2023 Awards - Innovation Submissions

Salford Primary Care Together has worked closed with a PCN within our locality to develop an urgent same day care model, providing GP practices additional on the day appointments. This has added additional resource and resilience at a PCN level.

All the appointments are face to face (unless patients prefer remote consultations) and patients are seen by clinical staff with skills in urgent care. There is an inclusion and exclusion criteria which has been shared with practices. This has been further supported by care navigation training to colleagues booking appointments.

Early evaluation of the data has suggested that there is a reduction in ED attendances for patients in this PCN. We have seen a 30% decrease in patients (within this PCN) being referred to primary care services from the front door of ED. We feel this innovative project by the PCN in collaboration with an urgent health care provider has ensured that patients have confidence that will be to access on the day care if needed.

Our patient survey results have provided excellent feedback with over 92% of patients rating the overall experience as good or excellent.

This model and subsequent data has been shared at regional meetings discussing primary care recovery plans. We feel that this model is also reflective of the ongoing discussion regarding same day demand in General Practice.

The Academy has been structured to address some of the recruitment and retention issues across the country in healthcare. The model focuses on the key needs in the primary and urgent care

sector with a partnership to offer pathways in education and mentorship at postgraduate level.

The three pathways within the Academy are:

1. Direct Entry - Graduate nurse or paramedic with at least two years experience post qualification.
2. High Potential Development Scheme - Graduate nurse, paramedic or clinical pharmacist with at least four years’ patient facing experience post qualification and who will already have achieved level 7 qualifications prior to entry.
3. Infinity Programme – A postgraduate nurse, paramedic or clinical pharmacist with significant work and academic history in a broad range of settings to include primary care.

Whilst funded higher education programmes are not unique to employers, the Academy is an innovative programme to retain, promote and advance skills of existing employees via a bespoke programme of study.

At application stage, the candidate is assessed using a strict 45 minute process using a number of techniques to include reflection and awareness of the organisation's Vision and Values with a particular focus on:

• Clinical safety
• Personal resilience and academic aspirations
• Health equity, equality, diversity and inclusion
• Change management and clinical innovation

The process is intended to showcase the beginning of the expectations of level 7 Masters study and what the organisation expects of a senior clinician.

The expected outcome of successful candidates is a PgCert in Clinical Practice with the following core subjects:

• Clinical Reasoning
• Advanced patient assessment
• Triage and rapid assessment in Pre-hospital, Primary and Secondary Care

The candidate is able to choose additional subjects to complete the full complement of the PgCert.

In September 2023, four candidates have been identified to be admitted to the Academy which will include clinical supervision and mentorship from existing senior clinicians

Reviewing post-treatment patient engagement and patient satisfaction questionnaires across our organisation showed there were issues. Cost was a factor with varying contracts lengths and prices among several different providers, even different costs for comparable contracts with the same providers. Consistency was an issue, different providers having different requirements and varying levels of quality and service provision. This incurred additional time and resources in dealing with multiple suppliers. The lack of timeliness to send out questionnaires was causing issues. Delays in sending (one supplier could only send weekly) meant patients were not always clear on what service they were giving feedback for. This was further compounded by not always being able to brand the surveys and therefore not have a clear Identity. Timeliness and identity were clearly factors in the low response rates we were seeing across most services.

After reviewing all the services in the market, it was felt that there wasn’t anything they could provide that was outside our inhouse skills. We mapped the ideal service delivery for questionnaires and commenced a small scale pilot. We were able to use tools which were already available to us, including SSRS, Microsoft Forms, Power Automate and Power BI. This allowed us to extract the patient information, create bespoke questionnaires, automate the sending to the desired schedule then process, analyse and communicate the responses. Following the successful pilot, we have rolled out this inhouse offering across all departments.

We can now send surveys as quickly as each individual service requires, to within 15 mins of patient contact. We can fully brand or configure these questionnaires as desired (where known, we can cater for age groups, language, disabilities etc). The questions are more consistent and concise across the organisation. We have experienced a significant increase in response rates. The teamwork required to implement this new service has resulted in a general upskilling for the individuals involved. They have also increased engagement with the operational teams to deliver this project, which has had further unintended benefits. Additionally, there is an actual cost saving, given that the time and effort to setup and maintain this new process using existing software is far less than the previous monetary costs for the multiple contracts. In summary, we and our patients are getting an enhanced bespoke service with richer information, for less cost. This will allow us to further improve our services for our patients and communities.

The 111 Clinical support HUB team operates in three sites covering the whole of Wales. They consist of admin support, GPs and pharmacists.

I am nominating them for their exceptional team working and the way they had to change the way they worked during the adastra outage and BCI. As soon as we went into BCI the CSH team came up with a new way of working and put in two new roles in order to help improve the coordination and flow of patients through the 111 system and into urgent primary care. This has continued and the service now runs in a more coordinated way , communication has improved between 111 and Out of Hours services. These new roles have improved patient flow and patient care.

The FAQ GP (flight controller GP) manages the CSH queues, they pull suitable calls from the 111 First Advise Queue and from the health board advise queues. They communicate with health boards and 111 throughout the shift and manage any issues that may arise.

There was also a HUB advise line (HAL) that was set up in BCI to give 111 call handlers a line to get GP advise on a call and add the GP to the call if needed for immediate advise at the first point of contact.

The CSH manage their areas - South East, South West and North but they are also able to flex their clinical staff to focus on health boards that maybe struggling with long waits for clinical advise. They have shown excellent team work and innovation.

Testing the impact of introducing an APNP workforce within the OOH service as part of a streaming pathway as an alternative to GP assessment. Understanding the impact on the system and service user experience

Our emergency departments across Cheshire & Merseyside are seeing a steady increase in attendance post Covid-19 pandemic. The reason for this is multifactorial, with custom and practice playing a significant part in this increase across the Liverpool footprint especially. During the height of the pandemic, the population were advised and chose to use remote access and NHS111 services for their initial urgent health needs. The C&M Children’s and Young People Network collaborated with the NHS111 service to pilot the use of paediatric expertise to manage paediatric calls within the NHS111 system. The outcomes of the calls managed as part of the pilot were compared with ‘generic’ operators within the service and showed significant impact: with more completed episodes and less primary care referrals and ambulance usage. To add to the body of evidence a further pilot was planned to test the use of experienced Advanced Paediatric Nurse Practitioners (APNPs) within the Out of Hours Service to assess cases for paediatric patients received from NHS111. in the out of hours service (XXXX) to manage paediatric calls from NHS111.

How have we achieved this, and what have the outcomes been?

• Engagement from key members of staff including Clinical Leadership team, Operational Managers, IT team, and Operational colleagues from our Call Centre who were key in developing these new pathways safely and effectively.
• Implemented new clinical governance processes at pace to safeguard the delivery of care and ensure that these practitioners were provided with full support and were subject to audit to maintain patient safety and excellence in care.
• We offered flexible working remotely, from satellite sites and from the Call Centre to attract members of the workforce and ensure clinical rota fulfilment.
• Overall, our Advanced Paediatric Nurse Practitioners assessed 8067 patients through the Paediatric Pathways pilot service.
• The data shows that the APNP consultation time is significantly less than average generalist consultation time by an average of 6 minutes. Over time, this results in a large number of additional patients being assessed and demonstrates improved efficiency.
• Approximately 4.9% of cases assessed by a APNP were referred to Emergency Departments, compared with 7.7% of paediatric cases assessed by generalist clinicians (such as GPs).
• 87% of the patients assessed did not require any further intervention within the following 48 hours, and 87% of the responses reported that they were confident in the advice provided by the APNP.
• Estimates of costs saved show that the use of the APNP workforce in place of GP produced approximate savings of £135,845, with similar or better outcomes for patients when compared with outcomes of assessments provided by generalist clinicians. The pilot was restricted by the funding available, however if reproduced at scale, the potential for savings is significant.
• We received overwhelmingly positive feedback from patient representatives, clinicians and operational colleagues alike who all felt the benefit of APNPs being on hand to provide assessments and advice to parents and guardians of poorly children and young people.
• We were approached to be a part of this pilot with the Beyond Children and Young People’s Transformation Programme as we are recognised within the local system as flexible, adaptive and responsive to the needs of the local patient population.

We were delighted to be asked to host this pilot and feel that our commitment to innovation through being part of this project has proved that diversifying workforce can provide patients with better experience and improved outcomes, and on a wider system level can address workforce challenges, ease pressures on local Emergency Departments and result in much needed cost savings.

We have attached a presentation which includes more detail and information around the pilot’s successes, and where we plan to take this as an organisation in the future.

Our Health@Home service represents a pioneering reorganisation of the provision of healthcare. Using Technology Enabled Care devices, we provide end to end digital solutions facilitating the remote monitoring of patients at home and in care homes thus alleviating pressure on GPs, reducing carbon footprint, increasing patient experience and engagement.

Health@Home is used to remotely monitor many key health metrics in patients’ own homes, with measurements obtained by the patients themselves or carers using wearable patches or individual spot monitoring using medical equipment. These include Coronavirus (SP02), blood pressure (BP), INR levels (Coag Check devices) for Warfarin patients, heart failure (BP, Weight, SPo2, Temperature) and Virtual Wards (continuous monitoring patch or spot monitoring checks). The service also encompasses the Digital Care Home service which uses the SBAR communication framework digitally for the transmission of referral information securely from 90 care homes 24/7 with NEWS2 scores being calculated digitally from collected measurements.

The services utilise one patient app (HealthWatch) which delivers all services in an easy-to-use interface with the results displayed in a single dashboard monitored by a non-clinical monitoring team. HealthWatch can connect to measuring devices via Bluetooth to upload monitoring measurements automatically or manually via entered data. Patients are provided with the assistance they need to eliminate digital exclusion, including options for email, phone call or SMS updates to clinicians and a support helpline.

Equipment used includes BP, SPo2, Scales, Thermometers and Coagu-check machines as well as a continuous monitoring patch which measures temperature, heart rate, respiratory rate, single lead ECG, body posture with a built in falls detector.

Innovative approaches to creating awareness of the Health@Home service were provided in conjunction with the NHS Melissa & Harri Busses. These buses have been converted into mobile health clinics and used to bring health screening closer to the patients we serve. Utilising the latest technologies available such as point of care testing equipment to provide Lipid and HBA1C results, Atrial Fibrillation checks on mobile phones as well as the plethora of measurements available within the HealthWatch solution we are able to provide full NHS Health checks on-board the bus and provide care closer to our rural patients. These approaches have resulted in an increase in prevalence for several diseases and long term conditions previously undetected.

Health@Home has benefited more than 2,000 patients between them and continues to grow.

Providing a home visiting service in conjunction with primary care during surgery operating hours 12pm to 6:30pm Monday to Friday. Provided and managed by Suffolk GP Federation (the Fed) on behalf of the East Suffolk Primary Care Networks (PCN’s).

The service supported 926 patients during the three month winter period, supporting primary care who are at capacity. The service provided visiting clinicians to patients in the community and at home on behalf on their own GP practice. This project also supports admission avoidance as a large proportion of these patients would have resulted in an 999 call out, thus providing a better patient outcome and keeping patients well within the community whilst still ensuring effective and safe patient care.

Feedback from Practices:

• Such a great service from the In-Hours home visiting support team. Being a rural practice stretching over three sites, this service was a crucial part in delivering a service for our patients. Please would you look at how this service now finishing will affect our rural surgeries as so many services we are seeing are being taken from the community. If the Fed had the staff cars and the need, why are we not looking at how we can keep it? – X Practice
• This service has been brilliant. It has been a really big help to general practices, as doing a home visit tends to the most time-consuming element of patient care. Being able to ask the visiting service for help with a visit has taken pressure off the in-hours practice team and has often made what might otherwise have been very pressured days into much more manageable ones. I am sorry the service is stopping - was it just for winter help? Are there any plans for it to re-start at any point? My thanks to everyone involved in running it! –X Practice

The success of this project enabled us to roll this out to the West of Suffolk PCN group who we also supported over the winter period.

Case Overview - System Innovation and ambition

One of the complexities facing all NHS and Social care services is the number of access points to urgent care.

The need for the Single Point of Access (SPA) project came following a review of data for local ambulance arrivals for ED Type1 and Type3 departments from April to September 2021, where the outcome has been coded as HRG VB08, 09 or 11z. The 3 lowest tariff codes, which are aligned to the lowest clinical need and intervention cases reported excluding attendances where haematology, microbiology and radiology tests have been performed, showed that activity increases throughout the 24-hour period.

The introduction of paramedic access via a single point to support decision-making throughout a 7-day period by a trusted clinical assessor would enable the impact to be measured.

The vision was to prevent avoidable admissions by extending the hours of the existing Care coordination service and supporting ambulance crews as well as GPs. Clinical decisions were made by ambulance crews to convey the patient to local acute trusts, the subsequent outcome was clinical and HRG coding based on the review of the patient within the department.

Therefore, at the point of decision made by the ambulance crew to convey, they would not know what the clinical coding outcome would be. Admissions by the new SPA system use trusted clinical assessors who are very familiar with the community service and have vast amount of experience in this area, preventing avoidable admissions.

A Care Coordination Centre (CCC) was originally set up to support GPs seeking access to Same Day Emergency Care (SDEC), direct admission to, or advice from, specialities at the local Acute Trust and referrals to community teams such as Rapid Response.

The service covered referrals from any community-based clinician across Shropshire, Telford and Wrekin (STW) Clinical Commissioning Group (CCG) area and avoids unnecessary conveyance to the Emergency Departments (EDs).

This provided a level of assurance that the extension of the service to a wider group of clinicians, specifically ambulance crews, would support the prevention of avoidable admissions. CCC has built up, since its inception in 2006, to manage, on average 2,100 cases per month.

Shropdoc Single Point of Access (SPA) is an engagement, triage and assessment service which supports Shropshire and Powys GPs as well as other Allied Health Professionals in providing easier access to hospital and community services and social care.

Our cross-organisation and cross-sector project - Single Point of Access -specifically reduces unplanned conveyance to ED by ambulance crews and relieves immense pressure on services across Shropshire.

The new and innovative system runs from 0830 to 2230 7 days a week, improving patient flow into acute services, avoiding the cluster of admissions at set times of the day.

The service with over 40 referral pathways, has managed around 19000 cases, of which 93% were referred to somewhere other than ED and 19% were managed into services for next-day appointments.

We are an established, innovative team of nurses and call handlers responsible for facilitating discharges into community settings. Adopting the trusted assessor model we signpost patients and health professionals to the appropriate setting utilising our knowledge base of local pathways working with the many services across Shropshire, Telford and Wrekin.

It also provides alternatives to hospital admissions and accident and emergency attendance by offering appropriate community or outpatient pathways to health and social care professionals across Shropshire & Powys. The service is staffed by nurse clinicians and non-clinical call handlers. Referrals are triaged and assessed based on the needs of the patient and aims to prevent unnecessary hospital admissions.

Outcomes

The aim of the project was to provide, through a single point of access the most appropriate care for patients while avoiding the need to attend ED. The service's trusted clinical assessors support referring clinicians to find the most appropriate commissioned service in Shropshire, Telford and Wrekin.

This includes facilitating telephone conference calls between referrers and the receiving specialties for advice and guidance and importantly also includes signposting to alternative community-based pathways and directly booking patients onto ambulatory emergency care pathways such as DVT, TIA IV and antibiotics at home.

Improved patient care and improved experience is achieved by increasing the the clinicians able to refer to the SPA service:

• Ambulance crews
• Primary Care GPs and healthcare professionals (including during extended access on weekends and bank holidays)
• Community Care healthcare professionals
• Urgent Treatment Centres
• Minor Injury Units
• Regional Clinical Assessment Service (CAS)
• GP out of hours

The service requires the referring clinician to have made the initial clinical assessment either in person, or by telephone, on the day that the referral is made and referring clinicians are required to contact the CCC directly by phone, where their call will be warm-transferred to a CCC trusted clinical assessor for a clinical assessor.

The improved outcomes achieved by the service include:

• Admission direct to a specialty Assessment area referral - Medical SDEC/Surgical SDEC/ Obstetrics and gynaecology/paediatrics/urgent ophthamology/Ear, nose and throat (ENT) and Maxillofacial surgery.
• Ambulatory Care Pathways - Deep Vein Thrombosis (DVT)/Transient Ischaemic Attack (TIA).
• Facilitate to Community Trust Pathways
• Community Hospital admission
• Out-of-hours GP home visit or base appointment
• Facilitated referral to STW's Integrated Community Service (ICS)

Cardiac Virtual Ward – Working in Partnership with Blackpool Victoria Hospital, Lancashire and South Cumbria ICB, NHS Greater Manchester Integrated Care and Manchester University Hospital.

COVID-19 has exacerbated elective waiting list pressures throughout services in the United Kingdom. Patients awaiting cardiac surgery are at particularly high risk of morbidity and mortality from prolonged delays. This inspired the idea to set up a Cardiac Remote Monitoring Service.

FCMS is working in partnership with the above hospitals and DOCOBO (our digital monitoring platform) from December 2022 to ensure that whilst awaiting outpatient surgery, patients can be monitored, maintained, and optimised for surgery using telehealth technologies at home. This has helped reduce need for admission to hospital for assessment and reduce pressure on GP / community services. Empowering the patients to take ownership over their health by providing them with the equipment and the training needed while ensuring the patients that these readings are being monitored daily with one of our clinicians always available at the other end of the phone.

Our service is all-inclusive to ALL patients even if unable to use the technology. Our team will carry out an individual assessment and a further visit to the patients home in order to be able provide these patients with a personalised care plan based on their needs.

In the absence of telehealth initiatives, patients who develop worsening symptoms whilst on an outpatient waiting list will have to take the initiative to bring their symptoms to the attention of the relevant team.

FCMS also committed to improving our service based on regular patient experience and feedback. Working together with our hospital colleagues to ensure the service is continually growing and improving to fit the needs of the patients.

Patient Feedback:

“Knowing you were there to help me and just one phone call away gave me such peace of mind – As a team you can take pride in knowing that you make a difference in looking after patients with such care.”

“ Being on this service feels like you are not forgotten about “

“ As someone who lives alone , it has given me such peace of mind and support while awaiting my surgery”

“ Everyone is extremely kind, approachable and genuinely caring”

“ The equipment is easy to use and is all easily explained by the staff upon initial visit”

“This is the gap that needed filling, left in limbo not knowing when the surgery is and whether our mother is safe whilst living abroad. Just what we needed. Thank you”

“ Great idea, felt empowered and reassured taking my readings and being reassured that everything is as it should be”

“ Someone visiting me made me feel like NHS cared about me after multiple appointment cancellations”

We proudly nominate the ‘Cornwall Acute Respiratory Illness (ARI) Hubs’ for the category of Best Innovation.

Outline

During winter 2022, healthcare organisations received a notification that Group A Streptococcus (GAS) infections, including scarlet fever, invasive infections (iGAS) and severe pulmonary infections were higher than normal in England.

Cornwall saw a 237% increase in calls to 111 against predicted activity, with an associated elongation of call back time and high levels of abandonment, therefore causing a sustained, high level of clinical risk being held in both the front end of 111 and in the local Clinical Assessment Service (CAS).

Innovation

In response to this surge in demand, Cornwall 111 IUCS rapidly mobilised two surge clinics based in central locations within the county, but with the capability to become mobile if demand required through obtaining mobile infectious unit hubs. The aim of these clinics was to provide single points of access for patients presenting with symptoms of GAS infections, thus reducing pressure on other services within the system and allowing a pressure relief system to the front end of 111. In rapid fashion, an adapted call flow mechanism was implemented, with changed made to NHS Online allowing for an alternate Strep A pathways to be implemented with targeted comms to the Cornish population being sent across all relevant areas to engage with NHS 111 Online to capture these presentations. From here, calls would flow into a specifically set up and monitored Strep A list for triage and/ or referral to the 2 Strep A hubs. Referrals were also open to all healthcare professionals, such as primary care, ambulance crews on scene, emergency departments and MIUs, as well as accessible to patients via 111.

Care and Quality

Over time, the scope of the hubs increased further to support pressures at the front end of 111 and General Practice. The Strep A hubs transitioned to infectious disease hubs managing Strep A, RSV, flu and an array of minor illness with continuing comms flowing.

Effectiveness

This partnership working between HUC and KHCIC saw a significant reduction in front end demand once mobilise and allowed patients with concerns to have rapid telephone triage after NHS Online assessment alongside 2 specific areas for face to face assessment. The rapid pilot was hailed as a success by the system and we are now in the process of creating a permanent surge capacity management hub initiative utilising this patient journey as a gold standard across the county.

This opportunity aligned with our commitment to collaborate, and we have linked-up with an international telemedicine business offering remote healthcare platforms. They provide digital solutions across the world - and are currently supporting the healthcare needs of over 40 million people.

This company developed a virtual waiting room system with us (for telephone assessment and advice) that is designed to offer us a host of benefits, including the ability to:

• Free up valuable time for clinicians to spend with their patients – instead of spending it searching for telephone numbers and making multiple contact attempts
• Keep patients better informed about their likely waiting time for a call-back – setting expectations and reducing the frustration from ‘not knowing’, and in turn reducing concerns and complaints
• Enable timely re-assessment and re-prioritisation of clinical cases – if patients make a follow-up contact to share that their condition is worsening

In August 2023, after an eight month project development we marked our first successful patient interaction – when the first call to our Clinical Assessment Service (CAS) was directed through our new virtual waiting room system.

It marked the end of the project to get to this point, but was the start of the next steps in our journey. Colleagues in our CAS paved the way for a new way of working that will also be implemented in our Derbyshire urgent care services and could be adapted for other areas of the business.

It is a large-scale transformation that brings together collaboration and innovation for the benefit of our patients and people - in exactly the way our company strategy envisages.

Every patient that uses the virtual waiting room receives a text message - asking them to answer a few questions. At the time of making this submission:

• 85% strongly agreed/agreed that they were happy with the number of text messages they received
• More than 90% strongly agreed/agreed helped them understand what was happening
• More than 90% strongly agreed/agreed said they understood what was happening when they received a phone call to connect them to a health care professional
• Around two thirds were happy with how long they waited to be connected to a healthcare professional once they received the phone call

These results show we are working more effectively, improving patient care, enabling teams to work well together so that our service and how we communicate improves.

Frailty-ACE (Assessment and Coordination of Emergency and urgent care) is an innovative approach to coordinating the health and care responses required to manage frail people at home, when a crisis would otherwise result in conveyance to the Emergency Department (ED) and/ or medical admission. The intervention is targeted to support our frailest patients who are at greatest risk of long admissions with 'no criteria to reside' in hospital.

The co-located F-ACE 'team of teams' comprises experienced urgent Primary Care and community clinicians, social worker and remote specialist frailty expertise, and works alongside our integrated mental health team. They remotely assess and manage frail people’s urgent physical health, mental health and care needs, including support for carers. F-ACE is closely integrated with Urgent Community Response, Frailty NHS@Home (virtual ward), social care, Frailty Same Day Emergency Care and 24-hour General Practice, enabling face to face assessment, and/ or ongoing monitoring and health, therapies or care interventions at home.

During the 6-week pilot, F-ACE managed 222 frail, complex and comorbid patients who were referred for medical admission, or by paramedics planning to convey, via a single point of access. ACE-F managed an unprecedented 65% without admission. Working as a joined-up, single team built trust, relationships and efficiencies across traditional service boundaries. These were key enablers for supported risk holding, shared decision making and person-centred coordination to tailor responses to patient's needs and wishes. ACE colleagues consistently reported how rewarding and enjoyable the work was, and valued the rich learning environment. Patient and carer feedback has been positive, with excellent paramedic and GP feedback.

The pilot period was associated with a step change in ED 4-hour performance for major cases of all ages, which appears to have been driven by people aged 80+. We estimate that coordination and collaboration between existing services during the ACE-F pilot saved up to 2016 bed days and £760,000, based on an average length of stay of 14 days each costing £5,300.

With a strong focus on improvement, we are looking to build our links with neighbourhoods and localities to support frail people to keep well. We want to translate the ACE principles to support urgent and emergency mental health (M-ACE) and paediatric (P-ACE) needs, and a true healthcare professional single point of access for the system.

Please see our supporting video https://youtu.be/CHmtgZGulZM