Impact case studies

PINGR is a web-based software app that suggests bespoke improvements to the care that patients with long-term conditions receive from GP practices. It analyses electronic health records to audit patient care against best practice clinical guidelines.

PINGR has been rolled out across Salford (240,000 population). An evaluation across 45 general practices in Salford before and after PINGR implementation found improvements in medication review (+9.0%) and blood pressure measurement (+5.2%).

Read a blog post about PINGR.

Innovative systems are needed in primary care to help prioritise patients. However, GM PSTRC researchers have previously found that digital triage systems that are poorly designed or lack rigorous evaluation can put patients at risk. Based on these considerations, our researchers have developed and evaluated a new system for online consultations in primary care, called PATCHS.

We conducted a large systematic review of online consultations to identify key features that impact on patients’ outcomes and used findings to inform the development of PATCHS with industry partners.

The result is an NHS-approved online consultation system, available for purchase by GP practices in England. In our evaluation of PATCHS, we found that most patients were highly satisfied with the system. Convenience and speed were cited as key benefits. Initial support was needed for those lacking in confidence, such as users aged 65 years and above, although they still rated their experience positively. Staff reported that PATCHS had improved access for patients, and reduced workload when medical queries could be dealt with solely through the system. However, their workload increased if patients didn’t supply enough detail or if the patient later required an appointment.

As a result, we’ve identified how artificial intelligence (AI) could be used in online consultations. We developed an AI model using 43,998 patient requests submitted to PATCHS to identify urgent and emergency medical issues. The next step was to test its performance in 14 GP practices in North West England and London. Our evaluation demonstrated that the AI model had a correct urgency assessment of 94%, which is higher than the performance of experienced physicians cited in published literature.

Read more here in this blog post.

Our research found that GPs in training made errors in 9% of prescriptions, double that of experienced GPs. As a result, we worked with the Royal College of General Practitioners (RCGP) to design an intervention to improve this. It involves trainee GPs reviewing prescriptions using a standardised approach to identify and learn from their own errors. Our researchers have developed a range of learning materials and there’s also an online reporting facility.

Following a successful national pilot in 2018, which we supported and evaluated, the General Medical Council (GMC) made the assessment essential for all GPs in training in 2019.

Our evaluation of the 2019 assessment involved analysis of medication data submitted by GPs in training, a questionnaire survey of 1,576 GP trainers and 1,741 GPs in training. Over 70% of GPs in training and 80% of trainers reported that our guidance documents helped them with their assessment, and over 75% of both groups agreed that the assessment was helpful for improving prescribing. Over 90% of GPs in training agreed that completing the assessment had resulted in a change in their prescribing practice.

A report to assess the suitability of the prescribing assessment for GPs in training was presented to the GMC by the RCGP’s Workplace Based Assessment Group. In July 2020, the prescribing assessment was approved by the GMC and has been rolled out as a ‘formal’ prescribing assessment for the 2020/21 cohort of over 3,000 final-year GP trainees in England.

• Read related blog posts.

Researchers have created a patient safety toolkit for pharmacies that aims to introduce pharmacists and their teams to practical tools to help continually improve patient safety. The toolkit is an online training programme and was launched in autumn 2020 by the Centre for Pharmacy Postgraduate Education (CPPE).  It is now available to all of CPPE’s 70,000 members.

The toolkit was quick to make a positive impact on pharmacy professionals as it was launched on the CPPE’s website in September 2020 and between then and July 2021 it was viewed 1,228 times by 674 pharmacy professionals. This learning programme can be used to support Continuing Professional Development (CPD) as part of the General Pharmaceutical Council revalidation process.

To accompany the toolkit’s launch, we produced two “learning articles” for The Pharmaceutical Journal – a professional pharmacy journal published by the Royal Pharmaceutical Society which is available to its 40,000 members – about understanding dispensing errors and practical ways to avoid them.

Read the blog post about a patient safety toolkit for pharmacists.

Prescribing errors in general practice are expensive and preventable patient safety incidents that may result in hospitalisation. Serious errors affect 1 in 550 prescription items in general practice and contribute to 1 in 25 hospital admissions.

We have developed, tested and implemented a pharmacist-led intervention, known as PINCER, to reduce the frequency of hazardous in primary care. PINCER involves searching GP clinical systems using prescribing safety indicators to identify patients at risk of harm. Pharmacists then intervene to reduce the risk.

A trial demonstrated that PINCER is a successful and cost-effective method for reducing errors that are common and have the potential to impact a patient’s health. Health Foundation funding enabled a roll out of PINCER to 370 general practices across 12 East Midlands Clinical Commissioning Groups (CCGs). Over 22,000 instances of hazardous prescribing were identified in a patient population of almost 3 million people.

Our evaluation demonstrated a 24% reduction in the number of patients that were at an increased risk of hazardous prescribing, particularly in relation to prescribing safety indicators associated with risk of gastrointestinal bleeding (31%). The level of uptake was high, with 94% of eligible practices completing the implementation of the intervention.

We designed a model for scaling up PINCER and this was used in a national rollout during 2018-2021.

By June 2021, 2,755 GP practices had participated and more than 26.6 million patient records had been searched to identify 216,626 patients at elevated risk of hazardous prescribing. At that point in time, more than 2,250 healthcare practitioners had been trained to deliver the intervention. Follow-up data from the first 1,060 practices to implement PINCER showed a reduction of 26% in prescribing errors associated with gastrointestinal bleeding, a common cause of medication-related hospital admissions.

The Safety Medication Dashboard (SMASH) has been developed and tested by GM PSTRC researchers. It builds on the same prescribing indicators as PINCER and is a pharmacist-led intervention using audit and feedback.

What makes SMASH unique is that it’s a digital intervention using a dashboard to identify patients who are exposed to potentially hazardous prescribing, which alerts healthcare professionals who can then decide on a possible course of action. SMASH was tested in Salford and due to its success it is being rolled out across Greater Manchester (446 general practices – a population of 2.8 million) through a partnership with Health Innovation Manchester (an Academic Health Science Network).

Working with a company called Graphnet, the dashboard has been embedded in the Greater Manchester Care Record, creating a real-time electronic audit and feedback medication safety surveillance system.

Read more about SMASH:

• Paper: SMASH! The Salford medication safety dashboard
• Paper: Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care
• Paper: Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: An interrupted time series analysis

Researchers from the GM PSTRC worked with Health Innovation Manchester to fund Safe Steps Ltd to develop and embed an evidence-based digital falls risk assessment platform (Safe Steps). The intervention aimed to help improve patient safety for older people in primary and social care settings. Testing was successful as the tool reduced the number of preventable falls for older people in primary and social care settings across Tameside and Glossop.

Safe Steps was an opportunity for the GM PSTRC to build capacity, working with partners in health and social care as well as industry to test an innovative intervention to see if it would benefit a wider population.

Alongside Health Innovation Manchester, the GM PSTRC funding enabled the Safe Steps approach to be tested while evaluating the adoption and benefits across all 41 care homes in Tameside & Glossop as well as the 90+ bed Intermediate Care Unit at Tameside General Hospital. Importantly, before this pilot, Safe Steps had not been used in a hospital setting.

In addition, the project upskilled the existing workforce through training and engagement of a digital-based approach for falls risk management, with all training delivered by the Safe Steps digital team. This was done to see whether the approach could be further applied across Greater Manchester.

Read a blog post about Safe Steps.

Acute kidney injury (AKI) is a common, harmful and costly clinical syndrome. In England, AKI affects nearly half a million people a year, complicating 7 in every 100 unplanned hospital admissions. AKI is an important marker of vulnerability, with people living with multiple long-term conditions (multimorbidity) being especially vulnerable to AKI. Nearly 1 in 5 people who sustain AKI die within 30 days.

Because AKI affects so many people each year, improved post-discharge care after AKI could make a considerable impact across healthcare. Building on our leadership within the NHS England Think Kidneys Programme (2014-2017) and working in partnerships with other NIHR and NHS organisations, we led a rigorous study to develop national guidance to improve post-discharge care for people affected by AKI. 

Our research resulted in the Royal College of General Practitioners (RCGP) publishing guidance on the timeliness of post-discharge care for adults following acute kidney injury. This was incorporated into our development of the RCGP Acute Kidney Injury Toolkit, which has been accessed 14,742 times since 2018.

Our focus on post-discharge care builds on our previous research methods in which we led the development of NHS England Think Kidneys guidance to improve the recognition and response to AKI in primary care. Since publication, these Think Kidneys resources have been accessed over 48,000 times. Our findings informed the Royal College of Pathologists guidance on the communication of critical and unexpected pathology results.

In addition, we have also developed an e-learning resource on the diagnosis and management of AKI in primary care, which has been completed 6,371 times. It incorporates findings from our research focused on recognition and response to AKI as well as the development of guidance to improve post-discharge care. The resource continues to be highly rated and has been accredited by 23 organisations across the world.

Read more about the impact of this AKI research.

The Royal College of Physicians (RCP) published guidance on medication safety at hospital discharge, and this includes SAFER-Plus, a new mental health discharge intervention that has been developed by researchers at the GM PSTRC.

The SAFER-Plus mental health discharge intervention included in the RCP guidance is based on years of work by researchers at the GM PSTRC and includes input from patients, carers, healthcare professionals and other organisations.

This intervention is based on the NHS Improvement SAFER patient flow bundle, which aims to improve care transitions across the NHS. There is evidence this intervention works, but our patient and public involvement group felt that it needed some changes to make it more suitable for mental health.

GM PSTRC researchers adapted the intervention based on interviews that were carried out, the advice of a panel of experts, plus findings from previous work. The intervention focuses on:

1. Using best practice guidelines
2. Capturing and sharing information
3. Sharing decision-making.

• Read a blog post on the SAFER-Plus intervention.
• Read the research paper which describes the methods used to develop the SAFER-Plus intervention.

Researchers at the GM PSTRC used anonymised data from a large patient database that contains information on 7 million patients registered with a GP in England.

The research looked at whether psychiatric disorders, prescription of antidepressants, or socioeconomic deprivation was more or less common among adolescents who had died by suicide or had self-harmed when compared to those who had not.

The findings highlight some areas to consider in the future planning of healthcare services.

For instance, most young people contacted their GP in the year before they died by suicide or their first self-harm event, which shows that primary care services could potentially intervene.

Currently, no treatments that focus on mental health or self-harm are available in primary care. Studies have shown that short interventions, such as “safety planning”, whereby patients and clinicians work together to develop strategies to protect against suicidal thoughts and behaviours, can be effective. Adapting interventions like these for use in primary care settings may improve long-term outcomes in individuals who start harming themselves as adolescents.

• Read a blog post about risk factors for non-fatal self-harm and suicide among adolescents.
• Read the research paper which describes this work.

Building on over 20 years of research at the National Confidential Inquiry into Suicide and Safety in Mental Health Services, Manchester Self-Harm Project, and previous NIHR-funded programmes, our research on psychosocial assessments, risk assessment, and psychological therapies has highlighted major gaps between evidence and the care people experience following an episode of self-harm.

Our research has revealed important reasons why some people do not receive an assessment when they attend hospital following self-harm, whilst also highlighting the barriers to and facilitators of accessing appropriate aftercare and psychological therapies.

Read the following press releases on our papers that highlight this:

• New research calls for better care for people who seek emergency help following self-harm
• New research reveals why some people do not receive NICE recommended care following self-harm

Together with NHS England, we developed a national Commissioning for Quality and Innovation (CQUIN) indicator for the number of patients receiving a psychosocial assessment as recommended by NICE guidelines. Our research informed the development of CQUIN and is cited within the guidance documents. We developed an audit tool that’s available for use nationally and on the ‘Future NHS collaborating network’. The CQUIN was implemented nationally in April 2022. We continue to support liaison teams and NHS England via the provision of updated guidance, quarterly interactive webinars, advice on audits, and networking opportunities.

In addition, through the NHS Long-Term Plan and NHS Mental Health Implementation Plan, we are delivering a programme to improve services for people who have self-harmed.

After reviewing our progress with 12 Sustainability and Transformation (STP) sites, NHS England commissioned the extension of the work to more than 40 sites nationwide. The completed programme will enhance patient safety via improved access to psychosocial assessments, psychological therapies, and better integrated care for people who have self-harmed.

Involving patients in their patient safety is a central recommendation of the UK National Patient Safety Strategy. However, how to do this in a way that is acceptable to patients, carers and healthcare practitioners was unclear. Researchers at the GM PSTRC have worked with members of the public, carers, GPs and pharmacists to design the patient safety guide for primary care that aims to address this. The patient safety guide is a multi-component intervention package with a booklet, mobile apps for both Apple and Android devices, and a dedicated website. 

The guide has been through two phases of testing in general practice. Adaptions have been made based on the initial findings. For example, changes were made in response to the COVID-19 pandemic.

To test the guide to see if it worked well in practice we recruited 8 GP practices over the pilot study and 133 patients and/or carers.  Participants reported using the guide to plan for consultations, as a memory aid during and after consultations, and to consider where to seek care. They described the guide as a tool to empower them to think about their care and to normalise their role in patient safety.

The next phase of the study is to work with partners to scale up and roll out the guide and to co-design and test adaptations for specific, marginalised groups.

• Read a blog post about the Patient Safety Guide.
• Paper: Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care