NHS leaders offered free access to resource to help address air pollution across England

By Gabriel Blaazer

A new resource is to be offered to every NHS Integrated Care System (ICS) to support their development as ‘Clean Air Champions’.

Data confirms that everyone in the UK is exposed to the threat of air pollution, with more than 97 per cent of postcodes in breach of at least one World Health Organisation (WHO) limit for toxic pollutants.¹

This includes vulnerable environments such as healthcare settings, including the one million people who attend GP appointments every day in the UK and the approximately 16 million people who travel to major A&E departments in England every year.²

In the UK, 36,000 premature deaths per year are caused by air pollution, one in five of all premature deaths, and tackling air pollution will be a vital strand of integrated care systems’ (ICS) efforts to address and reduce environmental determinants of poor health.^3,4

Launched at the NHS ConfedExpo, the ICS Clean Air Framework is a practical tool that empowers healthcare leaders to take action on cleaner air and has been developed to support every ICS in England to become a ‘Clean Air Champion’. Joining forces to drive the initiative forward are the environmental change charity Global Action Plan, Newcastle Hospitals and Boehringer Ingelheim. The Framework is freely available to all 42 ICSs nationally to aid the development of an action plan to improve air quality around all healthcare access points in England.

The Framework links to the mandated requirements of Green Plans, the NHS Standard Contract, the Delivering a greener NHS report and the UN’s Sustainable Development Goals. The tool supports the newly established ICS healthcare leaders to incorporate air quality improvement measures around hospitals and health hubs as part of their broader commitment to address environmental challenges.

The Framework launch coincides with Clean Air Day on June 16th, which this year reveals how air pollution impacts almost every organ in the body. Professor Sir Stephen Holgate, Special Advisor on air quality to the Royal College of Physicians and UKRI’s Clean Air Champion, explains “Air pollution is an invisible killer and plays a role in many of today’s major health challenges. The ICS Clean Air Framework is a ground-breaking resource to support the NHS in implementing air quality improvement initiatives that will ultimately protect the health, wellbeing and economic sustainability of today’s communities and future generations.”

The Framework is being pioneered by Newcastle Hospitals, who are first to drive the development of an action plan in their region. James Dixon, Associate Director of Sustainability at Newcastle Hospitals, explains “The NHS has an opportunity to lead by example and set the benchmark for clean air and safe workplaces. Through the creation of an action plan guided by the ICS Clean Air Framework, here at Newcastle Hospitals, we are already making progress and seeing direct benefits to our communities.”

Larissa Lockwood, Director of Clean Air, Global Action Plan, explains how the ICS Clean Air Framework can support healthcare leaders in taking action: “Air pollution kills seven million people globally each year, which is more than malaria, HIV/AIDS and obesity combined.^5,6,7 It is a public health crisis that needs immediate action from the health sector. It also cannot be right that our most vulnerable are exposed to it in our places of care – is it fair that a baby must take its first breath in a polluted environment? By developing this framework and working at the Integrated Care System level, we have the opportunity to tackle some of those area-wide issues, empowering healthcare leaders to pursue action on air pollution to secure a healthier future for their region.”

Uday Bose, Managing Director at Boehringer Ingelheim UK & Ireland, explains the impact of the project both now and for future generations, “People who are already suffering with poor health are most at risk of the detrimental effects of air pollution, so this initiative plays an important role in addressing health inequalities. Our commitment to transforming lives goes beyond the provision of medicines, as this initiative clearly illustrates. It also demonstrates the power of partnerships and delivers a real opportunity to create a healthier future for families, the NHS and the planet.”

The ICS Clean Air Framework aims to provide healthcare leaders with a platform to drive positive change and support the implementation of initiatives to improve air quality, without adding to the administrative burden. The NHS net zero targets are as ambitious as possible and are supported by the need for immediate action and commitment to continuous monitoring, evaluation and innovation. It is therefore critical that key stakeholders and local authorities work collectively to turn ambition into action.

More information regarding the Integrated Care for Cleaner Air initiative and the ICS Clean Air Framework is available from today at www.actionforcleanair.org.uk/health/ics-framework.

¹ addresspollution.org. 2022. Providing the public with the most accurate air pollution data available. [online] Available at: <https://www.addresspollution.org/> [Accessed 26 May 2022].

_{2</sup)The Kings Fund. 2019. Key facts and figures about the NHS. [online] Available at: <https://www.kingsfund.org.uk/audio-video/key-facts-figures-nhs#what-does-the-average-day-in-the-nhs-look-like> [Accessed 12 May 2022].}

³GOV.UK. 2019. Public Health England publishes air pollution evidence review. [online] Available at: <https://www.gov.uk/government/news/public-health-england-publishes-air-pollution-evidence-review#:~:text=Air%20pollution%20is%20the%20biggest,lung%20cancer%2C%20and%20exacerbates%20asthma.> [Accessed 26 May 2022].

⁴Who.int. n.d. Air pollution. [online] Available at: <https://www.who.int/health-topics/air-pollution#tab=tab_2> [Accessed 25 May 2022].

⁵Who.int. 2022. Fact sheet about malaria. [online] Available at: <https://www.who.int/news-room/fact-sheets/detail/malaria> [Accessed 25 May 2022].

⁶Who.int. 2021. Obesity. [online] Available at: <https://www.who.int/news-room/facts-in-pictures/detail/6-facts-on-obesity> [Accessed 25 May 2022].

⁷Who.int. 2021. HIV/AIDS. [online] Available at: <https://www.who.int/data/gho/data/themes/hiv-aids> [Accessed 25 May 2022].

Driving innovation: a case study using a simple evaluation tool

By Simon Dodds; Alan Macdonald; Fay Wilson; Terry Young

Professor Terry Young, Dr Fay Wilson, Alan MacDonald and Mr Simon Dodds describe for ICJ an evaluation tool that was used to support the development of a rapid access clinic in an existing health centre in Erdington.

Project management is simple: look after people, plan well, monitor effectively and intervene as needed. However, people, planning, monitoring and intervening are complicated, so good project managers mix in experience and tools they pick up over a lifetime.

Figure 1: Map of the project design to extend the capacity of an existing health centre (in blue) with rapid access care (click to enlarge).

Case study

The team from Badger (Birmingham and District GP Emergency Room) Group used a 6M Design® approach with three pre-implementation stages (map, measure, model – a prototype based on a simulation), and three phases of implementation (modify, monitor, maintain).

Once a working upgrade of the facility was in place, two reviews were conducted in January 2022, using a simulated set of patients (based on a typical case-mix) and putting this stream of virtual patients through the service to see how it was responding.

Across the two days, the workforce involved in the review included: heath care support workers; receptionists; and clinicians – around 8 people in all. A 4N framework was used for collecting and analysing the feedback.

To understand 4N, figure 2 (used with permission from SaaSoft) shows a creative journey into new territory – leaving behind what is already there and implementing what is desired. Specifically, 4N feedback uses the dimensions of time (present/future) and emotions (positive/negative) to create a chart which is split into quadrants, defined as:

Nuggets (relates to the present and the things about which the stakeholders have positive feelings)
Niggles (relating to the present but capturing features where the feelings are negative)
Nice Ifs (similarly, relating to the future and positive feelings)
No Nos (finally, relating to the future and negative feelings)

Niggles identify what hasn’t gone to plan to date. To grasp this feedback, an improvement tool called a Niggle-o-gram® was used, based on the familiar failure modes and effects analysis (FMEA). The list of niggles was graded based on three scores:

Incidence: how often does this niggle occur (never, 0 to 9, always)?
Impact: what is its effect (no impact, 0 to major impact, 9)
Influence: how much can we do (nothing, 0 to 9, change it completely)

Using this scheme, niggles that nobody could do anything about were assigned low priority. In this case, the top 5 niggles came out as shown in table 1.

Figure 2: Bridging the creative gap, while taking what works well with you. — Figure 2: Bridging the creative gap, while taking what works well with you (click to enlarge).

A more intuitive way of grasping the feedback is to produce a word cloud, weighting the size of words in each quadrant by their priority in the rankings.

Figure 3: Word cloud of key issues raised in all four quadrants of the 4N feedback process. — Figure 3: Word cloud of key issues raised in all four quadrants of the 4N feedback process (click to enlarge).

Using the findings to address key issues

One tension to emerge was around staffing, since booking patients in at reception takes less time than appointments with the healthcare worker or clinical staff. With everything running absolutely smoothly, a single receptionist might have coped, but interruptions and sporadic other tasks meant that having two receptionists was important for safety.

In turn, this created a tension between having a workload that would utilise two receptionists, and the capacity for healthcare and clinical appointments. In the end, a system designed for 10-minute appointments was fine tuned to 12-minute appointments to get the best combination of reception and other staff usage.

A second issue was Covid safety in a waiting room that could only accommodate 4 patients. Again, from modelling and other analysis, this was too few to manage the overall capacity planned for the centre, so a new process was developed whereby patients arriving in their cars would use their cars as their waiting room (and the receptionist would contact them to walk straight to their appointment), freeing up the waiting room for the exclusive use of those who arrived in other ways.

In the end…

Using a 4N framework as part of the management of an expansion of a health centre, an existing service was quickly upgraded for rapid access Covid patients, and tested robustly for capacity, throughput and safety.

Tools such as this are critical to the success of any agile or pop-up service. The good news is that the 4N approach is easy to understand, straightforward to implement and bridges the worlds of experience and clinical quality.

About the authors

Mr Simon Dodds, MA, MS, FRCS

Mr Simon Dodds is a general surgeon at University Hospitals Birmingham NHS Foundation Trust. He studied medicine and digital systems engineering before following a career in general and then vascular surgery. In 1999, he was appointed as a consultant surgeon at Good Hope Hospital in North Birmingham and applied his skills as an engineer and a clinician in the redesign of the vascular surgery clinic and the leg ulcer service.

In 2004, the project was awarded a national innovation award for service improvement. This experience led to the design, development, and delivery of the Health Care Systems Engineering (HCSE) programme.

Alan MacDonald, BSc

Alan studied at Nottingham Trent University and has a BSc (Hons) in Biomedical Science.

He worked for the Badger Group as an Out-Of-Hours primary care team leader and later became a data analyst. Since the start of the COVID-19 pandemic in March 2020, he became directly involved with the development of a multi-lane drive through Covid Referral Centre at the NEC.

He has been instrumental in the deployment of other temporary drive through clinics across Birmingham. He has also been actively part of the original team who were successful in applying this concept to the first purpose-built drive through clinic in the UK

He is frequently involved in new & novel projects within the out of hours primary care sector and is currently studying Health Care Systems Engineering.

Dr Fay Wilson, MBChB, FRCGP

Fay trained in Birmingham and has practiced there as a GP there since 1985. Her extensive national and local portfolio includes: NHS HA Non Exec, GMC fitness to practise chair, and associate postgraduate dean at Health Education West Midlands. She has served on the council of the BMA and other bodies. Fay brings people together to develop new models of care, a notable success being the Birmingham Multifund co-operative, a pioneering nurse-led walk-in centre and a prototype GP provider-at-scale ahead of its time in the mid-1990s.

Dr Wilson is medical director and co-founder of Badger, a GP social enterprise since 1996 providing out of hours and urgent primary care. COVID-19 introduced her to systems engineering, new people and new ways of thinking. Her ambition for the last decade has been to slow down.

Prof Terry Young, BSc, PhD, FBCS

After 16½ years as a research Engineer, Divisional Manager and Business Development Director, Terry became a professor at Brunel University London for 17 years.

He has a BSc in Electronic Engineering and Physics, a PhD in laser spectroscopy both from the University of Birmingham, UK.

His research has been in health technology, health services, and information systems. He has taught information system management, project management and e-Business.

His awards include the Operational Research Society’s Griffiths Medal, 2021, for analysing the return simulation methods offer when used to improve healthcare services.

Prof Young set up Datchet Consulting in 2018 to support innovation on the borders of academia, health and industry, of which the project reported here is an excellent example.

Getting to zero: why it can’t work

By Professor Terry Young, BSc, PhD, FBCS

Jeremy Hunt’s, Zero, Eliminating unnecessary deaths in a post-pandemic NHS, is honest and possessed of insight but there are still problems, not least with the title: cutting anything to zero is usually impossible at best and inadvisable at worst. It seems that Jeremy senses the pitfalls of zero, but not everyone calling for zero – including the patient safety community – grasps its dangerous underside.

In an example he cites, the airline industry got to zero in 2017, the first year without a passenger jet crashing anywhere, but things got worse again, not least with the 737 Max crashes. Absolute zero in temperature is absolutely impossible – you can get ever closer but never reach it.

If physicists can’t get there and airlines can’t sustain it, what chance is there for the rest of us? Here are four reasons why zero is a poor target: each step closer to zero is more expensive that the last; we can’t yet measure unnecessary deaths very well; the rhetoric of zero tolerance may impede good progress year-on-year; and zero is impossible (except by accident now and again).

Is ‘zero’ possible?

So, taking these in reverse order: life is risky, and sickness especially so. If it is not possible to eliminate the wasteful death of healthy people (and it is not), we have no hope with those who are already ill. This admission is not a council of despair: zero is unobtainable, but fewer is always within reach.

Second, while zero tolerance sounds good, it is better to commit to steady improvement (as Jeremy recognises with his airline examples). Big gestures cannot outpace systematic improvement. For instance, if we could save just 1 unnecessary death in 5 next year and maintain that progress, more than 4 out of 5 of today’s unnecessary deaths would be eliminated by the end of this decade. Yet the grand gesture of an impossible 80 per cent reduction in one hit may stop us making steady improvements that are within our grasp. Slow and steady may be poor oratory but it’s great practice.

You can’t zero what you can’t measure.

Third, you can’t zero what you can’t measure. A philosophical problem is that yesterday’s inevitable death may be today’s avoidable death but the more practical issue is that we can’t measure excess deaths as they happen. In a plane crash, the fatalities are evident immediately but it’s different in health where it usually takes time (a coroner’s verdict, for instance) to assess what happened.

During the pandemic, the NHS estimates of Covid deaths differed from those based on excess deaths, and the difference affected the whole narrative. Without a reliable, agreed, real-time measure, we cannot even begin.

Finally, each percentage safety improvement is more expensive than the last. My present car, like my first, is 1300cc but there the comparison ends. This one cost just over 10 times what my first car cost, half of which is accounted for by a fivefold inflationary increase over 35 years (and the fact that I’m not driving an entry-level model anymore). A large slice of the remaining difference is down to electronics (I had to install a radio in my first car), much which is safety related.

Three things in the past 35 years have made car safety work. First, safety systems – lane control, steering, antiskid braking, smart cruise control, collision warning and avoidance – became cheap. Second manufacturing costs have been relentlessly driven down for decades, creating a margin for safety spend. Finally, we got used to paying a hefty premium on new cars for the safety features. Health will be harder because we have not been making the basics cheaper in the same way since the ‘70s.

If not zero, then what?

Do we give up? Absolutely not! But we do need better measures, and even deaths are too crude and too late. People who have a heart attack, for instance, mostly either die quickly or recover close to where they were before. If you survive a stroke, however, your life is often a sad shadow of what it was. Let’s not design good measures for heart attacks that neglect strokes. Although it’s complicated, getting it right this time will be essential.

Next, we need to make every year safer than the year before. No grandstanding, no virtue-signalling targets: just steady systematic progress based on better evidence. No measure can be based on zero and success will take a decade to bed in, which is sad news for any political process.

Zero? Bad idea. Better? Absolutely!

Prof Terry Young, BSc, PhD, FBCS

After 16½ years as a research Engineer, Divisional Manager and Business Development Director, Terry became a professor at Brunel University London for 17 years.

He has a BSc in Electronic Engineering and Physics, a PhD in laser spectroscopy both from the University of Birmingham, UK.

His research has been in health technology, health services, and information systems. He has taught information system management, project management and e-Business.

His awards include the Operational Research Society’s Griffiths Medal, 2021, for analysing the return simulation methods offer when used to improve healthcare services.

Prof Young set up Datchet Consulting in 2018 to support innovation on the borders of academia, health and industry, of which the project reported here is an excellent example.

Health-tech sector can prosper from UK’s commitment to unleash potential of data

By Joost Bruggeman

The role of digital data in the UK’s healthcare systems is set to gain newfound recognition and clarity when the government unveils its Data Saves Lives strategy this spring. If it lives up to its promise, the plan will help to drive the efficiency and effectiveness of data infrastructure and promote interoperability, while establishing clear and open standards for safely sharing data.

The backdrop to the new strategy is the tumult caused by the pandemic, and the ensuing acceleration of digital trends. The government now wants to build on the momentum which has been established in the push towards digital transformation. Similar exercises can be seen elsewhere in Europe, such as in Germany, which is set to invest €59 billion into healthcare technology and digitalisation in the rush to improve services.

While the UK’s strategy is primarily focused on the internal workings of the national healthcare system, the implications are positive for all healthcare technology organisations which have demonstrated a commitment to data safety and security. It means they are well-placed, both technically and culturally, to support the NHS on its journey.

Encouraging innovation

On reading the draft document, what is most encouraging is the focus on supporting innovators – those most likely to be responsible for developing and delivering new solutions to benefit both healthcare professionals and patients. The new strategy is set to provide a clear set of standards for those creating or deploying new data-driven technology.

“We find ourselves in the middle of a very exciting time in the digital development of healthcare in the UK.” Joost Bruggeman, Siilo messenger co-founder

This commitment to creating an innovation-friendly environment, with a framework for testing, approval and deployment, can be the catalyst for continuous improvement in the technologies used by healthcare professionals. It will provide the confidence to support investment, rather than the hit-and-miss, rather opportunistic nature of the current environment.

**Joost Bruggeman, CEO of co-founder of Siilo**

As CEO and co-founder of Siilo, a healthcare specific digital communications tool, I understand the fine line that the Government needs to walk. On the one hand, it needs to build on the huge opportunities that new technologies present by keeping its doors open to innovation – doors which opened because of the challenges brought by the pandemic. But on the other hand, the Government needs to regulate and manage the relentless growth of new technologies.

Covid-19 played a part in Siilo’s own pathway into the UK healthcare market, due to the urgent need for rapid, reliable communication and information sharing. The other issue which facilitated Siilo’s entry was a series of daunting ransomware attacks in the UK, which prompted hospital boards to take preventive measures on all digital aspects of healthcare, pushing data security to the forefront, and seeing hospitals reject unsafe commercial messenger apps that posed a threat to data safety.

**Siilo’s image ‘edit’ function allows users to blur and anonymise information and point out specific details on an image using the ‘Arrow’ tool**

Without these driving factors, there is no doubt that Siilo’s route into the UK healthcare sector would have been far more difficult, especially as a tech company from outside the UK. So now that the panic of the pandemic is subsiding, the Data Saves Lives strategy is aiming to create an environment which is conducive to technological innovation, at a level which is appropriate for the NHS.

This is a significant challenge because oversight boards have to make decisions on topics and technologies that they may not be familiar with. Conversely, technology often develops so quickly that in vast structures such as the NHS, conducting a swift quality assurance and compliance strategy, as well as putting new regulations in place, is far more easily said than done.

**Siilo’s Messenger App allows patients and healthcare professionals to communicate instantly**

Siilo looks at the proposed strategy with great anticipation, while at the same time. understanding how things work in the real world. There’s unlikely to be a perfect solution, but that doesn’t mean that innovators should sit and wait until everything becomes more crystalised. It is the responsibility of the technology sector to interact with healthcare providers and the NHS, so we can hold up our side of any mutual agreement.

In short, it is also our job to provide clear data on our services so that decision makers have a good understanding of what we bring to the table, how we work, and how we can contribute to the NHS’s future aspirations and security regulations. And the sector should welcome any opportunities for dialogue, for we find ourselves in the middle of a very exciting time in the digital development of healthcare in the UK.

Joost Bruggeman is a former surgery resident at Amsterdam University Medical Centre and now CEO and co-founder of Siilo – Europe’s largest medical messenger app. For more information, please visit www.siilo.com.

North East and North Cumbria ICS initiative drives air quality improvement

By Niamh Macdonald

A new pilot project in the North East and North Cumbria aims to drive air quality improvement at an NHS systems level.

Poor air quality in the UK is an increasing health concern, new data published by The Lancet has revealed that pollution remains responsible for approximately nine million deaths per year, corresponding to one in six deaths worldwide.

Approximately 30 per cent of preventable deaths in England are due to non-communicable diseases explicitly connected to air pollution. The health and social care costs of air pollution in England could reach £18.6 billion by 2035 if air quality is not improved.

Global Action Plan, an environmental change charity, has been working with the North East and North Cumbria (NENC) Integrated Care System (ICS) over the last six months to identify opportunities to drive change around air quality improvement at healthcare access points.

The project aims to make sure air quality levels are controlled around health centres and help to protect the people who need to visit hospitals most frequently.

Newcastle upon Tyne Hospitals NHS Foundation Trust has committed to ensuring all employees will be given basic sustainability training. The green procurement is to be embedded across the organisation with the aim of encouraging all ICS members to switch to a renewable energy tariff.

The findings from the pilot project were published on 17 May in the ‘Levers for Change’ report. The report highlights how air pollution is linked to health challenges and inequalities and identifies key opportunities that developing an ICS focused action plan would present.

The progress being made in the NENC region forms part of the broader Integrated Care for Cleaner Air initiative with the goal of improving air quality around all healthcare access points in England.

Newcastle Hospitals, Global Action Plan, and Boehringer Ingelheim have formed a partnership with the joint goal of supporting every ICS in England to become a ‘Clean Air Champion.’

In preparation for ICS statutory footing in July, ICS leaders are currently submitting system-wide Green Plans. Many are already incorporating air quality improvement measures around hospitals as part of their broader commitment to tackle environmental challenges.

James Dixon, Associate Director Sustainability at The Newcastle upon Tyne Hospitals NHS Foundation Trust, said: “Sadly we know that people in the North East and North Cumbria are disproportionately burdened by ill health.

“The research presented in the ‘Levers for Change’ report is key to understanding the impact that air quality has on the health outcomes of the people of the region.

“The framework will be an extremely useful resource for us, as an ICS to use, to identify ways to work across organisations and reduce the impact that poor air quality has on the health and quality of life for the most vulnerable members of our society.”

Larissa Lockwood, Director of Clean Air, Global Action Plan, explains: ‘It is vital that we tackle air pollution at the regional ICS level, with partners from all across the health system, across primary and secondary care but also with local government.

“It is vital that everyone understands the NHS cannot tackle air pollution alone. Insights from the ‘Levers for Change’ report will be packaged into an interactive, freely available tool for all Integrated Care Systems in England to use. This tool will build on the Clean Air Hospital Framework developed in partnership with Great Ormond Street Hospital.”

Over half of Brits say their health has worsened due to rising cost of living

By Gabriel Blaazer

Over half of Brits (55 per cent) feel their health has been negatively affected by the rising cost of living, according to a YouGov poll commissioned by the Royal College of Physicians (RCP).

Of those who reported their health getting worse, 84 per cent said it was due to increased heating costs, over three quarters (78 per cent) a result of the rising cost of food and almost half (46 per cent) down to transport costs rising.

One in four (25 per cent) of those who said that their health had been negatively affected by the rising cost of living, had also been told this by a doctor or other medical professional.

16 per cent of those impacted by the rising cost of living had been told by a doctor or health professional in the last year that stress caused by rising living costs had worsened their health. 12 per cent had been told by a healthcare professional that their health had been made worse by the money they were having to spend on their heating and cooking.

The experiences of RCP members who responded to the poll include a woman whose ulcers on their fingertips were made worse by her house being cold and a patient not being able to afford to travel to hospital for lung cancer investigation and treatment. Other reports include respiratory conditions such as asthma and COPD being made worse by pollution and exposure to mould due to the location and quality of council housing.

Health inequalities – unfair and avoidable differences in health and access to healthcare across the population, and between different groups within society – have long been an issue in England, but the rising cost of living has exacerbated them.

The Inequalities in Health Alliance (IHA), a group of over 200 organisations convened by the RCP, is calling for a cross-government strategy to reduce health inequalities – one that covers areas such as poor housing, food quality, communities and place, employment, racism and discrimination, transport and air pollution. The government recently announced that it will publish a white paper on health disparities and the IHA is calling for it to commit to action on the social determinants of health. These largely sit outside the responsibility of the Department of Health and Social Care and the NHS.

Responding to these findings, Dr Andrew Goddard, President of the Royal College of Physicians, said: “The cost-of-living crisis has barely begun so the fact that one in two people is already experiencing worsening health should sound alarm bells, especially at a time when our health service is under more pressure than ever before.

“The health disparities white paper due later this year must lay out plans for a concerted effort from the whole of government to reduce health inequality. We can’t continue to see health inequality as an issue for health directives to solve. A cross-government approach to tackling the underlying causes of ill health will improve lives, protect the NHS and strengthen the economy.”

Professor Sir Michael Marmot, Director of the UCL Institute of Health Equity, commented: “This survey demonstrates that the cost of living crisis is damaging the perceived health and wellbeing of poorer people. The surprise is that people in above average income groups are affected, too. More than half say that their physical and mental health is affected by the rising cost of living, in particular food, heating and transport.

“In my recommendations for how to reduce health inequalities, sufficient income for a healthy life was one among six. But it is crucial as it relates so strongly to many of the others, in particular early child development, housing and health behaviours. As these figures show, the cost of living crisis is a potent cause of stress. If we require anything of government, at a minimum, it is to enable people to have the means to pursue a healthy life.”

Also responding to the survey was NHS Providers Chief Executive, Chris Hopson, who said: “Trust leaders are acutely aware of the soaring cost of living crisis facing the nation and the impact rising financial pressures could have on people’s health.

“This is particularly concerning in the wake of the COVID-19 pandemic which exposed deeply entrenched social, racial and health inequalities. As highlighted in this survey, there is a risk that the current cost of living crisis widens those inequalities.

“Trust leaders share the view that there is an opportunity to tackle the factors which lead to health inequalities and poor health. They have committed time and resource to reducing inequalities across their local communities.”

Health Inequality, News, Population Health, Primary Care, Thought Leadership May 17, 2022

How ICSs can help uproot risk aversion and progress innovation

By David Duffy

Integrated Care Journal speaks with Kathy Scott and Aejaz Zahid of the Yorkshire & Humber Academic Health Science Network (AHSN) on how the implementation of a dedicated innovation hub within ICS frameworks has helped to streamline innovation and improve patient care.

Above: Barnsley Hospital, part of South Yorkshire and Bassetlaw ICS.

Integration and innovation are two increasingly prominent principles that are, in part, designed to address the growing problems of unmet health needs. Each is intended to supplement and support the development of the other.

Integrated care systems (ICSs) offer new frameworks through which innovation can be adopted at scale, streamlining past previous bureaucratic and individualistic barriers to change and adopting a transformation led approach. Innovation is crucial in turning the core aspirations of integrated care into tangible realties, to use technology and sophisticated approaches to data to help address the root causes of ill-health and expand health service offerings.

The above outlines the core principles of integration and innovation, which can be found reiterated from a wealth of sources, if one is to engage in the sector for even a few days. Integrated care is not a new concept and neither is innovation, so how are these two principles coming together to improve patient outcomes in reality?

“There is a vast range of unmet need across the whole health and care sector.”

“There is a vast range of unmet need across the whole health and care sector,” says Aejaz Zahid, Yorkshire & Humber AHSN’s Director for the ICS Innovation Hub at South Yorkshire & Bassetlaw Integrated Care System (SYB ICS). “Much of this is of course clinical, but a huge part of this is more operational, system level needs.

“The ICS needs intelligence on all of this, but then must ascertain how it can use innovation to leverage economies of scale in terms of investing and finding solutions to those problems and challenges. What we are trying to do within the innovation hub is create straightforward and easily accessible processes which enable busy staff working on the ground to regularly bring those challenges and problems to our attention, while enabling ICS leadership to ascertain and prioritise needs which could benefit from a systemwide innovative solution.”

The ICS Innovation Hub is a single point of contact for health and care innovators in the SYB region. The hub works, via the AHSN, to identify and validate market ready innovations and help drive improved health outcomes, clinical processes and patient experience across the SYB health economy. The idea to set up a dedicated innovation hub within an ICS was developed by the Yorkshire & Humber Academic Health Science Network (Yorkshire & Humber AHSN) and has proved a successful model to help spread and adopt innovations at pace and scale. Yorkshire & Humber AHSN also provides innovation support to three different ICSs in the region.

Fostering a culture of innovation

Explaining how the Hub, and by extension, Yorkshire & Humber AHSN are working to cultivate innovation in the region, its Chief Operating Officer and Deputy CEO, Kathy Scott says “it is as much about identifying good practice as it is implementing the ‘shiny stuff’.

“As an AHSN we also have sight of a lot of potential solutions that can address those needs often identified by the innovation hub. So, we are able to nudge the ICS leadership towards potential solutions.

“We can push out new ideas and innovations as much as we like, but if you don’t have that culture of innovation and improvement there, it’s not going to stick.”

“It’s about growing the capability and capacity for change within a locality and for improvement techniques and innovation adaptive solutions to be implemented. Not simply implementing new technology and essentially running away.

“We can push out new ideas and innovations as much as we like,” continues Kathy, “but if you don’t have that culture of innovation and improvement there, it’s not going to stick.”

The ICS’s digital focus has also enabled significant work on pre-emptive care. For example, through the Yorkshire & Humber AHSN’s digital accelerator programme Propel@YH, the AHSN has worked with innovator DigiBete to support the adoption of their “one stop shop” app to help young people living with diabetes manage their treatment.

The app was clinically approved during the height of the pandemic, with extra funding provided from NHS England, and is now being used in 600 services across England. “This is an excellent example of how we can pre-emptively assess unmet need and streamline innovation into the system,” says Kathy.

Innovation as an antidote to health inequality

“Health inequalities are part of our design thinking from the get-go in any project,” says Aejaz, who points to the recent implementation of SkinVision, a tele dermatology app, as an example.

“The app was originally developed in the Netherlands, where predominantly you would have Caucasian skin that the AI would have been trained on,” he explains, “so, from the beginning, we have been mindful to capture more data on how well the app works on other skin types and feed that back to the company to improve their AI algorithms for wider populations.”

The Innovation Hub also works to ensure that implementing digital technology does not exacerbate inequality for less digitally mature users. “If somebody, for example, doesn’t have a smartphone that is able to run that app, there is always the non-digital pathway in parallel. So, it’s never either/or.”

An appetite for risk

“There is always a level of risk aversion when it comes to adopting something new in healthcare,” says Aejaz, “even with evidence backed solutions, we find there’s sometimes a level of reluctance. Staff want to know whether it’s going to work in their local context or not and whether introducing innovation would entail a significant ‘adoption’ curve. Building enthusiasm around a new idea and overcoming hesitancy to innovation is, therefore, central to the role of organisations such as the AHSN and, by extension, ICS innovation hubs.

“Building a culture of innovation is fundamentally about building a culture of increased risk appetite, where failure is most certainly an option.”

“Building a culture of innovation is fundamentally about building a culture of increased risk appetite, where failure is most certainly an option,” Aejaz continues. “We need to create systems which provide innovators with the necessary psychological safety that allows them to experiment.”

To help shift the mindset of NHS staff in favour of innovation, the Innovation Hub established a series of ‘exemplar projects’, designed to erode the fear of failure and capture learnings in the process. For example, for Population Health Management exemplars, one of the priority themes for the ICS, the hub called for providers to submit ideas to the Hub, all framed under high priority population health challenges such as cardiovascular health. Successful applicants with promising ideas received funding in the region of £25,000 as well as co-ordination support from the Hub towards their project.

The programme has enabled frontline innovators and has led to the development of a host of new services incorporating novel technologies, such as virtual wards and remote rehabilitation. The Hub is also working to transform dermatology pathways throughout the SYB region by introducing an app that allows patients to upload images of skin conditions and be processed more efficiently through the system. Funded by an NHSx Digital Partnerships award, this pilot project with Dermatology services in the Barnsley region will test out the use of this AI-enabled app to ascertain how well it can successfully identify low risk skin lesions which can be addressed in primary care. Thereby reducing demand on secondary care and speeding up access for higher risk patients. Each of these projects demonstrate the capacity for transformation when on the ground staff are given the freedom to innovate.

Interestingly, many of the ideas that the Hub works with are non-tech solutions. For example, primary care providers working with local football teams via a 12-week health coaching programme to engage with fans who may be at risk of cardiovascular disease, or introducing Cognitive Behaviour Therapy techniques to patients with severe respiratory conditions to help reduce anxiety when experiencing an episode of breathlessness.

To nurture a mentality more open to change, the Innovation Hub has developed learning networks across South Yorkshire. Through these networks, the Innovation Hub and AHSN teams have been reaching out to key leads from each of the provider organisations who are involved in innovation, improvement or research and invited them to become innovation ambassadors. “These ambassadors have become our eyes and ears on the ground across health providers, where they can start to introduce what we do and also help capture unmet needs from colleagues in their respective organisations,” explains Kathy.

Following in the footsteps of the first innovation hub established by the Yorkshire & Humber AHSN in South Yorkshire, other AHSNs across the country are now looking at setting up innovation hubs within their ICS by bringing leadership together, getting them out of their ‘comfort zone’ and giving them the space to innovate, and hoping to chip away at risk aversion and fear of experimentation. Introducing solutions outside of traditional domains will enable a culture of innovation and improvement. To streamline past bureaucratic and individualistic hurdles, ICS frameworks are key to facilitating transformational change in every region of the country.

If you would like to find out more about the Yorkshire & Humber AHSN, please contact info@yhahsn.com

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LDC Confederation: taking an active role in combatting discrimination

By Martin Skipper

Martin Skipper, Head of Policy for the LDC Confederation, discusses how the organisation is taking an active approach to addressing racism, working as part of the London Workforce Race Equality Strategy (WRES), to ensure that the dental profession benefits from the programme of work.

The aim of the London Workforce Race Equality Strategy work is to address the inequality experienced by a large proportion of the NHS workforce. The experience of professionals from black and minority ethnic backgrounds continues to lag behind that of white colleagues.

To address this imbalance, the objective is for the NHS in London to be a more inclusive place to work. The workforce strategy aims to create a step change by increasing the diversity of the workforce and promoting equality, diversity and inclusion strategies. This includes improving the leadership culture and growing and training the workforce. In a recent survey undertaken by the London WRES for Equality and Discrimination in Primary Care, around half of respondents said they had faced some sort of discrimination or harrasment at work, with 39 per cent saying that they had received this from patients. The remaining 29 per cent had been on the receiving end of discrimination or harrasment from colleagues. Of these cases only one third were reported.

Colleagues from Asian or African backgrounds were most likely to be on the receiving end of discrimination, and also less likely to know where to turn for help. Additionally, while ethnicity was the main factor reported to underlie discrimination and harrasment by a considerable margin, gender was the second most common factor. Unfortunately, responses from dental practice were very low, so few conclusions about issues specific to dentistry can be drawn.

Registration data from the General Dental Council, however, shows that many of the issues reported above can be expected to be true in dental practice. Over 50 per cent of dentists on the register are women, leaping to almost 93 per cent of dental care professionals (DCPs). At least 31 per cent of the dental workforce identify as Asian, Black, Chinese, mixed or other non-white ethnicity, with a further 17 per cent unknown. Around nine per cent of DCPs by contrast, identify as non-white, with a further 14 per cent whose ethnicity is not known.

There will be sizeable groups within both parts of the dental profession with at least one characteristic strongly associated with discrimination and harrasment. With 60 per cent of DCPs and 52 per cent of dentists being aged under 40, expectations of professionals will vary considerably from this younger cohort of professionals to their more established colleagues.

The LDC Confederation is supporting dental teams in several ways to make sure that their workplace is inviting and supportive to everyone. One these is working with the National Guardian’s Office to ensure that all practices in member LDCs have access to a clear pathway to a dental guardian. This impartial champion provides support and guidance to those in the dental team who are unsure of where to turn when they have a concern.

As many dental practices continue to be independent providers with relatively small teams, the LDC Confederation act as an impartial body able to support practices and practitioners alike. By providing this opportunity for confidential and impartial support we hope that a more open and accepting culture will be developed in dental practice.

We will continue to work with the London WRES to embed their plans for increased awareness among teams of the issues and behaviours, as well as providing a trusted environment for all members of the dental team to seek support. We will also maintain a campaign of zero tolerance towards harrasment and discrimination from patients. Individual LDCs will be working with their local training hubs to embed training opportunities at the local level and with EDI leads in the Integrated Care Systems to align practice processes and outcomes with those of system wide strategic objectives. Through these combined efforts, the LDC Confederation will continue to take an active approach to promoting equality, diversity and inclusivity in the dentistry profession.

New digital maternity pathway goes live in Devon

By TPP UK

TPP SystmOne Maternity technology goes live at Torbay and South Devon NHS Foundation, digitising the entire maternity pathway, from ante to postnatal care.

This week, Torbay and South Devon NHS Foundation Trust have gone live with TPP SystmOne Maternity. The system has enabled the Trust to digitise their entire maternity pathway, from antenatal through to postnatal care. It is being used by all midwives in the region, including those based at the hospital and those working in the community. More than 2,500 women will benefit from the new system every year, with their maternity care now centred on a complete, integrated digital care record.

Following the go-live, midwives now have instant access to all of the maternity data they need. For example, midwives working in postnatal care can easily view all antenatal care and delivery details. All medical and nursing notes are captured in a single record. This provides staff with the information required to make the best clinical decisions and improve safety for mothers and babies. Advanced functionality in the system is also supporting staff with the management of more complex pregnancies, through enhanced clinical decision support, alerts, and a complete maternity timeline.

TPP maternity — TPP SystmOne Maternity in use at Torbay Hospital

There has been strong clinical engagement throughout the project, from midwives, doctors and nurses. The teams have used TPP’s powerful Clinical Development Kit (CDK) functionality to develop exactly the data entry templates and visualisations they wanted. All staff members can quickly capture the information they need for a complete antenatal, labour, delivery and postnatal record. The Trust have also used CDK functionality to create customised safeguarding content, helping to support and protect the most vulnerable families. Staff are also benefiting from interactive inpatient screens in the system, allowing them to manage bed capacity and perform safe, efficient handovers.

The go-live has also included providing TPP’s smartphone application, Airmid, to all women under the maternity service. This is putting women at the very centre of their pregnancy journey. Airmid allows women to access their maternity records, manage their upcoming appointments, complete questionnaires at home, and receive personalised advice and education material. Airmid supports better engagement and seamless communication between women and their maternity care team.

SystmOne also provides significant improvements to integrated care across the region and to multidisciplinary working. For example, maternity staff can immediately access any important information entered by GPs. This is significantly improving patient experience. Women only have to tell their story once, without having to repeat themselves. GPs can directly refer into the maternity unit, improving efficiency across both services. Additionally, all new births are now automatically registered with regional Child Health services, with no extra burden placed on NHS staff.

Tracy Moss, Head of Strategic Systems’ Software Development at the Trust, said: “We are excited to be working with TPP to introduce a new maternity IT system here at Torbay and South Devon NHS Foundation Trust. The new system is expected to bring a wealth of clinical as well as efficiency benefits for our maternity teams and the wider organisation. The families we care for will also benefit from the system, as the new associated Airmid patient app will allow them to view their records, access information and be more involved in their care. Moving forward, we would like to continue to work with TPP to deploy other SystmOne products, both within our maternity unit and across our wider Torbay and South Devon organisation.”

Charlotte Knowles, Managing Director at TPP, said that “maternity services will always hold a particular place in my heart. Having had three babies, I know, from personal experience, what a superb job they do. We are delighted that the Trust are already seeing significant benefits for staff and patients from TPP Maternity. The dedication of the staff here has been truly inspiring. We are looking forward to working together to continue to make better use of technology to improve the experience and outcomes for pregnant women and their families.”

Government failing on social care and health inequalities

By Kari Gerstheimer

The government’s failure to reform social care funding in the Health and Care Act is compounding regional health inequalities, writes Kari Gerstheimer, CEO and Founder of Access Social Care.

Speaking before a Cabinet meeting last month Boris Johnson stated that: “With household bills and living costs rising in the face of global challenges, easing the burden on the British people and growing our economy must be a team effort across Cabinet.” He added that “we will continue to do all we can to support people without letting Government spending and debt spiral, whilst continuing to help Brits to find good jobs and earn more, no matter where they live.”

However, the Prime Minister’s own assurances on protecting the British public from rising costs were set against the Government’s actions regarding the Health and Care Act, which has just been enshrined in law.

The Prime Minister continues to make promises to help the British people with the growing cost burden, while the Health and Care Act leaves those on the lowest income exposed to spending a greater proportion of their assets on care costs, during the worst financial crisis we have seen in generations.

The Government’s own amendment to the Bill, which was subject to a fierce debate in both chambers of Parliament before ultimately being voted through, means that the local authority support people receive to help them meet their care costs, will no longer count towards the proposed £86,000 cap.

This is all the while that the PM has continued to make promises to address the decades-long social care funding crisis and widening health inequalities. The £5 billion in extra money announced for social care over the next 3 years, is of course welcome. But there is no mathematical link between the amount of money and the level of need. The Health Foundation calculates that at least £8 billion are needed per year, just to deliver what councils are legally obliged to.

Failure on “levelling-up”

Research commissioned by Access Social Care, which provides free legal advice for those with care needs, shows that poorer areas with lower council tax and business rate yields have been worse affected by the reduction in the central Government grant for social care.

This means that people living in poorer areas where social care need is often the greatest, are already getting a bad deal compared to other parts of the country, which flies in the face of the much-vaunted concept of “levelling-up.”

Rather than addressing this unfairness, the Government’s amendment is compounding it, by leaving people living in ‘red wall’ areas having to spend a greater percentage of their total assets on care.

The Health and Care Act is a clear contradiction in the PM’s assurance to focus efforts on easing the burden for British people and protecting the public from rising costs. It will instead deepen the cost of living to the poorest of our society and widen long-standing health inequalities.

Access Social Care are already seeing cases where the cost of living crisis means that people cannot afford the social care they so desperately need. The Government urgently needs to do more to ensure that everyone can get the social care they need, at a price they can afford.