Category: Patient Flow

Our Medicine Optimisation Care Home team successfully reduced the reliance on regular Lorazepam prescriptions in elderly residents of a dementia nursing care home, improving medication safety and appropriateness through comprehensive structured medication reviews and a multidisciplinary approach.

Background

A GP practice in Preston observed a concerning trend at a local dementia nursing care home. There was a notable increase in the number of Lorazepam prescriptions, alongside requests to shift from ‘when required’ to ‘regular’ dosing for its residents. Lorazepam, typically prescribed for short-term management of anxiety or insomnia with anxiety, is known for side effects such as drowsiness, loss of coordination, dizziness, and a heightened risk of falls, especially in the elderly. The primary goal was to ensure that the prescription of Lorazepam was clinically appropriate for each resident. This involved a collaborative effort with the care home’s carers, the GP, and the specialist mental health team, forming a multidisciplinary approach to optimise patient outcomes.

Action

NHS Midlands and Lancashire CSU’s (MLCSU) Medicine Optimisation Care Home (MOCH) team initiated a series of structured medication reviews (SMRs) for residents on Lorazepam, assessing the appropriateness of its prescription. The care home was guided to enhance care plans, detailing each resident’s typical and atypical behaviours. These plans were to include explicit guidelines on alternative techniques to be attempted before the administration of Lorazepam. During weekly ward rounds, the MOCH pharmacist, accompanied by an advanced nurse practitioner from the GP practice, reviewed positive behaviour plans and evaluated the judicious use of Lorazepam. Recommendations based on these evaluations were discussed and implemented as needed.

Impact

Over three months, the MOCH team conducted 12 structured medication reviews for residents prescribed Lorazepam, with a notable majority (83%) of these patients aged 75 or older. The initiative led to a total of 54 interventions categorised by their impact on patient safety and care quality:

– Low impact interventions (7 instances): These interventions included examples such as modifying paracetamol prescriptions to variable repeats and reducing the quantity of sodium feredetate from 500ml to 300ml for a 28-day supply.

– Medium impact interventions (38 instances): Actions taken included dose adjustments for antidepressants due to adverse ‘hang-over’ side effects, mental health referrals, and discontinuation of no longer needed medications like Lactulose, presenting a moderate risk to patient safety.

– High impact interventions (7 instances): These interventions had the potential to significantly impact patient safety, including the cessation of Lorazepam in a resident with Alzheimer’s disease, indicating a direct approach to minimising harm.

The team’s efforts resulted in 27 instances of cost savings, amounting to £7,137 annually. Additionally, 25 medicines were discontinued, contributing to a more streamlined and safer medication regimen for the residents.

Specific outcomes related to lorazepam included:

– Lorazepam was discontinued for 6 residents.

– For 2 residents, Lorazepam was adjusted from ‘regular’ to ‘when required’ doses.

– 3 residents experienced dose reductions.

– 1 resident’s Lorazepam treatment was deemed still appropriate after review.

For residents where lorazepam was discontinued, tailored positive behaviour plans were developed. These plans emphasised distraction techniques such as discussing family and organising activities such as singing and drawing to manage behaviours without medication.

The work of the MOCH team enhanced ongoing communication between the GP practice and the nursing care home, resulting in a collaborative environment for continuous improvement in patient care. Following the latest Care Quality Commission inspection, the care home received positive feedback for their approach to medication safety, specifically regarding the reduced use of ‘as and when required’ medicines. This multi-faceted approach underscores the significant strides taken to ensure the well-being and safety of residents through meticulous medication management and the promotion of non-pharmacological interventions.

Feedback

‘Working alongside Tanveela on medication reviews was a pleasure, undertaking 12 structured medication reviews for patients prescribed Lorazepam. The outcome was beneficial for the patients and a great learning curve for me, working alongside with someone with the experience to guide me to make switches for the benefit of the patients. The review highlighted the need to be aware of medication effects and the side effects for patients, the impact of not over-sedating, prevention of falls, and the prevention of admissions. Discussing positive behaviour plans also impacts greatly on the patient’s daily living and being able to manage escalations of mood. The interventions proved very successful. Anne-Marie Potter | Advanced Nurse Practitioner

Recorded live at the NHS ConfedExpo, join host Richard Caddy in an engaging dialogue with Kelly Bishop, Assistant Director of Urgent Care at the NHS Midlands and Lancashire CSU (MLCSU).

Tune in to “Inside MLCSU” online, or download the episode via Spotify, Apple Podcasts, and Amazon Music.

In this episode, Richard and Kelly Bishop explore groundbreaking efforts to transform urgent care across Northern Ireland. Addressing the pressing issues of protracted emergency department waits and ambulance delays, they discuss the MLCSU Nursing and Urgent Care Team’s multifaceted approach to healthcare innovation.

The conversation reveals the unique mix of expertise within the team, including senior clinical staff and data scientists, and emphasises their collective approach to overhauling the healthcare infrastructure. The episode dives into the complexities of managing hospital flow, introduces the concept of “golden patients,” and underscores the critical role of data-driven decisions in patient care enhancement.

Listeners will gain an understanding of how collaboration and data are pivotal in overcoming healthcare challenges. This discussion not only highlights the strategies leading to significant improvements in patient experiences and staff operations but also previews upcoming initiatives by the MLCSU.

Don’t miss this episode if you’re eager to learn about the dynamic methods being implemented to advance patient care and discover how strategic teamwork led to a more efficient healthcare system in Northern Ireland.

Find out more about our nursing and urgent care support: https://www.midlandsandlancashirecsu.nhs.uk/our-expertise/nursing-and-urgent-care/

Our Business Intelligence team in partnership with the Herefordshire and Worcestershire Integrate Care Board’s staff, revolutionised the data management and decision-making processes within the urgent care pathway, enhancing both efficiency and accuracy through the development of a comprehensive, interactive dashboard.

Background

The integrated care board (ICB) of Herefordshire and Worcestershire expressed a need for a dashboard. This tool was envisioned to illustrate the impact of each stage of the patient journey within the Urgent Care Pathway. This pathway encompasses various stages from the initial contact through dialling the NHS 111 service to the final stage of patient discharge.

Action

To address this requirement, NHS Midlands and Lancashire CSU’s Business Intelligence (BI) team developed an interactive dashboard using Power BI, incorporating and modifying the National Health Service England (NHSE) Statistical Process Control (SPC) template to suit the specific needs of this project. This required deep collaboration both with the Urgent Care team and the ICB’s BI team working on data models and tools. Collaborating with the Urgent Care team, over 250 metrics were identified and included in the dashboard to describe various stages of the patient journey. These metrics covered a wide range of indicators, including but not limited to NHS 111 referrals to ambulances, primary care appointments, urgent community responses, ambulance response times, Accident & Emergency (A&E) department times, emergency admissions, patients spending over 14 days in a bed, average length of stay, and discharge details by pathway.

The dashboard design features SPC charts for core metrics, a data table displaying the last 12 months of data, year-on-year growth comparisons, and benchmarking elements to contextualise current performance. Non-core metrics are accessible via a dedicated metrics search tool. The dashboard also includes summary pages, an overview page, and a user-friendly menu to facilitate easy navigation.

Impact

The implementation of this dashboard is significantly influencing the understanding of the patient journey through the urgent care pathway. It is enabling the customer, in this case, the ICB, to discern the impact of each stage on the overall patient journey. The SPC charts are particularly beneficial, allowing the customer to quickly determine whether observed variations are significant or merely common cause/natural variations.

The dashboard serves as a vital resource for the Urgent & Emergency Care Programme Board, informing its operations and decision-making processes. It is proving instrumental in meeting urgent time-scale requests for NHSE reporting and meetings.

Furthermore, the availability of an online version of the dashboard aligns with a self-service model, granting on-demand access to the information to a wide audience. The transition to this dashboard has reduced the need for manual intervention, leading to more reproducible outputs and a significant reduction in processing time, thereby freeing up capacity for other analytical work.

An image of an example of the dashboard view for users. It displays a line graph, a bar graph which show the response time against the mean time in minutes.

Feedback

“The dashboard provides all of the key metrics in one place, supporting a system-wide understanding of the performance and the interdependencies.” Jade Brooks | NHS Herefordshire & Worcestershire ICB

We are excited to announce that we will be speaking at The Patient Flow Conference North 2024. In attendance from NHS Midlands and Lancashire CSU will be, Justine Howe, Head of Urgent Care and Samantha Singh, Clinical Lead who will will be delivering a talk titled: Flowing together unblocking flow: Navigating Challenges in NHS Efficiency for Healthier Minds.

This serves as a pivotal platform for NHS urgent care leaders to collectively address the challenges impeding efficient patient flow within the healthcare system. With increasing patient footfall and complexity, balancing urgent and emergency care demands while ensuring streamlined access to care remains a critical challenge.

Amidst the current challenges within the healthcare system, this conference assumes utmost importance in strategising and optimising patient flow dynamics. It provides a timely opportunity for urgent care leaders to converge and deliberate on transformative solutions crucial for enhancing patient care delivery and resource utilisation efficiency.

Key subjects at the conference will cover:

– Development of streamlined processes for expedited patient admission, treatment, and discharge to ensure a seamless and efficient patient journey.

– Utilisation of innovative technologies such as AI-driven scheduling systems, telemedicine, and data analytics to optimise patient flow and alleviate pressures within the healthcare system.

– Implementation of comprehensive care coordination strategies facilitating smooth transitions across various healthcare settings, thereby enhancing patient flow and reducing hospitalisation requirements.

– Emphasis on preventive care initiatives and population health management strategies aimed at reducing the strain on healthcare resources and fostering a healthier populace.

The Patient Flow Conference North 2024 provides an indispensable opportunity for healthcare professionals to actively participate in revolutionising patient flow within the NHS.

Conference details:

– Date and location: 8 February 2024
– Venue: etc venues Manchester
– Event timing: 9am

Register now to be a part of this vital dialogue.

https://www.convenzis.co.uk/events/the-patient-flow-conference-north-2024

The recent communication from NHSE, referencing the letter titled ‘Addressing the significant financial challenges created by industrial action in 2023/24’, brings to the forefront the significant challenges that the NHS faces. This blog aims to dissect these challenges and ponder on the potential responses that healthcare providers might need to consider in these tumultuous times.

The year 2023/24 has been a period of unprecedented strain for the NHS, in part due to industrial action. This has not only led to a financial burden estimated at around £1 billion but also impacted patient care, particularly in elective and urgent services.

Challenges highlighted by the letter:

* Achieving financial balance: The foremost challenge is attaining a financial equilibrium. The industrial action has led to unexpected expenditures, complicating the already intricate financial landscape of the NHS.

* Prioritising patient safety and care: Healthcare providers are under pressure to prioritise patient safety, emergency services, and urgent care. This entails a careful balancing act, ensuring that critical services remain unhampered while managing limited resources.

* Rapid planning and response: The letter calls for a swift, two-week planning exercise. This rapid response is crucial but challenging, given the complexities involved in healthcare planning and delivery.

* Managing elective care amidst reduced targets: With a reduction in elective activity targets, healthcare providers must strategise effectively to manage long patient waits, especially for urgent and cancer care, within the new constraints.

* Strategies for healthcare providers:
– Efficiency and innovation: Embracing efficiency in operations and innovative patient care models could be key. This might include leveraging digital health technologies to streamline processes and improve patient engagement.

– Collaborative efforts: The role of Integrated Care Boards (ICBs) and trusts will be pivotal. Collaborative planning and resource sharing could help mitigate the impact of financial and operational constraints.

– Flexibility and adaptability: Providers must be prepared to adapt to changing scenarios, including the possibility of continued strikes. This includes having contingency plans and being able to pivot quickly.

The journey ahead for the NHS is fraught with challenges, yet it’s filled with opportunities for growth and innovation. Healthcare providers are at a critical juncture where strategic planning, innovative solutions, and collaborative efforts are more important than ever. Balancing financial limitations with the commitment to excellent patient care will test the resilience and adaptability of our healthcare system. However, with the collective effort of all stakeholders, we can navigate these turbulent waters and continue to uphold the high standards of care that the NHS is known for.

We strongly encourage healthcare professionals, policymakers, and interested parties to engage in a meaningful dialogue. Sharing experiences and strategies will be crucial in shaping an effective response to these challenges. For those seeking further information on how we can help navigate this, you can find more information on our clinical redesign and provider collaboration page.

https://www.midlandsandlancashirecsu.nhs.uk/offer/clinical-redesign-and-provider-collaboration/

A blog by Nicola Ainscough, Head of System Delivery at MLCSU.

We’re pleased to announce that Kelly Bishop, Assistant Director of Nursing and Urgent Care at NHS Midlands and Lancashire Commissioning Support Unit (MLCSU), will chair the Patient Flow Conference South 2023. This event is scheduled for 7 November 2023 at 15 Hatfields, London.

Key subjects at the conference will cover:

1. Increased focus on patient experience. The NHS is placing an increasing emphasis on improving the patient experience, including making it easier for patients to access care, reducing waiting times, and improving the quality of care.

2. Use of technology. The NHS is using technology to improve patient flow and reduce bottlenecks. This includes the use of electronic medical records, appointment scheduling systems, and telemedicine.

3. Integration of care. The NHS is working to better coordinate care across different settings and providers, with the goal of improving patient flow and reducing the need for hospitalisation.

4. Population health management. The NHS is focusing on preventative care and population health management, with the goal of improving the health of the population and reducing demand on the healthcare system.

5. Collaboration and partnerships. The NHS is forming collaborations and partnerships with other organisations, including community-based organisations and private providers, in order to improve patient flow and better meet the needs of patients.

Justine Howe, Head of Urgent Care at NHS MLCSU will be delivering the plenary.

Conference details:

– Date and location: 7 November 2023, 15 Hatfields, Chadwick Court, London SE1 8DJ
– Venue: Sustain ground floor
– Event timing: 8am – 4pm

Secure your spot now: https://www.convenzis.co.uk/events/the-urgent-care–patient-flow-conference-2023

We are thrilled to announce that our Medicines Management and Optimisation team has won two awards for Improving Medicines Safety and Learning Disabilities Initiatives of the Year at this year’s HSJ Patient Safety Awards which recognises safety, culture and positive experience in patient care.

A record-breaking 516 entries were received for the HSJ Patient Safety Awards 2023, with 206 organisations, projects and individuals making it to the final shortlist, following two rounds of rigorous judging. The high volume – and exceptional quality – of applications once again showcased the level of commitment to patient care within the UK’s healthcare networks.

Our Inhaler prescribing errors project won the award under the ‘Improving Medicines Safety’ category. This project focused on enhancing inhaler prescribing practice. Through a comprehensive audit of inhaler prescriptions, we discovered that ingredient duplication within the same therapeutic drug class was often overlooked as a potential interaction or cause of side effects. We identified 360 patients with inhaler ingredient duplication errors, and nearly one-third of these errors persisted even during respiratory reviews. Armed with these audit results, we engaged with individual practices and initiated a thorough review of prescribing policies. To prevent future errors, we developed an easy-to-use reference guide for inhaler prescribing and extensively educated staff in primary and secondary care as well as community pharmacy settings.

The second award won under the ‘Learning Disabilities Initiatives of the Year’ centred on promoting the Community of Practice Learning Disability and Autism pilot, which aimed to up-skill pharmacists working in primary care networks to conduct holistic structured medication reviews for individuals with a learning disability and/or autism. By providing extensive training and support, the pilot empowered primary care network pharmacists to deliver comprehensive medication reviews that consider the unique needs of these patients. This national project, co-produced with NHS England Health Improvement Pharmacy leads and the NHS Specialist Pharmacy Service, not only identified the learning and development needs of pharmacists but also delivered a model of support and collected data to demonstrate its success. The positive feedback received from participants and users further validated the effectiveness of this model, making it an ideal candidate for wider implementation.

The judging panel was made up of a diverse range of highly influential and respected figures within the healthcare community. All finalists and winners were judged against three clear criterias; clinical and specialist excellence; enacting organisation-wide change and service/system innovation.

On receiving these awards, Jonathan Horgan, our Director of Pharmacy Services, commented:

“We are so pleased to have achieved three finalist entries, leading to two winners at this year’s HSJ Patient Safety Awards. This is a great accolade for the staff,for MLCSU and a reflection of our commitment to excellence in medicines management and optimisation. Our Medicines Management and Optimisation team prioritise patient safety above all, ensuring every individual receives the highest standard of care. Achieving these HSJ Patient Safety Awards demonstrates that we are achieving our aims; to support NHS innovation, to work seamlessly in partnership and to share best practice in the NHS. We will continue to strive to be the best care support partner in the NHS.”

Paula Wilson, Associate Director of Pharmacy Services, commented:

“I am so happy our team’s work has been commended at these prestigious awards, both as finalists and winners. The improvements we have made to patient care, particularly in areas of safety and health inequalities, have been recognised and are hopefully an inspiration for similar projects across the NHS. Our partnership working approach has enabled our success. I would like to thank our team for their continued dedication to transform and deliver improved services to the population and improve health and wellbeing and thank our partners for their collaborative support.”

NHS Midlands and Lancashire CSU (MLCSU) also had two finalist projects at the awards:

1. Reducing mortality project. The initiative aimed at reducing mortality in people with learning disabilities and epilepsy was shortlisted for the Learning Disabilities Initiative of the Year at this year’s HSJ Patient Safety Awards.

2. Improving the safety of patients prescribed clozapine. This project focused on enhancing the safety of patients prescribed clozapine, a vital medication for managing specific mental health conditions.

A full list of all our awards and recognitions can be viewed at mlcsu.co.uk on the awards and recognitions page.

We adopted a systematic strategy to identify primary and secondary prevention of cardiovascular disease which resulted in enhanced lipid therapy, lifestyle advice and a 65% patient satisfaction rate.

Background

Lakeside Healthcare Group, a multi-site GP partnership in Cambridgeshire, Lincolnshire and Northamptonshire, secured funding to review more than 1,000 at-risk patients for primary and secondary prevention of cardiovascular disease (CVD). They asked NHS Midlands and Lancashire CSU (MLCSU) to identify high-risk patients, offer lifestyle advice, and undertake remote clinical reviews to optimise their lipid therapy using NICE-approved pathways.

Action

Our Medicines Management and Optimisation Team developed a standard operating procedure incorporating standardised review templates, structured clinical vocabulary, and treatment recommendations in line with the latest NICE pathways, guidance and evidence.

We used pathway searches to identify and risk-stratify patients – to determine the most appropriate intervention and care management based on their cardiovascular status, level of risk and priority. High-risk patients were prioritised and offered remote consultations with a pharmacist.

A patient-centred approach and shared decision-making principles resulted in patients being offered lifestyle advice, compliance advice, and/or a review of their lipid therapy. The team were keen to improve prevalence coding, and the accuracy of the information in practice registers whilst also ensuring to equip the primary care network team with the tools and processes required to continue identifying and reviewing at-risk patients.

Impact

1,311 patient reviews were completed from October 2021 to November 2022 – resulting in the optimisation of lipid therapy for 72 patients. 128 patients received lifestyle modification advice, and 15 were advised about their current lipid medications.

A patient satisfaction survey was offered to 137 patients, and 65% of respondents stated their experience with their lipid medication review was either good or very good.

Adopting a systematic strategy for identifying primary and secondary prevention CVD patients who require optimisation of lipid-modification therapy contributes significantly to reducing CVD cases. It improves population health, reduces health inequalities, and mitigates against escalating demand and costs leading to unsustainable pressures on the health and care system.

As a direct result of this project, patients were initiated on or had their lipid-modification therapy optimised as appropriate. A sustainable legacy was passed onto the local primary care network team to enable them to competently deliver lipid medication reviews going forward.

Feedback

The PCN Pharmacy team will implement the learning and continue developing the service to improve patient care. We hope to work with MLCSU on future projects.

Arvind Thandi, Head of Pharmacy and Dispensary Lakeside Healthcare, Lakeside Healthcare Group

We successfully improved patient flow efficiency in five acute and community trusts, achieving zero ambulance delays, reducing handover times, and implementing timely crew shift completions through data-driven strategies and on-site support.

Background
The Northern Ireland National Health Board brought in NHS Midlands and Lancashire CSU’s Nursing and Urgent Care Team (NUCT) to increase patient flow efficiency in five acute and community trusts.

Action
NUCT deployed data and analysis to devise innovative strategies that resulted in tangible improvements. They offered clinical and operational guidance, pinpointed recurring issues, and created cross-pathway solutions to system hurdles. Over three days per trust, they worked with clinical and operational teams, offering real-time information support for crucial decision-making. Senior nurses assumed coaching roles to improve patient flow in emergency departments, wards, and discharge pathways, advocating a uniform approach to demand and capacity management across hospital and community teams.

Impact
The team achieved zero ambulance delays, improved handover times, and timely crew shift completions through on-site presence. They set up hospital operation centres that used data to create an actionable unified view for decision-making.

By increasing early discharges and utilising discharge lounge capacity, hospital flow started three hours earlier daily, resulting in aligning capacity with demand and preventing delays.

Every cooperative action led to enhanced safety and patient outcomes, demonstrating that quality care goes beyond merely meeting targets. NUCT also collaborated with trust staff, recognising the necessary culture shift for the safe and successful implementation of change. They managed out-of-hospital information flows, speeding up hospital discharges and reducing unnecessary stays.

Feedback

Their contribution was excellent. Their expert, patient-focused challenge and support enabled the team to reflect on issues differently and to introduce improvements in practices and processes which remain in place today.
Executive Director of Nursing, Midwifery, AHPs and Patient Experience| South Eastern Health and Social Care Trust

By implementing effective strategies, we increased patient referrals to the National Diabetes Prevention Programme. The number of primary care referrals more than doubled, with 42 GP practices actively participating in the initiative. Through our efforts, we engaged with 3,680 patients and referred 2,130 individuals to the program.

Background

Between June 2021 and March 2023, NHS Midlands and Lancashire CSU (MLCSU) were commissioned by the Black Country and West Birmingham CCG (subsequently the Black Country ICS) to support GP practices to increase referrals to the National Diabetes Prevention Programme (NDPP). The Black Country ICB has one of the highest diabetes prevalence rates in England. The NDPP is designed to support adults who are at a high risk of developing type 2 Diabetes Mellitus. Participants are referred to 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 type 2 Diabetes Mellitus.

Action

To help practices increase referrals to the NDPP, we worked collaboratively with local NDPP providers and primary care commissioning leads to maximise GP practice engagement. With the appropriate information governance, we carried out an early implementation test at Thornley Street GP Practice to test processes prior to at-scale rollout across the Integrated Care System (ICS) footprint. We provided practices with:
* A dedicated secure NHS mail inbox for queries and transfer of data from primary care
* Pathway documents to provide practical information to support practice engagement and implementation of NDPP
* Clinical system searches to identify all eligible patients for referral within a practice
* Direct discussions with eligible patients to encourage referral to NDPP
* Electronic transfer documents including clinical library codes to inform practices of the outcomes of patient discussions.

Impact

In the first year of our support, referrals from primary care more than doubled (799) compared to the previous year (364).
In total, during this programme of support, we have:
– Engaged with 42 GP practices in the Black Country and West Birmingham
– Contacted 3,680 patients and referred 2,130 to the NDPP programme

In February 2023, a personalised video test of the concept was trialled across 5 practices. The video was personalised with the patient’s first name, GP practice, postcode, gender and blood sugar level result. 279 videos were generated with 61% of patients who had opened the video choosing to be referred or requesting more information. Results showed high levels of engagement and high levels of action taken by patients.
This project has shown that the at-scale approach employed by MLCSU for referrals is an effective means to increase diabetes prevention and support GP practice primary care capacity.

Feedback

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

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

We developed an alert which scans a whole health system for areas of health quality concern that need to be looked at and may need improvement.

Background

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.

The Safety Siren tracks an array of data, displays it visually and flags areas that may need a closer look. Its objective is not to draw a conclusion, but to signpost areas where further exploration could be worthwhile.

Some of the data the Safety Siren tracks includes:

• the Summary Hospital-level Mortality Indicators for each hospital
• condition-specific admission data (for example, lower-limb amputations)
• condition-specific mortality data (for example, fractured hip)
• excess mortality by council area (for example, the number of deaths that are and are not related to COVID-19)
• location of death (for example, home, hospital or care home)
• suicide rate for each area.

Impact

The real advantage of the Safety Siren is that it tracks data at the system level. This can feed into the new Integrated Care Board Quality Committee and help clinical leads know where to focus their attention and implement changes if necessary.

It also helps leads to plan ahead, with the ultimate goal of improving the health and quality of life of the local population.

The Safety Siren is a priority clinical report. The hope is that with time, the Safety Siren will become an embedded part of the new Integrated Care Board clinical governance.

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

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

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!

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

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

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.”

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.”

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.

Background
The long-term prescribing of anticholinergic drugs, used to treat urinary incontinence, has been associated with an increased risk of cognitive impairment, dementia and mortality.

Clinicians have been advised to consider offering patients ‘drug holidays’ for short periods to assess whether there has been any natural remission of the condition, whether the drugs are still effective and whether there is a continued need for treatment.

Action
Working with Greater Preston and Chorley and South Ribble Clinical Commissioning Groups (CCGs), our Medicines Optimisation team (MOT) created a review tool and templates for the EMIS system to enable a safe and consistent medication review process.

The team worked collaboratively with GP practices to identify patients for whom a four-week ‘drug holiday’ was appropriate.

Patients received an initial telephone consultation offering advice and guidance, followed by a further consultation four weeks later to assess outcomes.

Impact
Across Greater Preston and Chorley and South Ribble CCGs:

* urinary incontinence medication reviews were carried out across 32 GP practices
* 238 patients were identified as being suitable and agreeable to taking a ‘drug holiday’
* after four weeks, 144 patients (61%) did not restart drug treatment and their medication was discontinued
* the total anticholinergic burden score was reduced by 432 points* across the patient cohort
* an estimated annual NHS saving of £29,451 was recorded.

*assigning an ACB score of 3 on ACB calculator for each drug stopped.

Patient feedback:

“I have been taking this drug since 1999 and now I feel much fitter without it.”

“My dry mouth, headache and acid reflux have really improved since I stopped taking the bladder drug. So much so that I threw the oxybutynin tablets on the fire last week!”

“Stopping this medication has made no difference to my urinary symptoms.”

“I have been catheterised for nearly twenty years and wondered why I had to keep on taking this drug – big improvement in my life without it.”

Welcome to our new web product where you can access free content to help improve medicines optimisation support. Visit the new website at https://medsopt.midlandsandlancashirecsu.nhs.uk to learn about opportunities for improving your current services.

Content is regularly updated and packed full of useful resources such as case studies and reports which detail how to achieve best practice outcomes. There is a wide range of innovative projects we delivered while working with integrated care systems, primary care networks and other organisations in the healthcare, government, voluntary and private sectors.

Under our ‘Services’ and ‘Publications’ sections, you can learn more about service improvement opportunities, for example:

* Implementation of new medicines services such as electronic repeat dispensing and national Community Pharmacy Consultation Services (CPCS)
* Assurance and professional support to get the best from your primary care network’s pharmacy team
* Support for improving medicines use in care homes.

Find out about our range of support and keep up to date with our latest offering:

* Project consultancy delivered by working in collaborative partnerships
* Area Prescribing Committees
* Medicines Safety Assurance Tool (MSAT)
* Primary care rebate schemes
* Care home services including training webinars and educational programmes
* High cost drugs validation/Blueteq management
* QIPP implementation service
* Prescribing analytics at scale
* Prescribing newsletter
* And much more.

Whether you’re an existing customer or would like to learn about our full suite of services, the ‘Contact us’ page provides a convenient way to get in touch directly for more details.

Finally, if you are an NHS or private sector medicines management professional, the dedicated ‘Careers’ section will help you understand the diversity of our portfolio and why working for the Midlands and Lancashire CSU’s Medicines Management and Optimisation team will be a great next move in your career development.

We managed a programme of implementing infection prevention and control safety principles to reduce infection rates and provide better access to services during the pandemic.

Background

During the pandemic, there was an increased national focus on the effective application of infection prevention and control (IPC) principles and practice and how this relates to patient and staff safety and outcomes.

A national IPC safety support programme was established for providers of NHS services after the increase in healthcare needs associated with COVID-19 infections.

Midlands and Lancashire Commissioning Support Unit (MLCSU) managed the programme delivery, working with key leads from NHS England and Improvement’s Nursing and Improvement Directorates and regional IPC, quality and clinical colleagues.

Action

* The programme ensured effective change management processes were in place to document changes as agreed with stakeholders.
* The infrastructure and project management tools were developed at pace.
* We tracked benefits of the programme and recorded risks and lesson learnt.
* We created and maintained financial reporting templates and output reports to capture results.
* Weekly highlight reports provided assurance to the regional team.

Impact

For patients:

* Reduced rates of COVID-19 infections and other hospital-acquired infections
* Safer access to services through the establishment of clear pathways during the pandemic
* Increased confidence for patients and staff in trusts’ ability to effectively manage infection outbreaks.

For staff:

* Improved IPC systems, management, processes and practices, minimising the spread of infection, promoting staff safety, reducing anxiety and increasing confidence
* Reduced sickness absence from hospital-acquired COVID-19 infections
* Greater awareness and understanding of evidence-based IPC practices leading to better compliance and safety.

For trusts:

* Clear oversight by trust boards of IPC issues and understanding of their impact on services and patient outcomes
* Support for safety culture and quality improvement
* Reduced infections contracted in healthcare settings. This minimised loss of bed days and service capacity.

Annemarie Vicary, Programme Director, NHS England and Improvement, said:

“[MLCSU  colleagues were] experienced, keen to learn about the subject matter and the internal workings of the organisation, and had forward thinking ideas.”

Join us at the Patient Flow Conference tomorrow 16 November to hear about our system pressure coordination function which helped an integrated care system manage through COVID-19.

Our Director of Nursing and Urgent Care, Seamus McGirr, will be speaking at the Convenzis Patient Flow Conference 2021: Improving for the future, alongside sector-leading guest presenters from NHS trusts, think-tanks and consultancies.

Seamus will be discussing the Midlands and Lancashire Commissioning Support Unit’s approach to managing system pressure across a whole ICS by combining data, systems and expertise in a specialised coordination function. Our model helps health systems make informed tactical decisions. It provides collaboration and leadership capability to ensure that resource is distributed to where it is needed most based on evidence, insight tools and real-time analytics.

The conference provides a platform for NHS urgent care professionals and clinical specialists to meet and debate national policy and strategy changes.

Other speakers include experts from University Hospitals Sussex, Warrington and Halton Teaching Hospitals, Royal College of Emergency Medicine, NHS England and Improvement, the British Medical Journal and others. Book your place today – search Patient Flow Conference 2021!

Our Clinical directorate have been recognised for their hard work on the Lancashire and South Cumbria mass vaccination programme which was shortlisted for a Nursing Times Award in the Public Health Nursing category. The ceremony took place in London last month. Congratulations to all winners

For the programme in Lancashire and South Cumbria, the integrated care system rapidly set up seven mass COVID-19 vaccination centres across a wide area. The centres supplemented vaccines dispensed via primary care and community pharmacy.

A nurse-led clinical leadership model was used to deliver thousands of vaccinations. A team from the Midlands and Lancashire Commissioning Support Unit (MLCSU) Clinical directorate were deployed to provide nursing and pharmacy expertise and to support with leadership of the programme.

This is the second nomination MLCSU has directly supported this year from the Nursing Times. Our workforce project is also shortlisted for a Nursing Times Workforce Award. The ceremony is due to take place on 17 November 2021.

Our Data Quality team developed a custom data input template to streamline referrals of patient with post-Covid illness, saving time and effort for clinicians, improving access for patients and creating better reporting opportunities. 

Background
Pennine Lancashire Clinical Commissioning Group (CCG) approached our Data Quality team to help support their primary care network’s Neighbourhood Accelerator programme. This programme supports vulnerable patients experiencing ongoing symptomatic COVID-19.

As part of this work, it was decided to create a new patient referral form to be used across the Lancashire and South Cumbria integrated care system (ICS) to refer post-Covid patients to the Lancashire and South Cumbria NHS Foundation Trust. It was later agreed that the work being undertaken across Pennine Lancashire would be rolled out across the rest of the ICS footprint.

Action
The Data Quality team advised the Pennine Lancashire team on how to make the process as seamless as possible for those referring into the service.

Due to the nature of post-Covid illness, a lot of information was being asked during referrals. Reviewing the previous referral process, the team established that it  contained some coded information but also a lot of free text. This resulted in a lot of clinician typing and the potential for important information to be missed out. Also, none of the information being gathered during referral was being recorded back into the patient record as coded data.

Our Data Quality team developed a data input template to allow all of the information needed to be captured, auto populating fields with information recorded during the referral.

We carried out rigorous testing involving GP practices and the Trust. Once the system was ready to be rolled out, our team helped practices to install the package onto their clinical systems.

Impact

Since its introduction in March 2021, the system has been installed in 167 GP practices out of 178 across the ICS area.

It has given the region’s GP practices a quick and easy way to capture the data needed to refer a patient to the post-Covid service.

This comprehensive collection of data will also allow practices to provide detailed information around patients with post-Covid syndrome if it is needed by NHS England and Improvement in the future.

The project has also improved patient access to services by creating a streamlined process which reduces the number of rejected referrals as the form clearly identifies all of the information required.

Lee Hay, Programme Director – Blackburn with Darwen and East Lancashire CCGs, said:

“A huge thank you to Emma-Jane McDonald [from MLCSU]. She has been fantastic and pulled out all the stops to get this vital piece of work completed and rolled out. Thank you so much for all your amazing hard work and dedication, we are very grateful!”

Dr Quashuf Hussain, Deputy Medical Director – Pennine Lancashire, said:

“Emma-Jane, fantastic work, really appreciate your hard work on this.  It’s been a pleasure.”

Elaine Craven, Planning, Transformation & Delivery Officer – Pennine Lancashire, said:

“You are truly amazing, thank you so much for all your hard work and support. It’s been so interesting and really useful to get a glimpse of how EMIS works.”

The Sue Ryder charitable organisation has a portfolio of 10 services, one hub site and central support delivering palliative and neurological care services across the UK. In early 2020, the organisation’s clinical governance group approached MLCSU to scope out what support and advice we could offer in terms of medicines management and medicines governance across the organisation.

How we helped

Two site visits and face-to-face interviews were conducted and the medicines management systems were audited.

From this information, two anonymised questionnaires were developed, one for Heads of Service and clinical directors via Microsoft (MS) Teams and the other was a medicines governance review designed for a wider audience. 53 responses were received.

Additional stakeholders including pharmacists and business intelligence specialists were interviewed by telephone to discuss the support provided to the services, and the use and application of the Datix database.

Weekly meetings via MS Teams and the production of an interim report ensured the board were kept well informed of progress. A full report that included recommendations for next steps for the organisation was presented at the Healthcare Governance meeting.

Impact

MLCSU and Sue Ryder developed an excellent working relationship and both the interim report and full report were well received.

Recommendations included:

* Increase the number of medicines management audits in the services
* Each service to develop its own medicines policy
* Evaluation of the service level agreements with the community pharmacies that provide support to the services
* A scoping exercise to consider senior pharmacist support for the organisation both at central level and within the services
* Develop a governance framework for non medical prescribers (NMP) with audits of prescribing patterns
* Further develop the use of Datix with individual benchmarking for both neurological and palliative services.

Sue Ryder has approached MLCSU to discuss the provision of pharmacist support to assist with progressing the recommendations in the report.

Of our support to the charity, Dr Paul Perkins, Sue Ryder Chief Medical Director, said:

“Sue Ryder commissioned the Midlands and Lancashire Commissioning Support Unit to perform an assessment of governance in relation to medicines across our charity. 

“It was great to work with people with such knowledge and expertise. 

“The work was conducted efficiently and feedback from staff at our hospices and neurological care centres was positive with regards to interactions with the team. 

“We were provided with a final report which outlined the good things, but also where we could improve. 

“Helen and Rob were a pleasure to work with.”

The NHS Digital Weight Management Programme (DWMP) launched this week will help thousands of adults achieve a healthy weight and improve their wellbeing. Patients will access ‘tier two’ digital weight management services via the DWMP Referral Hub designed and produced by Midlands and Lancashire Commissioning Support Unit (MLCSU). This is a tool that allows people to choose the weight management provider which they feel they can connect with most successfully, and which then provides a flexible and tailored service to match their individual needs.

Part of the government’s obesity strategy, the Department of Health and Social Care announced that new services will be offered across England including online tools and funding for face-to-face consultations. The NHS DWMP will offer free online support for adults living with obesity, who also have diabetes, high blood pressure or both, to help manage their weight and improve their health.

Following an e-referral, MLCSU’s Referral Hub uses a triage algorithm process to identify the appropriate level of intervention based on the patient’s likelihood of completing the programme. The Hub then offers patients a choice of weight management service providers. They can select a provider they choose, and the system links them through and passes across key information to enable the patient to register and get started.

Easily accessing the Hub via smartphone or computer means more people are likely to complete the DWMP and improve their health. By cutting back on applications paperwork and making referrals through the Hub, primary care has seen a potential for major efficiency gains in saved time and resources.

Eligible NHS staff have also been offered free access to the Hub via self-referral.

Data from the first wave of the pandemic showed that people from certain backgrounds and communities are at higher risk to virus prevalence and mortality, which may contribute to poorer health outcomes. When planning the rollout of the vaccination programme, it’s important to consider equality early on. We have been working as a collective with experts from across the Integrated Care System (ICS) in Lancashire and South Cumbria to assess how the COVID-19 vaccination programme could impact different population groups, and to ensure good uptake.

Vaccination programme across Lancashire and South Cumbria

For the vaccination programme across Lancashire and South Cumbria, an Equality and Health Inequalities Impact Risk Assessment (EHIIRA) was undertaken. It looked at potential impact for each of the nine protected characteristics under the Equality Act (2010) – age, race, religion, disability, sex, marriage and civil partnership, maternity, gender reassignment and sexual orientation.

We developed the EHIIRA, which is under constant review, using regional assessment work by the regional team at Public Health England.  The purpose is to highlight how the way vaccinations are delivered might impact the uptake from groups at risk, and to point out what needs to be considered.

Risk of impact

The assessment highlights considerations and equality risks for different groups. One example is black, Asian and minority ethnic communities, where we might need to think about language needs and how to establish a dialogue early on to encourage high take up.

Once the risk was raised, colleagues from the ICS set out to gain insight directly from the communities. They reached out to influential religious leaders of the Muslim community in Blackburn and Darwen, asking what we needed to think about and what we could do to get a good level of acceptance.

The result was “a significant uptake in vaccinations from eligible members of the community”, as picked up by Amanda Pritchard, NHS England and Improvement’s Chief Operating Officer, and NHS Improvement’s Chief Executive, in a bulletin to healthcare leaders on 5 February.

Potential impacts were also raised about vaccinations during the month of Ramadan, a religious festival which is celebrated by Muslims. Work is under way both locally and nationally to provide clear information about the vaccine and that the vaccine can be received during Ramadan.

Equality audits

We also developed an audit for considering equality related matters at individual vaccination sites. It examines issues of disability access, location and travel, signage and communication and religion and belief – especially relevant where religious sites were considered.

Equality assessment in Cheshire

Our equality and inclusion experts are also supporting Cheshire CCG with an ongoing assessment of how factors specific to different communities could impact vaccine uptake. For example, early on in the vaccination programme, we identified an impact for housebound patients. The only approved vaccine at the time had to be kept at very low temperatures meaning it could not be transported to their homes. To receive the jab, these patients needed to be helped into the vaccination centres, which posed further risks.

While the approval of other vaccines resolved this issue, other community characteristics continue to create impacts which could lead to low levels of vaccinations. As a result of highlighting the risk, the CCGs in Cheshire have brought in a specialist consultant to further investigate why there may be hesitancy.

The assessment in Cheshire identified potential barriers to accessing the proposed mass vaccination sites and highlighted factors such as signage, parking and welfare facilities. Local communities, such as the farming and boating communities, as well as groups with protected characteristics, were carefully considered as part of the plan for ‘hard to reach’ groups. Our advice and guidance will continue throughout the vaccination programme, supporting both mass sites and hospital hubs, GPs and pharmacies.

Equality assessment elsewhere in England

We believe the findings from the assessment in Lancashire and South Cumbria may have similarities with risks associated with equality impacts in other regions and nationally. This is why we shared the assessment template with CCGs in Leicestershire, Hertfordshire, Worcestershire, Cheshire, Wirral, Trafford, Staffordshire and the North West Regional Delivery Team.

Our colleagues at the Strategy Unit have developed a capacity model to help people planning and running COVID-19 vaccine clinics to ease the flow of patients, reduce queueing and make the best use of facilities and staff for maximum effect.

Using modelling is a fast and cheap option for spotting problems and allows you to prevent them and plan ahead. The model is free for use by anyone and can help the design and operation of clinics.

This work stemmed from the Strategy Unit’s collaboration with the Wolverhampton Prevention and Population Health Unit team to aid in their advice on planning vaccine centres in Wolverhampton.

See model and instructions for use on the Strategy Unit’s website at www.stratgyunitwm.co.uk.

Blackpool Teaching Hospital NHS Foundation Trust commissioned Midlands and Lancashire Commissioning Support Unit to lead a two-year project (2019 – 2021) focusing on a number of work streams, with each having a defined objective towards the ‘reduction of occupied bed days’. Regular board level governance incorporated both the trust and the Fylde Coast Clinical Commissioning Groups.

Action

A comprehensive deep dive of local evidence by our analytics experts helped create a suite of quality indicators that demonstrated areas of improvement and was therefore key to the success of the overall Bed Reduction Programme. The support of 600 consultant days was agreed across a 2-year time frame, with an emphasis placed on a number of supplementary outcomes that were associated with the overall objective (see outcomes). Specific key areas of intervention and support around pathways and the full utilisation of existing resources were included in a detailed project plan which formed the basis of regular reports to gauge progress into the project board.

Each workstream was allocated a MLCSU clinical subject matter expert and a defined team structure that replicated triumvirate working from the appropriate areas of nursing and operational leadership teams from both the trust and the CCGs. Programme support, monitoring and leadership for each work stream was then led by the CSU.

Intervention and support was given both on site and remotely, with a firm emphasis placed on long term cultural change and future workforce capability within the trust to ensure strategic progress was monitored and permanent change was delivered.

Impact

Expected outcomes:

* Increase in zero-day length of stay (same day emergency care) rate from 23% to 33% (in line with the regional average)
* Increase direct admission rate from current 26.1% to 32.02% (in line with regional average)
* Targeted 15% reduction in occupied bed days* per 1000 population in 65 +age group

The outcomes to date:

* An increase in the zero-day rate to ~30% at the end of December 19
* A ‘direct admission rate’ (patients admitted via any route other than the A&E) of 33% as at November 19 and subsequently ensured direct admission rates were at 32.02% for three consecutive months
* Approximately 22 beds per day (net) have been released. The increase is largely amongst Blackpool CCG residents (Blackpool increase = 40 beds per day; Fylde and Wyre increase = 18 beds per day)

Nb: Average length of stay reductions seen for 27% of all Frailty inpatient service users (pre-Covid) and the new Frailty Assessment service was proven through a test of change phase (March 2020).

Direct admission to assessment wards, effectively by-passing A&E, allows for effective handling of patients within wards, and also generates capacity in the A&E bays.

Clinical commissioning groups (CCGs) need to ensure that funds are spent on treatments and procedures bringing the greatest value and benefits to patients in a way which is affordable and equitable. Chorley & South Ribble CCG and Greater Preston CCG wanted to improve their funding application process. The challenge was to change behaviour, educate clinicians, improve the patient journey, reduce inappropriate referrals and ensure consistent outcomes.

Action

We trained clinicians and created a bespoke, streamlined system for submitting funding applications. Our comprehensive Individual Prior Approval Scheme involves the provider of treatment seeking funding approval from the commissioner prior to treatment. CCGs can challenge providers for activity that does not have the relevant authorisation codes generated by the scheme, ensuring only appropriate treatments are delivered.

With Chorley & South Ribble CCG and Greater Preston CCG, we developed and implemented a robust manual Individual Prior Approval Scheme for seven policies over an initial six-month period. Following a successful outcome, this was extended for a further two years to cover 15 procedures of limited clinical value and nine cosmetic procedures.
In addition to the monitoring and validation of activity data, we captured qualitative data in relation to themes and trends affecting potential future commissioning intentions. We ensured commissioners and referring clinicians understood the requirements of the scheme. Reporting mechanisms were developed and continually reviewed in line with CCG requirements.

Our ‘wrap-around’ service included finance and contracting expertise to support reconciliation process at intervention level and clinical policy development support to ensure effective application of policy criteria.

Impact

Inappropriate referrals at Chorley & South Ribble CCG and Greater Preston CCG have fallen, resulting in efficiency savings and improved patient flow, with applications receiving a decision within five working days. Health outcomes have improved by ensuring the right treatment for patients at the right time, only undergoing elective treatments and interventions where benefit outweighs the clinical risk.

More than 9,000 applications went through the process over the first two years of implementation and 13 per cent were declined.

With increased knowledge of clinical policy criteria at secondary and primary care level, clinicians are managing patient expectations more appropriately, improving patient experience and reducing misunderstandings and complaints. Working relationships are enhanced between stakeholders, with a culture of continuous improvement.

Hospital providers involved have praised the Prior Approval system, saying they would like all CCGs to commission this process so there would be a single, robust and efficient system, making processing applications simple and easy for clinicians.

The scheme has contributed to quality and improvement programmes through the reduction of activity. It has also supported other commissioning demand management schemes to support CCGs to realise further activity and cost savings.

We worked with NHS Greater Preston and NHS Chorley and South Ribble CCGs to give patients a greater understanding of their medicines. We used resources from the Me and My Medicines campaign developed in Leeds. The campaign includes The Medicines Communication Charter and encourages patients and their carers to ask questions about their medicines to help them get the most benefit.

Action

One GP practice was selected as a pilot site for the Me and My Medicines clinics. Our practice-based medicines optimisation technicians created an EMIS web search to identify patients aged between 65-80 taking three to seven therapies.

Using the campaign resources, they conducted non-clinical medication reviews during 30-minute appointments. Each patient was encouraged to ask questions about their medicines or raise any concerns. They were asked to bring their medicines in to the appointment.

The technicians provided an overview of the clinics at a medicines coordinator GP practices training session.

After successfully running and reviewing two pilot clinics, a further nine GP practices were selected.

Impact

In the first seven months 257 patients with a wide range of comorbidities were seen in the Me and My Medicines clinics. The technicians gave inhaler counselling to 23 and realigned 52 medicine quantities.

There were four high level quality interventions (for example, stopping duplication of medication), 146 medium level (for example, correcting variation to licensed doses) and 532 low level (for example, appliance maintenance and reminder of blood pressure check).

Patient feedback during and at the end of consultations, and in follow-up conversations, was positive. Patients’ relatives and GP practice staff also gave positive feedback.

We are continuing to roll this programme out to other practices.