Welcome to our

Stakeholder Engagement Event

Professor Mark Gabbay

CLAHRC

North West Coast?

“The NIHR CLAHRC North West Coast provides the infrastructure

and mechanism for meaningful collaborations across key

stakeholders, to address the challenge of serious health inequalities

in our region.

Through applied health research, it will drive fundamental evidence

based change and innovation. Change that will drive down health

inequalities and drive up outcomes for the patients we serve”

Professor Mark Gabbay, Director, CLARHC NWC

– Key health challenge • Life expectancy below UK average

in 80% of boroughs

• Liverpool & Blackpool in bottom 10 nationally

• Up to 17 year difference in disability free years

– Resonates with: • NWC AHSN

• Health & Wellbeing Boards

• HEI & NHS partnerships

– Aligns with patient flows

Health Inequalities in NW

• Equity Lens

• Work with local authorities on determinants upstream of inequalities

• Multidisciplinary support for technical innovation & delivery

• Education

Innovation

Effecting Step Change through CCG

Influence

• Empowered through impacts on commissioning

• Access to all areas for innovative ways to tackle

inequalities

• Core drive for enabling change

• Public Health, Community & Population focus

• Integration of health & social care

NWC Evidence Synthesis Collaboration

14 Groups - 1 Goal

CLAHRC Syntheses

Methodology Innovation

Hubs & Groups

LRiG & NICE technology appraisals

Cochrane Collaborations

& Review Groups

Collaborations: 32 Organisations - £12,377,531

Our key assets • Critical mass – 160 core companies in North West Coast

• Commercial opportunity:

57,000 jobs in Life Sciences across LCR alone

Contributes £1.5B pa to NW economy (10%)

Potential “test bed” for industry

Rapid growth: 85% increase in core companies (2002-12) with an

average growth rate of 8.5%

• Existing mechanisms for R & D (AHSN, CLRN, NHS Trusts)

• Existing strong partner collaborations (Liverpool BioCampus, Liverpool Health

Partnership, Lancashire & Cumbria Clinical Research Hub)

Our added value - CLAHRC provides incubator to bring together academics PCPIE &

Professionals from NHS and LAs together with commercial partners

Working with Industry

PCPIE &

STAKEHOLDERS

Population Health & Quality

of Care

Organisational Excellence

Enabling Communities of

Practice

Organisations: HEIs- Academics Trusts- Clinicians, Managers LAs- Public Health Staff & Managers CCGs- Commissioners & Clinicians PCPIE groups

Management Team 3 Directors: • Research/CLAHRC • Stakeholder

Engagement & Implementation

• Capacity Building

Chair Steering Board 2 PCPIE CCG Lead 6 Theme Leads Senior Managers: • CLAHRC Manager • SRFs in Core Team • PPI Facilitator

Robust Relationships for Delivery

A partnership delivering on Health Inequalities through innovative, effective applied health research and implementation

CLAHRC

North West Coast?

Management Team Meetings: • Opportunities for cross theme synergy • Establishing relationships with partners • Agreeing principles and initial priorities, ways of working, communication etc. • Portfolio development • Team Building - core and new posts External Relationships • Steering Board and other structures • Working with themes • Working with AHSN on Implementation Strategy and working relationships • Event-seminar linked to on-line cpd on latest advances in Implementation Science

for NHS and LAs

Next Steps:

Capacity Building and Implementation

Professor Caroline Watkins

Professor Caroline Watkins

Director of Capacity and Implementation

NIHR CLAHRC NWC

clwatkins@uclan.ac.uk

Professor of Stroke & Older People’s Care, Director of

Research, School of Health, UCLan

Applied Health Research

• Clinical practice needs to be research based

• Research needs to be clinically relevant

• Work collaboratively and co-operatively

• Organisational and individual leadership

• Expected to work well together

• Different perspectives

• Different targets/measures of success

• Different destinations but shared pathways

• Potential for conflict!

• Opportunity for symbiosis!

Organisations and Individuals

Capacity Building

• Develop a culture of research

• Engage all partner organisations

• Engage individuals from organisations

• Engage patients, carers, and the public

• Capacity building recognised as key component

Scoping and Mapping Exercise

• Who wants to engage, with what, how and when?

• What is available, in what format, requiring what resources?

• How can we align the two?

• What would success look like?

Who wants to engage, with what, how

and when?

• Identify workforce and stakeholders for each theme

• Identify workforce strategies for each organisation

• Discuss collaborative research and capacity building opportunities

• Ensure high-level engagement

• Gain commitment to identify resources:

- People

- Time

- Funding

• Identify mentors and those that need mentoring

• Identify secondment/mentoring opportunities

• Develop/identify a range of CPD courses

• Identify development opportunities (experiential through to studentships or fellowships)

What is available, in what format,

requiring what resources?

• Core support – Research: expertise in statistics, health economics, qualitative

approaches, systematic review and research implementation

– Implementation: operational and delivery managers

• Knowledge Transfer and Evidence Synthesis Themes

• “Internal” Funding/Opportunities (courses, bursaries, fellowships) e.g. 16 fully funded PhDs

• Support for “External” applications

What is available?

• Who has engaged? (organisations and individuals)

• With what? (activities)

• How? (level or approach)

• When? (timeframe)

Evaluation

• Has there been engagement?

• Barriers and facilitators?

• Lessons learned?

• Changes made?

• What worked well?

• What has been achieved (qualifications, funding, outputs, outcomes)

• What has been the impact?

Evaluation

• Show what we’ve done

• Learn from what we’ve done

• Ongoing evaluation and feedback

• Respond and make changes

• Raise the quality of future delivery

• Deliver a sustainable research culture!

Summary

Thank you!

Evidence Synthesis Collaboration

Professor Rumona Dickson

…….to establish a collaborative, leadership

enhancing programme of activities that

contribute to the use of evidence synthesis by

CLAHRC partners and encourage

consideration of the effects of evidence

synthesis on health inequalities

Principle of inclusion

– Membership

– Research designs

– Synthesis methods

• To encourage, facilitate and support specific requests for evidence synthesis from CLAHRC stakeholders, partners and themes to inform policy and/or develop future research projects.

• To support stakeholder and partner teams, through continuing professional development programmes, to address current programme delivery issues through best use of available evidence in an environment that encourages the development of research and leadership skills to implement appropriate change.

Word for the day:

DAGU

Knowledge Exchange and Implementation

Professor Mike Pearson

Aim: To integrate knowledge exchange through all areas of our work, develop and deliver effective implementation with inbuilt

evaluation, and support new projects initiated by our stakeholders

And to do so in ways that support the theme based work

Knowledge Exchange

• Some ideas will be imported from other CLAHRCs and the best should be known in our locality.

• Interpreting and informing partners of other successes will hopefully stimulate local improvements

• And we will thus build on other success rather than re-inventing wheels.

• But this is a collaboration – and that means YOU have to help lead

the way if we are to create a practical research culture

Projects, Ideas and Knowledge arise in different ways

• Many good ideas need to be piloted and evaluated in a limited no of sites (see examples from themes).

• But our plans should always consider how to generalise from the test sites to the whole North West Coast.

• Sharing results but more importantly, HOW they were achieved so all can benefit

• Some ideas will come from other CLAHRCs and so importing and sharing examples that are known to work is of value but its not our main stream activity

Our CLAHRC will set up and lead some projects – and share the outputs

• Our brief is to instil a research/evaluation culture into the NHS

• We want you to come up with ideas that we can help you co-produce.

We can offer – Support to evaluate the literature – Methodology support (design, implementation, analysis) – Create links to existing researchers to support your staff in their projects – Opportunities for PhDs that enhance the skills of front line staff

• But ideas should link with our themes and MUST address the issue of inequalities.

Some projects will come from YOU

Engagement for co-production

Professor Jennie Popay

Our vision for engagement • To co-produce evidence from applied research with the

NHS, local government, universities and the people of the NW coast in order to contribute to reduced health inequalities and improved population health

• To achieve this we will: – Extend our reach and deepen relationships with existing partners – Develop new partnerships with industry and charitable sectors. – Communicate across the NW Coast region

Principles for engagement – we will ensure that:

• Our engagement processes are transparent and inclusive • We value all expertise including that of members of the public • Partners make a real difference to our:

– Research and evaluation activities – Outputs and how these are disseminated – Capacity building and knowledge exchange activities

• Staff and partners have opportunities to develop the skills and competencies needed to engage effectively with each other

• Resources and networks are coordinated with partners especially NWC AHSN to maximise synergies

• We evaluate the engagement and act on lessons

Establish and maintain diverse routes for engagement including:

• Partner and public representation in all our governance structures • A Public Reference Panel with oversight of our public engagement and involvement

policy and Public Engagement Champions helping attract new public volunteers. • An NHS and Local Authority Partners Panel of’ Engagement Leads with oversight of

our strategy, strengthening relationships and monitoring matched funds • Partner and public co-production of all our applied research projects and other

activities

• A wider Engagement Network supported through our website and social media. • Developing links with industry, including input to governance structures and applied

research and engaging with the new NIHR Funded Infrastructure

Learning about engagement and involvement

• We will undertake a formative evaluation of

– The experience of the people and organisations engaging with CLAHRC

– The impact of their engagement on all aspects of our work

• We will act on the findings of the evaluation and share the lessons with others

Public Health and Health Inequalities Theme

Professor Jennie Popay

Public Health and Health Inequalities Theme

• CLAHRC’s mission: researching

innovation with potential to reduce

health inequalities

• The public health theme contribution: 1. Developing and implementing a health equity audit process

across the CLAHRC

2. Working with local authorities and their partners in their public

health role to maximise impact on reducing health inequalities

1. Ensuring a health equity focus across CLAHRC

• Much of our work will focus on researching innovations to improve access to appropriate, high quality and timely diagnosis, treatment and care

• Inequalities in access to and abilities to benefit from services increase health inequalities but are not routinely included in research and practice

• To address this the Public Health theme will: – Develop a Health Equity Assessment toolkit (HEAT) and audit and monitoring

process to embed health equity in all implementation, research and capacity building activities

– Disseminate information about the HEAT tool and audit process to partners

– Develop training resources to increase awareness of health equity issues and how they can be addressed amongst staff in CLAHRC and our partners

2. Supporting Local Authorities and their partners to reduce health inequalities

• Behaviour change interventions dominate

action to reduce health Inequalities

• This approach clearly isn’t working!

• NW coast developing a focus on wider social determinants of health inequalities: improving places where people are born, grow up, live, work and grow old.

• We aim to support these developments

Supporting Local Authorities & partners …..

• Co-producing a programme of work to improve health in low income neighbourhoods

• Emerging focus on healthy places and resilient communities: three dimensions – More cohesive and engaged communities –democratic renewal – Greater economic security – Healthier physical places

• Approach to co-production

– Involve partners in reviewing evidence on effective ways to achieve objectives – Partners identify network of ‘neighbourhoods for learning’ in each LA area – Engage partners and residents of these NFL to develop interventions on basis of

evidence and building on existing policies – Implement and evaluate these interventions in neighbourhoods of learning – Share learning and build capacity for applied research and evidence utilisation.

A new girl on the health equity block • We recognise that there is a lot of experience of integrating

health into non-health policies and conducting health equity audits in the NW coast region and beyond

• We will work collaborative across and beyond the NW Coast

region to share knowledge, skills and learning. Thank you for listening

Improving Mental Health

Professor Rhiannon Corcoran

Theme lead: Richard Bentall

Deputy: Rhiannon Corcoran

Theme Co-ordinator and Research Fellow: Katie Bristow

Now To identify with stakeholders: • neighbourhoods with low mental wellbeing and high need for mental health services • factors that are associated with risk of low wellbeing and mental illness within these neighbourhooods. • co-produce community-based interventions for people suffering from the psychological sequelae of stroke and

women with perinatal mental health problems from low SES backgrounds • Agree and develop survey methods to enable measurement of public mental health and wellbeing Sooner • Deliver the pre-intervention public mental health survey • Co-produce community-based implementations to be used within the selected disadvantaged NWC CLAHRC

neighbourhoods for • (i) people with common mental health difficulties • (ii) people with low mental wellbeing • (iii) people misusing alcohol • (iv) people with mental illness living in the community Later • To evaluate the efficacy of community-based implementations using diverse methods • Deliver the post-intervention public mental health survey

Aims

• 3 main theme meetings to date

• Monthly Stakeholder LA and CCG meetings to take place across the NWC region – Liverpool Preston and Lancaster. Hosted by CCG or LA where possible

• Initial monthly PCPI meetings using above framework.

• Survey working group

Organising the theme

Improving mental health

Pieces of work

• (i) what environmental and social factors impact on public mental health and well-being?

• (ii) what are the likely mechanisms responsible for these associations?

• (iii) what evidence is available on the effectiveness of individual-level and community-level interventions designed to influence public mental health?

Evidence Synthesis

• A pragmatic stepped wedge designed trial to evaluate whether the Improving Access to Psychological Services model ameliorates the mental health and wellbeing consequences of stroke.

Outline ready for consideration

Implementation 1: Stroke

• Promote uptake of existing community based and health services in pregnancy and post-natally to enhance wellbeing and reduce common mental health symptoms in women from low socio-economic populations

• 3 key elements – facilitation by a supportive peer; individualised sign-posting to resources/services; and action-planning (“If-Then” Planning).

Implementation 2: Perinatal mental health

• Working with health inequalities theme towards resilient communities

• Co-produced survey focusing on key issues identified by LA public health stakeholders

• Community Control - Housing - Debt - Use of Open space

• Specific Interventions for improving MH

Public Mental Health Survey: pre and post implementations

• Which neighbourhoods?

• Comparison neighbourhoods?

• Who is going to do it (outsourcing)?

• Measures of mental health and mental well-being

• Field work – neighbourhood characteristics , prosocial indices

• Sub- survey for young people

Decisions: survey working group

• The Access to Mental Health in Primary Care programme -a model for improving access to MH services in disadvantaged groups involving community engagement, training primary care services and facilitating psychosocial interventions (culturally sensitive CBT).

• A pragmatic implementation design will be carried out in the disadvantaged neighbourhoods.

Neighbourhood Implementation 1: AMP

Web-based packages will provide

(1) access to mental health information

(2) access to more detailed self- management for service users and relatives covering coping strategies for common challenges

(3) access to and use of services

• A pragmatic implementation design will be carried out in the

disadvantaged neighbourhoods.

Neighbourhood Implementation 2: Web-based packages

• The Reader Organization’s GiR shared reading programme can improve common psychiatric disorders and increase feelings of wellbeing

• A pragmatic implementation design will be carried out in the

disadvantaged neighbourhoods.

Neighbourhood Implementation 3: Get into Reading

• Computerised self-control training aimed at reducing alcohol consumption.

• A pragmatic implementation design will be carried out in the disadvantaged neighbourhoods.

Neighbourhood Implementation 4: Alcohol use

• Open call

Contact Katie Bristow in the first instance:

kbristow@liverpool.ac.uk

Inputting ideas and projects into the Improving Mental Health theme

Personalised Health and Care

Dr Ana Alfirevic

Personalised Healthcare and Delivery Theme

Ana Alfirevic MD, PhD The Wolfson Centre for Personalised Medicine

Patient diversity and inequality

Drugs designed for

Patients treated with drugs

Personalised medicine

Why the need for personalised approaches?

• Dose variation

– 20-fold for warfarin

• Non response

– 30% of schizophrenics do not respond to antipsychotics

• Adverse drug reactions

– 100,000 deaths in the US in 1994

– 6,5% hospital admissions (£500 m) in the UK

Warfarin EFFICACY prevention of thrombosis

Warfarin SAFETY risk of haemorrhage

Barriers to clinical implementation of pharmacogenetics

• Low predictive value of genetic tests

• Cost-effectiveness of the test

health economics and health equality

• Ethical concerns over the use of DNA

security of data, confidentiality, terminal disease

• Education of healthcare providers

interpretation of results

• Equipment infrastructure

specialist equipment

Point-of-Care Testing (LGC)

Sample

5´

3´

5´

3´

3´

5´

PCR blocker Fluorophore

Probe sequence Target DNA

• Sample to result 90 mins

• Simple to use

• Single patient/sample combination

• Robust detection chemistry

• Inexpensive instrument

• Designed for near patient testing

Preloaded test reagents Genotyping for 3 SNPs

Genotype-guided dosing of warfarin Time in therapeutic range Time to reach stable dose

Pirmohamed M et al. N Engl J Med 2013;369:2294-2303.

Genotype guided Control

Genotype guided Control

Renal function monitoring study proposal

• Hearth failure-chronic treatment for many years

• Health inequalities – socioeconomic deprivation

• Diuretics renal impairment

• 2nd most common ADR causing hospital admissions

• Preventable ADRs

• Regular renal function monitoring

Regular renal function monitoring of patients on diuretics

Personalised approach

• Based on the characteristics of individual patients

• Dose of diuretics, severity of heart disease, concomitant medications, co-morbidity

Study design

Primary care databases

• identify patients on diuretics

• U&E testing frequency

• clinical decision change based on U&E results

• drug dosing monitoring

• patient factors → ADRs

Artificial neural network

• decision rules on U&E monitoring

• Development of personalised monitoring plans

Monitoring protocols

Reduce hospital admissions

Improve patient

quality of life

Change clinical care pathways

Multi-disciplinary team Clinical Pharmacology General Practice Renal Medicine Cardiology Health Economics Research Synthesis Nurses Commissioners Patient Public Involvement

Personalised Healthcare and Delivery Theme Conclusions

• Our ability to predict response to a treatment is limited

• Inadvertently introducing inequalities

• Improving prediction of response to treatment

Better clinical outcomes

Cost-effectiveness

Reduces inequalities

• Needs to be implemented - AHSN

• Active participation from all stakeholders

• Active engagement of PPI

Managing Complex Needs

Professor Tony Marson

Overall aim

• To implement a step change in the delivery of care for people with complex needs arising from long term conditions (LTCs).

• This will result in services that are more person-centred, cost

effective and that will improve quality of life for patients and their ability to undertake gainful employment.

• Achieved through collaboration across the NW AHSN footprint,

undertaking research that utilises quantitative, qualitative and health economic research methods to inform best commissioning and optimal services.

Broad strategy

1) Work with key stakeholders to identify complex needs that require service assessment to reduce inequalities, with a view to implementing and assessing change

2) Undertake systematic review and evidence synthesis as required 3) Use mixed methods approaches (qualitative and quantitative) to:

– assess existing services – develop metrics from routinely collected data – assess services and impact of implementing change

6) Feedback results to stakeholders and roll out successful models into routine care within the NWC AHSN

• Initially, the focus will be on musculoskeletal and neurological conditions as exemplar LTCs that may run throughout life, and which are associated with the development of complex physical, psychological and social needs arising from the diseases themselves or as a consequence of therapy.

• Both conditions have a serious negative impact on health and quality of

life, need long term therapy with a variety of medicines and require care to be delivered between hospitals and the community.

• Lessons learnt about the organisation and delivery of services for these

conditions will directly inform changes needed in service delivery for other complex neurological and rheumatological LTCs that will then be addressed.

Proposed project 1

• Improving access and coordination of care for adults presenting to emergency care with

seizures: Care Pathway for Seizures (CAPS)

• Builds on the results of the National Audit of Seizure Management in Hospitals (NASH), and ongoing work with Mersey and Cheshire commissioners to develop and implement a pathway.

In this project we propose to: • develop metrics for assessing performance of epilepsy services using routinely collected data

(e.g. HES) • develop patient reported outcomes for epilepsy clinics • assess patients experience of current services and preferences for service delivery • implement a new care pathway in a defined geography • assess patient experience of new service; and • assess metrics using routinely collected data

Proposed project 2

• Transitional Care for Young Adults with Long Term Conditions

• Builds upon work previously undertaken assessing transition care

for young adults with juvenile idiopathic arthritis (JIA) and young adults with epilepsy. The purpose of this study will be to: – refine ‘patient-centred/involved’ intervention(s) identified in recent

work – assemble these intervention(s) within the local health economies for

epilepsy and JIA; and – evaluate the effectiveness of these intervention(s) using quantitative

and qualitative outcome measures

Contact Details

Prof Gabbay Mark m.b.gabbay@liverpool.ac.uk

Prof Caroline Watkins clwatkins@uclan.ac.uk

Prof Rumona Dickson R.Dickson@liverpool.ac.uk

Prof Mike Pearson Michael.Pearson@liverpool.ac.uk

Prof Jennie Popay j.popay@lancaster.ac.uk

Prof Rhiannon Corcoran rhiannon.corcoran@liverpool.ac.uk

Dr Ana Alfirevic Ana.Alfirevic@liverpool.ac.uk

Prof Tony Marson A.G.Marson@liverpool.ac.uk

Email Info-clahrc-nwc@nihr.ac.uk

Twitter @clahrc-nwc

www.clahrc-nwc.nihr.ac.uk

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