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Meet the team


  • Pathology (Tom Butler)
  • GPs (Roberto Tamsanguan & Lesley Perkins)
  • Patient
  • 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 This model of care is outdated and inefficient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.

  1. 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
  2. Improvement: Improved self-management, patient activation and experience
  3. Value for money: Virtual follow up and remote monitoring will reduce unnecessary outpatient appointments
  4. 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

Plan timeline

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


  1. Hi MaryCate

    Really keen to hear how you are getting on with the project as would love to consider this for our patients living with cancer


  2. Congratulations on being short listed.

    I like your approach which is based on patient needs rather than diagnosis - I would be delighted to contribute and support your work

    Best wishes

  3. This is a good project to test some pathway/process visualization techniques.

    1. Thanks Thomas - I think so too. There's the digital/info transfer pathway, plus the context that pathways are different in each CCG area due to the provision in community phlebotomy.

  4. This is a good idea and needs testing as medicines that require ongoing monitoring often don't  have it putting patient at avoidable risk. So a good patient and medication safety improvement idea

    1. Hi Elizabeth - yes indeed. It has huge potential in terms of the treatment regimes that need safety bloods. And the impact that has for patients

  5. Very interesting concept. Something that is similar to a project we are currently working on, so would be more than happy to discuss collaborating if this is successful. We are also developing an app that has some cross-over, so it would be good to share experiences.

    1. I think that whatever happens with the vote Anthony there is potential to hook up and learn. So much digital innovation seems to happen in pockets

  6. Great idea. The renal team at South Tees have been testing this approach for their patients. If the project goes ahead I'd be happy to put you in touch if this would be helpful.

    1. Guest

      Hi Tony, we are definitely interested in thinking through and working with other patient groups. We would love to know any learning and patient insights. Thanks for taking the time to comment - I can get in touch directly


  7. Hi Sarah, thanks for taking the time to comment. Yes the virtual consultations/IBD clinic are on board, but they had a 'lets implement' approach, so lots of learning for us. Remote monitoring seems to be happening in pockets - so would eb really good to make contact with some teams

  8. Great idea, MaryCate.  I hope others with experience of remote monitoring can get in touch.  I wondered if your colleagues who have scaled-up virtual consultations could help on the QI side?  Different model of care, but perhaps some of the same principles?

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