Evaluating innovation in healthcare:

what, when and how

Tuesday 6 October

3DFD 3 Dimensions For People with Diabetes

Khalida Ismail6 October 2015

Diabetes is associated with nearly every psychiatric disorder

ICD-10 Chapter F categories Relative risk

General popn/no psych disorder 1 (reference group)

Dementia 2.0

Schizophrenia 3.0

Substance use ~?

Depression 2.0

Eating disorders 2-3.0

Chien et al Compr Psychiatry 2011; Anderson et al Diabetes Care 2000

Depression and mortality in people with their first diabetic foot ulcer (n=253)

Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. Diabetes Care 2007:30;1473-9Winkley K, Sallis H, Kariyawasam D, Leelarathra L, Chalder T, Edmonds M, Stahl D, Ismail K. Diabetologia 2012;155:303-10

Funding: Wellcome Trust

Social interventions

Psychiatry

Diabetes

Patient

Segregation: usual care

Integration: 3DFD

•diagnostic assessment

•risk management

•psychotropic

•brief psychological treatments

• family work

• patient-led MDT meeting

• increase self efficacy for diabetes

• HbA1c

• Patient reported outcomes

• medication support

• biomedical monitoring

• diabetes education

• technology

• complications

• debt management

• housing support

• occupational rehab

• literacy

• advocacy

Social interventions

Diabetes

PsychiatryPatient

Quantitative outcomes

Pre 3DFD Post 3DFD Change score p-value

Mean HbA1c, mmol/mol (SD)** 102 (22) 84 (22) -18 (17) <0.001

Mean Patient Health Questionnaire-9 depression score (SD)**

8.8 (6.5) 6.4 (5.8) -2.4 (2.2) 0.021

Mean General Anxiety Scale-7 score (SD)**

8.9 (5.3) 4.9 (5.3) -4.0 (3.5) <0.001

Mean Diabetes Distress Scale (SD)** 47.3 (17.1) 36.0 (15.4) -11.3 (19.1) 0.01

Mean Outcomes Star score (SD)** 55.9 (11.5) 61.6 (14.9) +5.7 (9.1) 0.003

** Service for first 6-12 months (n=198)

Main 3DFD outcomes - economic

Pre 3DFD Post 3DFD Change score p-value

No of admissions to A&E/previous year (n=119)

141 77 -64 <0.001

No of bed days/previous year (n=119)

381 300 -81 0.08

No of recurrent admissions (days)/previous year (n=119)

10 (73) 4 (14) -6 (-59) 0.012

Cost benefit analysis

Costs £94k/borough/year

• 0.5WTE Consultant liaison psychiatrist

• Community outreach worker

• Admin support and infrastructure

Savings £127k/borough/year-on-year

• Short term: reduction in unscheduled care

• Long term: reduction in developing diabetes complications

3DFD net saving £33K/borough/year/

100 patients

King’s College Hospital Best Diabetes Team Award 2014

Evaluation

External validation by awards (NHS Innovations 2010 & 2015, QiC 2011, BMJ 2014, D UK 2015)

GSTT Peer review on research methodology

Health Economics

Qualitative Patient feedback

Steering group of commissioners and Diabetes Modernisation Initiative

Quantitative Outcomes

Thank you

for its support

Sexual health: 24 hours a day

Proposition

A new online sexual health service, delivered in partnership with the NHS, providing people with free STI test kits, information and advice – 24 hours a day.

– SH:24 makes it easier for people to get tested for chlamydia, gonorrhoea, syphilis and HIV.

– The service is quick, discreet and completely confidential. SH:24 is fully integrated with specialist health services and also signposts users to other points of access in primary care and community pharmacy

A new online sexual health service, delivered in partnership with the NHS, providing people with free STI test kits, information and advice – 24 hours a day.

Mission:

To improve the health and wellbeing of people in Southwark and Lambeth, through a more accessible, more

efficient sexual health service.

Aims:

1. To improve the sexual health of the local population – Rapid diagnosis and treatment of infections

– Rapid access to contraception

– Promotion of self management

2. To improve access and quality – A convenient, discreet, user centred 24/7 service

– Working with local specialist clinical services - to agreed protocols

3. To increase productivity and reduce costs – Move less complex cases online, freeing up capacity in existing specialist

services for more complex case management

– Increased and improved activity for the same cost

Approach:

Collaborative / Highly visual / User centred / Iterative

Iterative prototyping:

Developing the minimum:

Develop only what is necessary / Fail fast / Fail cheap

User centred: personas

Collaboration: mapping

Highly visual: simplify language

#1

Receiving the test:

Our insights told us how important discretion was to our users - both the tangible and the intangible. We extensively prototyped the journey and physical touchpoints (including the kit and its packaging).

16

3 iterations of lab form, which interface with both end-users and the lab. Users demand confidentiality – the QR codes hide PID and allow the lab to efficiently process anonymous samples.

#2

The support method:

Our original hypothesis was that users wanted a number to call – a traditional ‘0800 helpline’ . But user insights told us that text messaging and webchat were users preferred method of contacting us for support.

…text messages in the last 6 months

1,314

Ghost webpages designed to track appetite for webchat on the live site.

#3

Returning the test:

24

25

The end-to-end funnel detailing potential cliffs edges (the point at which users decide not to complete their journey). This process allows us to mitigate issues and ultimately improve the entire user experience.

The blood test was, and still is our biggest cliff edge. Efforts to mitigate have included: changing the lancet and improving user support (what, where and how in various guises) which have resulted in an improved return rate. .

#4

Notifying users:

Working with service users and clinicians to map text message notifications – what information users receive when and why.

Singing, wellbeing and health:The value of mixed methods

Stephen CliftSidney De Haan Research Centre for Arts and Health

Canterbury Christ Church University

Breakfast research meeting 6 October 2015

Singing and mental wellbeing East Kent (2009-10), West Kent (2014-15)

•Participants with enduring mental health issues•Network of singing groups established •Joint performance events•Monitoring of mental wellbeing using the CORE •Significant reductions in mental distress•Film documentation

CORE scoresEast Kent 10 months follow up West Kent 6 months follow up

Baseline Follow up p

East Kent(n=42)(long form34 items)

9.4(6.6)

6.9(5.3)

p < 0.01

West Kent(n=24)(short form10 items)

13.0(8.6)

10.7(9.0)

p < 0.01

CORE items showing improvement (p ≤ 0.05)

Items East Kent West Kent

Felt tense, anxious or nervous (P) Yes Yes

Had someone to turn to (+)(F) - -

Felt able to cope (+)(F) - -

Talking to people too much (F) - -

Felt terror or panic (P) - -

Plans to end my life (R) - -

Difficulty getting to sleep (P) Yes Yes

Felt despairing or hopeless (P) Yes

Felt unhappy (P) Yes Yes

Unwanted memories distressing me (P) Yes Yes

Qualitative feedback

Having something to look forward to

A supportive happy group environment which engenders a more positive mood

A chance to meet new people and make friends

Learning new material and feeling a sense of achievement

A stimulus for promoting a sense of alertness and energy

A source of motivation to engage in activity

An experience which has a lasting effect for the rest of the day and even the rest of the week

Benefits to both mental and physical health

East Kent Singing and COPD Project

•Feasibility study on singing and COPD•100+ people with mild-very severe COPD•Six singing groups established and running weekly for 10 months•Combined performance events•Baseline and two follow up assessments•Spirometry and a battery of standardised measures

Spirometry changes over 10 months

Mean S.D. p

FEV1 baseline 1.30 0.49 ns

FEV1 follow up 1.32 0.52

FEV1% baseline 54.34 20.45 p < 0.01

FEV1% follow up 56.28 21.99

FVC baseline 2.43 0.75 p < 0.05

FVC follow up 2.54 0.75

FVC% baseline 81.72 22.60 p < 0.05

FVC% follow up 85.35 21.70

Qualitative feedback

Skingley, Page, Clift et al. (2013)

Written comments from 97 participants collected at three points

Large proportion felt breathing improved incrementally

General effects on physical wellbeing

Improved psychological and social wellbeing

Singing for Better BreathingLambeth and Southwark 2014-17

Further feasibility study in South London - socially and ethnically mixed urban area

Extended scope of evaluation: exercise and health economics

Recruitment proving to be a challenge

www.s4bb.org.uk

1

Singing, Health and Wellbeing: Quantitative and Qualitative Evidence

Sidney De Haan Research Centre for Arts and Healthcare

Guy's and St. Thomas Charity,

Research meeting, Tuesday 6 October 2015

Bungay, H., Clift, S. and Skingley, A. (2010) The Silver Song Club Project: A sense of wellbeing through participatory singing, Journal of Applied Arts and Health, 1, 2, 165-178. Clift, S. (2012) Creative arts as a public health resource: moving from practice-based research to evidence-based practice, Perspectives in Public Health, 132, 3, 120-127. Clift, S. and Hancox, G. (2001) The Perceived benefits of singing: findings from preliminary surveys with a university college choral society. Journal of the Royal Society for the Promotion of Health, 121, 4, 248-256. Clift, S. and Hancox, G.(2010) The significance of choral singing for sustaining psychological ellbeing: Findings from a survey of choristers in England, Australia and Germany, Music Performance Research, 3, 1, 79-96. Clift, S., Hancox, G., Morrison, I., Hess, B., Kreutz, G. and Stewart, D. (2010) Choral singing and psychological wellbeing: Quantitative and qualitative findings from English choirs in a cross-national survey, Journal of Applied Arts and Health, 1, 1, 19-34. Clift, S., Nicols, J., Raisbeck, M., Whitmore, C. and Morrison, I. (2010) Group singing, wellbeing and health: A systematic mapping of research evidence, The UNESCO Journal, Special issue on research on singing, 2,1, Available at: http://www.abp.unimelb.edu.au/unesco/ejournal/ Clift, S. and Morrison, I. (2011) Group singing fosters mental health and wellbeing: Findings from the East Kent ‘singing for health’ network project, Mental Health and Social Inclusion,15, 2, 88-97. Coulton, S., Clift, S., Skingley, A. and Rodriguez, J. (2015) Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: randomised controlled trial, British Journal of Psychiatry, 206, 1–6. doi: 10.1192/bjp.bp.113.129908 Livesey, L., Morrison, I., Clift, S. and Camic, P. (2012) Benefits of choral singing for social and mental wellbeing: qualitative findings from a cross-national survey of choir members, Public Mental Health, 11, 1, 10-26. Morrison, I., Clift, S., Page, S., Salisbury, I., Shipton, M., Skingley, A., Vella-Burrows, T., Coulton, S. and Treadwell, P. (2013) A UK feasibility study on the value of singing for people with chronic obstructive pulmonary disease (COPD), UNESCO Journal, 3, 3. Available from: http://web.education.unimelb.edu.au/UNESCO/pdfs/ejournals/vol3iss3_2013/003_MORRISON_PAPER.pdf

2

Skingley, A., Bungay, H. and Clift, S. (2011) Researching participatory arts, well-being and health: Some methodological issues. Journal of Arts and Communities, 3, 1, 73-87. Skingley, A., Bungay, H., Clift, S. and Warden, J. (2013) Experiences of being a control group: lessons from a UK based randomised controlled trial of group singing as a health promotion initiative for older people. Health Promotion International, doi:10.1093/heapro/dat026. Skingley, A., Clift, S., Coulton, S. and Rodriguez, J. (2011) The effectiveness and cost-effectiveness of a participative community singing programme as a health promotion initiative for older people: protocol for a randomised controlled trial. BMC Public Health, 11, 142. Available at: http://www.biomedcentral.com/content/pdf/1471-2458-11-142.pdf Skingley, A., Martin, A. and Clift, S. (2015) The contribution of community singing groups to the well-being and older people: Participant perspectives from the United Kingdom, Journal of Applied Gerontology, 1-23, DOI: 10.1177/0733464815577141 Skingley, A., Page, S., Clift, S., Morrison, I., Coulton, S., Treadwell, P., Vella-Burrows, T., Salisbury, I. And Shipton, M. (2013) ‘Singing for breathing’ groups for people with COPD: participants’ experiences, Arts & Health: an international journal for research, policy and practice, On-line publication available from: http://www.tandfonline.com/doi/full/10.1080/17533015.2013.840853 Von Lob, G., Camic, P. and Clift, S. (2010) The use of singing-in-a-group as a response to adverse life events, International Journal of Mental Health Promotion, 12, 3, 45-53. Films of singing for wellbeing projects can be viewed on the Sidney De Haan

Find out more about our work at www.gsttcharity.org.uk and follow us on Twitter @GSTTCharity