Insights into open and closed access intelligence

Andrew Lambe, Knowledge and Intelligence Manager, Sustainable Improvement Team, NHS England

Andrew Lambe, Knowledge and Intelligence Manager, Sustainable Improvement Team, NHS England

A couple of weeks ago, my team – the Knowledge and Intelligence team at NHS IQ – published anniversary editions of the Improvement Science Alert (ISA).  In a bibliographical format and drawing from over 250 sources, each month the ISA pulls together the recently published research, reports and opinion pieces around the themes of leadership, large scale transformational change and improvement science.  Its intent is to curate the relevant intelligence so busy improvement or change management colleagues don’t have to (but if you’d like to improve your curation skills so you receive intelligence tailored to your needs, access our Intelligence Handbook for support).  So the ISA ‘bridges’ to the evidence that addresses, for example:

  • How do you effectively implement a sustainable change initiative?
  • What’s the emerging evidence on implementing an effective learning culture?
  • What is good practice in measurement for improvement?
  • What does good system leadership look like?

ISA subscribers are increasing – colleagues in health and care engaged in improvement or change can mean just about everyone!  Interestingly, 10% of subscribers are from overseas.

Producing the anniversary editions threw up two interesting features, both stemming from the high volume of evidence that is ‘out there.’  (And there is a lot out there – the anniversary editions contain approximately 2,000 items!).

Firstly, sifting and assessing content to pick out the relevant ‘stuff’ – curating – is both a skill and an art.  In the last year, we’ve improved our ability to efficiently assess content, evidenced by more compact and focused ISAs.  We take account of an item’s source, author and keywords, to determine its relative merit.  And like any skill, the more you do it purposefully, the better you get.  And maybe we are a bit geeky too – we enjoy the ‘art’ of it!

Secondly, and more significantly, looking over the anniversary editions it’s quite striking the balance between ‘open’ and ‘closed’ content (you can see these stats in more detail by checking out our infographic here).

Generalising, open access content is typically articles, opinion or thought pieces, or research that can be re-produced without restriction.  Closed content is typically research that cannot be reproduced without permission and is behind a paywall.  It is peer-reviewed, takes longer to publish and is generally felt to be of higher ‘academic’ quality.  Both can be valuable, it depends on your needs.  In recognition of this, the ISA curates both, identifying a sub-type of closed content accessible via Open Athens – that is, content purchased nationally and accessible to NHS staff via the OpenAthens portal.

What’s striking is not the high volume of open and closed content, but the low volume of OpenAthens content.  Which means for the most part, to access the detailed research on improvement, leadership and change, you need to pay.

We feel In the face of the system’s unprecedented challenges of financial constraint, wide service variation and increasing demand, it’s more important than ever that change initiatives are informed by the available intelligence.  If colleagues are able to access the relevant knowledge in the system, not only will they make more informed decisions and deliver better change, but innovations will be more successfully implemented and productivity will rise.

For our part, we will continue improving our curation skills to deliver an impactful ISA. Equally, the research, information and library community must engage with the change community to consider how it can increase access to the intelligence.  That could mean how can we better curate relevant content?  How can we improve colleagues skills to access what is readily available?  And how can we get more closed content into the hands of busy health and care professionals?  It’s vital that we do.

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From the coalface – Managing high blood pressure, a Manchester practice

I am a nurse in a practice in South Manchester with approximately 12,000 patients.  My role primarily focusses on patients with cardio vascular disease including primary prevention. The area has a mixed population but it is well known that Manchester has the lowest life expectancy for women in England and the second lowest for men.  People in Manchester have the lowest healthy life expectancy in England (i.e. they have more chronic ill health than their counterparts in the rest of the country).  Given this demographic and the high number of patients we are helping to manage their high blood pressure (BP), this is a huge undertaking.

With this in mind I spent today training a new cohort of healthcare assistants in ‘gold standard’ blood pressure taking, checking pulses and the basics behind the surgery protocol that is in place to aid the identification and diagnosis of hypertension along with guiding a management plan.  We strongly advocate the use of home BP machines or 24 hour blood pressure monitors for patients with borderline blood pressure readings as per the National Institute for Health Care Excellence hypertension guidelines, and we are able to do this without prior GP approval.  We need to support nurses and health care assistants to feel confident in using this approach to help patients monitor their own blood pressure.

A strong partnership between GPs, nurses and health care assistants at the practice often results in patients having had all relevant investigations performed so that hypertension is often identified prior to an initial GP assessment. This gives us several opportunities to discuss the patient’s lifestyle and provide advice on interventions to help with any lifestyle changes.

Before writing this I had reservations about my credibility in adding my personal opinion on blood pressure to CVD experts in this field.  However I am passionate about my work and believe that to alter the current situation we must address issues around blood pressure at the coalface.

I do not believe we are in any way unique with this approach but I feel the value of using the full practice workforce and having appropriate training improves the patient experience and makes us more able to fully identify an ever-increasing population of people with hypertension.

Alison Morgan, Practice Nurse, Northenden Group Practice, South Manchester

The use of Twitter: A personal perspective

Polly Pascoe, Knowledge and Intelligence Coordinator

Polly Pascoe, Knowledge and Intelligence Coordinator (@pollynhs)

Having developed the Better Knowledge, Better Care Twitter Challenge that was piloted with over 200 health and care staff in September 2015 and released to all in October 2015, Polly Pascoe, Knowledge and Intelligence Coordinator shares her top five reasons for wanting to open up the world of social media to more staff in health and care.

As an advocate for the use of social media, I often find myself in conversations where someone will say, “but don’t people just tell you what they’re having for lunch?”. I’m not blind to the vast amount of frivolous information that can flood social media sites. However, when used correctly – as a place to connect, test ideas and stay up to date – social media’s benefits strongly outweigh the negatives.  In this blog, I outline the benefits to me; these are the reasons why I encourage everyone to get involved!

  • It means I’m instantly connected – not only to a wealth of expertise in the system, but to the issues that really matter to staff, patients and the public. Not only does this widen your frame of reference, enabling you to make the links between your work and the work of others, but it also challenges the mentality of silos by supporting system wide thinking, enabling you to access, and empathise with, different perspectives. Most importantly, I’ve found, it supports connections across traditional boundaries, supporting collaboration and partnerships.
  • The use of social media allows me to bounce ideas off others – for validation and With the development of dedicated communities on Twitter, instead of sense-making flat content in isolation, social media users are now connecting to seek opinions, examples of content use and usefulness. This type of activity has been invaluable to me. Both the fleeting and long-standing connections I have made on Twitter have provided input and feedback that have enabled me to produce much more informed, relevant – ‘three dimensional’ – outputs.
  • I’m able to gain a wider sense of comradery. Trust me, for every trolling story splashed across traditional media’s front page, there are hundreds of friendly, supportive people willing to make connections, particularly in health and care. At times, working in health and care can feel scary, lonely and overwhelming. Not a day goes by in which the NHS isn’t being attacked from one of many available angles, and we seem to exist in a state of constant crisis. Connecting with others in health and care via social media can provide additional support to face daily challenges, do my job well, and feel confident my work can make a difference and deliver better care.
  • I’m better informedin real time. As social media grows, so does its power. The rise of social media has ensured that if you wait until the 6 o’clock news, you’re likely already behind the news cycle, and missing out on a wide range of perspectives. Those on the ground – every day NHS staff – are now able to report in real time, what is actually happening, without media or political bias. Their output is often raw and unedited, and this can all be shared with colleagues at the click of a button. Causes can be shared and social movements are born – take #hellomynameis or #imatworkjeremy as two examples!
  • I’m able to constantly learn. While I’ve put this last, I feel this is the most important reason those who work in health and care should use Twitter. A great deal of my learning originates from participating in Tweetchats. They are an excellent way to connect with others that are working in the same field, or tackling similar issues. They have enabled me to gain knowledge from people working right here in the NHS, but also in different health systems across the world. These insights can support learning to inform your work before, during and after projects, tasks or initiatives. This has helped to me look at a number of tasks, barriers and concerns with “fresh eyes”, once being exposed to differing opinions, perspectives and experiences.

Now, don’t get me wrong. I don’t wear rose-tinted glasses when approaching social media. Behind every scare story, there is an element of truth and I would never encourage anyone to embark on a social media journey with their eyes shut, however my positive experiences of social media have outshone the negative ones.

I find the main hurdle in encouraging others to utilise social media is not convincing them to take the plunge, create an account and start tweeting, but the moment a person realises how expansive and busy Twitter can be. This is why I was keen to incorporate functions such as searching, filtering and lists in the Twitter Challenge. It is these tools that allow users of social media to make it work for them and I highly recommend that anyone interested in better using Twitter taps into these skills.

To access the Twitter Challenge, please click here.

You can follow Polly on Twitter: @pollynhs

Facilitated workshop in Castle Point and Rochford

Last month, as part of my new role of Delivery Support Manager for NHS Improving Quality, I co-facilitated a Long Term Conditions (LTC) Framework workshop at Castle Point and Rochford CCG.

In a nutshell, the workshop brings together stakeholders from across the health and care economy, to look at different aspects of person centred care for people with long term conditions. Each person attending provides elements of care and will see things from a different perspective – so it’s really important to get everyone’s opinion. From there, we can work together to wrap services around patients, to truly work towards person centred coordinated care.

Kevin McKenny, Director of Transformation, introduced the day, and brought us up to date with the current state of play around person centred care at Castle Point and Rochford. He then informed us how they compared to the rest of England. Some of the challenges included keeping people out of hospital and enable them to stay at home, and to provide services closer to home.

The room was split up into smaller groups, who were to look at a different element of the LTC framework. These elements were:

• Health and care professionals committed to partnership working
• Commissioning
• Engaged, informed individuals and carers
• Organisational and clinical processes.

Each group rated a series of questions on the current position, with 4 being high and 1 being low. Some really interesting discussions emerged around the questions, which were captured by the facilitators. The purpose of this was to get a good idea on what was working well in each area, and pinpoint potential areas for improvement for the future.

The results showed that some excellent procedures were in place around commissioning, and areas to maybe look more closely at included partnership working and person centred care. Again, this produced some lively discussion in the room.
I took the results and comments away, and compiled a report to capture all the outcomes of the day. This went back to Castle Point and Rochford CCG. From here, our LTC Improvement Programme team can offer bespoke support to help them achieve their goals.

I’m quite new to this role, but so far it’s very exciting. To think that your team can actually make a difference to the lives of our patients is really fulfilling. I think I’m going to like it here!

Lynnette Leman, Delivery Support Manager, Long Term Conditions

Hypertension, a major risk of premature mortality

The National Institute for Health and Care Excellence (NICE) guidelines makes the point that hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.

Blood pressure is normally distributed in the population and there is no natural cut-off point above which ‘hypertension’ definitively exists and below which it does not.

The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke.

Routine periodic screening for high blood pressure is now commonplace in the UK, but still many cases go undetected, and many are undertreated.

The diagnosis, treatment and follow-up of people with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and is expensive.

In the recent Systolic Blood Pressure Intervention Trial (SPRINT), a large study funded by the National Institutes of Health (which was stopped early).  It was found that a more intensive strategy of lowering blood pressure – one that aims to achieve a systolic blood pressure target of 120 mm Hg – reduces the risk of death and cardiovascular events when compared with a strategy that lowers systolic blood pressure to conventional targets. National Institutes of Health, Landmark study shows intensive blood pressure management may save lives  (press release, September 11 2015).

This research suggests that current targets may be too high

Discrepancy now exists between published targets for this population

Diabetes:

Hypertension:

People with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg if aged under 80 years, or below 150/90 mmHg if aged 80 years and over.

My policy is to discuss and agree with the patient an agreed target, and if possible encourage them to self- monitor, aiming for a systolic pressure of less than 130 unless there is a reason not to do so.

Professor Mike Kirby FRCP
University of Hertfordshire and The Prostate Centre, London

Person-centred Outcomes: understanding what really matters

 ‘Personalised care will only happen when statutory services recognise that patients’ own life goals are what really count’.

National Voices

The above statement appears in the NHS England 5 Year Forward View and we are currently working on developing a programme to ensure Person Centred Outcomes are a key driver in developing services

A number of Pathfinder sites were commissioned to explore and develop Patient Centred Outcome Measures appropriate in the context of healthcare for young people.  I had the pleasure of being part of the event on 17 Sept 2015 when these sites were brought together in a Learning Exchange workshop. We had a fantastic day of discussion, learning and sharing.

Part of the day gave participants an opportunity to come up with a number of topics for further exploration.  The top six themes were then discussed and developed during a World Cafe session, with lots of lively discussions and sharing of views.

The full list of all the themes raised were:

  • The power relationship between clinicians and patients
  • What is the relationship of
    • PCOMs (Person Centred Outcome Measures),
    • PCO (Person Centred Outcomes),
    • PROMs (Patient Reported Outcome Measures),
    • PREMs (Patient Reported Experience Measures),
    • PDOMs (Patient Defined Outcome Measures),
    • PGOMs (Patient Generated Outcome Measures) et al
  • Technology – a broad heading that covered aspects of how to use technology, whether this could impact on social divide etc.
  • How to ensure outcome measures are robust / have academic validation?
  • Engaging with patients/carers/citizens
  • How could PCOMs be used by Commissioners?
  • How do we get clinicians to “buy-in” to this work?
  • Can PCOMs be developed without clinicians?
  • What does a PCOM look like – is it specialist or generic?
  • Outcome measures for Wellbeing
  • Aspects of diversity and equality

The NHS England 2014-16 business plan ‘Putting Patients First’, makes a commitment to focus on the needs of people in every decision by making it possible for patients to easily and regularly tell us how they feel about their treatment, and demonstrate how we are using this feedback to make improvements.

PCOMs are ‘an opportunity break new ground …. which puts patients truly at the centre and gives them a voice’.  This work is ongoing and we are developing a community of interest to continue the work and develop and explore aspects of Person Centred Outcomes.  We would love to hear your views, so please join us on twitter using #personcentredoutcomes #PCOMs

We will also be holding a tweetchat on 7 Oct 2015 at 20.30 (8.30pm) to explore:

  • What are the outcomes that are really important to people (patients, carers and citizens) and how health and care (and other sectors) contribute to these
  • Initiatives that are underway that focus on person-centred outcomes and how we can learn from and work with these sites / organisations to appreciate what works (and doesn’t).
  • How we can best work with patients, carer and professionals to co-create a movement to prioritise person-centred outcomes and consider how this might be modelled to support commissioning and service delivery
  • How we can share ideas, developments, learning and opportunities across the health and care system and beyond?

Please join us using #wecomsers.

Prevent and diagnose hypertension as early as possible, because decades later it matters

Dr Nigel Rowell, GP, Endeavour Practice and GPSI in Heart Function, James Cook University Hospital, Middlesbrough

Dr Nigel Rowell, GP, Endeavour Practice and GPSI in Heart Function, James Cook University Hospital, Middlesbrough

One of my patients, Elsie, is 85 years old, overweight, diabetic, and has had hypertension for 44 years. She has oedema, or swelling, with fluid retention in her body and she gets breathless walking down the corridor.

Among her other symptoms, the pressure of blood within her veins is elevated. Her heart echo shows ’normal LV function,’ meaning that the left ventricle (the heart chamber that pumps blood around the body) is functioning OK, but the left atrium – one of the four chambers of the heart is very dilated and filling pressures are elevated.  Essentially, she has heart failure, the type in which the heart has difficulty filling with blood.

Elsie takes ‘water pills’, which work by reducing the amount of fluid in her body, they promote the
loss of salt and water from the kidneys and therefore healthy blood pressure.  Her blood pressure control may have been very good over the years she has had her condition, or it could also have been badly controlled.

Every week I see patients like Elsie come to the clinic with signs and symptoms of possible heart failure and raised B-type naturetic peptide (BNP), which is a possible indicator of heart failure. I send them for a heart echo test which uses ultrasound waves to look at the structures and functioning of the heart.

Having seen the impact it has on patients like Elsie, I’ve become more aggressive in tackling hypertension earlier. I try to help my patients maintain a healthy blood pressure by advising on simple interventions including regular exercise, eating less salt and reducing their alcohol intake.

It’s really important that we prevent and diagnose hypertension as early as possible, because decades later it’s much more difficult to pick up the pieces.

Dr Nigel Rowell, GP, Endeavour Practice and GPSI in Heart Function, James Cook University Hospital, Middlesbrough.