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John Craig, Chief Executive of Care City, blogs about their experience of innovation and improvement through their work as an NHS England Test Bed.

Saturn V launched the first space station, but legend has it that the plans for the rocket were lost. In recent years, NASA scientists looking to re-energise lunar exploration have not been working from documents – they have taken a 40-year-old Saturn V into their workshop, and tried to fire it up.

Is it a farce that NASA’s engineers have to start again? Not at all. The story that the plans for Saturn V were lost is false. Plans just aren’t as valuable as we think. NASA’s plans didn’t get close to capturing what it really took to make the rocket’s 1 million components, let alone how to make them work together.

Abstracted from the people who use them – and the culture in which they work – brilliant tools and plans make much less sense than we might expect. The problem for health care is that this kind of abstraction happens a lot.

Many improvement teams are clinically dominated, and spend most of their time working inside single health care organisations. Abstracted from the development of new tools and approaches, they can struggle to challenge prevailing orthodoxy.

At the same time, too much innovation is outside-in, driven by technologists and entrepreneurs rather than clinicians and patients. Abstracted from the people who use their products, they can focus too narrowly on specific transactions, and miss the bigger picture.

At Care City – through our work as an NHS England Test Bed – we have seen first-hand the effect of overcoming these divides, and better connecting technologists, entrepreneurs, clinicians and patients.

Even the best and most radical innovations require the same painstaking improvement cycles to really work and achieve excellence. No matter the quality of training, support and information, clinicians – like those NASA engineers armed with reams of blueprints – have a huge amount to do to make sense of an innovation and to make it work. Implementation is a creative act.

Equally, clinicians who only want to improve outcomes for their patients can drive dramatic innovation. Care City worked with Alivecor’s Kardia Mobile – a mobile ECG – looking at its potential for the atrial fibrillation pathway. We tested the technology with a huge range of stakeholders to generate ideas. We tested screening services, both within GP practices and community pharmacies. Building on what we learned, we tested a new pathway, enabling community pharmacies to refer directly to a one-stop clinic at Barts Health. The evidence suggests that this pathway is quicker, more cost-effective and has the potential to prevent 1,600 strokes nationwide.

But who was the innovator in this example? In the language of the Test Bed programme, it is Alivecor, but their product is unchanged by the process.  Leaders and clinicians on the other hand – like Dr Sotiris Antoniou from Barts Health – have led the development of a new pathway.

As Care City reflects on its first Test Bed programme, it is absolutely clear to us that the Health Foundation is right that improvement across health and care will not be achieved without the infrastructure, skills and relationships to support it.

We also reflect on some of the distinctions we take for granted in health care. First, health care still distinguishes strongly between improvement and innovation. Both are useful terms, and the way innovations introduce a ‘new dimension of performance’ is distinct. However, do these activities need to be pursued separately, by different people, in different organisations in different ways? This distinction may reinforce both the insularity of improvement work and the disconnection of innovation from the needs of health systems.

Relatedly, health care thinks of improvement as a science and innovation as an art. Is there much more to this than the personalities and habits of those engaged in the work? Improvers must retain ambition for dramatic progress, and be open to uncertainty and to the toughest challenges we face. Innovators must remember that – however beautiful the app or the tool – the only real benchmark is better outcomes for people using the innovation.

Lastly, we believe we should be more sensitive to the number of conversations that are about innovations or workforce, but not both. As shortages not just of money but also of people intensify, we need to be clearer that the purpose of all innovation is productivity. Developing our people and the tools they use should happen together, and that will be at the heart of Care City’s work for the future.

Care City and HealthUnlocked’s collaboration bears fruit as the HealthUnlocked EMIS plug-in for social prescribing goes live across Barking & Dagenham.

Barking and Dagenham GP’s will be able to quickly and easily deliver a digital social prescription to their patients as part of their standard consultation or appointment as the HealthUnlocked EMIS plug-in for social prescribing will go live across the Boroughs over the coming weeks.

The tool that directs and signposts patients to local services, charities and voluntary sector support, and relevant HealthUnlocked online support communities was developed and tested by HealthUnlocked in collaboration with Care City as part of the NHS England & Office of Life Sciences Innovation Test Bed Programme and has proved popular with both GPs and patients. London Borough of Barking & Dagenham and Barking & Dagenham CCG have agreed to work with Care City to grow its use and transform health and care services in the area for the better.

Since February, the HealthUnlocked solution has enabled over 600 social prescriptions to be issued in eleven practices across Barking & Dagenham. Of these prescriptions, most related to helping patients to get active, eat healthily and lose weight loss and to dealing with anxiety and depression.

The solution will be sustained and extended as part of Care City’s partnership with LB Barking & Dagenham, funded under the Better Care Fund. Most practices will use the tool to send social prescriptions directly to patients – in some cases, this will be mediated by a Link Worker, to whom the patient is referred, for more intensive face-to-face support.

John Craig, Chief Executive, Care City commented “As well as promoting healthy lifestyles, public services are very conscious that loneliness and isolation can undermining health and well-being, costing services money. Social prescribing tackles these issues head on. This digital approach to social prescribing enables GPs to connect people to the resources that exist all around them – places where they can make friends, get expert help, or both. These digital tools do not replace face-to-face help; on the contrary, they are designed to help people to build the relationships that can make a real difference to their lives”.

Dr Matt Jameson Evans, Chief Medical Officer of HealthUnlocked said: “By using digital social prescriptions and opening up support and services to patients, we can give people the tools to a better quality of life, reduce reliance on medications and reduce demand on Emergency Departments and GPs in the NHS. I’m delighted that our collaboration with Care City has extended beyond the initial pilot and is now going to be changing lives across Barking & Dagenham.”

This news follows the announcement last week that Care City alongside the BHR Provider Alliance has committed to rolling out its Atrial Fibrillation (AF) Pathway across Barking, Havering & Redbridge, working with local community pharmacies and hospitals to find and treat AF and prevent strokes.

The BHR Provider Alliance states that transforming the pathway of care for Atrial Fibrillation is its top priority.

We are delighted that the BHR Provider Alliance has committed to rolling out our Atrial Fibrillation (AF) Pathway across Barking, Havering & Redbridge, working with local community pharmacies and hospitals to find and treat AF and prevent strokes.

The BHR Provider Alliance brings together health and social care providers across Barking and Dagenham, Havering and Redbridge in order to deliver integrated care for our communities and improve population health. Local authority and NHS providers of services, including hospital, community and GP services, work together in the alliance to provide health and care services in the most appropriate way for their population. The Provider Alliance is working with local commissioners to support the development and delivery of an Integrated Care System across the boroughs.

Launched at the Health & Care Innovation Expo last year and developed as part of Care City’s NHS England Innovation Test Bed Programme, the new One Stop AF Pathway finds people with undiagnosed AF, reduces the number of appointments needed to confirm diagnosis and waiting times for treatment. Kardia Mobile, a handheld mobile ECG device can spot AF in 30-seconds. Those with an abnormal result are then reviewed by a Specialist Arrhythmia Nurse and where necessary invited to attend an appointment at the One Stop AF Clinic at Whipps Cross Hospital for further diagnostic tests and, if appropriate, treatment.

Initially only available at 20 community pharmacies, the BHR Provider Alliance has now committed to rolling out the technology and transforming the pathway of care for AF across the Boroughs of Barking, Havering and Redbridge. 

John Craig, Chief Executive, Care City commented “A challenge to the adoption of digital innovation across the health and care system has been how to secure commitment from clinicians to use the technology and understand the benefits to them, their patients and the NHS. We’ve found that the trick is to re-frame the problem, present how digital technology can enable clinicians to become innovators in their own right”.

He continued “Without pathway innovation like this, the NHS will struggle to realise the benefits of this great technology, for which they are paying millions. We are delighted that the BHR Provider Alliance understand this and that they have not just committed to distribute the technology, they are transforming their pathway at scale”.

John Brouder, Chief Executive, NELFT & Co-Chair, Provider Alliance, commented “As an alliance, we are determined to play our part in transforming the health and care system in the interests of local residents. As a local organisation dedicated to health and care innovation, we recognise that success is not about eye-catching initiatives, but improving outcomes at scale. Having reflected as an Alliance on our priorities for 18-19, we have decided to make work to transform the pathway of care for atrial fibrillation across BHR our top priority”.

He continued “We are impressed with the early findings from Care City's work deploying Alivecor's Kardia Mobile and are delighted to work with the Care City team to build on their learnings around AF and mobile ECG technology to transform the AF pathway across BHR. We hope that this can improve outcomes and experiences for our patients, and help to reduce costs. At the same time, we hope that it can be a model of the kind of integrated care we are seeking to develop as an Alliance, and of the ways in which we can work together across the system to transform services for the better”.