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Innovation 'Elevator Pitch':
The National Osteoporosis Society has pioneered a package of support for the commissioning and improvement of secondary fracture prevention services.  This can save the average CCG 1.7m over 5 years.
 
Overview of Innovation:
The Fracture Liaison Service (FLS) care model enables secondary fracture prevention through identification of low trauma or fragility fractures by means of dedicated case finding, with assessment and treatment of osteoporosis where appropriate.  This model has been replicated across the UK since April 2015 with the support and expertise of the National Osteoporosis Society.  A team of specialist development managers with clinical and commissioning experience is currently working with 167 sites (to date) to support new service development (50), or quality improvement of existing services (78).  Preliminary results from an analysis of the effectiveness of these services in preventing secondary fractures indicate a significant positive difference between sites with an FLS, and those without.

Operating in a tough economic climate with health budgets tightly constrained, investment in new services must demonstrate both a solid evidence-base and a strong business case.  There is strong evidence that investment in FLS results in improved quality of care and financial savings in health and social care.  The NOS has produced a suite of online resources to support FLS development and improvement.  A comprehensive FLS Implementation Toolkit supports providers and payers in the commissioning process and is provided free of charge. [1] Users can create a compelling, evidence based business case without the need for advanced skills in costing, modelling or other health economic techniques.  The SDT is also available at any stage throughout the implementation process to support clinical pathway or business case development.  Advice is available regarding outcome measures and performance indicators, as well as effective data collection for service evaluation.  This service is provided free of charge. 

To date, 9 new FLS have been commissioned (8 new services and 1 augmented service).  These new services represent FLS provision to an additional cumulative population of nearly three million people, which could prevent more than 1000 hip fractures over 5 years.  This in turn represents gross savings across health, social care, and community services of £17.3m (service costs typically run at less than 40% of the gross benefit).
 
[1] The Implementation Toolkit https://www.nos.org.uk/health-professionals
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':
OsCare Sono allows early assessment of Osteoporosis risk in an out of hospital environment. It is a low cost device, can be used by any healthcare professional, emits no radiation, proven technology & vastly improved patient outcomes and cost savings
Overview of Innovation:
The OsCare Sono™ measures ultrasound wave propagation longitudinally in the radial bone. In comparison to other ultrasound bone sonometers, the OsCare Sono™ has a lower ultrasound frequency, of about 200 kHz. The low frequency ultrasound travels deeper in to the bone tissue providing better correlation with cortical thickness and its patented transducers and algorithms help to eliminate the effect of soft tissue. Oscare Sono also uses the radial bone which is easier to access and more sensitive to osteoporotic changes.

The device compares the measurement result to the available reference population group data and calculates the Z- and T-Score values, indicating if the patient has an increased risk of osteoporosis and future fractures.
OsCare Sono™ measurement results help to recognize those individuals who are at higher risk for osteoporosis and potentially further investigations such as a DEXA.
Osteoporosis is an increasingly prevalent skeletal disease characterized by diminished bone strength and increased risk of fracture which costs the NHS £2.9bn annually.

‘The International Society of Clinical Densitometry (ISCD), the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economical Aspects of Osteoporosis and Osteoarthritis (ESCEO) describe in their position statements that although DXA (dual X-ray absorptiometry) and the femoral neck are the reference technology and site for diagnosing osteoporosis, other techniques such as quantitative ultrasound (QUS) can be used in clinical practice to identify patients at high or low risk of having osteoporosis. The Foundation and Societies stated that QUS is proven to predict osteoporotic fractures similarly to central DXA.’

Oscare Sono is highly portable and can be set up within minutes in an environment suitable for assessing patients.
No ionising radiation is emitted and therefore there is no restriction on location or IMIR regulations.

Early assessment of patients at risk of Osteoporosis in the NICE pathway will identify patients at risk of osteoporosis and allow early intervention.
Oscare will enable large scale assessment of patients at risk of Osteoporosis, facilitate early intervention and improve patient outcomes.
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 / Wealth creation / Clinical trials and evidence / Digital health / Innovation and adoption / Person centred care
Benefit to NHS:
Features:
  • Low-frequency (200 kHz) axial ultrasound velocity correlates well with bone mineral density (BMD) and cortical thickness, giving valuable information on bone strength
  • No ionizing radiation — measurement can be performed in any suitable location and repeated when required
  • Facilitates assessment in any appropriate setting, GP surgery, pharmacy etc.
  • Short assessment time, typically 10 minutes per patient
  • OsCare Sono™ is cost-effective and enables large scale assessment – A reliable and quick procedure
  • No specialised or qualified staff needed, short training cycle, easy to interpret report.
  • Measurement is on the radial bone which is easily accessible so no need for patients to undress
  • Patented soft tissue disturbance effect eliminates artefact producing a clear signal and improved diagnostic confidence
  • Compact in size & highly mobile. No dedicated PC needed, software runs in a standard Windows operating system
Cost savings from:
  • Reduction of referrals for DEXA scanning
  • Potentially significant cost savings in treating reduced numbers of fractures
  • Reduced demand on downstream services as 70% of patients with #NOF or pelvis fail to make a full recovery
  • Reduced emergency admission for osteoporotic fractures
The International Society of Clinical Densitometry (ISCD), the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economical Aspects of Osteoporosis and Osteoarthritis (ESCEO) recognize QUS methods as relatively inexpensive, transportable and proven to predict osteoporotic fractures as well as the central DXA. Compared to DXA, the OsCare Sono™ device is significantly less expensive, portable and, importantly, free of potentially harmful ionizing radiation.

Return on Investment
  • NHS Osteoporotic fracture burden is £2.9 or 3.5 Bn, depending on source
  • Identifying patients who may be at risk or actually have osteoporosis is not being undertaken currently at the rate which is needed. As the population ages, this will become more significant
  • The device is 80% the cost of one A&E admission
  • Early identification reduces decades of patient treatment costs
Initial Review Rating
5.00 (2 ratings)
Benefit to WM population:
Early assessment of patients will facilitate early identification of patients at risk of osteoporosis and enable early intervention. This will lead to reduced incidence of osteoporotic fractures, related mortality and morbidity and associated health costs.
It will dramatically improve patient outcomes by reducing the significant mortality and morbidity associated with osteoporosis which is frequently overlooked as a consequence of being older rather than a modifiable outcome - which it is.
There are currently not enough DEXA scanners in the West Midlands region to cope with demand.
The adoption of this technology within the West Midlands and across the UK. Would not only save some patients the inconvenience of going for a DEXA scan or even repeated scans, when they are not required whilst still providing the patients with confidence and reassurance.
This is not intended as a replacement for DEXA which is still the gold standard in diagnosis of Osteoporosis. This would mean that patients referred for DEXA scanning would have a higher diagnostic yield.
This in turn would reduce the costs of DEXA referrals and investigations for GPs/CCGs to where they are required thereby reducing the waiting times for such investigations and the costs and time associated with reporting negative results on the imaging consultation service and the GP on a subsequent patient visit to collect results.
It is estimated that Oscare Sono will facilitate a reduction of DEXA referrals which cost in the region of £278 per patient. The total number of DEXA scans undertaken in the region and the outcome is not known. But it is clearly not enough as many thousands of patients suffer osteoporotic fractures still and this number will continue to rise as the population ages.
Physiological Measurements Ltd are working closely with the Finnish inventors or this product and have secured a UK distribution and support agreement. The regional and wide scale adoption of this technology would allow the company to grow and take on additional specialist staff to train and support users of this technology as well as having a significant impact on the company and West Midlands Osteoporosis services.
Current and planned activity: 
The device and concept are a disruptive innovation and are not currently in place within the UK healthcare system.
We are about to start a small scale trial with a GP in the Northwest of England and a Pharmacy in the Midlands to gauge acceptance and identify how many people in a cohort are found to be at risk. We are contacting lead commissioners and clinical leads at each of the 44 CCGs that we are currently delivering services too.

Planned / required activity:
  • Procurement / Adoption of our OsCare Sono – First Line Osteoporosis Assessment technology -  We seek to disseminate via the network to clinicians at all levels, the potential impact of this innovation in terms of improved patient outcomes and a reduction on healthcare resource use at all levels.
  • Evaluation / Validation / Clinical Trial  - We would welcome the opportunity to work with an acute NHS trust to evaluate the impact this innovation could have on patient flow and also as a primary prevention tool.
What is the intellectual property status of your innovation?:
Patented Product held by Oscare Medial OY, Finland

Product Certification: CE IIa ref:0537 - - EC-Certificated 93/42/EEC - ISO13485:2003
Return on Investment (£ Value): 
Very high
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
Simple
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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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