The Realistic Medicine Value Improvement Fund provides funding for improvement projects within Health Boards, that are taking an innovative approach to improving patient care and outcomes. Three Project Leads from our 2018-2020 round of funding have kindly shared their “Lessons in Value” with us.
|The Issue||The 9 GP practice locations in NHSWI are spread across 3 island groups which prevents simultaneous daily access to the new Primary Care Pharmacists due to travel times/ferries etc.|
|The Solution||Develop a remote solution that will allow simultaneous access to all 9 practice sites servers to allow virtual attendance. Upon completion open this up to other staff groups who will benefit also.|
|The Results||Each practice was fitted with a ‘Terminal’ server that allows up to 100 remote log-ins at any one time giving capacity to expand the number of client groups who can access GP systems under strict protocol in order to protect confidentiality and provide an appropriate audit trail.|
|Next Steps||At present there are a limited number of staff groups accessing the terminal server (Pharmacy and Community Nursing). Capacity within IT has hindered roll out wider due to the constraints of COVID on the department. More learning will be required around use to see if this system is application to a National solution for remote access.|
|Do Differently||The initial estimate of cost was inadequate, and we required support from the Primary Care Improvement Fund to allow completion of installation. Better planning at the start would have been preferable.|
|Find out More||Dr Dave Rigby, RM Lead NHSWI (David.email@example.com)|
|The Issue||Children and young people with epilepsy are significantly more likely to develop mental health problems than their same aged peers or, indeed, children and young people with other types of chronic or long-term illnesses. Epilepsy clinic appointments would, understandably, focus on physical health concerns/ managing seizures. If mental health difficulties were identified in epilepsy clinics, young people would usually be referred to Child and Adolescent Mental Health Services (CAMHS). Unfortunately CAMHS waiting times are long. Also generic mental health teams may not be confident dealing with children who have epilepsy.|
|The Solution||Psychology Adding Value Epilepsy Screening (PAVES ) is an innovative, mental health screening method, teamed with a stepped care intervention pathway. The screening identifies potential mental health difficulties during routine, epilepsy clinic attendance. It uses a traffic light metaphor to guide medical clinicians’ understanding and further investigation. The traffic lights also map to appropriate, stepped, early intervention options. Interventions include signposting to ratified third sector organisations, self-help materials, parent workshops and a six-week psychosocial group for adolescents. With Realistic Medicine funding, we have been able to move from paper questionnaires, requiring the presence of a psychologist in epilepsy clinics to administer and score, to a custom website that automatically generates a report for clinicians to use in appointments. We have also been able to further develop the interventions to start to include communication with schools re the young person’s difficulties.|
|The Results||PAVES has not only highlighted the unmet need for children and young people with epilepsy but also developed a stepped-care early intervention model that has proven to reduce CAMHS referral rate by 62% and increase engagement by this population with third sector services. Over 600 screenings have been completed, with many families being screened multiple times, 123 families have received timely psychological support that they would have not otherwise have received. The average time to treatment was 11 weeks.|
|Next Steps||The electronic screening tool will be tested, and updated interventions will be piloted within NHS Lothian paediatric neurology clinics. There has been interest from other health boards regarding developing a local PAVES service. The PAVES model could also be applied to other healthcare populations, so future iterations of PAVES may screen children and young people with other chronic illnesses.|
|Do Differently||Despite expressed parental interest in workshop and group interventions, this was not reflected in uptake. QI projects revealed logistics appeared to be one of the main barriers to access. Some interventions are suitable for remote delivery, this will be explored/ developed and is hoped to improve accessibility. Website generated reports are expected to improve the efficiency of the screening process, families can also complete the questionnaires at home before their appointment.|
|Find out More||Kirsten.Verity@nhslothian.scot.nhs.uk|
|In Scotland 40% of the population live with one or more long term conditions. On average a person living with diabetes spends 3 hours a year with a healthcare professional and for the remaining 8,757 hours they manage their diabetes themselves.
There is an association between increased patient activation levels and reduced use of unscheduled care in primary and secondary care settings.
We wanted to better develop our GP Practice systems to support people to understand and manage their conditions and to live active and healthy lives. Our aim was to increase patient engagement and activation and to measure increased attendance at long term condition reviews in the practice.
|The Solution||We involved key partners from the outset including Tranent Medical Practice Patient Participation Group, Lothian House of Care Collaboration, East Lothian Local Intelligence Support Team, Alison Manson from Group Consultations, Rob Lawson from British Society of Lifestyle Medicine, Fa’side Area Partnership. Our whole practice team were involved.
One of our first steps was to create a driver diagram of our ideas for change. Staff training needs were identified, and regular planning meetings were established. Baseline data was extracted from our practice systems.
Gordon Amoh who was undertaking a Masters in Public Health at the University of Edinburgh carried out a mixed systematic review into patterns of attendance in Primary Care for patients living with chronic disease.
We developed a range of methods of engaging with patients. A Group Consultations programme was introduced to complement our pre-existing House of Care approach and we started using the Patient Activation Measure (PAM). Through the Primary Care Improvement Plan work led by East Lothian Health and Social Care Partnership a new network of Community Links Workers has been introduced.
|The Results||Over the course of this project, we achieved our aim of increasing patient attendance at annual chronic disease reviews – this has risen from 45% in September 2018 to 74% in September 2020.
Our Health Care Assistants now record a person’s Patient Activation Measure which is used during Care and Support Planning conversations. Preliminary analysis has shown an increase in mean PAM scores within the two lowest activation levels.
A Group Consultations programme was launched in the practice in Spring 2019, and we had excellent patient and staff feedback. Unfortunately, this programme had to be paused due to the Covid 19 pandemic, but we hope to re-introduce face to face Group Consultations when circumstances allow.
This work brought the Practice team together and created a joint purpose. We have developed an improved model of person-centred care enabling better supported and engaged patients to manage their own health. We have forged links with the community, with our patient population, external organisations and local professionals.
|Next Steps||It would be good to see more national resource to improve access in all care settings to models which support person centred care including Scotland’s House of Care and Group Consultations.
The Patient Activation Measure (PAM) Survey via Insignia Health is not yet widely used in primary care in Scotland. This assesses a person’s underlying knowledge, skills and confidence integral to managing his or her own health and healthcare. Support can be tailored to a person’s level of activation and the impact of an intervention can be measured by administering the PAM survey at regular intervals. The wider roll out of this measure would help healthcare providers to better support their patient population.
|Do Differently||The General Practice environment is an ideal setting for carrying out an improvement project such as this. We realised the importance of involving all key people and patients from the outset and building a shared vision.
The involvement of our Practice Manager Alisson Stewart was key to the success of this work and we should have established how to create protected time for her from the outset.
Implementing change is always messier than one would like it to be, but we stand by the words of Henry Ford “If you always do what you’ve always done, you’ll always get what you’ve always got”.
|Find out More||Jo Smail, GP Partner, Tranent Medical Practice firstname.lastname@example.org
Alisson Stewart, Practice Manager, Tranent Medical Practice
Leonie Hunter, Public Health Researcher, NHS Lothian
Scotland’s House of Care
Insignia Health – Patient Activation Measure