Overview
There are eleven project summaries in total for the Closing the Gap award. If you would like more information, you can also download a leaflet containing more detailed case studies on the projects (196 kb) ![[pdf]](http://www.health.org.uk/display_images/document_icons/pdf.gif){kind=icon}
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Enhancing care and saving lives of people with chronic kidney disease
Kidney Research UK and East Midlands Renal Network
Chronic kidney disease is a common condition affecting 10 per cent of the population. If it is caught early, treatment can prevent or delay its progression, but advanced forms can require intensive treatments such as dialysis, and may be life threatening. However, symptoms are difficult to detect. Many people are not diagnosed at all, or are diagnosed too late to avoid severe complications.
This project aims to ensure the condition is caught earlier within primary care, and to improve the consistency and quality of care of people with early kidney disease. In particular, it is seeking to build knowledge and understanding among primary care staff about best practice in managing chronic kidney disease, and to ensure that it is implemented. It is also working to establish measurable tools to help empower people with chronic kidney disease to better manage their condition, and is helping create a systematic body of knowledge about managing chronic kidney disease.
The initiative is targeting medical practitioners, through a care bundle (a set of interventions), and patients, through a set of patient empowerment tools. It is also working to evaluate the potential use of the care bundle approach in managing other long-term conditions, such as type 2 diabetes, chronic heart disease, and risk of stroke.
Delivering better care for infants with brain injury
Cambridge University Hospitals NHS Foundation Trust in conjunction with the East of England Perinatal Network
About one in 500 newborn infants develops hypoxic-ischaemic brain injury – a form of brain damage usually due to an oxygen shortage around the time of birth. 10-15% of these babies will die soon after birth. The remainder may develop cerebral palsy, learning difficulties, behavioural problems or autism, reducing their own quality of life and putting the whole family and wider community under strain.
Medical care of these infants has largely focused on minimising further damage. However, there is a growing awareness of the potential of techniques such as inducing mild hypothermia to prevent brain damage, and of the role of MRI scanning, developmental checks and parental involvement to paint a more detailed picture of the situation and address the child’s ongoing needs.
This project aims to improve the quality of care for children with brain injuries in their early years through an integrated, coordinated and family-centred service that brings together the key individuals responsible for their care. At the heart of the project is an expert team that focuses on developing training for healthcare professionals in all aspects of managing their care, and developing systems for parents to engage in and influence the services they receive – particularly after discharge. This work is supported by a dedicated neuroprotection coordinator responsible for ensuring that all babies receive the same standard of care, from birth to follow-up.
Abdominal aortic aneurysm, improving outcomes for patients
The Vascular Society of Great Britain and Ireland
Between 4 and 8% of older men are affected by an abdominal aortic aneurysm, and each year in England and Wales about 7,000 men die when these aneurysms rupture. But detecting an abdominal aortic aneurysm is challenging. Most do not produce symptoms, and an aneurysm may rupture without warning.
To reduce the number of deaths from this condition, the government has announced a national screening programme to identify and treat at-risk aneurysms before they rupture. However, the treatment itself comes at a risk. The operation – either open surgery or endovascular stenting – carries a 7.5% risk of mortality. For the screening programme to be effective, it is necessary to reduce the risk of death to a minimum. This should be feasible, as in other European countries this risk is lower, at 4%.
This project seeks to reduce the mortality rate of aneurysm surgery. It is doing this by introducing best-practice protocols for abdominal aortic aneurysm surgery to all UK vascular units, auditing the extent to which they are adopted, and targeting change in centres with high mortality or that are not adhering to the protocols. A 4% reduction in mortality would save 240 lives each year – not only ensuring the best standard of care possible to patients, but increasing the likelihood of success of the new screening programme.
Optimising care pathways for acute stroke and transient ischaemic attack
Network of two PCTs, three acute hospital trusts and the ambulance service, user organisations and academic expertise, in Coventry and Warwickshire
Stroke is the single biggest cause of major disability in the UK and the third cause of death in most western countries. Meanwhile, transient ischaemic stroke (also known as mini-stroke) is less serious, with symptoms resolving within 24 hours. However, there is a growing awareness that people who have had a mini-stroke are more likely to have a stroke, and must be diagnosed and undergo drug treatment and lifestyle changes to reduce this risk.
The underlying cause and effective treatment for strokes and mini-strokes are well understood. However, a high proportion of patients who have had mini-strokes still go on to suffer strokes, and the condition continues to cause significant morbidity and mortality. The UK has the most expensive stroke services, but its outcomes compare poorly with those of other countries, with high levels of avoidable disability and mortality.
This project has two main aims. The first is to improve the quality of urgent care for strokes, by improving the number and accuracy of referrals to urgent care (particularly by ambulance staff), improving the speed of access to urgent care, and raising awareness of best practice. The second is to develop and implement evidence-based care for people who have had mini-strokes. This involves a range of initiatives, including developing an agreed pathway of care for patients with a suspected mini-strokes, improving rapid access to acute care, and providing and testing awareness-raising programmes for hard-to-reach at-risk groups.
Using quality networks to improve mental health services
Four quality improvement networks managed by the Royal College of Psychiatrists Centre for Quality Improvement
The Royal College of Psychiatrists manages 12 national quality improvement networks that support UK mental health services to meet recognised standards. There have been many improvements as a result, but there are some areas of persistent and recurring problems.
To address this issue, the college has identified four networks to participate in a pilot to find ways to strengthen the capacity of their members, by designing and delivering tailored programmes that will effect change within services.
The Prescribing Observatory for Mental Health seeks to improve the quality of prescribing practice for people with severe mental illness. Its work has included highlighting failure to follow NICE guidance on prescribing antipsychotic drugs.
Both the Quality Network for Inpatient Children and Adolescent Mental Health Services and the Quality Improvement Network for Community Child and Adolescent Mental Health Services focus on young people’s mental health services. They argue that their respective services should be better integrated with each other, and have flagged up issues such as insufficient access to clinical psychologists in inpatient units.
Finally, the Community of Communities quality assures and accredits therapeutic communities offering highly specialised psychological therapies for people with complex needs such prison therapeutic services and memory clinics. One weak area it has identified is poor collation of outcomes-related data.
An implementation team will find new ways of enabling services within each of these networks to improve their performance, and will regularly measure and review progress. The approach can then be rolled out to all 12 networks.
Promoting earlier diagnosis of brain tumours in children
Children's Brain Tumour Research Centre University of Nottingham, Royal College of Paediatrics and Child Health and the Samantha Dickson Brain Tumour Trust
A quarter of all childhood cancer occurs in the brain, affecting 1 in 2,500 children, and more children die of brain tumours than any other cancer. Meanwhile, long-term survivors of childhood brain tumours are 10 times more likely to experience disability than well children, and often require state or family support in adulthood.
A key problem is the length of time it takes to diagnose. In the UK, children wait up to three times longer for diagnosis than children in Canada and the United States. In the UK children are often unwell for two-to-three months before diagnosis and may not be diagnosed until they are at risk of death or severe neurological damage. This increases the likelihood of long-term neurocognitive disability and visual impairment. The fact that children elsewhere are diagnosed more quickly indicates that there is room for improvement.
This project is a web-based initiative designed to support families, young people and healthcare professionals by raising awareness and promoting earlier diagnosis of childhood brain tumours, thereby enabling earlier medical intervention and improving outcomes. Its work involves enhancing awareness within practitioners of brain and spinal tumours in children, developing a website to support families and practitioners, and evaluating the programme and its impact. Its overall aim is to reduce the average diagnosis to less than five weeks from initial onset of symptoms.
Preventing blood-borne viruses through clinical networks
Central and North West London NHS Foundation Trust (mental health trust)
People with substance misuse problems have disproportionately high rates of blood-borne viruses such as hepatitis B, hepatitis C and HIV. These are transmitted mainly through injecting drugs – especially when using shared equipment – but also through the nose (when snorting drugs), and through sexual contact and tattooing.
These viruses pose a risk to the individual and their families, and pose a significant public health risk. However, surveys have indicated a poor awareness of blood-borne viruses among those most at risk. This project seeks to work through clinical networks and service user partnership, to reduce the incidence of blood-borne viruses among drug users.
The project is divided into four phases. Phase 1 involves providing screening for blood-borne viruses to all drug treatment service users, and developing systems for screening outside of these services. Phase 2 focuses on offering hepatitis B vaccination to all drug treatment service users. Phase 3 looks at clinical pathways – reviewing clinical pathways to specialist services for people with blood-borne viruses, and developing formal clinical networks between drug treatment, hepatitis and HIV services. Each of these three phases includes work to explore the patient experience, to identify potential obstacles to take-up.
Phase 4 involves setting up a workstream on sustainability, to ensure that best practice continues beyond the life of the project and is disseminated to other organisations. Finally, the project will implement a comprehensive communication strategy to publicise its outcomes and findings.
Improving quality and safety in primary care
Health Boards, NHS Quality Improvement Scotland, NHS Education Scotland, RCGP Scotland and University of Dundee, with Forth Valley Health Board acting as the host organisation and co-ordinator
Two areas of health cause particularly high levels of ill health and harm to patients: heart failure and adverse reactions to prescription drugs.
Heart failure affects 1-3% of the population, and up to 10% in the very elderly. However, patients with heart failure are under-treated. Meanwhile, 6% of hospital admissions are a result of adverse reactions to prescription drugs.This project seeks to enable 80 GP practices across four health boards in Scotland to improve their patient safety skills and quality of care, focusing on these two areas. The project involves providing training in identifying, reporting and reducing harm; improving the care of patients with heart failure within GP practices; and increasing the number receiving optimal treatment, to reduce morbidity, mortality and hospital admissions due to heart failure. The prescription drugs area of work involves supporting the practices to improve their prescribing management and monitoring of patients taking high-risk medications.
As a result of the project, the GP practices will develop their patient safety and improvement culture, with the potential for wider impact over time. Through participating in a project that focuses on just two topics, GP practice boards will develop their expertise in supporting practices to improve their care in a wide range of areas, through collaborative working, and in co-ordinating system-wide approaches to complex patient care.
Improving quality of care and outcomes for people with lung cancer
Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians and the National Clinical Audit Support Programme of the NHS Information Centre for Health and Social Care
Lung cancer is the commonest cause of cancer death in the western world. In the UK, around 38,500 cases are diagnosed each year. Between 85 and 90% of lung cancers are associated with cigarette smoking, but every year lung cancer claims the lives of more than 4,000 people who have never smoked.
Long-term survival rates for lung cancer patients are generally poor, but there are wide variations in treatment patterns and survival across the UK. Data from the Office for National Statistics in the 1990s showed an alarming four-fold difference in five-year survival rates for patients with lung cancer between the better- and poorer-performing regions of England. More recently, the National Lung Cancer Audit has shown that patients in certain hospital trusts are almost five times more likely to have surgery than patients in others.
This project seeks to raise the standards of all multi-disciplinary teams up to that of the best, to ensure major improvements in survival and quality of life for patients. It is doing this by drawing on National Lung Cancer Audit data to identify the reasons for variations, applying proven quality improvement methods to target specific problems, developing an educational programme for clinical settings, gathering patient-reported outcomes, and finally assessing the impact of the changes.
Its ultimate aim is to help teams consistently improve standards of care and therefore improve patient outcomes, both in terms of clinical measures and the patient experience.
Improving the quality of cardiovascular care by ambulance services
East Midlands Ambulance Service NHS Trust on behalf of the National Ambulance Clinical Audit Steering Group
Cardiovascular disease is the commonest cause of death in the United Kingdom, accounting for almost two-thirds of premature deaths. Cardiovascular disease affects 1.8% of the population each year, resulting in stroke, heart attacks and transient ischaemic attacks (mini-strokes). People suffering from cardiovascular disease often have to contact emergency services, and two-fifths of acute heart attacks result in sudden death.
We know that early and effective treatment can save lives, improve long-term health and reduce the risk of future disability. However, the UK death rate from coronary heart disease and stroke is still one of the highest in Western Europe. Ambulance services are well placed to deliver pre-hospital care, to improve patients’ chances of recovery. However, the nature of these services, with widely dispersed clinical teams working under great time pressure, is a barrier to improving quality.
This project seeks to improve pre-hospital care for cardiovascular disease by using a care-bundle approach to ensure that every patient presenting with heart attack or stroke receives each element of optimal care. The care bundle for suspected heart attack includes aspirin, glyceryl trinitrate, pain scoring before and after treatment, analgesia, and pre-hospital thrombolysis or rapid transfer for primary percutaneous coronary intervention. The suspected stroke bundle will include the face-arm-speech test (FAST), and recording blood glucose and blood pressure.
The project will start by assessing current performance, analysing the barriers and facilitators to improvement, and will then use improvement methods such as change management and transformation methods to put in place the care bundles and, ultimately, improve the quality of services.
Action on inpatient falls
National Falls and Bone Health Programme
Accidental falls are the most commonly reported patient safety incidents in NHS hospitals. More than 200,000 hospital falls are reported in English trusts each year, though the actual figure is thought to be much higher. Falls can lead to injury, including fractures and head injuries, impaired confidence, anxiety and poor rehabilitation, and are a frequent factor in patients needing long-term care.
Rates of falls vary significantly from one trust to the next. This may be related to case mix, as more falls occur in frailer older patients with multiple co-morbidities. However, it may also reflect differences in what staff are doing to prevent falls, or to record incidents. Falls are often a marker of factors such as muscle weakness, postural instability, low blood pressure, certain drugs, poor eyesight, environmental hazards and agitation. As such, a fall should always prompt staff to reassess the patient, address risk factors and put strategies in place to prevent further falls.
This project seeks to reduce levels of inpatient falls, by helping hospital wards to establish evidence-based assessments and interventions, and monitoring their impact. Participating wards will commit to monitor falls regularly, complete an assessment of the organisation and environment of the ward, put in place an evidence-based falls care bundle for older people who fall or are at risk of falling, and to use the ‘plan, do, study, act’ cycle and critical incident analysis approaches to improve the quality of care. The resulting reduction in falls will improve services and reduce costs.
Read more
- Overview
- Enhancing care and saving lives of people with chronic kidney disease
- Delivering better care for infants with brain injury
- Abdominal aortic aneurysm, improving outcomes for patients
- Optimising care pathways for acute stroke and transient ischaemic attack
- Using quality networks to improve mental health services
- Promoting earlier diagnosis of brain tumours in children
- Preventing blood-borne viruses through clinical networks
- Improving quality and safety in primary care
- Improving quality of care and outcomes for people with lung cancer
- Improving the quality of cardiovascular care by ambulance services
- Action on inpatient falls