NIHR Greater Manchester PSTRC Annual Report 2014-15

Greater Manchester Primary Care Patient Safety Translational Research Centre

Annual Report 2014 - 2015

Primary Care is healthcare provided in the community for people making an initial approach to a medical practitioner or clinic for advice or treatment.

Patient Safety

is the prevention of errors and adverse effects to patients associated with healthcare.

Contents

Introduction to the NIHR Greater Manchester PSTRC

2

Core Aims

3

Research Themes

4

Medication Safety

5

Case Study: Development of the PINCER Audit Tool

7

Multimorbidity 8

Case Study: Healthtalk Module - Living with Multiple Health Conditions

9

General Practice

10

Case Study: Missed Diagnostic Opportunities 11

Interface and Informatics

12

Patient and Public Involvement Research

13

Case Study: A Tool for the Evaluation of Patient and Public Involvement in Research

15

Patient and Public Involvement

16

Public Engagement

17

Governance

19

Communications

20

Research Capacity Building

21

PhD Students

22

Industry Links

24

Links with Other Organisations

25

Publications

26

Grant Income

27

Looking to the Future

27

Introduction Welcome to the National Institute for Health Research (NIHR) Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC) annual report for 2014-2015.

The NIHR Greater Manchester PSTRC is funded through the NIHR for five years (£6,291,208 from August 2012). It is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust with an ongoing collaboration with the University of Nottingham on its Medication Safety theme.

Eighty five percent of contacts with the NHS takes place in general practices, pharmacies or dental practices and estimates suggest that, for example, nearly two percent of all GP consultations (from 340 million yearly) and 4 percent of prescriptions (from 1 billion annually) result in a patient safety incident. This means that there are over 18,000 patient safety incidents every day, some of which will have serious consequences. Yet, despite these figures, patient safety in primary care remains under-researched compared to research in hospital settings. Our centre is helping to address that deficit by looking at areas where we believe there are major problems.

As our name suggests, all the research that we do is translational – research that seeks to investigate and test new tools and ideas so that they can be developed for further use in the NHS. We have four research themes, which cover a range of the main priority areas, where the majority of incidents take place, and where further research may help improve patient safety in primary care:

Prof Stephen Campbell Principal Investigator

• Medication Safety • Multimorbidity • General Practice • Interface and Informatics Forty seven projects have been put in place (12 completed, 30 ongoing and 5 planned). This report highlights progress in our research programmes and projects and provides examples of how our work is advancing our knowledge of patient safety in primary care.

Patient and public involvement and engagement is integral to our work.

In this report we have highlighted ways in which we have engaged and involved patients, carers and the public as partners. We are also collaborating with the Greater Manchester Clinical Commissioning Groups, Greater Manchester Academic Health Science Network (AHSN), general practices and pharmacies as we seek to improve safety in primary care.

Prof Aneez Esmail Director

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Core Aims To develop evidence-based approaches to keep patients safe in their interactions with primary care To develop capacity in primary care patient safety research To develop and test educational interventions aimed at both patients and practitioners to improve patient safety

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Research Themes Primary care has many components; whilst work within the NIHR Greater Manchester PSTRC focuses solely on GP surgeries and community pharmacy, we recognise that primary care as a whole encompasses additional aspects of healthcare, such as dental surgeries, optometrists and other non-acute community services.

Medication Safety

The biggest areas of concern and potential causes of harm in primary care are problems in the prescribing, dispensing and taking of medicines. Prescribing errors are thought to occur in nearly 1 in 20 prescriptions in primary care. In this theme we are developing ways to reduce this and other errors by providing better information to patients and healthcare professionals, particularly during the prescribing of medicines.

Multimorbidity People now live longer and are more likely to have more than one long term medical condition. This is known as multimorbidity. Having more than one medical condition often means taking more drugs, which need to be prescribed and taken appropriately. Because of the complexity of managing the multiple medical conditions in each person, the likelihood of things going wrong is increased. Our research aims to identify how we can help patients reduce the risk of harm in these situations.

General Practice Occurrences such as delayed and missed diagnoses can have a significant impact on a patient. Our research aims to increase understanding of diagnosis and patients’ interactions with primary care to provide better support to general practitioners (GPs) and patients. This will increase GP and patient awareness of how and why things can go wrong and increased awareness will allow patients to better manage their self-care.

Interface and Informatics The appropriate use of clinical information held in electronic patient records can improve the care provided to patients. We are developing a platform which will reference medication prescribing indicators against electronic patient records, to identify patients who may be at risk of a prescribing error.

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Medication Safety The pharmacist-led information technology intervention for medication errors (PINCER) was a trial previously carried out, in which pharmacists tested a piece of software designed to help prevent prescribing errors. PINCER+ built on this by identifying additional circumstances when prescribing errors may occur. This list of potential prescribing errors is used to identify, from electronic patient health records, those patients who may be at particular risk of prescribing errors.

Theme Lead Prof Darren Ashcroft

Work within the Medication Safety theme has been done to check that the PINCER+ medication prescribing errors are detectable in the electronic health data located in the Clinical Practice Research Database and Salford Integrated Record.

Nottingham Lead Prof Tony Avery

For more information on the development of the PINCER and PINCER+ studies, see the case study on page 7.

Other studies within the theme investigating medication safety issues include:

Highlights

• an e-learning module on prescribing that was developed for GPs and launched on the Royal College of General Practitioners website. The e-learning module provides education and training opportunities for GPs with a focus on avoiding prescribing errors. An evaluation of the e-learning module is taking place at the University of Nottingham, looking at how many GPs have completed the module, how useful they found it and whether they would recommend it to other GPs.

National Institute for Health and Care Excellence (NICE) endorsement of the PINCER study.

Patient Safety Toolkit selected as one of only three ‘Spotlight Projects’ by the Royal College of General Practitioners (RCGP). Each year the RCGP selects new clinical areas or aspects of care to raise their profile and increase awareness across primary care.

• a GP Patient Safety Toolkit has been developed, through other NIHR funding, which aims to improve safety through identifying and reducing risks to patients. The Toolkit covers a number of aspects of safety, such as safe systems, safety culture, communication, patient reported problems, diagnostic safety and prescribing safety. The Royal College of General Practitioners has selected it as a ‘Spotlight Project’, which will raise its profile and increase awareness across primary care. The Patient Safety Toolkit is available to GPs on the RCGP website.

Collaboration with the National Suicide Research Foundation, who are based in the Republic of Ireland and have collated a unique dataset on medicines and suicide.

The Medication Safety theme is based at the Universities of Manchester and Nottingham.

The overall aim of this theme is to develop a medication Safety Management System (SMS) covering key stages of the medicines’ use process, including the prescribing, dispensing and taking of medicines.

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• a trained clinical pharmacist is working with newly qualified GPs and GP trainers to evaluate the first 100 prescriptions that each new GP writes. The clinical pharmacist will then provide detailed feedback to the GPs, which as well as enhancing their learning, will also raise their awareness of patient safety issues when prescribing medicines.

• a study is taking place which involves visiting a general practice and observing medical appointments between GPs and patients. Discussions around the prescribing of medications during the appointment are noted by the observer, as well as the information provided to the patient, how medicines are managed for that patient and what happens after the medicine is prescribed.

• a group of researchers are looking at how medicines are managed for patients with Acute Kidney Injury (AKI) as care for their health passes between primary (GP) and secondary (hospital) care.

• a number of focus groups have taken place with targeted patient groups, including patients with hearing or visual impairments, or with mental health conditions. The purpose of the study is to identify common themes in the medication safety issues that are experienced by different patient groups.

• a collaboration with the National Suicide Research Foundation will look at incidents of intentional drug overdosing and hospital treatment, in the Republic of Ireland. The aim is to understand what factors lead to self-harm by drug overdosing and whether there are factors that can predict risk of suicide in the future.

• a series of workshops for community pharmacy staff will take place over a twelve month period. The workshops will use the Manchester Patient Safety Framework (MaPSaF), a tool to help healthcare teams assess their progress in developing a safety culture and to generate specific actions in the workplace. These actions will be evaluated at 3 monthly intervals, which will encourage continuous improvement in the work processes that could improve medication safety.

• Education & Cost-analysis Leading to Improved Prescribing Safety & Efficiency (ECLIPSE Live) is a system used on the Isle of Wight, available to the hospital, pharmacies and GPs, which links up patients’ test results with their current prescribed medicines, and flags up any potentially harmful interactions. An evaluation of ECLIPSE Live is taking place, looking at how healthcare professionals use the system, how well it works and whether the system helps to prevent medication prescribing errors.

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Case Study

Development of the PINCER Audit Tool The ‘PINCER’ intervention was a research project where pharmacists used computer software to help them to prevent medication prescribing errors by general practitioners. Pharmacists using the computer software to review prescriptions reduced the number of errors by up to 50 percent, as well as providing overall cost savings to the NHS. Following this, an audit tool based on PINCER was produced by PRIMIS, an organisation based at the University of Nottingham. The audit tool identifies patients who may be at risk, so that action can be taken to prevent medication prescribing errors from occurring. The audit tool is available to general practices within the UK and in the past 2 years, has been used by nearly 2000 practices.

A further study, PINCER+, identified an additional fifteen potential medication prescribing errors; for example, prescribing two medicines simultaneously, which could lead to a harmful effect on the person taking the medicines. The PINCER+ study also looked at how often medication prescribing errors happen.

To build further on the PINCER+ work, the NIHR Greater Manchester PSTRC is working with software company TCR (Nottingham) to develop ways of using data from primary care (i.e. general practices) and secondary care (i.e. hospitals) to see how the admissions process into hospital can be affected by serious medication errors and how using the PINCER and PINCER+ tools can help identify and reduce the likelihood of these errors happening.

Impact The PINCER intervention has been endorsed by the National Institute for Health and Clinical Excellence (NICE) in its ‘Medicines Optimisation Clinical Guideline’ as follows: ‘Organisations and health professionals should consider applying the principles of the PINCER intervention to reduce the number of medicines-related patient safety incidents, taking account of existing systems and resource implications.’

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Multimorbidity • a study called MAXimising Involvement in MUltiMorbidity (MAXIMUM) is underway. The study involves observing and interviewing patients with multiple health conditions, carers, GPs and other healthcare professionals over a two year period. This will help develop the understanding of the interactions that take place in primary care in relation to patients with multimorbidity.

• work has begun on a collaborative project between the PSTRC and the NIHR School for Primary Care Research to research and create resources for a multimorbidity module on the Healthtalk website.

Healthtalk is an online resource where patients can find information and hear real stories from patients about specific illnesses or healthcare experiences.

Interviews will take place with patients with multiple health conditions, which will be recorded in video and/or audio. From these interviews, ‘themes’ in the experiences of patients will be identified. These themes will form the basis of the sections to include in the Healthtalk module, and the video and audio clips will be used to illustrate these themes.

Theme Lead Prof Peter Bower

Highlights Collaborative funding between the PSTRC and NIHR School for Primary Care Research for “Living with Multimorbidity: A Qualitative Study”.

• a Multimorbidity Discussion Group has been formed, made up of patients with multiple long-term health conditions and their carers, and has had an initial meeting. The group encourages open and honest discussion of the challenges faced by patients with multimorbidity and their carers, as well as highlighting safety issues which are specific to this group. A video exploring the first meeting is available on the PSTRC YouTube channel.

Creation of a Multimorbidity module for the Healthtalk website is in progress.

Multimorbidity Discussion Group set up to help inform the work of the theme

Multimorbidity – having two or more long-term conditions at the same time – is increasingly common and makes up a significant proportion of the healthcare provision in primary care. However, currently much of the service delivery and quality improvement schemes within healthcare are focused around single conditions.

• a review of available literature has taken place, to investigate the relationship between patient safety incidents and patients with multiple long-term health conditions. A paper has been submitted to the Public Library of Science: Panagioti et al. Multimorbidity and patient safety incidents in primary care: A systematic review and meta-analysis. PLoS One. • a review of the literature available around whose responsibility primary care patient safety is, has taken place and a paper has been submitted: Daker-White et al. Blame the patient, blame the doctor or blame the system? A meta-synthesis of qualitative studies of patient safety in primary care’ PLoS One.

The Multimorbidity theme aims to help address this by better understanding the most prevalent safety issues faced by patients with multimorbidity, and to develop interventions which reduce their vulnerability to safety failures.

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Case Study

Healthtalk Module - Living with Multiple Health Conditions Healthtalk was created in 2001 as a resource for patients looking for information about health conditions or treatments. It is accredited by the NHS England’s Information Standard as a reliable source of information and when questioned, 85 percent of those people who responded stated that the website contained the best information they had seen. It is anticipated that the website will have seven million visitors in 2015.

According to a Scottish study, nearly a quarter of patients registered with a general practice have two or more long-term health conditions (multimorbidity), with numbers rising globally. However, there is very little information available for people who have more than one condition. The Multimorbidity theme of the NIHR Greater Manchester PSTRC is working with colleagues from the NIHR School for Primary Care Research to produce information on multimorbidity which will be published on the Healthtalk website. The study is capturing patients’ experiences of multimorbidity and from this, video and audio clips will be produced that best show what is important to patients. The audio and video clips will also be available to everyone through the Healthtalk website.

Impact The information on multimorbidity on the Healthtalk website will help patients and carers be better informed about how they can take care of themselves, use health care services and interact with healthcare workers.

It is also anticipated that health workers will use the information to understand better some of the challenges and issues facing patients with multiple health conditions.

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General Practice With the vast majority of NHS contact taking place in general practice surgeries, it is essential to understand the potential patient safety issues in this area.

A number of studies are taking place which aim to enable patients to visit, and professionals to work in, practices where knowledge about patient safety is understood and practised routinely. These studies include: • ‘Never Events’ are things that should never happen in healthcare. There is a list of Never Events for secondary care (e.g. amputating the wrong limb in hospitals) which has been shown to generate positive effects. A list for general practice was developed by NHS Education for Scotland and the PSTRC has worked with them to survey GPs about how often these events occur. Focus groups have taken place to explore GPs’ views of Never Events in general practice.

This resulted in real-world impact, as some of the GPs subsequently checked for instances where Never Events had occurred in their own practices.

Theme Lead Prof Stephen Campbell

Highlights A Differential Diagnosis Tools review has been completed, looking at tools used

by GPs that offer a range of diagnoses dependent on the symptoms entered.

• the Missed Diagnostic Opportunities study is using patient records to assess the extent of missed diagnostic opportunities (when something different could have been done to make the correct diagnosis earlier or the correct diagnosis was missed) in general practice.

Funding for ‘Understanding the nature and frequency of avoidable harm in primary care’ was awarded by the Department of Health Policy Research Programme.

‘Never Events’ focus groups encouraged GPs to proactively check for events in their own surgeries.

• Isabel is a commercially available web-based medical diagnostic tool. Patient characteristics such as age and gender as well as symptoms are entered into the tool’s web interface, which returns a list of potential diagnoses. This project assesses whether GPs find the tool useful and whether it is accurate, to indicate whether such tools could be used routinely in general practice.

• a literature review has been undertaken on electronic symptom checker tools (diagnostic aids or tools for professionals that suggest alternative diagnoses) in general practice evaluating the accuracy and usability of commercially available tools.

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Case Study

Missed Diagnostic Opportunities There are 340 million consultations in general practice each year in England and a recent review estimated that there may be a concern around patient safety in approximately two percent (or nearly seven million) of those consultations.

Missed diagnostic opportunities are one such type of patient safety concern. They relate to where a diagnosis was wrong, or where it could have been made earlier, or where an opportunity to make a diagnosis was missed completely.

The NIHR Greater Manchester PSTRC is undertaking a study to: • determine how often missed diagnostic opportunities occur in English general practice • identify the factors that lead to missed diagnostic opportunities • determine the impact or potential impact of the missed diagnostic opportunities on patients.

A number of GPs have been trained to identify missed diagnostic opportunities. A random set of one hundred electronic health records, covering a 12 month period, across (up to) 50 GP practices in Greater Manchester, will be assessed by the trained GPs. For any consultations within the records where a diagnosis was made, information will be collected on the consultation, the diagnosis made, information relating to the diagnosis and whether there were any missed diagnostic opportunities.

Impact The project is expected to result in a method for accurately estimating the number of missed diagnostic opportunities in general practice, which can then lead to the creation of new ways to reduce their frequency, as well as creating new training methods for healthcare professionals to avoid missed diagnostic opportunities.

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Interface and Informatics were based on the latest insights in this area. The dashboard identifies patients who may be in need of re-assessment to avoid potential harm from the medicines prescribed to them.

Theme Lead Prof Iain Buchan

• the user interface of the electronic patient safety dashboard has been developed with feedback from GPs, Clinical Commissioning Group pharmacists and a patient representative. It displays key information on patient safety to GPs and pharmacists, using tabulated numbers and graphs.

Project Lead Dr Niels Peek

• a study is being conducted, in collaboration with the School of Computer Science at The University of Manchester, to evaluate how users interact with the electronic patient safety dashboard, by using eye-tracking technology. Participants consist of members of the general public and GPs. Data generated by this study will identify potential usability issues, so that amendments can be made to the patient safety dashboard before it is trialled in GP surgeries in Salford.

Highlights Development of a patient safety dashboard (information system), which will be tested in an 18 month trial in GP surgeries in Salford.

• the patient safety dashboard will be used in general practices in Salford during an 18 month real-world trial. A pharmacist will visit the surgeries at specific intervals throughout the trial to offer additional expertise. The success of the combined intervention will be assessed by counting the number of patients that are at risk of medication-related harm before and after the trial. In addition, the study will also assess how GPs and pharmacists use the dashboard, how many medication prescribing and medication monitoring errors are identified, and whether any resulting action was taken.

Clinical Research Training Fellowship awarded to Interface and Informatics PhD researcher, Dr Ben Brown, by Wellcome Trust.

The main aim of the Interface and Informatics theme is to develop an alerting system that averts potentially unsafe situations with carefully targeted information.

The Interface and Informatics and Medication Safety themes are collaborating to create and test a patient safety dashboard: • the electronic patient safety dashboard searches for medication prescribing and monitoring errors in patient records by applying rules that were formulated through previous research on medication safety and

The Interface and Informatics theme is also providing valuable technological expertise into other studies within the Centre, such as: • the Missed Diagnostic Opportunities project in the General Practice theme • the Never Events project in the General Practice theme.

To maximise the impact of Interface and Informatics theme, it is collaborating with the relevant themes within the Medical Research Council-funded Health e-Research Centre (HeRC) such as Actionable Healthcare Analytics and Co-produced Health, and are also linking into the Farr Institute.

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PPI Research In its first year, the PSTRC set up a group consisting of 12 patients and members of the public, to work in partnership with the centre’s research themes advising and assisting on research taking place. This group is called the Research User Group.

There are currently three studies taking place looking at the role and impact of the Research User Group. These are: 1. an evaluation of the Research User Group expectations of patient and public involvement based on a questionnaire, which is completed by members of the group following each 6-weekly meeting. The evaluation has so-far shown high levels of satisfaction and engagement. Further information is available in the case study on page 15.

Theme Lead Prof Stephen Campbell

2. an evaluation of the impact of the Research User Group and patient and public involvement on the research of the centre, based on feedback forms which are completed by members of the Research User Group and centre researchers before each Research User Group meeting.

Highlights Collaboration with Flinders University in Australia on the development of a Primary Care Patient Measure of Safety (PC_PMOS).

3. an external evaluation carried out by Dr Jonathan Boote based at the University of Hertfordshire and Dr Jill Thomson at the University of Sheffield, assessing the impact of the Research User Group and patient and public involvement on the work of the centre, using feedback forms (described above), interviews with members of the Research User Group and key centre researchers and by observing Research User Group meetings.

A Patient and Public Involvement workshop was presented at the 2014 International Society of Quality and Safety (ISQua) Conference.

Patient Views of Patient Safety videos have been produced and are now available on the PSTRC YouTube channel.

Findings from the three evaluations are used to inform the PSTRC’s ongoing Patient and Public Involvement Strategy.

With the NIHR Greater Manchester PSTRC’s focus on patient and public involvement, the centre is working on a number of studies which will help to better evaluate and improve its own patient and public involvement processes, as well as examining and conducting other work which has, or will have, significant patient and public input into healthcare research.

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Other studies with an emphasis on the patient’s perspective are: • the Patients Association was commissioned to interview patients about their views of patient safety in primary care.

These interviews were recorded in video or audio and are now available as an open resource on the NIHR Greater Manchester PSTRC YouTube channel.

• a review of currently available primary care patient safety literature, to try to understand what factors are important in primary care patient safety, particularly from a patient perspective. This work has led to a collaboration with Flinders University in Australia, which, by conducting interviews with patients on their perspectives of safety, will produce a list of potential ways in which patient safety incidents can be measured.

• the Management of Multiple Medications study is aiming to help safely reduce the numbers of different medications prescribed to older people with multiple long-term conditions. New computer-based guidelines have been developed as a resource for GPs caring for older people and these guidelines are being trialled across five European countries. • a focus group was formed to advise on the development of a web-based system where patients will be able to record their experiences of medication prescribing errors. • a patient and public involvement group is advising on the format and content of a questionnaire, which will gather information to better understand patient perceptions of patient safety in primary care. The questionnaire is currently being piloted with a small group of patients, with a view to rolling it out more widely once finalised.

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Case Study

A Tool for the Evaluation of Patient and Public Involvement in Research Given the importance of and costs allocated to patient and public involvement (PPI) in the NIHR Greater Manchester PSTRC, it is important that the impact of patient and public involvement on health services research is evaluated. Therefore, the centre is undertaking an evaluation of its own patient and public involvement in research.

A pre-existing questionnaire has been refined by the PSTRC and Research User Group (RUG) members have been asked to complete it on a 4-6 weekly basis. Questions within the questionnaire have asked whether RUG members feel valued, are meeting their own goals and whether they feel they are able to make a contribution. The answers from the questionnaire are helping the centre understand how well patient and public involvement has been progressing in the eyes of RUG members, over time.

For the majority of RUG members there was no overall change in their views over the first six months, with scores starting high and remaining so. This suggests that the level of involvement has remained high during that period. Full published findings are available in BMJ Open (more infomation on page 26).

In addition to evaluating the effectiveness of the centre’s patient and public involvement, it was intended that the questionnaire would also be suitable for use by other organisations, who may wish to evaluate their own patient and public involvement.

Impact The questionnaire has been shown to work well and it is now being piloted by other organisations, such as groups within The University of Manchester, the University of Hertfordshire and Flinders University in Australia.

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Patient and Public Involvement PPI Lead Prof Stephen Campbell

The PSTRC works to the NIHR INVOLVE definition of patient and public involvement, which is “research being carried out ‘with’ or ‘by’ members of the public, rather than ‘to’, ‘about’ or ‘for’ them”.

Research User Group The NIHR Greater Manchester PSTRC has a patient and public involvement group called the Research User Group (RUG), which consists of up to 12 members. This was established in April 2013 and it meets six-weekly. Each member of the RUG affiliates to one of the centre’s research themes and acts in a governance role, overseeing the involvement and engagement activity within that theme. In addition, the RUG, patients and members of the public are offered opportunities to work collaboratively on individual projects within each of the themes throughout the PSTRC, with RUG members working on projects outside the theme in which they hold a governance role.

A document has been designed by and for Research User Group members and researchers to feed back on their patient and public involvement and engagement activity.

This document is now being used by other patient and public involvement groups within The University of Manchester, and also nationally and internationally.

Research User Group involvement Members of the Research User Group have been involved in the work of the PSTRC in a number of ways during the last year: • they have been co-applicants in ethics applications, have been co-authors of published papers and have presented at conferences • they were active partners in public engagement events: 1. the NIHR Greater Manchester PSTRC 2014 Research Symposium 2. the Wonder Drugs Roadshow as part of the Manchester Science Festival and at the British Science Week

• members worked with the Salford Research Training Academy, based in Salford Royal’s Research and Development department, to develop and deliver patient and public involvement training to members of the public • they were involved actively in a strategic review of patient and public involvement in the PSTRC. Theme-specific involvement includes: • General Practice theme: involvement in the planning of a patient handbook project • Multimorbidity theme: involvement in the co-ordination and running of a Multimorbidity Patient Panel • Medication Safety theme: involvement in developing topic guides for focus groups • Interface and Informatics theme: involvement in the assessment of patients’ online access and interpretation of lab test results.

Priorities Three main priorities have been identified by the PSTRC and Research User Group members going forward. These are: 1. building better partnerships to help the Research User Group and researchers work together 2. assessing the impact of patient and public involvement in the research process 3. helping to generate ideas for future funding opportunities.

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Public Engagement Acknowledging the importance of engaging patients, members of the public, healthcare professionals and wider stakeholders with its work, the NIHR Greater Manchester PSTRC utilises a variety of ways to encourage interest, involvement and action.

Between April 2014 and March 2015 the centre hosted two events designed to increase the visibility of the research taking place and to encourage involvement.

The first NIHR Greater Manchester PSTRC Annual Research Symposium “Evidence-based approaches to patient safety in primary care”, took place on 23 June 2014. 70 people registered to attend, including patients, members of the public and healthcare professionals. The symposium was split into two sessions, the first explaining some of the centre’s ongoing studies, and the second focused on patient and public involvement.

Wonderdrugs Roadshow - copyright MOSI

The Wonder Drugs Roadshow was a 3-part event which took place at the Museum of Science and Industry, Pendleton Gateway and Wythenshawe Forum, as part of the 2014 Manchester Science Festival. Using a variety of activities, visitors of all ages were challenged to think about the importance of patient safety in relation to the medicines they take. More than a thousand members of the public attended the three venues and the roadshow has since been taken to the British Science Festival. The Wonder Drugs Roadshow was nominated for The University of Manchester’s Making a Difference Awards for Social Responsibility, and PSTRC PhD student, Hayley Gorton, was awarded Outstanding Public Engagement (Student) at the same awards.

Speakers at the First Annual Research Symposium

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Governance The NIHR Greater Manchester PSTRC Principal Investigator and Director, in conjunction with the Research Theme Leads, Research User Group and the governance boards below, shape the strategy and overall direction of the Centre.

The PSTRC has two main governance groups:

Executive Management Board members

• the Executive Management Board (EMB) meets four times per year to oversee the NIHR Greater Manchester PSTRC and holds the PSTRC Leadership to account for the management and performance of the centre. It is under the chairmanship of Dr Mike Burrows (Managing Director: Great Manchester, East Lancashire & East Cheshire Academic Health Science Network) and vice-chair Sir David Dalton (Chief Executive Salford Royal NHS Foundation Trust). Members include the Chair of the Research User Group and key clinical leaders from The University of Manchester, Greater Manchester Clinical Commissioning Groups and Salford Royal NHS Foundation Trust.

• Mike Burrows (Chair) - Greater Manchester Academic Health Science Network • David Dalton (vice-Chair) - Salford Royal NHS Foundation Trust • Anne Talbot - Bolton Clinical Commissioning Group • Chair of the Research User Group • Ian Moston - Salford Royal NHS Foundation Trust • Ivan Benett - Central Manchester Clinical Commissioning Group • Jane Macdonald - Greater Manchester Academic Health Science Network • Jessica Williams - NHS England • Martin Tickle - University of Manchester • Simon Denegri - NIHR INVOLVE

• the Strategic Advisory Group (SAG) advises the Greater Manchester PSTRC Leadership on the forward direction of the centre and has met twice over the twelve month period, as planned. It includes membership from the World Health Organisation, The Patients Association and NIHR Imperial PSTRC.

Strategic Advisory Group members • Aziz Sheikh - Edinburgh University • Bryony Dean Franklin - NIHR Imperial Patient Safety Translational Research Centre • Cordula Wagner - Nivel, The Netherlands • Itziar Larizgoitia - World Health Organisation • Katherine Murphy - The Patients Association • Mike Kelly - NICE • Richard Roberts - WONCA • Sarah Yardley - Keele University

There are also a number of internal governance meetings that occur regularly: • Research Theme Lead meetings take place on a monthly basis, with coordination, planning and integration of research and development work across the PSTRC being discussed and agreed.

• Research Theme progress meetings are held quarterly with all relevant theme PSTRC staff, PhD students and Research User Group members.

A series of tools have been set up to help with monitoring the PSTRC’s progress. These are: • a set of Key Performance Indicators (KPIs) covering a number of areas including governance, finance, patient and public involvement, staffing, papers, grants, and impact

• Strategic Planning meetings for the future direction of the centre are held quarterly and involve the leadership of the PSTRC, Research Theme Leads, members of the Executive Management Board and Strategic Advisory Group, as well as senior leaders from across the Greater Manchester health economy including university researchers and health service leaders.

• review criteria to track core aims and progress, in order to manage the risks associated with each PSTRC project • a risk register that focuses on the delivery of the three core aims of the PSTRC.

• Research User Group meetings take place every six weeks, led by the elected Chair, who is also a member of the Executive Management Board.

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Communications The NIHR Greater Manchester PSTRC is committed to communicating information about its work to its stakeholders including members of the public, patients and healthcare professionals and it undertakes this in a variety of ways.

• Events The NIHR Greater Manchester PSTRC hosts public engagement events and an annual research symposium.

Find out more: http://bit.ly/WTmwN2

• Newsletter An e-newsletter is published quarterly with a Research User Group member on the planning and editorial group. It communicates to wider audiences across Greater Manchester and internationally, including patient support groups, community groups and professional networks, such as local medical and pharmacy committees. The latest PSTRC newsletter (January 2015) was sent to 502 subscribers. and was read most in the UK, USA, Australia, Italy and Spain.

See all newsletters: http://bit.ly/1CUShde Sign up at: http://bit.ly/GMPSTRC • Website Information on events, published papers and patient and public involvement opportunities can all be found on the centre’s website.

Find out more: www.gmpstrc.nihr.ac.uk

• Twitter The centre has three active Twitter accounts, the overarching centre account, @GM_PSTRC, plus two theme-specific accounts @Multimorbidity and @Meds_Safety.

Follow us on Twitter: https://twitter.com/GM_PSTRC

• Blog The PSTRC has a blog, hosted on Wordpress. From April 2014 to March 2015, a total of 25 posts were published, with a variety of authors, both internal and external to the PSTRC, as well as patients and members of the Research User Group.

Visit blog: https://gmpstrc.wordpress.com/

• YouTube channel The centre has also created a YouTube channel, with a selection of videos providing information on the centre’s research themes, PSTRC PhD students talking about their projects and patients speaking about their views of patient safety. A video of the former Chair of the Research User Group has been used as a resource by the Department of Health.

Visit YouTube: http://bit.ly/1sw7iYu

• Research papers explaining key research findings are published in leading journals (see page 26).

• Attendance and presentation of research findings at external conferences.

• The centre has also promoted its work through local radio and by having exhibition stands at regional events of interest, such as the 2014 Patient Safety Congress in Liverpool and the 2014 Manchester Science Festival.

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Research Capacity Building The University of Manchester has an internationally recognised track record in quality of care and patient safety research in primary care and offers extensive support for research, such as informatics, statistics and economics expertise.

Research capacity building in primary care patient safety is the second core aim of the NIHR Greater Manchester PSTRC. To build research capacity and capability in the field of primary care patient safety the NIHR Greater Manchester PSTRC has 6 fully funded doctoral students and provides training for staff and PhD students, and supports attendance at conferences for training purposes. In the 2014-15 financial year, 11.2 percent of the total budget was allocated to training, broken down as follows: • training for staff and PhD • conference attendance • PhD fees and stipends

1.3 percent 0.7 percent 9.2 percent

Each member of staff at Research Fellow and Research Associate level is allocated an annual conference budget and an annual training budget.

Training Examples of training undertaken by research staff from 2014-15 include:

The University of Manchester also provides a “New Academic Training” programme, which a number of PSTRC staff have completed, or are currently undertaking.

Patient and Public Involvement (PPI), and social media training for staff and students of the PSTRC has taken place; for example, the PSTRC organised a PPI training day in January 2015.

Training has also taken place, in conjunction with Salford Royal’s Citizen Scientist programme on the use of Citizen Juries (where members of the public become a jury, hearing evidence from experts and making a collective decision on a pre-defined question of importance in the field).

Conferences Members of staff and PhD students presented posters or oral presentations at conferences during the year, including: • INVOLVE conference 2014 • American Medical Informatics Association (AMIA) Annual Symposium 2014 • Society for Academic Primary Care Conference 2014 • Workshop at the International Society for Quality in Healthcare (ISQua) 2014.

• Modern web development • Managing challenging interviews • Analysing qualitative interviews • Conducting a mixed methods systematic review • “Underserved” or “Hard to Reach”? Community and participatory approaches in health research • Professional development in public health Non-research support staff are allocated an annual training budget. Examples of training undertaken by support staff from 2014-15 include: • Adobe InDesign, Illustrator and Photoshop • Change Management • PRojects IN Controlled Environments (PRINCE2) Project Management All PSTRC funded staff have an annual Performance and Development Review (PDR) with their line manager. The PDR includes advice in personal development, academic progression and career planning, as well as one-to-one support through mentoring.

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PhD Students The PSTRC has six fully funded doctoral students all based at The University of Manchester and in the second year of their programmes.

PSTRC PhD students have produced a variety of work this year, and have also been involved in promoting the work of the PSTRC. Examples include:

Shoba Dawson, aligned with the Centre for Primary Care, is completing a project on patient and public involvement for Black and Minority Ethnic (BME) groups.

Paolo Fraccaro, aligned with the Centre for Health Informatics, is working on developing context awareness for e-Health alerts to improve patient safety.

Hayley Gorton, aligned with the Manchester Pharmacy School, is completing a project on suicide and self-harm: implications for medication safety in primary care.

Jonathan Stokes, aligned with the Centre for Primary Care undertaking his PhD project on integrated care, patient safety, and Clinical Commissioning Groups (CCGs).

Christian Thomas, aligned with the Manchester Pharmacy School, is working on a project about addressing procedural violations in pharmacy.

Tina Wulff, aligned with the Manchester Business School, is completing a project on primary care patient safety improvement science.

Papers • co-author on a paper entitled “Adoption of Clinical Decision Support in Multimorbidity: A systematic review” • co-author on a paper entitled “Combining macula clinical signs and patient characteristics for agerelated macular degeneration diagnosis: a machine learning approach” • co-author on a paper entitled “Effectiveness of primary care case management for ‘at risk’ patients: A systematic review and meta-analysis” Conference presentations • presenting a poster at the 2014 BioMed Central Health Services Research Conference • presenting a poster at the 15th International Conference for Integrated Care • presenting a poster at the 2014 INVOLVE conference • presenting a poster at the University of Manchester Institute of Population PhD showcase Other • manning an exhibition stand at the 2014 Patient Safety Congress • involvement in the planning and running of the Wonder Drugs Roadshow There are also two PhD students at the University of Nottingham and four PhD students at The University of Manchester who are supervised by PSTRC funded staff and whose projects will feed in to the PSTRC’s research.

The PSTRC has established a PhD group for its doctoral students and the students are also part of The University of Manchester’s Centre for Primary Care PhD group, which consists of 28 PhD students, as well as the Institute of Population Heath doctoral training group with more than one hundred PhD students. PSTRC PhD students have access to modules in The University of Manchester Masters in Research (MRes) and the Masters in Public Health (MPH).

In addition, the PSTRC has created an innovative crossfaculty and multi-disciplinary doctoral training network with the Manchester Business School, which meets quarterly to provide collaborative training and support.

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Industry Links In 2014-15, the PSTRC linked in with a number of local and national organisations and companies, to enhance its work.

As described in the Multimorbidity theme section (page 8), work is ongoing to develop a Multimorbidity module for patients to access information and patient stories on managing multiple long-term health conditions.

Nottingham-based company PRIMIS, helped to develop an audit tool to use in conjunction with the PINCER indicators.

The audit tool identifies patients that may be of risk of a medication prescribing error.

North West People in Research Forum has promoted the work of the PSTRC via their networks.

Local pharmacies Isabel is one of a number of diagnostic tools that can be used

by GPs. Symptoms are entered into the programme and a number of possible diagnoses are returned for the GP to consider.

Inspiration North West has been involved in a consultancy capacity, advising on the centre’s patient and public involvement.

As described in the Medication Safety theme section (page 5), ‘safety culture’ workshops are taking place as part of the PSTRC’s evaluation of the Manchester Patient Safety Framework (MaPSaF)

Work is underway with the software company, TCR (Nottingham), to develop ways of extracting both primary and secondary care data and linking it, to allow investigation of hospital admissions which may be associated with serious medication-related adverse events.

TwoCan Associates have been advising on and promoting the PSTRC’s patient and public involvement work.

Safety Culture Associates Ltd

Working in collaboration with Medication Safety theme, Safety Culture Associates has provided expertise and support for the use of the Manchester Patient Safety Framework (MaPSaF) and on data analysis for a number of the Medication Safety projects.

TPP is the vendor of SystmOne, one of the most widely used primary care electronic health records in the UK. First Databank has developed software to enhance medication safety in clinical practice. The two companies are collaborating with the PSTRC to investigate how many computerised prescribing safety alerts are issued in UK general practice and through this, to evaluate how many patients are exposed to potentially hazardous prescribing.

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Links with Other Organisations

It is particularly beneficial for the PSTRC to link with other organisations, as it allows the sharing of ideas, builds upon work already done and results in a strong combined effort to lobby for change.

NIHR School for Primary Care Research Staff in the Medication Safety theme and General Practice theme of the PSTRC worked with researchers funded by the NIHR School for Primary Care Research to complete a project on “Developing, testing and implementing the NSPCR Patient Safety Toolkit in general practices in England”.

The PSTRC has linked in with a number of other NIHR infrastructure organisations, including:

There are close links between the Greater Manchester PSTRC Multimorbidity theme and staff and projects on long term conditions and multimorbidity which are funded or co-funded by the NIHR School for Primary Care Research.

NIHR Training

Professor Campbell is the Greater Manchester Training Lead and is part of the NIHR Training Leads group.

NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester (CLAHRC)

NIHR Imperial PSTRC

The Director of the NIHR CLAHRC Greater Manchester, Professor Ruth Boaden, sits on the Greater Manchester PSTRC Strategy Group meetings.

Professor Bryony Dean-Franklin of the NIHR Imperial PSTRC is a member of the Greater Manchester PSTRC Strategic Advisory Group. Professor Campbell, Principal Investigator of the PSTRC, is a member of the NIHR Imperial PSTRC Strategic Advisory Group.

NHS Education for Scotland

MAHSC

The University of Manchester, Salford Clinical Commissioning Group and Salford Royal NHS Foundation Trust are members of the Manchester Academic Health Science Centre (MAHSC).

The PSTRC is working with NHS Education for Scotland on further developing a set of ‘Never Events’ for primary care (see page 10).

National Institute for Health Research (NIHR) NIHR CLAHRC Greater Manchester NHS Education for Scotland NIHR School for Primary Care Research NIHR Imperial PSTRC MAHSC

www.nihr.ac.uk clahrc-gm.nihr.ac.uk/ http://www.nes.scot.nhs.uk/ www.spcr.nihr.ac.uk/ www1.imperial.ac.uk/cpssq/pstrc/ www.mahsc.ac.uk

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Publications The PSTRC has produced a number of publications over the last year, those marked with a * are available online at no charge.

Publication title

Authors

Published in:

*Application of a tool for the evaluation of public and patient involvement in research

Stocks SJ, Giles SJ, Cheraghi-Sohi S, Campbell SM.

BMJ Open

*Prevalence, nature and predictors of prescribing errors in mental health hospitals

Keers RN, Williams SD, Vattakatuchery JJ, Brown P, Miller J, Prescott L, Ashcroft DM.

BMJ Open

Standard deviation? The role of perceived behavioural control Phipps DL, Beatty PCW, Parker D. on procedural violations

Safety Science

*A constellation of misfortune: narrative accounts of adverse life events, chronic illness, and subjective social status

Daker-White G, Sanders C, Rogers A, Vassliev I, Blickem C, Cheraghi-Sohi S.

SAGE Open

*Self-management interventions in patients with long-term conditions: a structured review of approaches to reporting inclusion, assessment, and outcomes in multimorbidity

Kenning C, Coventry PA, Bower P.

Journal of Comorbidity

*Does patient experience of multimorbidity predict selfmanagement and health outcomes in a prospective study in primary care?

Kenning C, Coventry PA, Gibbons C, Bee P, Fisher L, Bower P.

Family Practice

*The potential for using a Universal Medication Schedule (UMS) to improve adherence in patients taking multiple medications in the UK

Kenning C, Protheroe J, Gray N, Ashcroft DM, Bower P.

BMC Health Services

*MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study

Daker-White G, Hays R, Esmail A, Minor B, Barlow W, Brown B, Blakeman T, Bower P.

BMJ Open

*The influence of personal communities on the selfmanagement of medication taking: A wider exploration of medicine work

Cheraghi-Sohi S, Jeffries M, Stevenson F, Ashcroft DM, Carr M, Oliver K, Rogers A.

Chronic Illness

*Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method

Bell BG, Spencer R, Avery AJ, Campbell SM.

BMC Family Practice

*Tools for primary care patient safety: a narrative review

Spencer R, Campbell SM.

BMC Family Practice

*Adoption of clinical decision support in multimorbidity: A systematic review

Fraccaro P, Casteleiro MA, Ainsworth J, Buchan IE.

JMIR Medical Informatics

*Primary care medication safety surveillance with integrated electronic health records: Insights from the UK

Akbarov A, Kontopantelis E, Sperrin M, Stocks SJ, Richard Williams R, Rodgers S, Avery AJ, Iain Buchan IE, Ashcroft DM.

Drug Safety

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Grant Income As a result of work taking place in the NIHR Greater Manchester PSTRC, the following grants have been secured in the centre’s third year:

Research Theme

Award Body

Grant Title

Medication Safety

Health Foundation

Improving prescribing safety in general practices in East Midlands through PINCER

Medication Safety

Department of Health Policy Research Programme

Understanding the nature and frequency of avoidable harm in primary care

Interface and Informatics

Wellcome Trust Clinical Research Training Fellowship

Harnessing opportunities for quality improvement from Primary Care electronic health records

Medication Safety

NIHR Research Capability Funding/ Nottingham City Clinical Commissioning Group

Preparing for a Phase IV implementation trial using PINCER methodology

Multimorbidity

NIHR School for Primary Care Research

Living with Multimorbidity: A Qualitative Study of Patients’ Experiences

Looking to the Future Our research investigates and tests new tools and ideas about primary care patient safety so that they can be developed for further use in the NHS. This report has provided updates on the many research projects within our research themes and our extensive patient and public involvement and engagement. It has highlighted progress in how we are directly advancing knowledge in primary care patient safety and the impact our research findings are having on policy and practice.

We are thinking strategically of future plans and priorities, building on successful grant awards and current policy and practice priorities within Greater Manchester and nationally. We shall continue to work in partnership with our PPI members, with patients, the public and healthcare providers to make primary care in Greater Manchester, and elsewhere, safer.

Significant progress made – still more to achieve.

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The National Institute for Health Research (NIHR) Greater Manchester Primary Care Patient Safety Translational Research (Greater Manchester PSTRC) is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust.

NIHR Greater Manchester PSTRC Suite 11, Floor 7, Williamson Building Institute of Population Health University of Manchester Oxford Road, Manchester M13 9PL