Research making a difference to practice

CLAHRC-NDL Bi-annual newsletter

Edition 4 - Autumn 2011

engageCLAHRC at ‘halfway’In March 2011 our incoming Director, Professor Rachel Munton, initiated a mid-term review of CLAHRC-NDL, which has enabled us to ‘take stock’ halfway through our five-year programme.

After a number of review panels, workshops and consultations with over 120 people, a draft document was circulated to staff in June 2011.

Sixty-four responses from staff, colleagues from our partner organisations, and others fed into proposals to make sure CLAHRC makes the best use of the expertise of its partner organisations and its staff.

We sent the proposals to three external reviewers in August, and their comments have confirmed a set of proposals - agreed by the CLAHRC Board and Senior Leadership Team - for implementation in the next phase of CLAHRC.

To find out more, see page 4.

AssociatesWe have over 750 Associates from a wide range of backgrounds who are interested in our applied health research. Associates are invited to free training, events, seminars and conferences. As well as receiving regular monthly updates and ‘Engage’ twice a year, you can follow us on Twitter (@CLAHRC_NDL) and LinkedIn.

If you have ideas for applied research, for implementing research or for improving evidence-based practice, please get in touch. If we can’t help, we probably know someone who can. We are keen to share new ideas, so why not visit us (online at www.clahrc-ndl.nihr.ac.uk or in person) to tell us what you think.

Welcome We’re halfway through our five-year programme, so this edition of Engage has a theme of ‘lessons learnt’. The blackboard images throughout the newsletter contain the ‘lessons’ for each article.

Alongside updates from our clinical themes, we give tips on surviving organisational restructuring, throw the spotlight on patient and public involvement, and report back on a cross-CLAHRC knowledge sharing and diffusion event.

Special features include CLAHRC BITEs (our new ‘bite-sized’ communications - see back page), a Social Return on Investment analysis of CLAHRC, how Map of Medicine is helping to share clinical information across boundaries, and Q&As with researchers, one from each theme.

Contents

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Research

Mental Health 6 Dental study, Building a career7 Mood disorder study Children & Young People8 GAPP mapping survey9 Steps to Active Kids (STAK)

Primary Care10 Regular attenders at GP practices11 Impact of injuries, Diffusion Fellow perspective from Julie Clarkson, Preventing diabetes and preconception care studies Stroke Rehabilitation 12 Return to work with Mary Grant, Early supported discharge13 HOVIS recruits 100th patient, Upper limb rehabilitation study

Engagement14 Surviving organisational restructuring15 Patient and public involvement, Mental Health Research Network supporting CLAHRC Implementation 16 Knowledge sharing & diffusion event

Features4 CLAHRC mid-term review An overview with our Director Professor Rachel Munton Professor Rachel Munton5 Map of Medicine From aneurysms to worms...

17 Social Return on Investment (SROI) An SROI analysis of CLAHRC-NDL

18 Q&As with researchers We grill four of our researchers - one from each clinical theme: Dr Janine Coates (Children & Young People), Mandeep Bhoday (Primary Care), Athfah Akhtar (Mental Health) and Dr Fiona Nouri (Stroke Rehabilitation) 20 CLAHRC BITEs A new ‘bite-sized’ method for communicating our research

Course dates for your diary

Date Title Location Booking10 November 2011 Preparing data for Jubilee Campus, alice.phillips@nottingham.ac.uk statistical analysis University of Nottingham 17 January 2012 Introduction to Structural Jubilee Campus, alice.phillips@nottingham.ac.uk Equation Modelling University of Nottingham

www.clahrc-ndl.nihr.ac.uk 3

It’s September already and I’ve been in post for 8 months; the time has flown by and I’ve met most CLAHRC staff. It’s a real privilege to be working with such a talented group of people.

Outside the CLAHRC it’s a busy, hugely challenging and confusing time for our partners. Our colleagues in Health and Social Care are going through unprecedented changes; services are being radically reconfigured, people are losing their jobs and there’s more to come. We don’t know yet exactly what the new commissioning landscape will look like, but we need to be sure that we’re well placed to understand and respond to the priorities of the NHS and social care.

I’ve been out and about talking to the people I think need to know more about the CLAHRC and who can help us in the future: I’ve visited Rosie Trainor from Nottingham University Hospitals; Jo Cooper and Tracy Pilcher from United Lincolnshire Hospitals; Ben Lobo from Derbyshire Community Health Services; Mark Lees from NIHR Office for Clinical Research Infrastructure; Jill Dhell from Department of Health; Peter Wozencroft from Nottingham University Hospitals; Deb Hall from Hearing BRU; Dianne Tetley from Lincolnshire Partnership NHS Foundation Trust; and Ann Priddey from East Midlands and South Yorkshire MHRN. I’ve presented at Nottingham University Hospitals, the School of Nursing and the Local Medical Council – all the time encouraging people to think about their evidence based practice and how research, and CLAHRC in particular, can help.

At the time of writing, the CLAHRC-NDL mid term review consultation has concluded and recommendations approved by our external reviewers, the CLAHRC Board and Senior Leadership Team. It’s important that the changes we implement are about making sure we have the best chance of succeeding in the next two years of CLAHRC to 2013, and give us the best chance of continued funding for CLAHRC in the future. See page 4 to find out more about the review.

Thank you one and all for your continued efforts to make CLAHRC-NDL a success. My door is always open so please drop in if you’re passing or make an appointment through Stephanie Chandler at stephanie.chandler@nottingham.ac.uk or 0115 82 31298.

Professor Rachel MuntonDirector of CLAHRC-NDL & East Midlands Leadership Academy

Welcome

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Mid-term reviewImpact of injuries

With Professor Rachel Munton

When I became director of the CLAHRC-NDL in February 2011, it had been established for two and a half years – so we were in the middle of our five year funding period. I had been clear that I wanted to conduct a stock-take of where we had got so far, to ensure that the particular strengths of CLAHRC-NDL were optimised, building on the excellent work of my predecessor Professor Graeme Currie. The purpose of the review was to identify CLAHRC’s achievements, and to be clear about where we needed to improve. CLAHRCs were established to:

• Carry out more, locally-relevant, applied health research;• Ensure the rapid use, influence and uptake of this research in local NHS systems of care; and• Build the capacity of local NHS partners to take on and use research-based information.

The particular contribution of the CLAHRC approach is the partnership with NHS and other local organisations in Nottinghamshire, Derbyshire and Lincolnshire, making sure that the research and implementation activities are produced together. As one of our external reviewers stated: “Ensuring proportionate attention to each of these aims is not easy: research activity can often be more easily defined, arranged, funded, assessed and defended than activities designed to support application and local (research-use) capacity building.” (Huw Davies, Professor of Health Care Policy and Management at the University of St Andrews).

We’re pleased to share 5 key messages to come out of the review:

1. The review is seen as appropriate, robustly and inclusively executed, and endorsed by the three external reviewers - Professor Huw Davies, Professor John Gabbay (Emeritus Professor School of Medicine, University of Southampton) and Professor Sue Dopson (Rhodes Trust Professor of Organisational Behaviour, Saïd Business School, University of Oxford). It has underlined that we must be responsive to local organisations, producing ideas together that support their research capacity and implementation in areas that matter to them.2. It enabled us to really focus on the impacts we are having on our local partners and on improving patient care and experience. 3. It helped us understand what we need to do to improve patient and public involvement - see page 15.4. We must make clearer links between the conduct and implementation of research – making sure that we learn from what works and what acts as a barrier in implementing research. We will be making changes to our internal structure in response to these messages, to ensure that we:

• Have a structure that is most effective in delivering the CLAHRC aims • Have a focus on our relationships with partner organisations as a key to our success• Have clarity about who does what, and who can be contacted for help and support• Develop our performance and our reputation giving us the best chance of future funding

I have enjoyed the review process and, although it has been challenging at times, it has helped us to really think through what we are good at and what we need to develop further. In the next edition of Engage, we will say more about the difference the review has made to what we are doing, and hear from you about how you find working with us, too. We will be sharing more information with our partners in the next couple of months.

Mid-term review timeline

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as a focus for discussion between commissioners, patients and clinicians in developing services, in making service roles and boundaries clearer, in identifying critical points in the patient journey, and in assessing resource allocation. A clear application of the maps is to assist patient choice and empowerment. Given the economic climate, commissioners see its advantage as a means to reduce variation and contain costs.

Richard Richards, Assistant Director of Public Health explained how Map of Medicine is being used in Derbyshire. It offers the facility to tailor local pathways which can therefore be informed by cost considerations. Derbyshire County PCT has developed five around priority areas: heart failure, stroke, deep vein thrombosis, knee replacement and bowel cancer. For each local pathway a steering

group was given 6 months to develop local guidelines which were then vetted by MoM. Torbay developed 100 maps in 2-5 years; South West Hants produced 50-60 in one year. Evaluating clinicians’ behaviour change in response to local maps is a related challenge, and there is work under way to measure this, as well as work to identify the cost implications of different pathways.

There is also scope for development and integration with other widely-used information resources. Professor Clive Adams, who leads the Cochrane Schizophrenia Group, is working to link the up-to-date

Cochrane evidence base to the Map of Medicine. All studies and reviews of the Cochrane Schizophrenia Group will be indexed in accordance with the path of the Map of Medicine. This evidence will be formatted to underpin the graphical interface from Map end users to inform regarding value and impact of data.

Map of MedicineFrom aneurysms to worms...

Map of Medicine (MoM) was the subject of a knowledge exchange event held in Belper in March 2011, organised by CLAHRC–NDL with Derbyshire County PCT. MoM is a web-based tool for sharing clinical information across traditional organisational and professional boundaries. It brings together agreed, optimal treatment pathways for a wide range of disorders, from aortic aneurysms to worms, presenting each treatment pathway as a tree diagram backed by information and clinical guidelines.

The maps, developed by experts in each field, condense vast amounts of information relevant to clinical practice. The pathway for bipolar disorder is shown below. “It’s a wonderful one page summary of how to manage a particular condition using technology cleverly, provided there is access to a computer” said CLAHRC-NDL Research Director, Professor Richard Morriss, who contributed to the map’s development as editor, with a team of national clinical experts.

Many maps are closely linked to NICE guidelines. There are also management resources, such as a ‘map’ on programme budgeting marginal analysis (PBMA) and information about care bundles, “a group of well-established, clinically proven interventions related to a disease process that, when implemented together, result in better outcomes than when implemented individually”.

Kath Holt, Client Services Consultant, and Michael Corkett, Clinical Editorial and Information Manager from MoM, presented the technology and described its use at the event in Belper. The idea behind Map of Medicine is to help clinicians to adopt consistent approaches to treatment and minimise variation in their practice, which is expected to reduce costs, minimise risks and improve outcomes. One advantage is a single access point for clinical guidelines, but the tool can be put to several uses:

“Map of Medicine pathways are a wonderful one page summary of how to manage a particular condition”

www.mapofmedicine.com

Mental Health

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Find out more about our Mental Health studies: www.clahrc-ndl.nihr.ac.uk/mentalhealth

Dental study welcomes Hannah Jones

Hannah Jones has joined the study on dental and physical health needs of people with serious mental illness as a Research Assistant. After completing her Masters in psychological research methods she was a research assistant at Rampton Hospital’s Literature and Evidence Research Unit before working at the University of Bristol as a systematic reviewer for the Cochrane Collaboration Depression Anxiety and Neurosis Review Group.

Study lead Clive Adams offered an update on progress so far:

“If there is one lesson, it is to do with pulling teeth. Working with clinicians and service users to design the trial was easy. The premise was that, if the trial was designed by those most involved in care, it would have more chance of implementation if evaluation suggested such action was indicated. Even putting together the detailed protocol for the trial to be dovetailed snugly into everyday clinical care was not that difficult.

What was painful was working though well-meaning legislative procedures designed largely for explanatory drug trials. These procedures are ill-suited and not comprehending of pragmatic, non-pharmaceutical studies. Pulling teeth. Implementation is difficult partly because much research has been un-implementable - yet current systems work best for this type of work. The inadequacies of these systems need radical reform if research and implementation are to converge”. hannah.jones@nottingham.ac.uk

Professor Clive Adams

Systems designed to govern pharmaceutical trials are not amenable to implementation-led studies. . .

Building a Career

People with mental health problems have the lowest employment rate of all disability groups. Overcoming the barriers is possible through Individual Placement and Support (IPS), which CLAHRC is implementing in Nottingham.

Over two years IPS Development Manager, Eric Wodke, delivered training and built systems around best practice in IPS, ultimately achieving an independently-rated ‘good fidelity’ service. He also edited a manual ‘Building a Career of your Choice’ for people with mental health problems who want to

have a regular working life, which is also aimed at employers, health professionals, family and friends who want to support a person into work. Copies of the booklet are available from shirley.woolley@nottingham.ac.uk

Lessons learnt about implementing IPS appear in the Psychiatric Rehabilitation Journal, autumn 2011, in an article called ‘Implementation of Individual Placement and Support: the Nottingham Experience’. Successful delivery requires a strong leader, an understanding of context, staff training and integration of IPS with mental health services. Central to this work is regular review of the new service’s fidelity to the IPS model, and of course stable funding for the new approach.

Regular review of your intervention’s fidelity to evidence-based standards keeps implementation on track . . .

‘Lesson learnt’

athfah.akhtar@nottingham.ac.uk

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Mood Disorder study

As the Mood Disorder RCT approaches its mid-point, there has been time to reflect on its progress and consider what we have learnt so far, for the future of the study and for the longer term goals of the research.

The principle aim of the study is to try to improve long term outcomes for participants through the application of evidence-based pharmacology in conjunction with psychotherapy in a collaborative care model.

The nature of such an investigation means that the team are acutely aware that how the research is conducted may impact significantly upon outcomes for both the treatment as usual and the specialised treatment group. Following feedback from participants, the team implemented several things to maximise participant involvement and knowledge. The team will:

» Ensure that service user perspectives, feedback and advice are accounted for when compiling study materials, such as information sheets and questionnaires » Regularly seek counsel from their consultant service user » Create a newsletter specifically for the readership of participants to inform them of the study’s

progress and as a forum to provide details of the study and answer any frequently asked questions

Furthermore, the clinical team have collaborated with Self-Help Nottingham to enable the development of user and carer support groups. There is also access to social inclusion initiatives.

Obviously a clinical trial such as this relies on the successful recruitment of participants and the retention of these participants throughout the follow up period. The team sincerely hope that through these initiatives they have managed to create and maintain a rapport with their participants, and the low withdrawal rate so far (<10%) may be evidence of this.

In order to maximise recruitment and accessibility to the study additional sites are currently being set up in Cambridgeshire and Peterborough NHS foundation Trust and North Nottingham, with a site based at Millbrook Hospital in Mansfield. There are also discussions taking place about creating a study site in Derbyshire NHS Foundation Trust.

clahrc-moodproject@nottingham.ac.uk

Responding to trial participant feedback is key to maximising their involvement AND the effectiveness of the research. . .

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Children & Young People

Specify who is likely to benefit most from any innovation and enforce inclusion criteria . . .

john.a.taylor@nottingham.ac.uk

GAPP Mapping Survey

Our GAPP study is looking at how effective early intervention parenting programmes delivered in school settings are in reducing common childhood behavioural difficulties such as inattention, overactivity and hyperactivity. Parenting programmes may help to improve health and educational outcomes in children and prevent the onset of additional problems. They are also recommended as a first line of treatment for children at risk of childhood behavioural disorders, such as Attention Deficit Hyperactivity Disorder (ADHD).

As part of this study, the team conducted a mapping survey of parenting programmes delivered across the NDL region. The survey asked stakeholders from across NDL working in Local Authorities (LAs), the NHS (including CAMHS), and voluntary agencies to provide details of what programmes they deliver, how parents are referred to programmes, who can attend programmes, how programmes are funded, and how facilitators are trained to deliver programmes.

The team have learned that several different parenting programmes are delivered across NDL, with most delivered through LAs. The majority of these are universal programmes which any parent can attend. Only one programme, 123 Magic, was found to be targeted towards specific behavioural difficulties (ADHD), and this tends to be delivered by CAMHS and voluntary agencies. The majority of funding for these programmes comes from the Department for Education Think Families Grant, and the mapping survey found that referral and collection of outcome and effectiveness data varied between services.

These findings have led to a number of key recommendations, such as the development of programme-specific eligibility criteria for entry onto parenting programmes to ensure that parents who attend share similar characteristics and needs. It was also recommended that schools play a greater role in referral processes and delivery of parenting programmes.

To read the report in full, visit the GAPP web pages on the CLAHRC site or email john.a.taylor@nottingham.ac.uk for a copy.

Find out more about our C&YP studies: www.clahrc-ndl.nihr.ac.uk/children

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Children & Young People

Steps to Active Kids (STAK)

With 18 primary schools and over 300 children currently taking part in the Steps to Active Kids (STAK) project, the team are just about to start the fifth and final group of schools. The lessons learnt over the past eighteen months have certainly resulted in a far smoother passage for all involved. Communication and dissemination of information in a school environment presented the team with a number of early challenges.

The first group of schools were recruited to the project via a letter and subsequent meeting with the headteacher. This was the only contact with the school prior to the start of the project and the team rapidly became aware of resistance from class teachers.

The reason for this resistance was the information left to be circulated by the headteacher did not in fact reach the people ‘at the coalface’ - the class teachers. The team promptly adjusted their method of communicating with the school and now meet with all class teachers prior to the start of the project. This has resulted in stronger working relationships with schools, an increased rate of recruitment and better response rates to questionnaires.

Stronger working relationships make the difference. Talk to the people affected directly by the changes you are making. . .

nivette.mullan@nottingham.ac.uk

Regular attenders at GP practices

It has taken longer than anticipated for the team to conduct their important pilot study, which is addressing the needs of regular attenders with mental health issues in primary care. However, they have found the experience very helpful in understanding more about this patient group and how to take the study into the next phase.

The team discovered that the patient group they are treating is much more complicated than originally understood. For example, some patients are keen to have treatment and others are not. There is still a lot more they need to understand about this patient group before they can confidently develop treatment. The team are therefore awaiting the go-ahead from the University Ethics Committee to adjust their protocol from offering Cognitive Behaviour Therapy to offering “Case Formulation” which allows therapist, patient and GP a better understanding of the complex issues underlying regular attendance.

Working with GPs in their practices has worked better than the team originally thought it was going to - they now understand that it takes time to develop good relationships with GPs but, once this is established and GPs have a greater understanding of the research, the benefits of having good working relationships between GP, patient and researcher are apparent.

In the summer of 2011 the team met with members of another university department who have been working on the development of tools to electronically extract data from medical records. Being able to share in this expertise will dramatically improve the accuracy of the team’s economic analysis of medical records, which will save them an immense amount of time.

Finally, the team have been able to revise and adjust the search criteria so that they now have greater knowledge of the anomalies within medical records that may skew searches. They have adjusted their criteria to ensure that they capture as many regular attenders as possible, and have a greater understanding of how different general practice database systems work and how this impacts on their research.

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Primary Care

Beware of ‘one size fits all’ approaches - patients’ needs are more complicated than we first thought. . .

michelle.stubley@nottingham.ac.uk

Find out more about our Primary Care studies: www.clahrc-ndl.nihr.ac.uk/primarycare

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Preventing diabetes and preconception care studies

The diabetes study is exploring how to increase physical activity levels in South Asians at risk of diabetes. The preconception study is raising awareness of preconception ‘risks’ in ethnically diverse communities.

Recruitment of participants to the exploratory phase of the preconception study has gone very well. The team adopted a flexible approach to recruit women from a wide range of community settings such as Sure Start Centres, Housing Associations and Sikh Temples. In contrast, recruitment to the diabetes study through general practices was slow. The team will therefore recruit to the feasibility phase of the diabetes study, and deliver the intervention, via community settings, rather than general practices.

Working with ethnically diverse populations, the teams have benefited hugely from having a multi-lingual researcher to conduct interviews and focus groups.

However, both the time and costs involved in translation and transcription services were underestimated. An alternative supplier for this service is being sought - another ‘lesson learnt’ for the next phase of the two studies.

Community recruitment seems to work better than seeking participants through GP practices. . .

Impact of injuries

The Impact of Injuries team have been recruiting accidentally injured patients to the study for over 12 months now. Although good progress has been made, the team are slightly behind their target follow up rate. The team have taken steps to improve this by ensuring the contact they make with participants is as personal as possible, such as: making sure that the follow up contact comes from a person whom the participants have already met on the project; including personalised compliments slips; and sending gift vouchers with the questionnaires.

Service user involvement has been extremely helpful to the study in terms of involvement in training, input into project management groups, ideas for maximising recruitment and follow up, and adding a lay perspective to the team’s understanding of interview data.

Personal contact works best to keep participants in the study. . .

blerina.kellezi@nottingham.ac.uk

Impact of injuriesA Diffusion Fellow’s perspective

“As a clinician of 26 years, I never had any direct involvement with research, so working on the Impact of injuries study has been a new experience for me. I have a basic understanding of research now which I certainly didn’t have before. I also understand why research takes so long considering the many processes and procedures required to get to the ‘hands-on’ bit; something I didn’t appreciate before. What has been interesting for me is that although I felt a little out of my depth in the first year, it was interesting to see that the researchers also had their own anxieties, for example in talking to patients and carers. It was reassuring that we all have our own anxieties - I felt less of a novice when I realised that I have transferable skills to pass on to the team.”

Julie Clarkson Occupational Therapist at Nottingham

University Hospitals NHS Trust

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Stroke RehabilitationFind out more about our Stroke Rehabilitation studies: www.clahrc-ndl.nihr.ac.uk/stroke

Return to work with Mary Grantmary.grant@nottingham.ac.uk

The team have recruited 27 people to the feasibility trial, which is well under way. Occupational Therapist Mary Grant is delivering stroke-specific vocational rehabilitation developed earlier in the study to people randomly allocated to the intervention. Her days are varied, visiting people at home and at work across Derby and Southern Derbyshire. Mary is working with stroke survivors, their families and employers to facilitate a phased return to work, and supports them in remaining in work in the longer term.

Mary’s role involves assessing the impact of stroke on a person’s job, educating them, their family and employer about the effects of stroke and how it might impact on their role and finding acceptable strategies to lessen the impact. For example, the use of memory aids or negotiating changes in a worker’s roles or work patterns. For some this work begins at home through establishing structured

Early Supported Discharge (ESD)

The team have produced a report on ESD services across the NDL region which has highlighted a number of key areas, including the importance of collaborative and well-informed decision-making among ward staff and ESD team members, and aligning ESD services within the local context of health and social care, among others.

Locally, the East Midlands Cardiac and Stroke Network used the team’s findings for their regional service specification. Nationally, details of the ESD consensus have been shared through collaborative links with the Stroke Improvement Programme who are implementing the National Stroke Strategy across England. This relationship led the team to conduct further work on longer term care for stroke survivors. Looking ahead, the team are aiming to produce a report in late 2011 on the impact on carers of discharging stroke survivors from hospital early, and also plan to extend their research into Derbyshire and Lincolnshire to highlight geographical challenges to commissioning.

100th patient recruited to HOVIS study

The Home Visit after Stroke team reached a milestone in August 2011 by recruiting the 100th patient to the study. David Thompson from Derby (pictured) said “I’m happy to help with this research, especially if it will help other people in the future.”

Patients are being recruited from the Stroke Rehabilitation Unit at the Royal Derby Hospital. The HOVIS team would like to thank all the patients recruited to date for their time and effort. They would also like to thank all of the staff on the Stroke Rehabilitation Unit for their ongoing support with the project.

routine with gradually-increasing activity levels and opportunities to practise the skills necessary for work or education. For example, computers can increase concentration, daily walks can increase physical stamina, and cooking helps practise multi-tasking. The intervention was tested with two stroke survivors, before being adopted for the trial. Both had visual problems and struggled with fatigue, but nevertheless successfully returned to work.

Mary is currently working with a variety of people, including a shipping officer, a security guard, a computer programmer, a landscape gardener and a district nurse. Last week she visited a pub landlord in the morning and a nun who runs the convent library in the afternoon. Another participant is preparing to return to work as a crew member of a vintage car rally team that travels all over the world. Sadly for Mary, the work site visit will have to be simulated in the UK!

One stroke survivor Mary visits is Office manager Sue, who is reaching the end of successful phased return to work, and resumes full-time work from September.

rebecca.fisher@nottingham.ac.uk phillip.j.whitehead@nottingham.ac.uk

Lesson learnt: Upwards collaboration with national policy leaders can bring mutual benefits

www.clahrc-ndl.nihr.ac.uk 13

Mary worked with Sue in hospital to analyse her job duties and responsibilities, and later visited her at home as Sue gradually learned to walk again, and started to build up mobility, balance and stamina. Fatigue was an issue so information and education were provided on how to balance activity and rest. Mary met Sue and her line manager to assess her work environment and plan a phased return. Heavy files which she needed to access were moved from a high shelf to a lower cupboard. As Sue improved she set herself more challenging goals including getting a bus into town to go shopping to prepare for her journey to work on public transport. Eventually Sue’s GP gave her permission to drive and she fulfilled a long-held ambition of buying a sports car.

Mary met with Sue and her line manager at regular intervals to review and monitor the phased return and gradually they increased the hours worked and tasks undertaken. Sue said that the most valuable part of the intervention was having someone to talk to who understood stroke

Effective back to work support must be tailored to the needs and preferences of theindividual. . .

100th patient recruited to HOVIS study

The Home Visit after Stroke team reached a milestone in August 2011 by recruiting the 100th patient to the study. David Thompson from Derby (pictured) said “I’m happy to help with this research, especially if it will help other people in the future.”

Patients are being recruited from the Stroke Rehabilitation Unit at the Royal Derby Hospital. The HOVIS team would like to thank all the patients recruited to date for their time and effort. They would also like to thank all of the staff on the Stroke Rehabilitation Unit for their ongoing support with the project.

The support and commitment of clinical staff helps increase patient recruitment. . .

and the difficulties she was experiencing, who could give feedback on goals and provide psychological support when preparing to return to work. She said she felt more assertive and that communication with her line manager had actually improved since returning to work. As a result Sue is no longer experiencing the same levels of stress at work as before the stroke, a factor that she hopes will prevent another stroke

happening in the future.

The team have learnt that processes and timescales for vocational rehabilitation, like those for stroke recovery, are highly individualised. Some people need little more than information and advice, whereas others need a highly structured pre-work vocational rehabilitation programme, detailed work place assessment and ongoing support.

Existing stroke services do not always allow for this type of flexibility or for the range of need among service users wanting to return to work.

Upper limb rehabilitation update

The virtual glove and games that will be used to deliver upper limb rehabilitation have required several rounds of development and testing to ensure robustness and reliability. This impacted on project timescales, but has been hugely valuable in affording time for both service users and providers to make important contributions to the project. For example, an engagement workshop with therapists in Derby helped with the design of a fourth game that is now in development.

This extra time to engage with therapists and stroke patients allowed the team to develop growing support for the project. For example, Nottingham City Community Stroke Team came on board as an additional recruitment site. In hindsight, even though the development of the technology took longer than anticipated, the project benefitted from the delays.

The team have showcased the project across the region, including a feature on local news programme BBC East Midlands Today. The team would like to thank Fred Higton, a service user who appeared in the report, for his numerous contributions to the project.

‘100th recruitee’ David Thompson (right) with Karen Fellows, Research

OT on the HOVIS study

Lesson learnt: Delays can be productive if you use the time to build strong working relationships

kate.threapleton@nottingham.ac.uk

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EngagementHow to Survive Organisational Restructuring By our resident Occupational Psychologist, Dr Louise Thomson (louise.thomson@nottingham.ac.uk)

In the current economic climate, the vast majority of organisations are having to review the way they work in order to adapt and survive. Working in an organisation that is undergoing restructuring or downsizing can lead to a variety of negative feelings such as uncertainty, anxiety, sadness and anger. These emotions can in turn have an impact on both employees’ health and their performance.

Organisational restructuring does not only affect the employees whose jobs are under most direct threat, but it can also have an impact on the survivors of job loss and those making restructuring decisions. However, there are many lessons to be learnt from the experiences of restructuring and downsizing during the last economic downturn in the 1990s which could help us to reduce some of the damaging effects.

Employees whose jobs are insecureFearing that you may lose your job can be emotionally debilitating, but there are a number of strategies you can use to help prevent this:

» Focus on the things that you have control over and which you can influence, whether this is at work or in other contexts » Network and talk to other people to find out what

opportunities there are available to you » Be flexible and adaptable to change – rigidly sticking to

“how things used to be” can have a negative impact on your physical and mental health » Don’t take on too many extra tasks or roles – although

it is tempting to make yourself ‘indispensible’, having too many demands can lead to higher levels of stress » Avoid blaming others – your energy and time can be

put to much better use » Avoid blaming yourself – try to remain positive and

focused on opportunities » Acknowledge your emotions and talk to someone

about them or write them down – re-telling an experience or problem either orally or in writing can help you analyse the situation and bring about a change in perspective.

Those managing restructuringChange in organisations is often associated with lower levels of trust, loyalty and engagement. This is usually not due to the changes themselves, but to the way they have

been planned and implemented. There has now been a great deal written about how to manage change effectively in order to reduce its negative impact both during and after the restructuring. Some of the key ingredients are:

» Procedural justice – having fair and transparent processes that are used throughout the restructuring » Openness – managers need to be visible and available,

not hiding behind closed doors » Communication – keeping employees informed is vital.

Even when there is nothing more to tell, you can always tell your employees that » Employee participation – give employees the

opportunity or ability to participate in decision making.

Job loss survivorsThose employees who remain after job losses often experience feelings of guilt, betrayal, resentment and uncertainty. They tend to be reluctant to take risks and seek new opportunities, reducing innovation and productivity. Leaders and managers need to acknowledge and respond to these feelings and emotions, rather than reiterating the logic and rationale for the restructuring. Good communication and openness are again important here. Other, more practical, suggestions include finding ways to keep relationships with some of the people that have been made redundant – such as creating job banks or alumni groups. The employees themselves can also reduce these difficulties through:

» Being sensitive to the situations of those around you » Investing your self-esteem in your work, not in where

you do your work or who you work with » Being positive about new opportunities that arise

We often hear about public sector workers being sacked and asked to re-apply for their jobs on inferior terms and conditions, staff being told to take unpaid leave, and whole services being cut. However, the way these changes are planned and implemented can make a difference to the effect that they have on employees. Individuals can also help themselves by focusing on the positives, taking control where they can, and using the sources of support available to help them through these difficult times.

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Involving patients and the public in CLAHRC - NDL

We are currently reviewing our approach to patient and public involvement (PPI), and commissioned Peter Bates (from the National Development Team for Inclusion) to carry out a stocktake of our current activities to involve service users and carers. In a well received report to the Leadership Team, Peter identified 25 different ways that service users and carers are involved in CLAHRC-NDL, from advising on study design, through the research process, to assisting with implementation.

The key findings from his work are that all 16 of our studies have some level of involvement by service users and carers – and some have achieved a very high level of involvement, such as Return to Work after Stroke and Mood Disorder.

However, Peter highlighted inconsistencies in our overall approach to PPI and recommended that a systematic approach be developed, which will create some centralised solutions to make sure that best practice can be rapidly incorporated and supported across the CLAHRC.

Thanks to all our service users, carers and researchers who gave more of their time to talk to Peter for this stocktake. We’ve listened, and we intend to act on his recommendations. We’ll give you more news in the next edition of Engage, due out in March 2012.

peter.bates@ndti.org.uk www.ndti.org.uk

Our own systems need help to achieve best practice in PPI. . .

Mental Health Research Network (MHRN) support for CLAHRC

The East Midlands Hub plus South Yorkshire (EMSY) is one of eight regional centres of the Mental Health Research Network. Led by Ann Priddey, its experts advise on issues common to all kinds of research. Debbie Butler (debbie.butler3@nhs.net) is responsible for Patient and Public Involvement, while Michaela Stevenson offers help with gaining access to services, research passports and other governance issues. Dr Stevenson (Kaela.Stevenson@nottshc.nhs.uk) is the best person to contact for advice on whether EMSY can provide support to a study.

We also have a ‘bank’ of 20 trained research staff who can assist with recruitment of study participants and data collection. These staff can be quickly deployed and come from a wide range of backgrounds, including experienced clinicians and new graduates, so they can be matched up to the particular needs of a study. We sometimes put university researchers onto the MHRN bank to increase workforce flexibility and skills retention.

We ‘re currently supporting the CLAHRC Mood Disorder study with a Clinical Studies Officer Sandra Simpson. Prof. Richard Morriss says that the MHRN input has been ‘critical’ to keeping the study recruitment on target.

David KellyActing Deputy Hub Manager MHRN

Peter Bates of NDTi

Knowledge sharing and diffusion: Cross-CLAHRC learning event

A cross-CLAHRC event attended by eight of the nine CLAHRCs was held in mid 2011 to hear about and learn from the experiences of individuals who share and diffuse knowledge about CLAHRC studies. In doing this, individuals – such as our Diffusion Fellows – carry out knowledge brokering and boundary spanning roles.

These roles are carried out in different ways. For instance, some are full-time positions, whereas others, like our Diffusion Fellow role, are part-time. Some are situated in the NHS, others are co-located and bridge the space between universities and the NHS. However, all these roles have a similar remit: to work across organisational, cultural, professional and geographic boundaries to advance CLAHRC research and implementation.

Despite these differences, we learnt that: a) there cannot be a one size fits all approach to knowledge brokering and boundary spanning. Rather, a negotiated and co-produced role is required to build trust and engagement; b) the role will evolve and; c) to be a successful knowledge broker and boundary spanner, you sometimes need to think outside of the box.

Reflecting on the learning event, our Diffusion Fellows said:

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Implementation

“Knowledge brokers are people whose job it is to move knowledge around and create connections between researchers and their various audiences”

Meyer 2010

“Knowledge brokers and boundary spanners are people who share information between research and practice, which helps to close the ‘know-do’ gap”.

“Reassurance again that it is not a one-size fits all and diversity is massive, but common threads and

themes underpin”.

“I had no idea that other CLAHRC’s were set up in such diverse ways and using their DF type people in such a variety of

roles and functions”.

“It was a great opportunity to see

how other CLAHRCs are making the bridge from research to practice

happen”.

“It was lovely to meet the ‘doers’. I learned about the different models which CLAHRCs are using to get research into practice and noticed that NDL is much more research focused than many of the others”.

emma.rowley@nottingham.ac.ukFurther reading: Lomas, J. The in-between worlds of knowledge brokering, British Medical Journal, 334, pp129-132. Meyer, M. The rise of the knowledge broker, Science Communication, 32(1), pp118-127.Ward, V. et al. Knowledge brokering: the missing link in the evidence to action chain?, Evidence & Policy, 5(3), pp267-279.

We learnt that there is a great amount of similarity but also much variation across the CLAHRCs in relation to these knowledge sharing roles. For example, the roles have different names such as Diffusion Fellows (NDL), CLAHRC Co-ordinators (Leicestershire Northampton & Rutland), Knowledge Transfer Associates (Greater Manchester), Knowledge Transfer Facilitators (South Yorkshire) and Locality Leads (Penninsula).

The CLAHRCs have different models of knowledge transfer, and also vary according to how they are ‘doing’ implementation. For example, some – like NDL – are striving to implement original research, whereas others are attempting to implement existing evidence. The commonality between the CLAHRCs is the important role of those people who are working hard to share and diffuse the knowledge that is being created.

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Feature: SROISocial Return on Investment: an evaluation of CLAHRC-NDL

What is SROI?

“Every day our actions and activities create and destroy value; they change the world around us. Although the value we create goes far beyond what can be captured in financial terms, this is, for the most part, the only type of value that is measured and accounted for. As a result, things that can be bought and sold take on a greater significance and many important things get left out. Decisions made like this may not be as good as they could be as they are based on incomplete information about full impacts. Social Return on Investment (SROI) is a framework for measuring and accounting for this much broader concept of value; it seeks to reduce inequality and environmental degradation and improve wellbeing by incorporating social, environmental and economic costs and benefits. SROI measures change in ways that are relevant to the people or organisations that experience or contribute to it. It tells the story of how change is being created by measuring social, environmental and economic outcomes and uses monetary values to represent them. This enables a ratio of benefits to costs to be calculated. For example, a ratio of 3:1 indicates that an investment of £1 delivers £3 of social value.”

Extract from ‘A Guide to Social Return on Investment’, London: Cabinet Office, 2009.

The problem Implementation activities are an essential feature of the CLAHRC approach but are seldom included in health economic analyses. Economic perspectives on improving health care should include as inputs the costs of implementating innovations, since this is an element which needs proper resourcing.

A comprehensive economic analysis of innovations in health care should include not only patient-related outcomes but also the impact of innovations on the wider society. Benefits, and costs (or savings) to social care, to the social security budget, to criminal justice services and to private individuals or households might all be attributable to health care improvements.

One solutionWe have commissioned an independent SROI evaluation of selected CLAHRC studies. Its purpose is, from a societal perspective, to focus on the costs and benefits of implementation over and above the costs of the innovations which CLAHRC-NDL is promoting.

It will identify how implementation resources have been used, measure their impact using a social return on investment approach, and cost this. It will investigate the implications of the CLAHRC project beyond the NHS, for instance on the lives of informal carers, on social security benefits claimed or on patients’ productivity. It will explore these questions in relation to selected CLAHRC-NDL projects, asking who are the ‘winners’ and ‘losers’ overall.

The impact on the groups which are not currently CLAHRC partners will be of particular interest.

This is a formative study which will shape the direction of the CLAHRC-NDL’s activities, as well as informing future research bids and commissioning of health care innovations. At the end of the study, in 12 months’ time, we expect to be able to demonstrate the impact of CLAHRC on the wider society, and to offer guideline costs for implementation in relation to at least three local service developments.

What is your study trying to achieve, and why is it important?The project is important because it aims to provide evidence for a preventive approach to common childhood behavioural difficulties before they become a real problem for the child, their parents and their school. Parent training has been promoted by NICE as a first step towards the treatment of ADHD-type behaviours, so we are interested to see if parent training is effective in the prevention and reduction of these kinds of behaviours.

How is the study progressing?We’ve worked hard to ensure that the parenting programme we are using fits the aims of the study. As well as developing a teacher training session so teachers and parents have similar strategies, we also completed a survey to determine what parenting programmes are delivered within NDL - the report is available on our website. In the spring of 2011 we recruited schools for our main study, which involved talking to head teachers and Special Educational Needs Coordinators (SENCOs). To date we have six schools taking part.

Has the CLAHRC model helped your study?The implementation side of the research plays a vital role in our study and will be key to “putting research

into practice”. The engagement team have also played a crucial role in enabling us to engage with commissioners, and they helpedorganise and run a successful stakeholder event in November 2010, allowing us to make links with several key people.

Have you learnt any lessons? Perseverance.

What are the next steps for the study?In September 2011 we will run programmes in the schools which have agreed to take part. Recruitment of schools will continue, as willour systematic review of the literature.

What is your favourite quote?It’s from American children’s author, Dr Seuss: “Today you are you, that is truer than true. There is no one alive who is you-er than you.”

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Researcher Q&As

“Implementation research...will be key to getting our work into practice”

Dr Janine Coates“Group ADHD Parenting Programme” - Children & Young People

What is your study trying to achieve, and why is it important?We aim to increase employment for people with severe mental health problems in Nottinghamshire. In the UK, over half a million people ofworking age have a mental health-related disability and these people are less likely to be employed than other disabled people. Our study iscomparing IPS alone, and with work-focused psychosocial support as an adjunct to IPS, to see which has the best outcome for service users.

Where is the study at the moment?The IPS service is successfully operating within the City recovery team at the Stonebridge Centre. Jobs gained have already exceeded CQUIN (Commissioning for Quality and Innovation) targets for 2010/11. The service is also currently being implemented in the Early Intervention in Psychosis Team - the study having started there in July 2011. So far seven people have been enrolled to the study.

Has the CLAHRC model helped your study?CLAHRC has helped our project considerably. The knowledge of the implementation researchers helped our IPS development manager, Eric Wodke, to embed the IPS service within the City recovery team. Second, the links fostered through the engagement team with stakeholders such as JobCentre Plus have helped raise the profile of our study. Finally, our Diffusion Fellow, Catherine Pope, is crucial to our project; as a champion for IPS in the Trust she advised us on Trust practices and worked to unblock administrative bottlenecks. Catherine remains instrumental in embedding IPS in the developing organisation.

Have you learnt any lessons? Successful delivery requires a strong leader, understanding of the context in which the new service is to beintroduced, staff training and integration of IPS with mental health services. Stable funding is key to all this.

What are the next steps for the study?To establish the IPS service in the Early Intervention in Psychosis Team and to evaluate the data collected from the City Recovery Team.

Any favourite words of wisdom?“In the middle of difficulty lies opportunity” - Albert Einstein

“The Engagement team...have helped raise the profile of our study”

Athfah Akhtar“Individual Placement Support” - Mental Health

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What is your study trying to achieve, and why is it important?Several randomised controlled trials of Early Supported Discharge (ESD) services found that they benefit stroke patients. Our study will establish whether these benefits exist in practice. We are also promoting research-based recommendations for practice and the implementation of evidence-based ESD services.

What’s your progress so far?The study has had an impact at local and national level. The East Midlands Cardiac and Stroke Network have used the findings from ourESD consensus to inform regional service specification. Nationally the consensus has been used by the Stroke Improvement Programmewho are responsible for implementating the National Stroke Strategy. Further collaboration is planned. As a team we organised aknowledge sharing event at the end of 2010, which allowed local and national stakeholders to share their perspectives on theimplementation of ESD services. The study has already led to five articles in high quality journals and our work has been presented 10times at internationally recognised conferences.

Has the CLAHRC model helped your study?Yes, it has provided a unique support system for our study. Our Diffusion Fellow, Kay Gaynor, is a stroke consultant at NUH and has given us loads of support, advice and practical assistance which we would havefound difficult to achieve without her. She has been the link between researchers and clinicians, making therecruitment process much more efficient. Kay has also been active in raising awareness of our research withstakeholders.

What have you learnt? The most time consuming aspect is obtaining ethics and R&D consent, so start as early as you can!

What are the next steps for the study?The evaluation is ongoing with more than 150 participants recruited to date. Recruitment and follow up ison target to be completed by the end of 2012. The mapping element of the study is also ongoing with morework planned in Derbyshire and Lincolnshire.

Have you got a favourite quote?“An investment in knowledge always pays the best interest”. Benjamin Franklin

What is your study trying to achieve, and why is it important?We’re developing, and exploring the acceptability and feasibility of, a community-informed intervention to reduce diabetes risk in people of South Asian origin. Diabetes is much more common and has poorer outcomes in South Asians, who have a 4 to 6-fold increased risk compared to white Europeans, as well as an earlier onset of the illness and a greater incidence of complications (cardiovascular andrenal disease). Reducing diabetes risk in people of South Asian origin is a strategic aim of local commissioners.

Where is the study at the moment?We’ve completed the exploratory phase where we conducted interviews with local South Asians to explore their views on the intervention which we will develop and test in the feasibility phase. Also, we conducted a focus group with health professionals, and qualitative and quantitative literature reviews.

Has the CLAHRC model helped your study?Our study has helped raise awareness with key stakeholders and has been incorporated into the Joint StrategicNeeds Assessment (JSNA) via our Diffusion Fellow who is our link to the Health and Wellbeing Board in Derby.

Is there anything you’ve learnt that you wish you’d known at the start? The study has benefited from having a researcher who is able to speak Punjabi and Urdu on the team so that the views of those who do not speak English as a first language have also been captured. However, the time taken for translation of these interviews led to a delay in analysing the data. In future, we would allow more time for the translation of the interviews.

What are the next steps for the study?The data analysed so far has helped to develop the protocol for the feasibility phase, which we are moving onto now.

What is your favourite saying?When nothing goes right… turn left.

Mandeep Bhoday“Reducing Diabetes Risk in South East Asians” - Primary Care

Dr Fiona Nouri“Early Supported Discharge after Stroke” - Stroke Rehabilitation

“Our study has been incorporated into the Joint Strategic Needs Assessment”

“Our work has achieved impact nationally, and is being used by the Stroke Improvement Programme”

NIHR CLAHRC Nottinghamshire, Derbyshire and Lincolnshire Sir Colin Campbell BuildingUniversity of NottinghamInnovation ParkTriumph RoadNottingham NG7 2TU

Tel: 0115 823 1253Fax: 0115 823 1289 Email: clahrc@nottingham.ac.uk

www.clahrc-ndl.nihr.ac.ukwww.twitter.com/CLAHRC_NDL

CLAHRC ‘BITEs’After talking to health and social care practitioners and managers, we have learned that the task of keeping up-to-date with the academic literature on a given subject can be daunting, particularly as many areas of health and social care generate hundreds of new journal articles every month.

On many occasions NHS staff just want the headline, ‘need to know’ information about a piece of research. So, in response to this, we have created the CLAHRC ‘BITE’ (Brokering Innovation Through Evidence). CLAHRC BITEs provide an accessible overview of the most important implications and conclusions of a piece of research. They also provide links to further, more in-depth information and references for further reading. Below you can see the first CLAHRC BITE we have produced. More BITEs are in production, with many more planned.

To find out more or to discuss ideas for further BITEs, contact ian.kingsbury@nottingham.ac.uk

Example BITE: front and back cover

This document can be made available in large print and other formats including translations upon request.