nihr clahrc east midlands annual meeting 2015 presentations - day 2

WelcomeNIHR CLAHRC East Midlands Annual Meeting

Partners in Progress – Sharing and Learning

A partnership between

Nottinghamshire Healthcare NHS Foundation Trust

and the Universities of Nottingham and Leicester

25 March 2015, Eastwood Hall Hotel, Nottingham

NIHR CLAHRC for EM Annual Meeting –

Welcome and Introduction

Kamlesh Khunti, Director, CLAHRC East Midlands




East Midlands

NHS Outcomes Framework 5 Domains

Public Health England Priorities

Department of Health Priorities for the East Midlands (Set out in the East Midlands Health Strategy 2009)

“The priorities for the East Midlands are to address health inequalities, levels of tobacco use, harmful alcohol use, obesity, physical activity, avoidable injury and death, affordable warmth and the health of children and young people.”

Key National and Local Priorities

Prevalance of Long Term Conditions • 15 million with LTC

• 70% NHS Budget

NIHR Clinical Research Infrastructure

Biomedical Research Centres

Biomedical Research Units

Clinical Research Facilities

Experimental Cancer Medicine Centres

Clinical Research Networks

Invention Evaluation Adoption

Healthcare Technology

Co-operatives

Diagnostic Evidence

Co-operatives

Patient Safety Translational

Research Centres

Collaborations for Leadership in

Applied Health Research and Care

Translational Research

Partnerships and

Collaborations

NIHR Collaborations for Leadership in Applied Health Research and Care

• 9 Pilot CLAHRCs created in 2008 for 5 years

• £50m funding awarded (rising to £88m over course of award)

• Second competition: 13 CLAHRCs funded for 5 years from January 2014

• Funding increased to £124 million

• Address the “second translational gap”

North West London

Greater

Manchester

West Midlands

South WestPeninsula

Yorkshire & Humber

13 NEW Collaborations from January 2014

East of England

NIHR Centres for Leadership in Applied Health Research and Care (CLAHRCs)

East Midlands

South London

North West Coast

North Thames

Oxford

West Country

Wessex

Pilot scheme to 2014

http://upload.wikimedia.org/wikipedia/en/e/e4/CPRE_England_tranquillity_map.jpg

http://upload.wikimedia.org/wikipedia/en/e/e4/CPRE_England_tranquillity_map.jpg

Contributions from Matched Funding

NIHR CLAHRC East Midlands

Structure

NIHR CLAHRC EM

Vision and Mission

Create an International

Centre for Excellence

Deliver a Large Volume of High Quality Applied Health Research

Build Strength and Capacity to

Implement World Class Research

NIHR CLAHRC EM

Partnership Vision

Partnerships are at the Centre of Everything we do!

NIHR CLAHRC EM

Partner Commitments

• Improve patient outcomes through the conduct and application of research evidence of local relevance and international quality

• Bring together health providers, commissioners, patient groups, health and research networks, life science industries and academic institutions to support the NHS Increase capacity in the EM to conduct high quality health research

Partnership Wheel

“Improve patient outcomes through the conduct and

application of research evidence of local relevance and international quality”

Applied Health Research

Year One

• 18 Phase One and Two projects are up and running across the East Midlands.

• 10 Projects provisionally selected for Phase Three from an rigorous approach involving Partners and Public

Bringing People Together

Year One

• Received £591k in matched cash funding

• On track to receive £18m in overall matched funding

• Set up the East Midlands CLAHRC faculty. We currently have 90 members.

• PARADES Event in December 2014 with the EM AHSN #StephenFryLiked

“Build on the achievements of the LNR and NDL CLAHRCs in

bringing together stake holders to support the NHS to meet locally identified priorities”

“Bring about a further step change in the quality and

quantity of activity taking place to bridge the second gap in

translation”

Implementing Evidence

Year One

• EM AHSN have pledged funding of £525,000 to support the implementation of CLAHRC EM projects.

• We have appointed 34

knowledge brokers who are

playing a key role in developing

research interest and capability

We said we’d: “Increase capacity in the EM to conduct

high quality health research and to apply research evidence”

Capacity Development

Year One

• We have appointed seven PhD students and three more planned in September

• Commenced our training programme presenting short courses for NHS staff in 2015. Courses were put forward after consultation with NHS partners.

Year One

• PPI strategy completed and being implemented.

• Partners Council set up and meeting regularly.

• Set up the Centre for BME Health. The Centre has already delivered 11 community health information events to raise awareness of diabetes and safer fasting during Ramadan to more than 250 individuals from 13 different ethnic groups.

Public Involvement

“Provide opportunities for stakeholder engagement and across

all of its structures, themes and projects so that intended end-users

of research can help to shape its selection, design, delivery,

dissemination and implementation”

• Overview of our progress including

achievements

• Give a wider perspective on the

relationship between our partners

• Outline our chanllenges

• Encourage networking

• To thank you for all that you have

done in the last year. We could

not have achieved this without

your support!

Aims and Objectives of Today

Mission Statement

Thank you for listening and

Enjoy the Day

[email protected]

www.clahrc-em.nihr.ac.uk

@kamleshkhunti

@CLAHRC_EM

This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands (NIHR CLAHRC EM). The views expressed in this presentation are those of

the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

NIHR CLAHRC East Midlands Annual Meeting





CLAHRC EM Annual Meeting 25th

March 2015

Partners in Progress:

Sharing & Learning

Professor Rachel Munton

Managing Director, EMAHSN

“There is a clear relationship between the

EM CLAHRC and EM AHSN, with the

CLAHRC resources supporting the

generation of high quality and locally

relevant evidence and developing the

science of implementation and the AHSN

supporting the practicalities of “putting

evidence into practice” at a suitable

stage of development.”

Creation

• new things

• new ideas

• new techniques

• new approaches

Assessment

• new things

• new ideas

• new techniques

• new approaches

Uptake

• new things

• new ideas

• new techniques

• new approaches

Spread

• new things

• new ideas

• new techniques

• new approaches

Basic ResearchApplied

ResearchCommissioning Patient Care

• Better Quality

• Better Value

•Health and Wealth

NIHRNHS

CommissionersMRC & others incl Charities

Providers of NHS services

Working across the Innovation Pathway

INVENTION EVALUATION ADOPTION DIFFUSION

7.9% employment rate for people with serious mental health

conditions

Work leads to better mental health, physical health and

economic well-being

IPS consistently more effective than other approaches at getting

people into work: 61% IPS vs 23% Traditional

IPS reduces health service use: fewer days in hospital, reduced

rates of readmission (Hoffman, 2014)

Economic studies estimate £1.59 saving for every £1 spent

(Van Stolk, 2014)

Individual Placement & Support

“We felt that it was very important to get back into full time work, where I was before I had my depression.” - IPS Service User

EMAHSN IPS Project Impacts

More people with severe mental illness will be offered evidenced best

practice employment support as part of their recovery plan

NHS providers will be afforded expert support and facilitation leading to

increased fidelity of IPS services available to patients

NHS providers will be given the means to ensure that these

improvements are sustained far beyond the life of this project

IPS practitioners will have a regional network of peers in order to share

best practice and access support

“Even though I live with a diagnosis of schizophrenia, with support I have achieved a sense of satisfaction in my job. Over time I have developed insight into my illness, which has helped my recovery and reduced the symptoms.” - IPS Service User

A £2m NIHR Research Programme constituting 5 research studies:

The event and dissemination activities look to spread best practice as

outputs from the programme and how they have influenced new NICE

guidelines on bipolar disorder (released 24th September

http://www.nice.org.uk/Guidance/CG185)

Better Care for People

with Bipolar Disorder:

.

http://www.nice.org.uk/Guidance/CG185

PARADES Event & Booklet

Event jointly hosted by CLAHRC EM and EMAHSN to:

• Launch the Advance Planning guide

• Communicate PARADES research findings to participants, service

users and healthcare professionals

• Showcase new NICE Guideline on Bipolar Disorder

Advance Planning guide received support from Stephen Fry, Nick

Clegg MP and Nicky Morgan MP – nearly 20,000 downloads from

EMAHSN website to date + 4000 distributed

EMAHSN now supporting Nottingham Recovery College in the delivery

of specialist educational provision on Advance Planning directly to

service users with a view to expanding to other Recovery Colleges in

the region in 2015/16

EMAHSN:

Transforming the health of

4.5m East Midlands

residents and stimulating

wealth creation

Name: Rachel Munton

Phone: 0115 8231300

Email: [email protected]

www.emahsn.org.uk

@EM_AHSN

@RachelMunton

mailto:[email protected]

NIHR CLAHRC East Midlands Annual Meeting –

Building Partnerships

Chair: Professor Richard Morriss, Director of Research




‘Building Partnerships’

Karen Glover

Director of Partner Relations and Operations,

NIHR CLAHRC EM

Head of Clinical Programmes EM AHSN


Nottinghamshire Healthcare and the

Universities of Nottingham and Leicester

• NHS, Industry, Academia

• Voluntary Sector and Local Authorities

• Patients/Public

• Region-wide: BRU, CRN, SCN, Clinical Senate,

HEEM, EMLA, AHSN

• National NIHR CLAHRC

Who are our Partners?

• Improve Population Health

• Increase Capacity and Capability for Research

and Innovation

• Shared Understanding and Ownership

• Translation of Research into Practice

Why Collaborate?

• Communications

• Networks

• Events

• Organisational Presentations - NHS, Academia

• Industry

How Do We Engage?

• Governance Arrangements

• Project Selection

• CLAHRC Faculty

• Networks of Practice

• Knowledge Brokers

How Do We Engage?

Thank you for listening

[email protected]


@CLAHRC_EM

This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands (NIHR CLAHRC EM). The views expressed in this presentation are those of

the speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

BUILDING PARTNERSHIPS

PROFESSOR AZHAR FAROOQIChair – Leicester City CCG

44

Leicester – one of the UK’s most richly diverse cities.

The resting place of Cardinals and Kings

Where all ethnic groups are a minority.

//upload.wikimedia.org/wikipedia/commons/4/4c/Leicester_Market_2009.jpg

//upload.wikimedia.org/wikipedia/commons/4/4c/Leicester_Market_2009.jpg

On average city residents live 4 years less than those in the county

• In some areas of the city the life expectancy gap rises to 10 years

• While life expectancy is improving, the gap with the rest of England is

widening

Understanding the reasons for the gap…

Deprivation and Ethnicity- ‘A Culturally Rich but Economically Deprived City’

Directorate of Public Health and Health Improvement

NHS Leicester City 4

WHAT IS KNOWN:• 75% of Leicester’s population live in the 40% most

deprived areas nationally, with nearly half living in the 20% most deprived areas.• An estimated 25,625 children in the city live in poverty• Leicester has a high proportion of black and minority

ethnic (BME) population (36%), primarily in the east of the city; the west of the city has a predominantly white

population• The majority of BME population is of Indian descent (26%)

IMPLICATIONS:

• Ethnicity and deprivation are strong independent factors causing health inequality in population, both point to high CVD

Premature deaths from cardiovascular and respiratory disease account for 2/3 of gap

Priorities

49

Our five year plan, focusing on things that…

• would do most to improve health and wellbeing;

• have biggest impact on closing the life expectancy gap;

• affect the largest numbers of patients;

• place heaviest demand on services;

• fit with what patients and partners told us should be a

priority.

Smoking prevalence is high, particularly in the west of the city

High levels of adult obesity, again concentrated in west of

the city

Over 10,000 patients registered in Leicester with CHD, with South

Asians suffering earlier onset

Diabetes prevalence higher than national average, particularly in areas where BME

population is high

APPROACH TO IDENTIFYING CHANGES

CLEAR PROPOSALS

GOOD IDEAS RADICAL THINKING

The proposal is well evidenced clinically –possibly NICE guidance or implemented best practice elsewhere

The proposal will demonstrably reduce large numbers of patients attending acute hospitals in the short term

The proposal is implementable and the revised pathway is supportable clinically across organisational boundaries

The proposal may have some clinical evidence or present just a good idea that has widespread clinical support

The idea must be accompanied with an associated logic as to how its implementation would reduce large numbers of patients attending acute hospitals in the short term

The proposal is implementable and supportable clinically across organisational boundaries

The proposal is outline in nature only and could be the result of a ‘what-if’ scenario or brain-storming

The thought must have some logic but will focus on the further work that is needed to firm up or discount the thought

No consideration is need for implementation of the change at this stage

EVIDENCE

CLINICAL LOGIC

CLINICAL SUPPORT

Clear proposals rather than radical thought

Priorities: CVD

1. Identify the unidentified and those at risk of CVD

– Systematic, high quality health check programme which is accessible, quality assured, and leads on to management and prevention

2. Transformation of pathways – appropriate left shift

– Services should be where they are most accessible, good quality, where they deliver services effectively and cost effectively

– Concentrate on 3 or 4 big areas – already working on transforming diabetes, atrial fibrillation and anti coagulation, heart failure, CHD pathways

– They will reduce admissions and dependency on hospital based care and improve overall quality

– Challenge– resources have to follow services

3. Invest to save – up skilling, particularly in primary care

– IT that works across whole pathway

– Need sufficient workforce, in the right areas. Could be partly about moving staff (i.e. from hospital to community) but also identifying gaps and workforce planning so the programme can be delivered properly

55

Three work programmes have been identified for PID development:

Partnership model of diabetes in LLRUHL, LPT, Primary care, Diabetes Centre

1.Primary care

(core)

2.Primary care

(enhanced)

Primary care setting Secondary and tertiary care setting

‘The Super Seven’1. Inpatient care2. Insulin pumps3. Renal4. Foot5.Children/adolescents6. Pregnancy7 complex and rare

3.Specialist support for Primary care (CDSST)

‘The Necessary Nine’1. Screening2. Prevention3. Regular review/surveillance4. Prescribing5. Insulin6. Patient education7. Cardiovascular8. Housebound/care homes9. Outcomes/audit

4.Complex care

Ensuring practices have the skills required for providing diabetes care – in city £300,000 x 3 years investment. Each practice has a PDP for diabetes

• Post graduate certificate• Regular updates• Case reviews

• Msc Diabetes• Case reviews & management• Journal club• Regular updates• Behaviour change training

• Mini modules

• Mentorship

• Healthcare Assistant training

• Patient education

• Mini modules

• CPD accredited training

• Insulin training

• Nursing home Community

Nurse support

• Mentorship

Cardiovascular disease

59

• 40,000+ residents have

received a health check;

• 4,000+ people are now

receiving care and

support.

• CLAHRC involved in

evaluation

• patients admitted to

hospital with suspected

strokes and irregular

heartbeats fell in

2013/14;

• emergency stroke

admissions reduced by

5.1% and atrial fibrillation

emergency admissions

by 16.7%.

Diabetes Atrial fibrillation40-74 health checks

• self-management

education programmes;

• Enhanced primary care

• Professional development

• better hospital care

• Better community

engagement-

collaboration with EM

Centre for BME health.

Respiratory disease and mental health

60

COPD telehealth Health in your hands

• Scheme could be helping

to reduce the number of

days patients spend in

hospital each year by as

much as 80%.LPT

partner

• Placed real money in the

hands of local

communities to tackle the

underlying causes of

COPD, supporting the

other work of the CCG.

Severe mental health support

• Tailored package of care

to support patients to live

independently in the

community and improve

and maintain their social

wellbeing. LPT partner

Older people

61

BCF programmes End of life care plans

• LPT, LA, Voluntary

sector, CHLARC• more than 1000

emergency care plans

created.

The Leicester City Integrated Care model- part of BTC

62

10 Joint Planned Intervention Teams

offering:

Community nursing services

LA planned services

Community Geriatrics

Care navigator per locality

Current LA offer across 12 teams

Integrated Crisis Response Service

Assistive technologies/Community equipment

Health and social care coordinators

Single Point of Contact

Emergency Duty Team

Adult mental health practitioners

Unscheduled Care Team offering:

RIT

ICRS

Night nursing

ICS

Community Geriatrics

H@H

EDT

Current community health offer across teams:

Rapid Intervention Team

Community nursing

24 virtual ICS capacity

Hospital at home

Therapy

Night nursing

Single point of Access/EDT

Up to 3 GP/ANP led ambulatory care teams offering:

Interventions targeted to high risk population

Range of diagnostics (except x-ray) to assess

and stabilise patient

Co-located with Non-elective Team above

Current ambulatory care offer across 4 localities:

GP service (24/7)

GP in a Car

Emergency Response Service

Various next day clinics

Live warm transfer capability between SPA & SPOC Access to a further 6 specialist step up/down virtual ICS beds

Inflow referral

points from

EMAS/111/

GP/SPA/SPOC

Outflow referral

points from

inpatient

beds/ED/GP/

SPA/SPOC

We cannot succeed without partnerships

• Engage- identify common problems and devise solutions

• Learning from other’s success

• Evaluate- role of universities, CLARHC

• improve

• Disseminate

• Thank You for Listening

Dr Peter Miller

Chief Executive

Leicestershire Partnership Trust


We have a problem

Su

rplu

s / D

efi

cit

(£

m)

Long Term Conditions

‘Without unprecedented, sustained increases in health service productivity, including more effective management of chronic conditions, funding for the NHS in England will need to increase in real terms between 2015/16 and 2021/22 to avoid cuts to the service or a fall in quality’

Innovation and Translation

The Heineken Challenge

NHS Trust Feedback

CLAHRC EM research and implementation activities aligned to the priorities of the Trust – Long term Conditions/Mental health

Rigorous assessment of projects ensures quality

Diffusion fellows/knowledge Brokers – embedded in clinical services

Important new opportunities for clinical staff and non-clinical staff to obtain funding for translational activities to get their research findings quickly into practice – again focused on Trust priorities

World class research – recruitment and retention

New training opportunities for non-medical staff to undergo PhD training and build new cadre of research active/aware staff

Good structures in place for learning and sharing experiences across East Midlands and beyond – CLAHRC EM ‘Show and Tell Events’ for example

Allows researchers to influence nationally

Encourages researchers in to ‘think bigger’ by facilitating collaborations across the East Midlands and beyond

But more challenge

• Alignment of research to big change programmes

• Emergency admissions in LLR up 8% in 14/15

• Adopt innovation at Pace and Scale

Public Involvement in CLAHRC

East MidlandsDr Paula Wray, Public Involvement Programme Lead




Why involve stakeholders?

http://forgetfulman.files.wordpress.com/2011/07/community.jpg

http://forgetfulman.files.wordpress.com/2011/07/community.jpg

http://www.overcomeobesity.org/

http://www.overcomeobesity.org/

A Whole System Approach

CLAHRC

Partners’ Council

Projects

Scientific Committee

Executive & Governance

Board

Partners

East Midlands Centre for

BME Health

Involvement, Engagement and Participation

“Being part of the Partners' Council has opened up a whole new world for

me. It's been a steep learning curve but with the support and

encouragement from colleagues I have grown in confidence. This has enabled me to gain new skills for

example as a Lay Assessor and I have already helped develop and refine a number of research proposals. It's

been so satisfying to utilise the extensive network of voluntary

groups I am involved in to help shape and inform research.”

Stakeholder views

"It is often not possible to meet our clinicians or patients face-to-face. However,our feedback from our PPI group (a family support group for ADHD) has providedthe research team with a valuable education in the need to have a flexibleapproach to communication, using the media (phone, email, text, postal letter)that is preferred for each given family. Additionally, it has been important to adaptthe implementation of our protocol to the needs and clinical practice of eachsite. By working closely with our clinicians, … we have developed a strongcommunity which is reflected in our participant and site recruitment andretention figures “ Researcher

“I am delighted to be a part of the Aqua Research Study, this is a very excitingproject to be involved in and could be revolutionary in ADHD Care, in particularthe assessment process. As a clinician, I have been an integral part of the study,the University of Nottingham and the team have ensured the engagement ofclinicians, on all levels. The help and support provided by the team has beenoverwhelming in my role as a knowledge broker.” Clinician

East Midlands Centre for Black and

Minority Ethnic Health

Health Literacy -The ability to understand, access and use health information.• Social and cognitive skills to do these tasks• Motivation and engagement in health‐promoting and disease‐management activitiesWorld Health Organization: Health Promotion Glossary. Health Promotion International 1998, 13(4):349‐364

East Midlands Centre for Black and

Minority Ethnic Health

• Capacity building programmes. • Workshop and seminar programmes

• PPI Panel to review and support funding applications

• Centralised repository of resources • Website with resources• Community facilitators, interpreters

and support • Celebration events • Community engagement

• Run health information events and workshops to share knowledge

• Training and support for individuals

Source: Out Front Minnesota

http://everydayfeminism.com/2014/09/equality-is-not-enough/

Thank you for listening

[email protected], [email protected]


@CLAHRC_EM

@EMCBMEH

This research was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health

Research and Care East Midlands (NIHR CLAHRC EM). The views expressed in this presentation are those of the

speaker(s) and not necessarily those of the NHS, the NIHR or the Department of Health.




Getting Research Into Practice





Dr Darren ClarkChief Executive

Medilink East Midlands


with Industry

Medilink UK Network

MedilinkY&H

MedilinkNW

MedilinkWM

MediWales

MedilinkEM

BioBusinessIreland

SEHTAMedilink SW

• Federation of regional organisations

• UK’s largest healthcare representative body

(1,500 members)

• Providing sector support for two decades

Common Goal

NPDTraditional Markets

Customer need Solution

Everybody’s Happy Sell to customer

Translate into product

NPDHealthcare

Clinician

Patient

Commissioner

Who is the

customer?

Allied HC

Professional

Optima Life

Aspiration:

• To introduce Firstbeat HEALTH heart rate monitoring device into the NHS

Medilink support helped:

• Identify a cardiology unit partner

• Support initial validation study - evaluation of exercise capacity in patients with chronic heart failure

Results:

• Better understanding of NHS needs / constraints

• Medilink award for collaboration

iQudosAspiration:

• To gain regulatory approval for clinical decision support software developed in the NHS


• Engagement with regulatory experts

• Reduce project risk

• Take software to full regulatory approval (one of the first in the country)

Results:

• New product ready for commercial role out

• Further investment secured

• Future job creation

• Digital Innovation award winners

www.iqudos.com

Biomarkers for prostate cancer

Aspiration:

• To define a panel of proteomic biomarkers to improve clinical management


• Introduce an additional pre-clinical trial

• Maximise the use of clinical data & samples

• Interaction with local SME

Results:

• New tools for biomarker discovery

• Conference presentations

• Additional funding applications

Future Ambition: collaborate to realize real impact

& do more for patients, the NHS & UK plc

To 2025…

• Significant reduction variation to single digit numbers through data transparency & resource planning.

From 2015…• Unwarranted variation in care and

outcomes (e.g. double digit variation between regions).

Patients

NHS

UK plc

• Limited long run performance improvements (efficiency 1-2% annually)

• Medical workforce shortages are becoming critical

• Significant long run performance improvements (efficiency 3-4%)

• MedTech supports resourcing & advanced med tech improves productivity of staff

• Limited SME start-up attractiveness• Approximately 3.300 companies• Employs 75.000 high-skilled jobs • Turnover £ 17B

• UK Top 3 MedTech start-up country• Above 3.500 companies• Above 100.000 high-skilled jobs1

• Above £ 30B turnover2

1. Assuming conservative growth rate of 3% year-on-year 2. Assuming conservative growth rate of 6% year-on-year

Assumption that current fundamental challenges are addressed

Further Information

Dr Darren ClarkChief Executive

Medilink East MidlandsBioCity Nottingham

Pennyfoot StreetNottingham

NG1 1GFTel: 0115 912 4330Fax: 0115 912 4331

e-mail: [email protected]: www.medilinkuk.com

www.medilinkem.com

Qbtech and East Midlands CLAHRC

Illustrated benefits of partnership

Tony Doyle

Managing Director Qbtech Ltd

Touch points

• Some context

• Better design

• Better delivery

What is QbTest?

FDA cleared Objective Testing Systemthat simultaneously measures attention, impulsivity and motor activity - core requirements of diagnostic criteria

The performance of each patient is compared to an age and gender matched normative control group.

6-12 years

12 countries

8 languages

More than 180 000 patients tested

Over 5 000 tests performed in the UK across >50 clinics in 2014

Cleared by FDA and registered by EMA

But..... we have a long way to go

QbTest - A Better View of ADHD

Qbtech and QbTest

QbTest

Touch points

• Some context

• Better design

• Better delivery

Better design

• Clinical audit data to inform the study from Qbtech

• Iteration of primary and secondary end points and design with experts from Nottingham

- Does providing feedback from QbTest lead to:

• earlier correct diagnosis?

• earlier optimisation of treatment?

• improved patient outcomes?

• A more relevant and potentially impactful study

Touch points

• Some context

• Better design

• Better delivery

Expertise from the Nottingham University Study team led by Professor Chris Hollis, Lead researcher Dr Charlotte Hall

Joint site recruitment effort

Real time data and weekly monitoring from Qbtech

Weekly contact with Site PIs by the Nottingham team

Monthly joint teleconferences and quarterly forums

Touch points

• Some context

• Better design

• Better delivery

• Stronger team

What are the benefits of Higher Education Institutions working with CLAHRC-EM?

Dr Lauren Sherar

Senior Lecturer Physical Activity and Public Health Research Group

Academic lead for the BHF National Centre for Physical Activity and Health

School of Sport, Exercise & Health Sciences, Loughborough University, UK

[email protected]


The aim of my research

Create evidence that can be used to leverage

changes to policies and practices to improve

physical activity opportunities for children and

youth

Have we done enough physical activity interventions in children?

So why aren’t all our children active?

Academics likely don’t know best!

Move to Teach Project

Benefits of HEI working with CLAHRC

Getting research into practice (GRIP)

1. Co-production of research

2. Knowledge mobilisation

3. Training and support

4. Flexibility and academic concession

5. Actively encouraging industry partnership

1. Co-production of research

Forces meaningful engagement, not just simple

consultation

Wider understanding of the problem

Insights that improve the intervention

More realistic, relevant and sustainable service

Update and innovate practice

Empower users by influencing change

Provides the ‘user’ with a voice

1. Co-production of research: Move to Teach project

Teacher/parent on advisory committee

Knowledge brokers

Teacher, pupil and parent involvement in

intervention development

Pilot of intervention in schools with teacher

and pupil feedback sessions

Wide interaction with a range of stakeholders

2. Knowledge mobilisation

Tacit knowledge co-created and shared in real

time between academia and practice

Knowledge brokers (diffusion fellows), CLAHRC

associates and stakeholder network facilitate this

continual knowledge mobilisation

Not just passive transfer of knowledge through

guidelines, policy, and professional bodies

standards

3. Training and Support

Engage with and support

research team in appointment

of knowledge brokers,

formation of stakeholder

research network etc.

Quarterly progress report to

monitor and advise on

implementation activities

Provide implementing change

guide and knowledge

translation strategy

Provide training events (e.g.

Implementing Change

seminar)

4. Flexibility and academic concession

Unlike some funders CLAHRC recognises the

shift in hierarchy of evidence when conducting

implementation research

Thus, academic concession is made

Not always a need for a RCT

Not all outcomes need to be measured

CLAHRC recognise implementation is not

linear, thus allow for iterative approach to

implementation

5. Actively encourage industry partnership

Partnership with industry is essential:

To translate research into practice

Drive innovation

Speed up transfer of the best ideas into new

interventions

Encourage sustainability

5. Actively encourage industry partnership: Move to Teach project

Benefits of industry partner to the project:

In kind contribution of marketing time to help with

the development of intervention resources

Disseminate the finalised teacher resource (e.g.

web platform, training materials) through existing

social media and websites

Promote the service and/or facilitate discussions

with their wider network of stakeholders and

policy makers

Funding for implementation research: The dangling carrot for HEI

The aim of my research

Create evidence that can be used to leverage

changes to policies and practices to improve

physical activity opportunities for children and

youth

Rather than informing, I want to be part of the solution

Thank you for listening!

8 year old boy, PPI event, Nov 11 2014

Cognitive Stimulation Therapy (CST)

for dementia

=> getting evidence into practice

Professor Martin Orrell

Director, Institute of Mental Health, Nottingham

Bob Woods, Aimee Spector, Elisa Aguirre, Amy Streater, Juanita Hoe, Zoe Hoare, Ian

Russell, Charlotte Gardner, Vasiliki Orgeta, Fara Hamidi, Phoung Leung, Lauren Yates

http://www.ucl.ac.uk/

http://www.ucl.ac.uk/

Cognitive Stimulation

• Distinguish from cognitive training and cognitive

rehabilitation (Clare & Woods, 2004)

• Cognitive stimulation:

– Targets cognitive and social function

– Has a social element – usually in a group or with a

family care-giver

– Cognitive activities do not primarily consist of practice

on specific cognitive modalities

NICE-SCIE guidance (2006) www.nice.org.uk

• People with mild/moderate

dementia of all types should be

given the opportunity to

participate in a structured

group cognitive stimulation

programme … provided by

workers with training and

supervision … irrespective of

any anti-dementia drug

received …’

http://www.nice.org.uk/

CST & maintenance CST

programme

The programme

1) 14, 45 minute sessions (2 x week, 7 weeks)

2) Participants asked to give a group name

3) RO board

4) Sessions begin with warm up exercise

5) Bridging between sessions, consistency in time,

place, participants and facilitators

6) Presenting sessions in a fun and stimulating way

CST trial (Spector et al., 2003)

CST Key Principles

• Orientating people sensitively / when appropriate

• Information processing and opinion rather than factual

knowledge -> implicit learning

• Multi-sensory stimulation

• Flexible activities to cater for group’s needs and abilities

• Using reminiscence (as an aid to here-and-now)

• Building / strengthening relationships

Attrition Rate: n= 201, n=168 at follow up

Significant improvement in the primary outcome measures

cognition and quality of life

Improvement in QoL mediated by improvement in cognitive

function

Numbers needed to treat for cognition = 6similar to AChEIs

CST trial (Spector et al., 2003)

•23 centres (18 care homes and 5 day care)

•A multicentre Randomised Controlled Trial (RCT)

Treatment and Control Groups -

differences between baseline and

follow up: Cognition (n=201)

MMSE

p=0.04

ADAS

p=0.01

-1

0

1

2

3

ch

an

ge

treatment

control

p=0.03

-1

-0.5

0

0.5

1

1.5

1ch

an

ge

QOL

Treatment and Control Groups -differences between baseline and

follow up: Quality of Life (n=201)

treatment

control

Cost-effectiveness (Knapp et al., 2006)

CST is more cost-effective than usual activities using both

outcome measures:

• Incremental cost-effectiveness ratio: £75.32 per

additional point on MMSE (111 euros), £22.82 per point

on QoL-AD (33.2 euros)

• Donepezil had larger cost per incremental outcome gain

(AD2000, 2004)

Conclusions: Small costs outweighed by larger gains likely

that decision makers will see CST as cost-effective.

Limitations – short time span, mainly focused on people in

residential care

Cochrane Review 2012Woods, Aguirre, Orrell, Spector

• 15 trials, 407 treatment and 311 controls participants

• Length of intervention varied: 1 to 24 months

• MMSE difference at follow up = 1.74 points (Z = 5.57, p < 0.00001)

• Holden Communication Scale SMD = 0.47 (Z = 3.22, p = 0.001)

• Wellbeing/QoL SMD = 0.38 (Z = 2.76, p = 0.006)

• Depression (GDS) SMD = 0.34 (Z = 1.88, p = 0.06)

• No benefits to ADL, behaviour, or carers measures

Development of the MCST trial

programme

Maintenance CST development

• Extract features of research trials which had demonstrated

effectiveness

• New themes : Useful tips (caring from oneself, memory

tips, use of calendars, alarms) and Visual Clips from

Requena (2007) and Olazaran (2004)

• 24 sessions based on the CST and MCST pilot plus new

identified studies

• Presentation of the draft version 1 in a consensus

conference to develop draft version 2 of the manual.

Modelling the programme

9 Focus Groups

(Aguirre et al., 2010)

• 17 people with dementia, 13 staff and 18 family carers

• Inductive thematic analysis to examine user perceptions

of the Maintenance CST programme

• Mental stimulation highly valued by PWD, vital to keep

healthy and active.

• Most family carers and staff very positive towards

cognitive stimulation programmes BUT some concerns:

- When use it or lose it doesn’t apply

- Concerns about loss of confidence, anxiety, sense of inferiority.

• Positive agreement was found among 14 themes and

suggestions were made for the 5 remaining themes.

• Carers and staff rated using money and current affairs

very low - felt using money could be a sensitive topic

and current affairs was a theme people with dementia

wouldn't relate to

• In contrast people with dementia expressed a great

interest in the using money theme and in the news

Focus Groups results

(Aguirre et al., 2010)

Maintenance CST vs. CST

8 to 10 ParticipantsCST group A

8 to 10 participantsTAU

Randomised 236

BASELINE

ASSESSMENT

7 WEEKS CST

Twice a week (14 session)

BASELINE

ASSESSMENT 2

3 MONTH Follow Up

24 WEEKS MCST

Once a week (24 session)

6 MONTH Follow Up

8 to 10 ParticipantsCST group B

8 to 10 participantsMCST

Randomised 272

CST Predictors of change

• 272 recruited to CST groups as first stage of

Maintenance CST Trial and 236 completed 7

weeks

• Improvement 1.09 MMSE points (p < 0.001),

ADAS-Cog 2.34 points (p< 0.001)

• Improvement 1.85 DEMQOL points (p < 0.003)

• Female gender was associated with higher

improvement

• use of ACHEIs did not alter improvement

Maintenance CST Trial –results

• 236 participants (123 MCST/123 CST only)

• After 6 months MCST

– Quality of life better QoL-AD p = 0.03

• After 3 months MCST

– Quality of life better (proxy)

DEMQOL p = 0.03, QoL-AD = 0.01

– ADCS-ADL better p = 0.04

• People on ACHEIs did significantly better on

cognition if MCST rather than on CST only

• Qualitative study of experiences of the people attending CST groups, carers & group facilitators (N=34)

• Data analysed using Framework Analysis

• Two main themes:' Positive experiences of being in the group’ & ‘Changes experienced in everyday life’

• Experience of CST seen as being emotionally positive

• Most reported some cognitive changes.

• Findings support the mechanisms of change suggested by the previous RCT of CST.

• Spector, Gardner, Orrell 2011

CST mechanisms of change

Maintenance CST implementation in practice

Amy Streater – study overview

Title STANDOUT trial MONOU trial Observational study

Aim To assess the

effectiveness of staff

training & outreach

support

To assess the

implementation in

practice of CST&

outreach support

To assess the effectiveness of

CST in practice

Participants Qualified & non qualified

dementia care staff

Qualified & non

qualified dementia

care staff

People with dementia

Expected

number

120 120 100

Actual

number

175 66 89

Resources CST manual,

maintenance CST

manual & DVD

CST manual,

maintenance CST

manual & DVD

CST manual, maintenance

CST manual & DVD

Training Yes Variable Variable

Outreach 50% 50% Variable

Assessment

schedule

Baseline, 6 & 12 months Baseline, 6 & 12

months

Before & after CST and after

maintenance CST

Outreach support queries

15 uses of outreach supporting across 35 centres raising 21 queries relating to:

group participation, inclusion criteria, practicalities, delivery of the programme, group facilitation. After CST, activity theme and general queries.

3 centres signed up to the online forum

Staff CST results

No statistically significant difference in the proportion of CST groups run in

the intervention group compared to the TAU group (p=.458).

Intervention Number of centres No CST CST programmesrun

Outreach support n (%)

35 17 (49) 18 (51)

No outreach support n (%)

28 16 (57) 12 (43)

Staff maintenance CST results

There is a statistically significant difference with more

maintenance CST groups run in the outreach support group

compared to TAU group (p=.011)

Secondary outcome measures

Approach to dementia, job satisfaction, controllability of challenging behaviour, sense of competence, learning transfer, barriers to change and dementia knowledge

No difference

Observational study

Cognition and quality of life remained unchanged over the duration of the study.

When excluded participants scoring 25 or above on the MMSE.

Significant improvement in cognition after CST (p=.04)

No difference between BL and after maintenance CST.

Quality of life remained unchanged.

Comparison with a control group

Measure Spector (2003) contolmean change (SD) [N]

Current study meanchange (SD) [N]

Values

MMSE -0.4(3.5) [70] 1(4.6) [47] t = 2.04; p = 0.04

QoL-AD -0.8(5.6) [70] -1.4(9.3) [46] t = 0.08; p = 0.94

Conducted as no control group for this study.

Meta analysis comparison of mean change in CST groups

compared to control group (Spector et al., 2003).

1.4 point increase on MMSE for CST programme.

Quality of life unchanged.

Development of Individual Cognitive Stimulation Therapy

• 75 individual cognitive stimulation

sessions

– Delivered by the family carer

– for 30 minutes, 3 times a week, over 25 weeks

Sessions aim to:

• Provide mental stimulation

• Each individual CST session consists of a themedactivity, i.e. being creative

• iCST is guided by therapeutic principles, avoidingdirect memory questions, focusing on opinions ratherthan facts

______________________________________________________________

iCST Revision of Materials

Useful comments by experts, people with dementia, and carers

Key comments and revisions

Emphasise on positive aspects of iCST

This will empower carers involved in the programme

iCST needs an emphasis on both the family carer and

the person with dementia and should be person centred

Describe the purpose and content of activities as an

opportunity for discussion

Focus on images in the iCST sessions, as ‘images are

less threatening than words”

______________________________________________________________

iCST Carer Support

Key areas of support for family carers in main RCT

Carers receive the following types of support

A Set-up visit

Home based training with an opportunity to ask questions about iCST

Telephone support (preference for weekly support)

Two home visits after completion of 50% of the iCST sessions and at the end of iCST

Training protocol in place to ensure consistency in training

Treatment protocol in order to guide researchers

Treatment Adherence Reporting following previous models emphasizing the need to specify treatment implementation

______________________________________________________________

Referred/screened (n = 1340)

Baseline Assessment & Randomisation (n = 356)

Follow-up 1 - 13 weeks assessment (n = 288) 68 losses52 withdrawals (including 4 deaths) 16 agreed to follow up 2

Follow-up 2 - 26 weeks assessment (n = 273) Further 31 dyads withdrew (4 deaths)83 withdrawals overall retention rate 77%, attrition rate was 21% excluding deaths (predicted rate in updated sample size calculations

No difference between centres at FUP2 p = 0.33

Perception of allocation at 26 weeks

Treatment allocation

Researcher rating iCST (%) TAU (%) Total (%)

‘Definite’ judgment: Correct 22 (19) 4 (3) 26 (10)

‘More likely’ judgment: Correct 17 (15) 17 (12) 34 (13)

Equally likely to be in iCST or TAU 65 (57) 80 (57) 145 (57)

‘More likely’ judgment: Incorrect 10 (9) 31 (22) 41 (16)

‘Definite’ judgment: Incorrect 0 9 (6) 9 (4)

Total 114 141 255

Main Results356 participants across 8 UK centres seen at baseline, 3 & 6 months

At six months no differences in primary outcomes

ADAS-Cog cognition: difference -0.55 (SE) 0.74; p = 0.45

quality of life: difference -0.14, (SE) 0.50; p = 0.78

People with dementia (iCST) improved carer relationship

difference 1.77 (SE) 0.77; p = 0.02

Improved quality of life for the carer at 6 months Carers (iCST) higher quality of life difference 0.06 (SE) 0.02; p = 0.01

Adherence analyses:

Dyads completing more iCST sessions also showed lower carer

depressive symptoms p = 0.018

Positive outcomes for people with dementia

My dad’s mood is

lifted during

sessions

My mum seems

more confident

and like her old

self

Mum is more alert

after sessions

Mum’s

conversational

skills seem to

have improved

Mum is enjoying

the activities

Cognitive Stimulation Therapy for dementia

• Cognitive and social activities in group or with family carer

• Easy to deliver using standard manuals & DVD

• CST principles also useful in practice

• Benefits to cognition and quality of life (Spector 2003; NICE, 2006, Woods 2012; World Alzheimer Report ADI, 2011; Orrell et al., 2014).

• Cost effective (Knapp et al 2006) and savings to NHS of potentially £54 million/year (Institute for Innovation 2011).

• Works in synergy with cholinesterase inhibitors

• Used in 65% of UK memory services

• CST website: www.cstdementia.com

• Making a difference 1/2/3 and DVDs from http://www.careinfo.org/books/

• 25 countries using CST

• Join the CST Network - email [email protected]

http://www.cstdementia.com/

http://www.careinfo.org/books/


Creating New Solutions to Healthcare Challenges




From Research to the

Real World

Facilitator – Sally Boyce,

Implementation Manager

Ambergate Room

Building a Research

Active Workforce

Facilitator – Dr Emma

Rowley, Capacity

Development Lead

Alfreton Room

Engaging Diverse

Communities: Why its

Crucial & How to Do it

Facilitator – Dr Paula Wray,

Public Involvement

Programme Lead

Barber Room

Thank you for attending


@CLAHRC_EM

nihr clahrc east midlands annual meeting 2015 presentations - day 2

Healthcare

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