Innovation in Healthcare Award: change from the front lineBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2487 (Published 08 April 2014) Cite this as: BMJ 2014;348:g2487
It is often said that frontline NHS staff know exactly how to improve care for their patients; they see the answer every day. The BMJ Innovation in Healthcare Award celebrates how that knowledge is shared with colleagues and acted on to deliver change. It takes commitment and collaboration to succeed but also courage to raise the possibility that things could be done differently.
Improving general practice referral, Tower Hamlets CCG, London
General practice referrals in Tower Hamlets, east London, had been creeping up for several years, when in 2011 general practitioners decided that action was needed. But Victoria Tzortziou Brown, a local GP and clinical commissioning group lead on planned care and research, said that doctors wanted to avoid a referral management centre because they “introduce another layer of administration, add costs, and deskill and undermine GPs.” Instead the CCG developed a package of interventions to improve the management of common conditions in four specialties—musculoskeletal disorders, dermatology, urology, and ear, nose, and throat—and targeted referral behaviour. The interventions were rolled out across all 36 general practices in Tower Hamlets with a “referral champion” in each of eight general practice networks.
Auditing and discussing 2670 referrals at practice meetings over the following months led to a 15% fall in referrals and a rise from 68% to 79% in recording of suspected diagnosis and history in referral letters. Variation between practices also levelled out, with the biggest reduction seen in dermatology referrals (interpractice variability fell from 13.51% to 9.29%). The programme has now expanded to other conditions, leading to savings of £1m (€1.2m; $1.7m) from reduced pathology requests alone. The secret to the programme’s success? “GPs were engaged from the start. Their enthusiasm to participate was especially surprising,” said Tzortziou Brown. “They saw [the review of audits] as playing their part rather than a punitive way of being judged.”
Bipolar education, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University
It was the evidence that inspired doctors, nurses, and psychologists in Cardiff to develop the bipolar patient education programme. They knew that patients’ lives could be transformed by having a better knowledge of their condition. “There was a real desire among patients and professionals for an approach that is not just focused on giving medication,” said Ian Jones, professor of psychiatry and deputy director of the MRC Centre for Neuropsychiatric Genetics and Genomics at Cardiff University. Instead they developed a holistic approach to increase understanding of potential triggers and the role of medication.
There were two formats—a 10 week psychoeducational group course and eight interactive web based modules called BeatingBipolar (www.beatingbipolar.org), both providing information about diagnosis and treatment and encouraging self management skills as well as collaboration with clinicians.
The dual delivery was essential, said Jones: “Not everyone likes a group environment for learning, and for them the online option of delivering the information has been a fantastic success.”
To date 396 people across Wales have been through the group course and 3250 people have accessed online modules. Nearly all patients who completed group tutorials (97%) said they would recommend it to other patients,1 2 and the package has been embraced by the charity BipolarUK, the Welsh government’s strategy for mental health, and staff training outlets in the UK, Northern Ireland, New Zealand, and Turkey.
Safety incident reporting by families, Great Ormond Street Hospital, London
In March 2013 Great Ormond Street Hospital began piloting a real time reporting system on its 14 bed renal ward. They wanted to see whether involving families of patients in reporting possible safety concerns might make the hospital safer. The novelty, in today’s high tech environment, was that the system involved no computers or gadgets, just a laminated card with pictures and colour coding. Family members could fill in the card at any time of day and take it to a ward sister, prompting a conversation about their concerns.
Project manager Charlotte Magness said this system was chosen for its simplicity and ease of use for all families, including those who could not speak English well and who have learning difficulties. “Technology can sometimes be a barrier to communication. Being able to talk to someone face to face is important,” she said.
Of the families approached, 86% agreed to participate and 27 families reported 33 problems, with communication (31%) and medication (21%) the largest categories of concerns. Problems with communication could mean that families didn’t understand what was happening to their child, that poor communication between doctors and nurses led to a delay in treatment, or a translator wasn’t available. Other wards at Great Ormond Street are now looking to adopt the scheme, as are safety advisers in the Netherlands and Australia.
Tackling chronic pain in people on benefits, Fit For Work Team, Leicestershire
The surprising thing about spending 90 minutes with someone with chronic pain—thoroughly examining them, talking to them about their problems with debt and getting around, discussing possible diagnoses and management options—is the subsequent reaction of their disability employment advisers (DEAs), said Rob Hampton, a GP and lead at the Leicestershire Fit for Work service. “After this intervention the DEAs said they felt that they were working with completely different people—that their clients were much more engaged,” he said.
Hampton ran the “From pain to prospects” pilot, which looked at whether input from a doctor, a pain management programme combined with employment support, and a case manager can help people with chronic pain get back to work. Over four months in 2013 the programme assessed 31 people, and so far five (16%) have found a job, three are doing voluntary work (10%), and three (10%) are undertaking vocational training.
An unexpected finding, said Hampton, was that many people lacked a good understanding of their pain and how to deal with it. In addition, four out of five had never had individual physiotherapy and 23 had unmet health needs.
Hampton said the findings highlight that GPs need more training in pain management and that these patients need more time with a doctor than the 10 minute consultation allows. What was encouraging, Hampton said, was the willingness of GPs to accept and implement treatment recommendations.
Education for patients starting warfarin for atrial fibrillation, University of Birmingham
One of the challenges of treating patients with atrial fibrillation with warfarin is overcoming their fear of harm because of the drug’s use as rat poison. That, and trying to maintain patients within the desired therapeutic range for more than 70% of the time, was the inspiration behind the University of Birmingham’s patient education strategy.
Together with patients, the team produced an intervention that included a one-off group session, an educational booklet, a self monitoring diary, and a worksheet. During the group session patients were shown a DVD with clips discussing concerns about warfarin, advice from a cardiologist, lifestyle recommendations, and a mock consultation. A randomised controlled trial (the TREAT study) conducted from 2010 to 2012 showed that the intervention significantly improved the proportion of patients staying within the therapeutic international normalised range during the first six months of treatment (76.2% v 71.3% in the non-intervention group; P=0.035) and also significantly improved patients’ understanding of the treatment as measured with a postal questionnaire after the intervention. At 12 months differences in the number in the therapeutic range between the groups were not significantly different (76% v 70%; P=0.44),3 suggesting that the intervention may need to be repeated to support and reinforce behavioural change.
Cite this as: BMJ 2014;348:g2487
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
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Provenance and peer review: Commissioned; not externally peer reviewed.