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Chris Goodwin, Senior QC Analyst, Betsi Cadwaldr University Health Board     

I’m Chris, and I am the Senior Analyst within the Pharmacy QC team at Wrexham and I am also part of the Bevan Exemplar programme’s Cohort 8.

15 months ago, I had some discussions with the Lead Antimicrobial Pharmacist here in Wrexham where he told me about the OPAT service that he was piloting and looking to scale up. OPAT stands for Outpatient Parenteral Antimicrobial Therapy and really simply what that means is having intravenous antibiotics outside of the hospital using the devices pictured to the left*. This has many benefits to the patient as they can be with family, go to work as well as many other quality of life improvements. There are also benefits to the Health Board in regards to patient flow, freeing nurse time and cost reductions.

I had not heard of this way of treating patients before but it sounded like a great option for patients to have, and the patient feedback on the service really reinforced these thoughts:

“I would absolutely use the service again; I think it is a fantastic idea with many benefits”

Unfortunately, the service was not being used to its full potential. The reasons being that not only are the devices needed quite hard to get hold of in a ready to use fashion but also very difficult to make yourself, particularly in the volume the service may require. The challenges it was facing did not seem insurmountable and so from these discussions, a rather ambitious project was set out:

Can we use semi-automation within the manufacturing suite in Technical Services to offer these devices in an efficient, cost effective manner and more importantly can we do it in the 12-month time span of the Bevan Exemplar programme?

Turns out you can, although it is a lot of hard work! Drawing on the expertise we have available in both the laboratory and manufacturing teams; new analytical methods were developed logistical barriers were overcome and production methods were refined. Over the course of the programme, we have managed to achieve the following:

• Reduction in manufacturing time by 85%
• Shelf life increase of around 300%, and also generated some data to enable room temperature storage
• Cost reduction of around 90% when compared to an in-patient and 80% compared to purchasing pre-filled OPAT device.

These outcomes highlighted to us the role that technology has in developing the aseptic service here in Wrexham and how by embracing these advances and change we are able to manufacture a product that we reasonably could not 10 years ago. Not only that, but it demonstrated how much ability there is within our technical services team and that we should have the confidence to push our service further and into new directions to better meet the ever evolving requirements of modern healthcare and, more importantly, patients.

2024 is looking to be an exciting year as we use the transferable learning points to begin development on new drug dosages and molecules so that we can offer a wider catalogue of treatments that will enable treatment  of a wider range of illness. We are also investigating other ways that technology can create efficiencies within the department freeing up capacity of the production team and increase the output of products.

*I would like to say that it is perfectly safe and controlled. Patients are vetted for suitability, trained and monitored by a team of nurses; patients are not left to their own devices with needle and vials of drugs, a concern I have come across quite a lot over the course of this project!

Emily Hoskins – Early Years Speech and Language Therapist, Aneurin Bevan University Health Board.

@EmsSLT

Speech, language and communication needs (SLCN) are the most common type of additional learning needs with 4.8% of school children having SLCN. If unaddressed, this has lifelong impacts for education, wellbeing, mental health, youth offending and employment Speech, Language and Communication (SLC) needs: infographics | GOV.WALES. We know that the most important predictor of language abilities is the communication environment and this project has worked on bringing SLC to the fore in Gwent’s early years teams. Modest investment into training early years practitioners can have a huge impact on SLC outcomes and this has been the focus of the last 12 months of work.

Image taken from 41062 Talk With Me (gov.wales)

There is no specific training for SLC within Health Visitor pre-registration training and this led to the Health Visiting department in ABUHB creating an innovative role to have an in-house Speech and Language Therapist to deliver a training programme for their whole workforce.  The training had been co-produced within Welsh Government for Health Visiting teams and ABUHB piloted integrating the rollout with Local Authority (LA) teams.

The second part of the project centres around developing a bespoke SLC contact for all children in Gwent to understand children’s SLC development, provide preventative public health SLC messages and offer targeted level support to address transient needs. The aim is simple, let’s see children early, improve their communication environment and reduce their risk of having SLCN!

Training rollout

Trained staff: 290

Overall increases in confidence from 6.19 à 8.60 across 6 domains…

Stakeholder engagement

Stakeholder engagement activities were completed to jointly design a bespoke SLC contact for Gwent….

• Staff survey: 28 responses, 11 Health Visiting, 17 LA​
• Parental survey (QR codes given to parents/posted on social media): 32 responses​
• Visited existing universal and targeted interventions to talk to parents, accessed 39 caregivers (33 Mums, 4 Dads, 1 Auntie, 1 Foster parent)​
• Showed proforma to one LA area Health Visiting team (11 staff present and video available)​

Themes identified

Parents want:

• To feel listened to
• Concerns taken seriously
• The session to not be rushed or feel like a checklist
• More time to discuss concerns
• Time to discuss SLC even if they didn’t have concerns
• Reassurance
• To hear what they’re doing well

Feedback was used to develop the proforma for a contact suitable for 18-21 month old children, using strengths-based feedback and natural play.

Outcome measures

In the contact, 2 outcome measures have been embedded

1. Parent self-rating their confidence on a scale of 1-5 to interact in a way that helps their child learn to talk
2. Observations of parents use of responsive communication strategies. Use of the Parental Responsiveness Rating Scale (PaRRiS). This is a 1-5 scale of how responsive a parent is in interactions (1 = very low 5 = very high)

Levickis, P. (2019) Parental Responsiveness Rating Scale (PaRRiS): Scoring Manual [unpublished manuscript]. Melbourne: The University of Melbourne, Melbourne Graduate School of Education, REEaCh Centre.

Pilots

2 LA areas have started pilots so far:

Initial outcomes

14 contacts completed from November 2023-January 2024

Intended outcomes

• Making SLC ‘everybody’s business’: Increasing the knowledge and confidence around SLC for Gwent’s Early Years workforce to support us to consistently discuss and support SLC development in line with the evidence base
• Speeding up the time staff take to find appropriate resources to share with families for SLC (85.8% of trainees agree or strongly agree with this)
• Increasing parental responsiveness which in turn supports language development as they are the experts in their child and can make the difference. A focus on prevention via the universal contact point for dedicated attention on SLC
• Using behaviour change models to identify the right time for a referral to SLC support services where appropriate. The right support, from the right person, at the right time
• Monitoring DNA and engagement patterns to targeted and specialised SLC support services, aiming for reduction in referrals, increased attendance or both

Next steps

• Support 2 existing pilots and monitor feedback and outcomes
• Identify more areas of Gwent to begin pilots in 3 remaining LA areas
• Adopt across Gwent, monitor the impact and share nationally with other Health Visiting and SALT teams
• Bi-annual ‘mop up’ training to future-proof the skills within Gwent early years, with all new starters accessing SLC training

In time we hope to see longitudinal outcomes on referral patterns, engagement and in turn the longer-term impacts of unaddressed SLCN.

Learning

You always have an ally! Times of transition from one stage to the next can seem daunting but they happen and then the next stage is upon you. Relationships are so important to help drive things forward, and to have someone to support you in moments of doubt! Part of delivering a project is reflection and mental analysis and sometimes being sat thinking can be just as tiring as doing. Seeing other people become passionate about your area of specialism is exciting and finally, ‘if it isn’t there, don’t force it’.

Siân Jones MBA– Business Development Manager, Red Kite.

Monika Rusiecka MSc – Pain management Practitioner, Red Kite.

@RedKiteHealth

Chronic pain is recognised as a growing problem, affecting between one-third and one-half of the UK population (BNF). As outlined as early as a 2006 study by Brevic, persistent pain accounted for around 20% of all primary care attendances, a percentage that continues to increase with an ageing population.

In recent years a majority of well-known and respected organisational bodies have released new and updated guidelines on how to tackle this problem and provide support for patients, including, the International Classification of Diseases 11th (ICD-11: 2022); Classifying Primary Chronic Pain Conditions as a disease state, that requires appropriate management; and the Living with Persistent Pain guidance – a refreshed document by the Welsh Government (2023). Guidance which focuses on improving awareness of persistent pain and advising on the range of management techniques and online tools available to improve management.

Although each guideline tries to address different aspects of pain management, our work in this area identified that both capacity and a uniform approach to delivering the aims of the guidance and improve the support for this chronic condition was lacking. Our aim was to provide the same level of provision that currently exists for patients suffering from other chronic condition in a primary care setting.

How did we do it?

We are Red Kite, a small community interest company, delivering health and care services that support the sustainability of primary care. We may be small in numbers but our aspirations to deliver modern and sustainable health solutions certainly make up for it. Our latest project, being the development of a persistent pain practitioner role in primary care, dedicated to improving the management of this often, debilitating condition.

Through our work, it became evident that there were gaps in provision around persistent pain management, with no dedicated services for early intervention or support for patients presenting to their GP. Additionally, there were no services available for patients who do not fit the criteria for secondary/community care services and a lack of available support for patients at a primary care level to ensure patients are cared for appropriately and efficiently at any stage of their journey.

Our aim was to implement a uniform approach to delivering the aims of persistent pain guidance and provide, at a minimum, the same level of provision that currently exists for patients suffering from other chronic conditions and to improve education and awareness of this condition at a primary care level.

This is why we developed the concept in which any healthcare professional interested in persistent pain management could develop themselves and in turn, implemented strategies that improve the quality of care and support available to patients with persistent pain.

We did this through the training of a pharmacy technician based in primary-care, with a keen interest in the management of pain. Working closely with local GP practices, we have

introduced practice-based patient clinics, educational sessions and the development of a go-to system to improve the management of pain in an over-burdened, primary-care system.

Our Ambition

Our hope is to see a dedicated Pain Management Practitioner available across primary care GP Practices,

• to support GPs and other clinicians with prescribing and reviewing analgesia regimes.
• to ensure continuity of care for patients suffering from persistent pain, including
  • patient education on their condition and modern self-management strategies
  • putting in place and regularly reviewing a management plan that is relevant to the individual
  • provide support for the patients during flare-ups, that might occur.
• being a one-point of contact for specialist Pain Management settings, providing additional information or to receive handover advice about individual patients.
• to raise awareness of modern Persistent Pain Management strategies in local communities, to empower patients to take their health and well-being into their own hands.

What have we achieved?

The primary care pain management intervention is a welcome addition in terms of the management and future management of persistent pain. The service has enabled primary care to support national guidance for the treatment of persistent pain being classed and treated as a disease state. A tailored service provides support in dealing with the increased demand in an over-burdened system and will be vital to ensuring patients can appropriately manage their pain symptoms and improve their quality of life.

Results have already shown:

• 63 patients receiving a person-centred assessment to identify factors contributing to pain and how this affects their life.
• Increased awareness and education across primary care
• The ability to meet government guidance for the management of pain
• Reduced and appropriate prescribing of pain medication
• Increased capacity for GP/Pharmacy
• Improved patient care
• Improved partnership working to develop a whole-system approach
• Reductions and interventions in line with the national prescribing indicators
• Development of MDT roles within primary care for the future

What next?

We are now planning to extend the service through outreach and support for patients diagnosed with osteoarthritis, improving the understanding of joint health as well as a

tailored exercise routine considering patients’ lifestyles and abilities. Additionally, we have started to upskill other members of the primary care team in pain management practice. We will continue to support patients as well as clinicians to ensure we work towards providing gold-standard care for patients living with persistent pain.

During the service development, we have learned some valuable lessons, one of them being that clinicians are very welcoming to change in the management and care of persistent pain patients as long as trust and professional boundaries are established. We have also learned that paradigm shifts in patient care need time to allow for natural organisational changes and adaptations but when implemented, benefit both patient lives and in-turn reduce costs and time to the NHS.