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Developing skills to improve staff wellbeing

We engaged with 600 key health and wellbeing influencers within the NHS at six virtual events to support NHS England’s agenda to develop leaders’ skills in improving staff wellbeing.

Background

The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) was approached to support NHS England’s National Wellbeing Team to deliver virtual events to Wellbeing Guardians, wellbeing leads, HR, organisational development (OD) and occupational health professionals.

Action

We delivered six successful, virtual events.

Holding weekly project management meetings with the client, we provided support and advice before, during and after each event. Our experience and expertise in engagement and events meant we were able to:

-Advice on different event types, including live streams and interactive events
-Professional speaker management and pre-event briefings for speakers and facilitators
-Resource development, including slide decks, facilitator support packs and post-event resources and reporting
-Technical support, including managing breakout rooms and using interactive feedback capture mechanisms such as Mentimeter and Jamboard.

Impact

We swiftly provided dedicated support for the project leads with skills and experience covering staff experience, engagement and communications.

We quickly built a great rapport with the client team and the event speakers. This resulted in us hosting and managing meaningful engagement events with over 600 HR and OD professionals. Developing their own knowledge and contributions which have shaped future focus and priorities at both regional and national level.

The events included:

-Three masterclasses for Wellbeing Guardians, wellbeing, HR, OD and occupational health leads
-One live stream event launching the NHS Wellbeing Framework, with insights from senior and influential speakers in health and social care
-Two workshop for violence prevention leads, marking the start of a community network
-Targeted wellbeing focus sessions on emerging topics.

“We have really enjoyed working with you on our virtual events, which thanks to your knowledge and skills have been delivered successfully.

“We’ve had some great feedback about how interactive and engaging they were and acknowledge that this was down to your support and steer in helping to shape it that way. We also found the resources you provided really useful, especially the facilitator support guide.”

Kath Marginson | Project Manager, NHS England

“I just wanted to say a personal thank you for all your advice, support and wisdom in the planning and running of the Health and Wellbeing Launch event today. It really helped knowing that you were in control! The feedback we have received so far has been excellent.”

Michelle Gibson | Health and Wellbeing Manager, NHS England

Helping a local council order equipment efficiently

Following taking over the management of the the community equipment service contract at Staffordshire County Council, staff across Staffordshire and Stoke-on-Trent are now able to order and receive equipment quickly, which supports timely hospital discharges.

Background

Following the retirement of the contract lead at Staffordshire County Council, the NHS Midlands and Lancashire CSU took over the management of the community equipment service. However, there were no governance arrangements in place, and stakeholder relationships had dried up since meetings and communications had been paused during the COVID-19 pandemic.

There were approximately 150 backlogged emails to process, and it was taking an average of 16 days to process new users.

Action

Although unfamiliar with the community equipment ordering site, we quickly got to grips with the system and cleared the backlog. The team took the opportunity to streamline administrative processes, review costs, highlight risks, and strengthen the quality assurance process.

By networking and building good working relations with stakeholders – including supplier Medequip and staff at Staffordshire and Stoke-on-Trent Integrated Care Board – the team re-established meetings and communications.

New terms of reference were agreed for joint contract quality review meetings and contract review meetings, which review complaints and feedback, discuss the impact of COVID-19 on services, and monitor key performance indicators (KPIs).

The Community Equipment Prescribers Action Group was formed to share good practice and help to resolve operational issues.

Impact

Since taking over the management of this contract, the backlog of adding users to the community equipment ordering site has been cleared. The team process an average of four new requests for users every day, and they are now processed within one working day.

Staff across Staffordshire and Stoke-on-Trent are now able to order and receive equipment quickly, which supports timely hospital discharges, which in turn has a positive impact on patients and staff.

Contract review groups all now meet monthly, and relationships between stakeholders are positive. The Action Group has taken ownership of a seven-point action plan to review processes and make recommendations for improvements.

Governance, risk and issues are now managed effectively.

Contract KPIs are being met and more are being developed. The contract itself is still awaiting novation over onto the NHS Contract.

“We value the support of CSU colleagues for their proactive organisation and administration of the recently reinstated CEPAG and CQRMs as part of the Community Medical Equipment contract. This includes the setting up of meetings, communicating with system partners, and circulating agendas and papers.

“CSU colleagues also chair the meetings which enable effective time-keeping and sharing of information, which supports discussions. CSU colleagues are always very helpful and responsive to requests, and we would like to thank them for all their hard work.”

Quality leads, Staffordshire
and Stoke-on-Trent
Integrated Care Board

Using automation to reduce waiting lists across two ICSs

Using a combination of automated chatbot, robotic process automation and human call agents, we helped trusts within two integrated care systems (ICSs) contact over 80% of their waiting lists, with about 10% of patients coming off them.

Background

The pressure on hospital patient waiting lists created by the pandemic required new ways of assessing the validation of waiting lists. Following a pilot with Worcestershire Acute Hospital Trust in 2021, we were approached by Lancashire and South Cumbria ICS about our combination of automated calls (chatbot) and our Referral Management Centre to validate their inpatient and outpatient lists over a number of specialities. The aim was to provide a more efficient way to cleanse the waiting list and expedite work that otherwise would take considerable time and staff resource to complete.

Action

Specialists from our Digital Innovation Unit, Referral Management Centre, Cloud Development team, Information Governance and Business Intelligence teams have been working together with the ICSs and acute trusts. We have developed a robust mechanism using chatbot functionality and referral management call handling expertise to support validating an initial cohort of 21,0000 inpatient and outpatient lists from across the four trusts in Lancashire and South Cumbria.

The outline process involves:

* Setting up project management for the scheme, including the end to end process
* Putting in clinical and information governance, including patient engagement
* Agreeing scripting to be run
* Accessing and processing waiting lists via a secure SharePoint
* Providing text messaging to patients advising them that they will receive a call
* Processing the calls starting with three chatbot calls and then two Referral Management Centre (human operator) calls
* Returning results of the calls to the providers to amend their patient administration system.

Key to success has been agreeing the end to end process and script design.

Impact

Using this combination of chatbot and our Referral Management Centre, we are helping trusts to prioritise and clinically validate waiting lists efficiently. It has helped to tackle the backlog of waiting lists and reduce waiting times, while maintaining quality of care.

We have successfully completed over 20,000 patient validations since starting in late 2021.

The results across the two ICSs have been remarkably similar. The key results are:

* Over 80% of those with validated numbers have been successfully contacted
* There are about 10% of patients indicating that they wish to come off the waiting list
* Of those wanting to come off the waiting list there are about 60% that have indicated that they have had their treatment elsewhere.

This solution saves huge amounts of time and staff resource, reducing hospital costs. Using automation avoids the need for temporary admin teams to be interviewed, employed, on-boarded, trained and so on. Chatbot costs are a tiny fraction of those incurred in producing, printing and posting letters.

Key stages

Stage 1 – Data receipt from trusts – The trust upload a patient cohort list (outpatient/inpatient) to a SharePoint site set up by the Midlands and Lancashire CSU (MLCSU) to enable quality checks of the data. MLCSU then uploads the data into the auto-dialler tool.

Stage 2 – Automation and referral management support – The automated call to patients asks a series of questions to determine if the patient still requires the appointment, would prefer to be taken off the list, and if they require an appointment whether they would be happy to receive a telephone or/and video consultation.

The automated call script to patients was designed with input from senior clinicians and validated through patient forums. If patients prefer not to speak to the chatbot, they are put through to our Referral Management Centre for a human call operator.

Stage 3 – Providing data to consultants to review the outpatient/inpatient waiting lists to help prioritise patients – following the validation exercise the information collated through chatbot and Referral Management Centre manual calls is provided back to the trust to enable them to take further clinical validation and remove patients who no longer require appointments due to being seen elsewhere or having reduced symptoms.

Blog: How to look at data

Primary Care Networks (PCNs) hold some of the richest data in health and care which can tell us a great deal about our local populations and their needs. However, faced with so much data, it can be difficult to know what to look at and what we can do with it to drive improvements in health and care of our population.

Writing for PULSE and Healthcare Leader, David Sgorbati, Chief Analyst for the Health Economics Unit, offered his insight and some examples as to how data analysis is being used to drive improvements to care up and down the country.

Originally published 31 October 2022.

Data is incredibly powerful when it comes to helping us make decisions about changes to care pathways or the allocation of resources and it really is true that PCNs hold the Crown Jewels of NHS data. As the ‘front door’ of the NHS, you have an unrivalled insight into your population, covering everything from consultation data to prescription information and a whole host of secondary care markers. What’s more, you also have a very deep and profound understanding of your community and its needs. For this reason, it’s vital that you are involved in shaping any collection and analysis of your local data.

What’s the right question?

One of the most crucial elements to get right when starting any data analysis project is choosing the right question. That might sound obvious, but it can be challenging to ensure the question we’re asking will give us the answers we are looking for. For example, we might say we want to understand how many patients are attending A&E each month. However, the answer we are looking for here might really be what proportion of patients attend A&E, or what the characteristics are of those patients who attend A&E, or even why patients are attending A&E, so we can understand if there are any trends or unexpected variations in the type of patients we find.

View the full article at https://www.pulsetoday.co.uk/pulse-pcn/how-to-look-at-data/

Prioritising health and wellbeing to improve morale and performance

Our health and wellbeing strategy has proven to have improved the morale and performance of our staff. It was also recognised by HR Magazine with an award for Best Health and Wellbeing Strategy as part of their HR Excellence Awards.

Background

With staff feeling exhausted after the pressures of the pandemic, staff wellbeing, motivation, morale and mental health were more important than ever. At a time when the NHS is undergoing vast change, we wanted to ensure that our people were well, engaged and motivated in order to deliver high quality work which ultimately impacts on patient services.

Action

The approach was person-centred, focusing on individual needs and preferences balanced with the needs of the team and the organisation. Wellbeing was prioritised as a major part of achieving our strategic and corporate objectives.

We teamed up employee engagement and our workforce data to identify pressing issues and shaped a comprehensive plan of wellbeing activities and interventions. They were broadly framed under physical wellbeing, mental wellbeing and financial wellbeing.

To implement these changes, we employed several enablers:

-Week-long virtual health and wellbeing festival
-Training and education campaign to help managers and employees better understand -remote working, resilience and physical fitness
-Weekly wellbeing sessions to discuss tips and resources
-A trained team of mental health first aiders
-Enlisting health and wellbeing champions to push from below and members of the board to role model and communicate healthy behaviours from above
-Embedding health and wellbeing into one-to-ones and appraisal documentation
-Blogs and intranet forums.

Impact

The effect on staff wellbeing was evident in the latest staff survey and workforce data:

-92% said that they did not feel pressured by their manager to come to work when ill
-94% said that they felt empowered to take informed decisions about their health
-number of people saying they had felt ill because of work related stress dropped
-15.5% increase in people who recognised the organisation was taking positive action on health and wellbeing
-18% drop in the number of days lost due to stress, anxiety or depression.

This clearly showed that engaging with employees and acting upon their feedback was positively received, and we were making huge gains with our people’s wellbeing offering.

The health and wellbeing festival had 759 attendees at 42 sessions over the course of the week. The average score was 4.83 out of 5 for overall experience by staff and 4.73 out of 5 for whether staff felt the session had benefited their health and wellbeing.

The network of 14 health and wellbeing champions played a key role in spreading and embedding the corporate initiatives as they connected with colleagues at a local level.

Messages from the board, both in video clips and written blogs, were also received well with people saying that they like the fact that they can relate and feel empowered to do the same.

“What is remarkable about this strategy, labelled outstanding by judges, was that it was delivered on a shoestring budget by a generalist team, driven by a passion for its people.

“Judges praised its clear focus on the business issue at hand and the engagement at every angle with its end goal of providing top-quality services to patients.”

HR Magazine

“A brilliant session and surpassed all of my expectations.”

“Fantastic session and really helped me to readjust my thoughts.”

Staff feedback on health and wellbeing festival sessions

Ensuring data protection for lung health checks

We helped a programme targeting ex-smokers with lung health checks to complete information governance procedures and ensure personal data is protected.

Background

The Targeted Lung Health Check (TLHC) Programme team at Lancashire and South Cumbria Integrated Care System (ICS) needed help with information governance (IG). The health checks are offered to current or ex-smokers aged 55-74, aiming to diagnose and treat lung conditions, often before symptoms appear.

This was part of a national pilot study, and the entire project needed a Data Protection Impact Assessment (DPIA). The main challenges were the number of stakeholders involved and the tight timescales dictated by the national team.

Action

We helped the ICS understand why and how to complete a DPIA. Where some decisions had not yet been made (for example system suppliers and clinical providers), our expert team shared their insights and recommendations to ensure the project team could move forward quickly once decisions were made.

The multi-agency project meant that multiple DPIAs were required, but we advised that the best approach would be to map and assess the project from end to end. This gave the ICS the confidence that all data protection risks would be identified and managed, and meant that a single robust DPIA could be completed for the entire project.

Impact

Although the project was fast-paced, we kept up with the key dates and ensured sufficient risk assessments were completed at every stage.

By providing expert advice on data sharing and processing across all partner organisations, we ensured that individuals’ rights were not infringed.

It was crucial that all stakeholders were able to understand the needs of the project. Our IG team took great care in explaining the key points in simple terms. This meant the IG teams at the local NHS trusts and the ICS had the confidence and assurance to support and progress the project.

The team clearly detailed the project needs in a single DPIA document. As later versions needed to include different data controllers and processes, we used the tools and learnings from previous risk assessments to ensure that the clinical benefit was always at the forefront of these submissions.

“By completing the DPIA for the entire project, the MLCSU IG team ensured that all data sharing and processing was mapped and all data protection risks were identified and mitigated.

“All required versions of the DPIA were completed in line with the project live dates, and we were confident that the patients’ needs were always at the forefront of the project.”

Anne Turner and Lisa Flanagan | Senior Programme Managers: Targeted Lung Health Checks

Raising awareness of health inequalities in the Midlands

We raised awareness of health inequalities among the 11 integrated care systems in the Midlands through promoting the government’s Health Equity Assessment Tool (HEAT) – used to identify and support local action to address health inequalities.

Background
Tackling health inequalities for Black, Asian and ethnic minority communities, hard-to-reach groups and deprived areas is a key priority for NHS England.

In January 2022, our Nursing and Urgent Care (NUC) team was commissioned by NHS England and the Office for Health Improvement and Disparities (OHID), to engage with the 11 Integrated Care Systems (ICS) across the Midlands to promote the government’s Health Equity Assessment Tool (HEAT) to identify and support local action to address health inequalities.

Five training sessions were to be delivered by 31 March 2022, each with a minimum of 60 participants.

Action
Our NUC team worked closely with ICS health inequality, quality and project management leads to promote HEAT training sessions to help them embed the tool into their quality improvement and business planning processes.

The team developed and delivered two types of HEAT training: ‘train the mentor’ and more general training, using evidence-based resources and live training on the Fingertips Outcome Framework (a public health framework containing life expectancy data for different communities and backgrounds).

Working closely with NHS England, OHID and other stakeholders, we developed a bespoke audit tool to support organisations to gather information about the use of HEAT and its impact.

Impact
The NUC team was given a challenging timeframe of 14 weeks in which to complete the project, but through coordinated and efficient delivery we were able to complete it in 11 weeks.

Our senior experts and project support team successfully raised awareness of health inequalities among the 11 ICSs through HEAT training sessions, attended by 407 people across five sessions – far exceeding the original target of 300.

We provided resources to support the HEAT programme going forward, including recordings of the two training sessions uploaded to the Midlands Health Inequalities and Long Term Plan Prevention Hub on the Future NHS Platform.

The audit tool can be used at both project and programme level, making it flexible for use across different organisations including ICSs, NHS, local government, devolution deals, and the voluntary sector.

A final evaluation report produced by the team outlined learning from the project. It also made a number of recommendations to NHS England and OHID to improve the HEAT training programme and help systems take this work forward.

“Can I say what a pleasure it has been to work with the [NUC] team. The CSU worked collegiately and delivered fantastic training.”

Karen Saunders, Consultant in Health and Wellbeing | DHSC, Office for Health Improvement and Disparities

Reuse, not replace: slashing our carbon footprint

As part of the NHS Midlands and Lancashire CSU’s Green Plan and commitment to reducing our carbon footprint, we have dedicated workstreams cutting across all aspects of how we operate.

This includes IT Procurement, which is working with suppliers and manufacturers to develop a way of assessing the carbon journey of the equipment we use – from manufacture to shipping.

As part of this, IT Procurement Manager Tracey Yates and her team have been asking suppliers for their Green Plan and requesting the Carbon Data Factsheet for each product. This information is then compared against that from alternative manufacturers and an assessment is made on the suitability of products based on their carbon output.

But it doesn’t end there. The IT Procurement team also assesses the Total Cost Ownership, which means the estimated carbon cost of using equipment. For example, the power required to run a typical staff computer and monitor for eight hours results in greenhouse gas emissions equivalent to around 70g CO2e. A standard laptop and monitor, operated over a five-year period, creates a carbon footprint of around 755Kg CO2e. It is important to bear in mind, however, that 85 per cent of this results from manufacture and shipping, while just 15 per cent is from electricity consumption.

Tracey said: “There is a lot to think about and assess when making green decisions in IT procurement, but it is very interesting to understand the carbon cost of different types of equipment. When we consider the full lifecycle impact of providing and using IT, we need to consider both the upstream impact of supply and the downstream impact of disposal.

“For example, there is a significant difference between the carbon impact of a desktop and a laptop, mainly due to people wanting to replace the laptops more frequently. Therefore, the option to re-use/repair/upgrade should be considered wherever possible, before the decision is made to scrap, and buy new.”

Tracey’s team has also looked at using one larger screen monitor as a greener alternative to running two smaller monitors – thus reducing power usage and the need for a docking station. They have included social value and net zero questions in tenders and assess the suitability of suppliers on a wide range of environmental factors, including the use of an electric-powered fleet and non-plastic packaging. And the team has also embarked on carbon literacy training and started questioning the need to purchase equipment when an upgrade or repair is more suitable.

Tracey said: “Given that 85 per cent of carbon output is in the manufacture, if we don’t need to buy something, we shouldn’t.”

What you need for a common electronic patient record

Through over 330 ours of focused work on engagement and gap analysis, we identified and consolidated the requirements for implementing a common Electronic Patient Record (EPR) system to enable seamless health care.

Background
Dudley Integrated Health and Care (DIHC) had already taken significant steps to integrate services, but were ambitious to push this further. An integrated Electronic Patient Record (EPR) system would be a major part of their drive towards much more seamless care for patients and efficiency for clinicians.

The Common EPR programme of work began in 2021/22 with support from the NHS Midlands and Lancashire CSU’s Digital Transformation team. The first phase to identify and define requirements has been completed, and the second phase involving the implementation is due to commence imminently.

Action

To establish DIHC’s requirements, we undertook a series of interviews and workshops with service leads, frontline clinicians, partners and other stakeholders. Building on this intelligence, we turned the identified requirements into a detailed, richer system specification.

We looked deeper by performing a gap analysis against the incumbent core clinical system supplier to establish and identify:

-how their solution could fulfil the requirements
-which requirements it could fulfil
-the implication of the gaps and the roadmap to fill these.

The team provided strategic EPR options and an executive recommendation for the project, before establishing the foundations for a Common EPR Business Case spanning primary care, mental health, children’s and adult community services.

Impact

In a truly collaborative effort, a total of 70 services and teams throughout Dudley were engaged in this project.

From October 2021 to March 2022, our Digital Transformation team spent over 330 hours of focused work on targeted service engagement, discovery workshops and interviews, documentation, follow-ups, validation and requirement consolidation and traceability activities.

The discovery process involved more than 115 NHS colleagues through more than 110 meetings, interviews and workshops. This ensured that service leads, frontline clinicians, partners and other stakeholders were at the forefront of defining what the Common EPR would look like.

We gathered 3,742 requirements through this process. These were consolidated into 843 individual EPR requirements before being categorised and prioritised.

Our iterative, analytical and fully traceable EPR Gap Analysis process involved:

-Fit and gap assessments with the incumbent system supplier
-Categorisation of requirements (e.g. Fully Met, Partially Met, Not Met) with supporting action plans
-Dashboard level analytics for communication across a wide range of stakeholder groups
-Emerging themes and barriers to progress consolidated into four strategic areas of concern for executive review and steer.

We completed a digital tools operational review for DIHC Primary Care Clinical Support Services in parallel to the Common EPR process, and established an action plan for operational system improvements.

“I was impressed with the way the team developed and implemented a programme structure which enabled a complex set of requirements to be delivered. The outcome of the EPR programme has enabled the organisation to understand the requirements of individual services, address gaps with current system suppliers and identify potential solutions for the future EPR. Thanks to everyone that has supported this project.”

Matthew Gamage, Acting Director of Finance, Dudley Integrated Health and Care

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HR award for health and wellbeing strategy

We have been recognised by HR Magazine with an award for Best Health and Wellbeing Strategy as part of their HR Excellence Awards.

The awards shine a light on best practice in HR. In the health and wellbeing category, judges noted the significant work we have done to support staff health and wellbeing, all of which has helped to strengthen the organisation by prioritising our people.

Highlighting the overall purpose and value for money, the magazine wrote:

“What is remarkable about this strategy, labelled outstanding by judges, was that it was delivered on a shoestring budget by a generalist team, driven by a passion for its people.

“Judges praised its clear focus on the business issue at hand and the engagement at every angle with its end goal of providing top-quality services to patients.”

Key for our health and wellbeing strategy have been employee engagement and a people driven approach. Teamed with utilising our workforce data to identify pressing issues, this shaped a comprehensive plan of wellbeing activities and interventions. They are broadly framed under physical wellbeing, mental wellbeing and financial wellbeing, and include a large range of offers for employees to pick and choose.

To implement these changes as a golden thread throughout the organisation, we employed several enablers including:
-Building a training and education campaign to help managers and employees better understand remote working, resilience and physical fitness
-Weekly wellbeing sessions to discuss wellbeing tips and resources
-A trained team of mental health first aiders
-Enlisting health and wellbeing champions to push from below and members of the board to role model and communicate healthy behaviours from above
-Embedding health and wellbeing into one-to-ones and appraisal documentation
-Blogs and intranet forums.

The effect on staff wellbeing was evident when in the latest staff survey, we saw the number of people saying they had felt ill because of work related stress drop. Almost all (92%) said that they did not feel pressured by their manager to come to work when ill, and that they felt empowered to take informed decisions about their health (94%). There was also a significant drop in the number of days lost due to stress, anxiety or depression – 18% between March 2021 and June 2022.

Fay Winstanley, People and Organisational Development Manager, said: “We are absolutely thrilled to win this award, which reflects our commitment to developing and delivering a strategy that is based on data and staff feedback, and where we can accurately measure the positive impact of what we do.

“Moving forward, we need to ensure that we continue to have a strong focus on our people’s wellbeing. We intend to build on our current offer, utilising data and employee engagement to deliver the right interventions and support at the right time. We are also looking at replicating our successful model at customer organisations.”

Sarah Sheppard, Director of People, said: “This is amazing recognition for the team at a challenging time when we need to ensure that our staff are well engaged and motivated to achieve the high-quality work which ultimately impacts on patient services.”

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Empowering people living with pain to explore alternatives

We helped the Black Country Integrated Care Board deliver an engagement campaign to help people living with chronic pain explore alternatives to pain medication.

Background

Flippin’ Pain is a public health campaign that engages with individuals and communities affected by persistent pain and empowers them through a better understanding. This is essential to delivering change in the approach to pain management across whole systems.

The Black Country Integrated Care Board (ICB) contacted Connect Health, a community services provider and champion of the Flippin’ Pain campaign in other areas of England, about bringing the campaign to the Black Country. To help facilitate the planning across multiple organisations, the ICB asked the NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) to assist.

Our aim was to target, engage and empower patients struggling with chronic pain who take regular analgesia, and help them understand that there is another way.

Action

-Facilitating collaboration between key stakeholders from Connect Health, the ICB medicines management and communications teams, venues, musculoskeletal (MSK) teams and pain specialists.
-Two full-day Brain Bus events to engage with the public and raise awareness.
-Face-to-face seminar event at YMCA, West Bromwich.
-Live webinar event with expert panel and Q&A.
-Promotion via social media, Black Country GP practices and hospital departments, charities and other networks.

Impact

-Brain Bus events were very well received and attended at two locations. The general public had time to ask specialists about any aspect of pain and also a chance to try out some interactive games to support and understand how we perceive pain.
-Several patients agreed to be involved further with the campaign and to share their stories of living with chronic pain with other patients.
-Face-to-face event had 35 people in attendance. The panel consisted of: Prof. Cormac Ryan, Flippin’ Pain’s Community Pain Champion and Professor of Clinical Rehabilitation at Teesside University; Dr. Deepak Ravindran, pain physician who developed an award winning community service for people living with persistent pain; specialist pain physiotherapists and patients experienced in living with chronic pain.
-Live webinar had 161 people registered including healthcare professionals. A recording is available and has been viewed many times. The panel included an expert patient who shared her story.

Feedback after all the events has been hugely positive, with many patients feeling a sense of optimism and also keen to explore with their doctors the option of reducing medication.

See campaign resources on the next page and more on the website: https://www.flippinpain.co.uk/resources/

“Firstly, I would like to thank MLCSU for the level of support and cooperation that has been critical to ensuring the completion of the objectives for this project.

“There were multiple engagement events as outcomes for the ICB. There was an underlying stakeholder engagement need, and meetings were undertaken to ensure any early barriers to the objectives were identified and solutions were created. Despite setbacks out of our control we were able to work collaboratively to achieve our aims.

Sumaira Tabassum| Head of Medicines Management – Walsall Place, Black Country ICB

“I know the painkillers do not really work but I take them anyway – it’s time to take control back”

“You’ve given me things to think about. I’m decades in”

“Thank you for engaging with people with chronic pain – it’s great to not be invisible!”

“Everything said gave me the boost I needed”

“I found this event very useful. I will think before taking medication whether I need it?”

‘Knowing I’m not on my own now. Great to see more being done than JUST giving medication”

Feedback from patients

A new website for Norfolk and Waveney ICS

Our team delivered an innovative, interactive and accessible website to inform and educate patients and the public about the Norfolk and Waveney Integrated Care Systems in just a few clicks.

Background

With Clinical Commissioning Groups (CCGs) transitioning to an Integrated Care Systems (ICSs) from July 2022, Norfolk and Waveney ICS commissioned our team of digital experts to create a new website that would replace the existing CCG site.

The site needed to be simple, helpful, and accessible and be fully optimised for mobile, working across multiple devices. It was crucial that the content management system (CMS) was user-friendly so their Communications team could easily maintain and use it to update the site when required.

Action

Our expert developers began to build the new website by implementing the design, mapping content and focusing on user journey optimisation for the best possible user experience.

The website was built on WordPress. This CMS is easy to use, allowing non-technical staff to easily upload content and other rich media to the site.

We provided Norfolk and Waveney with planning tools to help structure the content. They were also able to insert content directly so that we could transfer it to the new site.

By clearly mapping how users intended to travel through the website, we were able to assure the client that the user journey was optimised, and that key information could be found within three clicks. Thorough testing was undertaken prior to launch.

Impact

Our team delivered an innovative, interactive and accessible website that met the requirements and objectives laid out in the brief. We also provided the ICS Communications team with the management tools and training they needed to maintain the new site going forward.

The new website houses all the relevant content to inform and educate patients and the public about the ICS in just a few clicks. This includes information about ‘Our Work, ‘Get Involved’ and ‘Health and Care Careers’.

The site also includes a range of content-enhancing widgets such as accordions and slideshows to add interactivity and improve user experience.

https://improvinglivesnw.org.uk

“Working with the MLCSU Digital team on the build of our new ICS website was a really good experience.

“The team helped bring our design to a reality, whilst sharing our vision. They listened to our goals for the site and clearly explained how they could help us achieve these. They also provided suggestions that would further improve elements such as user experience (UX) and accessibility.

“As the team was able to help us within a short timeframe, we were able to launch the site with helpful information for our people and communities at the same time as the launch of our new ICS.”

Adam Dennis
Digital Communications and Engagement Lead | Norfolk and Waveney Integrated Care Board and Norfolk and Waveney Integrated Care System

Improving quality of care at a nursing home

Our Medicines Optimisation in Care Homes team conducted structured medication reviews of patients at a nursing home, avoiding potential harm as a result of improper medication and saving almost £5k.

Background

Having identified medicines-related issues at a nursing home, colleagues from Lancashire County Council requested support from MLCSU’s Medicine Optimisation Care Home (MOCH) team.

The objective was to help the nursing home to achieve the necessary standards through improved medicines management. This was to be achieved through tailored advice and training.

Action

The MOCH team began by undertaking structured medication reviews (SMRs) with carers for all residents of the nursing home. They also shared medication review feedback with the GP, the community pharmacist and the nursing home.

They attended quality improvement meetings with the Lancashire County Council and the GP.

All nursing home staff were given access to MOCH medicines training webinars, covering topics including:

-medicine administration
-waste management
-ordering and booking in of the monthly medication order

The team also provided medicines administration audit support, provision of advice on safe storage and monitoring of medicines and accurate documentation of care plans.

Impact

As a result of the MOCH team’s interventions over a six month period, 18 structured medication reviews were conducted for vulnerable residents of the nursing home. The majority (78%) of the patients were aged 75+.

A total of 69 interventions were made:

-23 low impact interventions. This included stopping a controlled drug which was no longer being taken and was removed from the medicine administration chart.
-39 medium impact interventions (moderate risk to patient safety). This included stopping an oral nutrition supplement in a patient who was becoming overweight.
-7 high impact interventions (potential to cause significant harm to the patient). This included stopping a blood pressure lowering medicine in a patient who had low blood pressure and a history of falls and seizures.

Approximately 25% of the patients reviewed avoided potential significant harm as a result of the actioned recommendations.

The team achieved a total of 21 cost savings to the value of £376 per month or £4,892 over a year.

Through the reviews,14 medicines were stopped.

The work of the team resulted in improved ongoing communication between the GP practice and nursing home.

The nursing home progressed from being rated in ‘special measures’ to a status of ‘overall improvement.’

“The Medicine Optimisation Care Home team have done a great job in looking after our patients holistically via doing SMRs which were tailored to each individual patient’s needs, social and clinical background.

“Everything was explained thoroughly and backed with evidence which resulted in a high level of care for our patients and avoided potential hospital admissions or harm.

“Appropriate medicine training was provided to the care home staff.

“We greatly appreciated the support.”

Dr Mohamed Hassan, GP Principal at Lytham Road Surgery, Preston

Blog: studies, part-time role and an NHS graduate

Ellen balanced her studies with a part-time role in Personalised Healthcare Commissioning (PHC), and she’s now applying for the NHS graduate scheme.

MLCSU’s Temporary Staffing Admin Bank is a great starting point for anyone looking for flexible, varied work within the NHS. We are proud to provide a supportive environment where recruits can learn and develop, and have opportunities to further their skills and career.

As part of future succession planning, the Personalised Healthcare Commissioning service recruited a number of young people through the Admin Bank. In this series of blogs, we meet some of them and hear their experiences.

Ellen Rintoul, Administrative Assistant, Lancashire and South Cumbria PHC Team:

I first heard about this opportunity when I was looking for a flexible, part-time job that I could easily fit around my linguistics degree. The vacancy was listed on NHS jobs, and sounded like something I that I could balance alongside my lectures, seminars and readings.

I was excited about the opportunity to develop new skills in emailing, phone calls and minute taking. I started in 2020 during my first year of university, and am now going into my final year of studies. I have found many of my new skills are transferrable into other areas such as academic meetings, and society and student union committees.

My role mainly involves creating documents detailing patients’ care, and sending them on to nursing homes, where their care is being continued after a hospital referral or change in care needs. I have developed many new skills by learning new elements of processes. I am really happy with my role, and feel very lucky to have maintained it throughout my studies.

The experience has also made rethink some of my plans for after university. I now plan to apply for the NHS graduate management training scheme, so hopefully I can work on health and social care policy in my future!

 

 

Two HSJ Partnership awards in prospect

We’re proud to have played our part in truly impactful change programmes, which have been shortlisted for two HSJ Partnership Awards, it has been announced.

Our partnership with Digital Space has delivered a cloud-based automated Waiting List Validation solution helping hospital trusts reduce waiting lists by around 10% while identifying priority patients for review. All with improved speed, efficiency, and working practices along with reduced cost. 

Digital Space and NHS Midlands and Lancashire CSU’s Digital Innovation Unit (DIU) built an automated service that called patients on the waiting list and asked them questions to assess their current needs. Where necessary, this was backed up with human operators and a manual call such that patients could be supported, resulting in contact with over 80% of patients.

As the NHS grapples with longer waiting lists, which grew due to the Covid pandemic, the solution provides a highly efficient approach to helping trusts deliver appropriate care more speedily – improving patient experience and outcomes as a result.

The work is shortlisted for the HSJ Partnership Award in the ‘Best Elective Care Recovery Initiative’ category. Download our case study below.

The NHS Transformation Unit (NHS TU), hosted by MLCSU, is celebrating its work being shortlisted in the ‘Most Effective Contribution to Clinical Redesign’ category. Their work in Cheshire and Merseyside to undertake an end-to-end pathway review across all gynaecological cancer services aimed to help providers achieve challenging cancer standards and to support the delivery of the NHS Long Term Plan. For more information about this work, visit the link below.

The teams behind the work look forward to the final award ceremony on Thursday 23 March 2023 in London.

Independent sector capacity and waiting lists

We procured independent sector hospital capacity to divert patients at the point of referrals from NHS trusts to prevent a build-up of patient waiting lists backlogs.

Background

Our Contract Management Team directly supported NHS Planning Priorities for 2022-23 by reducing waiting list backlogs as part of NHS England’s Elective Care Recovery Programme. The ask from the Lancashire and South Cumbria Integrated Care System (ICS) was to transfer patients from NHS trusts into independent sector (IS) hospitals, thereby alleviating the waiting list pressures on NHS trusts. An Independent Sector Coordination role was created to effectively utilise IS hospital capacity in the most efficient and effective way.

Action

We procured IS hospital capacity through the Increasing Capacity Framework which is an easy route to contract elective care services. This allowed us to develop and implement new models of working with ICS colleagues, including NHS trusts and IS hospitals.

A standard operating procedure to divert patients at the point of referrals from NHS trusts to IS hospitals was co-designed, by adopting good practice from other areas in the country and tailoring it to local needs and requirements. The standard operating procedure has become operational across several NHS trusts in Lancashire and South Cumbria due to its effective and efficient implementation.

Impact

Working in partnership enabled us to develop and implement the standard operating procedure to prevent a build-up of patient waiting lists backlogs.

The flow of new referral pathways which diverts patients from NHS trusts to the IS hospitals has increased by 200 patients per month on average for some of the trusts. These patients would have otherwise been left waiting for much longer for treatment.

The percentage of patients being diverted from NHS trusts to IS hospitals as part of this intervention is 90% on average, in some cases this has resulted in 50 patients diverted per week. Previously, on average only 30 patients per month were moved from NHS trusts to IS hospitals.

The work also provided assurance to Lancashire and South Cumbria Elective Care Recovery Group to effectively utilise IS hospital capacity.

Cassino Ao Vivo Online Jogos De Cassino » Cassino Betfai

Cassino Ao Vivo Online Jogos De Cassino » Cassino Betfair

Bem-vindo Ao Melhor Cassino Online Do Brasil

Content

É possível deducir de bônus de depósito e giros grátis, até acesso exclusivo a novos jogos e mais. A maioria dieses ofertas têm Termos e Condições, bastante como requisitos para aposta para cumprir. Abaixo, nós mostramos alguns dos muitos dos bônus também populares que você encontra em cassino online aqui no brasil. O mundo IGaming funciona com plataformas virtuais onde os jogadores podem acessar uma ampla variedade sobre jogos de casualidad e apostas, tudo através da web. É importante notar que a roleta online usa o gerador de números aleatórios (RNG) afin de garantir an imparcialidade do jogo. Além disso, muitos cassinos online oferecem an opção de jogar roleta ao vivo, onde um supplier humano gira the roda em pace real, proporcionando uma experiência mais autêntica.

  • Os jogadores deste site ainda encontram vantagens extras, asi como a liga Betano e ofertas exclusivas.
  • Neste momento, o pix é visto o método para pagamento mais well-known entre os brasileiros.
  • Dessa maneira você pode fazer qualquer tipo para transação de onde quer que você esteja.
  • A ausência de um aplicativo móvel específico é compensada pela eficiência do site móvel.
  • Essa opção de jogo é bastante útil para ter uma experiência com um video game anteriormente a começar an apostar de verdade.

Além disso, nossa organizacion é incrivelmente fácil de usar, possuindo uma navegação fácil para os apostadores iniciantes. Temos 1 design elegante e moderno, com botões intuitivos, categorias organizadas e filtros eficientes que lhe proporcionam encontrar os bons jogos de cassino online para o teu gosto. De ofertas de boas-vindas a new programas de fidelidade, você contará” “apresentando boas oportunidades afin de aumentar as suas chances de lucrar. E, com alguma excelente reputação para jogo limpo e termos e condições transparentes, nosso cassino online conta com um ambiente tranquilo e confiável para todos os nossos usuários.

Balzac Casino

Graças às transmissões ao vivo para alta qualidade, você pode jogar roleta, blackjack, poker, electronic muitos outros games clássicos, interagindo com crupiês reais electronic jogadores de todo o mundo, tudo no conforto da tua casa. Esta experiência combina a conveniência dos jogos on the internet com an emoção do cassino físico. As raspadinhas também são muito populares, principalmente para quem vai à uma Lotérica, não é mesmo? A concepção é permitir que os jogadores raspem as opções disponíveis para ganharem prêmios instantâneos 1win apostas.

  • A combinação de ofertas exclusivas e facilidade para uso o torna uma escolha ideal para aqueles la cual buscam uma experiência de jogo de alta qualidade.
  • Esse é um de item que priorizamos, pois erros podem acontecer, mas asi como o site irá lidar com” “isso, determinará se é ou não uma ótima plataforma.
  • Ainda o qual essa não possa ser uma unanimidade, a maioria das viviendas dão essa op??o aos seus usuários.
  • Dentre as promoções para destaque estão a roda da caso e rodadas grátis no cassino Betano.
  • Os jogadores giram os rolos e tentam combinar símbolos para ganhar prêmios.

O LeoVegas Casino, que também oferece serviço para apostas esportivas, é considerado um 2 sites mais completos e seguros weil indústria. E foi classificado como o melhor cassino móvel, por enfatizar at the aperfeiçoar o serviço de apostas através do seu aplicativo próprio, que foi considerado muitas vezes como excelente. Seja qual for tua plataforma de escolha, nós cuidamos para que tudo esteja a seu alcance. Com um design elegante e fácil para usar, próprio para” “usufructo no celular, você pode ter a melhor experiência online durante seus giros. O aplicativo da LeoVegas está disponível tanto para Android quanto para IOS.

Brasil Vence Inglaterra Com Gol De Endrick Na Estreia Sobre Dorival Júnior

E fazemos isso, utilizando sobre um sistema sobre classificação que varia de 1 the 5 pontos. A lista acima, e a lista” “também completa de gambling dens online confiáveis do Brasil. Portanto, não hesite em entrar no ano de contato conosco systems consultar a nossa página de Perguntas Frequentes. A regulamentação dos jogos on-line no Brasil significa o maior avanço pra o setor, la cual pode gerar benefícios econômicos e sociais para o país. Cada vez há mais cassinos o qual aceitam bitcoin electronic outras criptomoedas pra depósitos e retiradas em Brasil.

  • O fato para termos o selo de aprovação do Curaçao Gaming Command Board destacainda mais o nosso compromisso com essa querella.
  • Você tem a possibilidade de encontrar uma grande variedade de games de caça-níqueis, cada um com teus tempos de retirada, regras e temáticas.
  • Os cartões Visa for australia são um de métodos de pagamento mais populares nos casinos online, isso devido à sua segurança e conveniência.
  • Quando ze trata de jogar nos” “bons cassinos online nacionais, é importante decidir os mais seguros.
  • Não temos qualquer ligação direta com provedores ou corporações de jogo, um que significa que nossas análises são imparciais e honestas.

Se eles saírem antes do “crash”, ganham an aposta multiplicada pelo valor no ano de que saíram. No” “entanto, se o “crash” acontecer antes de saírem, eles perdem an aposta. Este jogo é semplicemente baseado em sorte e timing, oferecendo uma experiência emocionante e rápida afin de os jogadores.

Características Dos Mais Importantes Cassinos Online Do Brasil

Nosso cassino on the internet é operado através de uma equipe de profissionais experientes, com profundo conhecimento da indústria de games de azar online. Somos uma companhia comprometida com a great excelência e satisfação dos nossos clientes a todos os momentos. Os cassinos online, como a new KTO, oferecem jogos que você encontraria em cassinos reais. Os jogos são fornecidos por diferentes desenvolvedores de jogos de cassino electronic cada jogo é testado por agências independentes, como a eCOGRA, para garantir an imparcialidade. Isso visto que o site proporciona uma variedade de jogos, que vão desde as também clássicas mesas para Blackjack e Roleta ao vivo, até as mais modernas e lucrativas versões de Crash. Em parceria com elevados fornecedores, foi considerada uman excelente organizacion para jogadores o qual buscam dealer profissionais e mesas exclusivas.

Quando sony ericsson trata de jogar nos” “bons cassinos online do Brasil, é importante escolher os mais seguros. A seguir, explicamos os critérios mais rigorosos que os nossos especialistas realizam para preparar avaliações de cassinos on the internet no nosso país. Critérios que compartilhamos com você, para que também saiba u que procurar na hora de escolher um melhor casino on the internet com dinheiro genuine. Em suma, com uma organização impecável de jogos, promoções atrativas e a new praticidade de o aplicativo móvel, um site da Betano se consolida tais como um dos grandes cassinos online carry out Brasil.

Let’sgocasino – Grandes Opções Oferecidas Para Pagamentos Brasileiros

Por fim, fica clara an importância de estudos tais como esse que nos permitem vislumbrar as preferências e operating-system comportamentos dos jogadores online. Afinal, só por dados reais podemos compreender melhor o mercado para iGaming que, embora já esteja propagado entre o importante público, ainda é visto como alguma novidade para uma parte significativa 2 brasileiros. Embora u bingo tradicional possua raízes em jogos de loteria, a new versão online oferece uma experiência semelhante com algumas diferenças. Embora possa parecer complexo à 1ª vista, com várias opções de apostas, é um game de cassino bastante empolgante quando ze entende como es efectivo. O poker on the internet oferece uma gama de variações, incluindo Texas Hold’em e Omaha. É 1 jogo de habilidade e estratégia, em que os jogadores competem entre si.

  • Mas um dos grandes diferenciais desse cassino está na disponibilidade de criptomoedas afin de quem pretende dejar.
  • Procure em Spin Sports para ofertas incríveis no ano de tudo desde Futebol Americano até Basquete, Futebol, Rugby, Críquete, Boxe e Corrida de Cavalos.
  • As apostas esportivas na cassinos online permitem que os jogadores apostem em eventos esportivos e competições de todo o mundo.
  • Se todos os pontos acima forem positivos, damos uma nota final e escrevemos uma resenha detalhada sobre nossa experiência.

A KTO é an escolha preferida de milhares sobre brasileiros, sendo o qual uma pesquisa atual nos classificou asi como o quarto cassino cependant procurado no País brasileiro, com 1, seven milhão de buscas no Google durante mês. Cassinos on-line de renome em endossam como um membro fundador do Instituto Brasileiro de Jogo Responsável (IBJR). Temos uma grande variedade para raspadinhas” “la cual oferecem an op??o de ganhos instantâneos.

Bônus De Cassino Electronic Outras Ofertas

Se você é um amante de jogos clássicos, então estamos quase certos sobre que você ze apaixonará pela nossa excelente variedade para grandes jogos para cassino ao palpitante. Por fim, garantimos os resultados imparciais e justos sobre todos os nossos jogos de cassino online por meio de geradores para números aleatórios (RNG). Empregamos algoritmos aleatórios e” “imprevisíveis para fazer apresentando que os resultados de cada rodada ocorram de maneiras individuais, sem interferência de outros fatores que não a new sorte do próprio apostador. Por isso, para você jogar seus jogos de cassino de maneira segura e mantendo a diversão, oferecemos diversas ferramentas pra garantir o game seguro. Aqui na KTO, oferecemos uma considerável variedade de bônus para nossos jogadores de cassino on the internet.

  • Confira abaixo os grandes jogos de cassino que podem variar de gosto de pessoa para pessoa, pois dependem dieses preferências individuais.
  • Além disto, o seu site tem recursos afin de um jogo seguro, como alerta de atividade, autoexclusão, período de pausa e limites de depósito.
  • Independentemente 2 fatores que levam an uma vitória, você pode contar com muitas variações de blackjack afin de se entreter.
  • Se alguma mesa está cheia, isso normalmente cuenta que ação está se desenrolando em um ritmo grande, que ninguém saiu no meio perform jogo e la cual o carteador está fazendo um ótimo trabalho.

Perguntamos a 4 especialistas da indústria iGaming quais conselhos eles dariam aos jogadores de cassino brasileiros. As apostas virtuais, com cassinos online e previsões na partidas esportivas foram liberadas pela legislação brasileira recentemente, zero final de 2018. Muitos cassinos disponibilizam um aplicativo próprio para seus usuários, permitindo que um apostador tenha cependant liberdade para realizar sua aposta.

Catálogo De Games: Variedade De Opções

Entre seus destaques está an chollo de métodos para pagamento para depósitos e saques. Você pode encontrar métodos populares como Pics, AstroPay, Boleto Bancário, Pay4Fun e até Bitcoin. Em nossos cassinos recomendados, você pode ganhar bônus incríveis e jogar uma excelente gama de caça-níqueis e outros jogos para cassino. Na categoria de Cassino Ao Vivo, a trampolín oferece uma gama de jogos, incluindo blackjack, roleta, bacará, pôquer e video game shows.

  • Ao fazer u registro e ativar o bônus sobre inscrição, você poderá receber até R$ 7. 500+ 150 rodadas grátis afin de aproveitar no nosso cassino online.
  • Nosso site é criptografado com as também recentes tecnologias SSL, de modo que todas as informações que você compartilhar conosco, e somente conosco, são mantidas seguras.
  • Esses bônus geralmente representam uma porcentagem perform valor do depósito, proporcionando aos jogadores uma quantia additional para jogar.
  • A 1ª lista de empresas aprovadas para actuar no país será publicada em julho de 2024.

Em ambas as áreas encontramos uma boa chollo aos jogadores at the, na nossa opinião, é uma óptima opção para dar em futebol, MMA/UFC e tênis. O melhor cassino on-line é aquele la cual coloca os jogadores em primeiro local, dá preferência à qualidade ao invés da quantidade, tem uma variedade sobre jogos, protege os dados pessoais at the oferece uma jogabilidade lícita. O mercado” “de jogos de azar, está cada ocasião mais focado simply no público brasileiros, at the o sistema sobre pagamento nacional já está implantado na grande maioria de sites de cassino online. Sim, você pode jogar operating system melhores jogos grátis e a recurso financeiro real, usando um dispositivo móvel como um smartphone electronic tablet Android, i-phones, iPads ou dispositivos Windows. Usualmente, você pode escolher entre an opção instant play ou baixar o aplicativo móvel do cassino. Os melhores sites também oferecem um software de cassino afin de uma experiência para apostas online mais personalizada.

Como Registrar-se Em Um Cassino Online?

De acordo com os dados publicados, a renda disponível (48%) é o fator predominante que instiga operating system jogadores brasileiros a great apostarem online. Da mesma maneira, a good emoção dos games como” “divertimento (40%) e a new qualidade dos games (31%), são operating-system principais aspectos que motivam os brasileiros an apostarem on-line. Os cassinos on the internet representam uma evolução notável no cenário do entretenimento digital. Ao proporcionar alguma experiência conveniente electronic acessível, essas plataformas conquistaram a preferência de milhões de jogadores em en totalidad o mundo. Com a comodidade sobre acessar uma gama impressionante de games a partir do conforto do big, os usuários podem desfrutar de uma experiência imersiva at the emocionante, repleta sobre oportunidades de lucro. Confira abaixo tais como funciona as apostas esportivas em jogos de cassinos on-line.

  • Embora o tradicional black jack on-line seja uma boa forma para passar o teu tempo, ação é elevada um novo nível graças à presença do carteador de cassino ao vivo.
  • Além disso, graças à tecnologia de ponta, você tem a tranquilidade de que teus dados pessoais at the financeiros estão constantemente seguros e protegidos ao interagir possuindo nosso site.
  • Este jogo é puramente baseado em sorte e timing, oferecendo uma experiência blando e rápida para os jogadores.
  • Casino. org é um fornecedor independente de análises e de informação sobre cassinos on-line.

Em seguida descrevemos no item segurança así que usted todos entendam se a licença do casino é real ou não. Alguns sites sobrecarregam o sistema com informações ou imagem desnecessária, afetando diretamente an experiência do seu cliente. Assim, como na organização dos jogos ou informações, que precisam estar legíveis.

Posso Jogar No Móvil Em Um Cassino Online Brasileiro?

Se você é novo no mundo de cassinos online at the não sabe durante onde começar, aqui dizemos como. Sendo um dos jogos de cassino cependant famoso, a roleta pode ser jogada com muita ou pouca estratégia, consoante você desejar. Não perca as variações de roleta europeia, mini roleta at the roleta progressiva. Descubra vários tipos diferentes de jogos para poker, desde um poker clássico até ao poker para 3 cartas assim como o Texas Hold’em. Se você acha la cual” “possui perícia e uma boa cara de poker, vá checar operating system torneios de poker que estão the decorrer, onde en totalidad o tipo para prêmios estão à sua espera. Recomendamos apenas bônus possuindo rollovers viáveis, ganho máximo e expiração.

  • Aqui na KTO, oferecemos uma grande variedade de bônus para nossos jogadores de cassino on-line.
  • No Cassino Betfair, você pode conseguir certeza de que está nas mãos mais seguras.
  • Uma das características cependant marcantes dos cassinos online é essa variedade de opções de jogos disponíveis.
  • Nosso cassino on the internet é operado através de uma equipe para profissionais experientes, possuindo profundo conhecimento da indústria de games de azar online.
  • Notavelmente, o Galera. bet se destaca ao oferecer jogos ao vivo no ano de português, uma característica que poucos competidores possuem.

Abaixo, você tem a possibilidade de conferir as opções sobre pagamento mais populares pra jogar no cassino KTO. Os Accident Games também representam uma grande parte de todas as rodadas de jogos, exista tipo de game segue entre operating system mais populares mhh KTO desde um início de 2023. Veja abaixo as categorias de cassino também populares da KTO com base no ano de rodadas jogadas. Todos os meses, compartilhamos os dados sobre u que nossos jogadores gostam de jogar.

Cassino Online

Um 2 destaques do Monro são suas excelentes promoções de cassino, entre elas estão o bônus para boas-vindas, bônus sobre segundo e terceiro depósito, MONRO CASH e MONRO SPIN. Existem muitos motivos pelos quais u Spin Casino se posiciona como o melhor cassino do Brasil. O bingo on-line é uma versão eletrônica do game de bingo tradicional, onde os jogadores marcam números na seus cartões à” “medida que são chamados. O jogo para bingo é o jogo de casualidad popular que também está disponível no ano de muitos cassinos on the internet. Em conclusão, operating system cassinos online possibilitam uma experiência para jogo emocionante electronic conveniente, com uma ampla gama de opções. No entanto, é essencial la cual os jogadores joguem com responsabilidade electronic estejam cientes dasjenige leis de game em sua região antes de sony ericsson aventurarem nessas plataformas de entretenimento digital.

Nesse clássico jogo de cassino, você tentará adivinhar aonde a bolinha irá parar, após o sorteio ser realizado. Em cassinos na internet a grande vantagem é que você poderá jogar variações que disponibilizam recursos intensamente legais. Um bom exemplo é a Mess Roulette, que tem pagamentos elevados sobre maneira aleatória em suas rodadas.

Melhores Cassinos Online Do Brasil 2024

Existem várias variantes do poker, mas vou explicar as diretrizes básicas do online poker Texas Hold’em, que é uma dasjenige variantes mais buscados e amplamente jogadas em todo o mundo. As sobreposições gráficas ainda lo mostram quantas fichas você tem (com relação ao saldo da conta), e todos os lucro são totalizados at the exibidos na tela para você também. Muitas vezes, você encontrará estatísticas e opções ainda mais úteis na calo do jogo.

  • Se você gosta de jogos baseados apenas em tua sorte, os caça-níqueis são an escolha ideal.
  • A LegendPlay é uma casa de apostas online com conteúdo em português do Brasil, la cual opera conforme as leis de Curaçao, reconhecidas mundialmente.
  • Há muitos títulos para nicho para desfrutar também no cassino ao vivo de uma Betfair.

Você pode jogar jogos de cassino de qualidade como caça-níqueis, blackjack, roleta, poker e diferentes jogos de comensales. Alguns cassinos on the internet também permitem o qual você jogue para graça primeiro pra testar suas capacidades. Estes funcionam” “sobre forma diferente afin de cada cassino, contudo de forma geral recompensam jogadores com base em quando depositam.

Confirme Sua Conta

Bem asi como, após a descrição, listamos os mais importantes métodos de pagamentos em cassinos on the internet. Bem como conta com jackpots (slots com prêmio acumulado) com prêmios muito elevados. Há também uma seção exclusiva para jogar pôquer, onde você recebe um ótimo bônus de boas-vindas e pode baixar um programa em seu computador. Para quem gosta de jogar jogos de cassino pelo celular, é essencial saber o qual a bet365 apresenta um aplicativo grátis que pode ser baixado em dispositivos Android. A Rivalo Brasil reúne apostas esportivas e serviços de cassino online em um só site.

  • Uma das suas desvantagens é que os levantamentos não são tão rápidos asi como outros métodos disponíveis nos cassinos on the internet.
  • Nesse se, outra pessoa perform outro lado da tela interage com você enquanto você joga jogos para mesa.
  • Os cassinos online rapidamente conquistaram legiões de entusiastas na todo o País brasileiro.
  • O vinte-e-um, também conhecido como blackjack, é um jogo de cartas em que você joga enemistad o dealer.
  • O segundo pode ser respaldado nas políticas de privacidade, disponíveis em algum lugar carry out site, e na jurisdição em la cual o cassino está localizado.

Lembre-se de que o poker é o jogo complexo, electronic os detalhes das regras podem separar um pouco para uma variante para outra. Certifique-se sobre entender as diretrizes da variação de roleta que você está jogando e pratique o jogo responsável, definindo lignes de apostas electronic não apostando também do que você pode perder.” “[newline]Se você for o novato completo com cassino ao palpitante, dedique um tempo para ler nossas regras e guias de estratégia para cada jogo sobre cassino. Assim, since regras para o blackjack de cassino ao vivo são as mesmas dieses versões tradicionais carry out popular jogo para mesa, e desta forma por diante.

Faculdade Oferece Oficinas De Psicologia, Saúde E Arquitetura Para A Comunidade, No Ano De Manaus

Esses aplicativos podem ser usados no ano de dispositivos IOS electronic Android a fastidiar de um pc desktop, smartphone et tablet. Dessa maneira você pode produzir qualquer tipo sobre transação de onde quer que você esteja. Os cassinos apresentando saques rápidos estão entre os também procurados pelos apostadores brasileiros. Poder sacar seus ganhos sobre forma rápida é um requisito pra os jogadores cependant exigentes. Nossos especialistas testaram as grandes opções para que você escolha sem complicações. Monro é um cassino novo no mercado, já que abriu suas portas em 2023 afin de jogadores absolutamente todo u mundo, inclusive jogadores brasileiros.

  • Certifique-se sobre entender as recomendações da variação de roleta que você está jogando at the pratique o game responsável, definindo lignes de apostas electronic não apostando também do que você pode perder.” “[newline]Se você for um novato completo possuindo cassino ao vivo, dedique um pace para ler nossas regras e guias de estratégia pra cada jogo de cassino.
  • As ofertas de rodadas grátis podem variar em termos de quantidade, condições e jogos específicos aos quais estão vinculadas.
  • Ao analisar o cassino, é impossível não mencionar o aplicativo personal para” “computador, proporcionando uma experiência única para os usuários.
  • Graças às transmissões ao vivo para alta qualidade, você pode jogar roleta, blackjack, poker, e muitos outros games clássicos, interagindo apresentando crupiês reais e jogadores de todo o mundo, tudo no conforto da sua casa.

“Free spins” e “giros grátis” são termos usados em cassinos possuindo rodadas grátis la cual podem ser usadas em máquinas caça-níqueis ou jogos para slot. Durante since free spins, os jogadores têm an oportunidade de girar operating system rolos da máquina sem gastar teu saldo. Lançado em 2023, o DirectionBet está rapidamente se estabelecendo no setor dos cassinos on-line. Com uma larga variedade de games ao vivo, the plataforma proporciona alguma experiência divertida at the envolvente para os jogadores.

Os Jogos De Cassino Mais Populares No Brasil

O cassino também destaca-se pela seguran?a, com um RTP médio de 95, 54% e alguma variedade considerável de jogos com gerador de números aleatórios. A possibilidade sobre jogar no método demonstrativo, assim tais como a presença para jogos temáticos quentes, frios e favoritos, acrescenta valor à experiência. A seção de cassino ao vivo é cheia de variedade, incluindo jogos exclusivos, como também a área de torneios é dinâmica, apresentando competições frequentes electronic premiações atraentes.

  • Se desejar, pode abrir um Vulkan Vegas diretamente do seu dispositivo mobile e coger na sua conta para começar a good apostar por dinheiro real.
  • A Rivalo Brasil reúne apostas esportivas e serviços de cassino online em um só site.
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O fato de termos o selo de aprovação perform Curaçao Gaming Command Board destacainda mais o nosso compromisso com essa litigio. Gamblers Anonymous País e do mundo Esta é a good organização de auxílio apostadores viciados mais conhecida do globo. Normalmente, essa modalidade é chamada para Jogar por Diversão ou Play For Fun. Nesse caso, você pode visitar todas as funcionalidades do título, sem investir dinheiro electronic sem receber prêmios diante de uma vitória. Quem gosta para ter mais mobilidade no dia tem a possibilidade de fazer suas apostas com segurança com o smartphone.

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Essa pontuação pode ser encontrada individualmente em cada um dos 10 itens descritos abaixo, como na nota final, que ficará disponivel na conclusão do artigo. Tiago Aoki é um jogador de poker profissional que produz parte da nossa equipa de especialistas. Ao se cadastrar no BC. Sport o casino ght presenteará com 1 bônus de 300% em seu primeiro depósito de no mínimo R$50. Independentemente dos fatores que levam an uma vitória, você pode decir com muitas variações de blackjack para se divertir.

Impact of the menopause on women in the NHS

The Strategy Unit is excited to be launching its new in-depth report into how the menopause is affecting both individuals and the workforce as a whole, at online festival INSIGHT 2022.

Colleagues are invited to join the expert panel on Monday 28 November, 10-11.30pm, where they will be revealing some of the findings of the report, and exploring the issues it raises, including:

What are the characteristics of NHS women of menopausal age?

What is it like to experience the menopause as a NHS employee?

What does it cost the NHS as an employer?

The panel will include the project leads Abeda Mulla (Strategy Unit), Justine Wiltshire (Strategy Unit) and Lisa Cummins (Health Economics Unit), who will be joined by Jacqui McBurnie (Chair of the NHS England Menopause Network) and Sarah Sheppard (Director of People Services, NHS Midlands and Lancashire CSU). The session will be facilitated by Karen Bradley (Strategy Unit).

Find out more about the festival and book your free ticket: https://www.midlandsdecisionsupport.nhs.uk/training-events/insight-2022-day-6-losing-women/

Blog: Junior doctor Eilis gained valuable skills

Our Temporary Staffing Admin Bank is a great starting point for anyone looking for flexible, varied work within the NHS. We are proud to provide a supportive environment where recruits can learn and develop, and have opportunities to further their skills and career.

As part of future succession planning, the Personalised Healthcare Commissioning service recruited a number of young people through the Admin Bank. In this series of blogs, we meet some of them and hear their experiences.

Eilis Wardle, Administrative Assistant, Lancashire and South Cumbria IPA/CHC Team:

In spring 2021, I worked for Midlands and Lancashire CSU as Band 3 Administrative Assistant alongside my studies at medical school. Back in 2020, I had been part of the COVID-19 Taskforce – again whilst studying.

In the Continuing Healthcare (CHC) team, I was tasked with scheduling virtual CHC assessments during the COVID-19 recovery work in Lancashire and South Cumbria. This included communicating with care providers, social workers, nurse assessors, patients, and families, to find a mutually convenient time to complete the assessment.

The experience helped me to build on my communication and time management skills, which I need on a daily basis now I’m a junior doctor in the NHS. I also gained an understanding of the National CHC Framework and referral process, which has been helpful when working with older patients and those with complex health needs.

I am now in my second year as a junior doctor, having worked across a range of specialities. I really appreciate the valuable experience I gained during this placement, and the opportunity to contribute to the delivery of CHC assessments for patients in Lancashire and South Cumbria. Thanks to everyone I worked with.

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Бесплатные Онлайн-слоты 14 000 Слотов В Демоверсии

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Content

В 1940-х годах увидела неяркий первая электромеханическая разработка. Это не тарандг” “игровой автомат в определенном понимании этого терминов. Производитель Bally Entertainment, который работает а по сей следующее, выпустил пятикарточную покер-машину.

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Наиболее законными онлайн-казино являются те, которые лицензированы и регулируются респектабельными юрисдикциями. По требованиям надзорных органов, самые онлайн-казино обязаны условии честную игру, понадежнее платежи и отличную службу поддержки клиентов. Преимущество казино а играх сильно зависит от типа самой игры. Например, предполагаемая доходность может составлять всего 0, 3 %. А в популярной игре Кено комиссионных может составить до 25 %.

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Поэтому и решили облегчить вам поиск подходящего варианте. При помощи фильтров и инструментов сортировки на этой странице можно быстро найду интересующие вас видов игр и проблемы. Еще один весьма экзотичный вариант — это краш-игры, их часто встречаются и криптовалютных казино. Игроки ставят на то, когда виртуальный множитель «потерпит крушение» (с англ. crash — разбиваться, терпеть крушение). Игрок выиграет, когда” “проложит деньги до «крушения», при этом размер выигрыша будет зависимости от ставки. Такое сложное в другой игре — выбрать нужный момент дли вывода средств, этого получить максимальный выигрыш.

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В том же году компания Фея поставила автоматы в массовое производство. А 2001 году акции IGT появились же на третьей крупнейшими бирже США – S&P. 2003 недавнем IGT вышла в канадский рынок азартных игр, а и 2005 году – на российский и мексиканский.

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Вычисление преимущества казино или потенциальной доходности в рулетке — тривиальная практика, которая часто недоступна для других игр. Для составления правильных формул нужен комплексный комбинаторный выводы вместе с компьютерным моделированием. Наши высококвалифицированные реальные дилеры, блистающие в потрясающем HD и использующие новейшую технологию RFID, гарантируют восторг от игры с первого нажатия кнопки.

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а Играть На Мобильном?

Во-первых, слоты Вегас онлайн – так удобно, у вы уйдут секунды этого пересесть за и игровой автомат, тот всегда будет свободен для вас. Во-вторых, вы сможете играть в слоты Вегас столько, сколько вам только захочется. Регрессной при использовании бесплатных слотов Вегас вы не рискуете своими собственными средствами.

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Игроки могут оставлять твои отзывы о работы того или иные оператора. Эксперты последнего сайта по крупицам собирают информацию и интернете, предоставляя менее актуальные и честные данные о многочисленных операторах, предлагающих услуги на гемблинговом рынке. Только на самых ресурсах можно рассчитывали на гарантии выплат выигранных денег.

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Выигрыши присуждаются за разав и более символа подряд на выигрышной линии, начиная с крайнего левого барабана. Хотя в что слоте нет особенных бонусных функций вроде вайлдов, механика Megaways добавляет динамики а поддерживает азарт. В Fishin’ Frenzy Megaways удобно играть и ПК и мобильных устройствах. Gods of Olympus — продукт совместной разработки 1x2gaming и Iron Dog Studio с 5 барабанами, 3 рядами символов и 20 выигрышными линиями. Для начала используйте фильтр «Вид игры» же выберите интересующую вы категорию игр.

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Когда оператор не будет соблюдать свои обязательства перед клиентами, зарухом рискует лишиться лицензии, столкнуться с крупный штрафами. Получение разрешения — трудоемкая процедура, поэтому такие площадки стараются избегать конфликтов и уважают узкопартийные игроков. Самое важно достоинство, которым имеют официальные сайты казино — надежность. Если администрация ресурса позаботилась о получении разрешения, то” “так говорит о том, что она нацелена на долгую и честную работу. Эти компании дорожат клиентами, стараются заработать авторитет и доверие в сообществе игроков. Бесконтрольное увлечение азартными играми может быть опасный и привести нему зависимости!

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потому Задаваемые Вопросы об Бесплатных Слотах и Играх Казино

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Better reporting through an interactive dashboard

Our interactive visual dashboard helped the NHS Leadership Academy report more easily and more clearly engagement with their website and social media.

Background

The NHS Leadership Academy provides health and care leadership development through a large curriculum of programmes, resources, and activities to bring world-class learning and development to NHS people and partners.

The NHS Leadership Academy commissioned Midlands and Lancashire Commissioning Support Unit to create two Google Data Studio Dashboards, to support their monthly Google Analytics (GA).

Action

After receiving the brief and holding a meeting to discuss requirements and deadlines, the Digital team began creating the two dashboards. We used a range of charts, data sources and dimensions to hone in on particular data.

We encountered a few barriers – mainly associated with the way data studio pulls data in from social channels. But these were overcome by recommending using other tools alongside the dashboard such as Hootsuite or Sprout Social. This allowed for more detailed social media engagement reporting to be undertaken.

The dashboards pull in data direct from Google Analytics.

Impact

Interactive, easy-to-use, and visual dashboards were produced for the Leadership Academy’s website and social media channels. The fully customised design and range of charts enable smooth navigation of the data. The client can choose from a wide range of charts when exporting the data.

The dashboards will now improve their reporting and ease up some capacity at the end of each month.

Following the success of our Data Studio dashboards with the Leadership Academy, we are beginning to roll website dashboards out to other clients – they are already proving to be very popular, alleviating pressure from the communications teams and providing stakeholders with easy-to-access and flexible reporting.

“The NHS MLCSU Digital Team provided the NHS Leadership Academy Marketing team with invaluable insight and technical support to enhance website reporting.

“The dashboards created in Google Analytics have enabled our team to quickly monitor many metrics at once, to easily check key data, and see correlations between different reports in a few clicks.

“The team’s significant experience of managing and developing NHS organisations websites meant they had a good understanding of our requirements. The team was friendly, efficient, and really helpful.”

Chloe Newcombe-Rose, Online Content and Social Media Manager, NHS Leadership Academy

Quicker month-end process for an NHS trust

We reduced the month-end process by four days at an NHS trust and introduced new process to streamline payments and bring the month-end timetable forward.

Background

Blackpool Teaching Hospital Foundation Trust’s (BTHFT) finance team were investigating ways to align month-end reporting to the newly created Lancashire and South Cumbria Integrated Care System (ICS) reporting schedule.

The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) was approached to support their initial journey to reduce the time it took to close month-end from 8-9 to 4-5 working days, to align with ICS reporting intentions.

Our finance team, alongside with our Improvement Unit, worked closely with the BTHFT teams throughout March, April and May to assist and advise in the review of their month-end priorities.

Action

We worked as independent advisors and facilitators, alongside BTHFT’s Closedown Group, to identify and agree on amendments to the month-end process. The criteria was based on the potential release of capacity within the finance structure or current areas of concern within the finance function.

Following a thorough engagement process to understand the service change priorities, we delivered bespoke solutions built on our experience of public sector finance.

The areas of focus were:

– A detailed analysis of the month-end timetable with an agreed understanding of the feasibility of the suggested changes to deliver earlier achievement of income and non pay accruals

– A full review of low value, high volume recharges posted by BTHFT, to release capacity

– A focus on the large amount of time, about 175 hours per month, delivering Medical, Nursing and AHP agency accruals across the finance team; and

– The identification of future capacity and time savings and further priority areas.

To ensure that the positive changes delivered as part of this project were sustainable, the CSU promoted an open approach to issue identification and reflection through the delivery of several targeted workshops.  These were used to encourage internal ownership and engagement for future changes.

Impact

As a result of the work delivered as part of this project:

– BTHFT finance team month-end close was achieved on working day 5 in reporting months 1 and 2 of 2022/23

– A new process was developed for recharges to remove the posting of low value, high volume non-pay recharges. This has freed up about 11 hours every month of the team’s month-end time

– Since 175 hours per month were utilised on agency postings, it was a system priority to concentrate on agency accruals. We delivered a series of workshops and we suggested an automated process which was adopted by BTHFT over the subsequent months. Upon implementation, this would save an estimated 35 hours per month

– Several elements of the month-end timetable recording and accruing income and non pay areas were brought forward in time.

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Blog: The sky’s the limit for Lauren

Our Temporary Staffing Admin Bank is a great starting point for anyone looking for flexible, varied work within the NHS. We are proud to provide a supportive environment where recruits can learn and develop, and have opportunities to further their skills and career.

As part of future succession planning, the Personalised Healthcare Commissioning service recruited a number of young people through the Admin Bank. In this series of blogs, we meet some of them and hear their experiences.

Lauren Harkness, Administrative Assistant, Lancashire and South Cumbria Individual Patient Activity / Continuing Healthcare Team:

Back in 2020, I worked at a brewery as a Brewer and Operational Manager. Like many others, I was put on the furlough scheme at the start of the COVID-19 pandemic. I couldn’t just sit on my hands when I was seeing the amazing work being done by the NHS, so I decided to get involved.

The bank work available at the NHS Midlands and Lancashire CSU (MLCSU) seemed like the perfect fit for me, providing the flexibility to continue with my project management studies and to get some job security whilst the brewery work was on hold. After a successful interview, I started a six-month contract as a Band 3 Admin Assistant with the Continuing Healthcare COVID recovery project. After two months, I had the opportunity to apply for a Band 4 admin position within the project – which I secured.

It has been an incredible experience. My skills have developed exponentially and I’ve gained a much better understanding of how the NHS worked. This drove my decision to pursue a long-term career in the NHS.

As the end of my Band 4 contract approached, I was amazed at the number of opportunities available to me as an MLCSU employee. I joined NHS England’s oxygen COVID recovery project as a Band 5 Associate for three months, where I gained valuable experience working with NHS England and the Department of Health and Social Care as part of a major (and now award-winning) national project team.

I am now a Band 6 Project Manager working with my local NHS trust, and I couldn’t have done this without the opportunities and skills I gained with MLCSU in just seven months.

Digital Innovation Unit achieve international accreditation

We are very proud to announce that our Digital Innovation Unit (DIU) have successfully achieved International Standard Organisation (ISO) accreditation to the prestigious ISO 9001 and 27001 quality standards.

The ‘9001’ and the ‘27001’ quality standards focus on ‘Design’ and ‘Information Security Management’ respectively.

This success follows 18 months of hard work and planning culminating with an external in-depth assessment against the required ISO standards, which will be repeated annually from now on to maintain the ISO standards.

Debbie Bywater, Chief Information Officer, added: “This is an excellent achievement for the DIU and and the NHS Midlands and Lancashire CSU and an example of our commitment to ensuring quality and efficiency in all that we do.

“The new standards help us in enhancing our credibility with clients and their peace of mind that our services carry the ISO stamp of quality assurance.”

These accreditations are increasingly a pre-requisite to the delivery of digital services at NHS organisations. The DIU will now be able to provide support to even more customers and help them meet their digital transformation goals.

Well done to our colleagues in the Digital Innovation Unit.

SEO training improves new website performance

We created a range of bespoke materials to deliver SEO training to the Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) and Integrated Care System (ICS) Communications teams, which helped them improve the performance of their new websites.

Background

Following the launch of the websites for Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) and Integrated Care System (ICS), our team of digital experts were commissioned to provide Search Engine Optimisation (SEO) training to their Communications teams.

SEO training is crucial because it makes websites and content more visible, and results in more traffic to a website. Grounded in industry best practice, our training provides information on essential techniques, keywords, content optimisation, SEO plug-in tool Yoast and more.

Action

Our team of SEO experts created a range of bespoke materials to support the training for the ICB and ICS Communications teams. This included an interactive PowerPoint presentation.

The session was highly interactive, with a range of videos and activities to cement learning and understanding. We provided opportunities for participants to think actively about SEO, and apply the learning to their own website content.

After ensuring participants understood the difference between title tags, meta descriptions, slug URLs, and image alt tags, the training moved onto showing how to add these to pages on the website management platforms WordPress and Joomla. Our trainer also explained how Google uses these as hooks to rank websites.

Impact

A lot of positive feedback was received following the training. For example, participants found the training “easy to follow”, “helpful” and “straightforward.”

The session was highly interactive with a range of videos and activities to cement learning and understanding. We provided opportunities for participants to think actively about SEO and apply the learning to their own website content.

Since the training, many of the ICS and ICB webpages now use Yoast and the content is ranking highly on Google. This demonstrates that the team has been able to implement our tools and techniques to improve the performance of the website.

“I found the session really helpful and straightforward. It explained the key points of SEO, tips and recommendations to help our webpages score higher and key points on how to change writing styles to fit SEO, easy to follow and understand.”

Tanisha Steele, Digital Communications Officer, Staffordshire and Stoke-on-Trent ICB

Supporting elective care planning at every ICS in the country

We helped NHS England roll out a programme of planning support for the increase and improvement of elective care activity at every integrated care system (ICS) in the country.

Background

NHS England has set a national target to deliver 30% more elective activity by 2024/25 compared with pre-pandemic levels, as well as eliminating long wait times.

To achieve this, Integrated Care Systems (ICSs) needed to develop robust plans to ensure delivery of national targets, tailored to their region.

In a CSU collaborative programme, MLCSU worked with South, Central and West CSU (SCW) to provide national co-ordination support and evaluation for this programme.

Action

Our delivery team worked closely with the core national elective programme team, SCW and the NHS England regional teams to scope out the needs of the programme.

After liaising with ICS elective care leads, we identified their specific capability and capacity to deliver elective care plans, ensuring that consultancy packages were tailored to provide optimal support.

We provided risk management, assurance, planning support and budget monitoring throughout, as well as tracking customer satisfaction.

As the programme progressed, we shared best practice and learning among the organisations involved to maximise opportunities to standardise the approach across regions.

Impact

Our expert team of project and programme managers provided both strategic oversight and operational support to NHS England in this complex and extensive programme of elective care planning support.

Our dynamic delivery team enabled the programme to be rolled out at pace, meeting an ambitious national timetable.

Through robust programme management, proactively highlighting risks and identifying solutions, we were able to facilitate consultancy firms to deliver planning support services to every ICS in the country throughout February and March 2022. This was a vital step towards meeting NHS England’s elective recovery target.

“MLCSU were instrumental in helping us to set up and roll out the NHSE planning support programme at pace. They were highly effective in managing multiple stakeholder relationships including external consultancies, NHS systems, and NHSE regional and national teams.

“There was significant complexity and challenge in delivering aspects of the programme, and they not only recognised key risks and issues but proactively identified solutions and resolved issues.

“Without the support of MLCSU, we would not have successfully delivered the programme, and we were very satisfied with the service that was provided.”

Elective Recovery and Performance team at NHS England

Developing an accessible, user-friendly new website for Lincolnshire ICB

Designing and developing a new website for the Lincolnshire Integrated Care Board, we created an interactive platform for the public to get involved and find essential healthcare information.

Background

Lincolnshire Integrated Care Board (ICB) commissioned the collaborative  Campaigns, Creative and Digital (CCD) team from Midlands and Lancashire and Arden & GEM Commissioning Support Units (CSUs) to project manage the design and delivery of a new WordPress website in six months.

The new website needed to support the transition from Clinical Commissioning Group (CCG) to ICB, but with a fresher look and feel – incorporating their new branding. The ICB wanted the new website to follow a similar user layout, but they were conscious that it needed to act as a central hub of information to explain integrated care and show how the different parts of the health and care system fit together. Accessibility was also a priority for the new website.

Action

After reviewing the current website, our Digital team identified that performance was slow, and that website optimisation was required to improve user experience (UX), traffic flow and engagement. We worked closely with the ICB to clarify the user journey and agree on a site map. We made recommendations based on our expert knowledge of web builds, and we clarified the ICB’s objectives, which included:

-Using more images and video to engage and boost traffic

-Clear and prominent branding including new logo designs for the ICB rebrand

-Centring the design and layout around the new corporate vision and values

-Migrating content from the old site and optimising it for SEO with meta descriptions and tags

-Improving search functionality with easy content tagging that can be used across the whole site

-Integrating translation and accessibility tools within the site to improve access and engagement for those with language, literacy, and sensory impairment.

Weekly project meetings provided the opportunity to address any issues, and to advise on timescales and any risk factors which could impact delivery.

Our digital specialists followed a robust series of industry-standard quality checks, ensured the site met all accessibility compliance guidelines, and tested for mobile and desktop browser optimisation. This enabled any potential issues to be identified and resolved before launch.

Impact

We custom-built the new website on WordPress, as this provides a single dashboard and brings efficiencies for the ICB Communications team. We used Timber to build the templates within WordPress, as this gives better security and performance and allows our team to easily implement code changes – offering longer-term development flexibility.

Browsealoud was installed to support visually impaired users, and a WordPress accessibility tool helps the administrators check that header tags are suitable for screen readers.

To improve the user journey, we colour-themed each section, and added home page sliders, clickable call-to-action buttons and visual banners. Our developer improved the functionality of the search bar results to help users to find the page they need with fewer clicks.

After six months of dedicated support, the new interactive website was launched in July 2022. The site clearly signposts visitors to relevant content and provides a valuable resource.

Embedded video content and bold call-to-action buttons on the home page have created an interactive platform for the public to get involved and find essential healthcare information. Internal links to navigate traffic across the site has optimised the webpages.

There has been a clear improvement in how visitors engage with the new website. Visitor traffic rose from 4,000 to 5,100 following the launch of the new ICB website. The most popular pages are about walk-in vaccinations and GP consultations.

View the new website at www.lincolnshire.icb.nhs.uk

“The team were aware of our objectives and clearly identified how the new website needed to clearly signpost and better engage stakeholders and the general public as well as staff through the Intranet. The new website is fully accessible, and better optimised for organic searches, with easier to navigate information. The team are easy to work with, responsive to our requests and always work to find a solution that meets our needs. We are really pleased with our new website, it is easy to use, the training and materials were really helpful, the end product meets our expectations and ongoing support is fantastic.”

Stephanie Foster | Web and Social Media Officer | NHS Lincolnshire ICB

People Services team shortlisted for three awards

Our People Services team have been shortlisted for three awards. The HR Excellence Awards shine a light on best practice in HR and offer an unrivalled opportunity to celebrate our greatest asset: our people.

Spanning 19 categories, the awards celebrate HR professionals who, despite coming from organisations of all shapes and sizes, have a common goal: pushing the boundaries in people strategy.

This year, the NHS Midlands and Lancashire CSU have been shortlisted in three categories:

  • Best Recruitment and Workforce Planning Strategy – for our Talent One recruitment service
  • Best Health and Wellbeing Strategy – for our in house health and wellbeing approach
  • Best Flexible Working Strategy – for our strategy of agile working.

Each category has strong competition from big industry names, and to be shortlisted in itself has been a great achievement.

The awards ceremony will take place in London, 6 December 2022. Good luck to all finalists!

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Rtp Explained: What Does Indeed ‘return To Player’ Mean

Rtp Explained: What Does Indeed ‘return To Player’ Mean?

What Is Rtp? Understanding Casino Return In Order To Player Rates”

Las Vegas casinos are required to be able to have an RTP of 75% or perhaps greater. Some internet casinos have 97-99% RTP signboards prominently displayed in a particular cluster of slots but follow it on just one machine. You can always ask customer service even though, but they may rarely give a person a definitive answer in most instances. For example, think about a game along with” “the theoretical RTP associated with 97% played by a thousand players. In this scenario, the particular game is built to spend out winnings equal to 97% of the particular total amount wagered from the thousand gamers. Our team retains an eye on gambling dens offering blackjack together with different variations.

  • This is a new rather imprecise research, so there will be no specific length of time or exact amount of spins that I can demonstrate to be able to you.
  • It boosts confidence and helps make typically the most of the particular gambling budget.
  • The Tie bet, despite the large payout, holds the highest risk and lowest RTP.
  • However, employing games together with higher RTP proportions, players increase their particular chances of reaching more favourable outcomes and potentially increasing their winnings in the long term.
  • Commissions carry out not affect the editorial” “choices and the rankings we deliver to on-line sportsbooks and on line casino operators.

Pokie video games typically display their particular RTP percentages, permitting players to evaluate the potential returns. It’s important to note that RTP in slots is determined by the game’s design and style, such as the number associated with reels, pay ranges, symbols, and reward features. As a new result, individual gaming sessions can deviate significantly from typically the expected RTP.

Our Top Picks For Casinos In Terms Of Payout Percentages

The Link bet, despite the large payout, bears the highest risk and lowest RTP. Understanding the Residence Edge allows a person to estimate how much money that will not be returned to you over typically the long term of game play. While RTP offers an indication regarding the average amount of cash that can become won with time, it does not ensure specific results within individual gaming classes. In short, don’t put all of your respective resources on the particular back side of an assumptive RTP mostbet.

  • Even if it compensated out $95 , 000, 000 of that, it still makes the tidy profit of $5 million.
  • Figure 4 gives examples of some RTPs for a month coming from an online casino according to live have fun.
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  • Gambling and dependancy is actually a serious make a difference which should not become overlooked during on-line gaming.
  • Similarly, inside roulette, the existence of an individual zero (European roulette) or even a double absolutely no (American roulette) impacts the game’s RTP.

Each game need to state be it ‘Random’ or ‘Compensated’. By definition, the home advantage is the edge the casino offers over you being a player in the course of a specific game. Both residence edge and the RTP are connected in that one means the opposite of typically the other.

What Does (rtp) Return To Player Mean?

That being mentioned, though, whether an individual play a machine with a larger or lower RTP, it is the lot much easier to target on having enjoyment than how many a game will be paying out. Gambling without understanding RTP (Return-to-Player) is a new recipe for failing, especially with punters who invest lots of money into a game. Lower RTP game titles are enjoyable, but the higher RTP games could expand your gameplay. Every online casino that you simply find on this particular website is accredited and regulated.

  • So, for example , if a new game contains a home edge of 5%, that means for each and every $100 wagered, typically the casino will create an average profit of $5.
  • It does not really mean you’ll definitely succeed every round yet it will offer you a much better chance of winning in the long run.
  • Theoretically, a land on line casino can alter the RTP for the game at any time.
  • In addition in order to slot games, several casinos offer other games of possibility, which also impact the RTP from the casino.

For example, If a person head on over to 888casino and locate a slot together with an RTP of 95%, this indicates of which, theoretically, you might assume to win £95 back for every single £100 staked. However, that isn’t a promise that you could win that much money back any time playing. And we will explain why within the next section as we all require a more detailed look at just how it works.

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To delve deeper into the workings of RNG and its significance, check out our own RNG guide. The ability to program gameplay becomes crucial, transcending mere dependence on luck. Games like Roulette in addition to blackjack have noteworthy RTP differences. European Roulette typically functions a higher RTP due to the single zero. With its extra increase zero, American Different roulette games includes a slightly lower RTP. The number 100% – (House Edge) is referenced to as the particular game’s theoretical RTP mostbet app download.

  • It is a new percentage that indicates how much of your stake you’re most likely to win back over an endless amount of time.
  • For instance, if an online casino has a game together with a different RTP than advertised, it can get in trouble.
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  • So if, state, to get a variant associated with American Roulette this particular is 5. 25%, then RTP is usually 94. 75%.

Even together with a high RTP value, players can still experience intervals of losses and really should always gamble sensibly and within their own means. At great online casinos, an individual can expect the payout of about 97% to 98%. In addition to slot games, numerous casinos offer other games of chance, which also influence the RTP in the casino. In inclusion, almost all casinos have a very VIP program or offer bonus deals frequently. The added bonus programme results inside additional payouts, which often must be accounted for in the statistics.

How To Be Able To Choose The Right Online Slot

To keep things basic, the calculations are usually only done with a new single and” “splits bet in each case. For card-based games where you can create decisions – many of these as Blackjack, Carribbean Poker, Pai Gow Poker, and many more – an individual can actually increase your edge over the house. There are plenty associated with expert strategies about these games that tell you if you should hit/raise or once you should fold. What these actually carry out is give an individual the best chance of winning by stats. It does not mean you will definitely succeed every round but it will offer you a better chance of winning in the long term.

  • RTP and house edge are usually interconnected, representing the particular opposite sides regarding the same gold coin.
  • Betting upon the Banker inside baccarat offers the greatest win potential along with an RTP of around 98. 94%.
  • Each player’s individual RTP can vary greatly for the short term, which is why some individuals walk away with huge payouts while other folks might lose their stake.
  • Anyway, a sport with 97% RTP will play better as compared to one with 90% RTP in the long term.
  • The get, however , is that black jack is a skill based game, so typically the odds are somewhat affected by your current level of skill.

So if you gamble C$200 around the video game, you can anticipate to get back regarding C$190. And when you wager C$500, you can expect to get back again about C$475. All you have to do is take the sum of money paid away by the video game and divide it by the overall sum of money wagered on the game. You’d need to play thousands of hours of a sport to see precisely its RTP.

Blackjack

It is likewise important to think about that knowing RTP percentages decrease typically the likelihood of reckless gaming and allows the particular user to invest their money smartly. Gambling and dependancy is a serious make a difference which should not be overlooked during online gaming. As a new beginner, the best option is in order to find reviews associated with the games you are considering and gain a new perspective from more knowledgeable players. Combined using the review, you might also get the RTP percentage details. Theoretically,” “for instance , blackjack has the potential 99. 54% RTP. The capture, yet , is that blackjack is really a skill dependent game, so typically the odds are relatively affected by your current level of skill.

Therefore, the increased the RTP regarding a game, the particular lower the home edge, and bassesse versa. A game with a 95% RTP would have a 5% home edge, meaning that will, on average, typically the casino would retain 5% of typically the total wagers since profit in the particular” “long run. The term RTP stands for “Return to Player. ” Basically, RTP represents the typical amount regarding money that gamers can anticipate earning from a game depending on statistical computations. The payout percentage of other games, on the additional hand, is more hard to calculate since it depends on the strategy from the gamer. For example, right now there are various gambling bets that can be placed on craps (with typically the RTP starting from extremely high to extremely low), and presently there are plenty of abilities that can help one with black jack.

What Percentage Perform Slot Machines Typically Payout?

Which makes sense, since they’re virtually the giants on the internet casino sport developer world. RTP stands for return to be able to player, and it is the amount you may expect back coming from playing” “game titles at online gambling dens. The amount is usually calculated using typically the kind of a percentage based on the particular payout players acquire in the future. RTP percentages have primary implications on participant winnings in the long term.

  • Here’s what an individual should understand concerning understanding how these types of” “multipliers work.
  • Because whichever of these top online internet casinos you choose, you already know you’re in great hands.
  • RTP is more tangible inside table games and there is usually fewer things to consider.
  • If the Return-to-Player describes how a lot a player can expect to win above time, the house edge can be determined by subtracting the RTP.

The array of RTP percentages inside online casino game titles can vary tremendously depending on the type of video game and its specific characteristics. Games together with higher RTP values generally offer better probability of winning inside the long run compared to those along with lower RTP. By considering the RTP of a video game, players can create more informed choices about which video games to play and allocate their money accordingly. So without, further ado, let’s take a jump into how the particular return to player indicator works from online casinos, and why it’s so essential in the gambling world. Knowing which slot machines to choose will allow you to make a considerably more informed decision whenever choosing a slot machine. If you are centered in New Zealand, you might decide to use a site featuring an actual money casino NZ which means that a person need to get a good level of confidence inside winning.

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Since there’s not many strategy involved, your own best bet would be to look for bingo games that offer the highest RTP within that variety. This way, you do have a better shot at winning some money back as a person play. Slot games have RTPs that usually range through 92% to 97%, perhaps even up to be able to 99%. Higher RTP games are usually better for players due to the fact they give an individual a better possibility of winning over time. In saying this, online pokies often have hugely varying RTP proportions, ranging from about 92% to 98% and even higher. Players can make to help make slot RTP” “work with higher RTP ideals to jack up their chances associated with winning.

  • The better the RTP of a new slot, the much longer you can play with regard to your money.
  • And in case you’re still pondering that’s not sufficient profit, don’t worry, there are games using a lower RTP to make the casino enterprise profitable while preserving you in typically the winning range.
  • Some online sport providers offer as high as 98%, but there may never be the case of 100% RTP.
  • Before playing a new game, you may review the RTP percentage on the regulations page on most on the internet casinos.
  • It is most likely that either four or five winning tickets had been sold.

In the truth of online casinos, it is the variation between total sum of money gambled at the on-line casino and the sum returned to participants (the casino’s pay out rate). That is usually why for typically the most part in the event you see the RTP of a game like Mega Moolah, for example, at diverse online casinos, the odds will usually be exactly the same. Another value you’ll want to be conscious of when participating in Chumba Casino slots (which you could now play with 2 free sweeps tokens on us) will be the hit frequency percentage. Hit rate of recurrence appertains to the probability associated with a slot rewrite landing on a succeeding combination. For instance, if a slot machine game or online slot video game was only listed at a 10% hit frequency, next that means a person can expect pretty risky odds nine times out of ten. So… the simple question is usually, what online casino games offer you players the best RTP?

What Rtp Can A Person Expect When Enjoying Blackjack Online?

First of almost all, video slots” “are not as homogeneous since other types regarding casino games. Each video slot title can have an unique structure and methods it rewards the player and, therefore, an unique RTP. One slot machine can have an RTP of 96. 05%, the other 96. 70%, the next 93. 55%, and so on. If you’ve been around the on-line casino circuit or even have delved into the history regarding slots, you’ll know that the home edge is the casino’s advantage over the player.

  • It is also important when finding out the potential come back of your individual gamble.
  • Conversely, you may play slots together with low RTP (but highly volatile).
  • You can typically believe it is listed inside the game’s information section, under the paytable, so seem for it right now there.
  • In essence, the RTP for a certain game is calculated using a comprehensive mathematical model manufactured by game designers.
  • Both metrics help determine potential winnings and what the casino maintains.

At a great online casino, of which average number would certainly be considerably larger; usually, at very least 94%. If most likely specifically looking with regard to games using a large RTP, then unfortunately, you’ll simply have to consider a look in each game of which looks interesting and check it away yourself. Because on-line casinos do not really often enable you to search by this feature. Games with the higher RTP theoretically relinquish more to the players more than an extended length of gameplay. For example, a slot from Yeti Casino having an RTP of 97% should, over moment and also a significant quantity of spins, payback £97 for every £100 wagered. By opting for such game titles, you increase your prospect of more regular or more returns inside the long function.

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You are best recommended to begin gambling on simple slots to be able to get a very good grip on typically the game. So in case, say, you help to make 100 £1 bets on a video game with an RTP of 95%, a person could expect a new return of about £95 in profits. For instance, the banker bet in an 8-deck baccarat sport has a residence edge of 1. 06%, a gamer wager of 1. 24%, and a tie up of 14. 36%. So, to get a maximum RTP of 98. 94% in baccarat, you have to only play the particular banker bet. For example, a slot machine game game on PokerStars Casino with a good RTP of 98% theoretically gives the better return more than time compared to be able to a casino game with a good RTP of 92%. Choosing the former over the latter would mean the odds” “are slightly more within your favour.

  • House Edge pertains to the income of an online casino or gambling service.
  • You can’t estimate the home advantage from a single roll of the chop” “or perhaps hand of cards.
  • Even along with a high RTP value, players can still experience durations of losses and should always gamble reliably and within their particular means.
  • However, in the event the RTP is too small , consumers will switch companies – which is why the particular RTP has become a lot more and more good lately.

The stage is that the theoretical RTP ought to be pretty to the actual RTP for games that demand no strategy in addition to have a higher reach frequency. The even more rare a fantastic event (the lower the particular hit frequency), the more play is needed for these values to converge to be able to each other. There are only 9 winning tickets inside the lot of one million tickets, therefore somewhere between zero and 9 in the winning tickets is going to be sold. It is most likely that either four or five winning tickets had been sold. Slightly more unlikely is that either a few or 6 winning tickets were sold.

Slots With The Maximum Rtp

The only games the location where the RTP can end up being above 100% are certain video poker variations, such because Deuces Wild, which has an RTP of 100. 7%. Luck-based games for example video slots and roulette have a new hardcoded RTP that you can’t modify. No matter how you play and exactly what types of gambling bets you choose, the RTP stays the same.

  • Low variance slots have this title because there is little chance that you will drop your money rapidly.
  • So while the particular choice is eventually up to an individual, we recommend looking at the RTP of every casino game prior to this,.
  • Choosing the former more than the latter means the odds” “will be slightly more in your favour.
  • You can usually expect minimal differences in the RTP rates of any game as it will be an important selling point for some of the very most popular games in addition to operators want to attract customers.

Most standard games therefore have the long-term RTP of 95 % in order to 97 %. This means that the” “on line casino game returns 95% to 97% of each and every euro taken inside by the game in order to the players. Of course, RTP will be a theoretical concept meant to help you in picking a casino video game you have a new good potential for winning.

Results From Rtp

Once they sign up and satisfy all requirements, you can earn a $100 casino bonus and a 100% deposit match of up to $3, 500. As for the particular second one, you need to understand what you are usually getting into whenever deciding to try a game. If you want to be able to take more hazards, a game title with a lower RTP will be fine. If about to catch in that category of players, research for one with an RTP range associated with 96% or above. You don’t need to be subject to a scam, therefore make sure the online on line casino has all of the permits in” “location.

  • You don’t have to use just about all of the on the internet casino excitement to yourself.
  • Most of the time, the games are stored on typically the game provider’s machines, so the online casino doesn’t even possess use of them.
  • RTP is a theoretical statistical calculation of takes up that determine the particular value that will be returned in order to players.
  • Casinos achieve the house advantage with the addition associated with one or more ‘green’ zero pouches — a single zero in European roulette along with a double zero in United states roulette.” “[newline]Divide the full sum returned to players with the total sum wagered.

Variance in addition to return-to-player percentages will be closely related but very different in the way that it affects the ball player experience. A lower variance means lesser chances but higher winning benefit, while an increased variance game gives” “typically the illusion that a person are winning a lot. In typically the long-term, it takes up the amount of money that gamers win back within the long phrase. RTP is calculated from the total amount returned to participants as winnings split by all players’ total bets.

Return To Player: What Is Rtp In Slot Machines, Casino Games Plus Online Bingo?

RTP is usually more tangible inside table games as there are usually fewer things to consider. The RTP can be viewed the inverse of your home edge, and this is a fixed value across games. Of course, in credit card games there are several aspects that can alter RTP. Take Baccarat, where there may possibly be factors like as the quantity of decks, aspect bets, rules upon doubling, rules upon splitting, rules about when the supplier surrender, and thus on. These will certainly all replace the house edge and so alter the RTP portion of each sport. It depends upon paylines or ways to win, the magnitude of15356 payouts are, and naturally all the more features that may guide to additional earnings.

Although that does not ensure a win, a higher RTP offers players a better benefit to get back a portion regarding the bets they made as time passes. Each slot game provides a theoretical RTP that is typically the expected” “come back to player percentage prior to the actual RTP will be calculated. The movements allows for a good allowable tolerance over or below the theoretical RTP. Once there is a significant amount of plays by gamers, it’s expected of which the actual RTP will be near to the assumptive percentage. Generally, the particular RTP for slot machine game games in on-line casinos ranges coming from 92% to 98%, while table games are around 99%. It’s a way to show what percentage of money put into a game title gets paid back again to players over time.

🎰 What Will Rtp Indicate In Casino Terms, In Addition To How Does This Affect My Gameplay?

Anyway, a sport with 97% RTP may play better as compared to one with 90% RTP in the long term. Most of the period, the games will be stored on typically the game provider’s web servers, so the casinos doesn’t even possess use of them. When calculating the game’s RTP, there are lots of aspects game developers get into account. In the case of a slot video game, the provider will consider the quantity” “regarding paylines as properly as the additional bonuses included in the game. So, in case a slot has bonus spins, outrageous symbols, multipliers, and jackpots, calculating the particular RTP value can be extremely complex, as they all affect the payout rate. Las Vegas is probably the nearly all popular vacation destinations in the globe.

  • Whereas, when that” “video game has high volatility then there may be an allowable tolerance of some thing like 4. 75 above or under the RTP.
  • RTP is the abbreviation regarding Return to Player Percentage which are usually the rewards a player can expect in order to win from online slots.
  • We also advise checking the RTP of any video game before you begin playing.
  • That being said, even if you’re not yet particularly adept at the sport, the RTP regarding online blackjack is rarely below 95%.

After this specific sum is carried out, the resulting percentage received signifies the average amount of money players can get to win again over time from the particular game. Understanding slot machine RTP (commonly identified as pokies) is important for online on line casino players as this allows those to help to make informed decisions any time choosing which game titles to play. There is not a definitive response to this query, as RTP values can vary widely between different sorts of casino video games and even among different versions of the identical game.

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This can help to extend gameplay, allowing players to get more enjoyment plus time off their allotted budget. RTP, furthermore known as slot machine games odds, is a percentage value symbolizing the total quantity of bets compensated back to gamers over an offered amount of moment. RTP is generally utilized to decide upon the payback to be able to players over a period of time, frequently every 30 days of a season.

  • So, to find the best RTP online casino online, check out the casino RTP list on this” “page.
  • Some participants win a lot, others lose the lot – and the RTP simply gives the regular of most these activities.
  • Lower-variance slots have considerably more frequent but smaller wins, while higher-variance games generally have greater, less frequent hits.
  • For instance, along with an RTP of 96%, in the event you gamble $1, you may acquire $0. 96 back.
  • If you are completely looking for the on the internet slot machines with the highest RTP, all of us recommend checking away these online slots at these best online casinos.

In addition to well above average odds, they will be all safe, protected, and completely legit, with excellent games and great welcome bonuses to match up. You can’t calculate the home advantage through a single spin of the dice” “or perhaps hand of cards. Simply put, the home edge is the particular percentage the house (casino) is certain to gain through each bet. Oddsseeker. com and just about all content herein is intended for followers 21 and old. There is no way to increase your likelihood of winning, in addition to no content upon this website suggests otherwise. Oddsseeker. apresentando publishes news, information, and reviews about legal online gambling for entertainment purposes only and allows no liability with regard to gambling choices plus bets that a person make.

Casino Game Gear Rentals, Plan The Casino Party, Host A Casino Night Fundraiser Or Company Casino Even

Casino Game Gear Rentals, Plan The Casino Party, Host A Casino Night Fundraiser Or Company Casino Event

The 1 Best Casinos In Or Near Helsinki”

The casino encounter includes entertainment within an unique setting. The Casino Helsinki Sports Bar offers worldwide sporting experiences every single day, with a broad variety of stations, a giant screen, and 30 sports activities screens. You may also book your own own booth for you and your close friends, where one can” “pick the channel you need. The poker area at Casino Helsinki offers cash games every day. To participate in the cash games, a person can use Veikkaus application or enrol immediately with the poker space supervisor.

  • Building a highly qualified team that understands you…
  • The best online casinos will offer a fantastic assortment of promotions in addition to bonuses.
  • It maintains each of the interface elements, key settings, plus selection of entertainments.
  • They could really liven up a corporate event and promote some healthy competition and team development.
  • With all of us, you will find the same slot machine machine games as at the world’s biggest casinos, like the latest novelty themes.
  • Suggestions include placing a single $100 bill among the other $1 bills or incorporating paper gift certificates to local hot-spots.

The rental options may include black jack, poker, roulette, craps, and also slot devices. Casino-themed parties are an excellent approach to events of almost all types. They could really liven up the corporate event plus promote some healthy competition and team building. Casino parties may also be popular for bachelorette and bachelor parties—it’s much cheaper to be able to bring Vegas to you!

Roulette Wheels

The rent associated with online casino slots is definitely an useful alternative for both newbie projects and well-known brands that are looking in order to expand their video gaming portfolios. Full Home Casino Events client’s are responsible regarding researching and complying with all local, express, and federal regulations regarding fundraiser, corporate, or private online casino parties. During holiday months, like January, the pricing of each table changes. Contact your neighborhood, ARA-affiliated, rental store for information on available rental products plus services to fulfill your own casino game requires. To locate typically the rental store local you, utilize the Hire Store Quick Locator above. Whether you are a player, buying good time and enjoyable experiences, whether you value gourmet and/or simply curious, you are always welcome to the online casino mostbet bd.

The skilful team from 2WinPower is ready in order to disclose you every thing about the honest game manufacturers and select the proper versions to include in your online casino. Operators who choose to rent an on-line casino will be able to start their iGaming project in just 24 hrs. We have the effect of establishing up the regular operation of a new site and conserve entrepreneurs from unwanted paperwork. Easily added to your table, you can bring Vegas to your own guests with this particular enjoyment and exciting cards game. We would like to protect the particular joy of video gaming, and that will be why you will automatically become a member of typically the Know Your Sport programme, once you appear to play along with us. On your own first visit, an individual will get a Casino ID credit card, an important to our own world of games.

Casino Gaming Wheel: Top & Anchor

A dedicated Ace High team” “fellow member will guide an individual through the entire casino event planning process. Every event detail will get covered and we promise to get a flawless casino occasion planning experience. This is why we all are willing to perform everything we are able to to provide the ideal in order to you and your guests. Your guests will experience a true and authentic casino within your home or party venue. Casino parties and online casino events are thrilling and an incredibly popular theme regarding private parties, online casino night fundraisers, company events, and charitable organisation functions. If an individual select one of the package options for your own party instead of renting tables in the stand alone rate, you will decrease your costs significantly mostbet app download.

  • Finding the best expertise to create the particular right experience that fits your event’s unique needs while staying on budget.
  • The lessor is applicable smooth animation, scaling, touchscreen technology, and other elements of which make visiting a mobile site since comfortable as feasible.
  • Since many of them possess their own peculiarities, it may be time-consuming to study just about all of them according to” “your preferences.
  • This is why all of us are ready to do everything we can to be able to provide the best in order to you and your guests.

We understand that table quality is main priority when choosing a casino rental company. This is the reason why Ace High provides only the best quality gaming tables at most competitive value! Our authentic Vegas-quality gaming tables are made of solid wood with an ebony finish.

Corporate Events

Hire the best gathering Casino entertainment solutions in Baltimore, Baltimore, Washington D. D., & Northern Va. We are experts in all of your casino party planning and casino rental requirements. We provide online casino night parties in addition to tent rentals for parties that will be elegant and can be especially themed. Your online casino party options may depend on typically the company you choose to employ. Many” “full-service casino party firms offer both gear and professional sellers.

  • The rental choices may include blackjack, poker, roulette, craps, and also slot devices.
  • I’ve individuals all of them on some significant events (+500 guests) and they have got always done a new wonderful job.
  • Speak to some Fun Expert right now to discuss the bespoke upgrade alternatives available from added equipment, branding, awards, props and theming.
  • In the few years in order to come, gamers will certainly only have the ability to gain access to approved websites.
  • To locate the particular rental store closest you, make use of the Local rental Store Quick Locator above.

Our Craps table is weighty duty and comes with padded walls as well as locking legs. Dice and betting snacks are not incorporated, but betting chips may also be rented from Parties To Go. Navigate backward in order to interact with the particular calendar and choose to start a date. Press the particular question mark key to get the keyboard shortcuts with regard to changing dates. Navigate toward interact with the calendar in addition to select a day. Even if you were not trying to play, our services and atmosphere are open to a person from the dining places” “in addition to intimate live performances to sports grandstands.

Hold’em Poker Table: Caesar Series

Each table has padded armrests with premium black or red felt. Our fundraisers have verified to be extremely successful in elevating donations. The personnel at Arkansas On line casino Events will help you each and every stage to ensure greatest success. We can assist you with marketing ideas, ticket pricing as well as table sponsorship’s, venues and times, raffles and even supply sample letters regarding contributions.

  • An inflatable or regular framed cash cube can provide several hours of fun with regard to all involved.
  • We are happy to meet with you in the location regarding your choice to be able to discuss the logistics of your celebration and ensure the memorable experience regarding everyone involved.
  • Before you be satisfied with an on-line casino, you need to ensure that it is usually police registered and controlled.
  • Despite the strain, Finland’s online casinos and gambling constructions remain unaltered.
  • Navigate backward to interact with the calendar and pick a date.

Let us all plan an celebration of your dreams exactly where you get to dive into the world of the casino while enjoying great food and beverages. U. T. Casino Event Organizers is a full-service casino event service provider using a national reputation for superb high quality and customer support. We are happy to meet with you in the location associated with your choice in order to discuss the logistics of your occasion and ensure a new memorable experience with regard to everyone involved. All our games are usually offered in a good area subject in order to registration by the two Finnish and overseas casino guests. The Casino ID credit card, together with our professional staff, will assure you a responsible on line casino experience. The ideal online casinos may offer a fantastic variety of promotions and bonuses.

The 1 Greatest Casinos In Or Perhaps Near Helsinki

Contact our business office for assistance within making a casino evening party event of which your guests will never forget. We provide Las Sin city entertainment delivered best to your home. ARS Events provides a wide variety of after-prom party” “enjoyment, games and suggestions that will assist you keep teens safe on Prom night with fun activities.

  • It is also worthwhile to note that will Finland is labeled since the fifth largest gambling nation around the world.
  • Our authentic Vegas-quality gaming tables are made of wooden together with an ebony finish.
  • A devoted Ace High group” “fellow member will guide a person about the same casino celebration planning process.
  • Look zero further than Two times Down Entertainment, based in North Hat.
  • We would like you to definitely have the successful event and after looking by means of our site, you will notice that it is FULLLL of advice, because all of us really want to see you happy.

Our goal would be to make sure of which everybody can retain gaming on the joyful side by setting personal restrictions on their gaming. The best casino enables for secure and fast transactions. Be sure to evaluate the payment strategies in place and find sites that support varying repayment methods. One associated with the most popular ways of payment in online Casinos in Finland is Siru Mobile. That permits for instant debris using your cellular phone. You can likewise consider one that will accepts bank transfer, prepaid” “cards, and major free e cards.

More About The Slots Games

It is usually rather difficult in order to organise the functioning of the customer assistance department independently. Therefore, it is better to order professional technical maintenance through Rosloto. Communication may be organised through an interactive talk or a phone centre.

  • Many” “full-service casino party businesses offer both products and professional dealers.
  • Be sure to examine the payment strategies in place in addition to find sites that support varying transaction methods.
  • Using data from quotations sent through GigSalad, we’ve gathered typical nationwide pricing regarding hiring Casino Gathering Rentals.
  • Matters surrounding legislation within Finland are being worked well on so that will people who love in order to play free online games can only access trusted, licensed and certified websites.
  • Even if an individual were not trying to play, our services and atmosphere are open to a person from the restaurants” “in addition to intimate live gigs all the way to sports grandstands.
  • Then examine out reviews from past clients which means you know what that will be prefer to work with these people.

I’ve caused these people on some main events (+500 guests) and they have got always done a wonderful job. They definitely went over and above the call associated with duty on this specific last party that will we worked collectively on. Whether you are a gamer, buying good time and enjoyable encounters or just interested in us, you are always welcome to Online casino Helsinki. We ask you to observe how Our Approach is different from other Local rental companies.

More Casino Fun

The uses behind the cash cube can be varied, that an even even more exciting atmosphere. Suggestions include placing a solitary $100 bill between the other $1 bills or including paper gift certificates to local hot spots. You can likewise associated with activity simply because challenging as a person wish by setting amusing rules.

  • The Casino ID card, together with our professional staff, will assure a responsible casino experience.
  • Of course, one regarding the apparent factors to resort to be able to casino games leases is actually a cheaper cost, but there are usually some vivid drawbacks as well.
  • The fetta games are inside your hand’s get to immediately after you have got your Veikkaus Cards.
  • Let’s break that down what exactly you need for your gambling establishment.
  • There you” “will find all the info you need to calculate the rough quantity of tables for your guests.

We offer unique gaming experiences and tools of which help you handle your gaming much better. We are furthermore there for you when a person wish to limit your gaming. Therefore, all of our games are susceptible to authentication, which will be an indispensable part of a responsible on line casino experience. At Casino Helsinki you may find over 3 hundred slot machines plus 20 game furniture.

Casino Night (

Some lovers have even elected to add on line casino tables to their own wedding reception. Casino games would become a hit in a party, prom, or even college event. You let people wager with fake money, or put real money on the line plus use your on line casino night as a new fundraiser.

  • That enables for instant deposits using your mobile phone.
  • It is significantly simpler and cheaper in order to rent a web based on line casino from Rosloto.
  • That gives you the chance to check out new games without needing to risk thus much money.
  • Whether a person are a gamer, looking for a good time and enjoyable experiences, whether you enjoy gourmet and/or just curious, you are still pleasant to the on line casino.
  • An businessperson receives a superior quality gambling solution with a stylish design and style and simple navigation.

As with typically the individual rates of each table, our own discount package prices varies by area. Gambling business will be currently experiencing a rapid increase in popularity. With the highly developed modern society, it became convenient to offer amusement services to the particular audience. Mobile technologies made it achievable to play everybody’s favourite games directly on their devices. With this within mind, more in addition to more businessmen will be looking forward to launching their own online casinos.

Struggling To Make Your Current Mind Up? The Fun Experts Can Assist!

Our US based team of Account Specialists are right here to help each step of typically the way. Since 1997, we’ve connected coordinators with vendors with regard to over half a million activities. We show the almost all interesting NHL matches and player interviews on the screens of the Casino Helsinki Sports Bar. With us, you could watch the video games every weekend in prime time.

  • The Casino Helsinki Sports activities Bar offers worldwide sporting experiences every single day, with a large variety of programs, a giant display, and 30 sports activities screens.
  • Full House Casino Events is Texas’ Signature casino party rentals company serving Houston, Dallas, and all surrounding cities.
  • And this can make you feel comfortable before having to pay or” “enjoying on a site.
  • We provide other entertainment for example DJ’s, Bands, Solo Musicians, Karaoke, Trivia Nights, Vid…”

An entrepreneur receives a high-quality gambling solution together with a stylish style and simple routing. The document identifies the rights and obligations of” “each and every party, as well as the repayment schedule. As the rule, payments need to be made every month or quarter. Using data from estimates sent through GigSalad, we’ve gathered average nationwide pricing with regard to hiring Casino Celebration Rentals. Save music artists, entertainers, speakers, and services, and they’ll appear here. APJ Events/Productions provides On line casino Tables and Sellers using Accessories regarding your next Private Event/Fundraiser.

Slots Games

Staffed together with Professional Entertaining Retailers to make your party Fun in addition to Memorable. It’s free of charge to book and make secure online payments through The Party. Once the arranging for your selected On line casino Games is confirmed, it’s covered simply by our Booking Guarantee.

  • ARS Activities will brand and customize your casino event to your brand.
  • Casino parties may also be popular for bachelorette and bachelor parties—it’s much cheaper in order to bring Las Vegas to you!
  • APJ Events/Productions provides Online casino Tables and Sellers system Accessories regarding your next Personal Event/Fundraiser.
  • The personnel at Arkansas On line casino Events will assist you each and every action to ensure maximum success.
  • During vacation months, like December, the pricing regarding each table modifications.
  • The uses behind a cash cube may be varied, produce an even more exciting atmosphere.

You also want in order to ensure that the particular casino has continuing offers and has a loyalty program in order that you enjoy rewards from time to time. Before you be satisfied with an on-line casino, you should guarantee that it will be police registered and regulated. Playing at a new licensed and regulated site means that typically the online casino will be legit and their operations well acknowledged by the state. A modern iGaming project is not necessarily just an internet platform with slots. To compete with other successful sites, your company has to end up being constantly improved.

Plan, Publication, Celebrate—with Confidence

We want you to definitely have the successful event plus after looking via our site, you will see that it is FULLLL of recommendation, because we all really want to see an individual happy. Speak to a Fun Expert nowadays to discuss typically the bespoke upgrade choices available from extra equipment, branding, awards, props and theming. As we possess all our personal equipment we possess the flexibleness to adapt equipment to match your requirements. If you wish in order to feel extra free from danger, you are welcome to ask 2WinPower for help, and we will consult, choose, and” “set up all the required software for a person without any hazards from your part. A smart answer here is to connect additional options that will will make your current portal interesting in addition to profitable. A businessman needs to select a new title for the future gambling brand, simply because well as think about the website name and hosting.

  • Our casino table pricing is broken down simply by geographic location.
  • To compete with some other successful sites, your company has to be constantly improved.
  • We will select the best entertainment content, connect reliable economic aggregators, and create a powerful backend with high performance for your project.
  • With this inside mind, more in addition to more businessmen are looking forward in order to launching their very own online casinos.
  • It’s no cost to book create secure online payments through The Gathering.

We will select the best entertainment content, connect reliable monetary aggregators, and create a powerful after sales with high performance for your project. Our Do It Yourself events plus many of our novelties are available national. If you offer Casino Party Leases services in typically the United States or even Canada, get considerably more gigs by becoming a member of GigSalad. Look zero further than Increase Down Entertainment, centered in North Jersey. Serving the tri-state area of New Jersey, Nyc, in addition to Pennsylvania for more than 12-15 years, we are your one-sto… With confirmed reviews and hundreds and hundreds of ratings, it’s easy to book the perfect Casino Games regarding all types of events—no matter what size or small.

Planning Your On Line Casino Event

Baltimore On line casino Parties supplies the places best casino party rentals and retailers for private and corporate events and fundraisers. ARS Occasions will brand and customize your casino event to your current brand. We can help you transform your venue that an authentic casino experience at your own party with one of these online casino table rentals inside MD, DC, VIRTUAL ASSISTANT.

We offer a wide selection of international slots and table games, friendly poker, entertainment events and restaurant services. Call Party Vision to book your next Las Vegas style online casino party, casino equipment rental today. We are the largest and best casino rental company within New England. Of course, one of the apparent factors to resort in order to casino games rentals is a cheaper cost, but there are some vivid disadvantages as well. Let’s analyze all typically the possible outcomes a person may get coming from renting an on-line casino game.

Lotto Games

We also offer you game schools where you can understand everything about the likelihood of Roulette, typically the outs of Poker, or simply just the rules of Blackjack. Good to know that guys from 2WinPower can afford not just to help you buy casino games, considering your objectives but also describe you the necessity of renting of which software in some instances. Local specialists will make sure a person receive the nearly all reliable product from the end in support of win from that. The mobile system looks the same as the pc site.

  • We want to protect typically the joy of video gaming, and that is usually why you will certainly automatically become the member of the Know Your Sport programme, whenever you come to play together with us.
  • Local specialists will make sure an individual receive the almost all reliable product from the end and later win from it.
  • We’ve got ten enjoyment delete word a Fresh Year’s Eve gathering that people will be talking about just about all year long.
  • Our fundraisers have verified to be amazingly successful in raising donations.

Each area offers a wide selection of casino game tables in order to choose from. The individual” “costs of each desk is exclusive to their location. By picking a location coming from the options above you will find the price of your current desired game table.

Games – An Assortment Of Responsible Excitement

As you can see, it is just up in order to you whether to buy or rent your online casino games. You can always add more table rentals to any associated with our casino concept packages to get an excellent night to remember. Our casino table prices is divided simply by geographic location.

  • Playing at a new licensed and controlled site implies that typically the online casino is legit and their operations well recognized by the state.
  • The independent development of an iGaming project from the beginning is a new long and expensive procedure.
  • Once you locate a casino hire company you need to seek the services of, get all the details in writing with the contract or arranging agreement.

Let’s break that down what precisely you need for your own gambling establishment. Our team is not really responsible for those activities of persons making use of similar contact details. The lessor can be applied smooth animation, scaling, touchscreen technology, in addition to other elements of which make visiting a new mobile site since comfortable as feasible. The creation regarding a mobile edition of a web site contributes to typically the growth in the iGaming brand.

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When the COVID-19 pandemic hit, healthcare systems faced unprecedented challenges and reductions in some routine services.

Lancashire and South Cumbria needed a system that would help them remain focused on safe and effective care despite the ongoing pressures of the pandemic.

Action

Midlands and Lancashire Commissioning Support Unit (MLCSU) developed a Safety Siren to monitor quality at the system level.

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The Gta 5 Diamond Casino Heist Gta A Few Guid

The Gta 5 Diamond Casino Heist Gta A Few Guide

“gta Online Diamond Casino Heist Walkthrough

One requires you to go to a pool party and get the from typically the croupier. The other requires one to obtain it off regarding an inactive valet’s physique as you impersonate a new Coroner officer. From there, you’ll become able to perform Setup missions coming from the drawing panel. A cutscene will play which leads to your base regarding operations.

You could also go to typically the prison without hijacking the prison tour bus, which makes this ten times more quickly but is also ten times hazardous. Since you won’t have a jail guard disguise, once you enter the jail premises, you will get wanted degree and the jail guards are alerted. If you might have an Oppressor Mark II, it will make carrying out this” “technique a tad little bit easier. However, typically the snipers are still quite strong and could destroy you either way.

Gta Five Diamond Casino Heist: Complete Guide

First, Ancestor will phone you to typically the casino and request you to discover the rental car in the on line casino parking lot. Once you’ve identified the car, drive it to the places he will teach you to drive to be able to.” “[newline]First, you will require to take the particular car to typically the reservoir to say goodbye to it. Then middle of the way to the place, Ancestor will ask you to take the car for the abandoned lot and burn typically the car.

Before all of us start out with the heist, let’s go more than the final preparation board. Once Lester has identified the point, you need in order to find and search for the keycard on them. When you’ve grabbed several games for your own business, another landscape plays which starts off the heist planning. Billed as the most safe building in the whole city of Los Santos, the Gemstone Casino won’t be an easy risk-free to crack mostbet.

How Long Do I Have To Wait To Run Another Diamond Casino Heist?

Wait for the camera to seem towards the left aspect and then rapidly go down in addition to take cover by simply the wall. Then wait for the camera to appear to the proper side and quickly rush down. This is how a person can effectively stay away from the cameras and never have to take them out. Once you achieve the double door, do not undergo it immediately because there is a guard through the door. As you can see in the picture above, notice presently there is a shield through the doorway on the minimap.

  • This is how an individual can effectively avoid the cameras without needing to take them out.
  • It has six mandatory create tasks, and seven optionally available with a more locked objective.
  • This general prep work is also essential for The Huge Con approach.
  • This prep quest is an obligatory silent and sly approach specific preparation mission.
  • The great news is that you can set it all up upon your own, as an individual won’t need to know more than one player in order to complete it.

Afterwards, the player may continue in order to scope out a new total of six access points, or perhaps leave the location to give up. This quest may be replayed to scope any undocumented features or access points in typically the future. First, we are going to take an appearance at all typically the important prep tasks you need to do, besides the particular mandatory prep missions of course. Note that you may do all these heist prep quests either solo or perhaps together with your friends.

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You’ll also have got to invest considerably more in your hackers, given the strategy depends on hacking. These reasons lead most newcomers to decide on one of the other two procedures. The Diamond Casino Heist is a brand-new heist job within GTA Online‘s Diamond Casino and Holiday resort update.

  • To buy the Eight-Bit arcade and fully improve it costs $3, 901, 000 — so an more $1, 371, 000.
  • If you do typically the big con the particular right way you dont need safety passes since there is literally only 1 fingerprint door a person have to move.
  • Getting the vault keycards from prison is usually the easiest preparation mission.
  • After you’ve parked your van, it’s best to just take the elevator all the way right down to the particular basement.
  • If cops commence chasing you,  use the underground sewer system to acquire away from them plus stay undetected.
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While the Rhyme Station allows you to travel drones within the metropolis, as well since access the Nano Drone in Freemode. The diamonds are incredibly lucrative in case you get in existence with them as the biggest payout is over $3 million – although, that will have to be split with your team. If you’ve selected typically the Gruppe Sechs access disguise and The Big Con method, then you will start typically the heist mission within an armored truck, which is the very best for this objective. After you have chosen your staff, you can commence the six major” “prepare missions. In all these missions, you require to select which usually item types an individual wish to steal mostbet108.com/app.

The Fastest Plus Easiest Way In Order To Complete The Diamond Casino Heist

When you are choosing a gunman, there’s no want to spend any moment deciding which a single to pick as this specific heist is the silent and sneaky approach! You shouldn’t anticipate a lot regarding altercations and combat situations. Therefore, all of us recommend you select KARL ABOLAJI that takes only 5% from the ultimate cut. When you are choosing the system loadout, we advise the device Pistol loadout. It is the best of the particular two loadouts presented by Karl Abolaji for this method. Through optional installation missions you may plan multiple disguises to truly get you out associated with the casino as well.

To start the entire heist mission, you have to buy a new retro arcade. But to do of which, you have to register as a CEO or become a Motorbike Club President. The Diamond Casino Heist is one of the biggest in GTA Online, therefore it requires meticulous planning if you want to get the particular highest payouts. The great news is that you can set that all up upon your personal, as a person won’t need to know more compared with how one player to be able to complete it.

Unlocking Yung Ancestor & Full Diamond Casino Heist Walkthrough

Do not take that road and set your personal way point to be able to the purchaser. Support team members have diverse choices and percent cuts they receive at the finish of the heist, so players have to select what suits better. Lester takes a small cut, then your support crew just about all take their allocated piece. There are then optional bonuses you can buy to aid take the heat off of an individual in the escape. Better support deck hands come at a higher cut associated with the total take, and some” “are definitely more worth it as opposed to the way others. For occasion, you’ll definitely need as much time inside the vault as possible, so selecting an expert hacker is an easy option.

  • You will automatically equip the coroner officer’s clothes.
  • Any damage you take within the casino also reduces your consider while you drop information.
  • Wait for the guard to turn around and next move through the doors (a set regarding two doors) plus to the left use the keycard in order to access the steps.
  • These quests enables you to gather info and equipment to be able to aid within the heist.

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To start planning the Diamond On line casino Heist you have to buy a Retro Game property. All of this means that you’ll probably be playing by means of the Diamond Casino Heist many times, picking different paths to be able to success on each of your function. You’re working together with typically the Cheng crime family members to get one over on the particular current owners regarding the Diamond Casino, the Duggans.

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  • Some people may have digital cameras and they apparently captured some regarding Ancestor’s “activities” which often he doesn’t need anyone to know in relation to.
  • Be careful of this specific camera and get it out too if you obtain the chance.

But if you’re not planning upon being detected, then top tier guns are a waste. Once you’ve selected your approach, it’s time for you to get to work. Remember a person can pay in order to skip certain tasks, but not almost all of them. Your optional missions are identical as the Large Con, except that will you can locate an infiltration match and steal an EMP instead associated with getting an get out of disguise.

Emp Device

So, make sure you put together yourself to get both of them out silently. You can easily remove the guards quietly with a pistol whip. Just be quick about it or even else the rest of them will be alerted. After” “getting the guard, carry on down the hall and use your current keycard within the doorway to your instant right. Wait for that guard to turn around and after that move through opportunities (a set of two doors) plus to the remaining use the keycard in order in order to access the stairs.

  • It’s like the Doomsday Heist, while you once again have got to complete Prepare Jobs to reach the particular Finale.
  • “You may unlock Yung Antecedent, ascendant, ascendent, by going to the casino in addition to taking the elevator to the roofing terrace.
  • For example, this is illegal inside countries like Tiongkok, Russia, and Perú.
  • If you could have an Oppressor Mark II, it will make carrying out this” “technique a tad  little easier.

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  • You can do typically the DUGGAN SHIPMENT objective that will create the guards inside the finale significantly weaker.
  • After you’ve acquired the particular keycards, you may leave the jail not much different from the way you arrived in, using the bus, and you will be done.
  • Doing this, for some reason, makes you undetectable simply by the cones of vision of these N. O. O. S. E providers.
  • As you’re still dropping, be careful of the security digicam which you can come across.
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Having done that, move forward and keep to your right until a person come across a new double door. Only start moving if the guard inside will be turning the other way and” “not necessarily towards you, and the camera will be also looking away from you. Once you’re done with almost all the heist preparing missions, we are able to proceed with the real heist.

The Big Scam Heist

There are usually even popular different roulette games strategies that a person can implement to organize your expenses and make the particular whole experience considerably more interesting. These varieties of gambling sites deal exclusively with gambles placed on sporting events. Top playing sites for athletics usually cover major sports around the world including” “football, basketball, tennis, equine racing, and boxing. Users can position bets on the outcome of matches, in addition to also within the opportunity of different occasions happening in typically the games. For instance, you could be able to place a wager on who scores the first objective in a football complement.

  • In fact, the very best shell out by phone gambling dens provide a degree of handle over your playing expenses.
  • If you eliminate the target but the evidence falls out of their hand (like a camera) then you certainly need to shoot the camera also, to be able to destroy the particular evidence.
  • Top-rated casinos offer trial mode for many games that allows the players for more information on the game, learn typically the rules, etc.
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Once once again, he will change his mind and inquire you to grind the rental car at a scrapyard. Finally, he will certainly come to a final decision of providing the car for the Altruist Camp. Once you deliver the car to typically the Altruist Camp, your own mission is completed.

Setup

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  • If you acquire a mission wherever you need in order to go towards the FIB building, you can very first have to move kill some brokers and obtain the FIB agent pass so you can impersonate that agent.
  • The Silent and Sneaky approach is usually quite popular among on the internet players.
  • For the overall prep missions, you obviously want to do the vault keycards preparation mission, which will be mandatory, followed by the Patrol Ways prep mission.

If cops commence chasing you, use the underground sewer system to get away from them and stay undetected. The only problem you might” “come across during this ultimate stage of the particular heist will be the running after helicopter. Steal any car you observe in addition to use it to be able to deliver the loot (if you didn’t obtain the Clean Automobile option ahead of time).

How To Obtain Guaranteed Diamonds Inside Gta Online Casino Heist

So keep on to the following door and make use of your keypad system to unlock that door. Just create sure the safeguard has left the space before you carry out so. After that will quickly use the particular EMP out of your cell phone and enter this specific room, wait for the shield to come back again and take your pet out with a headshot. After you’ve gone through the particular double doors, take cover and wait for another guard to come. Wait for your pet” “in the future close to a person and then get him out as well. Follow down the particular hallway but just before continuing, you will see one more camera when you enter in the hallway where you killed the shield.

  • Underneath of which, you can change to either the particular level 1 move mission or degree two pass quest.
  • However, since we are not thinking about getting directly into any combat scenarios, this mission is usually not necessary.
  • Do not proceed through the door and wait here for the guard once more.
  • Completing all associated with the optional create missions gives a person the very best chance associated with success, although not 100% necessary.

You can capture a breather right here and look into the ways of the pads once again. Once you leave the vault you may need to employ your keycards simultaneously once again to open the door and return to the same staff reception where you originated in. When you achieve the area, wait for a shield to pass by and as soon since he does, go through the double doors and take out the camera to your right. Once the camera is taken straight down, take out the shield on the desk in addition to move forward. Once you’ve killed them almost all, get into the bird and go in order to the ULSA in addition to pick up typically the EMP device utilizing the Cargobob.

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With all those lamps and all that will money, it has been always going to be a new target. GTA Online’s latest heist will be ready and waiting, so here’s how to start the particular Diamond Casino Heist. Lester will take his cut, and you’ll need to offer each crew member their share. You’ll end up obtaining somewhere between GTA$400, 000 and $1, 750, 000.

It makes your heist much easier especially if you are doing silent & sneaky approach. Once you’ve taken typically the guard out noiselessly, turn around in addition to go down the hallway. Here another shield will be patrolling, hold out for him to turn back around, as soon because he turns again around, navigate to the room where your NOOSE outfits are. The other NOOSE attire will be within the room next to this one, and your friend can get that from there. Once you could have the outfits, exit out regarding the building with the STAFF LOBBY get out of door.

Starting Gta Diamond Casino Heist

The presents should have obvious terms and problems, and favorable betting requirements. Casinos will be expected to provide both new plus regular players along with generous bonuses and various promotions. CasinoHex is actually a place wherever the players could rely on dependability. Our website will not feature any paid/sponsored casino reviews. The assessments our staff creates are structured on transparency plus honesty. However, online gambling is also outright prohibited in many nations too – irrespective of a gaming license or not.

  • The player should proceed to the on line casino and hack into the security digital camera feed making use of the Sightseer app.
  • You do not have got to do the duggan shipments, power exercise and security intel prep missions.
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  • These reasons lead almost all newcomers to pick one of the particular other two procedures.

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The last preparation board needs to have the following options. Once you’re inside of, take out the metal detector blend box and next silently take out the guard in the front desk using your suppressed tool. After that move through the metal detector and to your left you will certainly come across one more camera. Quickly get out two protections to your left who will merely be chatting with every other.

  • But if you’re not planning on being detected, then top tier guns are a waste material.
  • Once you’ve exited the particular casino through personnel lobby, there’s a new couple of other new changes outdoors too.
  • For years, GTA players questioned Rock-star about whether or not they would be able to swing open the doors on the On line casino that sits by the racetrack in North Vinewood.
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After a person” “eliminate the drones, you have to collect their waste and bring these people back to the games so Lester could create a nano drone for a person. It is recommended that you have either an Oppressor Mark II or a Buzzard in order to carry out this particular mission. A good thing about this mission is that will you can collect the fallen jingle scraps whilst you’re in your vehicle. Quickly exit home and get into your vehicle which often you parked right in front regarding the entrance previously, lose the police officers and deliver the hacking device again to the game. Before going to typically the FIB building, a person will need to be able to take out several agents and acquire the FIB agent pass in order to enter typically the building by impersonating a realtor.

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Our work with Cheshire and Merseyside Health and Care Partnership to improve the remote management of patients with uncontrolled hypertension has been highly commended in the Innovate Awards.

NHS Confederation and the AHSN Network held the new Innovate Awards to celebrate excellence in innovation in health and care. Our digital transformation programme enabling at-home monitoring of blood pressure (BP) to help identify, triage and treat more patients was runner-up in the Enabling Safer Systems of Care Through Innovation award.

The Digital First Primary Care-funded ‘Hypertension Accelerator’ sites of Liverpool, Cheshire, and Wirral Places have been working collaboratively on the BP@Home approach. It supports General Practice to adopt innovation for delivering targeted, proactive, preventative BP care to those who need it most. It aims to empower patients to manage their health conditions at home.

Patient digital submission tools enable and support effective, low maintenance, and low cost direct data submission into General Practice, and ultimately the patient record and practice decision support systems.

Without the digital enablers, patients and practices rely on paper printouts, and average readings need to be calculated manually, increasing workload and scope for error or loss of results.

The digital enablement blueprint we developed is the first of its kind to improve remote management of patients in primary care settings. It is being shared via the FutureNHS online platform to support roll-out of remote monitoring for high blood pressure across England – and can be replicated to support other digital programmes.

Liverpool Heart and Chest Hospital, Innovation Agency North West Coast, The British Heart Foundation and Champs Public Health Collaborative were also involved in implementing the approach.

Debbie Bywater, MLCSU’s Chief Information Officer, said: “We are delighted with this recognition of our collective efforts to use digital technology to drive the best healthcare outcomes for patients. This work is a good example of organisations across an integrated care system collaborating to produce great results.”

OTiS Tactical helps ICSs track patient flow and emerging pressures

Our flexible OTiS Tactical tool is helping integrated care systems to monitor emerging pressures on urgent and emergency care and impact on patient flow through acute hospitals.

To inform tactical responses to COVID-19, Lancashire and South Cumbria (LSC) Integrated Care System required a flexible tool to monitor emerging pressures and impacts on the delivery of urgent and emergency care within acute hospitals.

To understand the changing current position in the context of medium-term trends, there was also a need to improve how existing data sources were interrogated.

They needed a tool that allowed system partners, including the LSC Resilience Hub to access the latest data 24/7, and that would facilitate the production of regular snapshot reports.

Our Clinical team built on their experience of developing the OTiS (Operational, Tactical, Insightful and Strategic) system – an interactive digital reporting suite to pinpoint blockages in a healthcare system. Working alongside developers and Business Intelligence analysts, they understood LSC’s requirements and built a solution.

Feeds from multiple data sources including national SitReps (situation reports), COVID-19 testing data and critical care data for the local network were secured and integrated in a dashboard accessible through Aristotle – MLCSU’s innovative business intelligence portal.

Data could then be analysed and benchmarked at ICS, provider or individual site level. The dashboard’s flexibility allows viewing in different time periods, in the context of longer-term trends, or in comparison with pre-COVID levels.

Functionality was added to allow commentary to be added and key issues to be highlighted for key decision-makers to review.

OTiS Tactical is used daily to support the tactical work of the LSC Resilience Hub, highlighting key issues such as those related to bed occupancy, long-stay patients, and discharge issues and pressures in the urgent care system.

It has been the main tool for spotting emerging pressures in Lancashire and South Cumbria. By tracking the emergence and impact of the Omicron variant of COVID-19, the team were able to advise on appropriate mitigating measures.

OTiS Tactical streamlined the production of a daily COVID-19 report, making it more timely and less resource-intensive. It has also informed other regular reporting for the system, including briefings for the various teams and boards overseeing the local urgent and emergency care system.

Having proved its worth in Lancashire and South Cumbria, OTiS Tactical has been adapted for system diagnostics in Cheshire and analysing the impact of COVID-19 on acute hospital flow across all North West providers. OTiS Tactical has proved to be invaluable in these applications.

Financial framework supports system transformation

Our Transformation Unit supported an integrated care system (ICS) to develop a financial framework that ensured a consistent approach across all its transformation programmes, ensuring progress and momentum.

Finance is changing in the NHS. The focus is shifting from organisational financial sustainability to system sustainability. Organisations are working ever closer together to provide better population focused health care.

This creates potential financial benefits for organisations, for example leveraging economies of scale. It also requires a paradigm shift.

System change programmes will have different financial implications for affected partners.

Northamptonshire ICS required support to:
• develop a financial framework to support system transformation programmes
• ensure progress and momentum across system transformation programmes.

Our first step was to work with the system directors of finance to develop a financial framework. We then supported the appointment of finance leads for each of its transformation programmes. A key focus of our support was to enable the finance leads to implement the framework.

One flagship programme, focusing on integration, needed business case approval. We helped articulate both the benefits and the financial implications of the programme. This involved working through difficult conversations that require significant maturity of system working.

The co-produced financial framework helps ensure a consistent approach across all transformation programmes.

The system also approved the business case of the flagship integration programme, which is now being implemented and is helping reduce avoidable admissions.

Digital leadership for new hospitals

We have been supporting the Lancashire and South Cumbria’s New Hospitals Programme to design and deliver digital infrastructures to benefit new hospital services, enhancing usability, data driven insights and automation.

Background

As part of the national New Hospital Programme, the Lancashire and South Cumbria region has been recognised as in need of funding to replace or refurbish existing hospital estate to address problems with ageing facilities and infrastructure in Preston at Royal Preston Hospital (RPH) and Lancaster at Royal Lancaster Infirmary (RLI).

Proposals also include investment in Furness General Hospital, required due to its geographically remote location and its proximity to some of the UK’s major strategic national assets.

This funding provides the region with a once-in-a-generation opportunity to transform hospitals by 2030, with the positive effects set to enhance the lives of local people living and working in Lancashire and South Cumbria both now, and in generations to come.

Action

Midlands and Lancashire Commissioning Support Unit are providing specialist digital leadership for the Lancashire and South Cumbria New Hospitals Programme to ensure that all digitally enabled functions and services are fully understood, considered and coordinated into the vision and delivery strategy.

Designing, integrating and delivering digital infrastructure and services that meets the needs of the new hospitals users, and that is innovative and user-centric are some of the key principles.

Impact

The Lancashire and South Cumbria New Hospitals Programme is benefitting from specialist digital in construction leadership to set strategic direction and to coordinate the integration of Lancashire and South Cumbria wide and site-specific digital services within a multi-site, large-scale construction programme.

The inputs will maximise the opportunities to create digitally enabled and coordinated hospitals from concept design stage. The eventual outputs will positively impact and benefit across all new hospital services, enhancing usability, data driven insights and automation; improving health and wellbeing; increasing sustainability and reducing capital expenditure by reducing duplication, sharing resources and decreasing operational costs.

“Having specialist digital in construction advice and expertise to develop and articulate a compelling vision and ambitious strategy for what can be achieved through digital transformation enabled by new hospital facilities has been invaluable for the programme. It helps to really bring to life the potential and impact for patients, staff and local communities in a tangible way. Importantly, this has been delivered within the context of the wider NHS Lancashire and South Cumbria Integrated Care Board digital strategic objectives, with strong relationships established at a programme and a system level.”

Rebecca Malin | Programme Director, Lancashire and South Cumbria New Hospitals Programme

Bringing back staff to continuing healthcare

A project to bring back a considerable number of staff to complete outstanding continuing healthcare assessments attracted skilled people from across health and care.

Background

The NHS Continuing Healthcare (CHC) framework was suspended for six months during the COVID-19 pandemic. To complete 38,484 outstanding NHS CHC assessments within the six-month deadline, a significant number of additional staff were needed with the right skills to handle the workload to ensure patients were assessed and that their care needs were coordinated in a timely way.

In partnership with NHS England and NHS Improvement (NHSEI), we developed a virtual workforce via the Bring Back Staff (BBS) returners programme. Our solution was a rapid, flexible and targeted recruitment and training process on a scale never seen before.

Action

NHSEI commissioned the NHS Midlands and Lancashire CSU to design and implement a national database to capture details of staff recruited or seconded, any training given, and additional working hours completed.

The CHC Workforce Project and talent pool built on ‘bank’ models for clinical commissioning groups to offer a choice of provider for temporary staffing.

We collaborated both internally and externally with recruitment specialists, IT services, business admin support and clinical leaders from a variety of health professional groups to ensure the processes worked smoothly and that we were able to target the training at the appropriate level for all candidates.

Impact

The success of the project was the result of highly-effective collaborative working as one to deliver at pace.

Training BBS returners at pace and then mobilising this agile workforce illustrated just how adaptable and transferable their skills and previous experience as nurses, paramedics, medical support workers, pharmacists and other allied health professionals were, and how useful their expertise is to CHC.

The programme attracted people who wanted to work flexibly in the NHS and retained their commitment, expertise and experience, offering the best use of resources and public investment.

A rapid recruitment, induction and training process enabled us to bring candidates on board in two to four weeks. Candidates were sourced from many healthcare professions and came with a wealth of valuable experience.

We adapted to the challenges of lockdowns and remote working, we provided equipment by courier, and developed a bespoke training package via interactive webinars and training videos.

CHC employers saved at least 260 hours of recruitment, administration and onboarding time. This blueprint for CHC workforce development recruits professionals considering CHC as career option, retaining their skills and knowledge within the NHS.

Feedback from applicants:

“My experience with MLCSU CHC team has been so different from the others. I feel supported in all aspects… I only wish I had started sooner.”

“The recruitment experience was impressively thorough and rapid, with a swift DBS check, provision of a laptop, phone and training.”

Feedback from a manager:

“The recruitment process was straightforward… very easy to navigate and a positive experience all round.”

NHS smoking cessation service in Leicester

We helped the University Hospitals of Leicester NHS Trust implement the national smoking cessation service referring patients discharged from hospital to GPs for ongoing stop smoking support.

Background

The University Hospitals of Leicester NHS trust required support with the new national NHS smoking cessation service. The NHS Midlands and Lancashire CSU (MLCSU) facilitated the service’s implementation and provided support throughout.

Action

We analysed the trust’s current resources and worked with various teams to establish working groups, agree on a referral pathway and engage with community pharmacies.

* We interpreted and applied all the necessary guidance from NHS England.
* We worked with pharmacy, IT, tobacco dependency, respiratory and other teams to highlight and work through technical and logistical issues.
* We worked with the trust and other stakeholders to set up a referral pathway and worked out how data and referrals will be exchanged throughout the stages of the service.
* We supported the local pharmaceutical committee with engagement events to ensure abundant local uptake of the service and that there was sufficient geographical coverage.

Impact

Our support allowed the trust to become one of the early implementors of the NHS smoking cessation service.

The trust is now set up to digitally refer patients being discharged from secondary care for ongoing smoking cessation support via their chosen community pharmacies.

The guidance we provided helped establish a digital referral pathway allowing for referrals to be quickly sent electronically and then received back to the trust upon completion of the patient pathway in a timely manner.

Our support helped the trust to efficiently deliver and contribute to the prevention ambitions as part of the NHS Long Term Plan.

“The MLCSU have been an outstanding partner to work with setting up our ‘Community Pharmacy pathway for smoking cessation’ in Leicester.

“The team have all the key qualities to get a new pathway up and running including being key members of our task and finish group, being responsive to queries, problem solving, working effectively with other stakeholders and generally being friendly, respectful and having a ‘can do’ approach.

“In addition, sharing their knowledge and experience working with other stakeholders across the country has been pivotal in getting our local pathway up and running in record time..”

Professor Sanjay Agrawal, Consultant in Respiratory and Intensive Care Medicine, University Hospitals of Leicester NHS Trust (UHL)

National Clinical Advisor for Tobacco Dependency, NHS England

Chair, Royal College of Physicians (RCP) Tobacco Advisory Group

INSIGHT 2022: festival of analysis

We are delighted to invite you to INSIGHT 2022, the annual festival of learning and sharing about analysis for the NHS, local government and other partners across health and care, hosted by the Midlands Decision Support Network in association with the NHS Midlands and Lancashire CSU’s Strategy Unit.

This year’s festival will run over a two-week period from Monday 3 October until Friday 14 October, and will include a mixture of talks, workshops and panel discussions. The theme is ‘The science and craft of decision making’, bringing together inspirational regional and national speakers to explore how insights from high quality analysis can drive change in health and care systems.

All events are online and everyone working in health and care is very welcome to attend. All sessions are free. You can commit as little or as much time as you’d like. Most of the sessions will be recorded so you can fit them into your schedule in a way that suits you.

Confirmed speakers include:

Nigel Edwards (Chief Executive, The Nuffield Trust)
Dr Bola Owolabi (Director – Health Inequalities at NHS England and NHS Improvement.
Sir David Dalton
Ben Marshall and Michael Lawrie (Ipsos UK)
Rony Arafin (Chief Executive Officer, AphA)
Professor Angie Hobbs (Professor of the Public Understanding of Philosophy).

…and many more will be added in the coming weeks.

How to attend

To register your interest simply complete your details on our Eventbrite page: https://www.eventbrite.co.uk/e/insight-2022-3rd-14th-october-2022-tickets-391179326897 – and we will share the full programme when it is available. You can also see the festival details on the Midlands Decision Support Network website: https://www.midlandsdecisionsupport.nhs.uk/training-events/insight-2022/

We look forward to seeing you!

Further information

If you have any questions, please email Kimberley Messam, Senior Consultant at The Strategy Unit: kimberley.messam@nhs.net

Digital support for at-home blood pressure monitoring earns innovation award short-listing

Our work with Cheshire and Merseyside Health and Care Partnership to improve the remote management of patients with uncontrolled hypertension has been short-listed for the Innovate Awards.

NHS Confederation and the Academic Health Science Networks are running the new Innovate Awards to celebrate excellence in innovation in health and care. Our digital transformation programme enabling at-home monitoring of blood pressure to help identify, triage and treat more patients has been short-listed for the Enabling Safer Systems of Care Through Innovation award.

The Digital First Primary Care-funded ‘Hypertension Accelerator’ sites of Liverpool, Cheshire, and Wirral Places have been working collaboratively on the BP@Home approach. Without the digital enablers, patients and practices rely on paper printouts, and average readings need to be calculated manually, increasing workload and scope for error or loss of results.

The digital enablement blueprint developed is the first of its kind to improve remote management of patients in primary care settings. It is being shared via the FutureNHS platform to support roll-out of remote monitoring for high blood pressure across England – and can be replicated to support other digital programmes.

Developing a plan for an integrated workforce

Our integrated workforce plan for Dudley’s primary care networks reflects their ethos, supports sustainability of primary care and reflects new career pathways and clinical models.

The Transformation Unit was asked to generate a comprehensive plan for maximising the roll‑out of the Additional Roles Reimbursement Scheme across the six local primary care networks in Dudley to help to meet the needs of the local population.

Our multiskilled team of workforce, engagement and analytical experts adopted a robust population and place based approach to workforce planning to ensure the clinical model had the right numbers, skills, values and behaviours to deliver high quality care closer to the Dudley population.

Through stakeholder engagement, application of intelligence regarding the networks, place, population and workforce we triangulated service, finance and workforce priorities to develop future workforce design principles which informed the development of an Integrated Workforce Plan.

The plan places a real emphasis on the need to develop new ways of working and new roles to meet the needs of the population now and in the future.

“This is an absolutely excellent piece of work”
Trust Director of Operations, Strategy & Partnerships

Integrated Medicines Optimisation Committee

The Black Country Integrated Medicines Optimisation Committee fosters partnerships across the integrated care system to optimise use medicines and care pathways, and improve patient safety and experience.

Background

Integrated care systems (ICSs) are bringing major changes in how health and care services are planned, paid for and delivered. The Black Country ICS has been setting up an Integrated Medicines Optimisation Committee (IMOC) to foster partnerships and optimise the use of medicines across the system.

The Midlands and Lancashire Commissioning Support Unit has been supporting the establishment of the Committee and leading on aspects of its formation.

Action

We worked collaboratively with the ICS to create the foundation and governance structure of the Black Country IMOC:

  • We set up joint working groups to advise the ICS and agree the key principles underpinning the purpose and operation of the IMOC
  • In the next phase, we facilitated the production of a robust governance structure and of fundamental processes required to run the IMOC
  • Finally, we supported the IMOC with organisational sign off on the governance outputs and recruitment of suitable talent.

Impact

The IMOC will have a significant positive impact on the Black Country ICS’s capability to harmonise health partnerships and strategies and optimise system wide medicines and care pathways that will benefit patients across the system. Benefits include:

  • Establishing how the proposed new structures will work in practice, and how the partnering organisations will relate to one another
  • Finding new ways to work more closely with and alongside local communities as key partners in shaping services and improving population health and wellbeing
  • Prioritising the reduction of health inequalities
  • Developing clear lines of accountability and transparency around how and where decisions are made, while continuing to allow flexibility for locally led change
  • Continuing to align oversight and regulation more closely behind the work of systems, prioritising the cultural and behavioural changes needed to support this.

We continue to consult stakeholders in the development of the Black Country IMOC.

“The formation of the Black Country IMOC is at the peak of NHS innovation in its unprecedented stage.

“Key deliverables included engagement, making sure every voice counts and listening to concerns and questions raised.

“Partnership with the MLCSU created scale working to provide solutions, service resilience and confidence when facing the challenges through this contract. The Black Country Integrated Care System innovation and collaborative working decisions in the phased approach of IMOC were made as closely as possible to the core principles and road map of the NHS Long Term Plan.”

Hemant Patel, Black Country Integrated Care Board Lead Pharmacist

Review supports clinical service redesign

The review of gynaecological cancer services in Cheshire and Merseyside by our Transformation Unit is being used to make improvements from the point of patient presentation in primary care through to treatment.

Cheshire & Merseyside Cancer Alliance (CMCA) commissioned the Transformation Unit to undertake a review of gynaecological cancer services across the Alliance footprint. The purpose of the work was to support delivery of the NHS Long-Term Plan, including delivery of Rapid Diagnostic Services (now the Faster Diagnostic Framework) by 2024. The last full review of gynaecology cancer services in Cheshire and Merseyside was more than 20 years ago.

We used a mixed methods approach to review data, guidance, service configuration, workforce, current practice, and transformational opportunities for symptomatic cervical, ovarian, vulval and endometrial cancers (both suspected and diagnosed) from patient presentation in primary care through to diagnosis and First Definitive Treatment. We engaged 93 stakeholders in the review process.

We developed a proposed model of care, mission, vision and 40 recommendations to inform short, medium and long term aims of the service, to be delivered through a Gynaecology Cancer Programme by the CMCA across a range of themes.

To engage stakeholders with our conclusions and gain support for delivery, we presented the outputs of our work at a regional event with over 130 people attending.

Our work has been shared with wider stakeholders including Macmillan, Cancer Research UK and Ovarian Cancer UK.

Ovarian Cancer UK has been particularly supportive of our approach and presented on our work at their national transformation meeting.

Liz Bishop, Senior Responsible Officer, CMCA said: “This clear and comprehensive review of gynaecology cancer services is a decisive step forward in improving the lives of women across Cheshire and Merseyside from presentation in primary care through to treatment.”

Jon Hayes (Managing Director) and Dr Chris Warburton (Clinical Director) at CMCA said: “[The review] gives an honest, clear, unvarnished insight into the strengths and weaknesses in cancer care and treatment and presents achievable recommendations for service change. The review will start us on a journey to achieve these aims for our population, to eliminate variation across communities and to improve earlier diagnosis, care, and treatment outcomes – whilst also giving patients a voice in how the recommendations are implemented.”

Improving health outcomes using our PHM tool

Our population health management (PHM) tool has helped identify people with clinical and social issues across Lancashire and South Cumbria, enabling early interventions to improve health outcomes.

The PHM Segmentation Tool was developed by our business intelligence specialists to enable a place-based approach to segmenting the population based on a number of similar health and wellbeing characteristics and needs. These include wider determinants such as ethnicity, digital exclusion, housing quality and social isolation. This means they can target interventions more effectively and focus on prevention.

The tool has been built and enhanced through partnership working with clinicians and strategic PHM leads across our client geographies, as well as drawing on multi-disciplinary expertise from across MLCSU.

We have also provided analytical expertise to support integrated care systems, place-based partnerships and primary care networks with actionable insights of their population, and share best practice and relevant interventions from across our client geographies.

To date, we have helped identify and reach approximately 5,500 people with clinical and social issues, enabling Lancashire and South Cumbria Health and Care Partnership to improve health outcomes at an early stage, avoiding patients becoming unwell, reducing hospital admissions and future healthcare costs. Our insight has helped decide where best to allocate funding to address needs and health inequalities, for example:

  • identifying the best location for a new community frailty service providing convenience to those most in need
  • reducing violence by placing additional community support at the electoral wards with highest levels of vandalism and crime
  • improving young people’s mental health by placing additional support at a list of schools with the most pupils at risk of having mental health issues
  • contacting 460 individuals with previously unknown issues to ensure they had access to the services and referrals they need given their personal and clinical circumstances
  • providing a list of patients with respiratory conditions who are likely to live in houses with a lack of adequate heating, which could exacerbate their condition.

Vicky Hepworth-Putt, Acting Consultant in Public Health, Cumbria County Council, said: “The PHM Tool enables me to identify clinical areas where the inequalities are widest across the area and also the wards that are outliers compared to their peers. This can help target interventions. This data can also be used strategically to target resources, although we are yet to test the success of that. The tool works well with the other PHM and PCN dashboards to provide a holistic picture of local health outcomes.”

MLCSU collaboration shortlisted for HSJ award

The HSJ Awards 2022 finalists were announced today, and the NHS Midlands and Lancashire CSU’s (MLCSU’s) joint project with the Greater Manchester Integrated Care Partnership was shortlisted for Provider Collaboration of the Year. This award recognises work carried out to align priorities between organisations, which lead to greater efficiency and the development of person-centred services.

Together, our two organisations worked in collaboration on a successful pilot to transfer smoking cessation care from hospital to community pharmacy.

In Greater Manchester, more than 5,000 people die each year from smoking related illnesses. Many live with the burden of smoking related diseases. Chances of quitting double if a stop smoking medicine is prescribed by a GP, pharmacist or other health professionals.

The innovative Oldham pilot scheme bridged the gap between primary and secondary care, offering stop smoking support to patients when they are discharged from hospital. This collaborative approach supports the work of hospital staff, so patients continue their stop smoking efforts.

The pilot ran until January 2022 and since it has been rolled out in pharmacies across England.

Rob Hebdon, Senior Medicines Optimisation Lead at MLCSU, said: “The smoking cessation transfer of care pilots represent a great example of cross organisational collaborative working. The outcomes of this have largely shaped how this service is being implemented nationally. So proud to have been involved and to have made the final shortlist!”

MLCSU has also worked with our partners to support several other projects and workstreams which have been shortlisted for HSJ Awards this year, including:

  • Workforce Initiative of the Year – Lancashire and South Cumbria Integrated Care Board, LAMP Programme
  • Covid Vaccination Programme Award – Herefordshire and Worcestershire ICS, Covid Vaccination Team
  • Innovation and Improvement in Reducing Healthcare Inequalities Award – Herefordshire and Worcestershire ICS, Tackling Inequalities through Covid vaccination
  • Innovation and Improvement in Reducing Healthcare Inequalities Award – University Hospitals Coventry and Warwickshire Trust, Waiting list Access and Inequalities Tool.

Congratulations and good luck to all HSJ Awards finalists!

Implementing financial reporting tools

Our support has resulted in a significant improvement in the quality of financial information held.

Background

The Finance Department at University Hospitals of North Midlands NHS Trust required support to implement a new accounting standard (IFRS 16 Leases), a new capital asset and lease register (Asset4000 and Lease4000) and to undertake an asset verification exercise.  The NHS Midlands and Lancashire CSU (MLCSU) was approached to lead these projects and provide technical and operational support.

Action

We reviewed the work to date and worked with the trust capital team to:

– Implement IFRS 16 Leases:

  • interpret and apply guidance from the Department of Heath and Social Care (DHSC)
  • work with the estates, IT, finance and procurement teams to identify and register leases
  • collate information to prepare and submit a return to DHSC forecasting the impact of the IFRS 16
  • provide training to finance and non-finance teams
  • populate templates for the new Lease4000 system and test
  • provide IFRS 16 information for year-end planning and for the year-end accounts.

– Implement Asset4000. We worked with the capital accountant to implement the new asset register, verifying the data to be uploaded to the system, testing and reconciling reports.

– Undertake an asset verification exercise. We analysed the asset register at 31 March to establish the scope and to determine a timeline and plan. We generated reports for budget holders, providing support and collating results to enable the capital accountant to update the asset register and process any disposals in line with trust policy. We also determined future steps to ensure asset verification is regularly undertaken in line with trust policies.

Impact

Our support enabled the trust to successfully implement the new IFRS16 lease standard in accordance with the requirements of DHSC.  The trust was able to submit the mandated returns accurately and timely for the financial year ending 31 March 2022.  The training we provided and the production of a lease register and templates helped establish processes and procedures for the new standard.

The new successfully implemented Capital Asset and Lease Register will facilitate accurate and timely reporting, at both month and year end.

The asset verification exercise has provided the Trust with further information on its assets and also assurance that the information held in the Asset Register is accurate and correctly stated.   This is an ongoing project but our support to date has resulted in a significant improvement in the quality of information held in the Asset Register which meets the requirements of external audit.

Additionally, our support was able to provide extra capacity to a small capital team which would not have had the resource to deliver the project in time for the year-end of 31 March 2022.

“MLCSU demonstrated strong leadership skills to ensure the projects were finished on time and the goals achieved. They collaborated fantastically well with finance and non-financial colleagues.

“MLCSU were able to use their technical knowledge, experience and worked hard to break the complex projects into manageable pieces, this enabled Hilary to organise, lead and support the team to deliver.

“Without their professionalism we would not have been able to deliver these projects. I can highly recommend them, I would have them back tomorrow.”

Dylan Davies, Deputy Director of Finance, University Hospitals of North Midlands NHS Trust

‘Might’ is right

In this blog, Peter Spilsbury, Director of the NHS Midlands and Lancashire CSU’s Strategy Unit, warns about the risks of expecting rapid change and moving from theory to practice too quickly.

A good idea can be ruined by over-selling. The NHS has a tendency to adopt ideas and then move rapidly to wanting them to become certainties.

What begins as a proposition rapidly becomes an assertion, a statement of fact, a policy, a target, a line in a mandated planning template…an obligatory mention in every sentence for the aspiring manager.

Things like ‘risk stratification’, ‘integration’ and various forms of ‘early intervention’ are obvious examples where what should have been ‘might work’ became ‘will work’ and with detrimental effect. I fear that our whole national approach to ‘big data’ and ‘tech’ and indeed to ‘integrated care systems’ could get caught in this space as well.

Learning stops as soon as something is pronounced as ‘will work’. That can be because the usual impositions that go with ‘will work‘ – such as targets and ‘development’ programmes where attendance is made compulsory -generate an environment that leads to distortion of the evidence and no incentive for honest reflection and learning.

The overriding imperative becomes to assert that it works, at least until everyone can safely shift (via the usual ‘good practice case studies’) to whatever is the next big thing.

The NHS says that it aspires to be a ‘learning system’. Critical to being open to learning is to be willing to acknowledge and embrace what we don’t know. So I believe that, by default, we should adopt the language of ‘might work…’

The evidence base will only ever support propositions, never certainty. And, as soon as we adopt the language of ‘might…’ then obvious and powerfully useful questions start to flow: Why do we think it might work? What is our theory of change? What mechanisms do we think are likely to be key to that? Which elements of our theory are we more, or less, confident about, and why? Can we quantify the extent of that uncertainty? Which questions contribute most to that uncertainty and what does that tell us? Do our colleagues and partners see any flaws in our theory, and do we understand why? What would we expect to see if starts to ‘work’ and how might we think to best track that (and also track the most likely types of unintended consequences?).

What factors can we see up front that might derail our theory in practice and what does that lead us to in terms of implementation strategy? (A ‘pre-mortem’ exercise can help here). How long are we willing to let this run before we decide to stop/change tack/continue, and what will be the trigger for that?

Thinking this way encourages us to think ‘experiment’ rather than ‘proof’. And, as my dear colleague Professor Mohammed Mohammed said to me recently, ‘if something doesn’t stack up in theory, it’s unlikely to do so in practice’.

‘Might…’ opens up a universe of possibilities and learning. It isn’t something that should stop progress, initiative or ambition. Quite the opposite.  It is just a different and far more effective way to proceed in making change happen. It has the golden benefit of being profoundly honest and authentic. It also reduces the gap between proclamation and reality: a gap occupied by cynicism.

Decision processes will also then embrace uncertainty and seek to understand it, bound it and address it. Planning processes will need to do the same – and we really should have no more ‘single point’ delivery plans. Rather we should have plans focussed on well understood ranges, and on how those ranges have been addressed through specific flexibilities and resilience.

The leadership we need will have the confidence and the insight to know when to say ‘might…’ rather than ‘will’. We need leadership that embraces uncertainty, rather than wishing it away. Those leaders will be trusted more and will likely achieve more as a result.

This is the one instance where ‘might is right’.

Pharmacy support to vaccination programme

We provided insight to clinical enquiries, produced reports and worked to develop standard operating procedures to help improve patient safety and increase access to the vaccine in Lancashire and South Cumbria

Background

The Lancashire and South Cumbria Integrated Care System (ICS) set up a System Vaccination Operation Centre (SVOC) and a Management and Coordination Organisation (MCO) to run the COVID-19 vaccination programme. The ICS required pharmacy oversight to the programme to ensure the safe and effective use of vaccines in line with regulations. Pharmacist leadership was required to support the SVOC and MCO functions.

Action

We ensured national guidance for the vaccines was followed. We worked in partnership with trust chief pharmacists to:

– Oversee the pharmacy aspects of setting up mass vaccination sites, including site visits to inspect vaccine storage, usage and supply

– Audit vaccination teams to ensure process was followed

– Set up a direct phone line to pharmacists for the vaccination centres to call with queries when gaining patient consent

– Support the MCO function with setting up new services for pop-up/ mobile/ roving models of vaccination

– Investigate incidents and set up panels to learn lessons

– Attend the vaccine oversight board as subject matter experts for the vaccines

– Train SVOC staff and host webinars for all sites

– Have a dedicated named senior pharmacist with oversight of the programme as part of the MCO.

Impact

Since the programme commenced we have handled 1019 telephone queries from vaccination centre nurses, which has lead to increased patient safety and better access to the COVID-19 vaccines where the general public may otherwise have been turned away.

Since the start we have responded to 438 clinical email queries.

We have dealt with 39 incidents, running panels and producing reports of lessons learnt – putting further processes in place to ensure the safe use of the vaccines. This work was often in partnership with the local Screening and Immunisations Team.

We have worked with regional and national colleagues to alter processes and standard operating procedures where improvements were identified.

Since September 2021, when the region delegated the authorisation of mutual aid between organisations to SVOCs, we have authorised 853 movements of vaccines to ensure maximum usage of vaccines. This included getting vaccines to places with urgent requirements when delivery mechanisms failed.

“The Medicines Management team have been a key and valued part of the vaccine programme. They have provided leadership and support to ensure the vaccine is handled and used correctly across all sites. The pharmacy phone line has dealt with many queries which has supported SVOC staff.”

Naveed Sharif | Head of Mass Vaccination and Coordination, Lancashire and South Cumbria ICS

“MLCSU Medicines Management team have been influential and extremely valuable in supporting the ICS vaccine programme across Lancashire and South Cumbria; from setting up sites to ongoing support to SVOC, MCO, sites and staff. They have ensured safety and kept us compliant with medicines regulations by challenging, and working hard to amend, proposals to the benefit of the vaccine programme and supporting maximised vaccine uptake.”

Jane Scattergood | Interim Director of Nursing & Quality, Lancashire and South Cumbria ICS

Improving high-dose opioid prescribing

We help to significantly reduce high-dose opioid prescribing, bringing it into line with evidence-based recommendations. In one area our work over four years yielded a 44 per cent reduction.

There is no evidence for efficacy of high dose opioids (>120mg/day morphine equivalent) in long-term pain. The Faculty of Pain Medicine has advised that increasing opioid load above this dose is unlikely to yield further benefits but exposes the patient to increased harm.

Since 2017, the MLCSU Medicines Management and Optimisation Team (MMOT) have prioritised the issue of high-dose opioid prescribing in non-cancer patients, working with GP practices in Greater Preston and Chorley & South Ribble, the Moving Well Service and Lancashire Teaching Hospitals’ pain team to bring prescribing into line with evidence-based recommendations.

We did this with:

  • Baseline audit in 2017, training, resources and individual medication reviews with re-audit in 2018, further training and discussion about challenges faced
  • Provision of step-down plans, patient letters and agreements, patient information leaflets, pain diaries
  • Meeting / Q&A session between local specialists and primary care network pharmacists
  • Webinar for completion by all prescribers of controlled drugs – currently completed by 68% of clinicians.

Impact
Overall reduction in number of patients taking >120mg Morphine Equivalent Daily Dose (MED) across 46 practices in Greater Preston and Chorley and South Ribble CCGs from August 2017 (MMOT work commences) to September 2021 is 232 (reduction from 527 to 295 patients) = 44% reduction.

“The MMOT have done a fantastic job in achieving a significant reduction in opioid prescriptions which is a national issue. The number of hours dedicated to delivering training for the practices and having the team working within practices reviewing these patients and supporting the clinicians is highly commendable.
Dr John Cairns, GP Director, Chorley and South Ribble CCG

“Considering the initial figures were already favourable compared to regional benchmarks, further reductions are all the more reason to be congratulated.”
Dr Praful Methakunta, GP Director, Greater Preston CCG

Cost saving with HR services at scale

We provide a centralised HR function to five integrated care boards which ensures that better quality and a wider breadth of HR services are provided at a lower cost due to efficiencies at scale.

Background

Due to scarce availability of HR professionals in the general job market and workforce pressures, there are gains for NHS organisations to centralise business support functions. When clinical commissioning groups (CCGs) transitioned to integrated care boards (ICBs), contracts for HR services were transferred over. This also ensured budgets would not soar as the scale of the NHS Midlands and Lancashire CSU (MLCSU) guarantees a robust structure of experienced NHS professionals in a variety of fields at a fraction of the cost of establishing those functions internally.

We are delivering HR services at scale to five ICBs – Lancashire and South Cumbria, Cheshire and Merseyside, Shropshire, Telford and Wrekin, Staffordshire and Stoke on Trent and Leicester, Leicestershire and Rutland, supporting a total of over 2,800 staff.

Action

We provide a full range of at-scale services to the five ICBs for HR advice and guidance, transactional HR, HR administration, workforce systems, employment services, recruitment, job matching, learning and development and equality and inclusion. We also evaluate processes, looking to integrate more technology and automate or digitise simple tasks, for example directly entering details from forms into systems, producing letters and auto contacting relevant people.

As an integrated partner service, we know our clients’ needs and priorities, by learning about their business through and through. That allows us to be proactive, help predict challenges and tasks and help them plan ahead.

To achieve this, we go through a mobilisation period with every new client including:

  • Mobilisation plan with agreed transition period
  • Project plan with changes to current operating models
  • Assigned lead professionals for each at-scale service – HR, recruitment, equality and so on
  • Assigned project manager
  • Communication plan.

Impact

Sourcing HR services at scale delivers many benefits:

  • Cost efficiency compared to employing in-house staff
  • Increased speed of response to HR queries
  • Automation saving time, providing validation and delivering better quality and accuracy
  • Increased agility and capacity by eliminating a single point of failure and covering sicknesses and absences
  • Better resilience through wider access to staff that you wouldn’t have in a single organisation
  • Ability to draw on deeper subject matter expertise for specific projects and asks – a more cost effective way to access specialised knowledge, for example a recruitment expert, an equality expert, a workforce planner
  • Professional support, learning and sharing, helping to develop HR and organisational development (OD) staff
  • Inbuilt professional network pool of knowledge and experience
  • Reduced overheads for the client – getting better deals on software, licensing and contracts because of buying in bulk
  • Flexibility to stretch to demand and support time-sensitive projects
  • Better HR support to staff through accessing a wider range of professionals.

Blueprint to support ICS digital transformation

The NHS Midlands and Lancashire CSU (MLCSU) has been working with the Cheshire and Merseyside Integrated Care System (ICS) to lead a digital transformation programme which became the first national blueprint for digital-first primary care. It enabled remote and at-home monitoring of blood pressure to help identify, triage and treat more patients. Find out more about the programme in our Digital Transformation section.

Data showed a pronounced reduction (25.3%) in hypertension (high blood pressure) patients not being treated to target during the pandemic, and 229 GPs across the region were set up as ‘Hypertension Accelerator’ sites. To deliver this, we have been supporting the ICS with the local roll out of the national BP@home programme, which distributes digital monitors to patients diagnosed with uncontrollable high blood pressure.

Our learning from the roll out of the programme and from developing the collaboration between primary care teams, digital providers, procurement and Innovation Agency NWC (the Academic Health Science Network for the North West Coast) was recognised as a blueprint for enabling digital transformation in primary care.

It has been made available via the FutureNHS platform, so health and care systems and providers across the country can take advantage of the shared knowledge.

The Champs Public Health Collaborative, a formal partnership of Cheshire and Merseyside’s nine Directors of Public Health and their teams, serving a population of 2.6 million people, has published the blueprint, explaining that:

“It is hoped that not only will the blueprint be used to aid digital enablers and clinicians in their roles to support the rollout of BP@Home across the country, but that the approach utilised can be replicated to support other digital programmes of work…particularly those in primary care settings.”

The blueprint was featured at a Health Tech Newspaper (HTN) session focused on blueprints for supporting ICSs where the panel of experts included Sally Deacon, the MCLSU Programme Manager working with Cheshire and Merseyside ICS, who shared our approach to home blood pressure monitoring across Cheshire and Merseyside.

Alex Chaplin, Head of Digital at Cheshire and Merseyside ICS, commented that:

“MLCSU have delivered an excellent collaboration across our system using digital enablers to empower patients across Cheshire and Merseyside to monitor their blood pressure levels and submit readings electronically to their GP in the comfort of their own homes, providing the first Digital Accelerator Blueprint to share learning, supporting rapid scaling and adoption of remote monitoring.”

 

The case for surgical hubs

The Strategy Unit at the NHS Midlands and Lancashire CSU has written a paper jointly with the Royal College of Surgeons of England (RSC) on surgical hubs as a potential solution to the NHS’s growing waiting list. The report which is out this week presents seven recommendations to government to support this.

The RSC writes: “A key strategy to avoid the cancellation of elective activity involves greater separation of the resources that support elective and emergency patients, to create surgical hubs. This report identifies three categories of surgical hub: integrated (or ‘hub within a hospital’), stand-alone and specialist. These categories are illustrated in the report by case studies of trusts that have successfully adapted the model to their needs.”

Download full version of the report from the link below.

 

Improving medicines safety in care homes

care home resident taking medicine

Our medicines management and optimisation team improved safety and care for elderly Wirral care home residents, helped to prevent falls and hospital admissions, and saved costs.

A team of pharmacists (equivalent to 1.5wte) were commissioned from our MLCSU Medicines Management Optimisation (MMO) team for two years using NHS England funding via the Medicines Optimisation in Care Homes (MOCH) scheme. The team:

  • Delivered medication reviews and completed medicine reconciliation
  • Supported care homes to reduce medication errors and develop medicine policies
  • Attended multi-disciplinary team meetings and advised on medication
  • Educated and trained care home staff and residents
  • Completed waste audits and advised regarding waste reduction.

The project resulted in improved safety and care for residents and also provided support during the COVID-19 pandemic.

  • 1,319 medication reviews and 146 medicines reconciliations were completed over the two year period resulting in 5,338 medication interventions and a cost improvement of £159,654
  • Residents and care staff were helped to understand medication regimes to reduce the risk of medication errors or adverse drug reactions and potentially avoid hospital admission
  • 443 interventions were deemed to have prevented a possible hospital admission saving £494,720 in admission costs
  • Rationalisation of medication regimes led to a reduction in medicine administration time for staff
  • Team support ensured prompt access to medicines such as those for end of life care
  • Advice following waste audits saved £3,714
  • Falls prevention support led to an improvement in the referral process for falls assessment that should reduce the risk of falls and hospital admission.

From the falls prevention perspective we find that the root cause of falling is often a case of combined side effects of polypharmacy, drugs that have been prescribed over long periods of time that are either no longer effective or doses are too high. I found our joint working very beneficial. For us, it enabled residents who were falling, whose risks had not been addressed by the home but identified by you, to be referred to us. It allowed us to highlight to you our concerns about medications, particularly those with high ACB scores which are known falls risks. Between us we were then able to inform the Quality Improvement Team who arranged a visit to the home… the benefits are more widespread than just the optimisation of medicines and [your service] plays a key role in improving the quality of life, care and safety of care home residents and improving the working knowledge of other teams involved with care homes around medicines management.
Julie Griffiths, Wirral Falls Prevention Service Manager

Digitally enabling blood pressure monitoring at home

We helped the Cheshire and Merseyside Integrated Care System increase patients measuring their blood pressure at home, delivering a major digital transformation within primary care which became the first national digital-first blueprint.

Background

The most recent Quality and Outcomes Framework (QOF) figures (2020/21) show that throughout the pandemic there has been a 22% reduction nationally in the proportion of people on the hypertension register who have been recorded as ‘treated to target’.

In Cheshire and Merseyside the reduction is more pronounced. The reduction across all ages has been from 70.1% (2019/20) to 44.8% (2020/21), a fall of 25.3%.

Liverpool, Cheshire and Wirral were funded by the Digital First Primary Care national programme to become ‘Hypertension Accelerator’ sites. This included 229 GPs covering over 1million people. In collaboration with the ‘BP@home’ programme, which helps people with home monitoring for high blood pressure (BP), they tested approaches and digital tools to enable remote management of hypertension patients in primary care. The aim was to inform the approach for at-home / remote BP monitoring to become business as usual for GPs across the Cheshire and Merseyside Integrated Care System (ICS).

Action

We deployed a senior programme consultant to develop the collaboration between primary care teams, digital providers, Innovation Agency NWC (the Academic Health Science Network for the North West Coast) and MLCSU technology and procurement experts. The goal was to implement a digital solution for primary care to deliver BP readings at home, with a combination of elements:

* Ability for texting between GPs and patients and forms for patients to submit BP readings
* GP systems applying approved clinical terminology (‘SNOMED’ codes)
* GP based Blood Pressure Quality Improvement (BPQI) tool offering:

– EMIS-embedded dashboard and audit tool (aligned to National Institute of Clinical Excellence (NICE) guidance) to support patient list risk stratification and identify cohorts for further management

– EMIS-embedded consultation templates (for new and existing patients)

– Practice protocols, printable patient information leaflets and training support

* Clinical Decision Support Tool (‘Ardens’), aligned to NICE guidance, to give clinicians easy access to best practice resources.
* Sharing knowledge of the first Digital Accelerator Blueprint across all NHS health systems by providing step by step guides and learning from the local rollout via the NHS England and Improvement Blueprint Futures platform.

Impact

Within the first three months of deployment approximately 50% of GPs downloaded the BPQI tool.

There has been a more than 300% increase in the number of patients within Liverpool, Cheshire and Wirral submitting their BP readings remotely via text and over 60 practices so far using patient digital submission tools for BP readings.

These figures are likely to increase as more GPs come onboard this ongoing project.

“MLCSU have delivered an excellent collaboration across our system using digital enablers to empower patients across Cheshire and Merseyside to monitor their blood pressure levels and submit readings electronically to their GP in the comfort of their own homes, providing the first Digital Accelerator Blueprint to share learning, supporting rapid scaling and adoption of remote monitoring.”

Alex Chaplin, Head of Digital, Cheshire & Merseyside ICS

“MLCSU resource has consistently impressed, with her skills in building a community of practice and commitment to this project, bringing a range of stakeholders and MLCSU expertise together across a wide region and instilling a genuine momentum to the ongoing progress of the project.”

Mike Purdie, IT Service Delivery Lead, Cheshire CCG

“MLCSU plays an integral role supporting the programme with a pragmatic and flexible approach. As a result, we have high engagement from stakeholders. For us, there has been good groundwork set for strengthening our approaches to BP and achieving our objectives.”

Dr Julia Reynolds, Associate Director of Transformation, Innovation Agency NWC

Assuring medicines safety

Our Medicines Safety Assurance Tool gives at-a-glance visibility of progress against actions required to ensure patient safety and helps commissioners and GP practices to provide assurance of compliance.

MLCSU Medicines Management and Optimisation (MMO) team working with GP Practices identified the burden on clerical and clinical staff to identify, share, action, and follow-up on medicines safety alerts. This led them to develop the Medicines Safety Assurance Tool or MSATTM that provides a systematic horizon scan of medicines safety information, and a means for commissioners and GP Practices alike to record actions, monitor implementation and ultimately provide assurance of compliance.

Over the last seven years, the team has developed and evolved the MSATTM into an at-scale innovative solution already utilised by 25 Clinical Commissioning Groups in the Midlands, Cheshire, Merseyside and Lancashire.

Its adaptability allows the tool to easily be tailored to local needs. The MSATTM is designed to meet the needs of individual GP Practices as well as Safety Committees, and provides effective governance and oversight to a larger network and organisation.

Each alert is listed with a recommended action and priority level via RAG status. The completed document is a permanent record that demonstrates compliance and gives assurance to patients, commissioners and regulators that care providers are meeting their NHS obligation to patient safety.

The primary purpose of the MSATTM is to reduce patient harm due to medicines. The data below shows by CCG the impact the MSAT had over a year:

  • 51 safety alerts were identified
  • 100% of the alerts were communicated in a prescribing newsletter to GPs, the CCG and community pharmacies
  • 75% of the safety alerts were implemented through decision support software
  • 70% of the alerts prompted a recommendation to complete a search of practice clinical systems.

As an innovative way to capture, record, and act upon safety alerts associated with medicines and medical devices, MSATTM can easily be shared at scale.

 “The MSAT is a highly valued resource for Wolverhampton CCG. MLCSU have worked to improve and develop this tool over a period of time to meet the CCG needs. The tool has proven to be an excellent checklist that helps the CCG take appropriate actions around patient safety. The tool is also used regularly to inform the content of our internal assurance committee report.”
David Birch, Head of Medicines Optimisation, Wolverhampton Clinical Commissioning Group

Wellbeing conversations with health and care staff

We helped health and care leaders in the Midlands to take a transparent, collaborative approach to uncovering opportunities for improvement in staff health and wellbeing and creating an actionable plan for the whole region.

Background

The Be Well Midlands programme created an opportunity for everyone working in health and social care in the Midlands to have a conversation about wellbeing by sharing thoughts, ideas and experiences in a safe, anonymous environment. This covered 260,000 staff across 11 integrated care systems (ICSs) and 81 NHS organisations.

Action

The NHS Midlands and Lancashire CSU (MLCSU) Business Intelligence and Improvement Unit helped with collecting information on existing health and wellbeing interventions and understanding of potential barriers to access. We worked with a third sector organisation (Clever Together) to facilitate staff engagement and gather insight.

We used workforce intelligence and triangulated data with population and wider inequalities. For example, sickness absence data may suggest a higher absence for BAME staff during the last 12 months. We looked into how this correlates to the health inequalities data for specific areas. This created comprehensive profiles based on population and workforce analysis, and it provided the basis on which ICSs across the Midlands could shape and develop health and wellbeing strategies.

The overall aim was to eventually have the Be Well Midlands work on the national agenda and be held up as a gold standard service.

Impact

The aim of the programme was to create an action plan that will improve wellbeing provision for people working in health and care – so that they can continue providing exceptional care to people living in the Midlands.

It created a first-of-its-kind workforce and population profile across the 11 ICSs. Leaders will now interpret it to develop health and wellbeing strategies and ensure that health inequalities in the workforce are addressed.

“The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) were recommended by another NHS organisation and I am so pleased to have made the connection.  From the first exploratory meeting, through the contract arrangements, to the final product itself – MLCSU colleagues were professional, knowledgeable, supportive and flexible, recognising the challenges of delivering within an NHS environment in the context of COVID and vaccination as a condition of deployment. 

“Nothing was ever too much of an ask for any of the team – always there to listen, support the programme and offer assistance to ensure successful delivery. 

“I am proud to say that these colleagues formed a trusted and reliable team, providing not only important value and contribution to their own role in delivery, but significant input on other factors of the programme that were delivered by other partners. 

“The skills that the team brought to the programme were invaluable, understanding the programme outcomes and recommending how best to support delivery.  The team always made themselves available and valued their understanding of an NHS environment to ensure the final product was delivered within context.”

Vicky Self, Programme Manager, Regional (Midlands) Enhanced Health & Wellbeing Programme

Increasing referrals to diabetes programme

We engaged with primary care providers to streamline the process for referrals into the National Diabetes Prevention Programme, and we contacted eligible patients directly to motivate a referral into the programme. Both of these activities resulted in a significant increase of referrals within the Black Country and West Birmingham area.

Background

We were commissioned by Black Country and West Birmingham health system to engage with GP practices and directly with patients to increase referrals into the National Diabetes Prevention Programme (NDPP). The NDPP is designed to support adults who are at a high risk of developing type 2 Diabetes Mellitus (T2DM). Participants are referred into a structured educational programme and attend a series of group sessions to empower them to make sustainable lifestyle changes to reduce their risk of developing T2DM.

Action

The collaborative project team between NHS Midlands and Lancashire CSU (MLCSU) and the health system provided a coordinated response to help increase referrals from primary care. This involved:

* A dedicated email inbox helpline for NDPP queries from primary care
* Pathway documents to provide practical information to support practice engagement and implementation of NDPP
* Development of clinical systems searches to identify patients eligible for referral to the NDPP.
* Direct discussions with eligible patients by pharmacy to encourage referral to NDPP
* Development of electronic transfer documents (EDT) including approved clinical language for IT systems (SNOMED codes) to inform practices of patient discussions.

An early implementation test with the help of Thornley Street GP Practice was fundamental to the success of the project, refining processes for rolling out to other practices.

Impact

Figures from the NDPP provider (Ingeus) show that referrals from primary care have almost doubled in the period since MLCSU engaged with practices – 799 referrals, compared to 364 in the year before.

Since the programme commenced we have:

* Contacted directly an additional 1930 patients and referred 1144 of these to the NDPP. This is a 59% referral rate for patients that answered the call
* Engaged with 21 GP practices in the Black Country and West Birmingham region
* Worked collaboratively with Ingeus and primary care commissioning leads to maximise GP practice engagement.

Diabetes prevention programmes can significantly reduce the progression to T2DM and lead to reductions in weight and glucose compared to usual care.1

1 A systematic review and meta analysis assessing the effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes mellitus in routine practice https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733053/PHE_Evidence_Review_of_diabetes_prevention_programmes-_FINAL.pdf

“Thank you very much for all your support and assistance. Clearly this exercise has been very useful. I will share the results with our team.“

Ikbir Kaur | Practice Manager, Hilltop Medical Centre

MLCSU-supported finance team win award

The NHS Midlands and Lancashire CSU Finance Team have been supporting the North Staffordshire Combined Healthcare NHS Trust by providing all their financial accounting. At a recent ceremony, the finance function at NSCHT won the West Midlands Healthcare Financial Management Association (HFMA) Finance Team of the Year Award.

In recognition of our Finance Team’s excellent work and support in helping the trust develop a finance function which has won the award, NSCHT’s Deputy Director of Finance, Kimberli McKinlay, said:

‘Thanks for all your support and hard work, this is your award too!’

A huge congratulations to everyone involved!

MLCSU director named HSJ100 wildcard

Andi Orlowski, Director of the Health Economics Unit, part of NHS Midlands and Lancashire CSU (MLCSU), has been named as one of the 20 “wildcards” for the 2022 HSJ100.

Andi Orlowski, Director of the Health Economics Unit

The HSJ100 is a list compiled by the Health Service Journal of the 100 most influential people in health. The HSJ100 wildcards are people and organisations with no formal power over the direction of national heath policy but who have ideas that could and should influence it.

The HSJ explains: “to select the final 20, we focused in on those who were well placed to make an impact on the particular challenges of the forthcoming 12 months.”

Andi has been named on the list alongside GPs, journalists and notable staff and directors from other NHS organisations, charities and the private sector.

The HSJ continues:

“Population health management may be a buzzword but it describes an important concept. Understanding the health needs of communities will be crucial for ICSs and will help recovery by ensuring the right services are provided to meet those needs. Mr Orlowski and his team provide the expertise and analytics to make this happen. He is also a strong and informed voice on how data can identify health inequalities and how such gaps can then be addressed.”

Find out more about the Health Economics Unit at https://healtheconomicsunit.nhs.uk/

Find out more about the HSJ100 wildcards at https://www.hsj.co.uk/hsj100-the-wildcards/7032608.article

Schedule of MLCSU experts at NHS ConfedExpo

This month NHS Confederation is uniting with NHS England and NHS Improvement to deliver one of the most significant events in the health care calendar: NHS ConfedExpo. We are pleased to announce our schedule of experts who will be available at stand E115 to answer all your questions and show you around our services.

Wednesday 15 June

10am to 11am How chatbots can reduce your patient waiting lists
11am to 12pm Innovative medicines management
12pm to 1pm How we help transform your clinical services and collaborate with partner providers
2pm to 3pm Maximise your estate with UBook Room and Desk Booking System
3pm to 4pm Personalised Healthcare Commissioning

Thursday 16 June

9am to 10am Supporting your workforce needs with TalentONE
11am to 12pm Transform and innovate your digital and IT footprint
1pm to 2pm Helping you to deliver inclusive, equitable care and business operations

Visit at these times to meet experts about solutions that might help you.

The conference and exhibition takes place 15-16 June in Liverpool. It brings together senior leaders from the NHS, SMEs, commercial organisations, charities and more to discuss key issues, share successes and explore how we can support each other to improve patient care.

Book your NHS ConfedExpo pass here: https://lnkd.in/guJb8PyB

Click the link below for a pdf version of our schedule, and a map showing how to find us.

Enabling remote healthcare monitoring

We designed and implemented a programme of transformation to enable remote monitoring across healthcare in the Black Country and West Birmingham health system.

Background

In 2021, NHS England added remote monitoring to the national priorities and operational planning guidance.

Remote monitoring is a golden thread that spans the continuum of care, including inpatients, outpatients and primary care in the community. It also includes Virtual Wards and Hospital at Home.

For Black Country and West Birmingham health system, remote monitoring aligned with another key goal: striving for patient-centred care by digitising and personalising healthcare.

The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) launched a multi-year digital transformation programme to provide remote monitoring at pace in Black Country and West Birmingham.

Action

A programme of this size required MLCSU to deploy hundreds of remote monitoring solutions, for everything from deterioration of care-home residents for primary care to acute step-down virtual wards in secondary care.

Each deployment required its own set of procedures, which included separate documentation, information governance, clinical models, bespoke care packages, training and testing.

We began by assigning a team of five at the customer organisation to increase capability and capacity. Three areas were key to the success of this project:

Establishing processes

* requirements gathering and specifications documentation
* overarching information governance
* clinical safety documentation, including DCB0160
* pathway and standard operating procedure redesign and input into amendments

Boosting awareness and engagement

* educating clinicians on the remote monitoring solutions available in their respective areas and ensuring they know how to use them

Ensuring follow-up

* establishing a pathway for the reporting and analysis of activities from the practice or trust, all the way to national level
* delivering reviews, top-up training and incremental adjustments to the solutions wherever necessary.

Impact

Our services added the extra capability and capacity that the system needed to meet the priority of remote monitoring.

Early statistics demonstrate a significant reduction in metrics like clinical hours spent, length of stay and the number of A&E / paediatric assessment unit visits. These factors have a substantial ripple effect, since freeing up a bed in a service improves flow throughout the system and releases clinician time.

“Black Country and West Birmingham (BC&WB) CCG called upon MLCSU to assist with the timely delivery of remote monitoring at scale. As we head towards FY22/23 we expect to really capitalise on the benefits of remote monitoring.”

Mike Hastings – Chief Information and Operations Officer, ICS Digital Lead, BC&WB CCG

“We’re incredibly excited on the benefits remote monitoring will deliver for our children, young people, their parents and carers. It feels like we’re scratching the surface of what’s possible.”

Lucy Rozga – Matron, Paediatrics and Neonates, The Dudley Group NHS Foundation Trust

“MLCSU have been able to deliver an effective service at pace. It is great to work with people with such knowledge and expertise.”

Dr Zishan Yousef – GP, Clinical Safety Officer and Remote Monitoring Co-Clinical Lead, BC&WB CCG

“Remote Monitoring is a key enabler for our clinicians in the delivery of quality Out Of Hospital healthcare”

Bal McAdam – Senior Strategic Commissioning Manager, Out of Hospital Services, BC&WB CCG

Improving care for people with disabilities

We codesigned and delivered a transformation programme for the improvement of care for people with learning disabilities and/or autism.

Background

NHS England and NHS Improvement set out key priorities for commissioners within the Learning Disability and Autism (LD&A) Programme and the NHS Long Term Plan. These include improving community-based preventative support, transitions into adulthood, and our understanding of best practice models. They also wish to address issues with workforce, funding flows, and the lack of appropriate housing to prevent admission to hospitals, and to facilitate discharges from hospitals. The NHS Midlands and Lancashire Commissioning Support Unit and Shropshire, Telford and Wrekin health system co-created an approach to develop and deliver a robust Transforming Care Programme (TCP) to meets these priorities.

Action

Our TCP Service provides a case management function for NHS funded individuals outside of continuing healthcare (CHC). The service aims to reduce expensive hospital admissions, and improve care outcomes and experiences for individuals with LD&A and complex needs. We provided an ongoing clinical case management service to offer robust support mechanisms for patients.

Deliverables:

* Supporting TCP policy development and stakeholder management to enable robust referral management
* Overseeing, governing, and attending Care, (Education) and Treatment Reviews
* Developing and maintaining a dynamic support register to update an individual’s risk of admission to inpatient or residential units in real time
* Brokering and sourcing care packages to meet individuals’ needs
* Providing clinical case management which includes engaging the individual, assessing, planning, linking with resources, consulting with families and collaborating with clinical and social care partners
* Providing a quality assurance process for referral management
* Attending inpatient discharge review meetings and discharge planning
* Implementing a robust care review process with local authorities where required.

Impact

* Improved person-centred care and individualised packages of support for people with learning disabilities and/or autism
* Brokering care in the most appropriate environment with effective use of resources
* Effective use of expertise, promoting multi-disciplinary team working
* Individuals are active participants in their care process
* Ensuring the role of carers are active participants in the reviewing process
* The responsibilities of partner agencies, ensuring they are active participants in the reviewing process
* Family members or carers feel well supported
* Individual satisfaction (involvement, decision-making, information, respect and dignity)
* Carer satisfaction
* The individual is treated with dignity and respect

Achieving the best from pharmacy teams

We provided a tailored package of strategic and operational support to a newly formed pharmacy team at a primary care network, helping them increase the rate of structured medication reviews.

Background

When a newly established Primary Care Network (PCN) covering thirteen GP Practices in the Northwest of England approached MLCSU for strategic and clinical support, MLCSU responded by developing a tailored package of year-long support that included clinical supervision, joined-up work planning and strategy development. MLCSU aimed to ensure the PCN achieved its Network Contract Direct Enhanced Services (DES) and Investment & Impact Fund (IIF) targets.

Action

An initial workforce survey highlighted learning needs. We provided senior pharmacist expertise in workforce development, outcome reporting methods, training and clinical supervision:

* Training and clinical supervision – monthly sessions with supported discussions forums to review any clinical issues
* Expert support and peer review – monthly one to one’s with senior MLCSU lead pharmacists and individual development plans with agreed objectives for the next 12 months
* Strategy and workplan development – structured workplan developed in line with DES and IIF requirements
* Operational support – a suite of standardised clinical system searches and tools were shared with the team to help them to identify patients for priority Structured Medication Reviews (SMRs).

Impact

The tailored package of support we developed included training on SMRs, the Community Pharmacy Consultation Service, Antimicrobial Stewardship, Area Prescribing Committees (APCs), Chronic pain, Opioids and medicines related safety. Local speakers were brought in to provide expert advice including the North West regional antimicrobial resistance lead, the local Controlled Drug Accountable Officer and the pan Mersey APC Secretariat.

Clinical supervision sessions provided a safe space for team discussions and interaction with experienced leads for mentorship and support. Group discussions often focussed on how work could be standardised. The team have now successfully implemented a scalable, hub-based model and operate as part of an agreed workplan and wider primary care strategy. Six extended training & clinical supervision sessions were held for the PCN Pharmacy team with a forum for team discussions, with mentorship and expertise provided by experienced MLCSU leads. This was complemented by monthly one to ones for all six clinical staff within the PCN.

Outcomes

* The PCN rated the MLCSU sessions as excellent, delivering improved pharmacist competencies through the use of MLCSU resources to meet their learning needs.
* The PCN progressed from 41 to 437 SMRs during the year with an additional 2,462 medication reviews undertaken.

“I really value [MLCSU’s] input and support. I would definitely like to see them support us for at least the next year.

“I enjoy the clinical supervision sessions, and really value the 1:1 support with the team. I hope that our Pharmacy Team relationship with MLCSU can continue as they support the direction of our growing and developing team.”

Pharmacist, St Helens South Primary Care Network

“I would like to say thank you to MLCSU for the service provided to date. I have seen an improvement in the pharmacy team and would like to continue on this trajectory.”

Dr Chibuzo Orjiekwe, St Helens South Primary Care Network

MLCSU at Health and Care Apprenticeship Awards

This June will see the first ever Lancashire & South Cumbria NHS Health & Care Apprenticeship Awards taking place. The awards recognise the outstanding contribution and achievements of apprentices from across Lancashire and South Cumbria have made over the last year. Those shortlisted must be working towards, or have recently completed an apprenticeship in an NHS, health or social care organisation within the region of Lancashire and South Cumbria.  

Our nominees

We are thrilled to announce that we have been shortlisted for the following awards:

* Above and Beyond Award
* Rising Star Award
* Employer of the Year Award.

We are extremely proud to have been nominated. Our strong track record in workforce resilience is the result of our dedication to developing our employees and offering an exciting place to work. Find out more about human resources and organisational development services in our Workforce Resilience section.

The winners will be announced at the awards ceremony taking place on Friday 17 June at Stanley House Hotel and Spa. A huge congratulations to all nominees and good luck to everyone involved!

We’re exhibiting at NHS ConfedExpo, 15-16 June

Join us at the NHS Confederation’s annual conference, taking place in Liverpool this summer. Delivered in partnership with NHS England and NHS Improvement, NHS ConfedExpo will bring together leaders from across the health and care profession for a two-day conference and exhibition.

The landmark event will explore the five key themes of People, Quality & clinical improvement, Health Inequalities, Collaboration & partnerships and Driving recovery. Book your pass and hotel accommodation online. It is set to be one of the most significant events in the health care calendar.

Be inspired by our expert speakers, choose relevant sessions that matter to you from over 140 hours of engaging content and meet experts and explore new products on the exhibition floor. 

Bookings are now open and can be secured online. 

https://www.nhsconfedexpo.org/welcome?utm_source=affiliate_exhibitor&utm_medium=organic&utm_campaign=booking_launch

Discovering efficiencies and service improvements

We helped an NHS trust analyse and visualise data on key performance indicators with the aim of releasing efficiencies and to assess inequalities in service provision on a range of areas.

Background

Leicestershire Partnership NHS Trust (LPT) were planning to take a systematic approach to transforming their services by reviewing a basket of indicators by service line. The aim was to enable efficiencies as part of their three-year financial plan, and to assess inequalities in service provision.

Action

The Midlands and Lancashire Commissioning Support Unit created a comprehensive report for LPT at the end of the 2021/22 financial year. The report provided detailed analysis of each of the indicators in the basket by service line and made recommendations for next steps based on the findings.

Impact

We provided insight on the following indicators:

* Workforce analysis – staffing profile and spend
* Average caseloads
* Travel undertaken
* Estates use, including travel spend
* Clinical activity: commissioned volume versus actual volume by contract type
* Demographic growth (historical and forecasted).

The trust had not analysed data in this way previously, and directors said that the visual representation (by service) is likely to support business cases to move forward much more quickly than previously.

The trust has since implemented new projects to address issues uncovered by the report such as recruitment gaps and reducing reliance on agency spend.

Claire Lacey, Programme Manager, Leicestershire Partnership NHS Trust, said: “The report was very well received by the Transformation Committee who have reviewed the initial findings and recommendations provided by MLCSU.

“The maps and visual representation of our patient journey through Covid, is showing really positive outcomes already, with the speedy implementation of new projects to address areas we uncovered – specifically recruitment gaps and reducing reliance on agency spend.”

Recovering hospital utility costs

We are helping hospital trusts identify the potential to recover energy costs from telecom devices mounted on the roofs of their buildings.

Background

NHS hospital buildings in England often house mobile telecom operators devices on their roofs. The issue identified is that NHS trusts often do not recover the costs of electricity and power consumption in relation to rooftop communications installations.

The potential rebates can be in the thousands depending on individual trust circumstances. Claims of up to 12 years back can be submitted.

The purpose of this project was to deliver savings for NHS trusts in support of their cost improvement programmes.

Action

* Desk top analysis to confirm the status of the electricity usage by each individual telecommunications tenant.
* Site audit to confirm the supply arrangements and take measurements to determine the usage.
* Determine the lease arrangement relating to electricity recovery of each individual tenant.
* Liaise with the tenants and their agents to confirm the status of their supply and their liability to the NHS.
* Calculate historic recovery sums for either 12 years (for contracts under deed) or 6 years (for standard agreements or to the date last invoiced).
* Determine if any use of the NHS’s electricity and power supply can be recovered.
* Invoice each individual tenant and recover the costs owed.
* Provide a report for each client with recommendations for recovery going forward

Impact

The George Eliot Hospital NHS Trust was able to recoup circa £170k from electricity costs.

Review of other trusts’ cost is currently ongoing, and we expect we could deliver similar savings for potential clients.

Sean Grant, Waste and Sustainability Manager, George Eliot Hospital NHS Trust, said: “Thanks to NHS Midlands and Lancashire CSU (MLCSU) for engaging George Eliot Hospital NHS Trust in the potential recovery of energy costs generated by mobile masts. We successfully backdated 10 years’ energy costs, which have contributed towards cost improvement programmes at the Trust. 

“The whole process from start to finish was made easy with clear engagement from MLCSU to ensure the project was successful. We fully recommend the service you provided in energy cost recovery from mobile masts. Thank you!”

Vaccine safety at PCN vaccination centres

We ensured that vaccination centres functioned with safety at the highest level by training staff and providing ongoing senior pharmaceutical support.

Background

When the COVID-19 vaccination programme began, our Medicines Optimisation team offered support to all eight Primary Care Network (PCN) vaccine centres across Chorley and South Ribble and Greater Preston.

Action

The team completed 10 hours of training provided by the local Hospital Trust and Health Education England. This ensured each member of the team could competently dilute the vaccine using aseptic technique and had the required knowledge to confidently respond to queries. We then supported the vaccination centres with:

* Dilution of Pfizer/BioNTech vaccine
* Training other staff how to competently dilute the vaccine
* Escalating queries from PCNs and vaccination centre staff to the local System Vaccination Operating Centre (SVOC)
* Storing vaccines appropriately and maintaining the cold chain
* Reporting defective or damaged vials via the Yellow Card Scheme and returning to the manufacturer.

We also provided senior pharmaceutical support including:

* Clinical assurance of vaccination centres
* Development and ratification of local policies
* Clinical support to the CCG vaccination programme lead
* Key information on legal and pharmaceutical issues
* Readily available advice to clinicians.

Impact

Seven PCN vaccination centres across Chorley and South Ribble and Greater Preston were supported by the MLCSU Medicines Optimisation team.

Senior pharmaceutical input enabled effective and efficient delivery of the vaccination programme including policy changes, clinical guidance, legal matters and cold change management.

We ensured the vaccine vials were stored and diluted safely by training many healthcare professionals across the vaccine centres.

New paperwork was created to ensure the processes of storage, dilution and administration of the vaccine followed standard operating procedure and that they were auditable and translatable across all sites.

Fridges were regularly reviewed and assessed for breaks in the cold chain to ensure minimal vaccine wastage.

We helped the operation of the vaccination bus during ‘Phase Two’ of the vaccine roll out. The bus delivered the vaccine to the heart of areas of Preston and Chorley where uptake had been poor.

Support was provided 7am-8pm, seven days a week, through flexible working and shift patterns to ensure there is cover during all PCN vaccination centres operating hours.

Andrea Trafford – PCN Non-Clinical Vaccine Lead, Chorley Central PCN, said: “The guidance and support that the team have provided has been invaluable in our journey in mobilising the COVID vaccination programme. Their expertise has ensured that our vaccination centre has functioned with safety at the highest level and the team are always happy to support and provide cover when asked.  As a Primary Care Network, we could not have asked for better support, the whole team should be commended, without them, our delivery programme may not have been as successful as it is. Thank you to you all, you have been outstanding and unwavering in your support to us all.”  

Gillian Stubbs – Practice Manager, Leyland PCN, said: “Fantastic support and thank you to all the team, you are amazing.” 

Tara Oxby – Pharmacy Technician, Chorley East PCN, said: “I just wanted to say a personal thank you to all the team that has helped us out at the COVID-19 vaccination centre, it has been an absolute pleasure working with each and every one of you, you have all been amazing! We really wouldn’t have been able to run the Pfizer clinics without your help.”

Brian Hann – PCN Non-Clinical Vaccine Lead, Chorley and South Ribble Health Network, said: “The amazing turnaround response to our request was testament to the teamwork approach I think we should all be proud of. On the days the Medicines Optimisation team are on site – everyone is great and works seamlessly as part of the wider delivery team.  Even when – unfortunately due to the nature of it – they are often left to themselves in the other end of the building!! In summary – I’d like to say the support has been and continues to be invaluable and I think it’s just one example of how Central Lancashire has worked so well together on this programme and other pandemic services.”

BI supports efficient and equitable vax service

Our business intelligence experts helped the Lancashire and South Cumbria COVID-19 Vaccination Programme to provide an efficient and equitable service.
We used local GP systems and national sources of data to fashion datasets providing maximum analytical value; constructed detailed planning tools to permit complex scenario modelling with clear and actionable outputs; produced operational and performance reports relating to various aspects of the programme; provided swift and effective responses to queries at a local, regional and national level, as well as sharing best practice in business intelligence.
This helped stakeholders make data-driven decisions in key areas of operational delivery throughout the rollout. Access to detailed and highly adaptive insight contributed to achieving many of the vaccination programme’s core objectives.
In particular, the daily Situation Report provided unparalleled access to information on site activity and population uptake across the health system. It enabled leaders to closely monitor programme delivery and the impact of their decisions, and to respond proactively to operational challenges as and when they arose.
Similarly, we used data on GP systems and existing data on our established business intelligence platform to produce reports which were invaluable tools in facilitating ad hoc deep-dive analyses of vaccination uptake across a diverse geography. They also supported wider system work around population health management and the reduction of health inequalities.

Innovative booking system reaches milestone

UBook, the resource-booking system designed by NHS Midlands and Lancashire Commissioning Support Unit, has just signed its 20th customer.
Many NHS organisations have traditionally reserved rooms, desks and parking spaces via a combination of spreadsheets, paper diaries and Outlook calendars. Staff often had to call multiple sites to locate a suitable room, and trying to change or trace a booking was difficult.
With UBook, staff can reserve meeting rooms, clinical rooms, hot desks, zones, parking spaces or any physical resource such as a projector with just a few clicks. The service can be accessed 24/7, via any browser, on any device.
Originally developed in 2017, UBook came into its own when the COVID-19 pandemic hit in 2020. Its developers responded rapidly, adding in social distancing measures – particularly useful for hot-desk reservations – and enabling organisations to better plan for hybrid working post-pandemic. A useful evolution of these features is that UBook can now offer estate managers a dashboard showing live and trended occupancy rates, non-check-in profiling and recharging data for invoices.
UBook’s rapidly growing customer base includes nine trusts, five clinical commissioning groups (CCGs) and three of the four commissioning support units, as well as its first integrated care system and local authority clients.
Bill Douglas of MLCSU explains how the team has regularly beaten off commercial competition on both feature set and price: “Our pricing model is tier based, so it’s reasonable and fair. You only pay for as many rooms and desks as you publish. That means affordability for a small network of GP practices and great economies of scale for a large acute.”
As for the future, Douglas says the product roadmap is continually evolving.
“We’re offering demonstrations of UBook every week and would love to continue adding more organisations to our customer base. The benefit of using UBook is that it’s a tool built by the NHS, for the NHS. Every feature is the result of a trust or CCG asking for it, and we have a closely managed collective roadmap for UBook’s future releases.”

How can digital advances help a greener NHS?

Lancashire and South Cumbria’s New Hospitals Programme aims to develop new, cutting-edge hospital facilities. The Programme’s Case for Change report, states that current infrastructure does not support either the digital or environmental ambitions for hospital facilities in the region.

The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) is providing digital consultancy services to the programme. In an earlier blog, we looked at why digital advances are so important to new hospitals. This time, Steven Hipwell, Senior Programme Consultant at MLCSU and Digital Lead for the New Hospitals Programme, discusses hospital sustainability and how new technology supports the programme’s vision for creating state-of-the-art, environmentally-friendly facilities.

Why is sustainability such a priority for the New Hospitals Programme?

As outlined in the New Hospitals Programme’s Case for Change report, our current infrastructure does not support either our digital or environmental ambitions for hospital facilities in our region.

The NHS has set out a plan to deliver net zero carbon services by 2040, called Greener NHS 2020. New infrastructure and related digital services will be crucial to building more efficient spaces, using them more effectively and reducing travel by delivering care closer to home. New hospital facilities in Lancashire and South Cumbria will follow this approach, playing our part in creating a greener NHS.

Our new facilities will be compliant with Health Building Notes, the best practice guidelines for healthcare buildings. They’ll also achieve an appropriate BREEAM (Building Research Establishment’s Environmental Assessment Methods) rating, the world’s leading sustainability assessment method.

How can digital technology help to achieve those ambitions?

Digital technology is one of the ways in which we’ll be able to deliver sustainable, high quality and accessible care. However, the poor condition of our current hospital estate and backlog of maintenance needs means our buildings are not as kind to the environment as they could be and are expensive to run.

Digital technology can improve comfort and carbon emissions, which will also help with the efficient and cost-effective running of the new hospital buildings. Some examples include:

* The building’s controls for services such as heating, lighting, ventilation, and air conditioning can be programmed to automatically adjust to a range of internal and external conditions to optimise comfort, operating costs and sustainability
* Heating, lighting and other services can be programmed against occupancy levels to help measure and manage utilisation
* Devices and services can be automated to switch on in preparation for expected use, and power-off accordingly
* Location and identity management technologies can be used to track and pinpoint the whereabouts of people and physical assets for access to services, security and safety, such as in the event of an evacuation.

Are there any examples of where this is working already?

Intelligent buildings have been around for years, but have been limited by the technology available. That is changing as more and more advances take place. There are many case studies from around the world, and nearer to home, of digital innovation helping hospital facilities to become more sustainable.

Wythenshawe Hospital in South Manchester was the first hospital to introduce biomass boilers, heating the facility using sustainable wood pellets instead of fossil fuels. This gave the hospital the capacity to reduce carbon emissions by 3,400 tonnes per year. This innovation was one of the reasons the hospital is known as ‘Britain’s Greenest Hospital.’

The VA Caribbean Healthcare System is a healthcare network for veterans in Florida, Georgia and the Caribbean. Its new Mayaguez Outpatient Clinic produces up to 90% of its energy from solar panels. This new site also captures and stores storm water for safe reuse in certain clinical operations.

In proposals for new hospital facilities in Leeds, sustainability provisions being considered include; rainwater collection and biofiltration, the capture and reuse of wasted heat, outdoor gardens and green space with provisions for bee, bat and bird hotels and onsite solar energy harvesting.

Sustainable buildings are a major priority for the New Hospitals Programme. Digital technology has a big role in making that happen.

Informing COVID-19 vaccination centre planning

Our dynamic heat maps showed where vaccine uptake was lower, where there was a higher concentration of social care providers and other population analyses by different criteria to inform the planning and placement of COVID-19 vaccination centres.

Background

The Birmingham and Solihull Integrated Care System (ICS) and University Hospitals Birmingham NHS Trust required support with the planning and rollout of COVID-19 vaccinations across their geography. There was a need to know where to place vaccination sites and direct resources, where the past, current and planned future vaccination sites were, and to evaluate the rollout.

Action

We provided a series of ‘heat maps’ showing areas with the highest proportion of patients at a greater risk of COVID-19 to support the placement of vaccination sites and the direction of resources.

The maps showed analysis of the population by small areas (about 1,500 residents) for the following criteria:

* Deprivation
* Population density
* Proportion of BAME residents
* Proportion of housebound residents
* Proportion of obese residents
* Location of residential and care homes.

Regular updates were provided to the maps to include COVID-19 vaccine uptake and current and proposed vaccination centres across the geography.

Using the ‘R’ data science tool, we pioneered a new way of sharing the maps which allowed quick and easy access. Interactivity enabled the vaccination team to zoom in or out and filter information.

Impact

In January 2021, we mapped vaccination centres alongside the 1,253 health and social providers across Birmingham and Solihull. At a crucial point of the vaccine rollout, this enabled the vaccination team to quickly advise providers where their nearest vaccination site was located.

In April 2021, we mapped the residency of patients vaccinated at mass vaccination sites. This enabled the team to see where patients were travelling from to be vaccinated and evaluate whether patient travel distance could be reduced.

In August 2021, we mapped uptake of the COVID-19 vaccine, split by ethnicity and gender, which supported the planning of targeted vaccination vans and sites in areas of lower uptake and with greater health inequalities.

By December 21, the regular map of current and proposed vaccination sites included 66 permanent vaccination sites and 86 sites which mobile vaccination vans had visited.

Increasing the uptake of health checks

We helped integrated care systems increase numbers of annual physicals health checks for patients with severe mental illness by finding and implementing suitable technology to enable healthcare staff to complete them in a single patient visit.

Background

As part of the national policy outlined in the five-year view to increasing annual physical health checks (APHC) for patients with severe mental illness (SMI), 11 integrated care systems (ICSs) across the Midlands needed to increase the uptake.

APHC helps prevent the development of more serious illnesses by identifying and treating health issues early.

The checks include monitoring body mass index, blood lipids, blood glucose, blood pressure, smoking and alcohol use, and take place across a variety of care settings, including in the community, at a care home or in the patient’s home.

The goal is to increase the number of these checks by 10,800 through the use of digital technology by the end of June 2022, to cover the national targets of 60% of patients on the Midlands SMI register.

Action

Midlands and Lancashire Commissioning Support Unit (MLCSU) proposed to scope, define and deliver the technology needed to deliver these checks during a single patient visit.

We are working with each ICS to discuss challenges, share best practices and ensure our solutions fit into their existing pathways for patients with SMI. We are also:

* acting as a central point of contact in the Midlands to raise awareness and provide project management support
* holding the event of a technology-enabled solution with Academic Health Science Network where suppliers can present their devices for ICS representatives to express interest
* operating a single procurement exercise to acquire technology on behalf of all ICSs
* ensuring a streamlined rollout by producing all regulatory assessments, training, and clinician safety assurance materials
* sharing data performance so each ICS can monitor their progress
* integrating the physical and mental health pathways to allow the roll out of technology
* ensuring the continual review of data coming from each ICS and flagging opportunities to complete full health checks.

Impact

This project is successfully contributing to increasing the uptake of annual physical health checks for patients with SMI.

* Across England, the Midlands has seen the largest increase in full health checks in 2021/22 (32.5%).
* The number of complete checks in the Midlands far exceeded the national averages for each quarter (increases of 2,622 [Q2] and 4,915 [Q3]). We estimate the total number of complete checks to be 34,124 by the end of 21/22, surpassing our goal.

A key factor in the success of this project is the portability of the technology, meaning healthcare staff can carry it to any location. This has allowed for more opportunities for patients to be offered a physical health check.

This project provides a model for sharing best practices and engagement across systems by using a joined-up approach to better serve patients. Full data on the impact of this project will be available in July 2022.

Eloise Barnes, Senior Delivery Manager, Digital Health Team, NHSX, said: “MLCSU’s direction and leadership brought clinicians and managers together to focus on the task, and their coordination and delivery of ICS level guidance to assist procurement and other governance standards has been invaluable in assisting ICS areas nationally.”

Darren Vella, Mental Health Clinical Network Senior QI Manager, NHSEI, said: “Together we have made the policy and clinical case for change, supported the team to mobilise, and embedded into regional functions and relationships to support delivery of this policy area. This integrated way of working has supported systems to understand the integrated nature of how this solution needs to operate whilst giving a cohesive NHS England message. Our collective approach has maximised our impact and way of relating back to systems – an approach we would seek to continue.”

Helping North Staffordshire trust pay suppliers

We quickly mobilised financial services helping an NHS trust to process and pay supplier invoices.

Background

In April 2021, a cohort of learning disabilities and mental health patient cases managed by Staffordshire Clinical Commissioning Groups were transferred to North Staffordshire Combined Healthcare Trust (NSCHT). The NHS Midlands and Lancashire Commissioning Support Unit’s At Scale Customer Finance team, were approached by NSCHT to take on accounts payable tasks to ensure their supplier invoices were processed and paid.

Action

In preparation, we met with the clients to fully understand their service requirements and learnt more about:

* Volumes of invoices
* Verification process
* Approval hierarchy
* Escalation process.

Using both this information and our previous experience of in-housing finance procedures for our other customers, we were able to quickly train our experienced Accounts Payable team to start supporting NSCHT.

Impact

As a team of more than 50 experienced transactional finance professionals, we were swiftly able to meet our customers’ requirements to ensure supplier invoices were registered onto their accounting system.

We mobilised the service efficiently within four weeks of learning about the work.

When NSCHT were experiencing resource issues, we stepped in to ensure due diligence was followed in finance processes.

The MLCSU team have since continued to provide ongoing support and are helping make a positive impact towards the Better Payment Practice Code by making sure the Trust’s invoices are registered, suppliers notified of any issues preventing payment and generally building a solid rapport with suppliers by providing a quality service.

Rachel Heath, Project Accountant, North Staffordshire Combined Healthcare NHS Trust, sad: “The Accounts Payable team have been very supportive since the two services integrated to the trust. They have been helpful and flexible as we continue to look for new ways to make both the invoicing and forecasting processes smoother for the finance and operational teams. When we have raised matters that require urgent attention, the MLCSU team have been quick to act upon these in order to resolve as quickly as possible.”

Why digital advances are so important to hospitals

Lancashire and South Cumbria’s New Hospitals Programme aims to develop new, cutting-edge hospital facilities that offer modern healthcare, and digital advances are a fundamental factor. The NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) is providing digital consultancy services to the programme. In the first of two blogs, Steven Hipwell, Senior Programme Consultant at MLCSU and Digital Lead for the New Hospitals Programme, discusses the benefits of technology in hospitals and why digital is so important for new hospital facilities.

What is your role in the New Hospitals Programme?

My job sits in an unusual place, somewhere between IT and construction. Digital can do more to support healthcare delivery than it ever has before. It’s my job to make sure that technological advances can enable comfort, health and wellbeing to everyone who uses our hospitals.

How can new technology improve hospitals for patients?

Lots of people are scared of hospitals. It’s often not somewhere you would choose to go. Patients go for very specific, sometimes nerve-wracking reasons. We want to be able to make it easier for patients to plan their visit and improve their experience when they are here.

Before patients even get to the hospital, we can make changes so that hospitals are easier to find. We can introduce clearer directions both on our hospital websites and at the buildings, with digital wayfinding.

We can create ways for patients to easily book and amend their appointments online, with as few clicks as possible. We can also make sure all information meets accessibility standards, for those who have additional needs.

Another benefit of technology in hospitals is how it makes the buildings much more inviting too. We can control and manage the lights, heating, and air conditioning with the click of a button, and make sure patient arrival is super smooth. We’ll also ensure WiFi is available and reliable for all.

Patients would also see the benefits of the improvements to patient record systems, some of which are still paper based, by moving them all to a digital system. This would ensure a more seamless approach to storing their personal information.

How can new technology improve hospitals for staff?

We would see major improvements if the many different electronic systems used by the different departments within the hospital (and other settings outside the hospital too) all work together. Digitising all patient record systems, for example, would not only improve the experience for patients, but also save time for staff as well.

Technology can also benefit our hardworking facilities teams, for example, automated ordering can also be used to re-order stock, book maintenance and look for the best deals on stock, against the procurement framework.

And of course, a more comfortable environment, enabled by digital advances, will make our staff’s general working day easier as well.

What about members of the public who aren’t great with technology? How will they cope with these changes?

We’ll be very careful to make sure that we keep the all-important human interaction element of our hospitals alongside new technology. For example, digital registration will be available for those who feel comfortable using it, to help speed up the movement of patients through our buildings. However, our staff will always be there to assist anyone who needs them, and we’ll listen to staff and patients to get their input as we introduce new technology, providing training and reassurance to everyone along the way.

Will this all need to be updated again in five years?

Probably, yes. Technology is advancing so quickly, that’s why it’s really important to make sure that the changes we make now are adaptable and flexible. Any new facilities that we build will have the infrastructure and power to adapt. For example, the cableways will be created so that they can be updated, and we’ll ensure cellular and Wi-Fi technologies are designed and co-ordinated to provide the best coverage and services.

Can technology help our hospitals become more environmentally friendly?

Digital is integral to the design, build and operation of new hospitals and their sustainability. Digital technologies are used right from the start of the process. Digital, 3D models of the hospitals are built to help the design process and a key part of this planning is sustainability.

These digital models can provide carbon output modelling for the building and make predictions for the future to ensure emissions are kept low and all performance standards are met.

Once operational, sensors can collect data and optimise building performance across a range of functions from power saving, heating, lighting, air-conditioning to ensure the best levels for comfort and safety. These same functions can be controlled even further at a local level, adjusting light levels to harmonise with natural sleeping and waking cycles to enhance patient comfort and experience, and to promote wellbeing.

Digital technology is fundamental to the sustainability of our new hospital facilities. It also ensures optimum patient comfort, safety and wellbeing which we hope, in turn, will enhance patient outcomes.

Look out for Steven’s next blog.

Combined intelligence for population health action

We helped key stakeholders in the Cheshire and Merseyside health system see combined intelligence reports on capacity and demand for health services, allowing them to respond to COVID-19 quickly.

Background

The CIPHA (Combined Intelligence for Population Health Action) platform was developed to bring together health and social care datasets within the Cheshire and Merseyside health system. The aim was to help inform key decisions when responding to COVID-19. Since October 2020, the Midlands and Lancashire Commissioning Support Unit have been supporting the CIPHA programme with business intelligence (BI).

Action

The Cheshire and Merseyside BI team have been providing daily reports to CIPHA. These reports cover COVID-19 testing, cases, deaths,  outbreak identification, hospital admissions, capacity and demand, discharge reporting, vaccination reporting and much more.

The team continue to provide a full end to end service in the tracking of capacity and demand for out of hospital (OOH) services. Support includes data processing, data quality validations and reporting, and also helping with any changes to the reports within the CIPHA platform.

Impact

We have facilitated a process to ensure that key stakeholders within the health system see CIPHA reports in a timely manner. This has informed clinical commissioning groups leads, provider trusts leads and others to make key decisions when responding to COVID-19.

The support provided in tracking capacity and demand for OOH services has helped the system leaders to understand current demand for OOH services including activity, case loads, bed occupancy and waits as related to intermediate care, community care, mental health services and social care. This has then enabled provider trusts to understand and utilise capacity in the community when discharging patients.

Helen Duckworth, Associate Director of Business Intelligence, Cheshire & Merseyside ICS, said: “It is a real pleasure working with you. Thank you to the BI team for your unparalleled professionalism and knowledge, and for investing your time and effort in doing an excellent job with a fantastically experienced hand. Nothing is too much to ask, and all our needs  are met with a smile. Having your support for the Demand and Capacity OOH Tracker meant we could rely on seeing up to date and easy to understand data, which helped system stakeholders make quick and informed decisions. ”

Helen Duckworth| Associate Director of Business Intelligence, Cheshire & Merseyside ICS

2021, our journey alongside ICS partners

2021 was, of course, another tough year for the NHS and social care. Against this challenging backdrop, the NHS Midlands and Lancashire CSU played its part in the COVID response and ongoing recovery as well as supporting establishment of integrated care systems.

Add the other innovative programmes benefiting patients that we have either led or supported and the result is a record that both surprises and pleases us to look back on. So much fitted into just 12 months!  A big ‘thank you’ goes to all our staff and partners for their hard work and immense dedication.

The Annual Review isn’t an exhaustive list – that would have been far too long – but hopefully an interesting selection of highlights and an indication of how much we can support integrated care systems.

It’s a quick read and you can find it below.

Blog: Treating people on waiting lists

There are millions of people waiting for treatment. How should we decide who gets called first? Peter Spilsbury, Director of our Strategy Unit, discusses in this blog how waiting lists are currently prioritised and how looking at richer data around complex socio-economic factors can help improve equity.

Waiting lists for elective care are in the news. The national plan has been issued, with the expectation that lists will continue to rise for some years – and that long waiting will not disappear anytime soon. Addressing this ‘backlog’ will remain a fundamental challenge for some time to come.

This raises the question of how people on the lists are prioritised. There are millions of people waiting for treatment. How should we decide who gets called first?

Previous Strategy Unit work showed that there is already inequity: richer people tend to get better access to elective treatment than poorer people. This trend emerged over the last decade. And, if we aren’t very careful, the final reckoning of how the NHS ‘recovers’ will see these inequities made much worse.

Who gets treated ahead of whom is a value judgement. No one has a monopoly on those – and there are no right or wrong answers.

To date, the NHS has largely worked by prioritising based on length of wait. During lockdown the NHS/government worked with the Royal Colleges to establish a clinical priority weighting system. So decisions about who to treat started by considering clinical priority, then length of wait.

This seems utterly reasonable, but is it sufficient?

Let me explain why it might not be.

Imagine that two people are waiting for a procedure that has a non-urgent clinical priority. In both cases, they have pain that seriously limits their mobility. The first, Patient A, has waited for 50 weeks. The second, Patient B, has waited for 20 weeks. A slot is available for the treatment they both need. Who gets called?

Based on the information you have at this stage, who would you choose?

Now let me add some more information. Patient A lives in an area that is in the upper quartile of socioeconomic status; Patient B lives in an area from the lower quartile. People living in upper quartile areas typically get greater access to this treatment (relative to need) than people living in the lower quartile.

Would that change your judgement?

Now some more information. Patient A is otherwise well and has a job that allows them to work from home at a desk. Patient B works on a building site, on a zero hours contract, and has underlying mental health issues.

Would that change your judgement?

These are complex considerations. And they are value judgements, so they entail difficult debates where final positions are hard to justify using evidence. So many of us might want to avoid this discussion, treating ‘clinical priority’ as though it were a single, neutral and over-ridding consideration.

But this is an illusion. Carrying on just doing what we’ve always done is as much a value-based position as changing it. There is no ‘neutral’ position. Choosing purely on time waited is a deliberate decision to NOT take into account other issues. So we MUST engage in the question.

And that is why I’m really excited that the Strategy Unit is helping to inform these debates. We are starting with two exciting pieces of work.

The first is with our colleagues at University Hospitals Coventry and Warwickshire NHS Trust. They have developed a waiting list prioritisation system that starts to incorporate socio-economic factors into their approach to working through waiting lists.

They have asked the Strategy Unit and our partners Ipsos MORI to work with them in exploring with their local populations what they think about these issues. This is a vital step as a key challenge to formalising value judgements in prioritisation decisions is about how to secure some form of legitimacy. The project involves running properly designed deliberative events and surveys with people in Coventry and Warwickshire to explore how they think about trade- offs in terms of individual prioritisation. What do they think matters when it comes to making these decisions?

It will then be for the decision makers in that patch, having heard that, to decide how they will prioritise. And they will do that with explicit reference to what they’ve heard from their public. We will then be working with the Trust to evaluate whether the approach they settle upon helps to achieve their objectives.

The second piece of work is more analytical. Following on from our work that showed current inequity, we will shortly publish a report that reviews the various strategies that can be adopted to tackle socioeconomic inequity in planned care. You can find out more about this work, which we are doing for the Midlands Decision Support Network, here.

Both pieces of work are a starting point for us. The scale and importance of the challenge means that the Strategy Unit will want to continue to apply our skills and efforts. And the nature of the questions involved in this topic means that multiple approaches, viewpoints and efforts are needed.

Collaboration is essential. So we would like to hear from other organisations as they approach waiting lists and the question of ‘what is fair?’

Tackle bullying and discrimination in the workplace

We facilitated the design of and implemented a bespoke online tool to make it easier for staff to report bullying, harassment and discrimination

Background

‘Your Voice: Report and Support’ is an online reporting tool that will allow staff working across the Leicester, Leicestershire and Rutland Integrated Care System (ICS) to report incidents of bullying, harassment and discrimination. The first online reporting tool of its kind hosted by an NHS organisation, Your Voice is available for staff (including bank staff), volunteers, apprentices and students on placement. it is hoped that the platform is extended to social care staff in phase two of the implementation.

With Your Voice staff can:

* Report an incident about themselves or someone else including other colleagues, patients, and visitors
* Make a report anonymously or by sharing contact information
* Report discrimination, harassment, vicitimisation and bullying including abusive behaviours
* Access support information, contacts and advice.

The tool provides an integrated information management system and allows organisations to monitor the numbers of incidents and analyse themes and actions whilst adhering to information governance policies and procedures. Stakeholders can also use the system to manage cases online and keep all information in one place.

Action

Our Equality and Inclusion team managed the development and implementation of Your Voice in Spring 2021, including:

* Research of existing reporting systems within and outside of the NHS
* Liaising with online technology developers Culture Shift, using their higher education system model to design a suitable tool and developing content such as reporting questions, guidance and support articles
* Stakeholder engagement on the platform design and content with ICS partners and staff networks
* Progress updates as part of the ICS’s Equality, Diversity and Inclusion taskforce
* Communication and engagement to raise staff awareness of Your Voice
* Data Protection Impact Assessment to ensure the tool is complaint regulations.

Impact

We worked effectively with system developers to design a bespoke tool for NHS staff.

Your Voice will provide healthcare staff with a safe and confidential space to disclose incidents – anonymously or by sharing contact information so they can receive further help. Either way, additional support includes articles focusing on bullying, harassment and discrimination.

Our team ensured that the system is accessible and that all reporting questions are inclusive.

We also reviewed other reporting mechanisms across the system and, working closely with Freedom to Speak Up Guardians, produced guidance for staff to the most appropriate reporting route.

Your Voice includes a data and analytics dashboard which allows ICS leaders to identify and analyse trends, and put measures in place to prevent bullying, harassment and  discrimination and improve the wellbeing and experiences of staff.

Menopause and the NHS workforce

NHS Midlands and Lancashire Commissioning Support Unit’s (MLCSU) Strategy Unit is undertaking a study to examine the impact of menopause on the NHS workforce.

Menopause is a natural part of ageing. It usually occurs between 45 and 55 years of age, as a woman’s oestrogen levels decline. The years leading up to menopause are referred to as the perimenopause, which usually lasts between four and eight years.

During this period, many women experience symptoms which adversely affect their personal and working lives. While experience is far from uniform, women frequently report lower productivity, reduced job satisfaction and problems with time management.

This is a significant issue for the NHS. It is the largest single employer in Europe, and around 75% of its 1.85 million employees are female. Given current pressures, it is especially important that the NHS understands the likely impacts of the menopause on its workforce.

Yet there are gaps in our knowledge. And this hampers employers’ ability to design effective support. To address this, the Strategy Unit is leading a study to explore:

* The proportion of the NHS workforce that are likely to be in the perimenopausal period and the socio-demographic and employment characteristics of this group.
* Sickness absence rates amongst perimenopausal women compared to younger and older women and to men of a similar age.
* The economic impact of NHS staff experiencing perimenopause and menopause, through assessing sickness absence. The rates of women joining and leaving the NHS workforce during the perimenopausal period, compared to younger and older women and to men of a similar age.
* The experience of women working in the NHS in managing their perimenopause and menopause symptoms whilst at work.
* The different experiences of women across Agenda for Change bands and staff groups in managing their symptoms and accessing workplace support.

The study will start in April and run for six months. The team will benefit from the involvement of two specialist clinical advisors for this study:

* Dr Louise Newson, who is a GP and menopause expert. Louise is the founder of Newson Health Menopause & Wellbeing Centre, and author of ‘Preparing for the Perimenopause and Menopause’
* Dr Sarah Hillman, who is a GP and University of Warwick researcher with a specialist interest in healthcare feminism (see Sarah’s TEDxNHS talk).
Equipped with insights from this work, the NHS will be more able to support its workforce.

For more information please contact Dr Abeda Mulla (abeda.mulla@nhs.net)

Success in setting up community pharmacy services

We helped commissioners with medicines management expertise in setting up and maintaining community pharmacy services, freeing up capacity across primary care.

Background

The Birmingham and Black Country Clinical Commissioning Groups (CCGs) requested our help with managing locally commissioned community pharmacy services. Several schemes were prioritised: Pharmacy First, COVID-19 Urgent Eye Care service, Specialist Palliative Care Drugs service and the Intravenous Antibiotic Supply service.

Action

* Produced several service documents and engaged with local key stakeholders
* Ensured service delivery was in line with the specification
* Contractor payments and payment queries were managed appropriately and on time
* Implemented an audit and reporting structure to demonstrate the quality and cost saving
* Automated services onto a digital platform to improve payment, reporting, audit and efficacy

Impact

We helped Black Country CCGs to set up and maintain a successful new Minor Ailments service under the name of ‘Pharmacy First’.

Over 300 pharmacies across the Black Country and Birmingham provide the service monthly covering GPs with a combined population of 1.46 million patients.

Compared to previous financial year, 18,931 Pharmacy First consultations (86.1%) were found to have freed up capacity across GP, A&E and walk-in services.

This was confirmed by audit data which showed that had the scheme not been available, patients would have booked a GP appointment. Community pharmacy in this case represents better ‘health value’ when comparing utilisation of skillsets and costs of community pharmacy services with costs for a GP appointment.

Jag Sangha, Pharmaceutical Adviser – Primary Care, Community Pharmacy and Public Health, Dudley CCG, said:

“The CCG and the Midlands and Lancashire Commissioning Support Unit have worked closely and successfully for a number of years. The MLCSU pharmacy team effectively developed, mobilised and managed the day to day operations of a number of local community pharmacy services we commission. This includes the Pharmacy First service (minor ailments service), COVID-19 Urgent Eye Care Service (formerly known as Minor Eye Conditions service) and the Specialist Palliative Care Drugs service. The team are excellent with engaging key stakeholders as well as exceeding any CCG requirements, helping to provide innovative solutions when needed in a timely fashion. I would recommend MLCSU as a choice of provider for community pharmacy services.”

Equalities and inclusive decision making

We helped an integrated care system implement a framework for making decisions that addresses bias and improves how equality is considered from the outset of decisions and proposals. 

Background

The Inclusive Decision Making Framework (IDMF) is developed to embed equality and health inequality considerations within decision making. Our Equality and Inclusion team helped implement the framework in the Leicester, Leicestershire and Rutland Integrated Care System (ICS). There are specific steps that embed equality and health inequality considerations within each stage of the decision making process:

* Foster a culture of inclusive decision making across the system
* Provide a shared equality, diversity and inclusion resource across different partners
* Provide practical steps to ensure that the needs of different communities and staff are considered when planning
* Meet the challenges of delivering the NHS Long Term Plan across the system
* Meet legal duties – in terms of equality, human rights and reducing health inequalities.

Action

We began in Spring 2021 by delivering workshops and engagement sessions for key stakeholders. We developed a range of supporting documents, communications and resources and shared them across the ICS for information and guidance.

To implement the framework, there was a period of transition of processes and systems at all partner organisations. To support this, we designed and delivered more workshops to trusts, local authorities and clinical commissioning group to outline best practice on how to use and embed the principles of the framework.

Each workshop included academic and theory based information and practical examples from Leicester, Leicestershire and Rutland case studies and ongoing work. Interactive elements ensured attendees were engaged and involved. An overview of the key transition steps was also provided in a pre-workshop delegate pack.

The workshops included discussions around the decision making process, fostering a culture of inclusive decision making, the importance of due regard and how to practically apply the specific steps.

Impact

The IDMF is an innovative approach that addresses bias and improves how equality is considered from the outset of decisions and proposals. Its successful implementation should help ensure that the needs of patients and staff from protected characteristic groups are embedded within every decision that is made across the Leicester, Leicestershire and Rutland system.

It will also ensure that insight gathered from Equality Impact Assessments informs every project and is included in any project planning documentation. This provides assurance that partner organisations meet the Public Sector Equality Duty and other legislative requirements.

Successful integration of the IDMF into current and future processes requires support from all partners and staff involved in decision making. A total of 12 IDMF workshops were delivered including two tailor-made sessions for the system’s People Board / Equality, Diversity and Inclusion Task group and one for a hospital’s People Services team.

Workshops were attended by a total of 147 staff from across the system who are helping to embed the IDMF within each of their teams and workstreams.

Equity and equality in maternity and neonatal care

We combined national metrics and local NHS, council and third sector data to help health systems understand where there are inequalities within local services.

Background

There was a national requirement from NHS England and NHS Improvement (NHSEI) for all local maternity systems to develop a maternity equity and equality audit by the end of November 2021. The aim was to understand where there are inequalities within the maternity services locally. This will be used to inform guidance to improve maternal health outcomes.

This case study looks at the Leicester, Leicestershire & Rutland (LLR) version of the maternity audit however the Midlands and Lancashire Commissioning Support Unit carried out this audit across our whole customer base.

Action

We analysed a large number of metrics:

* National metrics relating to maternity, neonatal and perinatal mental health
* Local provider data from organisations such as University Hospitals of Leicester Trust, Leicestershire Partnership NHS Trust, Leicestershire County Council and others.
* Voluntary sector data from, for example, the National Maternity Voices Partnership and others.

The audit was submitted to NHSEI as part of Stage 1 of the national requirement in November 2021.

Impact

The audit highlighted gaps in maternity services and suggested where further work was required, for example:

* Ethnic coding in the neonatal data set
* Data quality and data consistency
* Data provided to support anecdotal evidence.

Following the submission of the ‘Equity Plan’ to NHSEI, Stage 2 will be an action plan drawn up based on the analysis to improve maternal health outcomes, and will be locally focussed. The local maternity system will work with partners to develop those plans.

What the NHS is doing and how

The NHS is working to improve equity for mothers and babies and equality in experience for staff. The NHS has set out why this work is needed, the aims of this work and how the NHS will achieve its aims in two documents:

* ‘Equity and Equality: Guidance for Local Maternity Systems’: Based on the five health inequalities priorities in the 2021/22 Planning Guidance​, this will help local maternity systems align their plans with integrated care systems health inequalities work​.
* ‘NHS pledges to improve equity for mothers and babies and race equality for staff’: The four pledges help create a shared understanding of why work on equity and equality is needed, and the aims and outcomes of this work.

Scope

The guidance seeks to respond to the findings of the MBRRACE-UK reports about maternal and perinatal mortality, which show worse outcomes for those from Black, Asian and Mixed ethnic groups and those living in the most deprived areas. In doing so, consideration was given to the strong evidence highlighted in the NHS People Plan that “…where an NHS workforce is representative of the community that it serves, patient care and…patient experience is more personalised and improves”.  Therefore, the strategy recognises that improving equity for mothers and babies also requires a focus on race equality for staff.

Improving use of medicines across Merseyside

We had another successful year in 2020/21 at the Pan Mersey Area Prescribing Committee promoting the safe and efficient use of medicines and completing a series of medicines and policy reviews.

Background

The Pan Mersey APC is a professional group consisting of GPs, pharmacists and other key healthcare professionals. It seeks to identify and champion the best use of medicines taking into account cost effectiveness, quality, equity and above all, patient safety.

The Committee is responsible for making recommendations of medicines, especially high cost medicines, across the Merseyside and Warrington footprint.

Action

We have been working in collaboration with the APC providing medicines commissioning support.

We created a website to offer national and regional information on COVID-specific medicines issues.

We led phased reintroduction of Pan Mersey APC and subgroups after a COVID-19 pause (March- June 2020).

MLCSU medicines management team member was involved in discussions around future of Regional Medicines Optimisation Committee (RMOC).

We had the APC Conflicts of Interest policy and updated Declarations of Interest form approved.

Impact

147,879 visits made to APC website in 2020/21 (266,847 page views).

423,904 visits made to Pan Mersey formulary.

Cheshire and Merseyside antimicrobial review group completed review of full primary care antimicrobial guide, shared for localisation and adoption.

22 new medicines reviews and policy statements, 11 National Institute for Health and Care Excellence (NICE) technology appraisal (TA) reviews, and 11 policy statements and RAG recommendations produced by new medicines subgroup.

8 policy statements, 8 prescribing guidelines, and 6 formulary amendment recommendations produced by formulary and guidelines subgroup.

3 prescribing support documents, 5 new shared care frameworks and 6 shared care framework reviews produced by shared care subgroup. Expiry date extended for 16 documents.

1 guideline and 5 formulary updates produced by safety subgroup.