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Idea Description
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Innovation 'Elevator Pitch':

The NHS often does NOT know a patient’s wishes on treatment, their preferences or instructions. In a health emergency or mental crisis this information is vital.. MyDirectives gives everyone the chance to record their wishes in advance of a crisis.

Overview of Innovation:

MyDirectives.com and MyDirectives mobile gives every individual the opportunity to record their wishes for free. The service uses digitally delivered structured forms, video and audio messages to create high quality documents that health professionals trust to make best interest decisions. The service empowers individuals, allowing them to share their wishes with a close network of people (‘agents’) they trust to support them in a crisis or if they are unable to speak for themselves.  These ‘agents’ are sent instructional packs & urged to discuss preferences with the individuals concerned. MyDirectives then works with local health economies to integrate the person’s wishes & personal choices with primary, secondary and local authority databases & electronic health records so they can be confident their wishes & ‘digital voice’ will always be accessible & heard.
 
For health professionals this means they can be confident they are looking at the most up to date views of their patients, know who can speak for the patient & what their treatment choices & objectives are. This approach is both ‘human’ & from an innovation perspective, highly disruptive. It leads to faster, more appropriate & sensitive care decision making & can be easily scaled through MyDirectives' API to the whole care & health community.
 
The benefits of this pro-active approach are significant cash releasing savings that can be evidenced. An indication of how much this approach might save a health economy is a bill currently going though both houses of the US Congress that proposes to give every US citizen on Medicaid and Medicare £75 in return for creating a digital emergency, critical and advance care plan. MyDirectives has been live for four years and is used by individuals in 34 countries & is now looking for its first healthcare partner in the UK. 

We want a healthcare partner who can work with us to establish a UK integration network with GP suppliers, summary care record and organ donor lists and an adoption strategy using GP suppliers, secondary care providers, E-referrals, organ donor register and NHS Choices. We believe we can create a national system of adoption and retrieval using the NHS’ existing infrastructure. The end result will be a cost effective mechanism for recording and retrieving a patient's ‘voice’.

MyDirectives is the only company providing an integrated all digital solution to these issues.
 
See https://mydirectives for further details.

Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
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Innovation 'Elevator Pitch':
We connect people with a mental crisis to practitioners using a smartphone in an instant. Irrelevant of culture, language, or geography, instant access to counselling will be swiftly available, affordable and secure.
Overview of Innovation:
The launch of TOSPS (The One Stop Psychotherapy Shop) as an online secure platform from which therapy can be both sought & delivered lends itself to a real opportunity to revolutionise the way face-to-face crisis mental health therapy is delivered to people in need, in any location via the introduction of a crisis care platform.
It is vital that people have an opportunity to be assessed as quickly as possible before a crisis point is reached, therefore the development of a minimum interaction app to compliment the TOSPS web site is vital to ensure that people in (or approaching) a crisis are connected to a therapist quickly.
Background applications can enable complicity with NHS, Local Authority & 3rd sector mental health service provider’s requirements & interact with the digital systems records, booking systems within one application. An affordable application that is nondependent on any particular proprietary platform.
Early detection trigger guidelines allow quick diagnosis & referral to treatment for the client. Alerts to service users, carers & professionals when risks of crisis within individuals are elevated, prompting a call from a therapist or practitioner where applicable.
This app ensures that getting help & or treatment is as simple as ordering a pizza, To assist users, all of our registered therapists display our unique “on-line” light showing that they are available right now to provide instant help. The app can analyse stress triggers & alert people to potential looming issues, & seek early prevention treatment & can link to applications such as iHealth & S Health.
Payment modules can be adapted for pre-booked appointments or after event payments. Some people may wish to approach things methodically & be directed to the Mother web site, others who are in advanced crisis can be connected to immediate help via the app. The security protocols are already developed to reach current IGSoC compliance HIPAA & peer to peer security is established.
Stage of Development:
Close to market - Prototype near completion and final form may require additional validation/evaluation and all CE marking and regulatory requirements are in place
WMAHSN priorities and themes addressed: 
Mental Health: recovery, crisis and prevention / Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Education, training and future workforce / Wealth creation / Clinical trials and evidence / Digital health / Innovation and adoption / Person centred care
Benefit to NHS:
Reduce waiting time within the NHS by providing a pool of therapists across all sectors and specializations to be available at all times for emergency crisis intervention therapy and early diagnostic triggers.
Doctors and emergency services would have a central point of call with said pool of therapists who are available to provide face to face online counselling sessions in real time, day or night .
Reduction of waiting time has a positive effect on the reputation of local NHS facilities. The introductions of a central point of contact for therapy online would complement and provide the newer and more modernised NHS with a natural extension to its future modernisation programs in the deliverance of new methods for client access to crisis therapy, using the technologies the public already use on a day to day basis, phones tablets etc.  
Early intervention will reduce cost of treatment in the short and long terms. People can effectively access counselling from home thereby freeing up seats and room occupation.  Effectively the client pays for their own cyber space as opposed to the costs of the provision of therapy rooms and space.
Emergency room on call crisis mental health teams can see a relief from the growing numbers of people needing mental help assistance in the A & E. A triage type system implemented directing those in need of counselling either direct to a practitioner online or to a hospital department will streamline priorities. Cancellation time loss can be recycled. Run over time can be reduced as the client’s portal closes as soon as the session allocated time has finished. 
Safety to staff and clients is enhanced as there is no physical presence. Holiday and sickness schedules would no longer impact on the availability of counsellors, The pool of available therapists can expand and decrease to meet demand.
Geographic boundaries are removed and a greater pool of therapists are available. Therapists with free time can instantly be available to work. Language skills and multicultural issues can be less hindrance, as availability of specialized counsellors with extra skill sets can be found instantly.
Emergency triage of crisis mental health care can be portable, particularly in suicide situations. A seamless way to integrate private and NHS staff to provide counselling in times of public crisis and emergencies such as acts of terrorism or acts of God will be in place. 
Initial Review Rating
4.40 (2 ratings)
Benefit to WM population:
The West Midlands is a densely populated area; the residents are very diverse, multicultural with wide ranging needs. 
TOSPS has counsellors and therapists with a wealth and bounty of specialisms bringing with them an abundance of different language skills, English to Swahili, African, Asian, and European languages, a wide range of backgrounds, cultures, skills and knowledge would open counselling up to ethnic minorities who might shy away from help due to cultural inhibitors, fear of violence, shame or adversity.
The availability of therapists to meet their own cultural requirements without fear of prejudices is a key for some minority groups.  
The system caters for multiple needs, the 24/7 availability means that shift workers or people who experience crisis at all times of day and night will have access to someone who will help them.
Interactions with the app, intentional or unintentional, can act as a conduit to signpost people in crisis to the correct people for help. The socio-economic effect on work place downtime figures will improve as time away from work travelling to and from appointments can be removed.
Calibration with the Police and other social help associations like suicide watch will offer a portable crisis care that will assist them in their roles on the ground. The domino effect of assisting individuals take control of their mental health will filter through to the family environment.
Push notifications will remind people of follow-up appointments, and assure them that their practitioners have been notified of current or prior episodes.  
Large exhibition centres and train stations will be able to send push notification advising mentally vulnerable people registered on the system what to do in times of crisis, terrorism.  Alleviation of waiting times within NHS will promote a real improvement which will be noted by the people.  The app will empower those who often feel powerless and deliver an element of control back to those patients and can act as a buddy system bringing comfort to the mentally ill.  
A more settled and happy community who will support their NHS when they can see or hear that real progress has been made in the reduction of waiting times and costs to their NHS.  Instant access gives them control and boosts confidence. Portability of the app means counselling can be physically brought to the client any place. 
Current and planned activity: 
To grow the numbers of therapists currently registered to provide counselling online both mainstream and crisis care intervention to a start headcount of 400 therapists initially. This would provide scope to have 6 teams of 66 therapists online in 4 hour shifts across a 24 hour period. Training is already underway to ensure that each therapists IT equipment is cyber safe and certified on an  annual basis to protect data and patient confidentiality.
To develop a single point TOSPS app that can deliver all the benefits previously detailed whilst allowing the NHS to track patient costs / usage / progress automatically and work on a NHS agreed pricing and invoicing schedule for covered therapy. Additional therapy could be purchased directly by the patient or family members to supplement NHS treatment and referral fees could be offered back to the NHS to fund research into the benefits of online therapy to further promote the services and reduce overall costs of care
What is the intellectual property status of your innovation?:
TOSPS own all the rights to the name TOSPS and the delivery platform. The TOSPS app will be owned by TOSPS and their developer Proxicon who will continue to develop and maintain the app. 
Return on Investment (£ Value): 
Very high
Return on Investment (Timescale): 
6-12 mon
Ease of scalability: 
Simple
Regional Scalability:
The model can be classified as Simple scalability : 
Measures:
Due to the nature of the service we will be able to provide in depth reporting on the number of referrals received which have had a successful outcome in terms of delivery, we will be in a position to deep dive data which will show the number of therapeutic hours being delivered over any given time period and relate these back to specific NHS referrals.
We also believe that by engaging with NICE and IAPT and inviting them to independently monitor the quality of service and outcomes, we can confidently report on the successes and the learnings as TOSPS moves forward with the NHS.  TOSPS.com will also commit to working with other external agencies within the NHS and beyond to further understand the outcomes of its service with a view to continued development its services, feedback will be essential not only from clients but also from referring partners and charitable organisations.
 
Adoption target:
Currently the infrastructure to deliver this service is in a state of readiness; We believe that in order to launch effectively for WM NHS we will need in the region of 400 additional therapists. We will need some support from the NHS in the form of internal marketing to NHS therapists and referring agencies,
Rejection Reason:
Suitability of model to NHS
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Overview summary:
The co-occurrence of mental and physical health problems is common, leading to poorer health outcomes and increased healthcare costs. Birmingham and Solihull Mental Health NHS Foundation Trust developed the model for liaison psychiatry services as a pilot in Birmingham. The Liaison Psychiatry multi-disciplinary team assesses A&E attendees/inpatients 24/7 who might have mental health problems, and provides e-training. There is now a service in every hospital in Birmingham and Solihull and 27 organisations nationwide have taken up the service. 
Challenge identified and actions taken :
The co-occurrence of mental and physical health problems is very common among patients, often leading to poorer health outcomes and increased healthcare costs. People can face lengthy waits before being referred on to the relevant service.
 
Birmingham and Solihull Mental Health NHS Foundation Trust developed the model for liaison psychiatry services in December 2009 as a pilot in City Hospital in Birmingham, with an investment of £0.8 million. The Liaison Psychiatry team, comprising nurses, psychiatrists, psychologists and physicians assistants, will promptly assess anyone 24/7 attending A&E or who is a hospital inpatient, who might have mental health problems.
 
The Liaison Pschiatry network, which is supported by WMAHSN, was established to strengthen links between Liaison Psychiatry  services to facilitate collaborative working on research and innovation projects, facilitate adoption of the model and improve and expand the overall service provided by Liaison Psychiatry across the NHS. 
Impacts / outcomes: 
  • Following the success of Liaison Psychiatry in City Hospital, the trust now has a Liaison Psychiatry service established in every acute hospital in Birmingham
  • 27 organisations nationwide have now taken up Liaison Psychiatry
  • In its 2014 document Achieving Better Access to Mental Health Services by 2020, the Department of Health highlighted strong evidence that the model can deliver clinically and cost-effective care to patients with a range of mental health problems
  • A paper published in The Psychiatric Bulletin (2013) uses data from admissions to all 600 beds in City Hospital between December 2008 and July 2010. The paper showed that the main direct effect of the model was on time to readmission:
  • The rate of readmission in the Liaison Psychiatry group was four for every 100 patients, while in the pre-Liaison Psychiatry group it was 15 for every 100
  • Including the Liaison Pschiatry-influence group, the total reduction in readmissions is estimated to be 1,800 over 12 months. This equates to a saving of 8,100 bed-days per year
  • There is also a strong indirect effect resulting from the broader influence on those not referred to the service, in the form of reduced lengths of stay: the Liaison Psychiatry-influence group demonstrated an average length of stay 3.2 days shorter than that of the pre-Liaison Pschiatry group. This corresponds to a total saving of 13,935 bed-days per year
  • The Liaison Psychiatry model is estimated to save between 43 and 64 beds per day, which is equivalent to two-three wards
  • Most of the savings were accrued by geriatric wards
  • The study estimates the potential savings to be £4-6 million per hospital by reducing both admissions and length of stay
  • The service won a prestigious HSJ Award for innovation in mental health in 2010
  • Liaison Psychiatry was highlighted in 2011 in an NHS Confederation Mental Health Network briefing paper which documented the benefits of liaison psychiatry
  • An independent economic evaluation of the original Liaison Psychiatry service was produced by the London School of Economics and Centre for Mental Health in 2011
  • Liaison Psychiatry was cited in an a 2012 HSJ article, “Liaison psychiatry can bridge the gap”
  • An economic evaluation of the Liaison Psychiatry roll-out across Birmingham was produced in 2013 by the local Commissioning Support Unit, Midlands and Lancashire CSU
  • Further liaison psychiatry service guidance which discusses the range of potential models was produced for the South West Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions in 2014
  • A review was commissioned from the University of Birmingham’s Health Services Management Centre, with six West Midlands implementation sites involved (2015)
  • Dementia and self-harm e-learning, tailored for acute trust staff, has been delivered to more than 60 staff in each module across two acute trusts
  • A national Liaison Psychiatry Network has been established to support organisations and individuals who are using or planning to use Psychiatric Liaison models. To date two meetings have been held, the second of which had Geraldine Strathdee, National Director for Mental Health, as a key speaker. The Liaison Psychiatry network’s first event attracted delegates from across the region, along with people from across England and the wider UK. 61 people from 24 organisations attended the first event, and 64 people from 31 organisations registered for the second event. In total, representatives from 41 different organisations registered to attend, with 17 new organisations coming to the second event. This has created a mechanism for sharing best practice for liaison services nationally. In addition, the network’s long term funding has been secured by BSMHFT in partnership with East London NHS Foundation Trust
  • The national Liaison Psychiatry Network is supported by a website and newsletters
  • Two academic organisations, two acute trusts, two mental health trusts and three industry bodies were involved in project delivery.
Which local or national clinical or policy priorities does this innovation address:
• This is a priority area for the government, with a £30 million targeted investment in effective models of liaison psychiatry in more hospitals announced in October 2014 as part of its aspiration to put mental health care on an equal footing with physical healthcare • The NHS Five Year Forward View emphasises proper funding and integration of mental health crisis services, including liaison psychiatry.
Supporting quote for the innovation from key stakeholders:
John Short, Chief Executive at Birmingham and Solihull Mental Health NHS Foundation Trust, said: “Liaison Psychiatry has a track record of improving quality of care for patients and also saving money and has been independently evaluated and highlighted nationally as a best practice model for liaison psychiatry. We are delighted to host this network in order to bring together teams from across the NHS to share knowledge and learning and further develop and improve the model for the future.”
Plans for the future:
The Liaison Psychiatry review will be used to drive consistency and to support the tailoring of Liaison Psychiatry services regionally, to local needs and context while remaining true to the core principles which enable successful delivery. 
Tips for adoption:
  • Innovative new approaches can make an important contribution to improving outcomes and relieving pressures on other parts of the health system – but there are unlikely to be ‘magic answers’ or panaceas. Even where a new model appears to have significant early success it is unlikely to be something that can simply be imported/bought in in order to solve all problems locally
  • Many participants felt that Liaison Psychiatry had delivered (or had the potential to deliver) real benefits. However, the way in which Liaison Psychiatry was planned, resourced, staffed and supported were perceived to be key factors influencing its success
  • New services do better when they receive the support of senior managers and where the service is sufficiently resourced – a number of participants talk of a ‘critical mass’ that was needed to instigate real change
  • Liaison Psychiatry was more favourably evaluated by participants when services included a focus on older adults and where the service addressed the needs of inpatients, in addition to having a role in reducing waiting times in A&E
  • The Liaison Psychiatry service, designed to operate across a number of different services, could not be sufficiently evaluated by using single outcome measures i.e. reduced waiting times or cost savings
  • New models are designed in a specific way for a reason, and there needs to be a degree of fidelity to the underlying model if the successes of early service models are to be replicated. Only partially implementing a new approach is unlikely to work. Certainly, those Trusts that have taken the model and implemented only a proportion of the new approach shouldn’t be surprised if it doesn’t deliver what a full model might
  • At the same time, new ways of working need to be designed and implemented in ways that are appropriate within the context of existing local services, personalities and relationships. This means that models cannot be imported wholesale, but that there is a legitimate process of adaptation (which may take time to plan and implement)
  • Taken together, the two bullet points above suggest a tricky balance between being clear on/remaining true to the key elements of a successful model, whilst also being flexible about how best to implement in different local contexts. Adaption of the model needs to be mindful of existing services that are in operation and of local populations
  • ‘Soft’ outcomes matter too – even if they are harder to measure. It may take time for all outcomes to be produced because of “teething difficulties” as a service establishes itself and because an attitudinal change towards mental health is hard to achieve
  • Paying attention to practicalities is important (for example, access to IT and appropriate accommodation/space near to linked services). In order to have an integrated service, teams need to be physically close to each other and be able to access joint notes
  • Developing new ways of working takes time, and is as much about developing new relationships as anything else. By definition, liaison is a two-way process, and attention needs to focus on the host organisation as well as on the new service
  • Above all, we need to be clear about the outcomes we are trying to achieve by looking to a new service. Improving patient experience is a different type of outcome from trying to hit a 4-hour access target, which is different again from raising awareness of mental health issues amongst hospital staff, facilitating swift discharge, preventing readmissions and/or freeing up staff time to focus on other priorities. While it may be possible for one approach to do a number of these things at once, being clear about what success would look like seems to be an important precursor to knowing whether or not something has actually succeeded in practice.
Contact for further information:
Katie Saunders
katie.saunders@bsmhft.nhs.uk
0121 371 8061
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Innovation 'Elevator Pitch':
STarT Back utilises an innovative tool to screen patients according to their risk of persistent lower back pain disability. Ensuring their management is supported in primary care offering more effective and targeted physiotherapy treatment. 
Overview of Innovation:
STarT Back provides:
  • A simple prognostic screening tool used in primary care settings (GP / Community Physiotherapy) allocates patients to 3 risk groups (low, medium or high risk of persistent disabling problems)
  • Matched treatment pathways according to prognosis
    • Low risk treatment  - evidence-based consultation, simple messages about pain relief, exercises, written and verbal information – discharged after 1 session
    • Medium risk treatment – evidence based physiotherapy to reduce pain/disability, supporting patients to stay at or return to work – 4/5  physiotherapy sessions
    • High risk treatment – psychologically informed rehabilitation delivered by trained physiotherapists aimed at pain management, reducing disability and distress – up to 6 sessions
  • Improved clinical outcomes, patient satisfaction, reduced time off work
  • Reduced health care and societal costs
  • Prognostic screening tool guides clinical decision making – available in electronic and paper format
  • Training packages for primary / community and secondary care health practitioners to deliver targeted treatment
  • Resources available via website to support implementation – commissioners, clinicians and researchers (see website: http://www.keele.ac.uk/sbst/)
  • Supports review of clinical pathways for the management of back pain
In addition the following resources are readily available to any team wishing to implement stratified care for low back pain:
  • Established training course for physiotherapists in matched treatments
  • STarT Back website providing adoption and spread information on the roll out of the project across the West Midlands region and nationally through AHSN to AHSN working
  • Web resources supporting business case development, training, audit
  • Patient satisfaction audits
  • Audit of clinical pathways
  • Integrated IT platform for STarT Back within GP clinical systems
  • System to support automated referral to physiotherapy for medium/high risk material
  • High quality patient information to support self-management
  • GP resources to support consultations in primary care – available via website and patient.co.uk
  • Validated musculoskeletal patient reported outcome measure (MSK PROM)
Target groups are: general practitioners, physiotherapists, patients, commissioners, providers of musculoskeletal services.
 
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Education, training and future workforce / Person centred care
Benefit to NHS:
Low back pain (LBP) is the number one cause of years lived with disability worldwide (Global Burden of Disease). In the UK, 9% of adults consult their GP for LBP annually, accounting for 14% of consultations and an estimated annual cost to the NHS of £4.2 billion. Over 60% still report pain and disability a year later and up to 7% will develop severe persistent symptoms leading to high levels of re-consultation, work loss, and sickness certification.  In the UK low back pain is predominantly managed in primary care and yet there is wide variability in care in general practice. Implementation of STarT Back ensures that patients are directed to the right treatment at the first point of consultation. This approach of stratified care for LBP has been shown to improve patient outcomes and quality of life, reduce costs and days lost from work and reduce variation in practice. This translates into health and societal cost saving (est. £35 and £675 per patient); reduced physiotherapy wait times; reduced re-consultation; reduced sickness certification; less onward referral and imaging; up-skilling physiotherapy workforce.  The STarT Back trial identified broader health and social care savings including: reduction in the number of GP consultations, reduction in the number of visits to NHS consultants, reduced investigations (MRI/x-rays), reduction in epidural injections and medication usage (Whitehurst et al, 2012). Early STarT Back audit data shows “low risk” patients are being discharged earlier, reducing follow up rates in physiotherapy services and only 1% of patients being referred onto specialist pain services.
www.keele.ac.uk/sbst
Online Discussion Rating
4.80 (5 ratings)
Initial Review Rating
4.60 (1 ratings)
Benefit to WM population:
As above - stratified care means that individuals are directed to the right care at the right time, meaning individuals can return to work and manage their back pain reducing the amount of time that they are unable to work.  A healthier region is a wealthier one. 
Current and planned activity: 
Digital innovation: e-STarT Back tool currently integrated into GP clinical systems with associated self-management materials (available via patient.info) and auto-populated referrals for physiotherapy in accordance with care pathway.

Opportunity
Looking into the development of a patient App to support the STarT Back approach and provide patients with a further support system. PPI involvement will be used in the development of the APP and the review of patient information given within the GP consultation.
Potential development to support physiotherapy training.
Potential development to support occupational health departments.
What is the intellectual property status of your innovation?:
The STarT Back tool is a licensed tool ( ©2007 Keele University) that may not be modified.The copyright (©2007) of the STarT Back Tool and associated materials is owned by Keele University, the development of which was part funded by Arthritis Research UK:
i) the tool is designed for use by health care practitioners, with appropriate treatment packages for each of the stratified groups;ii) the tool is not intended to recommend the use of any particular product. For futher information please see http://www.keele.ac.uk/sbst/  
No license is required for non-commercial use.  If you would like to incorporate the tool in any way into commercial product materials, please contact Keele University for further advice.
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
1 year
Ease of scalability: 
2
Regional Scalability:
WMAHSN has worked in partnership with Keele University to support the rollout of STarT Back. Across the region GP practices/CCGs/physiotherapy service providers have worked to review care pathways to integrate the latest evidence for low back pain (STarT Back) into clinical practice. WMAHSN funded project management/clinical expertise to support engagement & training of healthcare professionals to adopt a stratified care approach to managing back pain. Care pathways have been negotiated with local CCGs/provider Trusts to support the roll out of this approach with the installation of the STarT Back screening tool into GP computerised consultation systems which “pops-up” each time someone consults with back pain. AHSN funding supported this change management/ training activity. The project plan also includes embedded audit to support evaluation of implementation of the STarT Back approach. This WMAHSN programme supported 15 CCGs/15 Provider Trusts to implement STarT Back into practice
Measures:
A series of measures around the use of the stratified care approach can be undertaken, these include:
  • Use of the SB tool to improve accuracy in matching patient to treatment
  • Ensure patients receive appropriate treatment by a skilled physiotherapist
  • Avoid over-treating patients (in low risk category)
  • Provision of patient information via patient.info
  • Improve pain and functions scores
  • Gain high patient satisfaction via a friends and family test
  • Reduce waiting times for routine and urgent physiotherapy appointments
  • Improve the discharge reporting process
  • Reduce the number of patients being referred on for a second opinion/diagnostics 
Individual service providers may undertake audits to support change in practice. This has been undertaken successfully in North Staffordshire and Worcester.
Adoption target:
It is anticipated all regional CCGs/Trusts will implement STarT Back endorsed by NICE Guidance/Pathfinder project. Other AHSNs are expected to embed a stratified care approach in the next 2 years areas of NWC AHSN are mandating the use of the tool across musculoskeletal pathways. International adoption Australia, Denmark, Scandinavia, Canada, USA 
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