was never involved in formulating guidelines before, so the guidelines were there and we just have to follow them, so being present in this group makes you realise how important it is to go on evidence based studies and data.” (IA05)

“And anyone really who needs to be involved. If it is the caretaker who needs to be involved because someone needs to be wheeled somewhere (laughter) or whatever, you know the porter, then we’ll involve them.” (FG202)

6.3.3.6 Resources; the impact of financial and human constraints

Resources, both financial and human was a strong theme relating to the context in which healthcare professionals function. They are discussed separately here although it is evident that they have an effect on each other.

Financial: A lack of financial resources was recorded as being a barrier to the provision of care, particularly in regards to resources for new staff, medication and new healthcare interventions including lifestyle interventions. The availability of and securing of financial resources was commonly mentioned and noted that without either, it would not be possible to implement the guidance. The ways in which financial resources could be secured was referred to often, linking it to politics, suggesting the involvement of the

157 Ministry of Health and other politicians, and increasing the awareness of those with

financial responsibility within and outside of the hospital.

“I think, I mean we really need to organise the staff before you can actually implement the guidelines. I mean somebody needs to sit down and finance the whole thing and make sure that the staff are around. There’s no use implementing a guideline and saying you need a psychologist post op and you don’t find one.” (IA03)

Now the politicians will come and say, I don’t have the money, I don’t have the money, but they’ll say they are on the NICE guideline as well.” (IA09)

“Now the problem with politicians is that they see only the short erm, erm, and that’s not an easy problem to solve.” (IA09)

“Finance, obviously that is the first, as is the first barrier, it’s the first, cost to implement them, you know financially it has to last for many years” (IB06)

“Its all going to come to finance. A report is always going to come down to finance; budget, budget, budget.” (IB05)

Human resources: The lack of human resources was considered to be as great, if not a greater problem as financial resources. Concern was expressed by participants that Malta had already reached the point at which there were no more available human resources. Reasons given for this were; the population of Malta is small and therefore there is a restricted amount of people to become healthcare professionals; it takes time to train people; there is a level of attrition as some leave Malta and work overseas or move into the private sector. It was disclosed that in many areas of healthcare professions, the health service in Malta is below the recommended complement of healthcare professionals by the World Health Organisation. Solutions were being sought such as making it attractive for Maltese healthcare professionals working overseas to return, employing healthcare professionals from overseas, identifying new pathways of care in an attempt to streamline the care needed. These challenges underpin the importance of considering how human resources can best be used, how the system can adapt in order to work with less and how an assumption cannot be made that human resources are an endless resource.

158 “when it comes to evidence based practice in terms of human resources, then it’s a totally

different scenario because if you don’t have the right compliment of people, ok then you can never do the evidence based practice.” (IB07)

“It would make it easier if I could, if I had the right staff complement. It would make it much more easier.” (IB07)

Participants expressed frustration that as individuals and departments they want to improve, and embrace new ways of working such as the incorporation of guidelines or models of delivery of care, but the human resources do not exist to allow this to happen. It was acknowledged that this lack of resources places restrictions on service provision and the development of services. Concern was expressed regarding how recommendations identified in the guidance could be implemented as they were seen as being resource intensive. Aspirational recommendations i.e. those that recommend something that may be regarded as unattainable in the short term but possible in the long term with

investment, were acknowledged as being of assistance and important to help move the service in a positive direction.

The following quote illustrates this frustration as it refers to a department that has no further capacity:

“…Are very keen to be involved, my experience is but again they are very severely

understaffed. So erm, they would want to take it up but they obviously have problems with coping with the case load because they can’t cope with the present load, so it requires staff recruitment.” (IA09)

“You can’t expect the same number of people and they do more and more stuff” (IB09)

A concerning finding was that there are services within the hospital that rely on one person. Participants recognised this as a risk in regards to the sustainability of the service, as it was stated that if something happens to the individual or they decide to leave then the whole service fails.

159 6.3.3.7 Political influence

Access to politicians was perceived by some participants as an effective way to influence and drive change. Participants stated that this was not difficult as both patients and members of the healthcare profession were able to contact politicians. The following quote illustrates this clearly, expanding on political accessibility and context / culture;

“I think you might have to appreciate something else about Maltese set up that sometimes supersedes the need for patient support groups felt in bigger countries. The distance between Jo public and your local MP is rather short. And you know pretty much everyone has everybody’s mobile number. Trust me if you need the mobile number of someone you don’t know in Malta typically he is just 2 people away from you. You know while in other countries I believe it is like 4 or 5. Em, what I am trying to say is sometimes it is not difficult for patients to make their voice heard.” (FG201)

“So it’s a political party to introduce new medicine, because people want new medicines, that’s going to come. And that’s what came.” (IB02)

Participants identified that government engagement and that of the Health Secretary and policy makers was a necessity for funding to be made available. Engagement was also deemed necessary as a means of educating politicians about the long term risks of chronic conditions such as obesity and the financial burden associated with them.

“Have to be presented to the politicians and to the GFLAC (Government Formulary List

Advisory Committee – the committee responsible for advising which medications should be added to the list)…to actually approve it and then start thinking about developing the

service”. (IA08)

6.3.3.8 Patient involvement in healthcare design and delivery

Findings suggested that in Malta, patient involvement in the development of healthcare policy or guidelines is not a regular practice and is not at a level whereby it could be seen as a norm. Such involvement is currently sporadic but was reported as evolving, which was evident in the way in which some healthcare professionals spoke when asked about the involvement of patients. Reasoning for a lack of involvement were mixed, mirroring the diverse views of the participants; patients were thought of as not having the ability to be objective and thus biased; disinclination by healthcare professionals to involve them in

160 anything that was regarded as being ‘technical’; a perceived patient driven reluctance, that they, the patients, feel they do not have the ability to contribute; a disregard for the intellectual ability of patients.

” … the Maltese are a bit difficult as patients I think, but even their intellect is not quite so high … they don’t even want to know if they suffer from a medical condition.” (IA01) “it depends on what type of patient you get … it depends on their education level…” (IA03)

Respondents described characteristics that they regarded as necessary for successful patient involvement, emphasising that participation was dependant on the type of patient. The main focus of attention about whether patients should be involved was the perceived level of patient knowledge and education and whether they have a medical background or not. Coping ability of the patient was raised, with concern expressed over how a patient would cope with being a part of such an exercise. Concern was expressed about equity of the patient voice as it was said that the more vocal a patient or patient group were, the more attention and resources they received and the more others are marginalised. This fed into the reluctance to involve such groups.

“There are some patient groups erm and these patient groups they work on a, if you scream loud enough we’ll get what we want.”( IA08)

a) Positive engagement of patient involvement

Attitudes of some participants towards the involvement of patients in the development of healthcare policy and guidelines, was positive and enjoyment was expressed in having the opportunity to involve them. Positive body language was observed when some of the healthcare professionals interviewed spoke of their engagement on a collaborative level with patients. The general sentiment was that patient involvement will eventually snowball and people will get more involved over time. It was noted that improvement could be seen in some departments and there was recognition of the patient journey and the need to identify it and give patients a voice.

“I still think it’s good to involve patient societies and also because by involving them more and by them gaining more knowhow, they em, will be in a better position to fulfil, what I believe is their primary role, in patient advocacy.” (IA09)

161

“I consider patients as being part of the healthcare team. Sometimes as professionals we only look at the scientific things and I think that the voice of the patient is important.”

(IA07)

b) When involvement should occur

For some however, the value of patient involvement was not really accepted, resulting in comments about the stage of policy or guideline development at which patients should be involved, rather than seeing involvement as a continuous occurrence. There were differing opinions on when this should be; from the beginning, on certain areas only, at the end when the discussions have already been had and recommendations made. It was also suggested that involvement should be limited to receiving feedback and providing anecdotal evidence as opposed to overall inclusion in the process.

A similar range of views were exhibited over what healthcare conditions participants thought would be suitable for patient contribution to the development of healthcare policies and guidelines, as not all were regarded as being suitable for patient involvement. Despite these caveats patient involvement was thought to be a powerful game changer and a driver for better care. In turn, the patient perspective was noted as being important and a place for patient advocacy was identified.

“They would actually, they might be able to shift the balance. So if there is a bit of an indecision, they might be able to shift the balance from one side or the other, saying that the effect will have a big effect on their life.” (IA08)

“The patients should be represented here especially in board meetings and where big decisions are taken. I think it would be good to have patient representative there.” (IA08) “They still think em that they are not as competent at interpreting data which in some sense is true but what they do not still comprehend fully is that when we try and involve patients, societies or patient representatives, we are not expecting expert opinion from them as regards interpretation of clinical data, we are expecting the patient perspective.” (IA09)