On Wednesday, 18 August 2021, we held a free webinar on how to effectively spread healthcare innovations and achieve impact at scale across the NHS.
The webinar introduced Spring Impact’s new practical tool, designed to help healthcare innovators replicate successfully, and shared our learnings from Exploring Social Franchising, a programme delivered in partnership with The Health Foundation which supported four teams to spread social innovation across the NHS from 2017 to 2021.
We heard from our expert panel, Kerry Oliver, Managing Director of PRIMIS (who led the scale-up of PINCER) and Oliver Smithson, Programme Manager at The Health Foundation, who shared their experience with scaling up healthcare interventions.
Read through the webinar Q&A below for a summary of their insights and to find out more about what it takes to get innovations adopted throughout the UK.
If you’d like to find out more about Spring Impact’s work to spread healthcare innovations, and how we can support you, please get in touch with Sam Edom, Managing Consultant at Spring Impact.
Q: From your experiences of the Exploring Social Franchising programme, what were your key lessons learned about spreading impact successfully in the NHS?
Kerry Oliver: Your innovation may seem simple, but the people, contexts, pathways in each locality are different and therefore like it or not, your innovation is going to be complex! Whichever replication model is used for scale and spread of any intervention; it needs to be flexible to allow for local implementation.
Also, mechanisms needed to be in place to systematically collect qualitative as well as quantitative data. We were very good at collecting quantitative data, which you can see from our impact data but less so at collecting qualitative data. This is because the relationships with the pharmacists (people on the ground delivering PINCER!) were not developed or being overseen by us, but by the AHSNs. You do need that feedback to inform your future work, to gain a greater in-depth understanding of your stakeholders’ issues and motivations and have good news stories to share. We do have this data now, but wished we had collected along the way, rather than retrospectively.
Oliver Smithson: One key lesson is the importance of focusing on commercial value as well as social value when you’re spreading an intervention. Healthcare innovators are often brilliant at explaining the benefit of their interventions for patients and clinicians. But can struggle to accurately cost up their spread approach. If you want to expand what you do, you’ll probably need to:
- Grow your team
- Develop new resources and processes
- And deliver training and support to new sites
You must be business-minded to truly understand how much this will cost you – and plan income generation accordingly. From our experience on the Social Franchising programme, this is not the natural mindset for people spreading health care interventions in the UK. But, ultimately, we need to shift that mindset if innovators are to cover their costs and be successful. And this isn’t about generating profit; it’s about resourcing spread work properly.
Q: What would you say to an innovator that is just now setting out on their journey to scale the impact of their proven intervention?
- Clearly express your intervention and the value proposition. There is a tendency within the NHS for the need to demonstrate a return on investment (particularly when allocating staffing resources), but we had never been asked to undertake an economic evaluation of PINCER, so we found this element particularly tricky and resource intensive. But we were still clear about the value proposition – developing these within a handbook (PINCER on a plate!) and myth buster.
- Working with an expert group like Spring Impact and The Health Foundation has been invaluable – they really challenged our assumptions around the best way to scale and spread the intervention.
- Don’t underestimate the resource and effort needed in the pre-planning stage. Being part of the Exploring Social Franchise Programme meant that we had dedicated time in the diary to sit down as a team and map out and agree how we were going to proceed.
Oliver Smithson: Don’t go it alone. Peer support is essential. The enormous value of networks among innovators and those taking up innovations was a key finding of our 2018 report, the Spread Challenge, which explored the experiences of 44 teams we funded to spread innovation – you should read it, it’s excellent.
If you are an innovator, and you talk with other innovators, even though your interventions may be different, I’m sure your experiences will be surprisingly similar.
Q: How can scaling up innovation in the health service address health inequalities?
Oliver Smithson: Scale-up can support the NHS to take up innovations that span boundaries between NHS and non-NHS organisations, which is an important way to work with communities to understand and focus on inequality.
IRISi is a great example. As a social enterprise that trains GPs to spot signs of domestic violence and refer people to specialist services, IRISi links primary care to community organisations, strengthening the NHS’s ability to focus on a group of people – women who are victims of violence – that face stark health inequalities.
But it’s important to highlight a big risk with other innovations – we need to be conscious that rapidly scaling certain technologies may fail to meet the needs of those with the poorest health outcomes (e.g virtual consultations – very good for some, not for all). This is why co-production and local adaptation is so important.
Kerry Oliver: PINCER is not specifically designed to address health inequalities; however, it is important to note that often, when you are promoting a new intervention, it is innovators and early adopters that will be attracted in the first instance. They are risk takers and are excited by the possibilities of new ideas and new ways of doing things and often have more reasonable access to finance and resources – they are the forward thinkers, and inevitably it is the patients from these populations that are more likely to benefit from new innovations and interventions first and foremost.
We thought very carefully about our delivery model to ensure that the technical implementation was as simple as possible and would be accessible to all GP practices in the country, if they so wished. We didn’t want localities to have to invest in additional software or data warehouses. But now that we have achieved a significant degree of scale and spread, it is clear to see that there has been a sort of levelling off of the practices and, in turn, their populations, that have benefitted from PINCER.
Q: I’m interested in whether creating employment and income generation was important to you in the projects? And, what kind of skills did you find important for you to have when franchising?
Sam Edom: The focus of these projects was on scaling better health outcomes rather than creating employment necessarily, although an important consideration for each project was how they would generate revenue to cover the costs of scaling.
Some of the skills that were most important for franchising were business development & partnership management skills – building and maintaining relationships with partners, as well as the ability to interpret data accurately and adapt delivery approaches accordingly.
Q: In relation to the question about applying this outside of healthcare – what particular areas/sectors do you think would benefit from social franchising?
Sam Edom: We think that just about any part of the nonprofit or impact sector could benefit from the ideas of social franchising. The Trussell Trust has used a social franchising model to great effect in scaling up its network of food banks across the UK, whilst London Bubble has created the Speech Bubbles social franchise to scale up its model of enabling theatre makers and creative practitioners to support young children’s speech and language skills.
Social franchising is not always the right answer though. Our work with The Health Foundation demonstrated that the key is to take a systematic approach to scaling your intervention, and build your model for scaling based on your particular requirements and the context that you find yourself in.
Q: I have been working nationally with AHSNs (led by Wessex), NHSE and NICE on a respiratory programme. Would PINCER include medicine optimisation when safety from over compliance, or non-adherence is linked to poor clinical outcomes and risk of exacerbations/hospitalisation and mortality, for example?
Kerry Oliver: Prior to the development of the PINCER intervention, we conducted a systematic review, and identified 12 drug groups which account for 80% of hospital admissions that are medication-related and preventable. We identified particular problems with three groups of drugs which are responsible for over a third of these admissions; anticoagulants, antiplatelets and non-steroidal anti-inflammatory drugs (which all cause gastrointestinal bleeding). An important implication from this study is that reducing hazardous prescribing (prescribing errors) in general practice associated with specific groups of drugs could prevent the majority of medication-related hospital admissions. The PINCER prescribing safety indicators were specifically designed to address this issue.
Although the PINCER indicators have been designed to identify a limited number of patients at significant clinical risk associated with specific groups of drugs, using the principles of root cause analysis and engaging the general practices in quality improvement cycles, it is typically the case that pharmacists are able to identify and take corrective action for hazardous prescribing associated with other drug groups too.
You may also be interested in the PRoTeCT programme (further information can be found here). As a result of the success of PINCER, the University of Nottingham has obtained further funding to find out whether the intervention also prevented serious harm to patients, including hospital admissions. This follow-on study involves more detailed analysis of the data from over 350 GP practices in the East Midlands who participated in the PINCER intervention during 2015-2017, including the linking of primary care data to other sources, with the aim of evaluating our hypothesis that PINCER reduces exposure to hazardous prescribing, reduces the incidence of serious avoidable harm, and represents value for money for the NHS.
Q: Does the PINCER system leverage AI to identify patterns in the medication history of patients or is it all based on human review?
Kerry Oliver: AI is not used within PINCER and the system is largely dependent on human review. The PINCER prescribing safety indicators are simple system searches that are run on the practice GP clinical information system, reporting on coded entries within the patient electronic patient record.Some of the coded entries are medications, which tend to be automatically coded into the patient record when the prescription is issued; disease and illness, usually a manual data entry made during a patient consultation or captured via a letter from a secondary care, as well as test results, which are typically automatically coded on receipt from the laboratories.
The output of the system searches is a list of patients that may be at risk of exposure to hazardous prescribing. The pharmacists undertake an initial review of the lists of patients. Using the principle of root cause analysis, they will examine the probable root cause of the identified cases. They will conduct a practice meeting to feedback all findings and discuss the potential risks of hazardous prescribing, seeking the involvement of the whole practice team including GPs, nurses and support staff.They will address any immediate risks, as agreed with the practice, as well as work with the practice to implement the action plan to alleviate any future risk.
In some complex cases, the benefits of continuing with the current treatment pathway can actually outweigh the risks posed via exposure to hazardous prescribing and therefore no action is taken. It is quite a sensitive process, which is reliant on good data quality and records management, clinical decision-making and the skill of the pharmacist to support change within the GP practice, where indicated.
Q: For the 21% of CCGs who haven’t participated in PINCER, is there anything you’ve learned about this group who haven’t joined? Are there commonalities or is it simply a matter of time to reach everyone?
Kerry Oliver: PINCER is a pharmacist-led intervention and gaining approval/ support for pharmacists to work on PINCER can be challenging, particularly if a health economics case is required (often CCGs are seeking a ROI case prior to giving their approval). One important lessons-learned from PINCER is understanding that work plans for the medicine’s optimisation teams are typically drawn up and agreed during Q3 and the timing of the AHSN engagement with CCGs was therefore very important. It is only very recently that clinical pharmacists working in primary care have been employed by Primary Care Networks (PCNs) or directly by GP practices (funding introduced from 2019), and with this expanding workforce, there may be new possibilities for engaging directly with PCNs on the PINCER intervention in the future.
In other areas, there may be an assumption that the PINCER intervention is already handled by decision support software that the CCG has invested in, not fully recognising that PINCER is a quality improvement initiative (the training of the pharmacist is of equal importance to the application of the indicators). Hence the importance of clearly expressing your intervention and the value proposition.