Service Delivery
Service Delivery
This category is looking for a team or organisation that embraces new ways of working and delivering care, across disciplines or boroughs, supported by technology. We are looking to celebrate an organisation that has undertaken a new initiative that has positively impacted individuals, organisation productivity and patient outcomes.
Winners, Runner Up and Highly Commended
Below are the details of the prize winners in this category. Click on the sections below to find out some tips on how you can replicate some of these projects in your own practice or care home.
If you would like to contact the nominees about further details of their work, please email neslisan.yilmaz@nhs.net and you will be connected with the project lead.
The Central Camden PCN Rectal Pathology Clinic
The Camden and Islington Wheelchair Service has been nominated for its exceptional dedication to improving accessibility and independence for individuals with mobility challenges. Serving children and adults registered with Camden or Islington GPs, the service provides manual and powered wheelchairs, buggies, and specialist seating solutions tailored to individual needs.
The service prioritises a client-centred approach, offering choice and education through initiatives like the voucher scheme, which empowers clients to select wheelchairs that best suit their preferences. Known for its professionalism, efficiency, and responsiveness, the service ensures timely support for users and referrers alike.
This vital service fosters independence and inclusion, enhancing the quality of life for people with permanent mobility disabilities in Camden and Islington.
Want to replicate this in your setting? Here are some top tips from the nominees:
To ensure the smooth running of this service, the key areas to focus on are: your relationship with your local hospital and/or trust, thorough training with the Colorectal Consultant, a clear pathway with well thought through inclusion/ exclusion criteria, and comms to your member practices.
When the team started this project, it was in collaboration with colleagues at UCLH and LumenEye. UCLH colleagues knew that there was a high demand for colorectal appointments due to the length of their 2ww waiting list, and one of their consultants was already using the LumenEye X1 in his private clinic. It was important that all parties involved in the collaboration shared the same goal as it meant all were fully invested and bought in to mobilisation and that patient care was central to the project. As a result, the consultant was allocated training time from UCLH to provide training to some of our allied healthcare professionals; the UCLH consultant attended the first 7 clinics with the team and returns every 2-3 months to check-in and answer any questions, along with providing advice and guidance. When the UCLH consultant is not in attendance, he is able to remotely login to the LumenEye clinic and review footage for complex cases as and when they come in.
Having a clear patient pathway allows staff to understand the patient journey from start to end, and define where each responsibility sits. We worked together with the UCLH consultant on the inclusion and exclusion criteria to ensure only low-risk cases are coming through to the clinic. This has been reviewed three times since the clinic began as key learnings have been identified, and the clinicians have been upskilled and gained confidence in seeing a wider range of cases. The current inclusion criteria is: adults under the age of 60, with a negative qFIT, and with rectal pain and/or bleeding. Circulating clear communications to member practices to ensure they are all aware of what the purpose of the service is and what they need to do to refer a patient in has been paramount to the success of this project.
We have updated practices at every PCN meeting since the launch to remind them when and how to refer, and to give them the opportunity to ask questions about the service. All appointment procedures and outcomes are recorded in the patient’s medical notes at their registered GP practice to ensure clear documentation and communication.
From a patient experience perspective, we ensure the clinicians relay information to the patient around what to expect from the appointment, advice following the procedure and whether a follow-up is required to ensure the best patient experience. A patient feedback form is also sent to patients following their discharge to understand what went well and what improvements could be made to the service which has been a valuable part of the PDSA cycle.
Heart Failure Health Inequalities Project
The Clinical Pharmacists from Enfield Unity PCN and Enfield Care Network PCN have been nominated for their impactful Heart Failure Health Inequalities Project, addressing the needs of at-risk adults in Enfield’s deprived eastern neighbourhoods.
Clinical pharmacists led the project, delivering in-house training and upskilling healthcare professionals. Their work resulted in significant achievements, including a 17.5% increase in heart failure prevalence identification, improved NYHA classifications for 40 patients, and optimisation of medication for patients with HFrEF, reducing hospital admission risks and mortality. This collaborative initiative highlights the essential role of clinical pharmacists in enhancing patient outcomes, reducing inequalities, and transforming heart failure care in primary care settings
Want to replicate this in your setting? Here are some top tips from the nominees:
This collaboration can easily be replicated and supports the British Society of Heart Failure manifesto: to prioritise patient care by supporting clinicians across specialities and healthcare systems to work together to prevent avoidable heart failure deaths, making every contact count and prioritise the heart failure training, education and upskilling of clinicians delivering HF care across specialities and healthcare landscapes to expedite diagnosis through better symptom recognition, earlier testing and collaboration. Also using the desktop review published by UCLPartners Proactive Care Framework: Heart Failure (First published October 2023) is s useful guide to easily demonstrate the process the clinical pharmacists use.
Professional responsive, safe service, working well with the local GPs and excellent communication
The Urgent Community Response (UCR) Team has been nominated for its professional, responsive, and safe service that supports local GPs and ensures seamless patient care. The UCR service provides rapid attendance within two hours of referral for acute or sub-acute medical needs by skilled professionals, including senior nurses, paramedics, physiotherapists, and occupational therapists.
Equipped with advanced tools such as point-of-care machines, ECG devices, and bladder scanners, the team offers swift diagnostics and interventions, complemented by advanced nursing care and non-medical prescribing. Their focus on keeping patients supported at home reduces unnecessary hospital admissions, with excellent communication ensuring GPs are fully informed. The team's competence and efficiency make this service indispensable for maintaining continuity of care and improving patient outcomes
Want to replicate this in your setting? Here are some top tips from the nominees:
Please consider email referral for GPs only as often holding on the phone for ages is difficult.
We recognised that the most frail and vulnerable members of our community missed out on annual health reviews because they are housebound.
Rutland House Surgery has been nominated for its innovative approach to providing personalised care for housebound patients. By conducting annual home visits, the practice addresses healthcare neglect, safety risks, and social isolation. This initiative removes barriers to care by bringing medical services directly to patients' homes, allowing for tailored interventions, safety assessments, and medication reviews.
The programme fosters mental health support, reduces hospital admissions, and ensures continuity of care through a multidisciplinary team. Rutland House Surgery’s efforts have inspired neighbouring PCNs to adopt similar initiatives, demonstrating its scalability and impact on improving patient outcomes and wellbeing
Want to replicate this in your setting? Here are some top tips from the nominees:
My advice to any team repeating this project is PREPARATION. I have included notes to help with this.
What did we need to do to deliver this project?
The Admin staff helped identify a comprehensive list of all house bound patients, and we determined what we hoped to achieve from the visits. Myself, the Senior Nurse and the Health Care Assistant discussed the annual health care needs, and QOF requirements, and transferred these to the proforma that I designed. We prepared blood /urine request forms and labels, sample carrying bags. Vaccines were ordered and set aside. Care homes and patients were contacted and convenient home visits booked. Chaperones arranged, consent from families collected, and time for nurse and HCA away from clinic was arranged.
What equipment did we need? How did we know what the patient needed during the visit, and record the results of the home visit on EMIS?
We completed a pre-visit assessment for each patient, and marked the required tests and reviews that were needed. We then used the proforma to document the results, which we transferred on to EMIS back in clinic, we scanned the proforma onto patients notes, and used it in the MDT to discuss the visit and plan the next steps. For the visits, we carried all of the equipment we would normally use in a long term condition management clinic. We purchased a bag, big enough to carry the following: Venepuncture items, sharps bin, Clinical waste bins, urine pots and dip sticks, height and weight scales, BP machine with small and large cuffs, hand held spirometer, O2 sats monitor, PFR monitors, Disposable mouth pieces, calibrated tuning fork, 10mg monofilament, scissors, dressing packs, headlamp and otoscope with ear speculums, thermal thermometer, Anaphylaxis kit, needles, syringes, B12 vials, (syringes, needles) various vaccines (flu, pneumonia, shingles), PPE, Masks, gloves aprons, waterproof sheets (for working on the floor), cotton wool, plasters and a small selection of dressings, non-toothed forceps and suture cutters.