Value-Adding Approach to Lot 4 Service Delivery

Through providing extensive planning and performance analytics to numerous health and care systems and NHS England, SCW is experienced in providing quality analytics services for planning, assurance, evaluation and research. This is evidenced by our ground-breaking analyses across conditions and settings of care (Symphony data in Somerset), live assurance reporting for provider performance, urgent and elective care, and the clinical research delivered through Hampshire Health Record Analytics (HHRA). We deliver these services through a workforce of 240 business intelligence specialists and 130 digital transformation specialists, supported by a long-standing partnership with Johns Hopkins University and their US-originated Adjusted Clinical Groups system, which SCW has adapted for UK health and social care and which is fundamental to population profiling. We also work with the academic sector (including AHSNs) for interpretation and advanced analytics, including the University of York Centre for Health Economics and the University of Southampton. Through our partnership with Lightfoot, we offer their ‘Signals from Noise’ solution for system assurance and their experience from the Canterbury system in New Zealand. We provide:  

  • Proven expertise to deliver patient-level data, linked across settings of care, including social care, and analysed by clinical condition, or multi-conditions, so systems can understand which patient cohorts can most benefit from integrated care
  • Expert analysis, including actuarial, benchmarking and statistical process control approaches
  • Expert visualisations, including GIS mapping, so that these findings can be communicated to clinicians and other non-analysts
  • Organisational development to support insight driven systems and analytical expertise across the system
  • System assurance reporting and dashboards, ‘live’ or ‘semi-live’ to keep systems informed on current metrics across a system
  • Working with partners (particularly Lightfoot) to take those metrics, predict outcomes and recommend corrective actions
  • Evaluation support, using robust and academically-proven methodologies, to ensure systems can move forward from pilots to established programmes with confidence in knowing that they delivered against the original objectives
  • Unleashing the power of developing interoperability programmes to support clinical research.

The case study that follows this response describes our analytical support to the Somerset system. This includes creating one of the first patient-level linked data sets to be used in the development of integrated care. It also demonstrates our ongoing work to provide daily reporting of urgent care system metrics and causal influences to poor A&E performance, and our current evaluation of the South Somerset PACS vanguard that we are delivering in partnership with CHE York University and South West AHSN. 

While we have the ability to produce credible and thought-provoking reports and plans, we invest most energy in actually delivering and embedding change in the fabric of a local system. We are passionate about creating beneficial change at the front line. We take accountability for delivering transformation outcomes, and we optimise sustainability by ensuring that local care teams are fully engaged in the process. We have an appetite for sharing the pain and pressure of change, which helps build commitment, motivation and resilience in the individuals delivering it. This is our definition of partnership working. 

Extended Case Study: Analytics for System Planning, Assurance and Evaluation in the Somerset Health System

The Somerset STP includes one CCG, two acute trusts (one in partnership with a local community and mental health provider) and a coterminous local authority. It also includes the South Somerset Symphony PACS Vanguard and a Digital Exemplar in Taunton. SCW has supported this health and care community with analytics for system planning, assurance and evaluation as follows.

 

By co-ordinating the development of a comprehensive patient-level data set and working with the University of York’s Centre For Health Economics on its interpretation, we have  given Somerset’s health and social care providers vital insight into the relationship between the cost of care and co-morbidity, facilitating the development of a more appropriate integrated care system in the region. The health and care system has subsequently developed an integrated care model, which initially focuses on patients with three or more co-morbidities, regardless of the type of disease conditions.

“Saw great data from Symphony Project today. The reality of multi-morbidity made stark. Multiple conditions drive cost exponentially, not age.” Dr Martin McShane, Director for Long Term Conditions, NHS England

In co-creating a fully costed patient-level dataset across all settings of care for the Somerset population, using our comprehensive and well-established risk-stratification process, SCW has provided an analytical resource that supports the system to:

  • Identify cohorts of patients suitable for integrated care, across the whole Somerset geography and for patients with any condition or any group of conditions;
  • Clearly understand how those patients interact across all settings of health and care, and the costs incurred in each;
  • Clearly understand multi-morbidity, which supports the design of care approaches to ‘treat the patient, not the condition’;
  • Define a benchmark from which to assess and measure developments in integrated care;
  • Complete further mapping analysis to identify geographical factors that influence the cost of care; and
  • Conduct further economic modelling to accurately predict changes in cost and activity across settings of care.

We have also collaborated with Experian to apply their Mosaic social indicator index at a household level to generate further insight into factors such as the effect of social isolation on the cost and settings of care; and with NHS Improvement to support their investigations into payment innovation mechanisms for long-term conditions. NHS Improvement used our work as a key case study in their guide for creating patient-level linked data sets. To enhance value for the system, our Symphony analysts in Somerset and SCW’s data management service worked with NHS Digital (NHSD) analysts to develop a DARS-compliant framework for integrated data. These proposals went to NHSD IGUARD approval in March 2017 and SCW was the first (and remains the only) proposal in the country for integrated data that has received NHSD IG sign-off.

SCW has developed a ‘live’ daily urgent care report to all accountable officers in all care organisations in Somerset, their senior staff, lead clinicians (including the Somerset LMC) and all care analysts across Somerset. In order to develop a report that could be instinctively used by all those parties without constant reference back to the team for clarification or extra information, we employed a number of innovative visual techniques to improve ‘self-service interpretation’. This included split x-axes, reporting with ‘111 and the centre’, and ‘corridor trend-lines’. Through this whole system delivery report, we are providing a self-service solution for accountable officers, chief executives and staff throughout their organisations.  Although time was invested in the design of these reports, the ongoing delivery is incorporated into the daily work-plan of a junior analyst (Band 5) and represents only a short amount of time involved each day, mainly to check the report before it is dispatched.

As part of a major service review, Somerset CCG wished to confirm the clinical benefits they would achieve by centralising stroke services at Taunton Hospital and closing the service at Yeovil Hospital. They tasked our Health GIS mapping team to complete a systematic analysis of how the proposed changes would impact the whole population of Somerset, a large county measuring 1,330 square miles. We applied our sophisticated GIS mapping and analytics tools to provide critical evidence that directly improved service provision for stroke patients, and completed a comprehensive travel time analysis covering emergency vehicles and private and public transport options, to identify the implications of change. The study confirmed that the clinical benefits of closing Yeovil Hospital would be far less significant than previously anticipated. In fact, the increased travel times would have a critical impact on speed of treatment for many stroke patients. The evidence we produced informed the planning process and led to Somerset CCG deciding to retain both stroke services, substantially altering the direction of the review. 

SCW won the national tender for formal evaluation of the Symphony PACS Vanguard. This was a consortium bid with York University’s Centre for Health Economics who would lead the quantitative econometric evaluation based on Symphony patient-level linked datasets previously created by SCW data teams. We also engaged the South West Academic Health Science Network to support further qualitative evaluation. The evaluation is ongoing and described later in our response.

My colleagues and I here in the New Care Models Team have been hugely impressed by your ambitions for Symphony, and by the progress that you have already made in connecting the data.

Samantha Jones, Director, New Care Models Programme – Five Year Forward View (extract from letter to Somerset prior to visit of Dr Geraint Lewis, Chief Data Officer for NHS England, and NHS Digital IGUARD sign-off for SCW’s linked data solution for Somerset in March 2017).

How We Work with Partners in Lot 4

Specifically within this Lot, we will continue working with organisations such as Johns Hopkins University, Baltimore, and their US-originated Adjusted Clinical Groups (ACG) system, which SCW has adapted for UK health and social care and which is fundamental to population profiling. We also work with the academic sector (including AHSNs) for interpretation and advanced analytics. We have a long-standing partnership with the University of York Centre for Health Economics for analysis and evaluation of the South Somerset (Symphony) PACS Vanguard, and we work with the University of Southampton for the clinical research opportunities delivered through Hampshire Health Record Analytics (HHRA).  We are also working closely with Lightfoot to deliver their ‘Signals from Noise’ solution for system assurance and their experiences from the Canterbury system in New Zealand.

 

Case Studies

SCW conducted a comprehensive IG compliance review for the Symphony PACS Vanguard data set in South Somerset. Because of our scale, we were able to use an independent IG team that had not been involved in the initial development project, and whose role was to critically review and confirm legal compliance for the project. They were also tasked to provide clarity on information ownership, access, safeguards and privacy impact assessment processes. The ultimate aim of the review was to establish the legal basis on which GPs would share patient data for use in the Symphony database; how SCW would link GP data with SUS and Social Care data; and whether underlying data flows, information sharing agreements and privacy impact assessments were appropriate. The final report confirmed compliance and recommended additional work and a regular review programme to ensure the system remained compliant as the project continued and extended in scope. 

Subsequently, working in conjunction with the national New Models of Care (NMOC) IG lead, we supported Somerset as an IG test site for NHS Digital’s DARS process. In December 2016, Dr Geraint Lewis from NHS Digital visited Somerset to run a workshop with key stakeholders. In January 2017, we supported Somerset to complete an NHS Digital IG Audit where Symphony data was a key area of scrutiny. As part of that process, we facilitated a full-day workshop in Leeds between NHS Digital, NHS England’s NMOC team, and representatives from Somerset and SCW to validate the application and associated IG plans. 

Our Symphony data analysts and in-house data management leads have worked with NHS Digital to develop a DARS-compliant framework for integrated data. These proposals went for NHS Digital IGUARD approval in March 2017 and SCW was the first integrated data proposal in the country to receive approval. NHS Digital has subsequently shared our IG solution widely.

“I've just been at the Vanguard PACS IG event where NHS Digital used our diagram as an example of good practice!” Jeremy Martin, Symphony Programme Director, Yeovil District Hospital NHS Foundation Trust.

SCW has worked closely with academic colleagues at the Johns Hopkins Bloomberg School of Public Health to recalibrate their ACG system for use with UK data. An initial recalibration was undertaken, which demonstrated existing U.S. model weightings worked well on UK data, but that the new co-created weightings worked even better. We also co-developed a new UK model to predict the risk of emergency admission, to align the ACG tools with UK priorities. 

In the most recent recalibration, we co-developed five new models for use in the UK, including models to predict Emergency Bed Days, Total Bed Days, Urgent Care Contacts, and Persistent High Costs. This range of predictive models supports a level of sophistication for bespoke case finding that is not available through most other risk prediction tools. Our joint work in this area has shown that a range of predictive models is required when supporting cohort identification programmes that seek to stratify beyond the historically typical top 1-2% of high-risk patients (risk of a non-elective admission). This is particularly relevant for most new models of care. Our continued collaboration with academic colleagues at Johns Hopkins ensures we have the flexibility to develop new models and markers as the UK market evolves and the need arises.

Partner Profile: “John Hopkins University and SCW have a special relationship that goes back eight years. We have done significant development work together including recalibration of the predictive models in the software and developing new analytical approaches to support the work of CCGs and more recently to support the population health management activities of STPs. We are grateful for the support SCW has given with our educational programme, speaking at various national and international conferences and contributing to our webinar series. We value the on-going relationship and look forward to continuing to work with SCW on developing not only the ACG System but an approach to population health management that supports the work of Health Systems.”  Alan Thompson, Director of User Support, UK Team Leader, Johns Hopkins ACG® System.

Starting in 2014 for the South Somerset Symphony PACS Vanguard, SCW collated anonymised healthcare and demographic data for Somerset patients including primary care (11 GP practices), acute care (Yeovil District Hospital FT), mental health and community services (Somerset Partnership FT) and social care (Somerset County Council). This created a single view of the care each patient received, for what type of conditions, and at what combined cost across all organisations. This base data was further enriched with each individual’s morbidity profile, derived from a full risk stratification process incorporating both acute and primary care. By co-ordinating the development of this comprehensive patient-level dataset and working with York University to interpret the data, SCW provided system leaders with vital insight. The data set and subsequent analysis created an evidence base on which the South Somerset health and care system can found their long-term strategy for health and social care integration and the whole-system changes that will deliver it. “Saw great data from Symphony Project today. The reality of multi-morbidity made stark. Multiple conditions drive cost exponentially, not age.” Dr Martin McShane, Director for Long Term Conditions for NHS England

Partner profile: SCW has worked with York University since 2014. Led by Professor Andrew Street, they supported analysis of the ‘Symphony Integrated Dataset’ and helped SCW to develop ‘insight skills’ and the ability to communicate insight to system and clinical leaders. SCW is currently working with CHE on the formal evaluation of the South Somerset PACS Vanguard. Our acclaimed joint work has been academically published nationally and internationally, citied by the Health and Care Select Committee and published on the front cover of the Health Service Journal.

The CCG knew their expenditure on cardiothoracic admissions was significantly higher than both demographically similar CCGs and CCGs in the surrounding area. Using RightCare evidence as the starting point, SCW led a deep dive analysis to identify the underlying drivers. To identify why the expenditure was higher, we considered four factors: population demographics; market forces factor (MFF); case-mix; and high overall activity rates. Our analysis showed that MFF, demographics and case-mix could be discounted but activity and a key cohort of patients were the underlying cause. By cross correlating with other CCGs in the system, we narrowed down the cause to a single provider. This enabled the wider SCW team to support the system to resolve this through contract negotiations with the provider.

Through the Patient Safety Measurement Unit that we support, SCW has used SPC to evidence change and model impact of sepsis-related interventions. Through a ‘suspicion of sepsis’ dashboard, we provide SPC charts for key patient outcomes including mortality and length of stay, plus insight into areas tackling the issue most successfully. Use of SPC allowed for an objective and statistically robust view highlighting where ‘special cause’ variation was evident in key outcomes. This analysis also allowed NHS Improvement and NHSE to understand the capability of the system to achieve improvements in sepsis outcomes across England, and provide estimates of impact at a national scale.

“SCW has done some terrific work within an extremely short time frame to advance the national, regional and organisational understanding of patients admitted to hospital with infection. This work is pivotal to both understanding the scale of the condition, its costs and being a starting point to developing a true operational definition of sepsis. Furthermore, it enables us to track improvement over time, a critical component of all improvement strategies; and to ascertain what the key characteristics and interventions associated with better outcomes in all cause infection and sepsis. I have no hesitation in commending the incredible work that has been accomplished already and am very excited to see what is to come and the collaboration that this data will enable in the future across the entire care pathway.” Matt Inada-Kim, National Clinical Advisor Sepsis and Deterioration.

  • Organisational: urgent care models including A&E at Oxford University Hospital; Great Western Hosptial Front Door System
  • System: formal evaluation of South Somerset Symphony Programme (for NHSE NMOC team); Portsmouth out-of-hospital urgent care system; BANES discharge planning and community capacity: STP whole-system models in Frimley (in conjunction with our partner Rubicon); Children’s and Young Persons Mental Health model (in partnership with HCD Economics)
  • Regional: Cancer dashboard and diagnostic modelling; dental planning in Bucks/Oxon and South West including analysis of access rates, housing development and population growth
  • National: producing national benchmarks for the National QIPP Delivery Programme; national estimates of impact for POLCE and 111 CAS (Clinical Assessment Service) evaluations

In 2016, SCW won the national tender for formal evaluation of the Symphony PACS Vanguard programme in Somerset. This was a combined bid from SCW (comprising local analysts and staff from the Quality Observatory that we host, based in Sussex) and the University of York, who would lead the quantitative econometric evaluation based on Symphony patient-level linked datasets. We later collaborated with the South West Academic Health Science Network to further support qualitative evaluation. 

To execute the analysis of South Somerset’s integrated care solutions (Complex Care Hub, Enhanced Primary Care), York University are conducting propensity score matching combined with a ‘difference in differences’ analysis (DiD) to establish detailed patient-level cohort case matching. Methodologically, it is analogous to a controlled before-and-after study and is considered a robust method for testing for an intervention’s effects in the absence of randomisation. Suitable controls are also being introduced to allow capture of the ‘counterfactual’ – that is, what would have happened in the absence of an intervention. This relies on identifying one or more matched cohorts of control patients. The evaluation is ongoing, and we are reporting to the NHSE New Models of Care team on a quarterly basis concerning observations and results from the Vanguard.

We have deployed interactive mapping tools developed to support the current East Berkshire Integrated Hub and Primary Care planning. Our multi-layered mapping tool allows commissioners and planners to visualise population demographics alongside current and potential configurations of primary and community care services. By combining different combinations of demographic information our customer can build a powerful visualisation tool to make the case for developing integrated services targeted at key populations. The map layers included are:

  • Service site locations: GP practices, hospitals, pharmacies, care homes and the potential new hub locations
  • Disease prevalence by GP practice and by geographic areas
  • Hospital activity (inpatients, outpatients, A&E) by CCG and by GP practice
  • Travel accessibility (private car and public transport) isochrones (travel times) to the potential hub sites and to GP surgeries and hospitals and travel based catchment areas for the provider sites

We have developed customised reports and outputs to support Integrated Care Teams, including a suite of bespoke reports based around core Programmes of Care. The reports enabled separate reporting and monitoring of patients who are resident in care or nursing homes or ‘flagged’ as having been referred to specific services and contain predictive information such as future risk, alongside information about current or recent care. 

The CCG specified a requirement for an at-scale automated CMS that provided in-year and annual planning / baseline / provider-offer capability. Their objectives were to manage a £500m contract portfolio efficiently, drive out efficiency gains and drive down overspends against very tight resources. Using our collaborative prototyping approach, SCW undertook extensive requirements mapping with Bedfordshire CCG, NHS England and SCW stakeholders. We then implemented a scalable CMS solution to transform their transactional reporting. We loaded, conformed, configured and mapped more than 25 providers’ data and either standardised historical reporting outputs or, to address gaps, developed standard reports from scratch. CMS is now a standardised and automated end-to-end process that includes in-year monitoring and forecast positions for acute trusts with community, mental health, ambulance and 111. 

Reporting is provided ‘vertically’ by provider, locality, or STP and ‘horizontally’ by specialty, HRG, type of A&E attendance, and adjustment (e.g. readmissions, challenges) amongst others.  Automated algorithm-based variance analysis enable exceptional variances to be automatically identified, as well as reporting all providers assurance across the system. Auto-narrative is an integral part of CCG/STP reports, which allows analysts to value by providing local insight and intelligence in a more focused way.

By standardising and automating these reports (particularly narratives), there is more time for investigation/ contextualisation. In-year monitoring now feeds the recurring contract baseline. As a last step, CMS reconciles to the financial ledger-close report so that provider financial positions are reported in line with reports to boards and the public. The CMS also incorporates STP reporting against STP financial control totals. Since being launched in Bedfordshire the solution has been deployed across SCW to a number of our customers.

Using Multivariate Regression Analysis upon the Somerset linked patient database which combines activity from GPs, acute, community, mental health and social care, the Centre for Health Economics at York University calculated the marginal effects of clinical co-morbidities and socio-economic factors for patient populations and cohorts. 

  

The results showed that for the cohort for patients with three of eight key long term conditions, the average cost of those of patients across all settings of care is £3,383. A diagnosis of cardiac or stroke increases the average cost by £601 and £735 respectively. However, social factors are important and we calculated that an Experian flag of ‘living alone (single)’ or ‘elderly on state support’ also increased the average cost of a patient by similar amounts (£632 and £682 respectively). Calculating these marginal factors is an essential step towards calculating an overall capitation formula for any particular cohort, and we are continuing to develop practical approaches to capitation with our partners.

The figure opposite shows the average annual costs against each of the eight key long-term conditions chosen in Somerset and shows the cost incurred in each setting of care. It reinforces the key message that multi-morbidity drives cost, with the exception of dementia and CKD (for which the patient cohort is small) the average cost is approximately the same across all disease markers. 

‘Symphony’ as a monthly performance tool: The linked dataset originally started life as an annual planning tool but has now been developed to a monthly performance tool and is central to the evaluation of the PACS Vanguard (see Q18). However, it still has a journey until it can become a live intervention tool.

‘End State’ for activity monitoring: We believe that the end state for ‘real time’ system data lies in the interoperability solutions we support systems to deliver. Until such solutions are fully in place, we work with systems to develop interim ‘real-time activity reporting’ solutions in both urgent and elective care settings. These dashboard solutions are described later in this response.

In Somerset, Big Data, developed by SCW, has been shared with providers as well as commissioners. We have also supported all analysts, from whichever organisation, to help interpret the data. We convened a ‘Somerset Analyst Workshop’ involving analysts from the CCG, CSU and local providers, led by Professor Andrew Street and his team from Centre for Health Economics (CHE), York University. Professor Street led the analysts through the dataset, the techniques of multivariate regression analysis, mechanisms of imputing of missing data, and how econometric calculators can be developed to predict changes in population demographics or future health delivery scenarios. CSU analysts have also attended residential courses at the University of York Centre for Health Economics.

SCW developed a ‘live’ daily report to all accountable officers in all care organisations in Somerset, their senior staff, lead clinicians (including the Somerset LMC) and all care analysts across Somerset. To develop a report that could be instinctively used by all those parties without reference back for clarification or extra information, the SCW BI team took a number of steps, working collaboratively with Somerset system stakeholders:

  • Data derived from our standard systems with a carefully considered delivery method. Senior staff wanted access through iPads so not tied either to a desktop or a main office location. The report was designed around a ‘portrait iPad orientation’ and delivered as a PDF as this allowed a natural expansion or magnification when used on an iPad. 
  • Detailed communication with senior staff included an eight-page PDF allowing users to see daily A&E status of the main acute trusts that serve Somerset patients, before ‘scrolling down’ to causal effects. 
  • As 111 performance was considered to drive the wider performance of the system, a screen was designed to put 111 at the centre, with the other ‘destinations’ spreading out from that central point.
  • In addition, the report also includes daily information on 999 performance and ambulance handover delays; ‘net patient flow’, elective and non-elective bed utilisation, cancelled operations at each trust; community hospital bed capacity (RAG rated and shown through mapping); and delayed transfers of care split by ‘NHS responsible’ and ‘social care responsible’. 

Through this report we are providing a self-service solution for system leaders and operational staff for a whole system delivery.  Although time was invested in the design of these reports, the ongoing delivery is incorporated into the daily work-plan of a junior analyst (Band 5) and represents only a short amount analytical of time each day to check before dispatch.

Using data extracts from national eReferral systems, SCW reports ‘as live’ on elective booking trends across all elective care providers (acute, ISTC, community-providers, and primary care). Drilling down to specialty (e.g. orthopaedic) and sub-specialty levels (e.g. knees) gives the system immediate sight of changes in provider demand and whether driven by changes in ‘overall demand’ or the’ mix between providers’. In a system where GP referrals are declining and providers are concerned about loss of income, it is a valuable tool that provides reassurance of market share and prevents competition complaints from independent providers.

SCW has developed a close relationship with the Department of Public Health within Medicine at the University of Southampton (USH), which supports the development of the Hampshire Health Record (HHR) in order to support the improvement of local patient care through insights and research. The award-winning HHR (Figure 20.1) is an integrated regional health and social care record that supports health and social care providers in Hampshire, Portsmouth and Southampton. It comprises longitudinal health and social care records for 3million people, providing analysis and integrated insight into the whole population for 20 stakeholder organisations. Through the development of HHR Analytics solution (HHRA), SCW has taken integrated records beyond the interoperability agenda and into advanced analytics for population profiling, clinical research and actuarial analysis. HHRA now provides the health economy with deep insight on everything from international benchmarking on system effectiveness/efficiency, to groundbreaking clinically-developed risk algorithms for predicting liver disease and AKI in the population.

As part of the HHRA development SCW created a Service Advisory Group that incorporated consultants, GPs, senior nurses and heads of adult social care for more than 20 organisations across Hampshire. This group reviewed the Programme of Work and advised on clinical use and development of the HHRA. We also led a strategic approach to Information Governance (IG), working closely with national regulators and local stakeholders to develop a governance framework that allowed all stakeholders to access the insight we generated. We also led a collaborative programme with the USH and other strategic partners to provide experts in actuarial analysis who were able to further enhance the quality and richness of the HHRA outputs.

 

By combining our rigorous approach to IG with transparent and clear communication across the local stakeholder community, SCW has supported USH to undertake research in support of life sciences. Other analytical uses include co-developing the HHRA technology strategy and its local links with Integrated Personal Commissioning; producing data quality dashboards; parity of esteem analysis; GP data to support outcomes-based contracting; USH research into chronic liver disease (expanded below), cancer and alcohol detoxification; analysis of frailty codes and frail nursing home patients (for University of Portsmouth); a QOF dementia refresh; evaluating the effectiveness of NHS Health Checks (USH) and end-of-life care plans.

The following extract is from an abstract submitted to The Lancet by Professor Nick Sheron, Head of Clinical Hepatology at the University of Southampton. By working with SCW’s HHRA analytics team, Professor Sheron gained access to longitudinal integrated data from the Hampshire Health Record to undertake a unique analysis of early predictive indicators for live disease. This was possible because of the ability to access anonymous data from a rich local shared care record, supported by the SCW multidisciplinary team on IG process development and data mining.

“Liver disease is second only to ischaemic heart disease in terms of years of working life lost in England and Wales, and is likely to become the leading cause in the next year or so. The tools currently available to detect cirrhosis have been developed in a population of liver patients all of whom have had disease serious enough to merit an invasive liver biopsy. The purpose of these tests being to replace the need for liver biopsy in selected patients already referred to a liver clinic. In contrast, the CIRRUS test was developed using a population of patients with proven cirrhosis and a large control population with no evidence of liver disease with the very different aim of detecting / predicting cirrhosis in an unselected primary care population.

“We believe that our approach has the potential to reduce liver disease mortality and morbidity by providing, for the first time, an accurate and practical tool to detect cirrhosis years before patients present to hospital - using data already freely available in primary care. This may help to enable the paradigm shift needed to take liver medicine out of hospitals and into communities. For this to happen we will need properly controlled multi-centre randomised clinical trials to prove that we can translate earlier detection and intervention into reduced mortality, morbidity and NHS costs.”

We worked with Portsmouth CCG and the University of Portsmouth to review the prevalence of prescribing within primary care in older patients in Portsmouth. This related to medicines classified as “high risk” in a pre-defined list based on the widely cited Beers criteria 2015 produced by the American Geriatrics Society and a study identifying the medicines associated with adverse events resulting in hospital admissions in two Merseyside hospitals (Pirmohamed et al. 2004). The data provided was used primarily to assess the prevalence of prescribing of such medicines locally in patients aged 65 years and over. This work highlighted discrepancies in prescribing patterns for elderly patients across the region and led to clinical leaders making changes to ensure safe prescribing practice based on regionally relevant evidence.

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