Learning Together local champions workshop October 11th 2017 Tell you about a project I have been involved with since registrar in london Presenting on behalf of team Dr Chloe Macaulay, Evelina London Wendy Riches, Project lead, RAUpartners Dr John Spicer, GP, HESL

Plan for the afternoon: 4.00pm Introductions and who we are 4.20pm What is learning together? how clinics work Evaluation results – what is important 4.40pm Role of local champion How to get started locally What support is out there? Why are you doing this? What do uou know about them already

Getting local, getting started– who is here?

How clinics work - summary [see the ‘clinic set up sheet’ on the resources page of our website] Pre Clinic: Patient selection & booking Discussion of patients pre-clinic – preparation/reading up Clinic: Discussion of patients pre-clinic Seeing patients together – turn taking, sharing knowledge, shared guidelines, discussion, joint management plans Post Clinic: Case discussion with GP trainer Feedback/discussion with wider team Virtual MDT Debrief/discussion with Paediatric supervisor How do clinics work? GP St3/Paed spr 5-8 local hsopiyal See mix of patients booked for 2 care /review chronic conditions/walk in – unfuiltered primary care Pre work/prepapration Se them together – shared skills/ expertise Dbrief – learning reflections Feedback to wider group Return to hospital

Results: what is learnt and how? Both types of trainees learn in all major themes: Clinical practice – knowledge, skills, etc Collaborative practice Learning about Service or system Teaching and project skills BUT they learn the most in different themes and they learn in very different ways

See it Do it Paed affirms How GP ST3s learn “Palpating an impacted stool - feels different to an adult!” Key mechanism: Paed SpR at a GP Practice is a new resource created by the intervention Partnered with an ST5-8 the ST3 GP will: discuss best practice observe partners skill and expertise at first hand in the primary care population, rapidly learn, absorbing new clinical knowledge, skills and practical tips practice those skills immediately implements new practice in routine primary care. Quality and outcomes improved for children 57 different clinical learning topics for 11 GP ST3s in 10 GP training practices – immediate learning put into practice! New practice becomes routine practice

How Paediatric registrars (ST5-8) learn Partnered to do a clinic in a GP Training practice the pediatrician will: Learn about collaborative practice Key to all other learning is a change in attitude, perception of GPs and Primary Care Key to attitude change is an anxious SpR who is repeatedly surprised by their experience and becomes part of the GP team More equal partnership emerges Key mechanism: the GP Trainer who endorses new management and affirms the SpR “Great to see that the patients are more forthcoming and relaxed with the GP than at the hospital – it’s a very friendly setting. Always had social/background info to hand” “And then the Trainer would ask specific questions: could it be done differently; do you really need to do this? Because they do more watch and wait than us.”

Results: Outcomes Quality Improvement outcomes Patient outcomes Change in care/Quality Improvement safety, quality of care Improved integrated care referral at right time, service use, activity avoided, right person seen in right place, improved pathway for the patients Patient outcomes Education and self-management patient and/or carer received education, able to self-manage Good experience positive feedback, appreciated additional time and specialist expertise Guidance adherence (proxy for health gain): evidence based care given Health gain improved health, time with improved/reinstated health

Results: how effective would clinics have to be to be considered “cost-effective”? 363 patients Economic modelling :what did LT replace? Data from 363 patient appointments in 61 LT clinics Model compares cost of normal training to LT training – ie 2 clinicians in a room Additional cost of £37 per clinic “to the system” One child with a common condition like constipation would need to be better for 2 weeks as a result of 4 clinics OR One GP appointment avoided (£44) No LT 118 OPD 152 GP 78 walk in 15 other 353 seen in LT clinics 10 DNAs Did some economic modeling – see how much the clinic model costs the system – primarily educational intervention – but need to know about resource use Collected data on what clinics replaced Worked out is £37 Using NICE cost effectiveness data – one child Cullen K, Riches W, Macaulay C, Spicer J. Learning Together Part 2: training costs and health gain. Education for Primary Care 2017 Vol 28 p36-44

Results: improved health GP ST3 Quality Improvement Project new data of “time child well” : 19 months First application of the rubric 19 months regained health is a lot more than 2 weeks Number of patients treated with constipation Number of responses Number better 7 months later Total months of good health Patients seen before LT clinics started 23 18 4/18 12 months Patients seen after LT started 17 (4 seen in LT clinics) 12 11/12 31 months All patients 0-18 y 5 month period prior to LT clinics starting All patinets seen in 5 months after LT clinics EMIS web search Follow up telephone call – are you better and for how long?

Conclusions Learning is wide reaching and transformative Outcomes are improved for children and young people through the educational intervention LT represents a “no brainer” as a training model “With half-filled rotas….Can I afford the luxury?” Paediatricians’ learning Improved patient outcomes Only 6 x ½ days of study leave… Should we all - Consultants and GPs - be taking something away as a service delivery and CPD model? Gps learn the most clinically Paediatricians learn about collaborative care Additional cost to system £37 per clinic – only need one child seen in set of 6 clinics to be better for 2 weeks for NICE approval!

Role of the Champion: Steps and support Finding someone to work with Are they here? How to find them How to set up clinic scheme locally Supporting clinics and learning Set up workshops Reflective workshops

Setting up scheme locally Local buy in – GP trainer/VTS lead/Paeds lead Advertise locally to trainees– where? Registration forms/information from people What days work for practice/trainees When can you have a lunchtime meeting/debrief Governance and supervision Setting up clinics practically How do you advertise clinics to practice? How do you book patients in? Start up workshop Reflective workshops – local or central

Snags and solutions Paediatrics often rate-limiting Find your champion! Meetings not emails Start small Talk about the difference it makes and personal learning at start up meeting

Next steps Find and talk to your people! Go to www.learningtogether.org.uk for lots of background info and resources

info@learningtogether.org.uk Chloe.macaulay@gstt.nhs.uk www.learningtogether.org.uk info@learningtogether.org.uk Chloe.macaulay@gstt.nhs.uk