Meet the team
Senior Improvement Adviser
Barts Healthcare NHS Trust
- England - London (North, East and Essex)
- Pathology (Tom Butler)
- GPs (Roberto Tamsanguan & Lesley Perkins)
- Community pharmacist (Harpreet Shergill)
- Strategy (Annie Karlin; Steph Good)
What is the challenge your project is going to address and how does it connect to your chosen theme?
In line with the NHS Long Term Plan challenge to reduce outpatients by up to a third, this project aims to transform the clinical pathway for patients who require long term monitoring for blood disorders. Outpatient activity has increased up by 11% in 2018/19, across Inner North East London and the system cannot cope with this level of growth. However a recent RCP survey showed that up to 20% of new patients don’t need to be seen in outpatient clinic at all.
A significant proportion of unnecessary outpatient activity includes patients with chronic disease who need regular monitoring via weekly visits to hospital in some cases. In a recent focus group, patients reported the impact of regular inconvenience, time off work and travel, for simple blood tests. The organisational challenge is that blood tests ordered in the acute trust cannot be undertaken in the community due to lack of integration. This model of care is outdated and inefficient
What does your project aim to achieve?
This project has two clear objectives to improve patient experience and reduce unnecessary hospital appointments by enabling patients to have blood tests closer to home, and direct two-way communication with specialists via an app. This app will serve as patient portal to coordinate care, organise blood tests, and share symptoms with specialists.
- Deliverables: Integration of Acute Trusts with Community Phlebotomy providers to enable specialist blood tests to be done in the community, and co-produce an app with patients to allow asynchronous communication with specialists
- Improvement: Improved self-management, patient activation and experience
- Value for money: Virtual follow up and remote monitoring will reduce unnecessary outpatient appointments
- Measurement: Quantitative and qualitative feedback from patients, carers, and clinicians, combined with activity data
How will the project be delivered?
The project is governed by the Inner North East London System Transformation Board bringing together provider, commissioner and local authority chief executives. The Deputy CEO at Barts Health is the project SRO. We have a robust governance structure to manage risks, and monitor progress and unblock barriers.
The improvement team consists of primary and secondary care clinicians, a Darzi fellow, project managers with expertise in large scale transformation, data analysts and a patient representative. We will also involve patients through focus groups. Together we will work an HSJ award winning app company.
Our high-level delivery plan is as follows:
Q1: Refinement of measures, baseline data collection, app development, and integrate systems to allow secondary care bloods to be done in the community
Q2: Patient and community services engagement and co-produce
Q3: Beta trial of initial app in a distinct cohort – with recurrent PDSA cycles
Q4: Roll-out to second cohort and evaluate
What and how is your project going to share learning throughout?
We will apply a PDSA approach to support learning throughout and identify commonalities, differences, and barriers. This approach will allow us to test how the new model of care works in across 3 boroughs with varying provision. We will produce an evaluation and lessons learned report which we will disseminate through all levels of the healthcare system through the following mechanisms:
Nationally through –
- our link to NHSE Outpatient Transformation lead who is a member of our board
- NHSx community of interest ‘Empower the Person’
- the Royal College of Pathology
Regionally through –
- Barts Health CMO, chair of the London Outpatient Transformation Board
- the INEL System Transformation Board where this project reports
Locally through established CCG and provider learning sessions
- Q community – this model of care will be scaled to other specialities across the INEL footprint, so we plan to connect with Qmembers who already work within INEL to share learning with them
How you can contribute
- To become a critical friend & advise
- Developing appropriate patient related outcome measures,
- Access to a wider pool of ideas & methodologies
- Learning from other digital/telehealth teams and initiatives
- Collaborate on scaling up the project from others
|1 Oct 2019||Due Diligience on message solution|
|1 Oct 2019||Identify message solution|
|1 Oct 2019||Identify printing/labelling solution|
|1 Oct 2019||Refine measures|
|1 Nov 2019||Baseline measurement|
|1 Nov 2019||Patient engagement /co-production|
|1 Jan 2020||Integrate systems|
|1 Feb 2020||PDSA cycles|
|1 Feb 2020||appdesign & development|
|1 Mar 2020||Patient focus group|
|1 Apr 2020||Pilot (Beta trial in cohort 1 – PDSA cycles)|
|1 May 2020||Pilot (Rollout to cohort 2 – PDSA cycles)|
|1 Jul 2020||Patient focus group|
|1 Aug 2020||evaluation|
3 Jun 2020
What have we learned so far?
As of Feb 2020, i.e. pre-Covid, we were in planning and stakeholder engagement stages. There were three distinct issues we were trying to understand:
1. Making digital health an alternative to, as opposed to addition with, hospital visits
2. Making the practicalities of working across organisational boundaries easier
3. How to facilitate ICT integration/two way flow or information
Covid19 response accelerated movement and volume of patients into community services (#1). The willingness to test in adversity and provide support in goodwill has been instrumental in getting the virtual phlebotomy model in place (#2). While not all community sites were in the 1st wave accepting patients, all are now in conversations as part of the Covid19 recovery, and therefore engaging with the project (#2)
Covid disrupted [drastically] patient pathways and expectations that were helpful to our iniative. The original test area was slower to adapt, but the most significant area [outpatients’ haematology clinics] is now the main focus. Everyone realises the value of avoiding unnecessary hospital appointments, and asking “what is necessary” (#1) without pre-conceived answers.
ICT integration (#3) is still a live issue. While we had buy-in at the initiation of the project, the pandemic has meant less progress than planned, and the current solution is very low-fi. While the app is in development; the company is still working out how to facilitate two-way communication. We need to bring together patients, clinicians and informatics experts in order to help solve this aspect
This (#3) has also meant obtaining regular data on number of blood tests has been challenging, due to internal IT infrastructure and variance in booking systems across the 3 CCGs. Measures have been much, much harder to source than expected, and remains in early stages of the provision of ongoing real-time measures
The pandemic has meant our plans (of a tight, neat, methodologically- robust QI project) is in disarray. We didn’t test small, there was minimal planning/briefing to relevant parts of the system about real-time data capture, or revealing the learning as we went along. The approach of the project is to now look at how we keep and maximise usage of the virtual phlebotomy model
What could others learn from our experience of working across boundaries, with a range of stakeholders?
The pandemic has taught the project team to push harder, and the wider health landscape has experienced significant change rapidly. Common purpose focused on patient safety has enabled this, and articulating the vision regularly.
We are about to embark on events with patients and multiple care providers as we seek to create a vision of what ‘remote care’ will actually mean, and making that happen will require changes by all parts of the service. There is still poor uptake of virtual consultations – clinicians have been providing telephone consultation – and we know this is less sustainable. The importance of this on-going co-design with patients will continue to persuade stakeholders to keep working together.
The project team use of technology has been an important awareness/parallel process. Virtual meetings are good enough to be able to plan, deliver and execute. No face to face meetings were needed, which was previous gold standard for project engagement and success. What has been created instead, is weekly 30 min updates with senior players, and this has been vital to build rapport and explore emerging issues across different partner organisations rapidly
What is working well and any challenges you have faced?
1. Community and hospital services are in agreement that hospital patients will be seen locally for blood tests, and this is happening
2. Clinical teams and patients are more creative in what they can envisage/accept as suitable care packages
3. Understanding/accounting for individual clinicians choices about care provision. If clinicians have been delaying care, there is a risk that they will want to re-establish traditional care.
4. The variance in how local phlebotomy is provided is a challenge as local level adaptations are needed: This is the antitheses of the Carter report and will need consideration in scale up and sustainability. It is also created the challenge to project measures.