At Mod 3 Info

Any town health system
A guide to finding further information on

the interventions
January 2014
Introduction
How do we use this Any town health system guide?
• This guide has thus far outlined the challenge facing health systems in the form of a potential quality and funding gap
by FY 2018/19.
• The following section highlights interventions that the evidence suggests can help health economies to achieve cost
savings while delivering better quality care and further interventions that we have not included in the modelling and
report but may be of interest to health systems. These include interventions provided by other partner organisations
such as Public Health England and we are very grateful for their contribution.
• However, we recognise that not all health economies are the same:
o Their demographic make-up and the prevalence of conditions among the population will vary considerably
o Some health economies may already have begun implementing some of the initiatives we have discussed
• Furthermore, we recognise that implementing each of these interventions could pose a significant challenge to health
economies. Which should be prioritised and how should a health economy approach the challenge?
• With this in mind, this section presents interventions, a list of leads to follow up on, and a series of guides to getting
started with each of the interventions.
• These guides are intended to provide a high-level ‘starter for ten’ to assist with initial planning, including:
o Initial selection of priority interventions (based on health economy characteristics and target population groups)
and further interventions not included in the main report;
o Enablers and implementation steps;
o Potential barriers; and
o Suggested phasing of the interventions.
• We recognise that health economy decision-makers are likely to require a greater level of detail in the course of the
planning and execution of each intervention. For this reason we provide a list of further reading, which includes case
studies, academic studies and, where relevant, contacts for organisations that have experience implementing the
intervention
2
High Impact Interventions (HII)
The evidence base
We have performed a non-exhaustive literature review to collate the evidence base behind our selected High
Impact Interventions. This review was composed of three inter-connected phases:
1
• We began with 270 self-reported case studies of healthcare interventions currently being
implemented by health economies around the country, which provided an overview of the breadth
Assessing NHS case of interventions already being trialled across the NHS.
studies
• While many of these did not meet our inclusion criteria (see next slide), those that did were short-
listed for further consideration.
2 • These internal case studies were supplemented through the use of academic reviews of specific
Incorporating interventions (e.g., primary care referral management and patient self-help).
interventions from • These provided context on the state of the evidence base for each intervention, as well as providing
existing academic some fully impact-assessed controlled studies of specific interventions.
reviews • Furthermore, NICE assessments were consulted where available (e.g., for the cost-effectiveness of
early diagnosis interventions).
3 • Finally, specific examples of innovative interventions were drawn from publications produced by
Adding specific case third sector organisations, such as the King’s Fund or the British Heart Foundation.
studies from Third • While many of these case studies did not fully meet our impact assessment criteria, those that did
Sector organisations were shortlisted for further study.
• Where these suggested the existence of impact assessment for interesting interventions we
followed this up in the academic literature.
This process resulted in a ‘long-list’ of potential interventions, which were then screened to determine their suitability for
inclusion in Any town health system
4
The short-listing exercise
We have used four criteria to short-list from a long list of interventions. The process for selecting high impact
interventions included input from subject matter experts and national clinical leads to further refine the list
1 The interventions are fully impact assessed from both a quality and finance perspective. Outcomes are clearly articulated, realised
and easily measurable for modelling purposes.
The outcomes derived from the interventions would contribute to the quality and financial challenge indicated previously in this
2 report – interventions where one benefits to the detriment of the other were excluded.
3 The narrative around the intervention is clearly articulated, so that an Any town health system could easily implement the
interventions.
The intervention is easily scalable to a broad population group (i.e. no interventions targeting ‘niche’ population groups that are
4
unlikely to exist in large numbers across many health economies) – this ensures the intervention produces a high impact.
5
The high impact interventions (HIIs)
In this section, for each high impact intervention we provide:
1 A high-level summary of the HII case study used to model the effects of the intervention and the quality and finance
benefits demonstrated in the source literature.
2 Further information on additional interesting case studies where the intervention has been implemented (where
available).
3
A deep-dive into the impact of the intervention on each quality ambition.
4
A brief primer on getting started with implementation – patient groups affected, potential enablers, barriers and likely
timeframes for realisation of the intervention’s benefits.
6
The high impact interventions (HIIs)
We have collected a range of case studies and produced a short-list as the high impact interventions
1. Early diagnosis:
Early detection and diagnosis to improve survival rates and lower overall treatment costs
Example case study:
Lovibond et al , 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011), The Lancet 378: 1219-1230
2. Reducing variability within primary care by optimising medicines use and referring
Reducing unwanted variation in primary care referring and prescribing to improve clinical outcomes and patient experience, whilst delivering financial savings
Example case study:
‘Reducing Unwarranted Variation to Deliver Efficiencies in Primary Care’ (NHS Erewash Clinical Commissioning Group)
3. Self-management: patient-carer communities:

Self-management programme for those suffering with a long-term condition, who educate and support each other
Example case study:
The Expert Patient Programme: Richardson et al, 'Cost Effectiveness of the Expert Patients Programme (EPP) for patients with chronic conditions' (2008), J Epidemiol Community
Health, 62, 361-367
4. Telehealth/telecare:
Using telecare/telehealth to transform health care through giving patients the confidence to manage their own condition more effectively in conjunction with their clinicians
Example case study:
a. Telemedicine for frail/elderly nursing home patients in Airedale - 'Airedale shares telemedicine success at global event' (Airedale NHS FT, 3 July 2013)
b. Telemonitoring of high-risk heart failure patients in Hull - Cruickshank & Paxman, "Yorkshire & the Humber Telehealth Hub: Project Evaluation" (2020health, 2013)
5. Case management and coordinated care:

Multi-disciplinary case management for the frail elderly and those suffering with a long-term condition
Example case study:
‘National Evaluation of the Department of Health’s Integrated Care Pilots’ (RAND Europe, 2012)
6. Mental Health – Rapid Assessment Interface and Discharge (RAID):

Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general hospitals
Example case study:
George Tadros, 'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience' (Birmingham and Solihull NHS Trust)
7. Dementia Pathway:
Improve health outcomes and achieve efficiencies in dementia care, by developing a fully integrated network model
Example case studies:
‘Service redevelopment: Integrated whole system services for people with dementia’ (Mersey Care NHS Trust, 2012)
8. Palliative care:
Community based, consultant-led palliative care service
Example case study:
Midhurst MacMillan, ‘Community Specialist Palliative Care Service, Delivering end-of-life care in the community’ (The King’s Fund, 2013)
7
The High Impact Interventions
1. Early diagnosis
2. Reducing variability within primary care by optimising medicines use
3. Self-management: patient-carer communities
4. Telehealth/telecare
5. Case management and coordinated care
6. Mental Health – Rapid Assessment Interface and Discharge (RAID)
7. Dementia Pathway
8. Palliative care
8
Case study: early diagnosis
Early diagnosis of high blood pressure improves quality of life, increases life expectancy, and reduces the overall
cost of healthcare
Name and Ambulatory screening for hypertension, assessed in Lovibond et al, 'Cost-effectiveness of options for the diagnosis of high
source of blood pressure in primary care: a modelling study' (2011) The Lancet 378: 1219-1230
literature http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61184-7/abstract
Description of The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and
intervention ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than
both clinic and home monitoring in diagnosing hypertension. This study aimed to compare the cost-effectiveness of different
diagnostic strategies for hypertension using a Markov model-based probabilistic analysis
Clinical The model weighs the increase in quality-adjusted life-years (QALYs) associated with early detection of hypertension via
outcomes ambulatory, home or clinic-based diagnostics
• For patients aged over 50, ambulatory screening is predicted to produce an average per patient increase in QALYs
Financial • Ambulatory screening is predicted to be cost-effective compared to other screening techniques, for all patients aged over
outcomes 40
• Modeled estimates of per patient lifetime savings ranged from £56 for men aged 75 to £323 for women aged over 40
Relevance to Early screening for a range of long-term conditions to prevent or delay onset of the disease has positive public health and
Any town health economic impacts. Through prevention and early treatment of an LTC, the time spent in the more severe and costly
system treatment settings can be markedly reduced. Specifically, the use of ambulatory diagnostics of hypertension has been
recommended by NICE
Other UK Cost-effectiveness of population-based screening for colorectal cancer, ‘British Journal of Cancer 2012’; ‘NICE cost impact
examples and commissioning assessment: quality standard for stroke’ (NICE cost impact and commissioning assessment, 2010)
Other ‘Cost effectiveness of early detection of breast cancer in Spain’, BMC Cancer, 2011; ‘Cost-effectiveness Analysis of a
international Prospective Breast Cancer Screening Program In Turkey’ (Middle East Technical University, 2011); ‘Cost effectiveness of an
examples integrated vascular risk assessment and management intervention’ (Australian Centre for Economic Research on Health,
Australian National University, 2011)
9
Impact of interventions on quality: early diagnosis
Early diagnosis – Ambulatory screening for hypertension
Indicator Effect on
Ambition CCG Indicator Effect of Intervention
Number Quality
Potential years of life lost (PYLL) from causes

1.1
considered amenable to healthcare - Adults This intervention produces a net QALY gain for hypertensive patients over
1. Secure additional years
50, and is expected to reduce PYLL in the long term. However, based on
of life Potential years of life lost (PYLL) from causes
available data it is not possible to map this benefit directly onto Ambition 1 1
considered amenable to healthcare - Children 1.1
and young people
This intervention produces a net QALY gain for hypertensive patients over
2. Increase QoL for People Health-related quality of life for people with
2 50, and is expected to improve HRQoL. However, based on available data
with Long-Term Conditions long-term conditions (EQ5D)
it is not possible to map this benefit directly onto Ambition 2 1
Unplanned hospitalisation for chronic

ambulatory care sensitive conditions (updated 2.6
methodology)
3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes This intervention produces a net cost saving for hypertensive patients over
2.7
time spent in hospital and epilepsy in under 19s 40, and is expected to reduce unplanned admissions for chronic
ambulatory care sensitive conditions. However, based on available data it
Emergency admissions for acute conditions is not possible to map this benefit directly onto Ambition 3 1
that should not usually require hospital 3.1
admission (updated methodology)
Emergency admissions for children with lower

3.4
respiratory tract infections
4. Increase the proportion [Proxy] Proportion of older people (65 and over)
of older people living who were still at home 91 days after discharge
independently following
discharge
from hospital into reablement / rehabilitation
services
2B This intervention does not target a change in Ambition 4
−
−
5. Reduce poor hospital This intervention does not target patient experience of hospital care, and
Patient experience of hospital care 4.b
care feedback so is not expected to produce a change in Ambition 5
−
7. Significantly reduce
Hospital deaths attributable to problems in care 5.c This intervention does not target a change in Ambition 7
hospital avoidable deaths
10
Strength of quality benefit: Suspected benefit Qualitative benefit
 Some quantified benefit  Strong quantified benefit − No impact
 The Lancet 378: 1219-1230
Source: (1) 'Lovibond et al, 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study' (2011)
Getting started: early diagnosis
Population groups affected: The literature suggests that this intervention will have a greater impact in health
 Adults with LTCs economies with the following characteristics:
 Frail elderly and dementia sufferers
Frail Depri-
LTCs Rural Urban Other
elderly ved
Have you thought about the following Have you considered whether the Have you considered how you will
enablers and implementation steps? following may be barriers? phase the intervention?
 One of the key success factors for this  Paying for the benefits: in some • It is to be expected that the benefits for this
intervention is patient education and cases ‘investigational’ costs (i.e. for intervention take some time to reach their full
scale, given that the emphasis is on preventing
awareness-raising, in order to monitoring for early signs of disease) future conditions or the worsening of current
achieve the maximum impact through are distinct from the budget for conditions
high uptake. This can be achieved medications, meaning that savings in • There is likely to be some initial benefit as
through advertising, literature, and the drug budget do not necessarily patients are diverted from A&E, but the majority
GPs, among other methods translate into resources for early of the benefit will emerge in subsequent years
detection. Tackling this requires • The graph below indicates the likely phasing of
 Alongside this, a sustained effort is
greater ‘joining up’ across the system this intervention
required to identify and target those
Forecast savings per year
patients who are most at risk and  Encouraging uptake: patient
Urban CCG (£m)
who are therefore most likely to benefit awareness may be a barrier, as 0.8
Initial benefits
from the intervention many at-risk patients may not realise 0.7 commence
 Investment in new devices as well as they are eligible for the screening 0.6
Further benefits
the support teams and other programme or wish to take 0.5 Intervention
launched
develop
0.4
infrastructure is an important aspect of advantage of it
0.3
the intervention 0.2 Planning
0.1 begins
0.0
2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
11
Key leads and further reading: early diagnosis
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? There are a range of examples available
through NHS England resources for CCGs (http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-1/
), including:
• NHS Erewash CCG – Atrial Fibrillation Detection Programme
• South London – screening programme
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful;
• 'Lovibond et al, 'Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling
study' (2011) The Lancet 378: 1219-1230
• ‘NICE cost impact and commissioning assessment: quality standard for stroke’ (NICE cost impact and
commissioning assessment, 2010)
12
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
13
Overview of medicines optimisation
The four principles of medicines optimisation

Medicines optimisation is a patient-focused approach to getting the best
from investment in and use of medicines that requires a holistic approach,
an enhanced level of patient centred professionalism, and partnership
between clinical professionals and a patient.
The Royal Pharmaceutical Society, working with patient representatives,
medical and nursing royal colleges, and the pharmaceutical industry,
endorsed by NHS England, has identified four key principles of medicines
optimisation:1
1. Aim to understand the patient’s experience: through an open,
ongoing dialogue about the patient’s experience of using medicines,
and recognising that the patient’s experience may change over time
2. Evidence based choice of medicines: the most clinically appropriate
and cost-effective medicines are used to meet the needs of the patient,
informed by the best available evidence base
3. Ensure medicines use is a safe as possible: healthcare
practitioners take responsibility for safe use of medicines and discuss
this with patients and carers. This includes unwanted effects,
interactions, safe processes and systems, and effective
communication between professionals
4. Make medicines optimisation part of routine practice: healthcare
professionals routinely discuss with one another and with patients how
to achieve the best outcomes from medicines
1. Royal Pharmaceutical Society, ‘Medicines optimisation: helping patients to make the most of medicines’ (May 2013) (http://
www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf)
14
Case study: reducing variability within primary care
This primary care intervention focuses on reducing variability in cost and patient outcomes through addressing
prescribing and secondary care referrals
Name and
Reducing Unwarranted Variation to Deliver Efficiencies in Primary Care – NHS Erewash Clinical Commissioning Group
source of
http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/d2-cs/#ere
literature
Description of During 2011-12, the CCG was expected to deliver savings of £4.1m as part of the QIPP agenda. This programme tackled the
intervention productivity challenge by engaging with patients and concentrating on quality standards within Primary Care, impacting on all
groups accessing primary care. The work was based on the Primary Care Foundation Report 2009, focusing on three
aspects of activity – referrals to secondary care, emergency admissions and prescribing. Specific changes in respect of
these three areas include the circulation of comparison data packs, practices were visited by Fellow GPs, secondary care
consultant master classes were held, introduction of prescribing advisors, a “buddying” system, and quality payments for the
development of care plans.
Clinical • Building solid foundations to a patient-centred approach to optimising medicines use through engaging with patients,
outcomes improving safety, collaboration across professions and sector, more appropriate prescribing and better monitoring of
outcomes
• High levels of patient feedback
• Secondary care clinicians reporting less duplication of tests from improved systems and processes and improved quality
of referral letters
• More appropriate prescribing, driving better patient safety and experience
Financial • Inappropriate hospital admissions prevented, down by 4% annually – (mainly long-term conditions and frail elderly) driving
outcomes better outcomes and experience for these patients
• Secondary care referrals from practices were down 14%
• Referral rate variance across 13 practices dropped from 202-378 per 1000 in 2010-11 to 174-257 - a reduction of over
50% in variation
• These improvements led to £1.04m saving on referrals and admissions – 14-fold return on the investment in 2011-12
• In addition, the CCG’s prescribing overspend was cut by 75%, saving £600,000
Relevance to Optimising medicines use can help reduce variation in the care provided to patients. This not only improves quality of care
Any town health and patient experience; financial savings on hospital care and prescribing can also be realised. The success of this case
system study can be widely applied to Primary Care across the NHS.
15
Impact of interventions on quality: primary care
Primary care – Reducing unwarranted variation in NHS Erewash Clinical Commissioning Group
Indicator Effect on
Number Quality

1.1
−
considered amenable to healthcare - Adults
1. Secure additional years The literature review has not revealed that this intervention would produce
of life Potential years of life lost (PYLL) from causes a significant effect upon PYLL
and young people
It is expected that the aspect of this intervention relating to safe and

2. Increase QoL for People Health-related quality of life for people with appropriate use of medicines would have a significant impact upon patient
2
with Long-Term Conditions long-term conditions (EQ5D) quality of life as a secondary benefit of a reduction in drug-related adverse
effects

methodology)
This intervention has produced an overall 14% reduction in elective
3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes
2.7 referrals to secondary care. The literature does not suggest a reduction in
time spent in hospital and epilepsy in under 19s
unplanned admissions1 However, techniques regarding safe and
Emergency admissions for acute conditions appropriate use of medicines might be expected to also reduce emergency
that should not usually require hospital 3.1 admissions as a secondary benefit of a reduction in drug-related adverse
admission (updated methodology) effects

3.4
None yet quantified – however, it may be expected that some of the
2B reduction in referrals produced by this intervention will produce a positive
independently following from hospital into reablement / rehabilitation
impact on Ambition 4
discharge services
−
5. Reduce poor hospital This intervention does not target patient experience of hospital care, and
Patient experience of hospital care 4b
−
7. Significantly reduce This intervention does not target hospital care, and so is not expected to
Hospital deaths attributable to problems in care 5c
hospital avoidable deaths produce a change in Ambition 7
16
Strength of quality benefit: Suspected benefit
Qualitative benefit
Source: (1) ‘0404 Case Study - QIPP CQUIN - Reducing Unwarranted Variation to Deliver Efficiencies in Primary Care’ (NHS Erewash
CCG, 2013)
Getting started: reducing variability within primary care
 All patient groups economies with the following characteristics:
Frail Depri-
elderly ved
 This intervention focuses on tackling  Ensuring that standards of care remain high • Some initial impact is likely to be experienced
unwarranted variations between practices and is a central concern, as well as reassuring in the first year of implementation
practitioners. A key element is therefore to patients that their health and well-being is • However, the full impact is likely to take at least
focus on changing behaviour not compromised in any way an additional year to materialise, and is
 Engaging patients in their medicines use to  Gaining practitioner buy-in is fundamental dependent on altered prescribing practices and
achieve optimal outcomes is key to the success of this intervention and is a the embedding of new prescribing norms
key challenge. It is more likely where there is • The graph below indicates the likely phasing of
 The intervention is more likely to be successful
an effective communication effort and this intervention
if it involves all practitioners across and
practitioners feel they are involved in the
within sectors
development of the intervention
 Shared experience, e.g. via personal Forecast savings per year
 Effectively monitoring and gaining
experience data packs circulated monthly,
compliance from practitioners is necessary
Urban CCG (£m)
5.0
enables clinicians to identify and tackle
to ensure the maximum impact from this 4.5 Main benefits
variations in their practices
intervention – previous experience suggests 4.0 commence
 Other effective tools include master classes that maintaining an ongoing dialogue with 3.5 Further
and practice based clinical pharmacists to practitioners is the most effective way to 3.0
incremental
benefits
increase levels of awareness and education achieve this 2.5
Intervention
 Peer support, encouragement and challenge 2.0 launched and
and a process of regular peer review are also 1.5 initial benefits
commence
key elements of the intervention 1.0
Planning
0.5 begins
 Practice quality payments can provide a
0.0
financial incentive 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
17
Key leads and further reading: reducing variability within primary care
‘Key leads’
Who could you speak to in order to find out how to do this intervention well?
• NHS Erewash CCG
• PrescQIPP is designed to support quality, optimised prescribing through providing guidance, resources and tools to
health economies. There are currently over 60 CCGs enrolled – visit http://
www.prescqipp.info/user/registration-notes/register for further info
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful.
• 0404 Case Study - QIPP CQUIN - Reducing unwarranted variation to deliver efficiencies in Primary Care (NHS
Erewash CCG, 2013)
18
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
19
Case study: Self-management - patient-carer
communities
This self-management intervention empowers patients through education and support, improving health related
quality of life and reducing their reliance on secondary care
Name and The Expert Patient Programme, analysed in, Richardson et al, 'Cost Effectiveness of the Expert Patients Programme (EPP)
source of for patients with chronic conditions' (2008) J Epidemiol Community Health, 62, 361-367
literature http://jech.bmj.com/content/62/4/361.short
Description of Originally based on the US Chronic Disease Self-Management Program, the Expert Patient Programme (EPP) is a patient-
intervention led system of group support for sufferers of a range of chronic diseases. The programme typically consists of 6 weekly 2.5
hour lay-led meetings of ~10 patients, who educate and support each other on topics such as dealing with pain / other
symptoms, coping with depression / anxiety and healthy lifestyle choices.
In 2008, Richardson et al assessed the cost-effectiveness and quality outcomes of the EPP in a RCT of ~700 chronic
disease sufferers from around England.
Clinical Over the 6 month trial, improvement across all five dimensions of the EQ5D system was observed for intervention patients.
outcomes Healthcare service usage was lower for EPP patients versus controls, with a 49% reduction in average number of inpatient
days, a 6% reduction in outpatient appointments and a 73% reduction in occupational therapy home visits for EPP patients.
Financial On the basis of these data a 0.02 QALY gain per patient for the intervention group was estimated. Once EPP provision costs
outcomes are accounted for, this produced a £27 per patient saving.
Relevance to Schemes such as this provide strong non-financial benefits in the form of improved patient outcomes (e.g., community
Any town health integration, sense of wellbeing / empowerment). Their broad applicability and low barriers to access mean that, while the per
system patient cost saving is low, across a health economy the potential aggregate savings are larger.
Other UK
‘People powered health co-production catalogue’ (NESTA, 2012); ‘Delivering better services for people with long-term
examples
conditions: building the house of care’ (The King’s Fund, 2013)
Other
international The CDSMP programme for chronic conditions: Lorig et al, 'Effect of a Self-Management Program on Patients with Chronic
examples Disease' (2001) Effective Clinical Practice, 4:256-62
20
Case study: Self-management - patient-carer
communities
For the purposes of modelling we have used UK-based impact assessed evidence. Whilst not based in the UK, we
present a case study from Kaiser Permanente that may be further explored by health economies
Innovators
Case study: Self-Management Program on Patients with Chronic Disease
For patients with chronic disease, there is growing interest in “self-management” programs that emphasise the patients’ central role in managing
their illness. The Chronic Disease Self-Management Program is a 7-week, small group intervention attended by people with different chronic
conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasises
problem solving, decision making, and confidence building.
The following metrics were monitored: health behaviour, self-efficacy (confidence in ability to deal with health problems), health status, and health
care utilisation. These were assessed at baseline and at 12 months by self-administered questionnaires.
At 1 year, participants in the program experienced statistically significant improvements in health behaviours (exercise, cognitive symptom
management, and communication with physicians), self-efficacy, health status (fatigue, shortness of breath, pain, role function, depression, and
health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared
with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the
differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomised, controlled
trial.
Programme costs were estimated to be about $200 per participant. The study replicated the results of our previous clinical trial of a chronic
disease self-management program in a “real-world” setting. One year after exposure to the program, most patients experienced statistically
significant improvements in a variety of health outcomes and had fewer ED visits.
21
Source: Lorig et al, 'Effect of a Self-Management Program on Patients with Chronic Disease' (2001) Effective Clinical Practice, 4:256-62
Impact of interventions on quality: self-management
Patient-Carer communities – The expert patient programme
Indicator Effect on
Number Quality

1.1
considered amenable to healthcare - Adults None yet quantified – however, by helping patients better manage their
conditions, it may be expected that the intervention will reduce PYLL in the
long term
and young people
2. Increase QoL for People

with Long-Term Conditions
Health-related quality of life for people with
long-term conditions (EQ5D)
2
The intervention has produced a 7.7% increase in health-related quality of
life for patients with long-term conditions 1 
methodology)
3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes None has yet been quantified – however, this intervention aims to reduce
2.7
time spent in hospital and epilepsy in under 19s admissions for patients with long-term conditions. Therefore, it can be
expected to produce an improvement in Indicator 2.6. Indeed, it has
Emergency admissions for acute conditions produced a quantified reduction in A&E attendances and inpatient bed-
that should not usually require hospital 3.1 days2

3.4
None yet quantified – however, this intervention can be expected to
2B increase the proportion of older patients still at home 91 days post-
discharge
discharge services
−
5. Reduce poor hospital This intervention does not target patient experience of hospital care and
−
7. Significantly reduce This intervention does not target hospital care and so is not expected to
Hospital deaths attributable to problems in care 5.c
22
Source: (1) Kennedy et al, 'The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with
long-term conditions: a pragmatic randomised
control trial' (2007) J Epidemiol Community Health, 61:254-261; (2) Richardson et al, 'Cost Effectiveness of the Expert Patient Programme (EPP) for patients with chronic conditions‘
(2008) J Epidemiol Community Health, 62:361-367
Getting started: self-management
 Adults with LTCs
economies with the following characteristics:
 Children with LTCs
 Carers
Have you thought about the following Frail Depri-

enablers and implementation steps? elderly ved
 Provide training for clinicians in the core
competencies of self care Have you considered whether the Have you considered how you will
 Develop a more personalised self-
following may be barriers? phase the intervention?
management pathway for patients, responding  Overcoming negative attitudes among staff to • Done well, self-help interventions can be a
to the feedback from patients that they can feel new approaches to patient care with an relatively quick win, with training courses and
they are treated ‘like robots’ emphasis on self-management. In many cases other forms of support for patients and
 Learn from the experience of patients and this can be mitigated through improved clinicians feeding through into rapid outcomes
clinicians to continually inform service design, provision of training and information (as quickly as four to six months in some
leading to a dynamic process of feedback and  Lack of awareness, both among patients and studies)
improvement staff, can also be a significant barrier to the • It is to be expected that benefits will continue to
 Identify and target patients with the conditions success of this intervention as this can lead to build over future years as awareness grows
that are most likely to benefit from self- lower rates of participation and service design is improved in response to
management  Patients may not be ready or confident for the experiences of patient and clinicians
 Ensure that self-management goals become self management and need to address any • The graph below indicates the likely phasing of
an integral part of the care process and form concerns they have Forecast savings per year
this intervention
part of a personalised care plan  Technical issues, such as the inability of 1.0
Urban CCG (£m)
current IT systems to register information such Intervention
 Co-ordinated action at both local and national
launched and
level is a powerful enabler of this initiative and as patients’ issues and goals 0.8
benefits commence
Further
offers a route to overcoming many of the  Multi-morbidity (for example, where the 0.6 incremental
challenges involved patient suffers from both mental and physical benefits
 Consider how self management programmes fit conditions) poses an additional challenge, 0.4
in with the wider strategy for self care and self given that most clinical guidelines and IT
0.2 Planning
management support systems are geared towards single conditions begins
0.0
 Use of third sector organisations
2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
23
Key leads and further reading: self-management
‘Key leads’
• The Expert Patients Programme: get.info@eppcic.co.uk
• Patient Participation team, NHS England: england.patientsincontrol@nhs.net)
Further reading
To help you read around this intervention, we have assembled a list of the literature which we have found most useful:
• http://www.expertpatients.co.uk/sites/default/files/files/Evidence%20for%20the%20Health.pdf
• Richardson et al, 'Cost Effectiveness of the Expert Patient Programme (EPP) for patients with chronic conditions'
(2008) J Epidemiol Community Health, 62:361-367
• Kennedy et al, 'The effectiveness and cost effectiveness of a national lay-led self care support programme for
patients with long-term conditions: a pragmatic randomised control trial' (2007) J Epidemiol community Health,
61:254-261
• ‘Delivering better services for people with long-term conditions: building the house of care’ (The King’s Fund, 2013)
• Patient Participation Guidance by NHS England ‘Transforming participation in health and care’ (2013)
http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf
• NESTA People Powered Health http://www.nesta.org.uk/publications/health-people-people-and-people
• Patient-centred care resource centre by the Health Foundation http://personcentredcare.health.org.uk/
24
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
25
Case study: telehealth and telecare
A broad range of telehealth / telecare interventions keep patients healthy and within their own home by allowing
remote consultation with physicians, monitoring of vital signs or phone-based coaching in self-care methods
Name and Telehealth for older patients and those with long-term conditions at Airedale NHS Foundation Trust, from 'Airedale shares
source of telemedicine success at global event' (Airedale NHS FT, 3 July 2013)
literature http://www.airedale-trust.nhs.uk/Media/NewsItems/2013/News03July13.html
Description of Airedale Hospital has a Telehealth Hub on site, which connects to over 1,000 patients across Airedale Hospital’s catchment
intervention area. These include those with chronic heart failure, chronic obstructive pulmonary disease (COPD), diabetes and the frail
elderly living at home and in 33 residential and nursing homes via secure video links. The service allows them to have face-
to-face consultations with nurses and doctors 24 hours a day, seven days a week. Patients can view consultants on either
their own TV with a set top box or a mobile video system. The system also covers several GP surgeries, 20 prisons and
Manorlands Hospice.
Clinical Compared to the year before intervention, telehealth delivered, in the 12 months post-intervention, for nursing home patients,
outcomes a:
• 69% reduction in A&E visits;
• 45% reduction in admissions from nursing homes; and a
• 30% reduction in length of inpatient stay from nursing homes
Financial While net financial benefits of the scheme have yet to be formally calculated, during its first 11 months of operation, the
outcomes system has saved £330,000 gross by avoiding 124 admissions and 94 face-to-face clinic appointments.
Relevance to This case study indicates the power of technology to deliver interventions which both improve the quality of care and clinical
Any town health outcomes while potentially driving significant cost savings. Technology is likely to be a key enabler of delivering ‘better for
system less’ in the Any town health system of the future
Other UK John Cruickshank, Jon Paxman, ‘Yorkshire & the Humber Telehealth Hub: Project Evaluation January 2013’ (2020health,
examples 2013); 3 million lives’ case studies
Other international Veterans’ Health Administration (VHA) telecare/telehealth (United States); Natasha Curry & Chris Ham, 'Clinical and Service
examples Integration' (The King's Fund, 2010)
26
Case study: telehealth and telecare
There are a number of other innovative case studies that could be further explored by local health economies –
below we detail an international example from the Veterans’ Association Health Administration
Innovators
Case study: Applying the evidence of impact of the Veterans’ Health Administration to the NHS in England
The VHA is a large, publicly-funded system delivering comprehensive services to a veteran population of 23 million, with an annual
budget of over £30 billion. Using telehealth, VHA aims to support patients with long-term conditions through care ‘at a distance’ and
self-management skills, leading to significant reductions in acute care. According to various studies, VHA consistently provides a
more cost-effective and better quality of care than other health systems in the USA, with around 50,000 VHA patients receiving
telehealth services in 2011.
The programme relies on health informatics, disease management and home telehealth technologies to enhance access and
improve healthcare services. With the use of telehealth, the VHA was able to integrate both vertically and virtually; in other words,
the patient was treated in an integrated fashion by the appropriate VHA case organisation or non-VHA provider through the use of a
care agreement and providers being able to integrate and share information via the patients Electronic Health Record, irrespective
of location.
Drawing parallels for England, based on the evidence from the VHA experience, reports suggest approximate decreases in bed
utilisation for four key disease areas: diabetes (-20.4%), hypertension (-30.3%), heart failure (-25.9%), COPD (-20.7%), and
depression (-56.4%).
27
Sources: ‘What can the NHS learn from the experience of the US Veterans Health Administration?’ (2020health, 2012); ‘Telecare and Telehealth –a game changer for health and social
care’ (Deloitte Centre for Health Solutions, 2012)
Impact of interventions on quality: telehealth and telecare
Telehealth and Telecare – Airedale NHS Foundation Trust

Indicator Effect on
Number Quality

1.1
considered amenable to healthcare - Adults None yet defined for Airedale – however, other telecare schemes have
demonstrated a 45% decrease in mortality (and hence PYLL) among
target patient groups1
and young people
2. Increase QoL for People Health-related quality of life for people with None yet quantified – however, in Airedale patients using the scheme
2
with Long-Term Conditions long-term conditions (EQ5D) qualitatively report improved HRQoL2

methodology)
Unplanned hospitalisation for asthma, diabetes

2.7
and epilepsy in under 19s
3. Reduce unnecessary
time spent in hospital Emergency admissions for acute conditions
This intervention has produced a 45% reduction in non-elective
admissions for patients with chronic ambulatory care sensitive conditions 3 
that should not usually require hospital
3.1 
3.4
While no benefit has yet ben quantified, it can be expected that this
2B intervention will increase the proportion of older patients still at home 91
days post-discharge
discharge services
−
5. Reduce poor hospital This intervention does not target an improved experience of hospital care
care feedback and so is not expected to produce a change in Ambition 5
−
6. Significantly reduce This intervention does not target hospital care and so is not expected to
28
cluster randomized trial' (2012) BMJ 344; (2)
Sources: (1) Steventon et al, 'Effect of teleheath on use of secondary care and mortality: findings from the Whole System Demonstrator
Jennifer Truland, "It's time for your screen test“, HSJ Telehealth (March 14 2013); (3) 'Airedale shares telemedicine success at global event' (Airedale NHS FT, 3 July 2013)
Getting started: telehealth and telecare
 Children with LTCs
Note: intervention may target one or all of these Frail Depri-
groups LTCs Rural Urban Other
elderly ved
 Keeping safe, digital records in secondary care to  Funding: implementing telehealth requires an initial • Initial impacts on cost and quality should begin to
allow integration with primary and other care settings is investment, and providers may be concerned that it materialise after a year. However, the full impact will
a precursor to giving patients and carers access to their will drive up their costs. Early identification of take longer to develop as ways of working adapt and
own records. Telecare equipment and health apps that funding sources and development of a clear provider more patients begin to use the equipment as part of
allow people, in conjunction with their physicians, to reimbursement model is therefore important their care packages
manage their own LTCs can then be introduced to  Scale: a telehealth intervention which fails to • The impact is likely to grow over many years,
empower patients, while at the same time ensuring that achieve adequate scale may not be cost-effective through reducing the growth in demand for healthcare
their actions remain embedded in the care they services to a manageable level
receive from the NHS. See ‘interoperable health  Staff engagement: without strong leadership and
getting staff buy-in, there is a risk that staff will resist • The graph below indicates the likely phasing of this
records’ in ‘Further Ideas’ for more detail.
adoption of new technology and ways of delivering intervention. As noted above, benefits are likely to
 The key to cost-effective implementation is achieving services to patients continue to mount beyond the five-year period due to
scale, as relatively high fixed costs are offset by low deflected future demand for services
 Public understanding and cultural/psychological
marginal costs for each additional user. This means a
single telehealth intervention is like to serve an area barriers: public awareness of the telehealth Forecast savings per year
larger than a single health economy. It is worth technology is low, especially among older population 1.4
segments who are more likely to benefit from the Urban CCG (£m)
considering: 1.2
technology
o Whether there is existing telehealth Initial benefits
 Working with industry: this is the best way to 1.0 commence
infrastructure with spare capacity that could be
utilised, or if combining with other health prevent excess costs and solutions that are not
0.8
economies is possible; adapted to the needs of patients Planning
Further
0.6 incremental
o If developing bespoke provision, what is the  Information governance: protection of confidential begins
benefits
potential market in terms of other users in the patient information is a priority, especially where 0.4
region and nationally? third party providers are involved, and ensuring this Intervention
0.2
 Ensure that telehealth is integrated into mainstream is a key consideration launched
healthcare provision, meaning it is considered as part 0.0
of any initial assessment, and is built into staff appraisal 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
29
Key leads and further reading: telehealth and telecare
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? We have identified three examples of
‘best practice’ in this area. For practical guidance and experience on implementing this intervention, these are the
people to speak to.
• Kent and Medway Commissioning Support (http://www.kmcsu.nhs.uk/#)
• Airedale (see
http://www.airedale-trust.nhs.uk/blog/3rd-july-2013-airedale-shares-telemedicine-success-at-global-event /)
• Wakefield City Council (see reference below)
Further reading
• John Cruickshank, Jon Paxman, ‘Yorkshire & the Humber Telehealth Hub: Project Evaluation January 2013’
(2020health, 2013)
• Leeds City Council, ‘Embedding telecare into reablement, intermediate care and delayed transfers of care services’
• ‘Transforming integrated care – using Telecare as a catalyst for change’ (Wakefield City Council, 2012)
• ‘Implementing Telecare to achieve efficiencies: Care Services Efficiency Delivery’ (Department of Health, 2009)
• Steventon et al, 'Effect of teleheath on use of secondary care and mortality: findings from the Whole System
Demonstrator cluster randomized trial' (2012) BMJ 344
• Jennifer Truland, ‘It's time for your screen test’, HSJ Telehealth (2013)
• 3 million lives project – includes resources on how much each CCG can save by adopting this approach (
https://3millionlives.co.uk)
30
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
31
Case study: case management and coordinated care
Case management and coordinated care works towards an integrated health and social care
system. Full integration can require > 5 years, case management can still produce significant
benefits within that time frame
Name and Integrated Care Pilots of case management for patients with LTCs and older people, analysed in ‘‘National Evaluation of the
source of Department of Health’s Integrated Care Pilots’ (RAND Europe, 2012)”
literature https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215103/dh_133127.pdf
Description of The programme of Integrated Care Pilots (ICPs) was a two-year DH initiative that aimed to explore different ways of
intervention providing integrated care to help drive improvements in care and well-being. Organisations across England were invited to put
forward approaches and interventions that reflected local needs and priorities - six of these specified case management as the
focus of their integration efforts. While each ICP targeted distinct patient groups, the two most common were patients with LTCs
and elderly patients at risk of inpatient admission. Here, we focus on the pilot site where case management solutions, such as
increased sharing of patient information and colocation of staff and services, aimed to reduce unplanned hospital admissions and
fragmentation of care pathways.
Clinical Over the course of the 2 years, these pilots demonstrated a:

outcomes • 21% reduction in elective admissions;
• 22% reduction in outpatient appointments;
• 3% reduction in A&E attendances; and a
• 9% increase in non-elective admissions
Financial
Across the pilot site an average cost saving of £446 per patient was observed (net of running costs)
outcomes
Relevance to This kind of co-ordinated care management is generally applicable across a range of patient groups and geographies. It has the
Any town health potential not only to reduce the cost associated with unnecessary admissions, but also (if applied correctly) to improve patient
system experience of treatment and clinical outcomes.
Other UK Continuity of care for older patients’ (The King’s Fund, 2012); ‘Enablers and Barriers to Integrated Care (Frontier Economics,
examples 2012); 'The development and impact of the British Heart Foundation and Big Lottery Fund heart failure specialist nurse services
in England: Final Report' (University of York, 2008)
Other PACE, VHA, ‘Clinical and Service Integration’ (The King’s Fund, 2010); David Meates, ‘Making integrated care work in
international Canterbury, New Zealand’ (The King’s Fund, 2013)
examples
32
Case study: case management and coordinated care
There are a number of other innovative case studies that could be further explored by local
health economies – we present a case study from Medicaid and Medicare below
Innovators
Case study: Programme for All-inclusive Care for the Elderly
The US PACE (Programme for All-inclusive Care for the Elderly) is an integrated provider model for individuals with Medicaid and
Medicare coverage. It aims at maintaining independent community living for frail older people for as long as possible.
The key feature of PACE is that services are co-ordinated by, and organised around, adult health day-centres which are run by its
own directly employed staff. The day centre is the primary setting for the delivery of most care services and operates similarly to a
geriatric outpatients clinic where primary medical care is provided along with ongoing clinical oversight. There is a multidisciplinary
team, comprising nurses, physicians, therapists, social workers and nutritionists. The team is responsible for managing patients,
dispensing services, promoting co-ordination and continuity of care and collectively holds clinical responsibility for each individual in
their charge.
Patient care is also facilitated by a data system that collects information on all aspects of a patient’s health status and forms the
basis of the patient’s care plan. Resources are pooled and – through capitation payments from Medicare and Medicaid – the
programme has total control over all long-term care expenditure, assuming financial risk for its population
When compared with a control group, PACE-enrolled older people showed a 50% decrease in hospital use, 20% decrease in
nursing home admissions, and when they were admitted, used 16 fewer bed days. However, PACE patients used more ambulatory
care services (93 per cent compared with 74 per cent in the control group). The overall cost-effectiveness of PACE is unclear,
although State Medicaid agencies estimates cost savings of 5 to 15 per cent over standard fee-for-service care.
In terms of patient experience, patients and their carers were 15% more likely to be satisfied with their care than those not in PACE.
Health status and quality-of-life outcomes have been found to be generally positive, with 43 per cent (vs. 37 per cent in the control
group) reporting good health and 72 per cent (vs. 55 per cent in the control group) reporting a ‘more satisfying life’.
33
Sources: Natasha Curry and Chris Ham, ‘Clinical and service integration, the route to improved outcomes’ (The King’s Fund, 2010); Kodner and Kay Kyriacou, ‘Fully Integrated Care for
Frail Elderly: Two American Models’ (International Journal of Integrated Care, 2000)
Impact of interventions on quality: case management
Case management & coordinated care – Integrated care pilots
Indicator Effect on
Number Quality

1.1
considered amenable to healthcare - Adults None yet quantified – however, it may be expected that this intervention
will reduce PYLL for the target patient group through a reduction in
mortality rates
and young people
Significant qualitative evidence of improved HRQoL exists. In other

2. Increase QoL for People Health-related quality of life for people with
2 settings, interventions of this kind have produced c.7% improvements in
with Long-Term Conditions long-term conditions (EQ5D)
HRQoL scores using standard measurement instruments 1,2

ambulatory care sensitive conditions (updated 2.6 In the National Evaluation of the DoH’s Integrated Care Pilots (ICPs) this
methodology) intervention produced a 12.0% increase in non-elective admissions for
patients with a chronic ambulatory care sensitive condition, despite
3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes targeting a reduction.3 Further statistical tests by the authors showed that
2.7
time spent in hospital and epilepsy in under 19s this increase is non-significant, and once confounding factors (such as
poor matching of control site patients) is accounted for, all that can be
Emergency admissions for acute conditions determined is that the intervention failed to reduce ACS admissions.
that should not usually require hospital 3.1 However, other case studies of this intervention have demonstrated a
admission (updated methodology) reduction in unplanned ACS admissions: for example, the BHF Specialist
Heart Failure Nurse programme has produced a 35% reduction in ACS
Emergency admissions for children with lower readmissions2
3.4
of older people living who were still at home 91 days after discharge In another setting, this intervention has produced a 23.2% decrease the
discharge
services
2B
proportion of older patients still at home 91 days after discharge 4 


5. Reduce poor hospital In the ICPs this intervention produced a moderate increase in poor patient
care feedback feedback, based on feelings of reduced choice3
7. Significantly reduce None yet quantified – however, it is expected that this intervention will
hospital avoidable deaths produce significant improvement in Ambition 7
34
Qualitative benefit
Sources: (1) 'Evaluation of the BHF Arrhythmia Care Co-ordinator Awards' (University of York, 2010); (2) 'The development and impact
of the British Heart Foundation and Big Lottery
Fund heart failure specialist nurse services in England: Final Report' (University of York, 2008); (3) Case management ICPs in: ‘National Evaluation of the DoH Integrated Care Pilots’
(RAND Europe, 2012); (4) Rich et al, 'A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure' (1995) N Engl J Med 333:1190-1195
Getting started: case management and coordinated care
Frail Depri-
elderly ved
 Strong leadership is crucial, with senior  Absence of strong leadership has been • Given the cross-organisational nature of this
sponsorship of the programme underpinning its identified as a significant barrier to progress in intervention, an initial period of investment
importance this intervention, especially where there is a lack and bedding in is likely to be required before
of sponsorship and ownership among senior impacts begin to emerge
 Invest in building key relationships and
staff • Based on previous examples, we anticipate
strengthening existing ones, especially across
organisations and disciplines  Failure to engage a key group of staff, e.g. that the impacts will begin to materialise in
GPs, means that the cross-organisational and the year following the commencement of
 Shared values and vision are key facilitating
multidisciplinary nature of the intervention will be the intervention
factors. This can be achieved through a strong
difficult to initiate and sustain • The graph below indicates the likely phasing
and consistent communication effort to gain
staff buy-in. In particular, clear communication of  Changes to individual staff roles can of this intervention
the benefits and involvement of staff in the generate resistance – one way to tackle this is
to ensure that staff feel informed about and Forecast savings per year
development of new services have been shown
to be of great importance in gaining the involved in any changes 3.5 Urban CCG (£m)
engagement and commitment of staff in the  Inadequate IT resources and infrastructure 3.0
Further
process can impede the effective implementation of the 2.5 incremental
 Assign resources to developing appropriate initiative. This can include both systems and benefits
2.0
education and training, especially where roles also policies and practices
1.5 Intervention Benefits
are required to change. Staff will need support to  Inadequate project management can launched commence
1.0
adapt to and perform well in changed roles undermine the scale and complexity needed to
Planning
 Development of personalised care plans that deliver the intervention 0.5
begins
clearly articulate patients’ goals  Little evidence of improved patient experience 0.0
or reduced secondary care costs in the short 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
35 term
Key leads and further reading: case management and coordinated care
‘Key leads’
• Six sites were identified in the RAND analysis (see reference below) of the Integrated Care Pilots as adopting a case management
approach. These provide strong examples of best practice. The sites are:
o Church View, Sunderland (Church View Medical Practice and City Hospitals Sunderland Foundation Trust)
o Cumbria (Cockermouth, Maryport and South Lakeland)
o Northamptonshire Integrated Care Partnership
o Norfolk Integrated Care Network
o Northumbria
o Principia Partners in Health, Nottinghamshire
Further reading
• National Evaluation of the DoH Integrated Care Pilots (RAND Europe, 2012)
• Frontier Economics, ‘Enablers and barriers to integrated care and implication for Monitor’ (2012)
• 'The development and impact of the British Heart Foundation and Big Lottery Fund heart failure specialist nurse services in England:
Final Report' (University of York, 2008)
• Rich et al, 'A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure' (1995) N
Engl J Med 333:1190-1195
• Bardsley et al, ‘Evaluating integrated and community-based care’ (Nuffield Trust, 2013)
• Patient-centred care resource centre by the Health Foundation http://personcentredcare.health.org.uk/
36
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
37
Case study: mental health
An effective liaison psychiatry service offers the prospect of improving health and wellbeing for patients with a
mental illness and promotes early supported discharge from an acute setting
Name and Rapid Assessment Interface and Discharge (RAID) at City Hospital, Birmingham. Impact assessed in: “Parsonage & Fossey,
source of Economic evaluation of a liaison psychiatry service( LSE, 2011)”
literature http://www.centreformentalhealth.org.uk/pdfs/economic_evaluation.pdf
Description of Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general
intervention hospitals. The co-occurrence of mental and physical health problems is very common among these patients, often leading to
poorer health outcomes and increased health care costs.
RAID offers comprehensive mental health support, available 24/7, to all people aged over 16 within the hospital. At the time
of assessment, the RAID service was provided by Birmingham and Solihull Mental Health NHS Foundation Trust and
commissioned jointly by Heart of Birmingham and Sandwell PCTs.
The service offers a comprehensive range of mental health specialities within one multi-disciplinary team, so that all patients
over the age of 16 (including those who self-harm, have substance misuse issues or have mental health difficulties
commonly associated with old age, including dementia) can be assessed, treated, signposted or referred appropriately
regardless of age, address, presenting complaint, time of presentation or severity. The service operates 24 hours a day, 7
days week, emphasising rapid response. The service also provides formal teaching and informal training on mental health to
acute staff throughout the hospital - a key feature to widen its impact beyond patients seen directly by RAID staff.
Clinical • Very strong patient and staff satisfaction ratings
outcomes • 14% increase in the proportion of older people at home 91 days after discharge
• 97% increase in discharge rate of older patients into their own homes rather than institutional care
Financial • 74% lower readmissions rate for mental health patients using RAID compared to those not using it
outcomes • 8.7% reduction in inpatient bed-days
• Total per annum savings of £3.4m (highly conservative estimate)
Relevance to The success of this case study can be widely applied to mental health care across the NHS, reducing care costs while also
Any town health improving patient experience and clinical outcomes
system
38
Impact of interventions on quality: mental health
Mental Health – Rapid Assessment Interface and Discharge (RAID) at City Hospital, Birmingham
Indicator Effect on
Number Quality

1.1
1. Secure additional years None yet quantified – however, it may be expected that this intervention
of life Potential years of life lost (PYLL) from causes will produce a mild reduction in PYLL due to better patient management
and young people
2. Increase QoL for People Health-related quality of life for people with There is strong qualitative evidence for improved patient QoL as a result of
2
with Long-Term Conditions long-term conditions (EQ5D) this intervention1

methodology)

2.7
Emergency admissions for acute conditions

This intervention produces reductions in inpatient admissions and length
of stay. However, it does not target the specific medical conditions covered
by the indicators we are considering under Ambition 3
−

3.4
of older people living who were still at home 91 days after discharge This intervention has produced a 14.0% decrease the proportion of older
2B
patients still at home 91 days after discharge1 
discharge services
5. Reduce poor hospital While no quantified change has been documented, the majority of patients
care feedback treated are very satisfied with this intervention 1
−
7. Significantly reduce The literature review does not suggest that this intervention will produce a
hospital avoidable deaths change in Ambition 7
39
Qualitative benefit
 and Solihull NHS Trust)

Source: (1) 'George Tadros, 'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience' (Birmingham
Getting started: mental health
 Adults with complex needs
Have you thought about the following Frail Depri-

enablers and implementation steps? elderly ved
 Based on previous experience of implementing
this intervention, training has been identified Have you considered whether the Have you considered how you will
as a key to success following may be barriers? phase the intervention?
o For staff directly involved in the intervention
o For acute staff throughout the hospital – for  Funding: while this intervention should • A small part of the impact is likely to be
example, regular one-hour weekly teaching provide good value for money, it requires experienced during the first year of the
sessions and periodic 2-day courses some up front investment (e.g. in training, intervention
certified by a higher education institution additional staff and clinics), the sources of • However, based on previous experience, the
this funding need to be identified at an early majority of the impact will materialise during
 Strong and focused leadership with real
stage and maintained for the duration of the the second year of the intervention and
commitment to driving the intervention through intervention to achieve the full effect
is likely to greatly enhance the chances of subsequently
success  Staff buy-in can be a barrier, especially • The graph below indicates the likely phasing of
where education and communication are this intervention
 The intervention is likely to be most effective if
inadequate and acute staff do not understand
it provides 24/7 coverage and involves a multi- the intervention. This could lead to resistance Forecast savings per year
disciplinary team offering a comprehensive to the intervention if not pre-empted 2.0 Urban CCG (£m)
range of mental health specialities
 Adequate staffing across the multi-
 To deliver its full potential, the intervention
disciplinary team is required in order to meet
should focus on rapid response – for example, rapid response and coverage targets –
1.5 Further benefits
a target time of 1 hour to assess referred develop
without this it will be difficult to meet the
patients who present to A&E, and 24 hours for targets for the intervention, meaning that 1.0
seeing referred patients on wards Planning Initial benefits
clinical and financial impacts could fall short begins commence
 Provide follow-up clinics for discharged of their potential 0.5
patients, focusing on specific mental health Intervention
needs such as self harm, substance misuse, launched
and old age psychiatry 0.0
2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
40
Key leads and further reading: mental health
‘Key leads’
Who could you speak to in order to find out how to do this intervention well? The following sites have been identified
by the Centre for Medical Health as examples of established liaison psychiatry services (see the reference below for
further details):
• St Helier Hospital Liaison Psychiatry Service, Carshalton, Surrey
• Exeter Liaison Service, Royal Devon and Exeter Hospital, Exeter, Devon
• Department of Liaison Psychiatry, Arrowe Park Hospital, The Wirral, Cheshire
• Department of Psychological Medicine, Hull Royal Infirmary, Hull, East Yorkshire
• Leeds Liaison Psychiatry Service, St James University Hospital & Leeds General Infirmary, Leeds, West Yorkshire
Further reading
• 'George Tadros, 'Can Improving Mental Health of Patients in Acute Hospital Save Money? The RAID Experience'
(Birmingham and Solihull NHS Trust)
• Michael Parsonage, Matt Fossey & Carly Tutty, ‘Liaison psychiatry in the modern NHS’ (Centre for Medical Health,
2012)
41
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
42
Case study: dementia pathway
Dementia pathways shifts care from acute care settings to locally-based and home-based services
Name and
‘Service redevelopment: Integrated whole system services for people with dementia’ (Mersey Care NHS Trust, 2012)
source of
http://www.evidence.nhs.uk/search?q=integrated%20whole%20services%20dementia
literature
Description of The intervention is intended to improve health outcomes and achieve efficiencies in dementia care across the North Mersey
intervention area by developing a fully integrated network model. This is to be achieved by redistributing resources from acute care
settings to locally-based and home-based services. The overall aim is to keep people with dementia independent for longer
and where they require hospital treatments to get them back into the community as swiftly and as well prepared for
independent life as possible. The pathway comprises four main components: general hospitals, home support, care homes
and reduction in antipsychotic drug prescribing. As this initiative is in the early stages of implementation, the benefits
described here are expected rather than demonstrated. However, the initiative is underpinned by guidance from NICE and
DH with extensive financial modelling of benefits.
Clinical Anticipated quality outcomes include:

outcomes • Reducing barriers to accessing care, including safer and more appropriate use of medicines
• Reduction in unnecessary prescribing of antipsychotics, improving patient safety
• Improved patient and carer experience
Financial Estimated net savings are £2.1m, or £246,000 per 100,000 population. These savings break down as follows:
outcomes • Reduction in dementia bed days: £1.28m
• Reduction in length of stay: £0.508m
• Reduction in older adult beds: £1.89m
• Savings in prescribing: £1.05m
• Less recurring costs of £2.617m
Relevance to The rising number of people with dementia will be a significant source of demand for services over the coming decade, owing
Any town health to longer life expectancy and the increase in the number of people aged over 85. This is therefore a key area where health
system economies will seek to improve quality and achieve efficiency savings.
Other UK Other examples of whole systems approaches to dementia include Leeds, Mary Godfrey, ‘Leeds Partnership for Older
examples People Pilot: Whole system change in later life, Final Report’ (University of Leeds, 2009), Oxleas, ‘Oxleas Advanced
Dementia Service’ (The King’s Fund, 2013) and Lincolnshire, ‘Improving services and support for people with dementia’
(NAO, 2007)
43
Case study: dementia pathway
There are a number of other innovative case studies that could be further explored by local health economies –
below is the Oxleas advanced dementia service
Innovators
Case study: Oxleas advanced dementia service
The Oxleas Advanced dementia service was formed in November 2012. It brought together two services – Greenwich Advanced
Dementia Service (GADS) and Bexley Advanced Dementia Care At Home project. Since 2005, GADS has provided care co-
ordination, palliative care and support to patients with advanced dementia living at home and their carers. The model was
implemented in Bexley in 2011 and they now operate jointly as Oxleas Advanced Dementia Service. The current service consists of
a consultant in old-age psychiatry, several specialist nurses and a dementia social worker.
This model aims to help patients with advanced dementia to live at home for as long as possible in the last year of life with support
from family and/or carers. The core team works with GPs, secondary care and social services to support carers in providing ongoing
and palliative care. Where possible, staff respond to crises at home to prevent unnecessary hospital admissions and reduce the
likelihood that patients are placed in residential care
In Greenwich, care co-ordination is led by a consultant old-age psychiatrist based in the local mental health trust, working alongside
specialist nurses called community matrons. In Bexley, the same psychiatrist works with a community psychiatric nurse (CPN), an
advanced practice nurse (APN) and a social worker specialising in dementia. Staff in the service liaise with community mental health
services and general practitioners (GPs) to provide care in patients’ own homes, focusing on supporting the carer and/or family to
provide palliative care for the patient.
An internal audit of the service has shown that 70 per cent of patients die at home, compared to 2010 figures for England and Wales
of 6 per cent for dementia patients. Analysis of the first year of the Bexley project observed improvements for the majority of patients
on the quality of life in late stage dementia (QUALID) scale and reduced stress levels for carers using the Relative Stress Scale.
44
Source: ‘Oxleas Advanced Dementia Service’ (The King’s Fund, 2013)
Impact of interventions on quality: dementia pathway
Integrated Dementia Care - Mersey Care NHS Trust

Indicator Effect on
Number Quality

1.1
The literature review has not revealed that this intervention would produce
a significant change in PYLL −
and young people
In another case study, this intervention has produced a 8.0% increase in

2. Increase QoL for People
with Long-Term Conditions
Health-related quality of life for people with
long-term conditions (EQ5D)
2 health-related quality of life for dementia patients, based on mapping of
improvement in the QUALID HRQoL indicator onto EQ5D1

methodology)

2.7
Emergency admissions for acute conditions

This intervention produces reductions in inpatient admissions and length
of stay. However, it does not target the specific medical conditions covered
by the indicators we are considering under Ambition 3
−

3.4
None yet quantified – however, it is expected that the intervention will
2B increase the proportion of older patients still at home 91 days post-
discharge
discharge services
5. Reduce poor hospital The literature suggests a strong improvement in patient experience of
care feedback hospital care is expected from this intervention 2
7. Significantly reduce None yet quantified – however, the literature review has not revealed that
hospital avoidable deaths this intervention would produce a significant effect upon Ambition 7
45
Qualitative benefit
 for people with dementia’ (Mersey Care NHS

Sources: (1) ‘Oxleas Advanced Dementia Service’, (The King’s Fund, 2013); (2) ‘Service redevelopment: Integrated whole system services
Trust, 2012)
Getting started: dementia pathway
Frail Depri-
elderly ved
 Invest in developing strong stakeholder  Inappropriate prescribing: a key • It is estimated that this intervention can be
buy-in. Owing to the complexity and scale element of the intervention is to reduce implemented in between one and three years,
of this intervention, and the emphasis on inappropriate prescribing of depending on the status quo and the extent of
the barriers encountered
multi-agency working, buy-in across the full antipsychotics, but in practice this can be
range of staff and organisations involved is difficult to effect. Neglecting this aspect of • Based on a three year implementation, it is
crucial to success. This includes the intervention could lead to reduced expected that a small impact will be evident
in the first year of the intervention, but that
stakeholders in social and acute care and cost savings and poorer clinical
the full impact will not be achieved until the
medicines optimisation outcomes third year
 Invest in dementia-specific training and  Complexity and scale: given that this • The graph below indicates the likely phasing of
support for staff, especially front-line staff intervention requires significant cross- this intervention
such as those in care homes, who will be organisation and multi-disciplinary Forecast savings per year
responsible for implementing many aspects collaboration, it requires clear planning, 0.8
Urban CCG (£m)
of the intervention strong leadership and communication to 0.7 Intervention
ensure it is able to gain traction launched: Further
 Given its complexity, the appointment of a 0.6
initial incremental
programme manager is crucial to provide  Impacts on staff morale: without 0.5 benefits benefits
commence Main benefits
strong leadership and co-ordinate the sufficient investment in communications 0.4
commence
implementation of the intervention and dementia-specific training, including 0.3
front-line staff, morale could be impacted 0.2

Planning
0.1
by the uncertainty generated by the begins
0.0
intervention 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
46
Key leads and further reading: dementia pathway
‘Key leads’
• The intervention is based on Mersey Care NHS Trust. They can be contacted by emailing qipp@nice.co.uk quoting
QIPP reference 11/0009
• Oxleas Advanced Dementia Service is another example of good practice (see the study listed below)
Further reading
• ‘Service redevelopment: Integrated whole system services for people with dementia’ (Mersey Care NHS Trust,
2012)
• ‘Improving services and support for people with dementia’ (National Audit Office, 2007)
• ‘Oxleas Advanced Dementia Service: supporting carers and building resilience’ (The King’s Fund, 2013)
47
The high impact interventions
1. Early diagnosis
7. Dementia Pathway
8. Palliative care
48
Case study: Palliative care
The Midhurst MacMillan specialist palliative care service gives patients the choice to die in their own home
Name and
Midhurst Macmillan Specialist Palliative Care Service – King’s Fund Review, August 2013
source of
http://www.kingsfund.org.uk/publications/midhurst-macmillan-community-specialist-palliative-care-service
literature
Description of The Midhurst Macmillan Specialist Palliative Care Service is a community-based, consultant-led palliative care model that
intervention allows many more people to die at home and many fewer to die in hospital. The service currently serves 150,000 people
across three counties in rural Southern England and is funded jointly by the NHS and Macmillan Cancer Support.
‘Midhurst’ is able to maximise patient choice by providing as much treatment and support in the home or community as
possible through a multidisciplinary community-based team. The scheme receives ~400 referrals a year, with 85% of these
cancer patients.
Clinical • Agreed care plans for 80% of patients, quarterly review of care plans
outcomes • 99% of patients allowed to die at home
• Less frequent A&E attendances for patients
• Decreased hospital admissions
Financial
outcomes • ~52% reductions in in-hospital deaths
• ~19% reduction in in-hospice deaths
Relevance to Effective palliative care solutions are still in their infancy across the UK and largely untested, with variations in both care and
Any town health patient experience.
system
Midhurst represents a model which provides best practice care, allows the patient control over their passing, and presents an
affordable alternative to traditional hospice models.
49
Impact of interventions on quality: palliative care
Palliative Care – Midhurst Macmillan Specialist Palliative Care Service

Indicator Effect on
Number Quality

1.1
−
1. Secure additional years This interaction does not target a change in Ambition 1, with a focus
of life Potential years of life lost (PYLL) from causes instead on quality of care at the end of a patient’s life
and young people
2. Increase QoL for People Health-related quality of life for people with There is strong qualitative evidence of improved HRQoL for patients using
2
with Long-Term Conditions long-term conditions (EQ5D) this intervention1

methodology)
3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes The intervention has produced a 52% decrease in the number of patients
2.7
time spent in hospital and epilepsy in under 19s wishing to die at home who ultimately die in hospital. This represents a
reduction in unnecessary time spent in hospital. However, based on the
Emergency admissions for acute conditions unavailability of cause of death data, it is not possible to directly map this
that should not usually require hospital 3.1 effect onto any of the Ambition 3 indicators 1

3.4
of older people living who were still at home 91 days after discharge Whilst this intervention does not directly target a change in Ambition 4, it
discharge
services
2B
does give patients the ability to die outside of a hospital if they desire
−
5. Reduce poor hospital The intervention almost doubled the number of patients able to die in their
Patient experience of hospital care 4b
care feedback own homes; a major positive along the patient experience dimension 1

7. Significantly reduce

−
Hospital deaths attributable to problems in care 5c This intervention does not target a change in Ambition 7
hospital avoidable deaths
50
 Some quantified benefit  Strong quantified benefit
− No impact
Source: (1) 'Midhurst Macmillan Community Specialist Palliative Care Service' (The King's Fund, 2013) 
Getting started: palliative care
 Adults with LTCs
Frail Depri-
elderly ved
 Building a strong relationship with an  Funding: without adequate resources it is • Because the intervention relies on changing
external co-funder and partner can be a unlikely that an effective intervention can be ways of working and building awareness and
powerful facilitator of this intervention. In the developed – these therefore need to be relationships, the full impact should not be
case of Midhurst the partner was Macmillan identified early in the process and secured for expected to materialise immediately
Cancer Support, providing not only funding but the long term • Based on previous experience, it is reasonable
also legal and financial advice, access to  Relationships: one lesson from the Midhurst to anticipate an initial impact in the year after
grants and volunteer services case study is that personalities and implementation, with the full impact emerging
 A dedicated care co-ordinator (usually a relationships are key to a successful in the following year
clinical nurse specialist) plays a crucial role by: intervention, and these need to be cultivated • The graph below indicates the likely phasing of
o being the principle point of contact for the over time to develop a truly effective this intervention
patient and their family intervention. A key part of this is a visible
o co-ordinating care from the team and wider
Forecast savings per year
presence on the ground by team managers
network of providers Urban CCG (£m)
 Barriers to information sharing: without an 1.2
 Rapid access to a multidisciplinary team is a integrated IT system enabling rapid sharing Initial benefits
1.0
commence
core element of this intervention, allowing care of information on patients between GPs and Further benefits
0.8
to be provided to patients in their homes community staff, time and resources are develop
 Clear accountability within teams enables wasted on inefficient information sharing 0.6 Intervention
processes launched
effective decision-making, which is particularly 0.4
important given the multidisciplinary nature of  Ensuring the right skills mix: the right staff Planning
0.2 begins
the teams can be difficult to find, and building an
 A focus on building awareness and key effective multidisciplinary team requires an 0.0
relationships will ensure maximum impact investment of time and resources 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
51
Key leads and further reading: palliative care
‘Key leads’
• Midhurst Macmillan Community Specialist Palliative Care Service (http://
www.sussexcommunity.nhs.uk/services/servicedetails.htm?directoryID=16353, and see reference below)
Further reading
• ‘Midhurst Macmillan Community Specialist Palliative Care Service: delivering end of life care in the community’
(The King’s Fund, 2013)
52
Early Adopter Interventions
The early adopter interventions
In addition to the high impact interventions, we have identified additional Early
Adopter Interventions (EAI). Although not fully impact assessed, these are
promising ideas which may offer health economies further benefits
1. Cancer screening programmes
2. GP tele-consultation
3. Medicines Optimisation
a. Norfolk b. PINCER
4. Safe and appropriate use of medicines
5. Acute visiting service
6. Reducing urgent care demand
7. 24-hour asthma services for children and

young people
8. Service user network
9. Reducing elective Caesarean sections
10. Acute stroke services
11. Integration of health and social care for older

people
12. Electronic Palliative Care Coordination

Systems (EPaCCS)
54
The short-listing exercise – Early Adopter Interventions
For the EAIs, a slightly different set of criteria has been used to inform the selection process
The intervention should be innovative and cutting edge – this means that it may not yet have been impact assessed, but it appears
1
to be a promising idea that has not yet been widely adopted
The intervention must have demonstrated quality impacts, where possible matching one or more of the indicators for the 7
2
Ambitions, or at least impacts that are mappable onto the Ambition indicators in a qualitative way
The intervention must appear likely to be either cost-neutral or cost-saving, although it is not necessary for this impact to have been
3
demonstrated, and owing to the looser evidence requirements we are not modelling precise savings expected
4 The intervention must have a clear narrative and be appropriate for widespread adoption by health economies
55
1. Cancer screening programme
3. Medicines optimisation
7. 24-hour asthma services for children and young people
9. Reducing elective Caesarean section
11. Integration of health and social care for older people
12. Electronic Palliative Care Coordination Systems (EPaCCS)
56
Overview: early diagnosis of cancer
Intervention name Earlier diagnosis of cancer (Department of Health, Strategy for Cancer, 2011)
What is it? One of the reasons for the UK’s generally lower cancer survival rates than other European countries is the tendency for
patients to present with more advanced stages of the disease at diagnosis. Detecting cancer at an earlier stage, when it
responds better to treatments designed to tackle the disease locally, greatly improves the patient’s chances of survival. This
intervention is designed to improve the public’s awareness of the signs and symptoms of cancer, encourage those with
symptoms to seek help earlier than they currently do and support primary care in diagnosing cancer earlier.
Why do it? • Earlier diagnosis should result in significantly better outcomes for patients, meaning higher survival rates
• The greatest benefit can be achieved by reducing the number of patients diagnosed with late stage cancers, and an
increase in the number of patients diagnosed with early stage cancers, which are more easily treated
• The Department of Health has concluded that earlier diagnoses should be cost-effective, if not necessarily cost-saving
What are the key • Awareness campaigns are likely to be most effective when operated on an ongoing basis over a wide area. This
enabling factors? intervention, therefore, could be particularly successful if run in conjunction with a national scheme or in partnership
with neighboring CCGs
• An effective approach could be to identify those cancers for which there is a high prevalence locally, and run a
targeted campaign focusing on prevention, in collaboration with neighboring CCGs
• An initial investment of resources is required, both in additional treatment, and in awareness-raising campaigns
among the public and GPs to increase diagnosis rates
What are the • The intervention is not proven to be cost-saving, and may in fact lead to an increase in treatment costs. This is likely to
potential balance out over time, as early diagnosis leads to patients who would otherwise have been late stage patients avoiding
barriers? further treatment. However, this effect will take some time to feed through (the Department for Health analysis
suggests that treatment costs will initially rise)
• Related to this is the possibility that awareness campaigns may lead to a rise in GP appointments, at least initially –
this needs to be factored into planning
Further reading
This intervention is based on the following publication:
• Department of Health, ‘Improving outcomes: a strategy for cancer’ (January 2011)
57
Source: ‘Strategy for Cancer’ (Department of Health, 2011)
58
Overview: GP telephone consultations
Intervention name Systematic approach to primary care pre-assessment and telephone consultation
What is it? The intervention links patients’ perceived accessibility of primary care to their likelihood of self-referring to A&E. A comparison of
GP practices showed that those with a ‘systematic’ (specifically organised and managed) approach to telephone consultations
exhibit, on average, lower corresponding rates of A&E attendance. Where this benefit was realised, it was apparent that practices
had implemented a specific innovation in terms of triaging and allocating time for patients suitable for telephone rather than face-
to-face consultation. A number of different micro-interventions were witnessed across the various practices, but common
elements included the initial response to all or most patient demand being a phone call from a GP, clear guidelines on how to
prioritise patient groups for appointments and structures for most effectively using practitioner time. In some cases this might be
done through a software package, for example the Doctor First application.
Why do it? • Systematic telephone consultations were associated with 20% lower A&E attendance by patients at these practices
• Less pressure on GPs and reduced requirement to work long hours, as they are more able to manage workload and demand
in primary care by limiting face-to-face appointments to only those patients who specifically want or need one
• The intervention was generally popular with patients; it was seen as a useful timesaver for GPs and patient alike, and was
associated with improvements in quality of care by improving patient access to primary care
What are the key • The majority of successful telephone consultation systems were the result of a specifically planned and managed
enabling factors? innovation; those that took a more informal approach were less successful in reducing A&E attendance and doctor stress
• Software is available that can help automate the appointment process, taking into account priority groups and practitioner
availability
What are the • While most patients appreciated the time-saving advantage of a telephone consultation, not all will be as comfortable outside
potential barriers? a face-to-face consultation. Sending the right message to patients to encourage their use of the system will be critical to
success
• Resistance among GPs to use of technology for appointments may also be encountered – this can be assuaged by
emphasising the benefits to both patients and GPs
• There is likely to be an initial surge in calls following adoption of the system, which may place pressure on staff and lines. This
should abate after a month or two, as patients and staff adapt to the new system. However, it is best to avoid starting the
scheme at particularly busy times, such as holiday periods
• There is an initial investment which must be agreed – a focus on the benefits achievable should enable the construction of a
strong business case
• The case study shows correlation, but not causation, between perceived availability of primary care and A&E attendance. The
intervention would need to be trialled over an extended period with the specific aim of measuring reduced A&E attendance to
give robust confirmation that the witnessed impact was sustainable
59
Source: Comparison of mode of access to GP telephone consultation and effect on A&E usage (Patient Access: Simply transformed, 2012); Digital First: The delivery choice for
England’s population, NHS (2012)
How GP telephone consultation system works
Admin
question
Patient given
Reception takes GP phones
appointment
call patient
with the GP
Patient given
Patient
appointment
problem solved
with the nurse
Source: http://www.patient-access.org.uk/wordpress/wp-content/uploads/2013/02/Patient-Access-Thurmaston-Case-Study-v7.pdf
60
Key leads and further reading: GP telephone consultations
Further reading
To help you read around this intervention, we have assembled a list of the literature that we found most useful:
• Comparison of mode of access to GP telephone consultation and effect on A&E usage (Patient Access: Simply
transformed, 2012)
• Digital First: The delivery choice for England’s population, NHS (2012) pp. 15-16
• http://www.pulsetoday.co.uk/practice-business/how-we-saved-90000-a-year-through-gp-phone-triage/
14179545.article#.UpSjZIFFDIU
• http://www.patient-access.org.uk/wordpress/wp-content/uploads/2013/02/Patient-Access-Thurmaston-Case-Study-
v7.pdf
• http://www.patient-access.org.uk/wordpress/wp-content/uploads/2013/01/N82070-Elms-v12.pdf
61
62
Overview: medicines optimisation
Intervention name Norfolk Medicine Support Service
What is it? In 2003, a Norfolk wide multi-agency group created the Norfolk Medicines Support Service (NMSS). This facilitated the
care of people living in their own home by providing a patient-centred professional service to ensure safe and appropriate
use of medicines. Patients are referred to the service if they are identified as having difficulties managing their medication in
their own home and following a pharmacist domiciliary visit they may receive ongoing adherence support. The aim of this
intervention was to improve patient drug adherence, and thus quality of life, while reducing the risk of emergency
admissions.
Why do it? • The study showed a 4.5% increase in patient adherence to medication, thereby improving clinical outcomes
• There is also likely to be a saving for commissioners through a reduction in emergency admissions owing to poor patient
adherence to medication
Intervention name A Pharmacist-led information technology intervention for medication errors (PINCER)
What is it? This is a pharmacist-delivered information technology intervention designed to reduce prescription and medication
monitoring errors. Key features are:
• An educational outreach approach and training for pharmacists and clinicians
• Strong working relations between pharmacists and general practices, enabling access to patients’ records and
empowering pharmacists to make practical changes to patients medications and organise blood tests etc
• Built upon an information technology platform, including the use of electronic patient records (cited as an essential
prerequisite by the authors of the study)
Why do it? • The trial indicated that this intervention can substantially reduce the frequency of a range of clinically important
prescription and medication monitoring errors
• It is therefore capable of improving clinical outcomes and reducing preventable patient harm
• Over time it is also likely to generate savings for commissioners, as fewer patients will need emergency care owing to
complications arising from prescribing errors. However, the impact of the intervention on activity levels has not yet been
assessed (work on this by the authors of the study is ongoing)
63
Source: ‘Desborough et al, ‘A cost-consequences analysis of an adherence focused pharmacist-led medication review service’, International Journal of Pharmacy Practice 20 (2011)
Key leads and further reading: medicines optimisation
Further reading
• Desborough et al, ‘A cost-consequences analysis of an adherence focused pharmacist-led medication review
service’ , International Journal of Pharmacy Practice 20 (2011)
• Avery et al, ‘A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre,
cluster randomised, controlled trial and cost-e ﬀectiveness analysis’, The Lancet vol. 379 (2012)
64
65
Overview: Safe and appropriate use of medicines
Intervention name Eclipse Live (Electronic Care Leading to Improved Patient Safety & Empowerment)
What is it? Eclipse Live was launched in August 2011 to allow Prescribing Leads to identify at-risk patients with an online risk
stratification tool. The system would enable new levels of patient analysis to accurately identify those at risk
and feedback the information as alerts to the prescribers. The group has grown to over 500 surgeries representing more
than 3 million patients.
Eclipse Live includes three main elements:

• Risk stratification.
• Integrated care.
• Self-management plans and personalised records.
Why do it? Eclipse Live is intended to reduce the number of preventable deaths from medication-related incidents. It is intended to
enable GPs to:
• Identify at-risk patients.
• Identify patients not fulfilling local guidelines.
• Undertake performance tracking.
• Access formularies, guidelines and contacts.
Eclipse Live generates lists of patients and virtual wards, which can be visited electronically by specialists or community
teams. By analysing millions of calculations on each patient every night it continually identify at-risk patients.
Although not fully impact assessed, initial studies indicate significant reductions in admissions in those practices that use
the system2. It is in the process of being formally appraised for its ability to prevent emergency admissions from medicine-
related events.
It should be noted that the impacts of this intervention are derived from literature from the system provider; in the absence
of an independent impact assessment this should be borne in mind as a potential limitation.
The opportunity According to the Eclipse Live impact assessment, in 2010 there were 4.9 million emergency admissions, costing the NHS
£8.8bn. Research has suggested that 6-7% of emergency admissions are related to medication, and 60% of these incidents
are preventable2. At a cost per admission of £5,000, this represents a potential opportunity to save around £1bn if a reliable
system could be implemented to identify at-risk patients before they were admitted.
66
(1) ‘Eclipse Live impact assessment’ (2013) (2) Value Health. 2011 Jan; 14(1):34-40.) HARM: Preventable hospital admissions related to medication
Key leads and further reading: safe use of medicines
Further reading
This intervention is based on the following sources:
• ‘Eclipse Live impact assessment’ (2013)
• www.eclipsesolutions.org
67
68
Overview: Acute visiting service
Intervention name Acute Visiting Service (St Helens CCG)

What is it? The aim of the Acute Visiting Service is to provide a rapid access doctor for acute care at home, thus reducing the need to
access urgent hospital care. In the case of St Helens CCG, the service was commissioned from the local out of hours
cooperative which provided the driver and vehicle and managed the calls. Local GPs (often early retirees or those operating
independent practices) make the visits. During their visits they discuss with patients options for integrated and community
care that would enable them to stay at home. This is in effect “assessing to admit rather than admitting to assess”.
Why do it? • This intervention offers a number of benefits tackling some of the most pressing challenges facing health economies,
including:
o Improving patient access to services
o Reducing emergency admissions
o Releasing capacity in GP surgeries for planned care
o Improving patient satisfaction with the quality of care
• The intervention is also likely to be cost-effective, with the St Helens initiative costing £6 per patient and being self-
funding, for a population of 50,000, if two complex elderly admissions are avoided per week.
What are the key • The system is patient-focused and uses the patient’s definition of urgent
enabling factors? • The success of the intervention in part depends on the speed with which patients can be seen. An effective and
adequately staffed system is therefore vital
• Sufficient resources should also be assigned so as to allow extended consultation times (up to 60 minutes), allowing
discussions with patients to allay concerns and discuss alternatives to admission to hospital
• Referrals to the service should come from a patient’s own practice, as the GPs there know the patient and can make
the most appropriate and informed decision about their needs
What are the • Lack of available staff, as the system needs to be adequately staffed in order to offer the appropriate speed of
potential response and length of consultations
barriers? • Quality of care must remain paramount, with patients triaged effectively and admitted to hospital if this is required
• The initiative challenges traditional models of working in General Practice – staff need to be reassured that this is the
right thing for both patients and healthcare professionals
• Patients may express a preference for their ‘usual GP’, but with sufficient patient education regarding the benefits of
the service this need not prove a barrier to use
69
Source: Dr Shikha Pitalia, ‘How our acute visiting service reduced emergency admissions by 30 per cent’ Pulse (March 14 2013)
How the acute visiting service works
Patient phones own

surgery requesting Planned
a same day or Routine practice
urgent appointment visit
Immediate
Triage to
telephone Refer to
assess severity Urgent
consultation with AVS
of condition
own GP or nurse
See a GP
within 60
minutes
Admission
avoided?
70
Source: Dr Shikha Pitalia, ‘How our acute visiting service reduced emergency admissions by 30 per cent’ Pulse (March 14 2013)
Key leads and further reading: Acute Visiting Service
Further reading
• Dr Shikha Pitalia, ‘Acute Visiting Service: An Urgent Care Success Story’ (St Helens CCG)
• A good description of the St Helens service is available at:
http://www.pulsetoday.co.uk/home/practical-commissioning/how-our-acute-visiting-service-reduced-emergency-ad
missions-by-30-per-cent/20002277.article#.
UoP9JoFFDIU
• Further discussion of the experience of implementing this intervention can be found at: http://
www.gpcaregroup-cic.co.uk/Acute-Visiting-Scheme.aspx
71
72
Overview: Reducing urgent care demand
Intervention name Create an acute GP unit to reduce emergency admissions (Pulse: Practical Commissioning 2009)
What is it? With non-elective emergency admissions rising nationally, this intervention uses a team of acute GPs to screen all incoming
emergency referrals. Because the GPs on duty in the acute unit are well acquainted with the community and social services
on offer within the NHS locally, they can often recommend an alternative to admission that the referring GP didn’t know
about or hadn’t thought of. This could be anything ranging from setting up a visit from the hospital-at-home team, to sending
them to a ‘hot’ clinic to see the cardiologist of the week, to reassuring the GP their patient management plan is sound.
Why do it? • The acute GP unit was able to divert, on average, 16% of GP referrals to A&E. At its peak the unit could divert up to 50%
of admissions
• During a five month pilot, overall emergency medical admissions were reduced by 30%
• Gross savings of £418’320 were made during the same period, equating to £2208 per working day net of costs
What are the key • The acute unit must develop a comprehensive knowledge of alternatives to A&E admission to recommend to referring
enabling factors? GPs; this can include hospital-at-homes teams, ‘hot’ clinics etc.
• The case study Trust (Royal Cornwall Hospital) already had a telephone referral system in place. This did not serve a
screening function prior to the intervention, but it will have simplified the implementation of the acute GP unit
What are the • Gaining the support of local GPs is essential to having the acute unit operate effectively. The case study describes an
potential initial reluctance from primary care staff to be ‘second guessed’ by a screening function. This was resolved by
barriers? highlighting the degree of specialisation the acute unit have in up-to-date knowledge of alternatives to admission, as well
as the fact that around 70% of savings cycle back to the PBC groups
• Startup costs in the subject PCT were £100k, plus an annual budget of £280k. Net saving prove to be significant,
however, and the pilot was subsequently extended and given 3 additional GPs
73
Source: Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (Pulse: Practical Commissioning, 2009)
Reducing urgent care demand: Occupational therapists
The Acute GP Unit offers alternatives to GP referrals to A&E; in cases where patients self-refer, or where GP
referral is unavoidable, case studies demonstrate that a team of Occupational Therapists can help to improve A&E
response time and reduce length of stay
Intervention name Providing Occupational Therapists to offer initial consultation to A&E attendees
What is it? The aim of the service is to provide early assessment to contribute to discharge planning, prevent unnecessary hospital
admission and facilitate a safe and timely discharge. Using an OT group to triage some attendees can more quickly identify
patients suitable for discharge, reducing the pressure on other A&E staff and improving lead times for patients.
Why do it? • The service enabled discharge home for 84% of patients seen and 49% required follow-up telephone call or home visit
• An average length of stay for a falls admission was quoted as 4 days (at £350 a day) compared with an average length
of time by the OT in A&E providing assessment and facilitating safe discharge in 2 hours, costing £15 per hour
• In one pilot, fewer than 19% of patients seen by the OT were subsequently admitted to hospital; most of the patients
seen were able to be discharged home after assessment and a third were discharged with follow-up
What are the key • The findings of the study led to a recommendation that a 7-day OT service was valuable in A&E. Outside the working
enabling factors? days of the study, hospital doctors and nurses referred to the OT department instead which resulted in more individual
home visits being required (both time-consuming and costly)
What are the • The intervention was deemed most effective when the OT team was available all week on extended hours. Before this
potential level of staffing can be achieved, the intervention may not demonstrate the full extent of benefits described above.
barriers?
74
Source: Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (Pulse: Practical Commissioning, 2009)
Key leads and further reading: Reducing urgent care demand
Further reading
• Robert White, ‘Create an acute GP unit to reduce emergency admissions’ (Pulse: Practical Commissioning, 2009)
• A review of the White article appears in ‘Reshaping the System: Transforming Northern Ireland’s Health and Social
Care Services’, Department of Health, Social Services and Public Safety, Northern Ireland (2010)
• Fact Sheet ‘Occupational therapists working in A&E teams help reduce admissions and re-admissions to hospital’,
College of Occupational Therapists (2013), http://www.cot.co.uk/sites/default/files/commissioning_ot/public/AE-
Evidence-Fact-sheet.pdf
• Carlill et al, ‘Preventing unnecessary hospital admissions: an occupational therapy and social work service in an
accident and emergency department’ (British Journal of Occupational Therapy, 2002)
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Overview: 24-hour asthma service for children and young people
Intervention name Integrated 24-hour children and young people's asthma service
What is it? This intervention provides a 24-hour home nursing service for children and young people with difficulty managing asthma. In
so doing it is intended to reduce unnecessary hospital admissions, and improve quality of care for this patient group by
enabling them to manage their conditions at home.
Key features of the integrated service are a single point of access and round-the-clock operating hours. Patients and/or their
parents were given a dedicated pager number to call for urgent advice and treatment of acute asthma episodes. Following a
set template, the duty nurse assessed the need for telephone triage, a home visit or an emergency ambulance.
Why do it? • Improved patient experience: visits to hospital can be a distressing experience for children and young people, so
avoiding unnecessary hospitalisation is preferable. This intervention offers a means to treat patients in a more comforting
home setting
• Cost of admission avoided: reductions in A&E attendances and further hospital admissions generate cost savings,
which the case study indicates are likely to exceed the costs of the service
What are the key • Cooperation of key stakeholders to enable service redesign is vital – including the trust board of the local primary care
enabling factors? organisation and acute hospital
• An effective and adequately-resourced project team will need to be recruited
• Effective training for relevant staff, e.g. paediatric nurses, is crucial to enable the service to be effectively deployed
• A paediatric community team is needed to bolt this service onto
What are the • Patient safety must not be compromised – this can be ensured through templates for nurses to follow when assessing
potential and treating patients, so that those who do need to be admitted to hospital are identified
barriers? • Community and acute trusts will need to work together to implement the intervention and develop protocols and agreed
practices
• Lack of resources is a potential barrier due to the potential extra workload for nurses – additional recruitment may be
required. This may require additional upfront investment, but the case study indicates that the intervention should be net
cost-saving due to hospital admissions avoided
• The level of existing infrastructure in the local health economy will influence how appropriate this intervention is for a
given CCG and how easily it can be implemented
• Paediatrics is a key shortage speciality, meaning that there could potentially be issues in recruiting the required staff
77
Source: ‘Proposed Quality and Productivity: Integrated 24-hour children and young people’s asthma service: Reducing unnecessary hospital attendance’ (South East Essex
Community Healthcare, 2011)
Key leads and further reading: 24-hour asthma service
Further reading
• Proposed quality and production example: ‘Integrated 24-hour children and young people's asthma service:
Reducing unnecessary hospital attendance’ (South East Essex) – available at:
www.arms.evidence.nhs.uk/resources/qipp/601092/attachment
• For further information on the case study, email contactus@evidence.nhs.uk quoting QIPP reference 10/0059
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Overview: Service user network
Intervention name Service User Network (SUN) (Croydon)
What is it? SUN is a support network developed for and by people who have long-standing emotional and behavioural problems
(personality disorders) in Croydon. SUN aims to help those who feel isolated and let down by mainstream services by
bringing together people who share the same experiences to support one another in formal and informal ways.
Members of SUN meet in support groups held several times a week. These are facilitated by professionals, but the
emphasis is very much on people learning from each other. Everyone’s experiences and opinions are valued, making these
sessions open and understanding.
Why do it? • SUN is an innovative model of patient self-help and co-designed services, which offers the potential to support
patients who have struggled within a more traditional model of care
• There is evidence that the SUN model decreases planned and unplanned hospital visits, by pre-empting periods of
crisis before these culminate in a visit to A&E
o An audit looking at the impact of SUN on hospital bed day use after six months of members joining the network
showed a total decrease from 330 days to 162 days
o A&E attendance was also down by 30 per cent for members after six months in the network
What are the key • Involving people in the design of services from the start is key to fostering a sense of collective ownership: this is a
enabling factors? key element of service co-design
• Peer networks can provide additional and different capacity from professional support that is often more flexible and
accessible to community members
• Members are a crucial part of delivering the care offered by SUN, by being there for one another in times of crisis, and by
challenging people’s responses to crises in the facilitated sessions
What are the • Resources: this intervention has not been costed, but will require some upfront investment of resources, especially in
potential professionals to facilitate the sessions. However, it is reasonable to expect that the intervention will be cost-saving over
barriers? time if it achieves the expected reduction in planned and emergency admissions
• Ownership: unless patients are genuinely allowed to co-own the network, it will not function as intended. This
intervention cannot therefore be delivered from the top down
• The intervention may be most suitable for urban health economies, owing to generally higher concentrations of
complex needs patients
80
Source: Nesta, ‘People Powered Health Co-Production Catalogue’ (April 2012)
Key leads and further reading: Service user network
Further reading
• Nesta, ‘People Powered Health Co-Production Catalogue’ (April 2012) – available at: http://
www.nesta.org.uk/about_us/assets/features/people-powered-health_catalogue
• An overview of useful contacts is available at http://
www.hear-us.org/aboutthem/croydonslam/slamsservices/touchstoneansthesunproject/pdf/CroydonSunProject.pdf
• The homepage for the SUN project is http://
www.hear-us.org/aboutthem/croydonsupportgroups/othersupportgroupssun.html
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Overview: Reducing unnecessary elective Caesareans
Intervention name Campaign for Normal Birth (NHS Institute for Innovation and Improvement; Royal College of Midwives etc.)
What is it? The rate of Caesarean sections in England has doubled since 1990 with no associated improvement in outcomes for the
baby. Additionally, unnecessary procedures (especially Caesareans) have been shown to carry an increased risk of
morbidity for the mother when compared to normal delivery. A number of Trusts have introduced programmes that offer
advice and support for expectant mothers, highlighting the risks of unnecessary procedures and the benefits of vaginal birth
where possible. A successful programme should include training and guidance for clinical staff; several obstetric
professionals have reported that unnecessary sections are often a result of under confidence in the safety of natural birth
compared to Caesarean, especially among more junior doctors. The intervention aims to make both mothers and obstetric
professionals alike more comfortable in pursuing vaginal birth where risk analysis indicates that this is appropriate.
Why do it? • Eliminating unnecessary Caesareans is likely to improve morbidity outcomes for low-risk mothers. The consequence of
this is likely to be an impact on patient experience of hospital care (indicator 4b)
• Typically up to 3 bed days can be saved per patient by offering normal birth over Caesarean
• Vaginal birth carries a significantly lower cost than Caesarean; every 1% rise in Caesarean rate costs the NHS £5m per
year (excluding cost of consequent extended hospital stay)
• Trusts that have piloted the programme have seen significant reductions in Caesarean rate (Blackpool Victoria Hospital
achieved a 20.4% reduction, for example). Moderate national targets could equate to £76.8m, or £540’000 per Trust
What are the key • The healthcare professionals will need to open the discussion of birthing method with mothers at an early stage,
enabling factors? especially those who have previously had a Caesarean and are statistically likely to do so again
• Sending the right message to junior doctors is key; some obstetric professionals have suggested that mentoring from
senior midwives when consultants may not be available could help improve confidence and reduce Caesarean rates
What are the • Lack of available staff, as the system needs to be adequately staffed in order to offer the appropriate level of
potential discussion to midwives, doctors and patients
barriers? • Reluctance of clinical staff to change working behaviour. Clear guidance will need to be given to overcome a ‘better
safe than sorry’ approach to Caesareans – especially given that, in most cases, unnecessary Caesareans are a higher-
risk alternative to vaginal birth
• Perception among mothers than Caesarean is a solution offering less problematic delivery. Again, this will need to be
built into the guidance offered to ensure that patients can make an informed choice on the safest and most appropriate
option (likely to be vaginal birth in the majority of low-risk cases)
83
Source: NHS Institute for Innovation and Improvement, ‘Toolkit for reducing Caesarean section rates’ (April 2008); Alex Smith and Anna Dixon, ‘Health care professionals’ views
about safety in maternity services’ (The King’s Fund, 2008); NHS Institute for Innovation and Improvement, ‘Promoting normal birth’ (2009), http://www.institute.nhs.uk/index2.php?
option=com_content&task=view&id=3360&pop=1&page=0&Itemid=3842 (accessed November 2013)
Key leads and further reading: Unnecessary Caesareans
Further reading
• NHS Institute for Innovation and Improvement, ‘Toolkit for reducing Caesarean section rates’ (April 2008)
• Caesarean section clinical guidance, NICE (2004)
• ‘Maternity Matters: Choice, access and continuity of care in a safe service’, Department of Health (2007)
• Alex Smith and Anna Dixon, ‘Health care professionals’ views about safety in maternity services’ (The King’s Fund,
2008)
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Overview: acute stroke services
Intervention name Hyper-Acute Stroke Unit (London Stroke Service)
What is it? This intervention seeks to optimise acute stroke services to ensure 24/7 access to specialist care (including thrombolysis)
and prompt admission to acute stroke units. Where necessary, service are reconfigured to ensure high-quality, safe and
effective care for all those experiencing stroke
Why do it? Stroke costs the UK around £7bn per annum, of which £2.4bn are acute care costs. In addition, stroke is a condition that
responds best to early treatment. Creating a hyper-acute stroke unit (HASU) that gets stroke patients into appropriate acute
care as rapidly as possible aims to improve clinical outcomes and reduce the time spent by stroke patients in hospital beds.
Evidence from implementation of the London Stroke Service indicates that following implementation, mortality from stroke in
London showed a 12% reduction relative to the rest of England. If the model could be applied to the urban population of
England, around 18 million people could benefit from similar services. A 18% reduction of mortality across this population
would mean 1,080 lives saved in England annually. Impact assessment suggests that in London the service saves £5.2m in
90-day treatment costs per annum (5.7% reduction per patient)
What are the key • For maximum effectiveness a HASU should be within maximum 30 minute drive from anywhere in the region
enabling factors? • There is a need for 24/7 immediate access to specialist care, including all investigation facilities
• Higher volume units are likely to be more effective, enabling high levels of nursing staffing and therapy to begin
immediately on admission
• Early supported discharge to shorten time as an in-patient is a key element of the intervention
• This intervention is likely to be most appropriate for large cities and conurbations
What are the • This intervention requires significant capital investment (c.£10m in London). However, as an intervention best
potential implemented at scale, these costs will be distributed across multiple health economies, and evidence from London
barriers? suggests that break-even is reached in year three post-implementation
• There will be ‘winners and losers’ in the process of selecting where to locate the stroke units. In the case of the London
Stroke Service, decisions on which hospitals given the services were decided on the quality of submitted bids but mainly
on geographical location
• In order to ensure that hospitals do not lose out, collaboration is important, for example with joint rotas involving
clinicians from ‘losing’ hospitals. To further avoid resistance, there should be extensive professional and public
consultation regarding changes
• It should be emphasised that it is equally important that acute stroke unit services are of high quality, as hyper-acute
stroke unit services – there is no ‘second class service’
86
Source: Damian Jenkinson, ‘The National Stroke Strategy: Half Time Successes and Challenges’; Hunter et al, ‘Impact on Clinical and Cost Outcomes of a Centralized Approach to
Acute Stroke Care in London: A Comparative Effectiveness Before and After Model’ (2013) PLoS One 8(8)
Key leads and further reading: acute stroke services
Further reading
• Damian Jenkinson, ‘The National Stroke Strategy: Half Time Successes and Challenges’, available at: http://
www.rcplondon.ac.uk/sites/default/files/documents/1000_jenkinson.pdf
• Hunter et al, ‘Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A
Comparative Effectiveness Before and After Model’ (2013) PLoS One 8(8)
• Further discussion of the London Acute Stroke Service is available at https://
www.myhealth.london.nhs.uk/health-communities/londons-health-services/acute-stroke-services-london
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Overview: Integration of health and social care
Intervention name Integration of health and social care for older people in Torbay
What is it? Health and social care provision for older patients in Torbay have been integrated through a series of wide-reaching
organisational, procedural and cultural changes. Since 2005 all care has been provided under the auspices of the
Torbay Care Trust, which benefits from a strong sense of shared purpose and close communication between senior NHS
and Local Authority leaders. Integration of patient care is underpinned by the presence of care co-ordinators with
responsibility for an individual patient’s outcomes and enhanced data-sharing between different service providers and
clinical teams. Further, front-line staff are empowered to modify patients’ care packages on the basis of changed
circumstances, ensuring responsiveness and continuity of care over time.
Why do it? • Patients experienced more coordinated and responsive care, with beneficial impacts both on their health and their
experience of interacting with health and social care providers
• At the same time, changes in activity produce financial savings which can be reinvested into the health economy.
Examples of activity changes noted in Torbay include:
o The daily average number of occupied inpatient beds fell 33% from 750 in 1998/99 to 502 in 2008/09
o Emergency bed-day use in the over 65 population was the lowest in the region, at 1,920 per in 2009/10
o Similarly, emergency bed-day use by the over 75s fell 24% between 2003 and 2008
o Delays in hospital transfer have been reduced to a negligible number
What are the key • Base any strategy on the benefits being sought for service users/patients
enabling factors? • Communicate the benefits, listen to staff feedback, and share results and experiences to achieve continual improvement
• Establish joint governance early – NHS, local authority and primary care
• Ensure senior and middle managers and clinical leaders are engaged from the start and avoid separate management
arrangements for individual professions
• Invest in a professional approach to organisational development/change management over an appropriate period of time
What are the • It is important to note that integration of health and social care in a long-term project requiring several years of
potential investment and effort before results may be realised. This requires strong and consistent leadership and project
barriers? management
• Financial pressures may appear to be a disincentive owing to the initial investment and longer pay-off period
• Clear governance and accountability needs to be established
• Cultural differences between professionals need to be taken into account
• Legal differences, such as differing terms and conditions in the workforce, need to be anticipated
• Information sharing may pose challenges, both because of lack of or incompatible IT systems and absence of
protocols and agreements between organisations
89
Source: Peter Thistlethwaite, ‘Integrating health and social care in Torbay: Improving care for Mrs Smith’ (The King’s Fund, March 2011)
Key leads and further reading: Integration of health and social care
Further reading
• Peter Thistlethwaite, ‘Integrating health and social care in Torbay: Improving care for Mrs Smith’ (The King’s Fund,
March 2011) – available at: http://www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbay. This
is a very useful and readable narrative account of the experience of Torbay in integrating health and social care,
with an emphasis on practical lessons for those looking to follow the same path
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Overview: Electronic Palliative Care Coordination Systems (EPaCCS)
Intervention name Electronic Palliative Care Coordination Systems (EPaCCS)
What is it? EPaCCS are a shared electronic record designed to improve end-of-life care and help patients to die in the location of their
choice.
They provide instant access to patient information for key healthcare providers, assisting coordination of care. Patients are
able to record their preferred place of death, ensuring that all those involved in provision of care are aware of patients’
preferences and wishes. They also provide a record of treatment, improving patient safety and ensuring that patients only
need to have ‘difficult conversations’ once.
Why do it? • Improved quality of care and patient safety: by reducing harm through coordinated communication, in standardised
format, to reduce the risk of inappropriate interventions
• More patients die in their place of choice: as those involved in care are aware of the patient’s wishes
• Reduced unnecessary hospital admissions and ambulance trips: recorded patient preferences means that they
may be allowed to remain out of hospital towards the end of their lives, reducing admissions and bed days
• Improved clinician productivity: reduced duplication of effort as information on patient preferences and previous
treatment is stored centrally, reducing the time spent by clinicians gathering this information
What are the key • Patients, family and carers should all be involved in discussions about the care planning process; and patients’
enabling factors? consent to sharing their personal information is vital
• To be useful, the record needs to be kept up to date and integrated into everyday ways of working for all those
involved in the patient’s care
• The standards set by the national information standard should be adopted to ensure consistent recording of
information and safe and effective management of sharing of information (see further reading for full guidance)
• EPaCCS should be seen as one part of a wider suite of interventions enabling effective end-of-life care, including
appropriate training and support for clinicians
What are the • Interoperability: different suppliers and systems may cause compatibility issues when sharing data. The DH Informatics
potential Team toolkit (see further reading) offers guidance on specifications to avoid this
barriers? • Patient and carer buy-in: initial doubts, for example over sharing data, may need to be overcome through discussion
and explanation of the benefits and the safeguards in place
• Clinician buy-in: this can be gained through training and support for clinicians in using the new systems, and clear
articulation of the benefits for both clinicians and their patients
• Costs: adequate budgetary resources need to be allocated to cover start-up and running costs
92
Source: Millington Sanders et al, ‘Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK’
(2013) (London Journal of Primary Care, 5:106–10
Case studies: EPaCCS in practice
Case Study 1
A patient with COPD, who had a life expectancy of a further 12 months, was seen at a clinic on a Tuesday. He stated that
he did not want to die at home, as he thought his wife wouldn’t be able to cope, but also did not want to go to hospital.
When the time came, he wanted to go the local hospice. A couple of days later the patient had a crisis and because his
details were on the EPaCCS, OOHs and his GP knew what he wanted and a bed was found for him at the hospice,
where he died a few days after. If the Hospital Palliative Care Nurse Specialist didn’t hold the clinic and hadn’t been able
to record his wishes, he would have been admitted to hospital and died there.
Case Study 2
An elderly man with lung cancer was admitted to hospital when he developed a chest infection, which was treated. When
he was discharged home, he decided he didn’t want to go into hospital again and wanted to die at home when the time
came. His details were added to EPaCCS by his GP and a Just in Case box organised. The multi-disciplinary team
discussed his ongoing care at their monthly Gold Standards Framework meetings. During a crisis at the end, Out of
Hours were contacted. As they were able to see his preferences, they contacted his GP and District Nurses who enabled
him to die peacefully at home.
93
Source: Millington Sanders et al, ‘Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK’ (2013)
(London Journal of Primary Care, 5:106–10
Key leads and further reading: EPaCCS
Further reading
• The National End of Life Care Programme’s report ‘EPaCCS: Making the case for change’ (2012) offers helpful
guidance and links to a range of other resources: available at http://
www.endoflifecare.nhs.uk/search-resources/resources-search/publications/epaccs-making-the-case-for-change.as
px
• NHS Improving Quality has also published an economic evaluation of the ePaCC early implementer sites, available
at: http://www.thewholesystem.co.uk/docs/3economic-eval-epaccs.pdf
• Information on the national information standard is available at: http://
www.endoflifecare.nhs.uk/search-resources/resources-search/publications/end-of-life-care-co-ordination-implement
ation-guidance.aspx
• An interoperability toolkit developed by the DH Informatics Team is available at: http://
www.connectingforhealth.nhs.uk/systemsandservices/interop
• Millington Sanders et al, ‘Electronic palliative care co-ordination system: an electronic record that supports
communication for end-of-life care – a pilot in Richmond, UK’ (London Journal of Primary Care 2013;5:106–10)
provides a good case study: available at http://
www.radcliffehealth.com/ljpc/article/electronic-palliative-care-co-ordination-system-electronic-record-supports
• An example ePaCC project brief for East Cheshire CCG is available at: http://
www.cheshire-epaige.nhs.uk/ePaige%20Documents/EPaCCS%20Early%20Adopter%20Project%20Brief%20v11%
20Final.pdf
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Further Ideas
Further transformational ideas
1 Urgent and emergency care networks

Regional networks of urgent and emergency care centres, consolidating specialist
expertise onto fewer major centres
2 Elective specialty centres
Centres of excellence for single specialties focusing on strong clinical outcomes and
operations excellence
3 Wellness programmes
Prevention programmes that incentivise healthy behaviours, improve quality of life, and
reduce the overall cost of healthcare
4 Interoperability of systems and patient records
Interoperability of systems and patient records aims to break down the barriers between
types of care, enabling presentation of patient information in a way that is accessible
and cross-compatible for all those involved with patient care.
5 Public Health England case studies
Additional interventions received from Public Health England, covering a variety of
conditions and points of delivery.
96
Further Ideas

97
Urgent and emergency care networks
t
The concep
Fragmented and diverse urgent and emergency services present a confusing and complex picture
to patients, who may find it extremely difficult to access care when they need it most. Consolidating
emergency care onto fewer sites may result in an improved experience for patients, as well as a
more efficient system overall. Networks have senior clinicians consolidated onto fewer sites, a
range of urgent care services in the community and within primary care, and linked reporting &
patient information systems.
What are the potential benefits of networks?

Patient experience Waiting times
An Australian study showed that An Australian study showed that
increasing the number of increasing the number of
consultants in the Emergency consultants in the Emergency
Department decreased complaints Department decreased waiting times
by 41% by 15%
Improving patient safety

Financial savings
Senior doctor input in patient care in Networks
The literature shows a decrease in
the ED adds accuracy to disposition
admission rates (from the ED) of
decisions, impacting on patient
27% for children, and a reduction of
safety and improving departmental
11.9% in admissions amongst adults
flow
98
Source: Positive impact of increased number of emergency consultants’. Geelhoed G and Geelhoed E, Archives of Disease in Childhood (September 2008); 93: 62–4.
White AL, Armstrong PAR, and Thakore S. “The impact of senior clinical review on patient disposition from the emergency department” Emergency Medicine Journal, 2010;27:262-265
Further Ideas

99
Elective Orthopaedic Centre (EOC)
t
The concep
The EOC is an NHS Treatment Centre providing regional elective orthopaedic surgery services (including inpatient, day-case
and outpatient). Established by the four South West London acute Trusts to deliver strategic change in the delivery of planned
orthopaedic care, the EOC provides high quality, cost efficient, elective orthopaedic services amongst the best in the world.
Since opening in January 2004, the EOC has earned a reputation as a centre of excellence for elective orthopaedic surgery
with excellent outcomes, low complications and high patient satisfaction. It has consistently achieved operational targets and
length of stay, infection rates and PROMs are amongst the best in the world.
What are the potential benefits of EOC?
Procurement savings
Quality improvements
There are potential savings through exploiting
Improvements to the quality of patient care are
scale to reduce procurement costs, e.g. for joints.
likely to be seen, in particular:
• Reduced waiting times for operations. The EOC leads a London Procurement
• Reduced post-surgery complications. Programme initiative for prosthetic purchasing.
• Improved quality of surgery, meaning that This has resulted in an annual saving for London
of some £3m.
replacement joints are likely to last longer.
Improved efficiency
EOC
Reduced patient complications
On average each consultant performs four
According to EOC calculations, EOC quality
operations per day, compared to a national NHS
agenda reduces post operative complications,
average of around three per day. This saves cost by
saving over £700 per patient compared to UK
increasing productivity, and reduces waiting times.
averages. If replicated nationally, this could save
[not quantified]. There is also a reduction in length
up to £92m across England and Wales.
of stay.
100
Source: Deloitte analysis
Aravind Eye Care - overview
t
The concep
Aravind Eye Care is one of the best-known examples of health care intervention, and has been extensively impact
assessed. From it’s origins in south India Aravind has provided end-to-end eye-care services for 20 years. It now
screens more than 2.7 million people annually, and performs some 285,000 surgeries per year. Aravind uses the
principle of ‘paraskilling’, whereby many technically less-demanding medical processes (such as eye washing prior
to surgery) are performed by trained nurses paramedics, but not by consultants. By adopting this approach, each
doctor is freed up to treat many more patients (seeing each patient only at diagnosis and during surgery, where two
patients are operated on simultaneously), reducing operating time and unit costs without compromising clinical
quality.
What are the potential benefits of Aravind?

Aravind carefully emphases clinical quality. Indeed, it has demonstrated infection rates comparable with those
achieved in UK eye clinics (4 per 100,000 operations vs. 6 per 100,000 operations in the UK).
Productivity improvements
Aravind’s high-throughput approach
Financial savings
significantly improves productivity
Aravind’s cost-effective approach performs
compared to other Indian hospitals. On
Aravind cataract surgeries at one sixth of the cost
average, each doctor conducts 2,600
to the NHS
operations per year, compared to 400 in
standard Indian clinic.
101
Source: ‘Emerging Markets, Emerging Models’ (Monitor Group, 2010); http://www.innovationunit.org/blog/201106/innovation-healthcare-aravind-eye-care-system
LifeSpring Maternity Hospitals - overview
t
The concep
LifeSpring Hospitals is a no-frills six-hospital chain of 20-bed facilities founded in 2005 and based
in the suburban areas around Hyderabad, India, specializing in maternal and child paediatric,
particularly labour and delivery. By using standardized procedures, ensuring only the most
specialized tasks are undertaken by consultants and a cross-subsidization model (private, semi-
private and general wards), LifeSpring has been able to significantly lower costs without
compromising clinical quality. It is now the largest chain of maternity hospitals in South India. More
than 300,000 patients have been treated and 18,500 healthy babies delivered to date.
What are the potential benefits of LifeSpring?
Productivity improvements
In LifeSpring hospitals, theatres
Financial savings accommodate 22-27 procedures
LifeSpring’s cost of delivery is 20-35% LifeSpring each week compared to 4-6 in a
the cost of private Indian clinics private clinic. Each doctor conducts
17-26 surgeries per month: four
times the private clinic rate.
102
Source: ‘Emerging Markets, Emerging Models’ (Monitor Group, 2010)
Narayana Hrudayalaya heart surgery
t
The concep
Narayana is an innovative hospital in Bangalore which specialises in cardiac procedures. The brainchild of Dr. Devi Shetty, the
hospital is based on a healthcare model which Shetty has sometimes described as the ‘Walmartisation’ of cardiac care. The
large size of the hospital (around 1000 beds, compared to 160 in an average US hospital) gives rise to economies of scale
which enable cardiac procedures to be delivered much more cost effectively, without compromising quality and patient safety.
This is an example of the ‘focused factories’ method of healthcare, focusing on performing one type of procedure efficiently and
to a high standard.
What are the potential benefits of Narayana?
Quality improvements Procurement savings

Because the hospital is specialised in delivering cardiac Because ‘focused factories’ concentrate the provision of
procedures, it delivers a high quality of care – the a given procedure, they increase the purchasing power
mortality rate within 30 days of coronary artery bypass of these providers, enabling them to obtain better deals
surgery is 1.4%. at Narayana, compared with and which can equate to a significant reduction in spend –
average of 1.9% in the US. for example, in this case there could be savings in the
procurement of heart valves [not separately quantified].
Improved efficiency Reduced cost of cardiac procedures

Surgeons become experts in particular types of heart Narayana has been estimated to reduce the cost of
surgery, meaning they can perform more operations in Narayana cardiac procedures by around 50%. Theoretically, in the
the same, leading to cost savings [not separately UK, where cardiovascular disease was estimated to
quantified]. cost £13.6 billion in 2006
103
Source: http://www.innovationunit.org/blog/201104/innovation-healthcare-narayana-hrudayalaya-heart-surgery
Further Ideas

104
Discovery Health’s Vitality programme
t
The concep
The Vitality programme is a wellness programme that encourages covered members to complete a
personal health review, set bespoke health goals and set a personal pathway that looks at disease
management, smoking cessation, mental health, nutrition, preventative care and physical activity.
Engagement is rewarded with Vitality points that can be turned into further incentives.
What are the potential benefits of the Vitality programme?
Lifestyle & customer benefits

Vitality points can be cashed in with Exercise
a large number of partners, including The programme has showed
travel, store cards, healthy food, increases in fitness engagement
cinema, and retail
Discovery
Health’s Vitality
programme Financial savings
Nutrition
Engaged Vitality members
The programme has showed an
experience 14% lower healthcare
uptake in the consumption of healthy
costs compared with non-Vitality
foods
members
105
Source: Discovery Health
Partnerships for Older People Projects (POPP)
t
The concep
The POPPs programme, financed by the Department of Health between 2006 and 2009, funded activities aimed at promoting
the health and well-being and independence of older people, and preventing or delaying their need for higher intensity or
institutional care. Twenty-nine local authorities were involved. One-hundred and forty-six core local services were established
for people needing significant support, such as people (and their carers) with long-term conditions. A further 530 small
‘upstream’ projects commissioned from the third sector were described as low level preventative programmes and were open to
all older people.
What are the potential benefits of POPP?

Promotion of healthy living Co-design in action
By creating a ‘network of information’, the This intervention is a strong example of
intervention volunteers help promote healthy putting the patient at the centre and involving
living and raise awareness of mental health them in their own care, helping them to
conditions. In so doing they may reduce future become active managers of their own health.
pressure on the healthcare system by changing This has the potential to improve care and
behaviours, enabling people to live healthier lives reduce pressure of health services for a
and manage their own conditions. range of other conditions and patient groups.
Reduction in emergency bed days POPP Improving access to services

Evidence from the studies indicates that for every The projects help vulnerable, isolated older
pound spent on the POPP services, there was a people access health services they might
£1.20 additional benefit in the form of savings on otherwise not be able to. As well as
emergency bed days. Overnight hospital stays improving quality of care and tackling
were reduced by 47% and A&E usage was inequality of access, this may reduce
reduced by 29%. demand for emergency services by pre-
empting the development of more serious
106 health issues.
Source: Nesta, ‘People powered health co-production catalogue’
Prevention and Access to Care and Treatment
t
The concep
Prevention and Access to Care and Treatment (PACT),

a US initiative drawing insights from NGO programmes in Haiti, originally serving the sickest and
most marginalized HIV-positive patients in Greater Boston. PACT has helped raise the standard of
care, while cutting costs in some of the poorest parts of Boston. It does this by supplementing
comprehensive medical care with “wraparound” antipoverty services. Its model is built on
accompaniment: CHWs are trained and paid to provide clinical care and deliver social support
services, health promotion, and harm reduction services within patient homes and communities.
From its origins in Boston HIV patients, PACT now serves patients with multiple chronic diseases
and behavioural health comorbidities in New York City, Miami, and the Navajo Nation.
What are the potential benefits of PACT?
Financial savings
70% of PACT-enrolled patients
Patients enrolled in the PACT
showed significant improvement in
programme have demonstrated a
PACT disease-specific indicator of clinical
60% reduction in hospitalization and
improvement (e.g., reduced viral
16% net cost savings
load, reduced A&E visits, etc.)
107
Source: http://www.ssireview.org/articles/entry/realigning_health_with_care
Further Ideas

108
Interoperability of systems and patient records - overview
t
The concep
Interoperability of systems and patient records aims to break down the barriers between social, residential,
community, mental health and hospital care, enabling presentation of patient information in a way that is
accessible and cross-compatible for all those involved with patient care. This process is supported by the NHS
Interoperability Toolkit (ITK). The ITK is a collection of specifications, implementation guides and related
documents, and is intended to bring consistency to system integration within the NHS.
1 2
Case study Case study
NHS Westminster Birmingham Central Care Record
Since 2009 NHS Westminster has used a system Care professionals in the Heart of Birmingham area
provided by Vision 360, which enables cross-sector now have access to a shared record for patients,
records for patients. Initially designed to provide including Sandwell and West Birmingham Hospitals
authorised clinicians in local out-of-hours and NHS Trust and over 70 local GP practices. This is
unscheduled care settings with access to patient part of wider initiative to develop a Central Care
records held by their GPs, it has now been Record across the area, giving health and social
extended to clinicians in other settings. Although in care professionals access to clinical information
its early stages, improvements to patient care and when they need it.
resource planning are expected.
Key lesson: expensive and disruptive new
Key lesson: a successful pilot can generate further systems can often be avoided in favour of adapting
buy-in from clinicians and organisations, allowing it existing systems.
to be extended further.
109
Interoperability of systems and patient records – further info
3
Case study
The Salford health economy has integrated primary, community and acute care through a real time shared patient record. Patient
data is uploaded to a central database every night, allowing clinicians in A&E to access a patient’s primary care record, while GPs
are able to access records of patient use of acute services. While this faced initial technical and political challenges – with access
to the data taking two years to negotiate - it has paid dividends in improvements in the the quality of patient care. In addition,
through the NorthWest EHealth health informatics spin-off company, the use of anonymised data has enabled the injection of £30m
into the local health economy, including through a world-leading clinical trial of respiratory medication using real-time data (the
Salford Lung Study). There have also been benefits in savings of GP time through greater efficiency and reduced duplication of
effort.
Enablers
• Providers of interoperability services and technologies should be compliant with the latest release of the ITK, to ensure
consistency in system integration across the NHS. The ITK provides further specifications and information guides to assist
with the process of integration
• Look at how the intervention interacts with the whole health economy – what are the political, personal and institutional enablers
and barriers?
• ‘Start small and iterate’ – the most successful systems are often those which evolve according to the needs of clinicians and
other users, and into which existing systems can be plugged, rather than attempting to transform everything at once
• Buy-in may be most easily gained by focusing on the benefits to patients, as well as savings to GP time through efficiencies,
and opportunities for income generation for the local health economy
Barriers
• Experience indicates that getting information governance, testing and project work going can be more challenging than the
actual implementation of the technology system
• To be effective, interoperability schemes require buy-in from clinicians and administrators across several different
organisations, which may be especially challenging following poor experiences with previous national schemes. Time needs to be
allowed to negotiate access to data: an opt-out agreement may be the most effective way of achieving this
• The benefits, while potentially significant, are as yet largely unproven owing to the early stage of most pilots
110
Interoperability of systems / patient records – resources
Resources
• NHS Interoperability Toolkit (ITK): http://www.connectingforhealth.nhs.uk/systemsandservices/interop
• The Power of Information (DH, May 2012):
http://webarchive.nationalarchives.gov.uk/20130802094648/https://
www.gov.uk/government/publications/giving-people-control-of-the-health-and-care-information-they-need
• Case study 1: http://www.inps4.co.uk/vision360/case-studies/nhs-westminster/
• Case study 2:
http://www.graphnethealth.com/news/NewsItem.aspx?Name=Graphnet%20scores%20interoperability%20su
ccess
• Case study 3: details of the Salford Lung Study available at: http://
www.rdforum.nhs.uk/confrep/annual13/SalfordLungStudy.pdf
111
Further Ideas

112
Management of foetal growth retardation
Name and QIPP: Reducing perinatal mortality and morbidity through improved antenatal detection of fetal growth restriction.
source of Perinatal Institute, 2011
literature www.pi.nhs.uk/cogs/IUGR_QIPP.pdf, http://www.perinatal.org.uk, BMJ article
http://bmjopen.bmj.com/content/3/12/e003942.abstract
Description of Improved antenatal identification of pregnancies which are at risk due to fetal growth problems in the West Midlands. This
intervention includes increased monitoring of fetal growth by using customised growth charts, ultrasound scanning protocols towards the
end of the pregnancy, escalation protocols to obstetric consultant care and in some cases the management of delivery up to
two weeks early. Designating and reporting on a performance indicator of antenatal detection of fetal growth restriction
underpinned this.
Health The West Midlands was the only region which showed a year on year drop in stillbirth rates, reaching in 2012 its lowest ever
Outcomes rate, 4.47/1000. This represents a 1.27/1000 reduction from the pre-2009 10-year average (2000-2009: 5.74/1000).
In addition to the reduction in stillbirths, analysis by the Perinatal Institute also estimates:
• Reduced asphyxia during childbirth – better detection of Intrauterine Growth Restriction (IUGR) would result in an
estimated 25% fewer such cases (36 per year fewer in the West Midlands region)
• Reduction in cerebral palsy – better detection of IUGR and timely delivery would lead to at least 12% reduction in cases
of cerebral palsy occurring after term delivery (12 fewer cases per year in the West Midlands region)
Cost The Perinatal Institute estimate a potential net saving of £5.4m per annum in the West Midlands primarily due to reduced
Effectiveness neonatal intensive care, cerebral palsy and reduced costs of obstetric litigation. This does not account for the value of fewer
perinatal deaths.
Costs of an estimated £1.2m per annum, primarily for ultrasound resources, implementation of protocols and training, and
additional inductions and caesarean sections are more than offset by the £6.6m per annum savings.
Relevance to Stillbirths are the largest contributor to perinatal mortality. 39% of all stillbirths (approximately 1,400 per year nationally) are
Any town health now known to be the result of fetal growth retardation (babies who are not growing as well as they should be in the womb).
system
Other UK Yorkshire and Humber have rolled out a comprehensive approach to the antenatal identification and management of babies
examples at risk of restricted growth, through the leadership and supervision of midwives. This initiative has resulted in 2012 stillbirth
rates being the lowest ever recorded in the region, a statistically significant improvement. [BMJ paper shortly to be
published]
113
Information sharing to reduce violent injury (Cardiff model)
Name and Anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury
source of http://www.bmj.com/highwire/filestream/380358/field_highwire_article_pdf/0/bmj.d3313.full.pdf
literature http://injuryprevention.bmj.com/content/early/2013/08/22/injuryprev-2012-040622
Description of The overall objective of the Cardiff project was to prevent violence of all types. By enhancing information available from the police with relevant
intervention data from emergency departments, and by including health professionals responsible for treating the injured as advocates for prevention, more
violence can be prevented than from police effort alone.
In essence, primary prevention of injury can be achieved by collecting and sharing unique information: each day, reception staff gathered 24-hour
electronic data on the precise location and time of violent incidents; on a monthly basis, this anonymised data can be shared by an in-house ED
analyst and the police, through a member of the Community Safety Partnership (CSP) (ideally a senior medical consultant). The CSP can then
combine police and ED data to produce a map and a report, illustrating violence times, locations, and weapons. Finally, the prevention action plan
can be updated and improved by the CSP violence task group.
Published evaluations have found that the best way to do this is for ED reception staff to collect data from patients who present with violence
related injuries, and those who accompany them when they first arrive. This means that busy clinical staff are not diverted from their core duties.
Health • This model has recently been evaluated in an experimental study and time series analysis that demonstrated a 42% reduction in hospital
Outcomes admissions relative to comparison cities where information sharing and use were not implemented
• There has been a 50% reduction in violence related A&E attendances in Cardiff (from around 80 per month in 2003 to around 40 per month in
2013)
Cost Anonymised information sharing and use led to a reduction in wounding recorded by the police, reducing the economic and social costs of violence
Effectiveness by £6.9 million in 2007 compared with the costs the intervention city, Cardiff, would have experienced in the absence of the programme. This
includes a gross cost reduction of £1.25 million to the health service.
By contrast, the costs associated with the programme were modest: setup costs of software modifications and prevention strategies were
£107,769, while the annual operating costs of the system were estimated as £210,433 (2003 GBP). The cumulative social benefit-cost ratio of the
programme from 2003 to 2007 was £82 in benefits for each pound spent on the programme, including a benefit-cost ratio of 14.80 for the health
service.
Relevance to There is a reduction in unscheduled attendances to A&E. Anonymised information sharing for violence prevention can produce substantial cost
Any town savings to health services and the criminal justice system. The Cardiff model work has been adopted as part of the Coalition Programme for
health system Government.
Other UK http://www.alcohollearningcentre.org.uk/LocalInitiatives/projects/projectDetail/?cid=6433 – Addenbrookes data sharing
examples http://www.alcohollearningcentre.org.uk/Topics/Latest/Resource/?cid=6396 – Data sharing London
More resources at https://www.gov.uk/government/news/resources-to-support-information-sharing-to-tackle-violence
114
Further info: Information sharing to reduce violent injury
Population Groups affected:

• All population groups, however as violence mainly results in injury of those aged 18-35, the principle beneficiaries are in this age
group
Logistic barriers to collection of evidence:

These include lack of appropriate software in ED reception and elsewhere, and lack of electronic links with crime analysts working in
crime reduction partnerships. These barriers can be overcome by receptionist training, simple adjustments to software by IT staff,
and establishment of formal links between ED consultants and local crime reduction partnerships.
A lack of professional analysts:

It has become apparent that there is currently a lack of qualified analysts able to quantify data, collate reports and communicate the
outcomes to ED staff. There is currently a call for the formation of a professional body to register analysts, set standards and
promote professional development.
Funding:
Relevant data collection, IT support and links with crime reduction partnerships can be achieved at no extra cost to local EDs.
Unjustified concerns about funding can get in the way of responsible practice. Solutions are, however, available from local crime
reduction partnerships, who are all funded to facilitate data sharing.
Time constraints:
Evaluations indicate that whilst doctors and nurses may be too busy to collect information about the circumstances of violence,
reception staff have opportunities during waiting room waits and also have access to appropriate IT systems. Data collection by
reception staff obviates the need for clinical staff to collect information, but responsible clinical care should still include enquiry about
cause of injury, police reporting and finding out whether one injury may be part of a series of attendances after injury at the hands of
the same attacker.
115
Alcohol identification and brief advice
Name and source of Alcohol Identification and Brief Advice (IBA) as part of a comprehensive, multidisciplinary Alcohol Care Service at Royal Bolton Hospital
literature http://fg.bmj.com/content/2/2/77.full.pdf+html / http://arms.evidence.nhs.uk/resources/qipp/29420/attachment
Description of The Royal Bolton Hospital has an integrated system of interventions, ranging from specialist care for dependent drinkers through to an
intervention industrial scale roll-out of IBA in the hospital, with over 600 staff in the Royal Bolton delivering IBA. All of which is linked to primary care,
where a GP champion leads large scale delivery of IBA by his colleagues.
Alcohol IBA is both an intervention in and of itself and a necessary precursor for the provision of enhanced intervention and specialist
treatment. In the Royal Bolton Hospital, the provision of IBA training and specialist support to a wide variety of staff enables the hospital to
offer alcohol support within all departments of the hospital and equips staff with information that may help to reduce alcohol harm amongst
the staff themselves, their friends and family. The on-going support provided by the alcohol specialist team ensures that alcohol IBA continues
to be delivered effectively and in line with best practice and the evidence base. Supporting effective delivery is essential to realising the
benefits of large scale preventative interventions.
Health Outcomes Research has found that for every eight people who receive simple alcohol advice, one will reduce their drinking to within lower risk levels.
NICE guidance (PH24) provides evidence in support of IBA delivery in any setting and recommends that all health and social care staff
should deliver it.
It is difficult to disaggregate the impact of the industrial scale use of IBA in the Royal Bolton Hospital from the allied interventions. Overall, the
comprehensive package of care for those who might benefit from an alcohol intervention in Bolton realised a 37% increase in ward
discharges; length of stay has fallen from 11.5 days to 8.9 days, and mortality from 11.2% to 6.0%.
A NW NHS Chief Executives Challenge Review identifies two principal patient cohorts who might benefit from intervention for which IBA is a
necessary first step. The first cohort is patients staying in hospital for 0–1 days, where effective intervention would result in 400 fewer alcohol-
related admissions per year, equating to a 1% reduction in alcohol-related admissions and liberating 2 hospital beds, saving £698,000
annually. The second cohort was patients whose admission has an alcohol-attributable (or aetiological) fraction and a length of stay of 10
days or more. These patients made up 17% of alcohol-related admissions, but occupied 66% of bed days. The service focus is on providing
assertive outreach support to reduce the number or repeat admissions to hospital. IBA forms a necessary first step in identifying these
cohorts and can deliver wider health benefits for those who do not require immediate clinical intervention.
Cost Effectiveness £1.6 million savings for a district general hospital serving a population of 250,000. This equates to £640,000 per 100,000 population.
Based on national indicators and length of stay costs, on average an alcohol-related admission costs a Primary Care Organisation (PCO)
£1824; an alcohol-related A&E attendance costs a PCO £80; and each avoided admission will save a provider £300.
Relevance to Any It is estimated that the annual cost of alcohol- related harm to the NHS in England is £3.5 billion. Of this amount, 78% of the costs were
town health system incurred as hospital- based care. A comprehensive Alcohol Care Service, including IBA can tackle this.
Other UK examples For other examples of Alcohol Care Teams see Royal Liverpool Hospital; Salford Royal Hospital; St Mary’s Hospital, Paddington;
Nottingham University Hospitals NHS Trust
116
Prevention of venous thromboembolism in hospitalised
patients
Name and source The national VTE Prevention Programme, analysed in Roberts et al, ‘Comprehensive VTE Prevention Program
of literature Incorporating Mandatory Risk Assessment Reduces the Incidence of Hospital-Associated Thrombosis’ (2013)
Chest 144(4):1276-81
Description of Implementation of the national VTE Prevention Programme in England, incorporating mandatory VTE risk
intervention assessment, standardised guidance for thromboprophylaxis (NICE CG92) and patient information together with
system levers to drive implementation. These included development of a CQUIN target around VTE risk
assessment and latterly root cause analysis as well as a NICE Quality Standard to define high quality care.
Health Outcomes 1. Current data reveal >95% adult patients admitted to hospital are risk assessed for VTE
2. Local audit and ST data shows a corresponding uplift in appropriate thromboprophylaxis rates and patients
made aware of their VTE risk
3. ONS data demonstrates a 25% reduction in VTE deaths since implementation of the national programme
4. Data from the QUORU unit in Birmingham links reduced deaths from hospital-associated thrombosis to
attainment of the national VTE risk assessment target
5. Local data from root cause analysis at King’s College Hospital shows improved outcomes upon
implementation of the national VTE prevention programme
Cost Treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with considerable cost to
Effectiveness the health service, estimated at £640 million (House of Commons Select Committee, 2005).

Costing analysis for NICE Clinical Guideline 92 (VTE - reducing the risk in hospitalised patients) estimated that
providing preventative treatment to patients at risk of VTE in England would result in savings per 100,000
population of £12,000.
Relevance to Any Support for implementation of the national VTE prevention programme by CCGs will result in better quality care,
town health improved patient outcomes and is cost-effective. A toolkit to inform CCGs about VTE prevention is available at:
system http://www.vteprevention-nhsengland.org.uk/commissioning/toolkit
117
Falls prevention
Name and source NHS Confederation http://www.nhsconfed.org/Publications/Documents/Falls_prevention_briefing_final_for_website_30_April.pdf

of literature
Description of In 2006, attending to fallers in the community within the Newcastle Primary Care Trust’s boundary cost North East Ambulance Service NHS
intervention Foundation Trust (NEAS) £376,000 (£145 per fall). That year, NEAS received 1,979 calls from fallers over the age of 65 in Newcastle alone,
with ambulance crews spending an average of 40 minutes on the scene with fallers.
NEAS, in partnership with Newcastle Upon Tyne Hospitals NHS Foundation Trust (NUTH), introduced an integrated falls prevention strategy to
provide a seamless route into established falls prevention services in Newcastle upon Tyne for fallers over the age of 50. It involves ambulance
crews based in Newcastle using a ‘first-line assessment’ tool to screen and triage fallers to the appropriate falls service. Where three or more
risk factors are identified, this is deemed an indication of a high risk of a future fall. The screening sheet completed by the ambulance crews is
sent to a single point of access referral centre.
For Newcastle patients this is the Falls and Syncope Service (FASS). FASS evaluates and triages the referrals to the most suitable falls
prevention team, either in primary care day hospital facilities services or secondary care specialist syncope services.
Professionals in health and social care and those working in the community, such as library staff, housing wardens, and community alarm
services, across the NEAS operational area now have a seamless route into established falls prevention services by using the same first‑ line
assessment tool.
The ambulance service has developed the strategy in conjunction with falls service physicians. Ambulance clinicians
who take fallers to A&E due to clinical needs recommend to A&E staff that falls assessments are carried out after treating the faller.
Health Outcomes • Older people who fall are receiving the right care, with a considerably reduced risk of a future fall
Cost Effectiveness • Reduced attendance from fallers has resulted in cost savings for commissioners
• Between 2006 and 2011, 999 calls for falls fell by over 75 per cent. This has enabled NEAS clinicians to be available more often for higher
priority (category A) calls
• The reduction in fallers has had a positive impact on A&E services. Fewer fallers are admitted by ambulance and, with recurrent fallers
receiving the right care, they do not fall as frequently or need transferring back to A&E
Also see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424053/ - The community falls prevention service delivered in this trial (not NEAS)
was cost-effective with little decision uncertainty. This study further justifies the development of clinical pathways linking the emergency
ambulance services to community therapy services note this was for people over 60 years of age living at home or in residential care who had
fallen and called an emergency ambulance but were not taken to hospital.
Relevance to Any Falls represent the most frequent and serious type of accident in people aged 65 and over. Furthermore, falls are the main cause of
town health disability and the leading cause of death from injury among people aged over 75 in the UK .Integrated falls prevention strategies can have a
system positive impact on demand for ambulance services and emergency admissions due to falls.
Other UK http://www.rospa.com/about/currentcampaigns/publichealth/info/hs3-casestudy2-bristol-falls.pdf - Bristol case study
examples http://www.ageuk.org.uk/Documents/EN-GB/Campaigns/Stop_falling_report_web.pdf?dtrk=true – various UK case studies
118
Inhaler Technique Improvement Project
Intervention name Inhaler Technique Improvement Project:

http://www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme/documents/120904%20CIREM_ITIP_HIEC_
Evaluation.pdf
What is it? • Inefficient inhaler technique is a common problem resulting in poor drug delivery, decreased disease control and increased
inhaler use. The costs to the nation and to patients are significant.
• Based on original work in the Isle of Wight a number of PCTs in the South adopted the project to support patients to use their
inhalers via a community pharmacy intervention.
Why do it? The evaluation found that the Inhaler Technique Improvement Project was a success on a number of levels:
• At the level of the individual patient (improved outcomes and quality of life).
• At a health systems level (improvements in emergency admissions).
• In innovation (use of IT system and inhaler devices).
• In education terms (enhanced skills applied in respiratory and other health related areas).
• In a more generic sense of the HIECs bringing together and integrating all component areas into a cohesive and effective
entity (Section 4.1.1).
The project delivered substantial improvements in the management of both asthma and COPD.
Other potential • Data on emergency admissions suggests a positive association between the introduction of the inhaler technique
improvement project and changes in hospital emergency admissions. A more detailed analysis would be required to look at
any more meaningful (i.e. statistically) significant correlation (Section 4.1.3).
• The training delivered by the project was well received by patients and, following the training, pharmacists were able to deal
effectively with patients’ concerns (Section 4.1.3).
• Other skills benefits which were reported included the view that patients: increased their knowledge of respiratory conditions
and how to control them better, developed greater confidence in controlling these conditions and were able to use “simple
tools”
Further potential - • One person dies from COPD every 20 minutes in England - around 23,000 deaths a year. If the whole NHS were to deliver
COPD services in line with the best around 7,500 lives could be saved.
• Death rates from COPD in the UK are almost double the EU average. 15% of those admitted to hospital with COPD die within
three months and around 25% die within a year of admission.
• COPD is the second most common cause of emergency admissions to hospital and one of the most costly inpatient
conditions to be treated by the NHS.
Further potential - • There are around 1,000 deaths from asthma a year in the UK, the majority of which are preventable.
asthma • The UK has the highest prevalence of asthma in the world, at around 9-10% of adults.
• Just under £1billion is spent on respiratory inhalers with £170 million spent on one product alone (the Seretide 250 evohaler).
119

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Any town health system

A guide to finding further information on

In this section, for each high impact intervention we provide:

3. Self-management: patient-carer communities:

5. Case management and coordinated care:

6. Mental Health – Rapid Assessment Interface and Discharge (RAID):

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

Potential years of life lost (PYLL) from causes

Unplanned hospitalisation for chronic

Emergency admissions for children with lower

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

The four principles of medicines optimisation

Potential years of life lost (PYLL) from causes

It is expected that the aspect of this intervention relating to safe and

Unplanned hospitalisation for chronic

Emergency admissions for children with lower

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

Potential years of life lost (PYLL) from causes

2. Increase QoL for People

Emergency admissions for children with lower

Have you thought about the following Frail Depri-

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

Telehealth and Telecare – Airedale NHS Foundation Trust

Potential years of life lost (PYLL) from causes

Unplanned hospitalisation for chronic

Unplanned hospitalisation for asthma, diabetes

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

Clinical Over the course of the 2 years, these pilots demonstrated a:

Case study: Programme for All-inclusive Care for the Elderly

Potential years of life lost (PYLL) from causes

Significant qualitative evidence of improved HRQoL exists. In other

Unplanned hospitalisation for chronic

2. Reducing variability within primary care by optimising medicines use

3. Self-management: patient-carer communities

5. Case management and coordinated care

6. Mental Health – Rapid Assessment Interface and Discharge (RAID)

Potential years of life lost (PYLL) from causes

Unplanned hospitalisation for chronic

3. Reduce unnecessary Unplanned hospitalisation for asthma, diabetes

Emergency admissions for acute conditions

Emergency admissions for children with lower

 and Solihull NHS Trust)