Chronic disease (integrated and holistic care)

Finding new, sustainable and cost effective ways of managing people with long-term conditions is increasingly being recognised as the next big challenge for health and adult social care.

The NIHR CLAHRC West Midlands was a five-year initiative (2014-19) with a mission to create lasting and effective collaborations across health and social care organisations, universities (Birmingham, Warwick and Keele) and local authorities to improve the services we can deliver for patient benefit.  It was funded through a £10million investment from the National Institute for Health Research (NIHR) together with a further £20.6million matched funding provided by NHS and local authority partners.

The Centre focused on four key themes which included Chronic Diseases (Integrated and Holistic Care). This fourth theme built on the work of the pilot CLAHRC which evaluated improvements in care for a number of individual long-term conditions, including stroke, diabetes and kidney disease. The theme had two priorities:

  • To evaluate new ways of delivering integrated care to people with multiple long-term conditions - study 1 involved a series of case studies of new services across health and social care organisations in the West Midlands.
  • To evaluate new ways of improving patient well-being - study 2 looked at the primary care management of musculoskeletal pain and mental health for patients with long-term conditions.
    Study 3 looked at how clinical skills can be improved in order to promote emotional and psychological well-being for patients.

Theme lead: Professor Jon Glasby

The theme incorporates a number of projects including:


The effectiveness of interventions to achieve co-ordinated multi-disciplinary care and reduce hospital use for people with chronic diseases.

Lead: Dr Sarah Damery, University of Birmingham

This systematic 'review of reviews' brought together the evidence about the effectiveness of interventions designed to provide integrated or co-ordinated care across different healthcare settings for patients with chronic diseases. Of particular interest were the successful interventions or models of care which enhanced patient experience, improve patient quality of life, reduced the use of hospital and other health services and allowed healthcare cost savings to be made. Completed: April 2016.


Evaluating the predictive strength of the LACE index at identifying patients at high-risk of readmission to hospital following an inpatient episode.

Lead: Dr Sarah Damery, University of Birmingham

Health & Social Care Partner Organisations: Sandwell and West Birmingham NHS Trust

This work aimed to identify effective ways to reduce rates of 30-day readmissions following a hospital stay by assessing whether a risk prediction tool (the 'LACE' tool) which uses information on patient length of stay, admission type, other health conditions and previous emergency admissions, can predict accurately whether or not a patient is likely to be readmitted to hospital after being discharged. Completed: March 2016


HECTOR - Heartlands Elderly Care, Trauma and Ongoing Recovery Project. A service-level evaluation of a pilot programme designed to improve outcomes for elderly patients sustaining trauma injuries.

Lead: Dr Sarah Flanagan, University of Birmingham

Health & Social Care Partner Organisations: Heart of England NHS Foundation Trust

HECTOR is a service level intervention designed to improve outcomes for older patients who are admitted to hospital with trauma injuries. The intervention is being undertaken at Birmingham Heartlands Hospital. Our involvement with the project was to undertake an evaluation to measure patient related outcomes (levels of complications, length of stay in hospital, where patients are discharged to). We also undertook interviews with staff to learn about their experiences of delivering the new intervention. Evaluation to be completed: September 2017.

Integrating emotional and psychological support into the end-stage renal disease pathway: use of mixed methods to identify the most effective support to meet patients’ lower-level needs

Lead: Study initially led by Francesca Taylor, University of Birmingham. Current study lead is Dr Sarah Damery, University of Birmingham

Health & Social Care Partner Organisations: University Hospital of North  Staffordshire NHS Trust; The Royal Wolverhampton NHS Trust; Heart of England NHS Trust; University Hospitals Coventry and Warwickshire

A 4-year programme of research designed and undertaken to support the lower level emotional and psychological needs of renal patients. Several stages of qualitative and quantitative research will be conducted among renal patients and clinicians. The findings will be used to develop an evidence-based framework for emotional and psychological support integrated into chronic kidney disease and end-stage renal disease pathways. Completion date: 2018.

Development and evaluation of a training package to test the assessment, treatment and referral of osteoarthritis (OA) related pain and mental health conditions in an enhanced chronic disease review in primary care (study 2)

Lead: Dr Emma Healey, Keele University

Health & Social Care Partner Organisations: Various primary care settings

Getting to hospital at a single stroke. A crash course for GP receptionists on the recognition and handling of acute stroke

Lead: Dr Elizabeth Bates, University of Birmingham

Health & Social Care Partner Organisations: Various primary care settings

A training project to help GP reception staff recognise stroke and TIA and to ensure patients reach appropriate care as quickly as possible. Findings from a previous study showed that for 20% of stroke patients in the West Midlands the first course of action is to telephone their GP when they realise that they may have the symptoms of a stroke. However, it was found that none of these patients were getting through for thrombolysis. Studies have shown that some delays occur after the patient has called their GP surgery. The median time to thrombolysis is 55 minutes after the onset of symptoms; however there is a delay in patients getting thrombolysed if they contacted primary care instead of calling for an ambulance. The project wanted to look in greater detail at this part of the pathway and what was happening when receptionists at GP surgeries took the call. The study used trained medical role players, posing as patients or relatives, to make telephone calls to GP practices in order to find out what is said during the call and how receptionists perform. Completion date: 2016.

An evidence synthesis to develop optimal management packages for patients with pain and mental health problems and comorbid long term conditions in primary care

Lead: Dr Clare Jinks, Keele University

Health & Social Care Partner Organisations: Various primary care settings

Improving primary care for people with long term conditions: integrated working between general practice and adult social work teams

Lead: Robin Millar, University of Birmingham

Health & Social Care Partner Organisations: Staffordshire County Council &Staffordshire CCG

This study was designed to better understand the relationship between GPs and social workers, and to develop interprofessional educational resources (a toolkit) that both professions can use to improve collaboration. The project involves general practices and linked adult social work teams. Separate focus groups were held for GPs and for the social work teams to find out their perception of each other’s professions; their experience of working together; and what would help them work better together. The findings were used to arrange an interprofessional educational event to try to embrace some of issues raised. The same focus groups were consulted after a 3-4 month period to determine whether there has been any improvement in collaborative working and to share with them the training resources that were developed. 

Evaluation of a programme to improve safety in care homes

Lead: Dr Sarah Damery, University of Birmingham

Most patient safety initiatives have focused on hospitals, and relatively little work has been undertaken in care homes, even though care home residents are an increasingly frail and elderly population for whom adverse safety events can quickly escalate into hospital attendance and admission. This study is designed to evaluate a safety programme being funded by the West Midlands Patient Safety Collaborative, in which 30 care homes in two CCG areas will participate in a programme to skill up staff in service improvement techniques. The aim of the programme is to reduce the incidence of harm and improve safety culture in the participating homes. Training and workshops will be combined with facilitation of groups of staff in individual care homes who will also be undertaking local improvement projects. The evaluation will continue for two years and will use mixed methods, combining quantitative assessment of changes in safety culture and hospital admissions with qualitative staff interviews, focus groups and four in-depth care home case studies. Start date, October 2016, completion date: 2018.

Improving safety in care homes: protocol for evaluation of the Walsall and Wolverhampton care home improvement programme

Evaluation of Supported Integrated Discharge at Heart of England Foundation Trust

Lead: Elaine O’Connell-Francischetto, University of Birmingham

Health & Social Care Partner Organisations: Staffordshire County Council &Staffordshire CCG

The aim of this study is to explore how the Heartlands Hospital integrated discharge service works, and to understand the experiences of staff, patients and informal/formal carers involved in the service. The work will have 3 main components, first the service will be mapped by conducting semi-structured interviews with staff involved in managing and delivering the service. Then, further semi-structured interviews will be conducted with staff to explore their experiences of the service. Finally semi-structured interviews will be conducted with patients and their informal/formal carers. This process will allow an in depth exploration of how the service works and potential barriers, whilst also exploring what users think of the service. This work is being undertaken as part of a CLAHRC-WM PhD.

Virtual clinics versus standard face-to-face appointments for liver transplant patients in routine hospital care: a pragmatic randomised evaluation of myVirtualClinic.

Lead: Elaine O’Connell-Francischetto, University of Birmingham

Health & Social Care Partner Organisations: University Hospitals Birmingham NHS Foundation Trust

University Hospitals Birmingham (UHB) are introducing virtual clinics for the follow-up care for liver transplant patients to reduce the need for patients to make unnecessary hospital visits. This study is in collaborating with colleagues at UHB to evaluate whether the virtual clinic improves patient satisfaction compared to standard face-to-face appointments for patients who have undergone a liver transplant. A randomised evaluation and embedded qualitative study will: (1) test the effectiveness of virtual clinics in terms of patient satisfaction; (2) evaluate the costs associated with virtual clinics compared to standard outpatient care; (3) explore experiences of the virtual clinics from the perspective of patients, carers and health professionals; and (4) assess whether a patient records portal can be used to collect study data.

A Randomised Controlled Trial to investigate the effectiveness of ThOracic Epidural and Paravertebral Blockade In reducing Chronic Post-Thoracotomy Pain – TOPIC Feasibility Study

Lead: Dr Sarah Flanagan, University of Birmingham

Health & Social Care Partner Organisations: Heart of England NHS Foundation Trust

Surgery through the side of the chest (thoracotomy) causes pain post-operatively with more than half of patients developing chronic post-thoracotomy pain (CPTP) which can last for months or years.

TOPIC aimed to investigate the feasibility of undertaking a randomised controlled trial to explore the clinical and cost effectiveness of using PVB (Paravertebral blockade), which is a type of pain relief method. It is one of two commonly used methods of pain relief, the other being TEB (Thoracic epidural blockade). There is some evidence that PVB can reduce the likelihood of longer term pain for patients undergoing a thoracotomy. This feasibility study sought to clarify aspects of the trial such as how many patients will consent to be randomised to PVB or TEB and what factors motivate, or become barriers for clinicians and patients to agree to be randomised. Completion date: Early 2016

The Impact of Giant Cell Arteritis (GCA) Study

Lead: Professor Christian Mallen, Keele University

The Joint Symptoms Questionnaire Study

Lead: Professor Christian Mallen, Keele University

Polymyalgia Rheumatica (PMR): a qualitative interview study of general practitioners

Lead: Professor Christian Mallen, Keele University

Survey of Physiotherapist INtervention with PMR patients (SPIN PMR)

Lead: Professor Christian Mallen, Keele University

Colchicine Or Naproxen Treatment for ACute gouT (CONTACT)

Lead: Dr Ed Roddy,, Keele University

Stratified Care for Patients with Sciatica and Suspected Sciatica in Primary Care: A randomised trial (the SCOPiC trial - SCiatica Outcomes in Primary Care)

Lead: Professor Nadine Foster, Keele University

Improving the Care of People with Long Term Conditions (ENHANCE)

Lead: Professor Christian Mallen, Keele University

Smart Rehabilitation at Home before and after Lung Surgery (Fit for Surgery)

Lead: Dr Sarah Flanagan, University of Birmingham

Health & Social Care Partner Organisations: Heart of England NHS Foundation Trust

5700 patients a year in the UK undergo major surgery to remove part of their lungs; primarily to cure cancer. A common post-operative complication is collapse or infection in the remaining lung. These complications are linked to increased risk of death, likelihood of admission into an intensive care unit and longer hospital stay. Furthermore, survivors of cancer have a range of physical, psychological, social, spiritual, and financial and information needs which are unmet. Avoidance of these complications and addressing unmet needs offers great benefits to patients. A comprehensive pulmonary rehabilitation programme (ROC- Shine 2010) of an out-patient based programme consisting of exercise training, self-management education, nutritional and smoking cessation support demonstrated improvement in complication and hospital readmission rates. Lack of immediate access to pulmonary rehabilitation programmes across the country has hampered spread. There is thus a need to develop a service that can be delivered immediately at the convenience and in control of the patient. Completion date: February 2017. Application for Programme grant to develop the work further submitted August 2017.

Evaluation of the Older Person's Assessment and Liaison service (OPAL)

Lead: Dr Kiran Rai, University of Birmingham

Health & Social Care Partner Organisations: University Hospitals Birmingham NHS Foundation Trust

Research has shown that comprehensive geriatric assessment for older adults admitted to hospital shows a significant improvement in the chances of a patient being alive and in their own home at up to a year after an emergency hospital admission if they receive co-ordinated specialist services. University Hospitals Birmingham have introduced a multidisciplinary geriatric assessment service for patients aged 70 years and over which operates at the point of hospital admission. The goal of the service, which includes consultant, nurse and therapist expertise, is to prevent admission for patients who do not need it. For those that are admitted to hospital, early and comprehensive assessment should positively influence their care and ensure their length of stay is shorter. CLAHRCWM collaborated with colleagues at UHB to undertake a qualitative evaluation of the service. Completed March 2017.

Discharge interventions for older patients leaving hospital: Protocol for a systematic meta-review.

Lead: Ms Elaine O’Connell Francischetto, University of Birmingham

There is an increased need for additional care and support services for the older population. Although there is a large evidence base focusing on discharge services and their impact on patients which shows some potential benefits, it is unclear what elements of discharge interventions could be most beneficial to older people. This meta-review aims to identify existing systematic reviews of discharge interventions for older people, evaluate the effective elements of discharge services for this patient group and identify areas where further work may still be needed. This work is being undertaken as part of a CLAHRCWM PhD project.

Published protocol

Introduction of a pharmacy and psychosocial intervention in care homes to limit the use of psychotropic medication to treat Behavioural and Psychological Symptoms of Dementia (BPSD) – a feasibility study

Lead: Dr Sarah Damery, University of Birmingham

Health & Social Care Partner Organisations: Birmingham and Solihull Mental Health Foundation Trust

This feasibility study assessed the effectiveness of a medication review for patients diagnosed with dementia in residential care homes to assess whether prescribing of anti-psychotic medication can be reduced. Completion date: December 2017.

Published Protocol

Modelling the effects of treatment frequency for home haemodialysis patients

Lead: Dr Gill Combes, University of Birmingham

Health & Social Care Partner Organisations: University of Birmingham

This work was undertaken for the Sheffield NIHT HTC for Devices for Dignity Collaborative. The aim of the project was to develop a cost effectiveness model for haemodialysis which is undertaken by patients at home more frequently than the standard prescription of 3 times per week. This study looked at the existing published data for patients doing: short daily haemodialysis, nocturnal haemodialysis, and haemodialysis on alternate days. It is hoped that the results of this project will provide evidence of cost effectiveness for a new model of haemodialysis delivery that may increase the independence and promote the dignity of patients, with a direct impact on their quality of life. Completed: 2015.

Feasibility of a brief weight management intervention embedded within routine health care consultations for the prevention of weight gain after renal transplant: RCT (PROMPT)

Lead: Dr Helen Paretti

Health & Social Care Partner Organisations: UoB, UHBFT, University of Oxford, CLAHRC Oxford

This is a randomised controlled trial investigating an intervention to prevent weight gain after a kidney transplant. The intervention will be embedded into routine follow up care after kidney transplantations so we are particularly interested in whether the intervention is practicable and acceptable to patients and doctors. Previous studies have shown that most people gain weight after a kidney transplant and this can affect how well the transplant works. Current guidelines suggest that kidney doctors should give advice to prevent weight gain, but this advice is often not given or it is inconsistent.

In this study participants will be randomised to receive usual care plus weight management advice and feedback on their progress at their outpatient appointments or usual care only. The aim will be to prevent weight gain over six months. Patients will be able to participate if they are over 18 years and just had a first kidney transplant. At the end of the study we will interviews doctors, dietitians and participants to get feedback on the study and hear their views about the weight management intervention. The information from this study will contribute to the development of a larger trial in the future. The study will be conducted at Queen Elizabeth Hospital, Birmingham.

Scoping review of systematic reviews and RCTs focusing on polypharmacy and inappropriate prescribing interventions

Lead: Ms Elaine O’Connell Francischetto, University of Birmingham

A scoping review to describe the current evidence base regarding interventions used to aid polypharmacy and inappropriate prescribing and identify potential gaps in the literature to inform future research.

A rapid scoping review of systematic overview methodologies and search strategy effectiveness

Leads: Ms Elaine O’Connell Francischetto and Dr Sarah Damery, University of Birmingham

A rapid scoping review summarising the methods used in recent systematic review of reviews and informing recommendations for future reviews.

Audit of current outpatient clinical care for liver patients and the need for improvement

Lead: Mrs Elaine O’Connell Francischetto, University of Birmingham

Health & Social Care Partner Organisations: University Hospitals, Birmingham NHS Foundation Trust

This work is being led by Elaine O’Connell Francischetto and Katherine Arndtz who are conducting an audit of outpatient care for pre and post-transplant patients. This audit will help understand liver transplant patients’ opinions of their current outpatient care, current costs, current levels of technology use and their views of having virtual consultations.

Themes in the NIHR CLAHRC West Midlands

  • Theme 1 – Maternity and Child Health
  • Theme 2 – Prevention and Early Intervention in Youth Mental Health
  • Theme 3 – Prevention and Detection of Diseases
  • Theme 4 – Chronic Diseases (Integrated and Holistic Care) 

This work is supported by two cross-cutting themes: 

  • Theme 5 - Implementation and Organisational Studies
  • Theme 6 - Research Methods

Find out more NIHR CLAHRC West Midlands

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