Innovation Warehouse - Stories
Meridian is a resource for you to be able to share the changes that you have made to the way that you do things that have resulted in improved health outcomes for patients, a more effective way of delivering more for less, an increase in the productivity or just a different way of doing things.  Please use this space to upload the innovations that you wish to share and that others can benefit from.
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Innovation (Approved)

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 RAID model for liaison psychiatry services as a pilot in Birmingham. The RAID multi-disciplinary team assesses A&E attendees/inpatients 24/7 who might have mental health problems, and provides e-training. There is now a RAID service in every hospital in Birmingham and Solihull and 27 organisations nationwide have taken up RAID. 
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 RAID (Rapid Assessment, Interface and Discharge) model for liaison psychiatry services in December 2009 as a pilot in City Hospital in Birmingham, with an investment of £0.8 million. The RAID 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 RAID network, which is supported by WMAHSN, was established to strengthen links between RAID services to facilitate collaborative working on research and innovation projects, facilitate adoption of RAID and improve and expand the overall service provided by RAID across the NHS. 
Impacts / outcomes: 
  • Following the success of RAID in City Hospital, the trust now has a RAID service established in every acute hospital in Birmingham
  • 27 organisations nationwide have now taken up RAID
  • In its 2014 document Achieving Better Access to Mental Health Services by 2020, the Department of Health highlighted strong evidence that the RAID 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 RAID model was on time to readmission:
  • The rate of readmission in the RAID group was four for every 100 patients, while in the pre-RAID group it was 15 for every 100
  • Including the RAID-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 RAID-influence group demonstrated an average length of stay 3.2 days shorter than that of the pre-RAID group. This corresponds to a total saving of 13,935 bed-days per year
  • The RAID 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
  • RAID 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 RAID service was produced by the London School of Economics and Centre for Mental Health in 2011
  • RAID was cited in an a 2012 HSJ article, “Liaison psychiatry can bridge the gap”
  • An economic evaluation of the RAID 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 RAID 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 RAID 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 RAID 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 RAID 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: “RAID 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 RAID model for the future.”
Plans for the future:
The RAID review will be used to drive consistency and to support the tailoring of RAID 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 RAID had delivered (or had the potential to deliver) real benefits. However, the way in which RAID 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
  • RAID 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 RAID 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 RAID 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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Sarah Millard 28/01/2016 - 16:36 Approved
Overview summary:
Technology Enabled Care Services (TECS) can transform the way people engage in and control their own healthcare. One method is Florence Simple Telehealth (Flo), a mobile phone text service. WMAHSN has supported Flo as an exemplar of technology in healthcare, providing resources and training for participating organisations.
Challenge identified and actions taken :
The UK’s diversity means that traditional methods of communication between clinician and patient are changing. Technology Enabled Care Services (TECS), such as telehealth and self-care apps, have the potential to transform the way people engage in and control their own healthcare, allowing citizens to monitor their health and activity levels by themselves, so the need to take up valuable clinician time is no longer necessary. One TECS method is Florence Simple Telehealth (Flo), a mobile text service to communicate with patients. A free mobile texting service, it is easy to use and was designed by NHS professionals to provide support and advice for patients to manage their own health conditions. Flo give prompts and advice and helps to monitor vital signs. Flo is being promoted to the whole population of West Midlands via all 22 CCGs and some acute and community trusts, alongside other forms of TECS:
  • CCG intelligence packs
  • Staying Independent online checklist
  • apps (COPD, asthma and diabetes type 2)
  • Skype and social media online toolkits (with some direct expert support)
  • general awareness of Flo with some support and resources for COPD and asthma.
Impacts / outcomes: 
  • Integrated care development continues across participating organisations and now with other interested organisations e.g. interest from community pharmacies in Flo protocols to support the delivery of their New Medicines Service and Medication Use Reviews to support patients, better medicines optimisation and improved patient experience, and avoided healthcare usage
  • A vision of how TECS underpins integrated care has been published (Tackling Telehealth 2) which describes different definitions of integrated care and how Flo and other TECS fit in. The draft paper received broad acknowledgment from clinicians around the country and key TECS leads at NHS England. This paper covers the transformative role that TECS can play in creating integrated health and social care systems based around the patient
  • Since organisations (CCGs/trusts) took out WMAHSN-related project licences - between April 2014 and March 2015 - 2,489 patients had signed up to Flo, with some CCGs and trusts initially piloting Flo on Stoke-on-Trent CCG’s overall Flo licence prior to their own project licence being funded
  • The service hosted events across the West Midlands region - Stafford, West Bromwich, Coventry, Shrewsbury and Worcester - to raise awareness of the range of technology that can support common long term conditions, including COPD, asthma and diabetes, and redress adverse lifestyle habits, using social media, apps, Skype and telehealth. The events were aimed at general practice teams (practice managers, practice nurses and GPs), CCGs and acute and community trust staff. The events covered creating TECS in the NHS and digital delivery in workplace. The events were attended by more than 200 delegates from a wide range of health professionals, GPs, practice nurses, CCG managers and trust representatives. The project team was also pleased to have received the support from the Managing Director of the WMAHSN, who attended the Shrewsbury event
  • Heart failure (HF), diabetes and community pharmacy Flo protocols are ready for use. The HF protocols are related to an integrated care project between acute and primary care to upskill GPs in the titration of HF medication. Flo protocols have also been developed with a mental health trust and are now being deployed for pre-vascular dementia, mood management and depression. Pilot protocols being evolved or used are pre-bariatric surgery weight loss, multiple sclerosis, community and secondary care pharmacies– new medicine and medication review services, wound fluid discharge, enuresis and informal carers’ stress.
  • There is a wealth of additional interest and further innovations:
  • primary care interest in proactive/preventative monitoring of acute HF patients through monitoring of patient submitted data, blood pressure, weight etc.
  • wound fluid discharge monitoring in a community setting, alleviating time for clinician to attend patient home purely for this purpose
  • acute pharmacy interest in stratifying patients through A&E attendance due to medication issues and using Flo to support the patients with their medicines regime for a period of time post discharge
  • anxiety/stress management for carers to support their wellbeing, therefore reducing the chance of failure of care
  • Matched funds from Stoke-on-Trent CCG has supported the evolution of the TECS Staying Independent Checklist, a resource to allow health and social care and other professionals, during assessment of an individual’s support needs, identify what TECS are available and suitable for them
  • Organisations are keen to learn about broader work around TECS and the programme provides a good opportunity to share, promote and relate learning including Skype, child and adult asthma avatar apps, the TECS referral pathway and other WMAHSN projects including STarT Back, the Manage Your Health app and COPD primary care training, so the Flo programme has developed a wider TECS scope
  • The extensive networking undertaken created further interest, links and opportunities in the Flo exemplar project and related TECS
  • The capture of patient outcomes has been included in the evaluation with standard feedback captured at point of patient sign up to Flo and at termination and determined points in the Flo protocols.
  • The team is also working with each participating organisation to capture and evaluate their patient case studies to build a body of qualitative evidence to share and use to promote further the benefits of Flo
  • The Flo data will be used to review patient adherence to protocol/pathway and, dependent upon the LTC, determine any sustained patient outcomes e.g. blood pressure, improved inhaler use
  • There is a focused evaluation underway.
Which local or national clinical or policy priorities does this innovation address:
From the NHS Five Year Forward View: • Incentivising and supporting healthier behaviour • Targeted prevention • NHS support to help people get and stay in employment • Empowering patients • Out-of-hospital care needs to become a much larger part of what the NHS does • Services need to be integrated around the patient • We should learn much faster from the best examples, not just from within the UK but internationally • As we introduce them, we need to evaluate new care models to establish which produce the best experience for patients and the best value for money.
Supporting quote for the innovation from key stakeholders:
Jeff, Flo service user: “FLO resembles a friendly, good natured and trusted member of the family. I feel more able to cope and more confident about the future. Most importantly, it helps me cope with my situation.”
 
Sarah, Lead Nurse for respiratory medicine (general practice): “The app has excellent content, is quick to download and ensures patients have their asthma management plans with them all the time, rather than at the back of a drawer. Inhaler technique is key to managing asthma and the avatar demonstrates this perfectly. This app could help prevent hospital admissions and deaths.”
 
Dr Ruth Chambers OBE, GP principal, Stoke-on-Trent, Chair, Stoke-on-Trent Clinical Commissioning Group, Honorary Professor, Keele and Staffordshire Universities and Clinical Lead for Long Term Conditions, WMAHSN: “The importance of what we are trying to help teams deliver cannot be overstated. Demands on our services are continuing to increase. Utilising technology will not only enable us to shape services to suit the needs and preferences of individual patients; embracing it will also help us take on the challenges we face every day.”
Plans for the future:
  • To drive person-centred care through the use of TECs (with Flo as an exemplar) to span patient pathways across different healthcare settings with general practice teams and other providers prioritising applications that best meet the needs of their population, at specific points on those pathways
  • To drive regional spread/deployment of  Flo within organisations to disseminate the knowledge and learning achieved from previous deployment and successes to support the move towards a culture shift/perception of TECS for asthma, COPD, medication adherence and hypertension
  • Development of other Flo protocols ready for 2015/16 to support other LTCs beyond the project’s initial launch protocols.  
Tips for adoption:
To take TECS forward at pace we need to:
  • establish and support leaders and champions of TECS throughout the commissioning cycle to communicate the benefits and drive change
  • enable patient and public involvement and engagement
  • use digital modes of delivery such as Skype, telehealth, telecare, teleconsultations or telediagnostics to drive person-centred, integrated care rather than standalone solutions
  • focus digital delivery of care on areas in patient pathways where enhancing self-care has a substantial impact by improving patients’ clinical outcomes and/or reducing avoidable healthcare usage  
  • anticipate consequence costs such as increased frequency of clinician alerts
  • train health and social care professionals: enhance workforce competences and capabilities for the rollout of technology enabled care
  • match the mode of digital delivery of care to suit the patient population – selected mode or individualised for their needs and preferences
  • rigorously evaluate any implementation or trial of TECS and use this information to underpin any future business cases
  • utilise improvement tools to underpin commissioning and service improvement – leadership, transformational change and service redesign
work closely with all stakeholders to integrate technology in care to improve outcomes for all services; redress ongoing issues in constructive ways before progress with rollout is stalled.
Contact for further information:
Dr Ruth Chambers
ruth.chambers@stoke.nhs.uk
0121 371 8061
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Sarah Millard 07/01/2016 - 17:00 Approved
Overview summary:
Capitalising on a successful e-learning programme, we are developing SCRIPT for nurses. SCRIPT is a suite of 15 modules aimed at developing and maintaining professional knowledge and competence relating to medicines. The platform is generating a significant amount of interest and support.
Challenge identified and actions taken :
Medicines are the most common intervention in the NHS, but evidence suggests that the use of medicines in the NHS is often sub-optimal. Medication errors account for 10–20% of all adverse events in the NHS and preventable harm from medicines costs more than £750 million each year. Ten days after starting a new medicine, nearly a third of patients are non-adherent. To address the training needs relating to medicines management/optimisation, SCRIPT is an established suite of web-based e-learning 15 modules, aimed at developing and maintaining professional knowledge and competence relating to medicines. The modules, agreed as a result of feedback at WMAHSN events, have been authored by specialist physicians, nurses and pharmacists in the region and six modules are currently in final production ready for launch. Planned outcomes were a suite of modules to develop and maintain the professional knowledge and competence of qualified nursing staff relating to the safer use of medicines. This work builds on the established SCRIPT e-learning programme available for junior doctors (www.safeprescriber.org). The modules were scoped and developed as part of a collaboration between Coventry and Warwickshire NHS Partnership Trust, the University of Birmingham and OCB Media. 
Impacts / outcomes: 
  • The scale of delivery has already increased from the original proposal, from nine modules to 15 module categories finalised
  • Specialist physicians, nurses and pharmacists in the region have been involved in the authoring of modules
  • Six modules have been launched (UK Medicines Policy, Evidence-Based Practice, Introduction to Pain Management, Pharmacological Pain Management, and Adverse Drug Reactions, Anticoagulation Part 1)
  • Two modules are currently undergoing final edit (Anticoagulation Part 2 and Medicines Management in Care Homes)
  • One module with author for final review (Respiratory)
  • Two modules currently undergoing edit (Dosing and Calculation and Advanced Pain Management)
  • Nursing SCRIPT User Guide drafted
  • The e-learning platform is available online at www.saferuseofmedicines.org
  • As this e-learning will be available to all nurses across the healthcare sector, it is generating a significant amount of interest and support. In addition, interest is being received from academic institutions in the West Midlands that train nurses at undergraduate level as they are keen to ensure that nursing competencies with regards to medication administration are gained prior to entry in clinical practice
  • Working in collaboration with a number of authors from various backgrounds and trusts across the region, SCRIPT has not only built a network of clients but a wider regional interest in drug safety.
Which local or national clinical or policy priorities does this innovation address:
From the NHS Five Year Forward View: • As the ‘stock’ of population health risk gets worse, the ‘flow’ of costly NHS treatments increases as a consequence • Future models will expand the leadership of primary care to include nurses, therapists and other community based professionals. It could also offer some care in fundamentally different ways, making fuller use of digital technologies, new skills and roles, and offering greater convenience for patients • access to GPs or nurses working from community bases equipped to provide a much greater range of tests and treatments. In partnership with local authority social services departments, and using the opportunity created by the establishment of the Better Care Fund, we will work with the NHS locally and the care home sector to develop new shared models of in-reach support, including medical reviews, medication reviews and rehab services. NICE guidance on medicines management, adherence and optimisation.
Supporting quote for the innovation from key stakeholders:
Dr Jamie Coleman, Professor of Clinical Pharmacology and Medical Education, University of Birmingham: “The administration of medicines occurs in all areas of health and social care, many of which are given by nurses and professional carers. Errors that occur at the administration stage are often not intercepted by others, unless the patient notices an error, and therefore this is an important focus for education and training. The SCRIPT project team are excited to be working on new e-learning modules to provide for the Safer Use of Medicines for the region.” 
Plans for the future:
  • Completion of remaining modules
  • The e-learning platform will be promoted regionally in the first instance, with the ability to expand the scope nationally
  • The first six modules will be officially launched by March 2016.
Contact for further information:
Prof Jamie Coleman 
j.j.coleman@bham.ac.uk 
0121 414 3778
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Sarah Millard 07/01/2016 - 15:51 Approved
Overview summary:
This Programme will support primary care to reduce the burden of AF-related Stroke in our population through achieving the following clinical aims: Where appropriate, to increase rates of anticoagulation use in AF patients identified as high risk of AF-related stroke not currently receiving appropriate anticoagulation; Optimise anticoagulation of AF patients unstable on Warfarin through transfer to NOACs where appropriate.  The programme is funded through a joint working project between Bayer HealthCare and West of England AHSN.
Challenge identified and actions taken :
The UK sees 150,000 strokes per year of which 20% are attributable to AF (Ball 2013) giving a figure of 30,000 AF-related strokes. Extrapolating the results from phase one may result in approximately 15% fewer strokes in high risk patients across the UK.
  • Quality Improvement: Create an approach that will enable clinicians to re-evaluate how identification, diagnosis and treatment occurs and consider NOACs alongside traditional anticoagulants
  • Strategic: Create an approach that will enable a CCG to sustainably drive implementation of the above (including appreciation of risks (financial and otherwise) of implementation).
Impacts / outcomes: 
Phase One: Across eleven partner practices in phase one, 2,688 patients with AF were identified. Of these, 335 patients were rated as being at ‘high risk’ (i.e. had a CHA2DS2Vasc score of greater than one); over a three-month period, 131 patients were reviewed with regard to optimising their management.

As a consequence, it has been estimated that between five and six strokes were prevented over this period.

Investigations into the potential financial implications of a stroke have suggested an associated cost of £23,315 per stroke (National Audit Office, 2010).  Applying this principle to the findings of the innovator phase could suggest costs between £116,575 and £139,890 may have been avoided.
Which local or national clinical or policy priorities does this innovation address:
Enhancing quality of life for people with long-term conditions
Supporting quote for the innovation from key stakeholders:
The programme is funded through a joint working project between Bayer HealthCare and West of England AHSN.
Plans for the future:
 It is anticipated that accredited online training resources will be available by Q1 16/17.
Tips for adoption:
Project management resource; CCG Leads (clinical; managerial; pharmacist); Other CCG support (comms; finance; project sponsor; primary care team); Resource to deliver training (clinical updates and quality improvement); quality improvement mentoring and coaching; caseload audit resource; availability of practice support pharmacists to work with practices; informatics (to enable quantitative evaluation of impact). Online tools to support patients and practices in shared decision-making, implementing a quality improvement project are already available.
  • Clinical Champions (both at strategic and project level)
  • Modelling of Health Economic impact of adoption
  • Building a community of practice (with regard to both clinical case for change, as well as creating a shared language and experience underpinning the quality improvement element)
  • CCG also included this clinical area in their primary care offer.
It is critical that the health economic impact of the project and associated changes in prescribing costs should be explored with each CCG during initiation. We have a local health economic modelling tool that could be adapted to suit local needs.
Contact for further information:
Anna Burhouse, Director of Quality (anna.burhouse@weahsn.net) Stephen Ray, Programme Manager (stephen.ray@weahsn.net).

www.dontwaittoanticoagulate.com; Phase one evaluation (full version and executive summary) available; Health economic modelling tool.
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Joanne Mewis 20/01/2016 - 12:48 Approved
Overview summary:
Four years ago Wandsworth CCG embarked on their Referral Management Programme and chose Kinesis as one of the core elements supporting it.
In 2015 Kinesis was used to seek advice on 3639 patients by GPs from across the CCG. The advice they received from specialists at their providers resulted in 1700 of these patients avoiding an outpatient referral & receiving faster access to appropriate treatment. They also saved over £300,000 in referral costs. Since then 6 further CCGs to adopt Kinesis and are beginning to see the same benefits.
Challenge identified and actions taken :
The average cost of an outpatient clinic referral is around £204.
In 2009 the problem associated with increasing referrals was reported by NHS Institute for Innovation & Improvement (Delivering Quality and Value - Focus on: Productivity and Efficiency. April 2009); evidence presented showed that “up to 65% of patients attending outpatient specialty clinics are discharged with no significant pathology being detected”.
NHS Midlands & East reported (Confer: End of Pilot Report 2012) “marked and ongoing increases in outpatient referrals” (13% during 2008/09 HES online) and discussed the demand management challenge for primary care commissioners and acute trusts. The trend has continued with 13.6m GP referrals in 2015, a 5% rise on the previous year.
Continued pressure on outpatient clinics due to increased demand, and the necessity of decreasing the time to appropriate treatment in order to minimise health costs and maximise clinical outcomes lead some organisations to wonder if there were better ways of supporting GPs when making referral decisions.
 
A Kings Fund Report concluded that supporting GPs in their practice to make better referral decisions was the best way forward (Referral Management – Lessons for Success. Candace Imison and Chris Naylor, Kings Fund 2010).
Introduction of Kinesis has begun to adress this
Impacts / outcomes: 
Since adopting the programme was a CCG now have 5 providers supporting over 40 specialties. All GPs in the area are able to request advice about a patient using a secure but simple browser-based application and expect to receive a reply within a day.
Wandsworth are on target to make over 4000 requests for advice this year with 58% of these resulting in a permanently avoided outpatient appointment.
6 further CCGs have adopted the same approach and are beginning to see equally positive results.
Where patients do need to be referred, this is often to the correct clinic with the right information and tests having been completed and, in some cases, an expedited referral since a specialist has effectively triaged the referral and is expecting this particular patient.
The benefits are not restricted to time-saving and cost saving. Patients benefit from greater reduced waiting times for appointments and treatment, and mostly benefit from continuing to be treated in primary care without a burdensome trip to hospital. GPs have responded I favourably to the system and report significantly improve care and treatment options for patients as well as being able to build relationships with their secondary care colleagues. They also report increased knowledge and confidence in their referral practice and this is reflected in the referral data. Meanwhile the specialists avoid their clinics being burdened with unnecessary referrals, ensuring they can spend more time with patients with greater needs; they also report enhanced relationships with their primary care colleagues and the ability to pass on their knowledge and expertise.

The experience at Wandsworth CCG is a sustained 5 to 1 ROI can be achieved within two years, based on avoidance of referral tariffs alone. It is believed (as suggested by the CCGs) an equal amount of savings are experienced across the health economy in terms of improved clinical outcomes, but this is not be objectively measured.
Which local or national clinical or policy priorities does this innovation address:
Referral management and reducing time to treatment
Supporting quote for the innovation from key stakeholders:
  • and there’s now an opportunity for us ALL to benefit from the recent progress
"It's a very well designed and easy to use system that bears no relationship to typical NHS IT"
Sarah Thurlbeck, Consultant Paediatrician, St Georges Hospital
 
"I think you have an impressive system in Kinesis. It's simple and intuitive and  really makes a difference."
Mike Conlon, Service Redesign Manager, Sutton CCG
 
"the issue isn't really about these savings, it's about the improved patient care…"
Dr Nicola Jones, chair Wandsworth CCG
 
Plans for the future:
We are in ongoing discussions with eRS to integrate Kinesis once they have released the APIs that will allow this. We are also aiming to integrate directly with the main primary care systems to make it even easier for GPs to request advice when required.
In the longer term we are looking at using machine learning to provide even quicker suggestions based on the responses from specialists.
However our main goal is to drive up the number of CCGs and GPs using the system and to increase the number of times they seek a conferral rather than a referral.
Tips for adoption:
  • Ensure that you have a dedicated programme manager - change management is harder than technology.
  • Get the support of your local seconary providers - the CEO is good to have on board, but equally find some individual specialist who really want this to work
  • Chase down any requests for advice that take longer than a couple of days to receive a reply - GPs need to have faith in the process.
  • Feedback to users on how much good it is delivering
Contact for further information:
info@kinesisgp.co.uk
or call Simon Hudson on  0773505295
 
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Simon Hudson 25/10/2016 - 16:15 Approved
Overview summary:
Brush DJ is an app designed to motivate children to have an effective oral hygiene routine by making tooth-brushing fun! The main feature of the app is a timer, which plays 2 minutes of music taken at random from the user’s device or cloud. The app also contains the evidence-based oral health information given in the Public Health England document ‘Delivering Better Oral Health’.  Reminders can be set to prompt at least twice a day brushing, when to change toothbrushes and visit the dentist.   
Challenge identified and actions taken :
Approx 26,000 children are admitted to hospital each year (England) to have decayed teeth extracted under general anaesthetic, the most common reason for children between 5 & 9 to be admitted to hospital. At least 50% of NHS dental budget is spent on treatment of preventable disease c.£1-1.5bn p.a. (England) with £30m spent on hospital tooth extraction for children aged under 18, these costs don’t include loss of income/productivity for parents/carers & lost school hours or the psychological cost of treatment to all involved.
 
The Brush DJ app is free (no in-app purchases or adverts). Videos showing how to effectively use a manual toothbrush, floss & interdental brush can be watched for free on YouTube. Using an app to raise awareness of evidence-based oral health information has financial advantages over methods such as leaflets as there is no printing, storage, distribution cost associated with an app. Apps are instantly scalable & updatable with the cost of producing one app being the same as any multiple, unlike a physical product. Because an app can use local reminders generated by the app itself they have an advantage over text message reminders, which have been used to motivate better oral health.  
Impacts / outcomes: 
The Brush DJ app has been already been downloaded in 193 countries on to 246,000 devices and received mainly 5 star reviews in the app stores https://itunes.apple.com/us/app/brush-dj/id475739913?mt=8 https://play.google.com/store/apps/details?id=uk.co.appware.brushdj&hl=en .  Diffusion of the app can be measured by the number of downloads it achieves.

The main measure of success of the Brush DJ app at a population level will be if there is a fall in the number of decayed, missing or filled teeth reported in the Nation Dental Epidemiology Programme for England, oral health survey of five-year-old children and a reduction in the number of children attending hospital for tooth extraction under general anaesthesia.

The information given in the app comes from the Public Health England document ‘Delivering Better Oral Health – an evidence-based toolkit for prevention’ https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention . PHE have reviewed the app and have no concerns.

The next step in the development of the app will be to include software to measure when users open the app, how long they stay on each screen and if they uninstall the app. The data obtained from this would be used to improve the user experience.

Research is soon to begin to measure the effectiveness and cost effectiveness of the app in comparison to traditional methods to motivate an evidence-based oral hygiene routine in children. This will involve a randomised control trial comparing the app to traditional methods by monitoring levels of plaque on children’s teeth in the short and long-term.
Which local or national clinical or policy priorities does this innovation address:
Wellness and prevention of illness.
Supporting quote for the innovation from key stakeholders:
The City of York council has started to promote the app in children’s centres and reception classes. http://www.yorkpress.co.uk/news/14306759.Free_dental_packs_for_York_children__as_city_tries_to_tackle_shocking_child_tooth_decay_figures/?ref=fbshr
Plans for the future:
The next step in the development of the app will be to include software to measure when users open the app, how long they stay on each screen and if they uninstall the app. The data obtained from this would be used to improve the user experience.
 
The main barrier to scaling the app is lack of awareness – this could be reduced by all those involved in health in the WMAHSN region actively promoting the app at every contact with patients and the public who would benefit from using it - making every contact count.
 
I have recently been appointed as one of the inaugural NHS Innovation Accelerator fellows http://www.england.nhs.uk/ourwork/innovation/nia/ to try to get the app adopted at a scale and pace in the NHS. With the programme comes a bursary which is being used to improve the app and raise awareness.  To make the app sustainable in the future funding will be needed to cover the cost promoting and maintaining the app.
 
Research is soon to begin to measure the effectiveness and cost effectiveness of the app in comparison to traditional methods to motivate an evidence-based oral hygiene routine in children. This will involve a randomised control trial comparing the app to traditional methods by monitoring levels of plaque on children’s teeth in the short and long-term. 
 
The main measure of success of the Brush DJ app at a population level will be if there is a fall in the number of decayed, missing or filled teeth reported in the Nation Dental Epidemiology Programme for England, oral health survey of five-year-old children and a reduction in the number of children attending hospital for tooth extraction under general anaesthesia.
Tips for adoption:
The City of York council has started to promote the app in children’s centres and reception classes. http://www.yorkpress.co.uk/news/14306759.Free_dental_packs_for_York_children__as_city_tries_to_tackle_shocking_child_tooth_decay_figures/?ref=fbshr
Contact for further information:
Ben Underwood - ben@brushdj.com
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Ben Underwood 19/05/2016 - 09:57 Approved
Overview summary:
Move it or Lose it! supplied instructors to deliver FABS exercise classes to patients with COPD within Birmingham CrossCity CCG. Classes took place in the GP surgeries once per week, for 12 weeks. Physical and psychosocial wellbeing was monitored throughout. The results have shown incredible improvements in physical capacity including a reduced frailty, enhanced mental state following classes and high levels of enjoyment. Patients have reported reduced medication use showing potential for impact for wealth as well as health for the region. 
Challenge identified and actions taken :
There are currently 1 million diagnosed cases of COPD in the UK, and 2 million undiagnosed cases. It is the fifth biggest killer disease in the UK and costs the NHS an estimated £1.2 billion per annum. It is the second largest cause of emergency admissions accounting for one million bed day per year. 
Not only does COPD impact on the health of those with the condition, but it also places huge economical burdens on the NHS. 
Move it or Lose it! supplied instructors to deliver FABS exercise classes to patients with COPD within Birmingham CrossCity CCG. Classes took place in the GP surgeries once per week, for 12 weeks. Physical and psychosocial wellbeing was monitored throughout.
Impacts / outcomes: 
Following the 12 weeks of FABS exercise classes: 
  • 30s sit to stand scores increased by 120%
  • Timed Up and Go times improved by 27% to within the normal age-related range
  • Patient use of medication reduced, including steroids, antibiotics and COPD exacerbation pack 
  • Physical frailty reduced from 'mildly frail' to 'managing well' 
  • Patients reported high levels of enjoyment and social interaction 
Which local or national clinical or policy priorities does this innovation address:
Long-term health conditions
Supporting quote for the innovation from key stakeholders:
Patient quotes:
"I have really enjoyed the classes. This has changed my life!"
"Breathing is easier to control."

Here are some videos that demonstrate the benefits:
https://www.youtube.com/watch?v=lWFBTQGrILY
 https://player.vimeo.com/external/214476540.hd.mp4?s=efd5a41e987f6998e458bfa9f7089f750f605af7&profile_id=119
Plans for the future:
Scale the programme nationally and adopt for other long term health conditions such as diabetes, frailty.
Tips for adoption:
This programme can be delivered in GP surgeries where room allows, or in local community centres which are easily accessible.
Contact for further information:
Joe Robinson 
0800 612 7785
joe@moveitorloseit.co.uk
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Joe Robinson 19/10/2016 - 17:39 Approved
Overview summary:
By negotiating a new business model with our laundry service provider, we were able to introduce a more dignified patient robe, as well as make a cost saving on laundry. This new arrangement could now be exploited by other organisations wishing to improve on patient dignity.
 
Challenge identified and actions taken :
Patients undergoing imaging are asked to undress and wear a traditional hospital robe. This ensures no metal is present in the MRI scanner, and that quality images can be achieved without any artefacts.
The robe ties around the patient, but does not completely cover the naked skin. Patients have complained about their loss of dignity. To address this, patients are offered two robes; one to tie around the front, the other round the back. However, this creates two new issues. Firstly, patients with restricted mobility find it difficult to tie fastenings around their back. Secondly, use of two robes per patient doubles our laundry costs.
As per our innovation development process, we searched the market to see what solutions may already exist. The 3-armed robe was identified as the best choice. This design ensures patients are completely covered. There are no fastenings; closure is provided by the garment having three arms (see attachements). Walsall Healthcare NHS trust had already introduced these robes and reported good patient feedback, so we decided to adopt the same. It was not viable for us to purchase the robes outright and then pay out again for the special return-to-sender laundry service.  Instead, we needed to negotiate a new business model with our laundry service provider. 
Impacts / outcomes: 
Since HEFT is a large trust, the large volumes required for the imaging services meant that it made good business sense for the laundry service provider to have the robes manufactured, and then provide them to us on the usual rental basis. The improved design enables us to provide each patient with one robe rather than two, and so as well as improving the dignity of our patients, we have also achieved a cost saving on laundry. We are waiting for delivery of the new robes and anticipate the same positive feedback experienced by our neighbour.
Which local or national clinical or policy priorities does this innovation address:
Adoption of innovation
Supporting quote for the innovation from key stakeholders:
Patients attending Walsall Healthcare NHS Trust have said they much prefer the three-armed gown because it allows their dignity to be preserved.
 
Plans for the future:
Our large volume requirement (purchasing power) has enabled the laundry service provider to source a manufacturer and provide the robes to us on a rental basis. Other trusts wishing to improve patient dignity can now benefit from this arrangement.
Tips for adoption:
Whilst the majority of patients put the robes on correctly, it may be useful to provide patients with photographic instructions. 
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Vicki Ensor 08/01/2016 - 13:26 Approved
Overview summary:
Diabetes is a major health challenge in the UK with a rapidly increasing number of people affected. Active disease of the foot is a crisis situation for a patient with diabetes & requires timely referral & management. A new solution for reliable & remote monitoring of diabetes foot ulcers, Silhouette, was implemented as part of an integrated primary & secondary care pathway. This initiative is supported by EMAHSN.

Who’s involved? 
  • Entec Health Ltd
  • Aranz Medical Ltd
  • Derby Teaching Hospitals NHS FT
  • Derbyshire Community Healthcare Services NHS FT
  • EMAHSN
Challenge identified and actions taken :
The challenge:
  • > 61,000 people with a Diabetic Foot Ulcer (DFU) at any given time
  • 6,000 people with diabetes have leg, foot or toe amputations each year in England - many avoidable
  • Improving DFU outcomes can avoid amputations, improve quality of life & mortality
  • Total NHS spending on ulceration & amputation estimated at £651m
  • 50% of foot care expenditure in diabetes is for primary, community & outpatient care
Innovation deployed:
  • Technology-enabled new model of care: 3D wound imaging & information system - Silhouette®. Enabling routine DFU treatment to be delivered in the community
  • SilhouetteStar camera uses laser-assisted 3D measurement technology to accurately map wound size, enabling clinicians to assess wound progress & response to treatment with objective data
  • Supports reliable, reproducible & remote monitoring & management of patients with active DFU & chronic complex wounds
How?
  • The partners have collaborated to implement the Silhouette® 3D wound imaging system as part of an integrated pathway across both primary & secondary care
  • EMAHSN assisted with the procurement of the system & worked with all partners to get the new pathway implemented in four settings
  • EMAHSN is providing support with the implementation, communications, patient & public involvement, planning & procurement for wide adoption & spread
Impacts / outcomes: 
Impacts to date:
  • Moving 35% treatment sessions to community clinics forecast to reduce DFU service costs by 15- 20%
  • Patient feedback very positive
  • Quality of treatment maintained with opportunities for improvements
  • Secondary applications of digital wound imaging system being explored
  • Projected savings if deployed across the East Midlands: £0.9m-£1.8m per annum


Nigel Baggaley - Podiatrist at Ripley Community Clinic


SilhouetteStar Camera


Dr Bruce Davey - CEO ARANZ Medical with SilhouetteStar Camera

        
Which local or national clinical or policy priorities does this innovation address:
Long term conditions: a whole system, person-centred approach
Supporting quote for the innovation from key stakeholders:
Clinical Champion:
Professor Fran Game, Consultant Diabetologist, Derby Teaching Hospitals NHS Foundation Trust said; “This innovative service means patients can be seen and monitored much closer to home, outside of the often busy hospital environment. This is better for the patients and is also easing the pressure on our foot clinic at the hospital."

Service User, Patient Experience: 
Albert Sutton from Kilburn said; “We only live just down the road from the clinic and it saves so much time for us, it is much closer to home than the hospital is, which means we are not spending so much time getting to and from appointments.”
Plans for the future:
Next steps:
The project is being evaluated to confirm the health economic model and business case for spread of the innovation to other locations within and outside the East Midlands.
Tips for adoption:
  • Develop good relationships with all the key stakeholders.
  • Fully define the challenges experienced first, then consider if this is the right solution.
  • Ensure there is a clinical champion.
Contact for further information:
Achala Patel, Managing Director – achala.patel@entechealth.com
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Achala Patel 02/03/2017 - 11:43 Approved
Overview summary:
For three years now, dedicated staff in Birmingham Children’s Hospital have been using Appreciative Inquiry as the method for a programme called Learning from Excellence, and the WMAHSN has had such good reports of their work and such interest from its members that they have decided to support its rollout across the region.
Challenge identified and actions taken :
We all have a strong tendency to reflect on things that haven’t worked well, but Appreciative Inquiry helps us understand that we can learn much more from things that go well. It’s an idea that’s catching on in the mainstream, too. Increasingly, it’s an idea being used in sports psychology, where teams who review their good performance are shown to improve more than teams who review the things that didn’t go well.

Traditionally, safety in healthcare has focused on avoiding harm by learning from error, but this approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it.
Impacts / outcomes: 
When we learn from our good practice, morale and resilience is improved and our psyche is in a better position to learn. It’s called Learning from Excellence.

A series of introductory talks have ran called Where did it all go right? and then asked interested people to sign up for a two-day AI training course run by Appreciating People. We’ve been asked to provide five of these two-day courses, and they’ve all been fully booked. The participants on them have been amazing – dedicated, talented and really interested in using Appreciative Inquiry to take another approach to learning and enhancing safety.

The participants we worked with at WMAHSN really responded to using AI to create positive education, and work on their Quality Improvement. It helped them build resilience, as they were focusing on the things they were good at, and celebrated their successes.
Which local or national clinical or policy priorities does this innovation address:
Learning from Excellence - Patient Safety
Supporting quote for the innovation from key stakeholders:
In Learning from Excellence [learningfromexcellence.com/], Adrian Plunkett says: We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. It’s time to redress the balance. We believe that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale.'

Quote from a participant of AI training: ‘The Appreciative Inquiry training will help me to run round table meetings exploring episodes of excellence better. But it will also be useful for my everyday practice, where I will use its strength-based methodology to help me get the best out of the theatre teams I work in.’
Plans for the future:
Studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale. The plan is to continue to study excellence and create more opportunities for learning.

Also aim to get other health organisations in the region to begin to adopt Learning from Excellence and Appreciating Inquiry in their work of practice. 

 
Contact for further information:
Helen Hunt: helen.hunt@wmahsn.org 
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Manish Patel 02/06/2017 - 10:22 Approved
Overview summary:
WIN is a group of professionals and enthusiasts passionate about utilising digital technology to improve the healthcare. It collates information and provide guidance on health informatics solutions. It facilitates discussion forums through social media, website, workshops and conferences to discuss and disseminate learning around priority areas in health informatics. We will also support educational initiatives to enhance health informatics knowledge and research programmes that will transform the delivery of healthcare services.
Challenge identified and actions taken :
Despite an initial surge in membership of clinicians and academics following the development of the network, growth decreased considerably. In order to address this, steps were taken to ensure that the reach of WIN extended beyond those initially deemed relevant:
 
  • Widened geographic reach to include and individuals / organisations that may wish to do business within the West Midlands
  • Increased industry engagement to include different forms of health provision
  • Increased local authority engagement to address aspects of integrated health and care
  • Development of public sector, industry and academic databases for targeted communications
  • Updated Advisory Group terms of reference to incorporate multi-stakeholder representation
  • Formalised policies and processes, with professional marketing material.
Impacts / outcomes: 
  • A continually growing membership of 644 members as of December 2015
  • A dedicated website with online discussion forums and events
  • Active engagement from the informatics community across healthcare, academia and industry
  • A health informatics educational needs assessment has been undertaken
  • An elected advisory group now established
  • Significant reputational benefits to WMAHSN by successful, well-attended regional events and presentation at national events, including EHI Live
  • Over 250 attendances at WIN events in 2014/15: WIN National Conference in December 2014 with 81 delegates, WIN industry event in January 2015 with 78 delegates and 95-100 attendees at the November 2015 event
  • Raised profile through membership and social media presence (Twitter, LinkedIn).
Which local or national clinical or policy priorities does this innovation address:
Harnessing the Information Revolution
Supporting quote for the innovation from key stakeholders:
Professor Theodoros N. Arvanitis, Head of Research, Institute of Digital Healthcare, WMG, University of Warwick and Co-Director of the Digital Theme, West Midlands Academic Health Science Network: “The West Midlands Health Informatics Network (WIN) is passionate about health service improvement, education and research in the health informatics domain. Our aim is to support the NHS and affiliated healthcare organisations in adopting information technology solutions in order to provide effective, efficient and high quality healthcare for patients/carers. We do this by connecting health informatics experts, professionals and enthusiasts across geographical, organisational and professional boundaries to work towards the goal of achieving in West Midlands and beyond. This is an independent network, with a culture of reciprocity, mutual respect, sharing good practice, support, equal access and shared responsibility.”
Plans for the future:
  • New website to allow members to access knowledge and expertise within the network.
  • Consideration of implications of digital health / justice
  • Increased networking activities to promote best practice and innovation.
Contact for further information:
Theo Arvanitis
t.arvanitis@warwick.ac.uk 
02476 151341
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Sarah Millard 28/01/2016 - 16:42 Approved
Overview summary:
The Solihull Approach, an NHS based team of health professionals, have developed an exciting online course for parents, carers and professionals. ‘Understanding Your Child’ includes 12 modules (20 minutes each) and follows 5 other families. The focus of the course is  how our emotions affect our relationships and behaviour. It looks at brain development, play, styles of parenting, sleep, temper tantrums, communication and more and is based on the nationally and internationally acclaimed face to face course.
Challenge identified and actions taken :
Unlike antenatal support, there is a stigma around accessing parenting support.
We know a great deal about preventing mental health problems in future generations. We know that the brain develops in response to its environment and is especially sensitive to the quality of relationships with caregivers, particularly in the first three years of life.
There is “floor to ceiling” evidence that intervening early and preventatively pays both economically, emotionally, and cognitively and achieves life long impact.
A trial of universal parenting support was undertaken by the coalition government (CanParent trial 2012-15). The Solihull Approach was a provider in the trial. The range of courses on offer were very popular with those who took them but the trial reached only a fraction of the intended audience, less than 3000 out of an intended 20,000. A CanParent survey revealed that most 98% of parents would be interested in a course, but the difficulty is accessing one.
The Solihull Approach developed the online coures in response to this finding.
The Solihull Approach face to face course and online course were  the first in the country to be awarded the DfE’s Quality Mark.
The Solihull Approach is offering multi-user licences to corporates, schools, NHS trusts, local authorities, public health, and prisons.
 
Impacts / outcomes: 
Data analysed so far: 121 parents highly significant reductions in conflict and increases in closeness in the relationships between the parents and their children on the two subscales and overall score on the Child Parent Relationship Scale (Pianta, 1992).
Published research demonstrating effectiveness of face to face course:
 
  • Johnson, R., Wilson, H. (2012) Parents’ evaluation of Understanding Your Child’s Behaviour, a parenting group based on the Solihull Approach. Community Practitioner, 85: 5, 29-33.
  • Vella, L., Butterworth, R.,  Johnson, R.  and Urquhart Law, G. (2015) Parents' experiences of being in the Solihull Approach parenting group, ‘Understanding Your Child's Behaviour’: an interpretative phenomenological analysis. Child: Care, Health and Development 41:6, 882–894.
  • Baladi, R., Johnson, R., and Urquhart Law, G. (in progress) A pre, post and follow-up evaluation of Understanding Your Child’s Behaviour (UYCB): A parenting group intervention based on the Solihull Approach. Child: Care, Health and Development.
Which local or national clinical or policy priorities does this innovation address:
National Institute for Clinical Excellence (NICE) Guidelines for conduct disorder: ‘Antisocial behaviour and conduct disorders in children and young people: recognition and management’ NICE guidelines [CG158] Published date: March 2013 http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguida...
Supporting quote for the innovation from key stakeholders:
“The most amazing and immediately life changing course I have ever been on! And that’s after 5 years in childcare!” (Parent)
“Really enjoyed doing it and found it useful. Yes it made a difference. Was going to make a referral to the MAT team. Children's behaviour problematic at home, being managed at school, but a problem. Saw an improvement after the parent took the course. We could see a difference in school. Children much, much better. The mum was being more positive, a bit more confident, she seemed able to see things from their point of view, and had  changed the way she spoke to the children.” (Pastoral Lead at a Primary School)
 
Plans for the future:
To engage with corporate partners, health, education and social care. Develop implementation kits  to assist organisations to launch the course to employees and customers. Reach the whole population thereby elevating the emotional wellbeing of future generations.  
 
Tips for adoption:
Multi-user licences are available. Implementation kits are in development.
 
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Rebecca Johnson 11/01/2016 - 16:43 Approved
Overview summary:
The review of mortality within health care settings is a long established tool for quality improvement. There is no agreed methodology or standardised measure and no national mortality measures for community hospitals.
Challenge identified and actions taken :
In 2015 I set the task for all deaths in community hospitals will be reviewed to learn about the quality of care provided to patients and in year added for all unexpected deaths for patients outside of community hospitals will be reported and reviewed by our Mortality Review Group (MRG).
Impacts / outcomes: 
Our team have developed a mortality trigger tool that allows a review of any death and then grades it according to NCEPOD style grading. The tool has been refined over the past 12 months by front line clinicians and allows us to analyse our mortality data as well as use the tool as part of MDT case reviews. We have gone from reviewing 48% of deaths by a labourious paper based system in 2013-14 to 98% for 2015-16 with the current version of the the tool. The CCGs and Trust Board are much more assured about the quality of care and analysis of our mortality data. 
Which local or national clinical or policy priorities does this innovation address:
Reducing avoidable harm
Supporting quote for the innovation from key stakeholders:
To be added - we have just had a review of our mortlaity processes from the CQC and await their assessment which will be added to this page in due course
Plans for the future:
We are looking to develop a mortality tool for use in community non-bed based settings. 

If anybody is interested in using the tool then please contact myself, the WMAHSN or James Turner at MidTECH innovations (www.midtech.org.uk).

 
Tips for adoption:
This requires a sense of purpose, a defined end point, a vision and people committed to learn from mortality and quality improvement.
Contact for further information:
Dr James Shipman, Medical Director SSOTP
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James Shipman 11/08/2016 - 16:25 Approved
Overview summary:
Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. 
Challenge identified and actions taken :
Evidence shows that 5-8% of unplanned admissions are due to medication issues and when patients are prescribed a new medicine, a third are non-adherent after 10 days and 30-50% of medicines are not taken as intended.  However on-going community pharmacist support has been shown to improve medicines adherence. 
In an attempt to improve medicine adherence, improve patient safety and improve patient outcomes, Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. The AHSN NENC supported the development and implementation of this framework across the region. The project is now gaining traction nationally.
Impacts / outcomes: 
Through active communication and participation in the national AHSN Medicines Optimisation network this work has been established as an exemplar model of communication between secondary care and community pharmacy.
  • Seven acute trusts are now making referrals to a potential 504 community pharmacies for follow up support with their medication after discharge from hospital;
  • Over 750 patients have received follow up support since the initiation of this service in July 2014;
  • Community pharmacists have reported nearly 90% of patients had a better understanding of their medicines as a result of their consultation and would be therefore more likely to adhere to their prescribed medicine regimes.
  • The project team have won two prestigious HSJ awards in 2015, in the categories for  ‘Enhancing Care by Sharing Data and Information’ and ' Most effective adoption and diffusion of best practice'
  • The work has directly contributed to the production of a Hospital referral to community pharmacy toolkit, distributed nationally by the Royal Pharmaceutical Society;
  • The Transfer of Care work initiated in the AHSN NENC has attracted national interest and has been adopted in a number of areas throughout the country.  
Which local or national clinical or policy priorities does this innovation address:
Health and well-being; patient experience.
Supporting quote for the innovation from key stakeholders:
At the HSJ Awards the project was described by judges as a "beautiful, simple solution that works...developed by clinical leaders who saw potential in existing functionality". The judges went on to praise how the Trust “genuinely demonstrated adoption and diffusion of innovative practice across the region” and that "Every hospital should be doing this."
Plans for the future:
  • Outcome measures collected through PharmOutcomes will help inform the direction and development of the project.
  • Further rollout of the project nationally will continue
  • The e-referral system is being further developed to involve GPs, doctors and nurses as well as pharmacists.
  • Development of Trust systems will facilitate the auto-population of the referral form, further speeding up the process.
  • The evidence base will be further enhanced through publication to the BMJ of research being undertaken by academics at Durham and Manchester Universities.
Tips for adoption:
Trust staff need the buy-in of community pharmacies.
The NENC region uses PharmOutcomes for E-referral and it helps if systems are complementary across regions but this is not a pre-requisite for the methodology to be adopted across Trusts.
Contact for further information:
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Anonymous 22/01/2016 - 11:52 Approved
Overview summary:
Dr Amit Arora is a consultant geriatrician at the University Hospital of North Midlands and has served as Chairman of England Council of the British Geriatrics Society. He and his team developed the “National Deconditioning Awareness and Prevention Campaign” that encouraged elderly patients to “Sit up, Get Dressed, Keep Moving”. The campaign aims to stop older patients becoming deconditioned whilst in hospital or care homes. The campaign was initially used locally and then launched nationally on Older People’s Day, 1st October 2016.
Challenge identified and actions taken :
During hospitalisation, older people can spend up to 83% of their time sitting in bed and often a further 12% in a chair, therefore becoming deconditioned. Deconditioning can start as early as the first 24 hours where patients could lose up to 2-5% of muscle mass. It is often said that ten days of bed rest can be considered to be equivalent to ten years of muscle ageing in people over 80 years. Up to 65% of older people can experience decline in functionality during hospitalisation. Moreover, patients may experience:
  • Reduced mobility and functional ability
  • Increased dependence
  • Confusion, loss of self-confidence, depression, and demotivation
  • Further complications such as falls, delayed recovery, pneumonias and associated complications
These factors can lead to what he describes as ‘Deconditioning Syndrome’. Deconditioning is preventable but requires a strategic approach and awareness. Recovery from deconditioning can take twice as long.

Dr Arora: “Deconditioning is common but it is under-recognized and under-reported. There are many people who may have experienced deconditioning... Across our hospitals and care homes, we need to make healthcare staff and families aware of deconditioning to minimise and prevent it. To create awareness, we’ve developed the ‘National Deconditioning Awareness and Prevention Campaign’.
Impacts / outcomes: 

Within the deconditioning campaign there are resources such as banners, posters, screen savers, information leaflets, exercise programs, videos and practical demonstrations to raise awareness.

As older people are the core users of the NHS, they benefit most from this campaign.

Dr Arora says “An appropriate level of exercise, activity and mobility in older people is easily do-able with in the usual surroundings. We are not talking about going to gymnasiums here. It is about doing simple activities of daily living, exercises in bed or chair, walking to toilet, sitting out in chair, standing, walking etc...” Some of the information available includes advice on how people could be supported and encouraged to stay active and independent by performing activities of daily living and movement when in hospitals and care homes. For example staff could ensure that:
  • Glasses, hearing aids, calendars and clocks are readily available and visible to promote awareness.
  • Patients are sat up in chairs, rather than remaining stationary in beds.
  • They should be dressed properly in their own clothes rather than in hospital gowns as it can make people feel better and more able.
  • Meals are eaten whilst sitting in chairs and not spoon fed in bed unless circumstances dictate so.
  • Patients should be encouraged to wash and dress independently, walk to the toilet where possible.
    • Appropriate mobility aids should be provided earlier on if needed.
    • We should ask if the mobility aids are of the right height.
    • We should check if the height of the chair for example is not so low that the patient can’t get up.
    • Patients should be encouraged to keep their arms and legs moving in their beds or chairs especially if they are unable to mobilize themselves.
  • Restrictions on visiting hours should be adjusted to encourage normal social interactions, which will also help to maintain functionality, regain independence and reduce loneliness.
  • Patients should be supported and encouraged to move as quickly as possible, where possible.
All of this support and encouragement movements could help to:
  • Reduce the risk of harm from falls, infection, thrombosis and delirium.
  • Reduce length of stay in hospital.
  • Reduce the likelihood of having an increase in their future care needs.
In addition there are many benefits of staying active in hospital:
  • Better able to fight infections
  • Better appetite
  • Better sleep
  • Better mood
  • Better able to cope at home
  • Lower risk of pressure sores
  • Less weakness and fatigue
  • Less dizziness
  • Lower risk of falls
  • Less pain
  • Less confusion
Moreover, this project noted that the biggest change was the individual’s behaviour and organisational culture generated through awareness.
 
The initial intended outcome was to achieve a 25% increase in the number of patients sat out, dressed and engaging in meaningful activity during their acute illness. However, there was an increase in the number of patients sat out, dressed in their own attire and mobilized by 60%. There was also an increase in therapy review and therapy led plan setting within 24 hours of admission. However, these can be fluctuant and dips were commonly noted so it is important to keep the momentum going.

There was also an enhancement in patient experience and in both staff and relative satisfaction...

Overall, the outcome from the ‘National Deconditioning Awareness and Prevention Campaign’ to get patients to “Sit up, Get Dressed, Keep Moving” has had a positive impact on patients and staff.  
Which local or national clinical or policy priorities does this innovation address:
With the support from the British Geriatrics Society and NHS England, within a month there were requests for our material from clinical staff at over 20 hospitals, including hospitals from Australia, New Zealand and Canada and more have joined since. This campaign also received unprecedented support from the #endpjparalysus campaign and Jane Cummings (Chief Nurse, NHS England) and the efforts to prevent deconditioning became popular. Overall, this innovation generates awareness about this common condition in older people especially when they are hospitalized and less active. It also addresses how deconditioning syndrome can be prevented. Furthermore, the campaign’s material was requested by 40 NHS hospitals and more enquires have followed from the UK. The freely available downloadable material has already been requested by 40 hospitals; the team has certainly made an impact.
Supporting quote for the innovation from key stakeholders:
Many people were pleased with the information that was given to them about the ‘Deconditioning Awareness and Prevention Campaign’ and how it can affect a patient’s well-being. Here are a few supporting quotes that showcase how the campaign has been effective and successful, being adopted across different NHS Trusts:

“Hi Amit
This is a great campaign. Thanks for sharing it with us. As Andy said, it should fit well within the Care of the Elderly teaching blocks.”


“Hi Doctor Arora, 
I am a physiotherapy student at Keele University and have recently started placement on frail elderly at UHNM. Whilst embarking on pre-placement reading, I came across the deconditioning awareness campaign. I have also highlighted deconditioning and behaviour change as potential topics for my placement presentation.”


“Thank you so much Amit.
I wish there were more stars in the NHS like you. Normally sharing material is not an easy matter & people get protective over their material. I will send you updates when we get them produced.” 


“Hi
We love your staying active in hospital patient information and would like to have permission to use in Western Sussex Hospitals NHS Foundation Trust.
Of course credit still going to University Hospitals of North Midlands.”


Here are some supporting quotes from Dr Amit Arora himself on how he came to create the ‘Deconditioning Awareness Campaign’ and how deconditioning can affect a patient’s well-being:

Dr Arora said: “Many years ago I was subject to restricted mobility following an emergency appendicectomy. It took me a surprisingly long time to regain my strengths and abilities. I noted that despite my youth and the will, my muscles would not move. It took a while to recover back to normal.

When I related this to the frail old people that I see in hospitals, I can understand why someone who was able to function well before they came to hospital takes longer to regain their functions. A prolonged hospital stay, bed rest and other risks lead to loss of muscle power, strength and abilities…”


Dr Arora also said: “We should encourage patients to wash and dress independently, walk to the toilet where possible, provide appropriate mobility aids earlier on and encourage patients to keep their arms and legs moving in bed or chair. Even moving arms, legs and sitting up in bed offers a small degree of physiotherapy. It sounds so simple yet very often it just doesn’t happen.”

Amanda Futers, Clinical Nurse Specialist said: “Staff and families have an important role to play in preventing deconditioning. There is sometimes a misconception by families that staff should be doing everything for their loved ones because “they are in hospital”. Educating patients, relatives, carers and staff about the dangers of deconditioning is vital, since bed rest continues to be expected during a hospital stay, despite the considerable evidence showing potential adverse effects from inactivity. Of course there are times and conditions when best rest would be advisable, but more often than not this is not the case.”
Plans for the future:
  • To continue to build on ward-based exercise groups to maintain muscle tone and abilities.
  • To launch campaigns and engage influencers at local Older People’s Day events.
  • Hold national/international conferences at UHNM in 2018.
  • Continue to speak at national conferences to generate awareness.
  • Help nurses, therapists and medics conduct further research on methods of effective implementation of such programs.
  • Continue to roll out locally and nationally via schools, fire service, public, patient and CCG networks.
  • Engage champions from ward to board and into community.
Overall, we must continue to build on the campaign’s message.
Tips for adoption:
If you would like some tips on how to adopt the ‘Deconditioning Awareness Campaign’, “Sit up, Get Dressed, Keep Moving” then do not hesitate to download our material (This material may be copied without prior permission being sought from the copyright holder provided the purpose of copying is not for commercial gain and due acknowledgement is given):

View 'Poster' here (fo​r hospitals and care homes​)​​
View 'Bann​er' here
View 'Patient Information Leaflet' here​​
View Screensavers here

Or contact Dr Amit Arora: 
amit.arora@uhns.nhs.uk
@betterageing
www.betterageing.co.uk
 
Contact for further information:
Contact Dr Amit Arora: 
amit.arora@uhns.nhs.uk
@betterageing
www.betterageing.co.uk
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Amit Arora 24/05/2018 - 14:09 Approved

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