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Greater Manchester Primary Care Patient Safety Translational Research Centre
Annual Report 2015-2016
The National Institute for Health Research (NIHR) Greater Manchester Primary Care Patient Safety Translational Research Centre is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust
Contents Introduction and Aims Introduction 1-2 Core Aims
Research Themes 3-11 Medication Safety
Multimorbidity General Practice Interface and Informatics
Case Studies
12-17 Development of the PINCER intervention Patient Safety Guide Patient Safety Toolkit
Involvement 18-21 Patient and Public Involvement Public Engagement
Other Information 22-36
Governance Communications Research Capacity Building PhD Students Industry and Charity Links Links with NIHR Infrastructure Publications Grant Income Looking to the Future
Introduction Introduction and Aims and Aims
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.
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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 2015-2016. The Greater Manchester PSTRC is funded through the NIHR for five years (ÂŁ6,291,208 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. The Greater Manchester PSTRC has built a unique research capability for the UK and established a critical mass of partnerships with patients, communities and care systems. This report highlights how we have completed ground-breaking studies which will improve safety in primary care.
Prof Stephen Campbell Principal Investigator
As a translational research centre, our role is to develop and test new interventions. In each of our research themes we have developed interventions that will impact on making care safer for patients in primary care. Many of these interventions will be rolled out across the whole of the NHS, reducing the over 18,000 patient safety incidents that occur every day in primary care. The range of the interventions that we have developed is extensive. Examples include safer prescribing and dispensing of medications through prescribing safety indicators and a missed opportunity detector for potentially hazardous prescribing, developing digital technologies to support people with serious mental illness, codesigning a Patient Safety Toolkit for general practices and co-designing an online module for people living with multimorbidity. We are developing patient safety guides designed to empower patients to work with their clinicians to reduce safety incidents and better use of data to support GPs in identifying medication errors.
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
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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 pharmacies, it is recognised 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, new ways of reducing this and other errors by providing better information to patients and healthcare professionals, particularly during the prescribing of medicines, are being developed.
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. This research theme aims to increase the understanding of diagnosis and patients’ interactions with primary care to provide better support to 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 anonymised clinical information held in electronic patient records can improve the care provided to patients. A platform which is being developed 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
Theme Lead
Prof Darren Ashcroft
Nottingham Lead Prof Tony Avery
Completed projects • Two papers have been published – one in the BMJ and one in Drug Safety – about surveillance of medication safety using prescribing safety indicators (which describe scenarios where there is potentially inappropriate and/or unsafe prescribing). These papers will be influential in health services research and policy worldwide. This work has generated a great deal of positive publicity and media coverage for the University of Manchester, PSTRC and NIHR, for example, an ‘Eyes on Evidence’ NICE Expert Commentary. • A study was completed which looked at a computer-based system, which is available to GPs, pharmacists and hospitals in a number of locations across England. The system highlights potentially harmful interactions between medicines that are prescribed to patients. The study, called Education and Costanalysis Leading to Improved Prescribing Safety and Efficiency (ECLIPSE Live), evaluated in a Clinical Commissioning Group (CCG) how much the system is used and why, and whether there are any barriers to it being used more widely. • The PSTRC supported completion of studies exploring medicines management issues when transferring high-risk patients (patients with acute kidney injury or serious mental illness) between primary and secondary care. The findings highlighted the importance of collaborative work between primary and secondary
The overall aim of the Medication Safety theme is to develop a medication safety system for primary care, which will cover the prescribing, dispensing and taking of medicines. In year four, this theme has been continuing its work towards this final output. healthcare professionals and the ways in which this work could be supported through training. • The Medication Safety theme has involved members of the Research User Group to undertake focus groups with a broad cross-section of the general public to learn about their understanding and experiences of medication-related problems in primary care. The study findings are being used to inform recommendations for the involvement of service users in medication safety. Current projects • Users of the Royal College of General Practitioners (RCGP) e-learning prescribing module for GPs, reported that they planned to make changes in their practice as a result of completing the online course that the PSTRC developed. Changes included performing more comprehensive medication reviews and providing clearer instructions on prescriptions. One GP fed back: “This is the best prescribing module that I’ve done...because it includes real type scenarios of people with multiple drug lists and multiple morbidities”. By the end of 2015, almost 2,000 RCGP members had used the online learning package. • The Medication Safety theme has tested the use of a tool called the Manchester Patient Safety Assessment Framework (MaPSaF) in several community pharmacies. Initial findings suggest
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Medication Safety that using MaPSaF helped pharmacies to make positive improvements to patient safety, and as a result there are plans to implement the tool on a wider scale. • In order to develop additional safety improvement tools for community pharmacies, the Medication Safety theme has established a research collaborative with a range of community pharmacy staff. The collaborative’s activities involve reviewing and testing safety improvement methods which are used in other healthcare or industrial sectors. • Estimates from the rollout of the ‘pharmacist-led information technology intervention for medication errors’ (PINCER) suggest that it could prevent 1,375 serious harms per year and save over £3million in NHS costs per year. Funding was secured from the Health Foundation to roll out the PINCER intervention in 530 general practices across 17 Clinical Commissioning Groups (CCGs) in the East Midlands. • The PINCER approach is currently being rolled out and evaluated in Salford using an updated medication safety dashboard produced by the Medication Safety and Interface and Informatics themes of the PSTRC. The Medication Safety theme is currently leading on the roll-out and early evaluation of PINCER in this region, with 12 general practices having already taken on the intervention.
• A study is underway to examine the causes and effects of deviation from standard procedures in community pharmacy. So far, this study has resulted in a paper published in BMJ Open, with further papers in preparation. In addition, the findings to date have been used to develop professional practice workshops for The University of Manchester’s Pharmacy teaching programme. • A second study examines a selection of community pharmacies which are performing their duties to a particularly high standard. This study uses observational and interview data from these pharmacies, together with interviews with pharmacy superintendents and medication safety officers, in order to understand the background to the high standard of performance. These characteristics can then be promoted to raise the standards across all pharmacies. • Other work is looking at non-psychotropic medication (medicines which do not affect the mind, emotions or behaviour) and examining whether their use can predict, or contribute to, unnatural deaths. The study is specifically exploring the use of anti-epileptic drug therapies which have had regulatory warnings in Europe and the USA.
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Multimorbidity
Theme Lead
The Multimorbidity theme aims to better understand the most common safety issues faced by patients with multimorbidity (having one or more long-term conditions) and to develop ways of reducing their vulnerability to safety failures. The theme is working with patients to minimise safety failures through active patient involvement.
Prof Peter Bower Completed projects • The findings from a review on the effectiveness of integrated case management (provision of a joined-up and personalised health service) were published in PLOS One and have generated a great deal of media interest, including being cited in the BMJ. Two other reviews were published in the same journal. Current projects • A study called MAXimising Involvement in MUltiMorbidity (MAXIMUM) is underway. This is an in-depth study of patients in the community which explores how safety failures occur and then identifies opportunities to prevent these failures through active patient and carer involvement. • A Multimorbidity Research Advisory Group (MRAG) has been set-up to ensure that the patient perspective is incorporated into the PSTRC’s research. The MRAG has met three times, and its 19 members have found attending meetings to be “interesting”, “stimulating” and “very useful”, providing opportunities to share problems and ideas, to discover “how other people cope” and to gain comfort from the fact that “we are not alone”. The MRAG has supported the development of two funding applications; one successful bid for an experience-based codesign project (EPHESUS, NIHR School for Primary Care Research -see ‘Future Project’ in this section), and one awaiting assessment (NIHR Doctoral Research Fellowship).
• The Healthtalk website’s multimorbidity module is co-funded by the Greater Manchester PSTRC and the NIHR School for Primary Care Research, through collaboration with the University of Oxford and the Healthtalk charity DIPEx. The module will be launched in September 2016 to coincide with the planned publication of the NICE guidelines on multimorbidity. The PSTRC has generated material to create the module, which it is anticipated will become a well-known and well-used resource for patients and carers, as well as healthcare professionals in training. • A further study is looking at different models of ‘integrated care’, and will use advanced statistical methods to look at the effectiveness of integrated care within Greater Manchester, especially for patients with multimorbidity. These local approaches will be compared with international evidence, to see if there are things to be learnt from other health systems to improve our own. Future project • The EPHESUS project, involving a group of patients and carers and started in 2016, is designed to take insights from the PSTRC’s published reviews, the MAXIMUM project and the MRAG and to use a process called experience-based co-design (where patients and staff give information about their experiences of healthcare, which is then analysed to help make improvements), to develop guidance and interventions that can support patients’ involvement in improving their safety in primary care.
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General Practice Patients have the right to expect and receive safe primary care. The overall strategy and aim of the General Practice theme is to build on existing research, to identify innovations related to patient safety, and test them locally to encourage improvement in general practice. Theme Lead
Prof Stephen Campbell
Completed projects • A review of all literature relating to Differential Diagnosis Tools (aids or tools for professionals that suggest diagnoses based on the information and symptoms provided) has taken place and a paper has been published in PLoS One. The paper recommends caution before using Differential Diagnosis Tools in routine clinical practice. • A survey study was completed in general practices in Greater Manchester looking at the frequency of Never Events (serious incidents that are preventable). The study provides the first epidemiological data (which looks at how often things happen, as well as where and why they happen) on the frequency of Never Events in general practice. Never Events are rare in general practice but can be used for safety improvement learning when they occur. • The ISABEL study explored the views and experiences of GPs after using a differential diagnosis tool in general practice. Use of the tool has two potential benefits: o the direct benefit to the patient when additional test(s) which are suggested by using the tool, lead to the correct diagnosis being made earlier o the potential long-term reduction in cost through avoiding unnecessary tests.
• The launch of the Patient Safety Toolkit on the Royal College of General Practitioners (RCGP) website is listed as one of the top 10 achievements for the NIHR School for Primary Care Research (NIHR SPCR) over the last 10 years. See Patient Safety Toolkit case study on page 17 for more information. Ongoing projects • The Patient Safety Guide will be a resource designed for patients to use during their interactions with general practices and community pharmacy services. Equivalent guides currently exist for patients going into hospital, but not for primary care. There is extensive ongoing involvement from patients, carers, GPs and pharmacists in shaping the guide. See the Patient Safety Guide case study on page 15 for more information. • Missed Diagnostic Opportunities are when something different could have been done to make a correct diagnosis earlier, or the correct diagnosis was missed. The Missed Diagnostic Opportunities (MDOs) project, working with Interface and Informatics theme, will create a precise way of estimating MDOs in general practice. • An avoidable harm study is underway, which is funded by the Department of Health. It will increase understanding of the nature and frequency of avoidable harm in primary care. An example of
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General Practice avoidable harm would be prescribing medication to a patient when they have a recorded intolerance to it. • Focus groups took place with GPs in Manchester and Glasgow to explore their views of Never Events. Following the focus groups, participants reported having reviewed procedures at their own practices and putting strategies in place to prevent Never Events. • A study is underway looking at how GPs deal with diagnostic uncertainty, which is when a definite diagnosis cannot be made based on the symptoms described. Training is being developed for GPs to help them to deal with this uncertainty and to better communicate it to their patients. • Although there are tools available to measure patient safety feedback in hospitals, there were no tools to measure patients’ experiences of safety in a primary care setting. Using the knowledge gained from a review of available literature, and adapting an existing hospital patient measure of safety (PMOS), the
aim of this study was to develop an effective primary care patient measure of safety (PC_PMOS). After testing the PC_PMOS with a small group of patients and healthcare professionals in Australia and the UK, the project will now ensure that the PC_PMOS questionnaire is as effective as possible, by testing it with 500 patients from 10 GP practices in Greater Manchester. •
A survey has been developed by the PSTRC and PPI members on patients’ perceived unsafe events in primary care, with the pilot survey involving over 600 people. The PSTRC has since worked with Ipsos MORI, a specialist survey company, to conduct a wider survey of 4,000 people, which is the largest of its kind.
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A further study exploring GPs’ experiences of putting safety interventions (techniques to improve a healthcare outcome) into practice, will make recommendations on how to encourage GPs to deliver safety improvements.
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Interface and Informatics The main aim of the Interface and Informatics theme is to develop an alerting system that averts potentially unsafe situations with carefully targeted information. Theme Lead
Prof Iain Buchan
Project Lead Dr Niels Peek
Projects completed • The theme has developed a state-of-the-art dashboard, where information on patient safety is displayed to GPs. Alongside this, and in collaboration with Medication Safety theme, work has taken place to look at the best way to display information to GPs on the dashboard, in order to encourage its use. • Citizens’ Juries are a way to gather public opinion on important topics which can be included in policy-making decisions. A Citizens’ Jury takes place over several days with public jury members hearing expert opinions on a topic, and the final result being a verdict or set of recommendations from the Jury which are fed into policy-making decisions. This year, the Greater Manchester PSTRC and Health eResearch Centre (HeRC) arranged two Citizens’ Juries, each consisting of 17 adults from Greater Manchester. Each Jury met to deliberate the sharing of health data. The results were presented at a workshop where the National Data Guardian, Dame Fiona Caldicott, and senior representatives from the Information Commissioner’s Office (ICO), Health and Social Care Information Centre (HSCIC), NHS England and the National Institute for Health Research (NIHR) were present. Ongoing projects • The dashboard described above is being trialled in general practices in Salford, which has a population size of 234,000. Pharmacists will visit general practices at various stages of the trial,
in order to provide additional training or advice to GPs on prescribing to GPs. It is hoped that use of the dashboard, in conjunction with pharmacist input, will alter how GPs make decisions around prescribing. Following the trial, it is expected that the dashboard will begin to be used across Greater Manchester, which has a population size of 2.55 million. • Work that was carried out by the Greater Manchester PSTRC and the Farr Institute has led to development of the “Health North: Connected Health Cities” programme. This programme is funded by the Department of Health as part of the Northern Powerhouse, and aims to use data and analytics to improve health services across North England. In Greater Manchester the programme focuses on three care ‘pathways’: antibiotic prescribing and reduction of antimicrobial resistance; acute and post-acute stroke services, and community management of pressure ulcers. • PatientView is a system that is currently used by more than 30,000 Chronic Kidney Disease patients across the UK. One of its key functions is to allow patients to view the results from biochemical blood tests which are performed to monitor kidney function over time. Work by the Interface and Informatics theme aims to define how these results should be displayed to make the information most meaningful and easy for patients to understand. Recommendations will be fed back to the companies and organisations involved in PatientView, so that they can take action.
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Case Studies
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Development of the PINCER intervention A previous study led by the University of Nottingham called PINCER, used prescribing indicators, which describe scenarios where there is potentially inappropriate and unsafe prescribing.
Through the following actions, the PINCER intervention has been further developed:
The expected outcomes from the PINCER intervention include:
• collaborating with colleagues from the Universities of Nottingham and Edinburgh to secure further funding to continue work around the PINCER intervention • demonstrating the scale of hazardous prescribing in English general practices • developing an updated set of the most important prescribing safety indicators • adding the PINCER prescribing safety indicators into the Patient Safety Toolkit (PST) • working with the Greater Manchester Academic Health Science Network (GM AHSN) to pilot a new medication safety dashboard that incorporates the PINCER intervention in to ten Salford GP practices • working with stakeholders to encourage as many general practices as possible to use the PINCER intervention.
• a reduction in hazardous prescribing and the avoidance of patient harm, including medication-related hospital admissions and deaths • improvements in prescribing safety in NHS general practice. • cost savings to the NHS. The NIHR Greater Manchester PSTRC will be evaluating outcomes as part of a recently awarded NIHR Programme Grant called Avoiding patient harm through the application of prescribing safety indicators in English general practices (acronym: PRoTeCT).
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Patient Safety Guide The opportunity for patients to have a key role in maintaining their safety in healthcare is increasingly important. In order for patients to do this, additional information, tools and support that are made available could help.
The aim of the Patient Safety Guide project is to develop a resource, through collaboration with patients, carers and healthcare professionals, which will help patients and carers to address key patient safety questions and to identify points where they can make their care safer. Patient and public involvement as well as healthcare professional involvement has been a key element of this project to date. A range of stakeholders have been involved in the project including patients, carers, GPs, pharmacists and researchers. There is a virtual stakeholder involvement group as well as a patient and public involvement group who are working on the project. Working together, a co-development event was designed and delivered, where a wider group of stakeholders discussed their experiences and shared ideas on which key patient safety issues should be included in the
guidebook resource. Feedback from the event was very positive, with attendees finding that the mix of service providers and service users encouraged open and honest discussions about patient safety issues in primary care. Participants expressed the wish to be involved in future work to develop the Guide and following the event further patients, carers and healthcare professionals have been recruited to be involved in the project. Future plans for the project are to refine the initial guide and website prototypes based on this joint work. To maximise the potential for use of the guidebook, the NIHR Greater Manchester PSTRC has established links with key primary care groups, such as The Patients Association and the Royal College of General Practitioners (RCGP).
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Patient Safety Toolkit Patient safety is complex and made up of many different elements, including diagnosis and prescribing safety, communication (both within and between general practices and other healthcare settings), the culture of safety within organisations, and patient-reported problems. Each of these factors requires a different method of assessment and improvement. To address this, the NIHR Greater Manchester PSTRC has been involved in the development and dissemination of a Patient Safety Toolkit, which is the first ever comprehensive method to help UK general practices to engage with the different safety issues encountered within their practices. The tools included have been tested for practicality and reliability with a specific focus on their relevance to UK general practice.
with more than half of those visits resulting in the download of a resource.
The Patient Safety Toolkit has been hosted on the RCGP website since August 2015. One of the main aims for the Greater Manchester PSTRC in collaborating with the RCGP to roll out the Patient Safety Toolkit, was to enable wide-ranging publicity and to raise awareness of the Toolkit amongst practice staff as a whole. The PSTRC was keen for practices to have an opportunity to access and use the tools in practice, for the benefit of their practices and their patients. The Patient Safety Toolkit webpage has now been visited over 5,000 times,
There has been a variety of media coverage, with the Patient Safety Toolkit being discussed in several RCGP Chair blogs, a radio interview conducted with Professor Tony Avery and various national news articles featuring the Toolkit. The launch of the Patient Safety Toolkit was selected as one of the top 10 achievements for the NIHR School for Primary Care Research (a collaboration of primary care research centres across eight leading British universities) over the last ten years.
Patient safety workshops have also been hosted across the UK, and provided a high-profile way of highlighting the availability and role of the Patient Safety Toolkit. The workshops also allowed general practice staff to share their experiences and ideas around patient safety.
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Involvement
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Patient and Public Involvement Patient and Public Involvement (PPI) is fully integrated into the work of the NIHR Greater Manchester PSTRC. In year four of the centre, 7.5 percent of all expenditure was used to ensure patients and members of the public advised on, fed into, and were partners in the PSTRC’s work. Research User Group The PSTRC set up a Research User Group (RUG) in 2013, made up of ten to twelve users of healthcare services, who are actively involved in the research taking place within the centre. Governance RUG members oversee PPI in each of the research themes, discussing what makes good PPI, suggesting to research themes where there may be gaps in their PPI and, in conjunction with PPI leads in the centre, providing support and advice to researchers. Project PPI members, rather than advising on PPI, are closely involved in individual research projects. RUG development Over time, the Greater Manchester PSTRC has developed from a centre in its infancy, into a complex PSTRC with multiple projects, methods of research and strategies. In order to address the current needs of the centre and its patient and public members, during year four, a full review of the PPI structures in the PSTRC took place. As of April 2015, there are more Project PPI members involved in research and a greater focus on projects with direct relevance to patient needs. Governance oversight of themes is now undertaken by a small defined group of RUG members, with no project links to the theme they oversee. RUG involvement Members of the RUG are involved in a range of the PSTRC’s projects and activities, from advising on whether the language used in a document is suitable for its audience, to analysing data within projects. Examples of involvement in year four include: • A pro-forma was designed by and for RUG members and researchers to feed back on their activity at theme level and
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in projects. RUG members had active partnership roles in the development and running of the centre’s second research symposium, “Patient Safety in Primary Care: A Shared Responsibility”. A public engagement event on sharing health data and a related commissioned play “The Nest” both had significant input from members of the RUG. RUG members were actively involved in designing and conducting a survey of patients’ perceptions/understanding of safety. A Multimorbidity Research Action Group (MRAG), which includes a number of the PSTRC’s Project PPI members, is helping to shape research priorities and methods. For example, information from those involved in the MRAG informed a subsequent research fellowship application, which focused on an under-researched area of communication. Patients and carers are advising on the Patient Safety Guide which is intended to provide support to patients when they see a GP or other healthcare professional and were instrumental in an event which set out to decide what the guide should include.
PPI research • Evaluations of the impact of the Research User Group (RUG) and PPI on the PSTRC’s research are ongoing, both inside and outside the centre. A questionnaire which was designed to assess the impact of the RUG on research, is now being used nationally and internationally. • The views and experiences of South Asian participants in PPI in health research are being explored, and will result in recommendations on how to involve more diverse groups of patients in primary care patient safety research.
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Public Engagement Public engagement takes place to help connect the work of the NIHR Greater Manchester PSTRC with those people its affects, namely everybody who is registered with, uses, or works in, primary care. Between April 2015 and March 2016 the centre hosted three events designed to increase the visibility of the research taking place and to encourage involvement and participation from members of the public. Research symposium
More Than Just A Number
The Nest
On 1 July 2015, the NIHR Greater Manchester PSTRC’s second research symposium, “Patient Safety in Primary Care: A Shared Responsibility”, took place in Manchester city centre, with over 70 people attending.
The PSTRC wanted to bring the important topic of sharing data, particularly sharing healthcare data, to the people of Greater Manchester. So, a session was developed and run at the Museum of Science and Industry on 28 October 2015, as part of the Manchester Science Festival.
The Nest is an interactive theatrical drama, commissioned by the PSTRC and written and produced by Strawberry Blonde Curls Theatre Company, which tackles the topic of sharing health data. The play was performed to a sold-out audience at Z-Arts in Manchester on 29 October 2015.
Speakers included: • members of the PSTRC’s Research User Group (RUG) • invited patient speakers • NIHR Greater Manchester PSTRC researchers and PhD students Key messages from the symposium were that each patient has their own, unique healthcare experiences and that it is important patients are listened to, to ensure they receive the best treatment possible and are able to participate in their own care plan.
A series of interactive activities were hosted by researchers and staff from the Interface and Informatics theme, designed to help visitors to answer the questions: • Where is your health information held? • How anonymous can you ever be? • Would you share your health data? There was engagement with people of all ages and the activities were well received.
The play followed a father and daughter relationship and posed the question: “in a world where our personal information is shared constantly, at what point should we take control of it for ourselves?” It presented some thought provoking questions, which were discussed in a Q&A session after the performance.
The Greater Manchester PSTRC has collaborative links to The Patients’ Association, North West People in Research Forum, Public Programmes Team at Central Manchester University Hospitals NHS Foundation Trust, Citizen Scientist, Research and Development department at Salford Royal NHS Foundation Trust, Primary Care Research in Manchester Engagement Resource (PRIMER), and the Health eResearch Centre (HeRC). Through these links, the centre builds upon and shares its knowledge on involving and engaging patients and members of the public in research.
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Other Information
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Governance The NIHR Greater Manchester PSTRC’s Principal Investigator and Director, in conjunction with the Research Theme Leads, Research User Group and the governance boards, shape the strategy and overall direction of the Centre. The PSTRC has three main governance groups: • the Executive Management Board (EMB) meets four times per year to oversee the 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). Members include the Chair of the Research User Group and key clinical leaders from The University of Manchester, NHS England, Greater Manchester Clinical Commissioning Groups and Salford Royal NHS Foundation Trust. • the Strategic Advisory Group (SAG) advises the PSTRC Leadership on the forward direction of the centre. It includes membership from the World Health Organisation (WHO), The Patients Association and NIHR Imperial PSTRC. • The Governance Research User Group (RUG) is made up of members of the public, patients and carers and advises on the Patient and Public Involvement (PPI) taking place within the PSTRC. See page 20 for more information. 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 relevant theme PSTRC staff, PhD students and Research User Group members. • Strategic planning meetings for the future direction of the centre are held quarterly and involve a range of board members listed on this page, as well as senior leaders from across the Greater Manchester health economy including university researchers and health service leaders.
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. • 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.
Executive Management Board members • Mike Burrows (Chair), Jane Macdonald: Greater Manchester Academic Health Science Network • Carolyn Gamble: NIHR Greater Manchester PSTRC Research User Group (RUG) • Rob Bellingham, Maxine Power, Sara Roscoe: NHS England • Simon Denegri: NIHR INVOLVE • Ian Moston and Diane Morrison: Salford Royal NHS Foundation Trust • Hamish Stedman and Anne Talbot: Greater Manchester CCGs • Martin Tickle:The University of Manchester Strategic Advisory Group members • Aziz Sheikh: Edinburgh University • Bryony Dean Franklin: NIHR Imperial Patient Safety Translational Research Centre (PSTRC) • Cordula Wagner: Nivel, The Netherlands • Katherine Murphy: The Patients Association • Mike Kelly: NICE • Richard Roberts: WONCA
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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 does this in a variety of ways. Website The PSTRC’s website is the main information hub for the centre. It links out to social media sites, lists published papers, provides information on events and opportunities to become involved in the work of the centre, as well as to find out about the projects and their findings. Newsletter The PSTRC publishes a quarterly newsletter to keep members of the public, healthcare professionals and researchers informed about its latest work. The Editorial Group includes a member of the RUG to ensure the language used is suitable. The most recent PSTRC newsletter (issue 9, Jan 2016) was sent to 561 subscribers with 10 percent of readers being outside the UK in countries including Website: research.bmh.manchester.ac.uk/primary-care-patient-safety
Blog: www.gmpstrc.wordpress.com YouTube: www.youtube.com/channel/UC18GlgZdtIjV8kX_OA5GJkg
PPI Case Studies:
http://research.bmh.manchester.ac.uk/primary-care-patient-safety/ GetInvolved/
Plain English publication summaries:
http://research.bmh.manchester.ac.uk/primary-care-patient-safety/ publications/
Follow us on Twitter: https://twitter.com/GM_PSTRC
Canada, the USA, Spain and Australia. Blog The ‘GM PSTRC’ blog has continued throughout the centre’s fourth year, with more than 20 blog posts being published and over 2,500 views. Members of the Research User Group write regular blog posts on their experiences of being involved in the PSTRC. YouTube channel The PSTRC has a YouTube channel, which has a number of videos commissioned by the centre, including introductions to the centre and its research themes, an animation explaining the meaning of ‘patient safety’ and ‘primary care’, as well as interviews with patients about their views of patient safety in primary care. Twitter The centre has four active Twitter accounts; the main centre account, two theme-specific accounts and a project-specific account. • @GM_PSTRC • @Multimorbidity and @Meds_Safety • @JLA_PtSafetyPSP Patient and Public Involvement (PPI) Case studies Ways in which PPI has been instrumental in specific research projects are written up into case studies and shared on the PSTRC website. Plain English publication summaries Each time a research paper is published, a plain English summary is written to explain to a general audience what the study involved and what the findings were.
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Research Capacity Building Research capacity building in primary care patient safety is the second core aim of the NIHR Greater Manchester PSTRC.
In the 2015-16 financial year, 12.6 percent of the centre’s total budget was allocated to training, broken down as follows: • Training for staff and PhD students 1.2 percent • Conference attendance for research staff 1.1 percent • PhD fees and salary 10.3 percent In addition, a Daphne Jackson Fellowship has also been supported (Jane Sarginson). This role is looking at the diagnosis of depression in children and adolescents and, linked to this, the patterns of prescribing antidepressants to children and adolescents. The Fellowship will run until March 2017. During the NIHR Greater Manchester PSTRC’s fourth year, each member of staff at Research Fellow and Research Associate level and all PhD students were allocated an annual conference budget and an annual training budget. Allocation of individual budgets is in discussion with the relevant line manager in order to help meet the aims of the research theme. Examples of training undertaken by staff and students in 2015-16 include: • Analysing qualitative interviews and reporting qualitative data • Self-care, shared care: rethinking the management of long-term conditions • Policy evaluation methods • NVivo qualitative research software training • Advanced Stata • Realist methodology design and implementation
Non-research professional support staff members are allocated an annual training budget. Examples of training completed by professional support staff include:
• Making short films using iPhones and iPads • Additional skills development in leadership • Photoshop Advanced • HTML and CSS Essentials • Meetings, minutes and agendas
All Greater Manchester PSTRC funded staff have an annual Performance and Development Review (P&DR) with their line manager. The P&DR includes discussion on personal development, academic progression and career planning, as well as one-to-one support through mentoring. The University of Manchester has an internationally recognised track record in informatics, statistics, economics and research methods. Greater Manchester PSTRC staff and students work across various research environments within the Institute of Population Health and the Manchester Pharmacy School. Each location has a scheduled seminar series, research mentors and journal club meetings. The University of Manchester provides a “New Academic Training” programme, with places awarded through open competition. Four PSTRC members of staff have completed, or are in the process of completing, the programme.
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PhD Students The PSTRC has six fully-funded PhD students, all of whom are in the third year of their programmes. • 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, is undertaking his PhD project on integrated care and multimorbidity. • Christian Thomas, aligned with the Manchester Pharmacy School, is working on a project addressing procedural violations in pharmacy. • Tina Wulff, aligned with the Manchester Business School, is completing a project on primary care patient safety improvement science.
There are also two PhD students at the University of Nottingham (Rachel Spencer, Richard Knox), one PhD student at the University of Amsterdam (Wouter Gude), and four PhD students at The University of Manchester (Ben Brown, Mark Jeffries, Reinis Jones, Harish Thampy) who are supervised by PSTRC-funded staff and whose projects will feed into the PSTRC’s research, but who are not funded directly by the Greater Manchester PSTRC. This year, the centre’s PhD students have been involved in a variety of work for the centre, including: Papers • Lead author on “Development and preliminary validation of a dynamic, patient-tailored method to detect abnormal laboratory
test results.” • Lead author on “Effectiveness of case management for ‘at risk’ patients in primary care: A systematic review and meta- analysis”. • Lead author on “Non-Psychotropic Medication and Risk of Suicide and Attempted Suicide: a Systematic Review”. • Co-author on “Multimorbidity and patient safety incidents in primary care: A systematic review and meta-analysis”. Presentations • An oral presentation on “Qualitative insights about the effect of procedures on professional autonomy in community pharmacy” at the 2015 Royal Pharmaceutical Society conference. • Presentation on “Development and preliminary validation of a dynamic, patient-tailored method to detect abnormal laboratory test results” at the MedInfo 2015 conference. • Presentation on “What do we know about the involvement of minority ethnic groups (MEG) in health and social care research?” at the Society for Academic Primary Care 2015 conference. Paolo Fraccaro was awarded the Early Career Award by the Chartered Institute for IT recognising innovation and excellence in primary care computing. The Greater Manchester PSTRC has a PhD group for its own PhD students. The PSTRC PhD students are also part of the Centre for Primary Care PhD group, which consists of 30 PhD students; as well as the Institute of Population Heath doctoral training group, with more than 100 PhD student members. Greater Manchester PSTRC PhD students also have access to modules in The University of Manchester’s Masters in Research (MRes) and Masters in Public Health (MPH).
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Industry and Charity Links In 2015-16, the PSTRC linked in with a number of local and national organisations and companies, to enhance its work. Isabel is a diagnosis tool which was trialled by GPs, who then gave their views and experiences of using the tool. A module is being developed for the Healthtalk.org website, which will focus on multimorbidity. Once complete, the module will be an online resource for patients suffering from more than one longterm condition. NWPiRF supports the PSTRC by promoting its work and events through their networks. The Medication Safety theme has worked collaboratively with TPP on prescribing safety systems The PSTRC has collaborated with the RCGP on the Patient Safety Toolkit, which is hosted on the RCGP website.
Safety Culture Associates Ltd
Working with Medication Safety theme, Safety Culture Associates Ltd has provided expertise and support for use of the MaPSaF framework (see page 5)
Ipsos MORI is a company specialising in surveys, and the Core theme is working with them on a project evaluating patient views and experiences of primary care patient safety. The PSTRC is part-way through its funding of a Daphne Jackson Fellowship, an initiative which encourages Science, Technology, Engineering and Maths (STEM) professionals back into the workplace after a career break. The Public Programmes Team works with the PSTRC to develop and run public engagement events. A Priority Setting Partnership is taking place in conjunction with the JLA, to identify the ‘Top 10’ unanswered questions about patient safety in primary care. The Nest, a play about the sharing of health data, was commissioned by the PSTRC and written, directed and performed by Strawberry Blonde Curls.
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Links with NIHR Infrastructure The NIHR Greater Manchester PSTRC has established numerous links with other NIHR-funded organisations. This ensures that NIHR aims are a central focus and further enhances the work of the PSTRC. The Greater Manchester PSTRC has strong historical and ongoing links with the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the NIHR School for Primary Care Research (SPCR). The NIHR Greater Manchester PSTRC and the NIHR CLAHRC Greater Manchester are both hosted by Salford Royal NHS Foundation Trust.
funded by the NIHR SPCR.
Professor Stephen Campbell has worked with Dr Tom Blakeman on an NIHR CLAHRC Greater Manchester-funded project to improve the diagnosis and treatment of Acute Kidney Disease. The recommendations from this collaboration have been sent to NHS England.
The Multimorbidity theme has ongoing links with healthtalk.org, a collaboration between a charity (DIPEx) and the University of Oxford (see page 7), through development of a Multimorbidity module project, which was part-funded by the NIHR SPCR.
The NIHR Greater Manchester PSTRC and NIHR Imperial PSTRC have a reciprocal agreement, whereby researchers from each PSTRC sit on the other’s Strategic Advisory Group. Professor Stephen Campbell, Principal Investigator of the Greater Manchester PSTRC, is also the centre’s Training Lead and is part of the NIHR Training Leads group. PSTRC members of staff have been instrumental in working with the Royal College of General Practitioners (RCGP) to roll out the Patient Safety Toolkit (see page 17). Development of the Toolkit was funded by the NIHR SPCR and the PSTRC funded and led on work with the RCGP to share the Toolkit widely. There are close links between the Greater Manchester PSTRC Multimorbidity theme, and staff working on long-term conditions and multimorbidity-focused projects which are funded or co-
There are links between the Greater Manchester PSTRC Research User Group (RUG) and PRIMER, which is The University of Manchester’s Centre for Primary Care Patient and Public Involvement Group, which was funded originally by the NIHR SPCR.
National Institute for Health Research (NIHR) nihr.ac.uk NIHR CLAHRC Greater Manchester clahrc-gm.nihr.ac.uk/ NIHR School for Primary Care Research spcr.nihr.ac.uk/ NIHR Imperial PSTRC imperial.ac.uk/patient-safety-translational-research-centre PRIMER research.bmh.manchester.ac.uk/PRIMER/about/
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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:
Audit: Using data to drive improvement
Brown B, Peek N.
InnovAiT 2015
*Developing a primary care patient measure of safety (PC PMOS): a modified Delphi process and face validity testing
Hernan AL, Giles S, O’Hara J, Fuller J, Johnson JK, Dunbar JA.
BMJ Quality and Safety
*Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study
Hernan AL, Giles SJ, Fuller J, Johnson JK, Walker C, Dunbar JA.
BMJ Quality and Safety
*Contributory factors to patient safety incidents in primary care: protocol for a systematic review
Giles S, Panagioti M, Hernan A, CheraghiSohi S, Lawton R.
Systematic Reviewer
*Primary Care Medication Safety Surveillance with Integrated Primary and Secondary Care Electronic Health Records: A CrossSectional Study
Akbarov A, Kontopantelis E, Sperrin M, Stocks Drug Safety SJ, Williams R, Rodgers S, Avery A, Buchan I, Ashcroft DM.
*What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study
Adeniji C, Kenning C, Coventry P, Bower P.
BMC Health Services Research
*Effectiveness of case management for ‘at risk’ patients in primary care: A systematic review and meta-analysis
Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P.
PLoS One
*Multimorbidity and patient safety incidents in primary care: A systematic review and meta-analysis
Panagioti M, Stokes J, Esmail A, Coventry P, Cheraghi-Sohi S, Alam R, Bower P.
PLoS One
*The care.data consensus? A qualitative analysis of opinions expressed on Twitter
Hays R, Daker-White G.
BMC Public Health
*Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: Prospective study in 20 UK hospitals
Ashcroft DM, Lewis PJ, Tully MP, Farragher TM, Taylor D, Wass V, Williams SD, Dornan T.
Drug Safety
Development and preliminary validation of a dynamic, patienttailored method to detect abnormal laboratory test results
Fraccaro P, Brown B, Prosperi M, Sperrin M, Buchan I, Peek N.
Studies in Health Tech.and Informatics
A two-stage dynamic model to enable updating of clinical risk prediction from longitudinal health record data: Illustrated with kidney function
Akbarov A, Williams R, Brown B, Mamas M, Peek N, Buchan I, Sperrin M.
Studies in Health Tech.and Informatics
The case for conceptual and computable cross-fertilization between Brown B, Peek N, Buchan I. audit and feedback and clinical decision support
Studies in Health Tech.and Informatics
*Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the Linneaus collaboration on patient safety in primary care
Parker D, Wensing M, Esmail A et al.
European Journal of General Practice
*Reducing diagnostic errors in primary care. A systematic metareview of computerized diagnostic decision support systems by the Linneaus collaboration on patient safety in primary care
Nurek M, Kostopoulou O, Delaney BC, Esmail A.
European Journal of General Practice
*First experiences with patient safety initiatives in Greek rural primary care. Action research by the Linneaus collaboration on patient safety in primary care
Skalkidis Y, Manoli A, Evagelos D, Nikolaos T, Sekeri Z, Dantsi F, Wensing M, Esmail A.
European Journal of General Practice
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Publications
Publication title
Authors
Published in:
*Patient safety initiatives in Central and Eastern Europe. A mixed methods approach by the Linneaus collaboration on patient safety in primary care
Godycki-Cwirko M, Esmail A, Dovey et al.
European Journal of General Practice
*A safety incident reporting system for primary care. A systematic literature review and consensus procedure by the Linneaus collaboration on patient safety in primary care
Klemp K, Zwart D, Hansen J, Hellebek T, Luttel D, Verstappen W, Beyer M, Gerlach F, Hoffman B, Esmail A.
European Journal of General Practice
*A research agenda on patient safety in primary care. Recommendations by the Linneaus collaboration on patient safety in primary care
Verstappen W Gaal S, Bowie, P, Parker D, Lainer M, Valderas J, Wensing M, Esmail A.
European Journal of General Practice
*Developing a research agenda for patient safety in primary care. Background, aims and output of the Linneaus collaboration on patient safety in primary care
Esmail A, Valderas JM, Verstappen M, Godycki-Cwirko, Wensing M.
European Journal of General Practice
*Researching patient safety in primary care: Now and in the future
Vincent C, Esmail A.
European Journal of General Practice
*Sensemaking and the co-production of safety: a qualitative study of primary medical care patients
Rhodes P, McDonald R, Campbell S, DakerWhite G, Sanders C.
Sociology of Health and Illness
*Effect of health system reforms in Turkey on user satisfaction
Stokes J, Gurol-Urganci I, Hone T, Atun R.
Journal of Global Health
*Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink
Stocks SJ, Kontopantelis E, Akbarov A, Rodgers S, Avery AJ, Ashcroft DM.
BMJ
*Non-psychotropic medication and risk of suicide or attempted suicide: a systematic review
Gorton HC, Webb RT, Kapur N, Ashcroft DM.
BMJ Open
*The Effectiveness of Electronic Differential Diagnoses (DDX) Generators: A Systematic Review and Meta-Analysis
Riches N, Panagioti M, Alam R, Cheraghi-Sohi PLoS One S, Campbell S, Esmail A, Bower P.
*Missed diagnostic opportunities and English general practice: a study to determine their incidence, confounding and contributing factors and potential impact on patients through retrospective review of electronic medical records
Cheraghi-Sohi S, Singh H, Reeves D, Stocks J, Morris R, Esmail A, Campbell S, de Wet C.
Implementation Science
*Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care
Daker-White G, Hays R, McSharry J, Giles S, Cheraghi-Sohi S, Rhodes P, Sanders C.
PLoS One
*Clinical management following self-harm in a UK-wide primary care cohort
Carr MJ, Ashcroft DM, Kontopantelis E, While D, Awenat Y, Cooper J, Chew-Graham C, Kapur N, Webb RT.
Journal of Affective Disorders
*The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001-2013
Carr MJ, Ashcroft DM, Kontopantelis E, Awenat Y, Cooper J, Chew-Graham C, Kapur N, Webb RT.
BMC Psychiatry
*Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals
Keers RN, Williams SD, Vattakatuchery JJ, Brown P, Miller J, Prescott L, Ashcroft DM.
Journal of Clinical Pharmacy and Therapeutics
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Grant Income The following grants were awarded to the NIHR Greater Manchester PSTRC, or were ongoing, during the centre’s fourth year.
Research Theme
Award Body
Grant Title
Medication Safety
Department of Health Policy Research Programme
Self-harm in primary care patients: a nationally representative cohort study examining patterns of attendance, treatment and referral and risk of self-harm repetition, suicide and other causes of premature death
Interface and Informatics
Department of Health
Health North: Connected Health Cities
General Practice
Department of Health Policy Research Programme
Understanding the nature and frequency of avoidable harm in primary care
Multimorbidity
Health Services and Delivery Research Programme
Improving the management of patients with multimorbidity in general practice (3D)
Multimorbidity
Health Services and Delivery Research Programme
Comprehensive Longitudinal Assessment of Salford Integrated Care (CLASSIC)
General Practice
Health Services and Delivery Research Programme
Evaluation of national surveillance system for mortality alerts
Core
Health Foundation
Closing the gap: evaluation of safety surveillance in Hospital Trust Boards and CCG Governing Bodies
Medication Safety
Health Foundation and East Midlands Academic Health Science Network
Improving prescribing safety in general practices in East Midlands through PINCER
Medication Safety
Nottingham City Clinical Commissioning Group
Preparing for a Phase IV implementation trial using PINCER methodology
Medication Safety
NIHR Programme Grant
Avoiding patient harm through the application of prescribing safety indicators in English general practice (PRoTeCT)
Multimorbidity
NIHR School for Primary Care Research
Living with Multimorbidity: A qualitative study of patients’ experiences
Multimorbidity
NIHR School for Primary Care Research
Empowering People to Help Speak Up about Safety (EPHESUS) in Primary Care
Interface and Informatics
Wellcome Trust
Harnessing opportunities for quality improvement from Primary Care electronic health records
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Looking to the Future
The NIHR Greater Manchester PSTRC is a unique facility that harnesses the research power of The University of Manchester, and patient safety and transition expertise of Salford Royal NHS Foundation Trust, to develop and test early translational research for long-term benefit. The PSTRC will be a world-leading translational research powerhouse at the heart of the Greater Manchester Health and Social Care Partnership (GMHSCP), which integrates Manchester’s £6bn annual health and social care budget and which serves a population of three million people. Patient safety transcends professional boundaries and is part of a wider integrated health and social care system with interfaces and transitions with other community providers and secondary care. We will continue to develop and test digital and behavioural interventions in primary care and also interfaces and transitions to improve patient safety, particularly for patients with complex needs. Our partnerships with Nottingham/East Midlands and the Connected Health Cities programme across the north of England will generalise our research so it can be implemented rapidly throughout the UK.
NIHR Greater Manchester PSTRC Suite 11 Floor 7 Williamson Building Centre for Primary Care University of Manchester | Oxford Road Manchester | M13 9PL Email: gmpstrc@manchester.ac.uk