Background

Speech and Language Therapy (SLT) is one of the first services children are referred to when they are presenting with social communication difficulties or early signs of Autism Spectrum Disorder (ASD). The prevalence of ASD is significantly higher than previously reported with around one in 57 (1.76%) children in the UK with a diagnosis (Roman-Urrestarazu, R et al. 2021). Prior to the Covid-19 disruptions to services, the pressure on the SALT service due to referrals for children with social communication difficulties and/or emerging ASD were high. Adding in the aftermath of Covid-19 which delayed feeder services to provide early input and referrals to our service, the demand has now reached a peak resulting in our current model of working as insufficient.

Aim

To develop and pilot a new social communication pathway in speech and language therapy which encompasses the Prudent Healthcare Principles, with the intention of:

– Reducing clinical case load sizes

– Reducing the length of episodes of treatment

– Increasing parental satisfaction with the service

– Increasing parent and Early Years Practitioner (EYP) skills and knowledge to support children

– Increasing therapist wellbeing and job satisfaction

Method

• Pre-intentional referrals triaged into ‘Building Blocks for Communication Workshops’
• Workshops offered to parents and EYPs in NHS and local authority – those who directly support the children

Outcomes/ Benefits

– 80 hours to deliver traditional input to 8 families reduced to 16 hours

– Clinical caseloads reduced by 18%

– Increased parent and EYP confidence and satisfaction

– Better outcomes and support for children until they reach an age that they can benefit from treatment

What next?

– Project outcomes and resources to be shared with SLT colleagues nationally

– Inform the All Wales Social Communication Pathway

– Support wider adoption

Michelle Price, AHP Lead, Person Centred Care
Rhiannon Edwards, Neurological & Rare Disease Implementation Group Coordinator

Neurological Implementations Group, Supported by Powys Teaching Health Board

Background

The Neurological Conditions Implementation Group (NCIG) has recognised that there are significant delays in getting a diagnosis for people in Wales who experience neurological symptoms. This has been exacerbated by the Covid-19 pandemic and the difficulty recruiting to consultant neurologist posts. This can result in significant distress to those who are awaiting a diagnosis, increases in unplanned admissions and emergency department attendances, delays in treatment and potentially worse outcomes for patients. Service users across Wales have highlighted their frustration at the time it takes to get a diagnosis of a neurological condition and the impact this has on their lives. Focusing on improving this first element of the patient journey has the potential to improve outcomes for people with neurological conditions and release capacity in the system to enable further service improvements.

Aims

• Improve the patient experience to neurological diagnosis at primary care
• Map the referral processes and pathways from primary care and identify any gaps
• Collate data on current waiting times from primary care to diagnosis
• Produce an all Wales resource for GPs and patients to provide better support and outcomes

Method

– Collate data on current waiting time and pathways from primary care referral to diagnosis

– Explore patient experience of journey to diagnosis to inform gaps in service provision

– Investigate opportunities to impact on the delays and quality of care provided to the patient

– Develop resources to support the improved outcomes for patients

Outcomes / Benefits

• Roll out of an all Wales Headache Pathway and Toolkit for the diagnosis and management of headaches (scaling an existing pathway delivered by SBUHB, shown to reduce referrals to neurology by 40%)
• Headache Toolkit tested and coproduced with patients
• Development of a national referral database to inform/ support future specific neurological pathways
• Development of resources and access to specialist information for GPs to aid decision making and referrals into neurology
• Development of resources for patients

What next?

– Continue to evaluate the headache toolkit usage, and monitor neurology referral data to assess impact.

– Work with service managers to develop a mechanism to record specific referrals into neurology to support workplan management.

– Utilise learning from engagement and coproduction activities to translate into future workstreams

The length of time people are waiting for treatment is growing rapidly and it is understood that the backlog is estimated to take up to five years to clear. This service offers opportunities to provide alternative non-medical intervention to improve people’s health and wellbeing whilst waiting for treatment.

Development of Wellness HUBs offers alternative non-medical intervention review to patients. The HUB will target patients who are currently on secondary care waiting lists for treatment and anybody requiring support to better manage long term conditions.

The purpose is to adapt the Population Health approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population of Cwm Taf Morgannwg.

Aims of the programme:

• Reduce the risk of worsening health conditions whilst on waiting lists.
• Improve symptom control and reduce planned care demand.
• Ingrain self-management as part of a routine to improve health conditions.
• Reduce flow into secondary care lists.

Anticipated outcomes:

• Increased patient understanding of their condition.
• Improved health literacy.
• Reduced symptom burden.
• Less representations to the GP to request more medications for symptom management and less requests for expedite letters to secondary care.
• Patients present less to A&E for exacerbations of long term conditions.
• Patients improved readiness for change score.
• Reduction in patient weight/waist circumference.
• Increased number of patients engaged with community activity opportunities.
• Positive impact on patients health and wellbeing- GAD score.
• Increased number of patients removed from waiting list and using Patient Initiated Follow-up.
• Improved patient experience- measured through PROMS/PREMS.
• Increase in social prescribing and use of community assets- measured through elemental.
• Collaboration and integration of Community, Primary and Third Sector Care.
• Pathways agreed and developed in primary care to reduce secondary care flow.
• Patients activation levels improved.
• Integration of digital behaviour change and social prescribing tools.

Patient Outcomes:

Reductions in weight, BMI and waist circumference and improvements in blood pressure, stress levels and enhanced mood and wellbeing.

The attendance of patients at nutrition and physical activity opportunities with the related improvements in health.

Reduced social isolation and improved sense of vitality and life purpose with patients feeling less defined by illness and more optimistic about wellness.

Patients developing a sense of empowerment about their own ability to positively affect their long term health and an enhanced motivation to share their knowledge with their family and friends.

Programme findings / Benefits:

• 95% increased their physical activity score.
• 94% improved blood pressure.
• 80% reduction in weight.
• 83% improved waist circumference.
• 99% recommend to others.
• Uses evidenced based strategies.
• Patients can be referred from healthcare professionals or self-refer.

What next:

• Broaden scope to women’s health, dementia care and cancer.
• Digital inclusion – including AI cCach Bot for digital wellness coaching and online training platform.

The urgent and emergency care system has witnessed significant increase in demand spanning several decades. Less than 10% of emergency service users experience life-threatening conditions however, they consist primarily of frail and elderly fallers with long-term sequelae of complex co-morbidities. These patients now experience significant delays in ambulance response and, once ‘in the system’, may face lengthy delays in secondary care before returning to community living.

As much as two in every five patients accessing Emergency Department (ED) services receive an imaging examination. Accordingly, the aim of this project is to evaluate the feasibility and impact of an X-ray Urgent Response Team, delivered to Welsh communities by the Welsh Ambulance Services NHS Trust.

The project objectives include:

• Evaluating suitability of equipment and quality of x-ray films in the pre-hospital setting.
• Determining risk and governance implications, from a medical physics perspective, that reflect safety and suitability of mobile x-ray imaging within Ambulance Service and community contexts.
• Developing a portable x-ray deployment model that details staff skills and competency requirements; booking system processes; ICT infrastructure and integration with local healthcare systems.

Evaluating the impact of portable x-ray provision on:

• Patient transport requests.
• Project cost-benefit parameters.
• Patient safety and quality of care.
• ED referral rates for x-ray diagnostics.
• Elective/outpatient services.
• Added value and the patient experience.
• Added value and staff experience.

Background

An audit in 2017 showed 20% of patients referred to secondary care gastroenterology services within BCUHB East were diagnosed with functional gut issues. There is currently a 144 week (784 patients) waiting list for routine gastroenterology patients, which continues to increase year on year. The urgent waiting list is 53 weeks (328 patients). Consultant Gastroenterology outpatient services at BCUHB East have had a 39% increase in outpatient referrals over the past 4 years; on top of this there is inadequate gastroenterology consultant staffing due to the inability to recruit with current staffing at 3 fulltime consultants and 1 part time consultant, instead of the recommended 6WTE consultants per 250,000 population. This has increased waiting times as above which has associated financial implications, negative impacts on quality of patient care as well as failing to meet targets set out by national standards for patient groups. Evidence shows that routine gastroenterology patients can be managed successfully in a First Contact Dietitian Led Gastroenterology clinic

Aims

• Reduce the number of non-urgent routine gastroenterology patients who are seen by gastroenterology consultants by triaging them to First Contact Dietitian Led Clinics

• Reduce the 3 year waiting list for non-urgent gastroenterology patients by offering appointments for assessment and management within the First Contact Dietitian Led Clinics.

• Reduce waiting times for secondary care gastroenterology consultant outpatient services overall – Enable consultants to see urgent or more complex patients timely reducing risk of admission and improving management plans for patient
• Provide a more streamlined, safe and effective pathway for the patient

Process

Triage and referral criteria were developed to enable the gastroenterology consultants to refer appropriate non-urgent gastroenterology patients to an ACP gastroenterology dietitian for initial clinical and dietetic assessment, diagnostics and appropriate management. This has been supported by robust pathways, protocols and scope of practice for clinical governance share across primary and secondary care.

Outcomes / Benefits

• 318 patients removed from secondary care waiting list
• 500 consultant appointment slots released
• 14% increase in gastroenterology clinic capacity
• £108,000 minimum cost release (consultant time)
• Routine functional gut waits reduced from 3 years to 4 months
• Most cases managed solely by ACP dietician through medication, lifestyle or investigation checks
• Gastroenterology consultants fully supportive of clinics
• 90% of patients scored the service as excellent, 10% – very good

What Next?

• Aiming to acquire permanent funding for this post
• Identified other areas of gastroenterology where pathways can be re-evaluated and improved with joint work between the gastro consultants, nurses and dietitian
• With support of Bevan Commission, look to promote adopt and spread of this role/service
• Publish work in journals to promote the work and feasibility of adopting and spreading such a service elsewhere
• Create ACP gastroenterology dietitian network to standardize competencies and job roles

All Radiology patients need to attend in person for each examination they require, however this can cause limitations to patient flow in terms of urgent and planned care. All Radiology modalities collaborate well however, there is no continuous path or connection for each patient or between each modality. Delays can develop from this loss of connection lengthening the patient pathway. Streamlining this system would allow a more synchronous patient journey leading to more prompt diagnosis and optimal treatment options.

Radiology investigations and procedures, along with the pathway process can cause unnecessary anxiety for patients. Introducing new Radiology pathway systems will provide more clinical coordination for the patient ensuring they receive a seamless experience. Work is also required on pre appointment patient information and developing an electronic referrals system, both of which can contribute significantly to throughput, flow, and patient experience. This improved pathway system of coordination will significantly support the delivery of the Single Cancer Pathway (SCP).

The aim of the project is to implement a new Radiology Navigation system by attaining these key objectives:

• Streamline and reduce delays in radiology pathways.

• Reduce the waiting times from request to appointment.

• Provide coordinated care for those patients requiring multiple examinations.

• Provide a Radiology point of contact for patients and pathway teams.

• Improve pre and post procedure patient information – developing online access.

• Improve the Radiology referral system.

Work will involve reviewing each National Optimal Pathway within cancer services, beginning with Lower GI and Lung pathways. Process review will be undertaken for Radiology requesting which will include following each specialty request into each modality using process mapping. This data will show throughput time frames with any suspect areas of concern being targeted for development, by streamlining and changing the processes used. Using these newly developed streamlined pathways will reduce footfall within the department, lowering the resources needed and preventing patients from not attending. A Radiology Navigator will provide a link between each Pathway within cancer services, connecting the patient to Radiology and providing more beneficial Radiology information. Patients will be able to have more telephone contact and conversations, with more appropriate opportunity for discussion of procedures in greater detail if necessary, with written information available.

The Outcomes/ Benefits

• Vetting process reduced from 5 to 2 days.
• 7 touch points reduced to 4.
• Average wait from colonoscopy to CT staging referral reduced from 13 to 4 days (target – 10).
• 996 hours of radiology and management time released by the dedicated role.
• CT scanning capacity increased to 118%, with 530 extra patients scanned during the project period.
• Improved patient experience.

What next?

• Ongoing collaboration with cancer colleagues and network to promote the role.
• Funding sought to expand the offering through CTMUHB, to include a ‘Navigator Assistant’.

Background

The COVID 19 pandemic has led to waiting times for planned care, increased health and care needs of the population and recruitment challenges across the health and care sector. Consequently, there is an increased demand in general practice, which has reduced the availability of primary care clinicians to manage complex health and care needs for their patients in the community, resulting in an escalation of referrals to secondary care and the local authority. Through improving the coordination of care between the different organisations who provide individual patient support in the community, there will be less duplication and the care will be more patient centred.  This will make better use of resources and improve the health and wellbeing of the population.

Aim

The project intends to transform the way that general practice, community pharmacy, community health services, local authority services and the third sector work together to provide integrated patient centred care. Through enabling the local community (including statutory partners in health and care) to deliver more effectively, the resilience, health and wellbeing will be improved for all residents and visitors and their families in the locality.

A clinical health and care coordinator based in general practice will case manage integrated multi-disciplinary team working between primary care, Hywel Dda University Health Board, Ceredigion County Council and the third sector. Through shared decision making with the patient anticipatory care will improve the health and wellbeing of the population reducing both unscheduled and planned referrals to secondary care and social services. This will also ensure improved patient health and wellbeing whilst on long waiting lists and establish an effective community led discharge planning process.

The Approach

• Clinical Care Coordinator, band 8A employed in Borth Practice
• Admin support
• Terms of reference established
• Weekly 1 hour long MAT meetings to discuss patient’s registered with Borth Surgery

• Roll out to second federation practice in January 2023

Outcomes / Benefits

• Reduction in average number of GP appointments for frail regular attending patients

• Marked reduction in hospital length of stay

• 553 bed days saved
• Resource releasing calculated to be £250,000 net benefit
• Increased referrals to third sector
• Correlation with reduced hospital mortality rates

What Next?

• Role embedded in regular service
• Support scale and spread to other federation practices
• Promote wider adoption

Greater numbers of older patients are undergoing surgery. There is increasing evidence that patients who are frail or have cognitive impairment are particularly vulnerable to increased morbidity and mortality. Such patients would benefit from comprehensive geriatric assessment. Comprehensive Geriatric Assessment (CGA) is a geriatrician led multidisciplinary process to establish a care plan to identify and meet any medical, social and functional needs. CGA for patients undergoing elective surgery leads to reductions in length of hospital stay, postoperative morbidity and mortality, and patients are more likely to be discharged to their original place of residence. This approach has become known as POPS – perioperative care of the older patient undergoing surgery. With limited staff resource we need to explore novel ways of delivering CGA to our frail patients.

Aim

To establish a POPS service in our elective surgery stream, to demonstrate it’s effectiveness and to capture data to inform a business case to sustain and expand the service. A Band 6 frailty nurse and band 2 frailty support worker will be working with us for 12 months to establish routine and accurate frailty screening in all our patients over 65 attending our preoperative assessment clinic. CGA will be offered to those who are frail, and findings shared with the relevant therapy staff (physio, occupational therapy and dietetics) prior to admission. Patients will also be signposted to resources to aid their preoperative prehabilitation. This proactive identification of a patient’s needs will optimise the use of current resources and highlight any unmet need. During the admission the frailty nurses will attend ward board rounds and liaise with therapists to progress care.  The team will also work to upskill our perioperative colleagues developing and delivering education in common geriatric syndromes. There will be a focus on delerium anticipation and management in our ward teaching.

We hope that upskilling staff will improve recognition of older patients at high risk of perioperative complications and facilitate earlier appropriate intervention to reduce their incidence. Improving quality of care will reduce length of stay and benefit patient experience. We also hope to see decreased readmission rates and need for change of discharge residence to higher care.

Background

We have a growing ageing population, coupled with increasing numbers of patients awaiting operations for longer periods of time.  Older and frailer patients are more complex and are associated with longer lengths of stay and worse outcomes postoperatively, making the ability to process the ever growing waiting list more difficult.

Aim

We know that early intervention by geriatricians improves outcomes, with reduced post-operative complications and improved patients outcomes, and with improved utilization of services.  However we do not know who will benefit.

Objectives

• Assess the demand for perioperative geriatric services
• Assess the cost benefit of the service
• Identify a screening tool that can be used electronically to identify patients that would benefit from geriatric review
• Map out additional benefits in improving patient care
• Develop the service with robust patient involvement and feedback

The Approach

• Written questionnaire sent to all (256) patients over 65 years on the laparoscopic cholecystectomy (LC) list
• Telephone contact to do clinical frailty risk score, hospital frailty risk score and CRANE questionnaire
• MDT discussion to determine whether patient would benefit from clinical review

Outcome / Benefits

• Waiting list reduction
• 15% of patients over 65 years old removed from LC list
• 40% of patients seen in hernia clinic removed from list
• £250,000 LC savings/ cost avoidance
• Patient centred care with excellent feedback
• Patients medically optimised
• Reduced single specialist referrals
• Reduced medicines cost
• Supports waiting list screening

Background:

Short courses of radiotherapy are often used to help patients with symptoms due to advanced cancer – and it can be very effective. Often it may be needed quite rapidly to help improve symptoms. It can also come with a burden to the patient and may involve multiple visits to hospital. Access can be limited due to availability of staff with the appropriate skills to make decisions with patients, plan and deliver the radiotherapy in a timely way.

Aims:

1. Involve a wide range of people in describing and understanding ways that symptom control radiotherapy can be improved.
2. Increase our capabilities and capacity for symptom control radiotherapy in Wales through radiographer training.
3. Improve decision making and communication skills.

Method:

Establishment of a working group involving multi-professional staff from all 3 cancer centres in Wales, with involvement (through a variety of methods/options) of a wider range of staff and patients.

Delivery of formal training to a number of radiographers to enhance their skills and improve clinical service resilience/quality.

Approach:

• Based on previous work to extend the roles of specialist therapeutic radiographers to support consultant caseloads in palliative radiotherapy planning, prescribing and consenting.
• Three cancer centres collaborating monthly to drive advanced practitioner training, support and clinical services.
• Collaboration with Canada and England where AP clinics are well defined and developed.
• Development of a ‘community of practice’ focussed on palliative radiotherapy – new for Wales (strategic vision, future opportunities, practical developments)

Outcomes / Benefits:

• 7 radiographers in AP training.
• Weekly consultant led AP clinics in SBUHB and VCC.
• £57/ hour cost saving if service moved to band 7 radiographer (2000 patients seen a year).
• Patient satisfaction 9.6/10, strong focus on high quality patient care and experience.
• Fewer hospital visits – 90% of patients seen in 2 visits.
• Reduced carbon footprint and costs around travel.
• 72% treated with one session as opposed to usual baseline of 42%.
• Faster treatment – medium 2 days as opposed to 7 days.
• High quality clinical training and career development.
• Pan Wales Patient Centred Palliative Radiotherapy Showcase in May 2023.
• Highlighted an important area of cancer.

What Next?

• National MDT Community of Practice to be established more formally with other cancer partner organisations supporting.
• Find a way to embed the operational changes.
• Work with Advancing Radiotherapy Cymru academy to develop further opportunities.