Lessons in Value from Value Improvement Fund Project Leads

The Realistic Medicine Value Improvement Fund provides funding for improvement projects within Health Boards, that are taking an innovative approach to improving patient care and outcomes. Three Project Leads from our 2018-2020 round of funding have kindly shared their “Lessons in Value” with us.

Providing Virtual Primary Care Pharmacists to all NHS Western Isles Practices
The Issue The 9 GP practice locations in NHSWI are spread across 3 island groups which prevents simultaneous daily access to the new Primary Care Pharmacists due to travel times/ferries etc.
The Solution Develop a remote solution that will allow simultaneous access to all 9 practice sites servers to allow virtual attendance. Upon completion open this up to other staff groups who will benefit also.
The Results Each practice was fitted with a ‘Terminal’ server that allows up to 100 remote log-ins at any one time giving capacity to expand the number of client groups who can access GP systems under strict protocol in order to protect confidentiality and provide an appropriate audit trail.
Next Steps At present there are a limited number of staff groups accessing the terminal server (Pharmacy and Community Nursing). Capacity within IT has hindered roll out wider due to the constraints of COVID on the department. More learning will be required around use to see if this system is application to a National solution for remote access.
Do Differently The initial estimate of cost was inadequate, and we required support from the Primary Care Improvement Fund to allow completion of installation. Better planning at the start would have been preferable.
Find out More Dr Dave Rigby, RM Lead NHSWI (David.rigby@nhs.scot)


Psychology Adding Value Epilepsy Screening (PAVES)

The Issue Children and young people with epilepsy are significantly more likely to develop mental health problems than their same aged peers or, indeed, children and young people with other types of chronic or long-term illnesses. Epilepsy clinic appointments would, understandably, focus on physical health concerns/ managing seizures. If mental health difficulties were identified in epilepsy clinics, young people would usually be referred to Child and Adolescent Mental Health Services (CAMHS). Unfortunately CAMHS waiting times are long. Also generic mental health teams may not be confident dealing with children who have epilepsy.
The Solution Psychology Adding Value Epilepsy Screening (PAVES ) is an innovative, mental health screening method, teamed with a stepped care intervention pathway. The screening identifies potential mental health difficulties during routine, epilepsy clinic attendance. It uses a traffic light metaphor to guide medical clinicians’ understanding and further investigation. The traffic lights also map to appropriate, stepped, early intervention options. Interventions include signposting to ratified third sector organisations, self-help materials, parent workshops and a six-week psychosocial group for adolescents.  With Realistic Medicine funding, we have been able to move from paper questionnaires, requiring the presence of a psychologist in epilepsy clinics to administer and score, to a custom website that automatically generates a report for clinicians to use in appointments.  We have also been able to further develop the interventions to start to include communication with schools re the young person’s difficulties.
The Results PAVES has not only highlighted the unmet need for children and young people with epilepsy but also developed a stepped-care early intervention model that has proven to reduce CAMHS referral rate by 62% and increase engagement by this population with third sector services. Over 600 screenings have been completed, with many families being screened multiple times, 123 families have received timely psychological support that they would have not otherwise have received. The average time to treatment  was 11 weeks.
Next Steps The electronic screening tool will be tested, and updated interventions will be piloted within NHS Lothian paediatric neurology clinics. There has been interest from other health boards regarding developing a local PAVES service. The PAVES model could also be applied to other healthcare populations, so future iterations of PAVES may screen children and young people with other chronic illnesses.
Do Differently Despite expressed parental interest in workshop and group interventions, this was not reflected in uptake. QI projects revealed logistics appeared to be one of the main barriers to access. Some interventions are suitable for remote delivery, this will be explored/ developed and is hoped to improve accessibility. Website generated reports are expected to improve the efficiency of the screening process, families can also complete the questionnaires at home before their appointment.
Find out More Kirsten.Verity@nhslothian.scot.nhs.uk


Improving Patient Engagement and Activation

The Issue

In Scotland 40% of the population live with one or more long term conditions. On average a person living with diabetes spends 3 hours a year with a healthcare professional and for the remaining 8,757 hours they manage their diabetes themselves.

There is an association between increased patient activation levels and reduced use of unscheduled care in primary and secondary care settings.

We wanted to better develop our GP Practice systems to support people to understand and manage their conditions and to live active and healthy lives. Our aim was to increase patient engagement and activation and to measure increased attendance at long term condition reviews in the practice.

The Solution We involved key partners from the outset including Tranent Medical Practice Patient Participation Group, Lothian House of Care Collaboration, East Lothian Local Intelligence Support Team, Alison Manson from Group Consultations, Rob Lawson from British Society of Lifestyle Medicine, Fa’side Area Partnership. Our whole practice team were involved.

One of our first steps was to create a driver diagram of our ideas for change. Staff training needs were identified, and regular planning meetings were established. Baseline data was extracted from our practice systems.

Gordon Amoh who was undertaking a Masters in Public Health at the University of Edinburgh carried out a mixed systematic review into patterns of attendance in Primary Care for patients living with chronic disease.

We developed a range of methods of engaging with patients.  A Group Consultations programme was introduced to complement our pre-existing House of Care approach and we started using the Patient Activation Measure (PAM). Through the Primary Care Improvement Plan work led by East Lothian Health and Social Care Partnership a new network of Community Links Workers has been introduced.

The Results Over the course of this project, we achieved our aim of increasing patient attendance at annual chronic disease reviews – this has risen from 45% in September 2018 to 74% in September 2020.

Our Health Care Assistants now record a person’s Patient Activation Measure which is used during Care and Support Planning conversations.   Preliminary analysis has shown an increase in mean PAM scores within the two lowest activation levels.

A Group Consultations programme was launched in the practice in Spring 2019, and we had excellent patient and staff feedback.  Unfortunately, this programme had to be paused due to the Covid 19 pandemic, but we hope to re-introduce face to face Group Consultations when circumstances allow.

This work brought the Practice team together and created a joint purpose. We have developed an improved model of person-centred care enabling better supported and engaged patients to manage their own health. We have forged links with the community, with our patient population, external organisations and local professionals.

Next Steps It would be good to see more national resource to improve access in all care settings to models which support person centred care including Scotland’s House of Care and Group Consultations.

The Patient Activation Measure (PAM) Survey via Insignia Health is not yet widely used in primary care in Scotland.    This assesses a person’s underlying knowledge, skills and confidence integral to managing his or her own health and healthcare.   Support can be tailored to a person’s level of activation and the impact of an intervention can be measured by administering the PAM survey at regular intervals.   The wider roll out of this measure would help healthcare providers to better support their patient population.

Do Differently The General Practice environment is an ideal setting for carrying out an improvement project such as this.  We realised the importance of involving all key people and patients from the outset and building a shared vision.

The involvement of our Practice Manager Alisson Stewart was key to the success of this work and we should have established how to create protected time for her from the outset.

Implementing change is always messier than one would like it to be, but we stand by the words of Henry Ford “If you always do what you’ve always done, you’ll always get what you’ve always got”.

Find out More Jo Smail, GP Partner, Tranent Medical Practice  joanna.smail@nhslothian.scot.nhs.uk

Alisson Stewart, Practice Manager, Tranent Medical Practice

RM mailbox

Leonie Hunter, Public Health Researcher, NHS Lothian

RM mailbox

Scotland’s House of Care


Group Consultations



Insignia Health – Patient Activation Measure



Enabling patient preferences in the treatment of osteoporosis
The Issue The issue was to figure out how best to communicate benefits of osteoporosis treatment to facilitate shared decision making. A specific aim of the project was to determine if presenting benefits of treatment for osteoporosis in absolute terms (expected number of fractures prevented by treatment individualised to the patient) as opposed to a relative risk reduction (for example, the fracture risk would reduce by 25%), and asses if this impacted on the patients’ likelihood of accepting treatment
The Solution We approached patients who were being offered treatment as part of normal clinical practice. We first asked them how likely they would be to accept treatment on a 5-point scale (very likely to very unlikely) based on the relative risk reduction (RRR). The phrasing was “If I told you that this treatment would reduce your risk of fracture by 25% over the next 5 years how likely would you be to take it?”. The answer was recorded, and the same patient was next presented with the absolute risk reduction and the question repeated. “If I told you that, based on your individual profile, that without treatment you would have a 8% risk of fracture over the next 5 years and that with the treatment I mentioned a 6% risk  of risk of fracture (in other words having treatment would mean a 2% chance of preventing a fracture that would have otherwise occurred), how likely would you be to take it?”. The answer was recorded again and we also noted whether changing presentation from RRR to ARR altered the patient’s decision about accepting treatment.
The Results Patients were significantly less likely to accept treatment when presented with ARR compared to RRR (mean code on five-point scale with ARR 2.673 (95% CI 2.452 to 2.894) vs. RRR 2.019 (95% CI 1.895 to 2.143) p=<0.001). Participants who elected to decline treatment when presented with ARR had a significantly lower 5-year risk of fracture than those who did not (9.33%% (95% CI 8.18 to 10.49) vs. 12.68 (95% CI 11.63 to 13.73%), p=<0.001).  In keeping with this there was a negative correlation between absolute fracture risk and the likelihood of accepting treatment (Spearman r = -0.32, 95% CI -0.46 to -0.17, p=<0.001). All participants found it helpful for the benefits of treatment to be presented in terms of absolute benefit.
Next Steps Based on the results of the study we have built a smartphone App and also set up a website where clinicians (or patients) can calculate absolute benefits on an individual basis. The App is called the Osteoporosis Risk Benefit Calculator (ORB) and can be downloaded from the Apple store and Google Play free or charge. It also can be accessed through the University of Edinburgh’s website https://www.cgem.ed.ac.uk/research/rheumatological/ORBCalculator/

The calculator has been publicised locally in NHS Lothian. We have written a paper describing the results of the survey and mentioning the calculator and this is due to be submitted to a medical journal in the near future

Do Differently We would have like to survey a larger number of patients but the project was negatively affected by Covid since for many months we were able to see very few patients face-to face. Since we had started the survey on the basis of face to face consultations we did not think it would be right to gather other responses by remote consultation
Find out More stuart.ralston@ed.ac.uk