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Maternal and Child health

Catalyst for a regional register for congenital anomalies:
There has been longstanding concern about the high levels of childhood disability in Bradford, yet little evidence about the prevalence despite national recommendations for regional registers. The Maternal and Child Health Collaboration for Leadership in Applied Health Research and Care (CLARHC) was able to review the evidence about the benefits and methods for setting up a congenital anomalies register. Working with our network of paediatricians we established a bespoke reporting system and a Bradford congenital anomalies register. The benefits of this work led to a successful proposal to Directors of Public Health across Yorkshire to establish a regional congenital anomalies register (YCAR) to help monitor patterns of anomalies and inform public health planning.

Setting up the first UK universal testing for gestational diabetes:
The Maternal and Child Health CLAHRC team worked with the Born in Bradford team and our network of obstetricians to review the risk factors for gestational diabetes for women in pregnancy and establish universal screening in Bradford Teaching Hospitals NHS Foundation Trust. The team has evaluated the universal testing which demonstrated an increased detection rate from 2% to 7% of pregnant women, allowing clinicians to target effective treatment to reduce adverse pregnancy outcomes. Since universal screening began, 2.3 times more women (around 2730 women) have been treated for gestational diabetes. One of the team has now been invited onto the NICE guideline committee for diabetes in pregnancy, providing the opportunity to feed our results into national practice. A HTA application has been successful and work is underway to provide definitive evidence of the cost-effectiveness of different approaches to screening. 

Introduction of routine vitamin D supplementation in pregnancy:
The Maternal and Child Health CLAHRC team were able to investigate concerns from midwives and paediatricians about low levels of Vitamin D supplementation in a high risk population. Using BiB data we demonstrated less than 10% of eligible women were taking supplements. Qualitative interviews found that lack of awareness of the recommendations for vitamin D supplementation in pregnancy, English being a second language and fear of side effects were amongst the barriers to these women taking the recommended vitamin D supplements during pregnancy. We used this quantitative and qualitative evidence to work with clinicians to establish provision of vitamin D during attendance at ultrasound visits. A re-audit (n=123 women) demonstrated 97% of women recalled being offered supplements and 87% took up the offer.

Identifying and supporting children with difficulties:
The Healthy Children Healthy Families (HCHF) CLARHC theme have been working with 77 primary schools in Bradford to assess children and provide feedback to teachers on literacy, motor control and social, emotional and behavioural health. This has enabled teachers to target support to children more effectively. Our team has also developed a web-based resource for school leaders, Evidence 4 Impact (E4I), to find proven approaches for helping children succeed. The CLAHRC is now supporting the dissemination of this tool to local authorities in West Yorkshire.

Improving air quality:
Our CLAHRC programme has worked with the European Escape study to use results which show a clear link between exposure to pollutants in pregnancy and low birth weight to convince Bradford Metropolitan District Council to tackle air pollution in the city. £400,000 will be spent on retro-fitting 25 buses which travel the most polluted routes in the city, with selective catalytic reduction systems which reduce emissions by 80%.

Changing midwifery and health visitor practice:
The Maternal and Child Health CLAHRC team established two communities of practice (CoPs), one with local midwives (MW) and one with local health visitors (HV). These CoPs have investigated how data on maternal smoking habits and breast feeding are collected. From the findings, a number of recommendations to improve data collection processes and clinical practice have been made. For example, the development of a high risk care pathway for smoking mothers was recommended by the CoP and has now been implemented. Changes were also made to the processes of collecting and recording a wide variety of data via the Child Health Informatics Service, thus improving the quality of local data available to inform local clinical practice. 

Identifying children with high levels of adiposity:
There is increasing evidence that for a given BMI South Asian children have greater total and central adiposity than White British children and are potentially more metabolically sensitive to body fat. These differences are not identified by BMI. The HCHF theme is working in partnership with school nurses in Bradford to improve the identification of South Asian children who are overweight and obese by using more appropriate measures of adiposity.   We have raised the local authority and school nurses awareness of ethnic differences in childhood adiposity and have contributed to a review of the future role of school nurses, encouraging the addition of skinfold measurements into the National Child Measurement Programme in Bradford.

Redesigning classrooms to reduce sedentary behaviour:
Adverse associations between sedentary behaviour and cardiometabolic health risk markers (obesity, blood pressure, cholesterol, insulin) have been reported in children. In a feasibility study, researchers from the HCHF theme installed height adjustable desks in two primary school classrooms and we were able to reduce children’s sitting time. The study is the first of its kind in Europe and found promising results with children’s sitting time reduced by 81 minutes per day.

Changing practice across professions:
A major aim for both CoPs has been to improve communications between MWs and HVs in the antenatal and postnatal periods. Significant progress has been achieved in this since the CoPs secured the necessary agreements to change the time of distribution for the Personal Child Health Record (the ‘Red Book’). The PCHR was being given to parents after delivery by their HV; it is now be distributed during pregnancy by the MW and be used to improve the two-way transfer of information between professionals throughout the antenatal and postnatal periods.

 Developing a national public health tool for monitoring child health:
Our CLAHRC programme has been working closely with ChiMat and the Department of Health to develop a population based tool to help with mapping the potential future outcomes for children aged five years, based on indicators of the family around birth and up to nine months of age. The outcomes are based on learning and development, behaviour and health. The indicators used and the weightings given within the tool are based on academically rigorous research carried out by the University of York. The PREview tool is now available for national use:

Determining the cost effectiveness of healthy start vitamins:
The Healthy Start vitamin scheme is UK wide for pregnant women, new mothers and children under the age of 4 years old, who are in receipt of income-related benefits or tax credits.  The HCHF theme has contributed to the National Institute for Clinical Excellence special report on the cost-effectiveness of relaxing the eligibility criteria of the scheme.  The BiB study collected information about pregnant mothers’ use of vitamin supplements, and this information was used in a key scenario analysis as part of the economic modelling for the NICE report. Based on this modelling, NICE makes recommendations on the cost-effectiveness of different universal offerings of the Healthy Start scheme.

Stroke Research Impact

Implementation of a new strategy to support stroke survivors and their carers in the long-term: Moving Forward.
Three teams across the Yorkshire and Humber region are currently providing a novel service for stroke survivors and their carers, developed by the Academic Unit of Elderly Care and Rehabilitation (AUECR) as part of a National Institute for Health Research funded programme grant. The new service comprises individualised supported problem solving, help to develop social support and brief, usable information. In practice this focuses on the needs a survivor considers relevant and supports them to develop ways of overcoming these needs that are fitting for them. Training and materials help the facilitator to deliver the intervention. The teams have implemented and adapted the service in their localities with the support of the AUECR as part of an action research process to field test and develop the strategy. Early results of the implementation are promising, with sites successfully setting up and providing the service to dozens of survivors. Qualitative feedback indicates the service has changed the institutional mindset to life after stroke away from a medical perspective, can build confidence in survivors and change their behaviour. These new services would not have been implemented without the research conducted in this programme grant. This new strategy will next be tested in a cluster randomised feasibility trial ahead of a definitive trial and national roll-out.

Primary Care-Based Management of Frailty in Older People

The development of an electronic Frailty Index (eFI)
Frailty is a detectable abnormal health state associated with adverse outcomes including move to long-term care residence, hospitalisation and mortality. The current response to frailty is predominantly reactive and secondary care based, in part because of the lack of a simple, reliable tool to identify frailty in primary care. The electronic Frailty Index (eFI) has been developed as a partnership between the University of Leeds and The Phoenix Partnership (TPP). Its function is to identify and severity grade frailty using routine data (Read codes) in primary care. This positive and early identification of people who are frail will allow the introduction of new preventative and proactive care models for frailty. Internal and external validation work is complete and the eFI has now been implemented in SystmOne, the electronic patient record platform used by more than 2,500 GP practices across England. We anticipate implementation into other electronic health record platforms (e.g. EMIS and Vision) within this year, thus increasing its scope and capacity nationally. Frailty and the use of the eFI has been highlighted through several routes to reach different audiences: The British Geriatric Society ‘Fit for Frailty Commissioning Guidelines; Living with Frailty – a guide for primary care; Effectiveness Matters: Recognising and Managing Frailty in Primary Care.

Improving recruitment of older people with frailty into clinical research
There is evidence of under-recruitment of older people to research studies. The CLAHRC has developed the Community Ageing Research 75+ (CARE 75+) cohort study to increase participation of older people with well-characterised frailty into clinical research. The innovative cohort multiple Randomised Controlled Trial (cmRCT) design enables observational research, as well as providing a platform for randomised controlled trials, qualitative studies, and pilot/feasibility studies. The CARE 75+ study is currently supporting two studies and attracting interest from clinicians and academics for future studies relevant to older people. The CARE 75+ study is the first international ageing and frailty research study to use the cmRCT design.

The Community Ageing Research (CARE 75+) study model of public engagement, the Frailty Oversight Group (FOG)
The complexity and long-term nature of the cohort multiple RCT (cmRCT) design requires oversight and public engagement for the duration of the observational study as well as for the individual sub-studies. It is essential that there is continued governance and monitoring of the original aims and objectives of the observational study for which the cohort was developed. Any changes need to be reviewed carefully and objectively to avoid any unnecessary additional burden on the participants. To assist with this work we have constructed a Frailty Oversight Group (FOG). The remit of this group is to provide monitoring and governance of the observational study and provide input into the direction of the CARE cohort in terms of the range and the scope of future studies which will use the cohort. It also facilitates networking with more specialised user groups e.g. care home residents, Black, Minority and Ethnic (BME) groups and dementia service users and their families if necessary. The model of engagement undertaken for CARE 75+ was presented as a workshop at the 2015 HSRN conference in Nottingham. A member of the FOG team assisted with the workshop.

Development of a real time data capture tool for research: an example of successful collaboration between academia and the private sector that has enabled on-going dialogue to support Health Service Research in Yorkshire &Humber
As part of the CLAHRC CARE 75+ cohort study, we needed to develop a software application for data capture. The request went out to tender and the successful company was Tigerteam.   The collaboration with Tigerteam has been highly productive and has led to the development of a new application to increase recruitment capacity to the cohort study. In addition, we have provided TigerTeam links to academic partners in Sheffield at the Centre for Assistive Technology and Healthcare (CATCH) to take forward a prototype Care and Wellness Plan they have developed.   Through this collaboration they were able to obtain funding and the Tigerteam-CATCH partnership are in the process of conducting a feasibility study of the prototype. If the feasibility work is successful this project will lead to more substantial work between the two partners to help turn the CWP into a commercial product.

Evidence Based Transformation in the NHS

Patient Reporting for Action and a Safe Environment (PRASE):
PRASE is the first intervention in the world designed to allow patients to provide feedback on the safety of their care which staff then use as the trigger for improvement work. The intervention has, at its core, two measurement tools – the Patient Incident Reporting Tool and the Patient Measure of Safety developed with NIHR funding. Staff use the feedback provided by patients to diagnose areas of strength and areas for improvement and develop action plans to address these. It has been evaluated across 33 wards in 3 acute NHS Trusts in the Yorkshire and Humber region, enabling 2400 patients to provide feedback to the NHS. Action plans for improvement were then implemented across the evaluation sites. PRASE has attracted £445,000 further funding from the Health Foundation to develop mechanisms for roll-out across the NHS and has been adopted for use as part of a suite of safety improvement tools employed by the AHSN Improvement Academy. The tool is being used in Australia and New Zealand as part of interventional research studies and is currently being adapted by the Primary Care Patient Safety Translational Research Centre, University of Manchester, for use in general practices. In the last year we have attracted further funding to explore a) the collection of PRASE feedback by hospital volunteers (a Health Foundation grant) and b) the role of PRASE data collection as an important learning experience for undergraduate nursing and medical students (RCF Leeds, CLAHRC YH).

A Behaviour Chance Approach (ABC) to Implementing Safety Guidelines:
Members of the Evidence Based Transformation theme have developed and implemented a behaviour change approach that when applied to pH testing for correct naso-gastic tube placement demonstrated a reduction in staff use of x-ray during this procedure from 55-24%. The estimated net savings per participating hospital in the first year were £29,573 rising to £57,205 in subsequent years and £1m and £1.94m respectively across the region. This approach involves working with teams of health professionals to identify barriers to change and then develop a tailored intervention that specifically addresses these barriers. With support from senior management, the intervention is then delivered within the Trust. Based on our evaluation of this approach across four hospital Trusts, health economists were able to calculate the savings associated with the increase in pH testing for checking the correct placement of a nasogastric tube (NGT). This led to a reduction in the use of x-rays (an expensive way of verifying tube position that can be misinterpreted and lead to feeding in the lungs, a serious patient safety incident) from 55 to 24% of occasions when a naso-gastric tube was placed. We have now delivered behaviour change training to some 300 people from all the acute (as well as GP practices, care homes and community) Trusts in Yorkshire and Humber. Six behaviour change projects are currently being supported within the region through the Academic Health Science Network, Improvement Academy. NHS IQ have commissioned this behaviour change training at a national level to support the spread of this approach beyond Yorkshire and Humber.