Scope:

Hywel Dda’s Children’s Community Integrated Nursing Service has been a pilot project bringing together two small nursing workforces, generic and continuing care into one community team. It has also allowed a separated assessment capability which focuses on needs assessment & care provision recommendations from care package management.

Context:

Hywel Dda University Health Board is the second sparsely populated Local Health Board in Wales serving a 0-18 years population of 71,058 across the counties of Carmarthenshire, Ceredigion and Pembrokeshire.

Starting Position – February 2016:

Children’s Continuing Care Nurses x 3:

• 1 based in Ceredigion
• 1 based in Pembrokeshire
• 1 based in Carmarthenshire

= managed by 1 team leader.

The nurses undertook the continuing care assessment process and managed a total of 16 packages averaging 800 care hours/week delivered by the third sector. Seven packages located in Carmarthenshire, six packages in Pembrokeshire and three in Ceredigion resulting in the Ceredigion nurse having to travel from North Ceredigion to manage a package in both Pembrokeshire and Carmarthenshire. In addition there was one WellChild Transitional Care Nurse based in Carmarthenshire working across both services.

Generic Children’s Community Nurses x 6.5

• 3 based in Pembrokeshire of which 0.8 was the Team Leader
• 3 based in Carmarthenshire of which
• 0.2 is the Practice Teacher
• 0.5 based in Ceredigion

A caseload of 270 children and young people (CYP) across the three counties with varying health needs including long term, life limiting and complex health needs. A number of the CYP were defined as being inactive i.e. no nurse contact for 4 weeks. In Pembrokeshire there is an additional 0.48 nursing post funded by education-based in specialist school. Due to the Children’s Continuing Care Team Leader securing another post led to a review of how the workforce continues to meet its service demand.

It provided the opportunity to pilot the integration of the two small nursing workforces and funding to recruit 1.26 WTE Band 5 nurses and additional 5 hours for the Team Leader post. Agreement from the nursing workforce and planning for the pilot began in February 2016 with the start of a six-month pilot from March 1, 2017. Participatory action research approach was applied as a reflective process of progressive problem solving.

Planning & Development:

The planning process involved the team undertaking an analysis of the strengths, weaknesses, opportunities and threats, barriers and counter measures leading to the development of pilot objectives, education programmes, a review and development to the teaching library resource and the implementation of a single nurse assessor role for the continuing care process. Nurse bases were reviewed with two sites in Ceredigion-north and south, two sites in Carmarthenshire-east and west, and two sites in Pembrokeshire-mid and south.

The development of a traffic light system provided a risk framework  to support the delivery of an equitable, safe and sustainable children’s community nursing service.

Benefits:

• The risk framework facilitated implementation of the centralised referral system.
• Initiated the pilot of a nurse led clinic service for CYP requiring overnight oxygen saturation monitoring Instead of receiving home visit by a nurse, the CYP attends the clinic to collect and return saturation monitor the next day for the nurse to download their recordings for review by the prescribing doctor.

At the end of the six months, there was agreement that we cannot return to being two teams, maintain the nurse assessor role and review in 3 months.

Fit with Prudent Healthcare:

• The pilot facilitated the development of an in-house education programme, mentoring/buddy system to support the development/updating of nursing knowledge and skills.
• The integration of two small nursing workforces maximises clinical capacity by having nurses based across six sites.
• The risk framework promotes the identification for the right practitioner, providing the right care at the right time and right place, acknowledging the need for further service mapping.

Context:

Currently all GP referrals are ‘vetted’ in secondary care and a priority assigned. This process accounts for between 0.5% – 1% of all Welsh NHS Consultant time. These decisions are usually made from only a few lines of infor- mation from the referring GP.

Aim:

We hypothesised that we could train an algorithm to predict the prioritisation decisions of our consultants, thereby allowing us to release this time, as well as providing instant information to referring GP’s and patients of the likely timescale to be seen in secondary care.

Planning & Development:

With the aid of several senior clinicians, ABCi’s mathematical modelling capability, and NWIS, decision-tree algorithms were developed, initially for secondary care breast services referrals, to be incorporated within the national electronic WCCG referral architecture.

GP assessment of case priority, either routine, urgent, or Urgent Suspected Cancer (USC), was equivalent to Consultant assessment in only 50% of cases, significantly surpassed by algorithm equivalence in 75-90% of cases.

Despite minimal algorithm under-prioritisation rates, patient safety was of paramount importance to the team. Any cases which the algorithm classed to be a ‘USC’ priority could be deemed as such, requiring no further human prioritisation, but all others – routine and urgent – would continue to be reviewed by a consultant as a safety net.

Outcomes:

This approach delivers a potential time efficiency saving to the Welsh NHS of £256-641k per year once scaled nationally, releasing consultants to deliver direct patient care, whilst also providing GP’s and patients with instant information regarding referral timeframes.

Fit with Prudent Healthcare:

• In an age of increasing hype around Artificial Intelligence, Clever Referrals is the Welsh NHS’s first steps in this regard to support the interface between primary and secondary care.
• Clever Referrals demonstrates a key area where consultant time can be released to deliver better value, whilst reducing inappropriate variation by aligning national practice, and through this, ensuring consistent prioritisation so that those with the greatest health need are cared for first.

Aim:

To highlight the benefits of introducing Frailty Support Workers in the acute hospital setting and how their interventions bridge the gaps between different healthcare disciplines and lead to improved outcomes and cost savings.

The role allows for individualised patient care in a busy acute environment and has demonstrated to have a positive impact on patient experience and demonstrated a reduction in length of stay.

Context:

Senior nursing staff and ward clinicians recognised that there were difficulties in maintaining existing good clinical practice for frail elderly patients as well as supporting other interventions (mobilising, rehabilitation and group activities).

The complexity of patient needs in a cohort of dependent patients attributed to an increased workload in relation to fundamental patient care, reducing the amount of time available for staff to focus on all patient’s holistic needs.

It has been recognised that for every day a patient spends in bed it takes a further week to rehabilitate them thus increasing patients length of stay, risk of pressure damage and hospital acquired infections. As a result, the Frailty Support Workers (FSW) role was introduced.

Planning & Development:

The role of the Frailty Support Worker (FSW) is to work in conjunction with other members of the multi disciplinary team in assessing patients for frailty.

Through an assessment based on Comprehensive Geriatric Assessment (CGA) FSW can determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances.

Whilst working closely with patients, their families and carers they aim to establish an individual’s previous functional ability which allows them to identify areas contributing to the patients decline and to bring about improvements and interventions to aid return of independence and their previous level of function.

The FSW role has improved patient outcomes and experience, as well as reducing length of stay.

Through frequent mobilisation and improved nutritional input, patients are able to maintain and improve their previous level of function and independence.

A reduction in hospital length of stay by 1 day for the whole ward was recorded following introduction of the FSW for 24 beds which equated to an annual saving of £198,000.

Following introduction of the milkshake rounds by the FSW the nutritional status of patients evidenced improvement with improved nutritional scores and a mean patient weight gain of 1.5kg, with £18,000 saved through reduction in nutritional supplement prescribing.

During April 2016 – February 2017 a total of 147 patients were identified as being suitable for frailty intervention:

• 112 patients gained weight – 76%
• 118 patients Nutritional Screening Score improved or maintained – 80%
• 146 patients frailty scores improved or maintained – 99%

Fit with Prudent Healthcare:

By working in conjunction with other members of the multidisciplinary team and by adopting a prudent view and frailty model that best suits the health needs of a significant frail older population will aid in preventing, preserving and supporting their wellbeing in order to maximise a more positive outcome for those individuals.

Context:

To ensure a safer, equitable and sustainable care delivery for the needs of residents in care homes. We have identified the need for a new Multi-Disciplinary (MDT) model of support, monitoring and development within care homes across North Wales.

Over the past two years there has been a consistent increase in the number of nursing homes being put under formal escalating concerns, closing due to financial or quality issues as well as a number of homes having increasing quality and safeguarding issues. A recent audit has also shown a high level of admissions form nursing homes that could have been potentially prevented.

A solution to this is for the MDT to support the health and wellbeing of patients by proactively reviewing and initiating new treatment regimes. To enhance the competencies and skills of clinical staff working in the homes by providing training, education and clinical skills. To ensure implementation of evidence based practice delivery by undertaking quality monitoring and structured leadership.

Planning & Development:

The MDT consisted of ANP, pharmacist, physiotherapist, speech & language, dietetics, practice development nurses and occupational therapists. To influence key health board senior managers data has been collected regarding, admissions, quality concerns, WAST data and district nursing visits, POVA and safeguarding. This data was then used to inform the selection of homes requiring further support and to test the model.

A pilot within four care homes across North Wales is currently being implemented. Funding has been secured from intermediate care funds across two areas.

Benefits:

Patient & Safety experience:

• Ensure patients are treated with dignity and respect and are properly consulted regarding their care and changes to their treatment plan;
• Development and promotion of patient-centred care delivered within the patients home; and,
• Prevention of patient deterioration and improvement of quality of life and increase in delivery of evidence-based safe and effective care.

Staff:

• Increased competencies of staff;
• Access to education and education; and,
• Access to specialist support, advice and leadership.

Efficiency benefits:

• Contribute to reduction in A/E attendance, hospital admissions and enable earlier discharge to the home;
• Provide appropriate information, knowledge and support for care home staff in order to enable them to identify early need for intervention; and,
• Cost savings in medication and consumables.

Regulatory benefits:

• Reduction in escalation concerns, safeguarding incidents and complaints;
• Reduction of loss of beds from placements; and
• Reduction in home closures.

Context:

If nurses wish to check if their patients’ laboratory test results are available, current practice is to repeatedly log onto the Welsh Clinical Portal (WCP) to view the status of their request or to telephone the pathology department.

A 2014 Betsi Cadwaladr UHB study at Wrexham Maelor Hospital found nurses in a typical paediatric ward spend an average of 28 minutes per shift doing this activity, for adult wards this figure is expected to be higher.

Aim:

Our aim was to produce a tool for healthcare professionals that allows them to provide safe, quality care in a timely manner. Our guiding principles ensure that we can reach this goal in a prudent manner:

User-Centred Design: The healthcare practitioners who will use the system are placed at the centre of design and development. Our work is progressively revised in an iterative design process with frequent consultation, requirements capture and qualitative usability testing.

Easy to Implement: Ping aids and augments practice works alongside existing IT systems with no disruption to current infrastructure.

The Project:

CHAI™ Ping is a notification service for use in clinical environments integrating with PAS (Patient Administration System) and Clinical Portals.

A permanently connected interface lists patients on the ward and alerts when results are ready for collection, in real time.

Safety and Privacy:

Ping assists with ensuring patient safety by maintaining logs on notifications, dismissal and resulting action.

The contents of test results themselves are not released, thereby safeguarding patient privacy; users must complete a further verification step by logging into WCP to retrieve results. Users retrieve actual results by verifiably logging in to WCP as normal.

Ping ensures effective use of the clinical portal.

Outcomes:

Following extensive testing with simulated PAS and WCP systems, CHAI™ Ping is ready for integration with real patient data for benchmark testing, final evaluation and roll-out.

Future Plans:

Future development plans will extend functionality to single-user registered apps on mobile devices; facilitating clinician-customised patient lists and auditing.

Context:

Eye departments are experiencing unprecedented demand due to increasing drug treatments available for elderly and diabetic populations. Stable patients must be monitored regularly yet there is simply not enough capacity in the current eye care system to meet this requirement.

The traditional eye chart remains largely unchanged over the last 150 years. While very useful for checking glasses, the eye chart in (its current form) is now known to be a poor indicator of disease. Incorporating measurements of vision, such as sensitivity to low contrast, is scientifically known to monitor cataract more effectively. However, convention is such that the uptake into eye clinics is very limited.

Scope:

The advent of devices such as tablets and smartphones provides a platform for the measurement of vision in a more comprehensive way. Not only can small detail (like on the traditional eye chart) be measured, but many other scientific principles previously confined to the laboratory.

Gaming technology is used to maintain interest of the patient, providing much more accurate responses, collecting data based on what the patient does and does not respond to.

Of course, further development of the technology will mean that patients can safely monitor their vision from home, and away from hospital clinics.

The above model demonstrates how specialist review is a time-consuming aspect of the treatment cycle.

With the developing tech, stable patients may be monitored regularly from home, freeing up capacity for patients with worsening vision who need close specialist monitoring, in hospital clinics, in person.

Fit with Prudent Healthcare:

Public and professionals as equal partners: This technology will allow a patient to measure their own vision when they wish, and access their own vision data, from home.

Care for those with greatest health need first: When fully developed, this technology will identify and prioritise those with largest drops in vision for automatic e-booking to specialist clinic.

Do only what is needed, and no harm: This tech is designed to measure vision more accurately than ever before, and to provide an individual’s own data reliability index, preventing false positives and unnecessary treatment.

Reduce inappropriate variation: Currently, patients with eye care problems living far from hospitals must travel many miles to establish if their vision is stable or not. This tech will allow them to access quality eye care assessment from home.

Aim:

Our Wellbeing Champions encourage colleagues to seek early intervention for their health issues so that they feel supported and valued and able to remain in work.

Planning & Development:

We have empowered and encouraged our Champions to feel valued in their role of supporting colleagues to manage their own health and wellbeing.

We began with 40 ABMU staff who volunteered to become Wellbeing Champions, this has now grown to more than 150 in less than 12 months and continues to flourish, with more staff volunteering to help and support their colleagues.

Feedback:

What our Champions have told us:

“I feel very proud and excited about being a Wellbeing Champion”

“When we feel well at work we flourish and are able to reach our full potential. This has a positive impact for everyone. I feel strongly that everyone should be given the support to blossom and believe my role in that is an important one”

 Feedback from ABMU staff:

“My Champion took the time to listen to me and what I was struggling with. She was empathetic and took the initiative to support me in accessing the correct services”

 “The role of the Champions is greatly valued in our team. It is so reassuring to know there is support available”

 Wellbeing services available to NHS staff in ABMU Health Board:

Counselling; Stress-busting sessions; Discounted Leisure Facilities; Physiotherapy; Occupational Health; Emotional Support; Wellbeing Courses; Emotional Support; Cycle for Health; and, Fast-track MSK Appointments.

Fit with Prudent Healthcare:

• Caring for Each Other is one of the ABMU’s core values. Providing a supportive environment and opportunities which positively impact the lives of employees, will demonstrate that we value the health and wellbeing of our staff and want to work together to create a workplace that supports and nurtures this.
• Our staff play a vital role in the delivery of NHS provisions – without them it would not be possible to  provide high-quality and effective services. Improving staff experience will have a positive impact not only on employee health and wellbeing, but also on the experience and outcomes of the patients we serve.

Context:

My Bevan Exemplar project was about finding ways of including substantial patient representation within the local decision making process of our innovative, health board-run primary care service.

Aim:

It is so much more than a group of patients telling us whether they like ideas that we’ve come up with. The real reward for everyone is a council that can successfully share the ideas generation, the pain when making tough resource decisions and that can help our community explore the obligations that we all have as patients to make good lifestyle choices and use healthcare services prudently.

I think it’s really important. Yet I haven’t managed to get very far, despite working hard. I’m further along than I was 12 months ago, but it’s been slow progress – although I will get there.

Challenges:

Successfully delivering change within complex systems, is much tougher than you think, even with the great support of organisations such as the Bevan Commission.

The challenges will be different for others, but here are a few of mine…

General Workload: It’s been hard to find things to shift to allow time to undertake service change activity.

Priorities: This piece of work competed with several other changes relating to managed practices. Mid-way through the year I then unexpectedly inherited an additional managed practice, requiring lots of time. And clinical events through the year ended up taking priority too – “patient safety today” took priority over “patient safety tomorrow”.

Politics: A couple of existing groups felt they should already be considered “the Council”. It’s taken more time than I expected to work this through to satisfy them that they aren’t able to fulfil this role.

Personal pressures: Three children undertaking combinations of GCSE’s and A/S-level exams. Enough said!

I don’t get it: Never underestimate the power of other teams with- in large organisations to obstruct your work, particu- larly when you are innovating!

Targets:

Never give up! I’m still moving the project forward, and we’ll get there, although with a longer timescale.

I’ve learned a lot in the last year about introducing change. And I will be continuing to share that learning within my own organisation, and in particular the absolute need to protect time and resource for those trying to innovate and spread change to improve services for our patients.

Context:

Collectively, musculoskeletal conditions are the greatest cause of disability in the UK accounting for a third of years lived with disability. Between 1990 and 2010 the disability due to OA has increased by 16%.

Cwm Taf University Health Board has among the highest rate of referrals to orthopaedics and the highest rate of conversions to surgery in Wales. GP referrals to orthopaedics in Cwm Taf are above the Welsh average, with an average of around 800 referrals per month.

The World Health Organisation (WHO) defines Health Literacy as: “… personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health.”

Health Literacy is a key determinant of health. There is a strong correlation between low literacy and low numeracy skills and poor health literacy. Poor Health Literacy in turn is associated with poorer health and poorer health outcomes. Poor health literacy is associated with increased hospital admissions and readmissions, less participation in preventive activities, higher prevalence of health risk factors, poorer self-management of chronic conditions and poorer disease outcomes, lower functional status and increased mortality. Improving Health Literacy is a key priority for WHO and Royal College of General Practitioners and the Welsh Government because of the link between poor Health Literacy and poor health outcomes, and is also an enabler to reduce health inequalities.

Aim:

The overall project aim is to tailor interventions based on Health Literacy baseline levels to improve this asset in order to allow patients to choose alternative strategies for management and to ensure more appropriate selection of patients for surgery through working with citizens and local communities to co-design solutions to their health needs.

Planning & Development:

Phases 1 and 2 are currently underway.

Phase 1:

• Establish baseline Health Literacy levels for patients with hip or knee joint pain who have been referred by their GP to secondary care.
• Conduct a narrative review of co-production use in healthcare.

Phase 2:

• Three workshops:

Workshop 1 Citizens:To co-design interventions to improve self-management of their condition and develop tools to help informed, shared decisions about management options.

Workshop 2 Healthcare  Professionals: Healthcare professionals such as orthopaedic surgeon and physiotherapists to discuss their understanding of the challenges and solutions.

Workshop 3 Citizens & Healthcare Professionals: Workshop to allow citizens and healthcare professionals to co-design interventions. Evaluate the co-production sessions.

Phase 3:

• Implement the interventions co-designed on a new cohort of 100 patients referred in by their GP.

Phase 4:

• Evaluate interventions regarding impact on patient decisions about management options including a cost-effectiveness analysis.  Evaluate Health Literacy following co-design events and implementation of interventions.

Fit with Prudent Healthcare:

• Co-designing solutions locally improves uptake and use of tools through ownership.
• Improving health literacy empowers patients to work with healthcare professionals to derive a more patient-centred decision on management.

Context:

Trying to understand how people choose the food they eat and the impact it has on their health is really complex – below visualises how complex the issue we face. Trying to force change on people and their food choices is even harder. Research shows that those who need the healthiest food the most find it hardest to access – for this project, we’ve called this the Inverse Food Law.

The Obesity Systems Map, Foresight Commission 2007

Aim:

We have been trying to find a way to change people’s food choices for the better where there’s little agreement on what needs to be done and a lack of certainty about the best way forward. To start with, we have brought together a number of stakeholders from different agencies and interests to help them understand each other in order that they can work together more effectively.

Secondly, we have been working with residents to better understand how different determinants impact on their food choices – with the support of our partner agencies.

We will collect this information using the SenseMaker system, and then use those insights to guide the actions and interventions of the newly established Food Vale partnership as a whole.

Planning:

Getting the different stakeholders interested, involved and sharing resources has taken a lot of effort but has laid the foundations for the long-term impact of this project.

There’s an old African Proverb which says ‘if you want to go fast, go alone. If you want to go far, go together.’ We want Food Vale to go far, which has meant putting a great deal of effort into this part of the process.

It’s also very easy to be busy, but harder to achieve and make long-term change. The Bevan Commission has provided the opportunity to reflect on how to approach and develop this work and the time to talk and share ideas has been invaluable.

Fit with Prudent Healthcare:

The time taken to co-produce the Food Vale approach has been challenging but rewarding We are targeting those in greatest need in the more deprived areas within the Vale. We aim to do only what’s needed using the insights from Sensemaker and Network members. We aim to reduce variation in access and affordability of healthy foods.