For our latest interview we were joined by David Hammond, deputy chief strategy officer, and Claire Wedge, chief nursing information officer and deputy chief nurse, both from Wirral Community Health and Care NHS Foundation Trust. David and Claire joined us to discuss their work using data around falls and frailty.
David has the trust’s programme management office as part of his portfolio and is a strategic project lead for a range of projects, including one around population health management and proactive care which he and Claire went on to discuss in more detail. He described himself taking a “very practical” approach: “With strategy as a key part of my role, I always keep in mind that unless you can turn it into something meaningful, it doesn’t add real value. ”
Claire has been a registered nurse for 24 years and has previously worked in NHS acute, research and community settings. She is also a Florence Nightingale scholar and leads a broad portfolio within the trust including clinical digital transformation, quality and safety. She shared that she has recently commenced a professional doctorate with the intention of focusing on how to ensure clinical safety when working with multiple partners across the system, which she noted “may highlight some areas where we can enhance the use of digital technologies”.
Picking up on David’s point about needing to add value, Claire said: “It comes back to the question of ‘so what?’ It’s so vitally important to ask that. Whatever we do with digital and data, it needs to add value for our staff so that they can deliver services to people in our settings and our community.”
Digital and data at Wirral Community Health and Care
Claire: Our work in this area is all underpinned by our three-year digital strategy, which we developed in 2022. There are four key aims within the strategy; firstly, supporting teams to deliver efficient, safe, high quality care, by making best use of shared service platforms. The other aims focus on helping people to access services easily and manage their own health and wellbeing where appropriate; to improve wider population health; and to improve the environment for our workforce, so that staff feel psychologically assured that they are accessing real-time information that can help them make clinical decisions.
From a CNIO perspective, these aims have led to a number of digital workstreams, including how we use technology and remote monitoring to support access and how we have developed and enhanced internal governance via the use of dashboards supporting increasingly mature triangulation of data and data analysis. That’s trust-wide and runs across all services; it’s centralised on one accessible platform, the Trust Information Gateway, and it provides assurance that all staff can access the same consistent information irrespective of role or location.
We’re currently reviewing our clinical systems to identify opportunities for streamlining digital systems, to ensure that they are intuitive and provide a positive end user experience. Coming back to the point about practicality; they need to work, and they need to work well.
A key project Dave and I will discuss today is the development of the falls predictive risk tool, which was a collaborative project with system partners.
The challenge of connectivity
David: Over the past five or so years, within the Wirral system, I’ve been focusing very much on how we can provide better services for people who are particularly vulnerable to experiencing health inequalities. Numerically, older people with frailty are one of the largest groups who may face this – particularly those at the more moderate-to-severe end of that frailty spectrum. That is where people are most likely to need the support of health and care services, and where people are most likely to have quite a lot of engagement with services.
I think a challenge in the wider NHS lies in coordinating care around these individuals. They can receive lots of input from different teams, organisations and services, but often it is done in quite a haphazard way. I would probably say that this has increased since 2019 with the development of primary care networks and all the additional roles within the PCN footprint, such as physiotherapists and advanced nurse practitioners. It means we’ve got even more complexity in the system. About three years ago, we did some work with our local PCNs which aimed to explore the range of services that may be involved for an older person with moderate or severe frailty. The lack of connectivity between those services was quite stark.
More recently, we have been working with three of the PCNs and with one in particular, looking at how we can provide well-coordinated, person-centred and proactive care by making the best use of the information that we already have. We found that when we looked at a case study of one individual, it was not difficult to piece together all the component parts of a holistic assessment; but it did take a long time, because all of the information wasn’t in one place and it required searching through uncoded data, attached files, letters between providers, and the like. What was particularly absent was any log of what mattered to him as an individual, or what mattered to his loved ones.
We identified that whilst we might have all the different pieces to the puzzle for understanding what a person might need, based on what we know and what’s already being done, we weren’t putting them together. There’s a massive opportunity to do that, and that’s been a real focus of the project I’ve been leading: what does a genuinely integrated approach look like?
Developing the falls predictive risk tool
Claire: During my career I’ve had a passion for working with older people, and I’ve previously worked in falls prevention services within the community. Falls can have a devastating impact on people, leading to social isolation, reduced activity and deconditioning, which in itself can increase the risk of falling.
Along with colleagues in the system from across Wirral, we started to analyse data regarding admission to hospital following a fall. That helped us to identify learning themes, but it’s retrospective. With a view to taking proactive action, I started to explore how we could use the available data to develop a bespoke tool to predict the risk of a person within the community experiencing a fall likely to put them in hospital, over the next 12 months.
There are other tools that clinicians can use, but we didn’t have anything centralised that could bring in a whole system view of all the data these different services have.
We developed this tool over 12 months; it was clinically led and digitally enabled, with a multidisciplinary team working on it. We had lots of roles involved such as occupational therapists, physiotherapists, nurses and medical input. All these people formed a group and we met regularly. It was important to ensure that we had structured, robust governance throughout and clear communication flows – we asked staff for their experiences of frontline clinical practice and what data would they need to be accessible to inform their decision making. Then we worked with a technology supplier to help us develop this into an intuitive tool to support that decision making.
The tool that we have developed is very visual; we’ve used theographs which are visual representations of the contacts that an individual has had with health and care services over a particular period. Using that visual representation, you can look at whole PCNs, practices or an individual level. You can start to understand activities and map it across geographical areas, looking from an inequalities lens, to really understand where you need to focus attention and how you can maximise clinical support to particular areas or individuals within GP practices. From a multidisciplinary perspective, that really supports you in taking a proactive approach.
It started off from a falls perspective, but the tool can be adapted to other settings – for example, it works really well with Dave’s frailty work. The future will see us hopefully test and incorporate this tool into that area of work.
David: I think that’s the challenge – you can be data-rich, but you need to have a means of doing something with that data. It needs to be part of somebody’s job to do something with it, and they need to understand it, to view it as a core part of their toolkit and not something additional.
Using the tool within an integrated team
David: That’s been the thinking behind the work we are doing with Moreton and Meols PCN. What is the functionality that is needed on a PCN footprint, to provide really good, well-coordinated, person-centred care? We need to 1) collectively recognise those people who are going to benefit from that particular approach, 2) bring existing information about them into one place, 3) consistently do really high-quality assessment and care planning, and then 4) the output of that can be shared and individuals can be tracked within that PCN. That way, we’ll know who’s had what level of support and what assessment and care planning may be needed; when they are due a review; and also if something happens in the meantime, they can be quickly followed up. It comes back that idea of ‘care traffic control’ and understanding who requires this level of proactive support and how we can actively coordinate that.
Over the course of a few months, to test this model, we have developed an integrated frailty team including a paramedic and pharmacist from the PCN, a nurse practitioner for older people and a combined admin and clinical role as well as a senior matron. This team uses a combination of risk stratification and referrals to identify people in need of support, and the falls predictive tool is going to be one of the component parts of their armoury.
It’s early days, still; the team formed in January, but I would say it’s been a joy to see just how engaged they are, and how fast this approach has been developed.
One member of the team is really confident with using EMIS, and it’s been really interesting to observe how she has been able to build searches within EMIS to pull coded information from the health record to inform fast clinical decision-making. It has become a core part of the triage process, and so much time that was taken up by trying to share information manually has been cut. We’ve had someone comment that they feel as though they were working in an analogue world and they’ve suddenly stepped into a digital world – they feel that it is helping them to rapidly make change happen.
Next steps
Claire: We have subsequently taken the falls predictive tool to a GP practice and they have tested it out on a small caseload of their own. It was found to be accurate in terms of identifying people who are at risk and it resulted in some significant assessments.
Our next stage of testing will be to incorporate it into our wider frailty work so that it becomes a main tool for those teams. At the end of the day, with tools like this, it’s all about adoption; so many great pieces of work end up not getting used. But I’m really hopeful that this tool will prove to be effective and continue to develop.
We need to see the outcome of this pilot, and then we aim to scale up use of the tool at pace. We need to make sure that we listen to people’s feedback as they use it and take it on board, learning and collaborating as we go – that includes patients and carers. It needs to be holistic, both for the people we are providing services to and our frontline staff.
Ultimately, we’d love to get to a point where we can roll the tool out across the Wirral system, dependent on the data and feedback we get back. And I think we can be bold; if it works at Wirral place level, surely it can work at ICB level and maybe even nationally.
Tips for other teams
Claire: With regards to advice for other trust teams who may be looking at implementing data-driven projects, it comes back to engagement and collaboration, particularly ensuring that you have that in place from the earliest part of the process.
I think it’s important to acknowledge that there are different levels of knowledge across the system and different levels of digital readiness – we need to be mindful of that and work collaboratively with people. You need to have very clear aims on what you are trying to achieve and think about how you are going to evidence the success of the project.
David: There is absolutely no substitute for regular, detailed discussion with the people who are actually doing the work, and approaching the project with a quality improvement mindset. I was involved in a hospital discharge project where we made six significant changes to a pathway based on frontline feedback, and I think any project could follow that same path.
With data, I think it’s key that people can track progress as well as make comparisons. We’ve been looking at the data from A&E visits and unplanned admissions for people with severe frailty (based on the electronic frailty Index) and we’ve been able to break that down to practice level. We’ve then developed a ‘control group’ of sorts – by that I mean other PCNs in the Wirral area with a similar level of frailty within their practice populations. As the months progress, we’ll be able to compare this data as well as tracking the changes for Moreton and Meols PCN specifically.
Ultimately, the use of data like this must become part of the day job; and in order for that to happen, it has to be really simple and straightforward for staff.
Many thanks to David and Claire for sharing their insights.
