WMBGS research talk 2016

CRN workforce and structure

  • 15 Local Clinical Research Networks
  • National Coordinating Centre
  • Network funded staff in NHS hospital trusts, Universities and other health and social care settings
  • 30 clinical specialties managed via six specialty cluster leads with oversight from the CRN Executive Team

How the CRN works

The CRN supports studies by:

  • Funding research support posts in the NHS and providing training, so that researchers have access to experienced front-line staff, who can carry out the additional practical activities required
  • Providing funding to meet the costs of using facilities, such as scanners and X-rays that are needed
  • Helping identify and recruit patients, so that researchers can be confident of completing the study on time, and on target

CRN: high level objectives

  1. Increase the number of participants recruited into NIHR CRN Portfolio studies
  2. Increase the proportion of studies in the NIHR CRN Portfolio delivering to recruitment time and target
  3. Increase the number of commercial contract studies delivered through the NIHR CRN
  4. Reduce the time taken for eligible studies to achieve set up in the NHS
  5. Reduce the time taken to recruit first participant into NIHR CRN Portfolio studies
  6. Increase NHS participation in NIHR CRN Portfolio studies
  7. Increase the number of participants recruited into Dementias and neurodegeneration (DeNDRoN) studies on the NIHR CRN Portfolio

Breakthrough research
Argus II study (Bionic eye) – Second Sight sponsored study

  • In July 2015, a partially sighted 80 year old man had his central vision restored after he received a bionic eye following being recruited to a Network study
  • World’s first patient with advanced age-related macular degeneration (AMD) to receive the implant

LUMINOUS – a Novartis sponsored study (2011-2015)

  • Long-term safety and effectiveness of Ranibzumab for all licenced indications
    Recruitment target of 30,000 globally
  • UK was top recruiter globally – contributing over 11,000 patients across indications
  • 49 UK sites active with subjects
  • Top two recruiting sites for neovascular AMD globally were from the UK

Delivering research

The NIHR CRN supports the delivery of non-commercial and commercial research

Non-commercial research
The NIHR CRN provides guidance on the practical aspects of delivering study in the NHS environment, including;

  • Support for study planning
  • Support for study set-up and delivery

Commercial research
The NIHR CRN oversees the set-up and delivery of various types of commercial research across the UK, such as;

  • Feasibility
  • Set-up
  • Performance management

Healthy Aging talk-Feb 2017

What’s the challenge?

Definition of Healthy Ageing
Healthy ageing is the process of optimising opportunities for physical, social and mental health to enable older people to take an active part in society without discrimination and to enjoy an independent and good quality of life.

The challenge of Healthy Ageing
The need for healthy ageing is a challenge to all European countries.
By 2025 about one-third of Europe’s population will be aged 60 years and over
There will be a particularly rapid increase in the number of people aged above 80 years.
This will have an enormous impact on European societies.

The Challenge
Living Longer……..
and Ageing Better

Key themes for intervention

  • Retirement and pre-retirement.
  • Social capital
  • Mental health
  • Environment
  • Nutrition
  • Physical activity and deconditioning
  • Injury prevention
  • Substance use/misuse (tobacco and alcohol)
  • Use of medication and associated problems
  • Preventive health services

Is health promotion for older people worthwhile?
Cost-benefit analyses of programmes relevant to older people indicate that the programmes lead to improved quality of life and decreased health care consumption. The potential health gains of a prevention programme are greater in the older population than among young people.

Recommendations on policy, research and practice
The recommendations in this Report on policy, research and practice are based on the findings of the project and on the following core principles:

  • older people are of intrinsic value to society
  • it is never to late to promote health
  • equity in health
  • autonomy and personal control
  • heterogeneity

Catch-up Situation

  • Clinical technology and impact on healthcare
  • Minimal impact on self care and care provision
  • Consumer experience still the same
  • Is there lack of opportunity or education and awareness or willingness?
  • No risk of losing human interaction in health care but it can become better informed and efficient with good data

In 2014, 59% of all citizens in the UK have a smartphone and 84% of adults use the internet; however, when asked, only 2% of the population report any digitally enabled transaction with the NHS.

TIME TO THINK DIFFERENTLY?

Five simple healthy habits can lengthen life and dramatically cut the risk of a range of crippling diseases, a 35 year long, Welsh study of 2500 men:

People live longest and healthiest if they:

exercise regularly,
stay slim,
eat plenty of vegetables,
don’t smoke
drink less than two glasses of wine a day

Those who followed at least four of these recommendations from 1979 were 60 per cent less likely to have died since. They had 60 per cent fewer heart attacks, 60 per cent fewer cases of dementia, 40 per cent fewer cancers and 70 per cent fewer cases of diabetes.

ENRICH seminar April 2017

THE NIHR

The National Institute for Health Research (NIHR) is funded by the Department of Health to improve the health and wealth of the nation through research.

The NIHR plays a key role in the Government’s strategy for economic growth, attracting investment by the life-sciences industries through its world-class infrastructure for health research.

Together, the NIHR people, programmes, centres of excellence and systems represent the most integrated health research system in the world.

The NIHR is the research arm of the NHS.

CRN workforce and structure

  • 15 Local Clinical Research Networks
  • National Coordinating Centre
  • Network funded staff in NHS hospital trusts, Universities and other health and social care settings
  • 30 clinical specialties managed via six specialty cluster leads with oversight from the CRN Executive Team

How the CRN works

The CRN supports studies by:

  • Funding research support posts in the NHS and providing training, so that researchers have access to experienced front-line staff, who can carry out the additional practical activities required
  • Providing funding to meet the costs of using facilities, such as scanners and X-rays that are needed
  • Helping identify and recruit patients, so that researchers can be confident of completing the study on time, and on target

Over the last 18 months the ENRICH project (Enabling Research In Care Homes) has been developing it the West Midlands; this is due to changes in the structure of our organisation.

This has been a driving force in supporting care homes to be involved in research. With the aim of helping individual homes to become research ready and active.
Understanding what research is and how it can benefit individuals and especially for those living in a care home.

We have been working hard to raise awareness into research and break down barriers that limit an individual’s right to be involved if they want to be involved.

What do we do?
I work as part of the Network along with the ENRICH care home facilitators to Help care homes get research ready and active.
So I work a lot liaising with all these groups helping to join the dots between resources and other organisations that can help get research going.

How can you Help?

Think about studies that can apply to those who are over 65
Questionnaire based or Genetic studies.
Care Homes are full of people with all sorts of conditions.
Considered using care homes?
Considered using Join Dementia Research(JDR)?
The CRN are keen to support recruitment to these studies.
ENRICH has access currently to 82 care homes and villages throughout the West Midlands for potential studies.

Interventions need to be based on evidence that is appropriate to the patient group. With statistics like these, it seems obvious and logical that older people should be involved in research that provides that evidence. To look at this another way, the 15 Local CRNs deliver research across 30 clinical specialties and of those, only two of those listed on the main CRN website – Children; and Reproductive Health and Childbirth – have little or nothing to do with older people.

Bolton slides

Current policy frameworks

In England the 3 million lives programme is set to extend telehealth and telecare to at least 3 million more people over five years from December 2011

David Cameron



Digital Health Modality Descriptions

Telecare – Devices in or away from the home that support independence, that can be used as stand alone or linked to a support service such as a call centre. Many of these devices related to social needs in relation to activities of daily living.

Telehealth – Devices used in or away from the home that enable health parameter measurements such as blood pressure, glucose, weight, wound management that supports decision making around personalised care planning and appropriate interventions.
Tele-health can be used as stand alone or linked to a response service

Mobile Apps & online self management – A growing area of support where people use a mobile device, device or smartphone to manage their own health and well being. This area is mainly aimed at self management and so is most appropriate for the lower levels of need, however increasing use of mobile apps is having an impact in supporting staff and carers in monitoring and care co-ordination

Video Consultations & Tele-Diagnostics – Again growing in popularity and relies on infrastructure being available to support, this includes webex, facetime and skype. This can be between patients and staff, groups of patients and staff and between staff & staff. All allow a non-face to face consultation that enables decisions to be made without the need for anyone to leave their desk or home.
Tele-diagnostics include near patient testing and this needs to be used in selected environments / cohorts. This could be patients / carers testing themselves or could be community staff doing testing in the patients home.

Packages personalised around needs

  • Dementia package
  • Falls package
  • Learning difficulties package
  • Safe and secure at home package
  • Winter chills package
  • Personalised to meet individual need

Legal clarity and Bottlenecks

Lack of legal clarity

  • Licensing, Accreditation
  • Registration of telemedicine services and professionals
  • Data protection, Liability, Reimbursement
  • Jurisdiction – e.g. cross border provision of telemedicine services also require
  • egal clarification with regard to privacy
  • Broadband access, standardization
  • Information Governance issues
  • Better Health Using Technology To Support Outcomes

Not a one size fits all

Start of an exciting time, sp. as they get widely available and cheaper

Think beyond traditional ways, be a part of the change

‘The opportunity is Huge and the Time is Now’

No straightforward ‘impact’ of technology
It works well for some people, at some stages of their lives, in some contexts
Not a one size fits all, nor a solution for all the problems in the NHS
Tele Care may not transform the health of its users but it may afford small relative benefits on psychological and health related Quality of Life outcomes

Birmingham WIN slides

NHS England
TECHNOLOGY ENABLED CARE SERVICES (TECS) 3 Million Lives

2014-17 National Delivery Plan

  • To support Integrated Care
  • Management of long term conditions and the enablement of seven day services
  • Work with NHS, Social Care, Housing and other key stakeholders to simplify procurement and commissioning processes

The Whole System Demonstrator (WSD) was the largest randomised control trial of telehealth and telecare in the world, involving 6191 patients and 238 GP practices across three sites in England. Findings showed a reduction in A&E visits, hospital admissions and mortality rates for diabetes, heart failure or COPD. More information is available from the Department of Health and King’s Fund websites.

Virtual Clinic: Primary care enhanced service to care home

  • 23% reduction in A/E attendances after intervention
  • 29% reduction in A/E admissions
  • No change in comparator care homes
  • Staff education, sustained benefit
  • Not perceived as threatening

Reducing the Incidence of Falls in Nursing Homes: Does it work?

>100 people supported with AT / 14 Nursing Homes.

Feedback from early adopters :

> 90% staff satisfaction

30-40% reduction in falls in 1 early adopter home

Relatives feel people cared for in a safer environment

Night staff happy that it removed need for hourly checks

Difficulties in introducing and sustaining technologies

Stakeholders need to take into consideration patients needs and care priorities:
Packages personalised around needs and benefits

  • Dementia package
  • Falls package
  • Learning difficulties package
  • Safe and secure at home package
  • Winter chills package
  • Personalised to meet individual need

Do we need to make it part of
Comprehensive Geriatric Assessment?

Assistive Technology: benefits

  • Reassurance and safety
  • Confidence and self management
  • Early safer discharges from hospitals
  • Timely medication
  • Improve dignity
  • Improve independence
  • Sense of well being
  • Reduced readmissions
  • Remote areas consultation
  • Monitor drug effects
  • Help in recreational, household activities or personal care
  • No travelling or parking chaos
  • Reduced loneliness
  • Reduced health care associated infections
  • Reduced waiting times
  • Lesser follow ups
  • Help with 7 day working

Patients want to be at home, not in hospitals
But then, what are the barriers?

Banglore Talk

Today’s Talk

  • Geriatric Medicine in England
  • Frailty- frailty identification tool, flag and register
  • Comprehensive Geriatric Assessment
  • Deconditioning awareness campaign

I am not here today to teach you medicine –my focus will be on Geriatric medicine in England. I will share with you some of the success stories and challenges we are facing in UK, Also a small discussion around what we are aiming for and how identifying and preventing with frailty is part of my routine work as I work in Frail Elderly Assessment Unit. I am Not qualified to comment on Indian Healthcare but
I am also interested to see how much resonance these issues have for you

There is still much to be done, but there has possibly never been a better time to be old and ill or disabled in the UK. A key component of this success is teamwork. A successful service for old people depends on the skills of many people, including nurses, therapists, social workers, and others.

Reported prevalence of disability clearly rises with age. We also need to understand how the severity of disability varies with age.

Electronic Frailty Index

  • John Young and Andy Clegg et al.
  • Martin Vernon (NCD)
  • Rockwood et al
  • Find
  • Recognize
  • Assess
  • Intervene
  • Long term

Preventing (managing) frailty

Identifying Frailty Is the Key:
Slow gait speed, the PRISMA questionnaire, the timed-up-and-go test, The Edmonton Frail Scale
Provide training in frailty recognition to all health and social care staff
Fit for Frailty (BGS)
Preventing Frailty
Primary prevention
Healthy lifestyle
Secondary prevention
Disease management
Tertiary prevention
Comprehensive geriatric assessment

Frail older people are different…Frailty is a distinctive health state related to the ageing process in which multiple body Non-specific presentations
Homeostatic failure
Multiple comorbidities → polypharmacy
Functional decline

Comprehensive Geriatric Assessment

Key components of geriatric medicine

  • Co-ordinated multidisciplinary assessment
  • Identification of medical, functional, social and psychological problems
  • The formation of a plan of care including appropriate rehabilitation
  • The ability to directly implement treatment recommodations made by the multidisciplinary team
  • Long term follow-up

Ellis G, Whitehead M, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: a systematic review (prototcol) (2006). The Cochrane Library 2008, Issue 3

What are we aiming for?

  • Outcomes
  • Quality
  • Safety
  • Efficiency
  • Evidence based
  • Patient experience
  • Sustainability

If one looks after the basics quality will follow

AT Bangalore 2014 final

National Issues
We have an Ageing population, limited resources

‘Care in Crisis’ report, Age UK 2014:

    • People aged over 85 years has increased by 30%
    • Day centre attendances has reduced by 49%
    • People needing care homes has increased by 20%
    • 15.4m people in UK have one or more long term condition

Dementia

    • 800k people are living with dementia
    • Number will double in 30 years

AT: clinical solutions

  • Face time /Skype
  • Tele-health monitors
  • Mobile phones apps
  • Sleep watch
  • Nan-cams
  • Virtual clinics
  • Incontinence detectors
  • Bed occupancy alarms
  • Life Line
  • Falls alarms
  • Smoke alarms
  • Carbon monoxide alarms

Legal clarity and Bottlenecks

Lack of legal clarity

  • Licensing, Accreditation
  • Registration of telemedicine services and professionals
  • Data protection, Liability, Reimbursement
  • Jurisdiction – e.g. cross border provision of telemedicine services also require legal clarification with regard to privacy
  • Broadband access, standardization
  • Information Governance issues

AT- benefits to carers reducing harm, supporting carers

  • Reassurance
  • Safety
  • Monitoring
  • Reduce travel
  • Comforting
  • Wanderers
  • Falls sensors
  • Bed wetting
  • LTC monitoring
  • Medical back up

Deconditioning Campaign

National Deconditioning
Awareness and Prevention Campaign:
Sit Up, Get Dressed, Keep Moving
Dr Amit Arora
ANP Amanda Futers
Cliff Hathaway, (Older Peoples’ Engagement Network)
HSJ awards presentation
4th October 2017

Frail Older People
Fastest growing cohort attending ED

In my early days a s a consultant I used to think about why ……
In time it became clearer when patients went into the deeper bed bases, they get deconditioned and then we took more time in rectifying the damage due to inactivity caused whilst in hospitals.
Why not address these issues on arrival….

 

The Ambition

  • Transformation of Older Peoples’ Services (TOPS).
  • Learnt from past experiences/service redesigns.
  • Safer, Faster, Better- NHS Improvement.
  • Evidence based – BGS, NICE, AFN.
  • Patient safety is paramount.
  • Cost-efficient.
  • Engagement and Involvement of staff and users.
  • Where there is a will, there is a way

 

Involvement

  • Staff Awards
  • Feedback forums
  • Weekly education sessions
  • Everyone counts
  • Open door policy and open honest communication
  • Staff development
  • Service user and staff development involved in every theme
  • Local and National bodies- from ward to board and beyond (NHSE comms, BGS comms, NHSI comms etc.)

It is a sad fact that awareness around deconditioning is poor and that MDT working to prevent this phenomenon is not always heeded.
By preventing or limiting Decon could be the difference between someone going home or into a care home
None of us wants a repeat of the Andrews story or the Mathews story because we could not place the right person at the right place at the right time. We want to get it right first time.

Bradwell tele MDT project led to 23% reduction on AE attendances and 29% reduced admissions- led to NHSE sponsored visit to VA and now piloting skype consultations in GP surgeries and care homes with CCG
CGA and medication optimization with geriatricians in primary care- published BMJ online Sept 2017
Working with local charity like Beat the Cold: reducing admissions to hospitals and promoting better health for older people in cold homes- raised money and encouraging social enterprise
Frailty school: WMAHSN patient safety collaborative has agreed to support this and they are known to promote adoption and dissemination of proven innovation.
Keele Frailty course- Sharing leadership and making champions of the future
Working with ECIP leading change for improvement in other health economies bringing in clinical perspective and acting as clinical change leader

Return on investment always a key indicator with success but quite simply we had none provided and worked within the existing workforce and financial envelope by reconfiguration of resources, improving morale, giving staff the ownership and leadership of change. They felt proud of the job they did, it made them feel better and things now happen automatically, they are no more dependent on me and I trust they will deliver.