1. 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

2. 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

3. Getting local, getting started– who is here?

4. 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

5. 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

6. 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

7. 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.”

8. 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

9. 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 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

10. 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?

11. 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!

12. 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

13. 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

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

15. Next steps Find and talk to your people!
Go to for lots of background info and resources

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