Supporting webinar to raise awareness about the use of Urgent Community Response services in south east London

Our Community and Care Home Programmes Team has been supporting South East London Integrated Care System (ICS) to increase awareness of Urgent Community Response services amongst care homes and telehealth (pendant alarm) services.

On 10 August 2023, Health Innovation Network supported South East London integrated care system colleagues to bring together over 60 staff drawn from care homes, telehealth services and London Ambulance Service at a webinar chaired by Helen Smith from south east London’s Community Provider Network.

The webinar featured presentations from each of the Urgent Community Response providers in south east London, namely Bromley Healthcare, Lewisham and Greenwich NHS Trust, Oxleas NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust.

Clinical case studies were used to demonstrate the wide range of conditions that the services can support.

A recording of the webinar and the presentations are available. Another webinar is planned to take place in November 2023.

Please also see here for South East London’s Urgent Community Response services booklet which gives contact details and further service information.

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The real impact remote monitoring has on care home residents and those who care for them

Project Manager at the Health Innovation Network Andrew Scott-Lee reflects on the learnings from an evaluation of more than 170 London care homes using remote monitoring.

The use of Remote Monitoring (RM) technology to monitor physical health conditions outside of hospital has increased rapidly in recent years, and in particular since the Covid pandemic. This growth in use has also been seen in care homes where the technology has been introduced to enable monitoring of residents’ health at home and to improve the chances of identifying deterioration quicker.

Our evaluation of the implementation of remote monitoring in 173 care homes across four London Integrated Care Systems in 2021 found that 73% of homes continued to use the equipment months after implementation. Many care home staff reported benefits to them, residents, and the wider healthcare system.

The report highlights the confidence that RM instils in care home staff, who are often not trained to the same level of nurses or doctors. Utilising the physical health monitoring kit, baseline health data is collected, and guidance is available so that appropriate action can be taken when readings change. Training in use of the technology empowers staff to interpret observation readings and communicate effectively, confidently and in a clinically appropriate way with GPs, urgent care, and ambulance services.

I was able to explore in detail the approach that South West London (SWL) Integrated Care System took to implement RM in care homes, by undertaking a series of interviews with staff who led the digital transformation, and care home managers. The experience of these staff is described in this report.

You can see from the report that SWL’s Integrated Care System has made impressive progress in implementing digital transformation in care homes. My conversations with staff also highlighted the challenges faced by the care home sector in general in making the transition to digital ways of working.

Prior to the pandemic, many care homes predominantly used paper-based approaches for tracking and monitoring resident care, so the transition to digital monitoring requires - for some - a change in mindset. Care homes continue to experience high staff turnover rates, making it difficult to embed change. The amount of training and on-going support for digital transition may vary across different geographies, which impacts a home’s ability to sustain a digital transition once they have begun the journey.

Despite challenges, the commitment of care home staff to do what is best for their residents dominates. Although RM remains in its early stages of adoption in care homes overall, care home staff and GPs recognise its value.

Further evaluation may demonstrate that more consistent early identification of deterioration could result in fewer 999 calls and ambulance conveyances from care homes, and shorter, more appropriate hospital attendances and admissions.

Technological advances offer the potential for health and care services to work even better together to ensure that care home residents receive the right care, in the right place and at the right time, and services are used as efficiently as possible.

This can only be good news for care home residents, and the people who support them.

Download the report

Find out more about the impact of remote monitoring in care homes in our full evaluation report.

Download here

Applications open for HIN and My Home Life’s Care Home Pioneer Programme 2023 Cohort 5

The Health Innovation Network (HIN) and My Home Life England are delighted to announce the fifth South London Care Home Pioneer Programme – a leadership support and professional development programme delivered free of charge to Care Home Managers, Deputies and Senior Nurses to advance their skills, facilitate personal growth and enable them to effectively manage the complex everyday issues that impact on the quality of their service.

The programme is now open for applications from care home managers, deputies, and senior nurses, working in the following settings: older person’s residential homes, older person’s nursing homes, learning disability and mental health care settings, and supported living settings, in south London.

Did you know?

  • Since 2017, 84 managers from 77 care homes in South London have participated in the programme.
  • The Pioneer programme has had representatives from all the South London boroughs.

The Pioneers programme is a collaboration between My Home Life England and the Health Innovation Network, which has delivered leadership development to 84 care home managers across South London, over 4 cohorts since 2017.

The Care Home Pioneer Programme uses Action Learning techniques, involving experiential learning through a continuous process of action, learning and reflection, supported by colleagues, with an intention of improving practice. The Pioneers will work alongside mentors from the HIN to deliver a real-world service improvement project in their care home. Previous Pioneer projects have led to significant improvements in local priority areas such as falls reduction or oral health.

The free programme is jointly funded by care home commissioners and the NHS and will consist of a combination of four face-to-face workshops and nine monthly action learning sets, both virtual and in-person. At the end of the programme, there will be a celebration day to celebrate all that has been achieved.

If you are interested and want to know more about the programme, click the link here to read the flyer and apply.

This infographic highlights key feedback from Pioneers who took part in the programme in 2022.

Table Reads; 2022 Pioneer Programme post-programme survey  Cohort 4’s Pioneer Care Home Leader’s completed surveys following their Celebration Event. This infographic details high level overview of their feedback. *,	92% of respondents stated that… Their sense of achievement had improved 	92% of respondents stated that… Their understanding of how to improve the culture of care had improved, 92% of respondents stated that… Their quality of management and leadership had improved,	92% of respondents stated that… Their confidence as professionals had improved,	92% of respondents state that… The quality of their engagement with staff had improved, My Home Life England and HIN logos,	*Based on 12 respondents

Pioneer, Cohort 4, Care Home Pioneers, said: “The Health Innovation Network and the support from My Home Life England team has boosted my confidence, skills, and knowledge in working jointly with the multidisciplinary team. The forum that was held has empowered me to exercise the duty of care and leadership while supporting a positive professional working relationship. I aim to maintain the good practice and to continue to grow and develop together with my team..”

Andrea Carter, Programme Director, Healthy Ageing Team, Health Innovation Network, said: “The resilience and kindness of this particular group shone through and will stay with me for a long time, even after 27 years working in health and social care.”

You can find some great examples of Pioneer projects that have been carried out by clicking on the following here or alternatively watching the video below.

Further information

Find out more about the programme and how to apply.


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Get in touch for more information about Cohort 5 of the Care Home Pioneers programme.

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Investing in our Care Home Leaders

Cohort 4 of the Care Home Pioneers programme


Post Title

The Care Home Pioneers programme is a leadership support and professional development programme for care home leaders in south London. To date, we have supported over 70 care home managers, nurses and senior deputies on the programme, facilitating their personal growth in order to deal with the complexities of care home life.

On 7 December, the Health Innovation Network welcomed participants from the latest cohort of the programme to their graduation ceremony. The day celebrated all the Pioneers’ achievements over the course of the programme. Andrea Carter, the Healthy Ageing team’s Programme Director, reflects on the day and the importance of supporting the professional development of care home leaders.  

Inspiring, humbling, innovative.

These were the one-word descriptions given by participants and stakeholders at a recent celebration which concluded a leadership development programme for care home managers.

Care home managers became all of our heroes during the pandemic. Nightly news coverage described the challenges they faced trying to safeguard their residents, while implementing policy decisions which changed weekly, if not daily.

Over the past nine months, the Health Innovation Network, in partnership with My Home Life, has supported over 30 ‘Care Home Pioneers’ – managers leading care homes in south London. This is part of our wider programme of collaborative learning opportunities, designed to support our health and care workforce in developing technical and leadership skills and real-world improvement projects.

During the programme, we witnessed emotionally bruised staff recovering, re-committing themselves to the challenge, and striving for improvement: for themselves and their residents. The resilience and kindness of this particular group shone through and will stay with me for a long time, even after 27 years working in health and social care.

At the end of the programme the Pioneers shared their experiences and described their needs going forward.

Many described their gratitude for the ‘safe space’ that the programme provided, to discuss challenges, as well as develop creative solutions to common problems. A few explained how the programme had enabled them to secure promotion within the care home sector.

The resilience and kindness of this particular group shone through and will stay with me for a long time, even after 27 years working in health and social care. Andrea Carter, Programme Director, Healthy Ageing team

Innovation was evident. Quality Improvement projects delivered during the programme covered a breadth of topics, including how to escalate concerns to health service colleagues when residents became unwell, new ways of supporting residents to live well with dementia, and creative approaches to encourage residents to eat and drink well.

This poster presentation and video describe their achievements in more detail. Additionally, the South London Care Home Pioneer Programme 2022: Cohort 4 poster can be found here.

We’re all familiar with the extreme challenges of providing emergency care in the current climate. In London, recent data suggests that the number of care home residents represents 0.4 per cent of the population, yet accounts for around 4 per cent of ambulance conveyances and around 10 per cent of occupied hospital bed days.

Care home staff often tell us their residents do not wish to be taken to hospital, and it is vitally important that we get our escalation response right for residents, as well as for the wider system.

To achieve this, continued dialogue with care home leaders is vital. They understand the factors that come into play when determining how an unwell resident can receive the right care in the right place at the right time, including how to ensure their residents don’t suffer the indignity of death in an unfamiliar place.

Care home leaders need to be able to share their wisdom as true partners in delivering health and social care. Let’s not forget the knowledge amongst this group of leaders, and all strive to ensure that we embrace the opportunities afforded by Integrated Care Systems and Local Care Partnerships by properly engaging them in local debate.

HIN colleagues at the Care Home Pioneers graduation ceremony

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For more information about the 2023 Care Home Pioneer Programme, please get in touch.

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Using leadership development to improve the quality of care provided to people living with dementia


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With more people living with dementia, it’s important that care home leaders feel well equipped in supporting those living with it.  Dr Caroline Chill, the Clinical Director for the Healthy Ageing Programme at the Health Innovation Network (HIN), spoke at the 16th UK Dementia Congress in Birmingham on how we can use leadership development to improve care for people living with dementia.

At the HIN, helping develop skills of those working in the health and care systems is one of our top priorities. Our flagship programme aimed at professional development in the care sector is the South London Care Home Pioneers Leadership Programme, facilitated in partnership with My Home Life England. Having recently completed its fourth cohort, the programme has helped over 70 care home managers and senior staff across south London to develop their skills, share learning and become champions for improving dementia care in their local area.

Dr Chill used the presentation to explore the Service Improvement Projects, which Pioneers undertook as part of the programme within their homes, many of which focus on care home residents living with dementia. To celebrate the work that the senior care home staff have been doing, we interviewed, and filmed two Pioneers from care homes in Bromley: Natasha Leslie and Nicola Orme. Nicola focused on helping relatives understand more about dementia while Natasha explained how she had introduced activities to respond to ‘sundowning’ – a period of agitation commonly experienced by people living with dementia in the late afternoon.

Nicola found that families’ understanding of dementia had increased following her Service Improvement Project, scoring on average 3.0 on a pre-workshop questionnaire and 4.75 post-workshop. Natasha also reported residents felt more supported and engaged in activities, with fewer incidents in the care homes such as falls and behaviours of concern. This had a knock-on effect with fewer 999 and 111 calls. Both projects have made a difference in the quality of care for residents, as well as a reduction in complaints and improvement in relationships between residents, staff, and their families. You can watch the full interview below.

“Presenting at the 16th UK Dementia Congress was a great opportunity to showcase the achievements of care home staff and to demonstrate the importance and value of quality improvement work in care home settings.” Dr Caroline Chill, Clinical Director, Healthy Ageing, Health Innovation Network

More information on the programme

The South London Care Home Pioneers Programme is a leadership support and professional development programme delivered to Care Home Managers, Deputies, and Senior Nurses to advance their skills, facilitate personal growth and help them manage the complex everyday issues that impact on the quality of their service. The programme consists of a combination of four workshops, three which cover the managing of self, others, and change, and one service improvement workshop. Additionally, participants on the programme undergo nine monthly action learning sets, which involve experiential learning through a continuous process of action and reflection, supported by colleagues. The Pioneers on the programme also benefit from working alongside mentors from the HIN, who provide support to deliver a service improvement project within their care homes.

If you would like to learn more about dementia, and understand how it affects the brain and memories, take a look at this video from Dementia UK. Alternatively, if you are interested in learning more about the Care Home Pioneer Programme and how it can support leaders to deal with the complexities of dementia, please get in touch.

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If you would like to find out more on the Care Home Pioneers programme and our work supporting people living with dementia, please get in touch.

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Applications open for HIN and My Home Life’s Care Home Pioneer Programme 2022

The Health Innovation Network and My Home Life are delighted to announce the fourth Care Home Pioneer Programme – a  leadership support and professional development programme delivered FREE of charge to Care Home Managers, Deputies, and Senior Nurses to advance their skills, facilitate personal growth and enable them to effectively manage the complex everyday issues that impact on the quality of their service.

Did you know?

  • Since the programme started in 2017, 23 managers have attended from South East London and 21 from South West London
  • The Pioneer programme has had representatives from all of the South London boroughs

The ‘Pioneers’ programme is a collaboration between My Home Life England and Health Innovation Network, which has delivered leadership development to 44 care home managers across South London, over 3 cohorts since 2017.

The Care Home Pioneer Programme will use Action Learning techniques which involve experiential learning through a continuous process of action, learning and reflection, supported by colleagues, with an intention of improving practice. The Pioneers will also work alongside mentors from the HIN to deliver a service improvement project within their care homes, such as reducing falls or improving oral health.

The FREE programme is jointly funded by care home commissioners and the NHS, and will consist of a combination of four workshops and nine monthly action learning sets. At the end of the programme, there will be a graduation day to celebrate all that has been achieved and to welcome you into the Pioneer Alumni. 

This infographic highlights key feedback from Pioneers who took part in the programme from 2020-2021.

Pioneer, Cohort 3, Care Home Pioneers, said: It’s not a training programme. We are learning from one another. The impact of it has given me a huge amount of confidence to deal with things differently.”

Pioneer, Cohort 3, Care Home Pioneers, said: “I have introduced daily team meeting with the nurses which has helped to boost self-esteem as they are able to discuss any difficulties they may have in their work”

George Croft, Healthy Ageing Project Support Officer, Health Innovation Network, said: “The feedback from the Pioneers shows that the programme has played an important role in supporting care home managers during the toughest times that the sector has faced in its history, arming leaders with an array of skills and confidence to engage with wider clinical services to help keep residents safe.”

Further information

Find out more about the programme and how to apply.


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Keeping older people safe: why London is focusing on remote monitoring in care homes

Most people living in care homes are over the age of 80, have multiple long-term health conditions and are affected by physical disability and cognitive impairment. Our Head of Healthy Ageing Fay Sibley, who is leading on the NHSX Innovation Collaborative for London, sets out here why remote monitoring in care homes is so important for this vulnerable population.

The Covid-19 pandemic raised a new set of challenges for care home staff and their residents, including accessing healthcare services remotely, caring for residents with complex health needs and providing palliative care for residents, often without the face-to-face support from healthcare services they would normally receive. Care homes also face significant workforce challenges with many staff off sick, self-isolating due to Covid-19 or unable to work due to fear and anxiety for their own safety. In the England, residents of care homes for older people have been particularly affected by Covid-19 and have made up 39 per cent of all Covid-related deaths[i].

Most people living in care homes are over the age of 80, have multiple long-term health conditions and are affected by physical disability and cognitive impairment[ii]. These factors explain, in part, the vulnerability of older people living in care homes to Covid-19, and why there has been an increased focus from the NHS to support care homes over the last nine months, with several initiatives concentrating on improving quality and efficiency. However, many of these require vastly improved IT systems and technological solutions, further complicated by the variety in size, digital maturity and type of care provided by care homes.

If local authorities and CCGs are aware of these differences, they can better target support and interventions to London care homes so they:

  • have the right Wi-Fi and infrastructure so they can access a range of digital products and solutions for care and wellbeing;
  • can communicate sensitive care information safely, securely and in a timely way so care decisions can be jointly made while residents’ privacy and security are protected;
  • can access and share care documentation and management, meaning staff from different organisations work together to develop a shared plan and each resident experiences joined up care without needing to repeat themselves if they change location;
  • plan and manage care electronically, so that care provision is recorded and stored, and productivity is improved;
  • have staff with the skills and confidence to use digital tools to access remote health care support for their residents and themselves; and
  • undertake virtual consultations and remotely monitor the health of residents, so care can be provided where the residents are, care decisions are made at the earliest time possible and care is provided safely during the Covid-19 pandemic.

Remote monitoring is a fantastic opportunity for care homes to improve care. This is where hardware and a digital platform allows care home staff to take, record and monitor vital signs of care home residents. This information is then stored on a digital platform, which can be accessed by healthcare professionals, such as the GP. Having access to clinical information such as temperature, heart rate and blood pressure allows care homes to spot signs that a resident is becoming unwell early and share their concerns with healthcare professionals. Care home staff, in partnership with clinical staff, can then plan and prioritise care accordingly.

In partnership with the seven regions of the NHS in England, NHSX is pioneering a new Innovation Collaborative to (1) build on the digital health gains achieved during the pandemic, (2) accelerate the scale of those digital innovations that enable a redesigned outpatient and remote care service and (3) help save staff time. For the reasons outlined above, all five of London’s sustainability and transformation partnerships (also known as integrated care systems in some areas) have committed to work collaboratively to support the increased use of remote monitoring technology in care homes.

The London region is currently working with six remote monitoring companies to implement remote monitoring in approximately 600 care homes, supporting 21,000 older people to remain well in their own homes. Our collaborative will look at different methods and products for implementing and supporting remote monitoring and allow learning and best practice from each method to be shared across London.  This will improve the care of not just current but future care home residents, some of our most vulnerable members of society.





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If you’re interested in finding out more you can contact the London Innovation Collaborative programme lead Fay Sibley.

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Thousands of Londoners to benefit from digital urgent care plans

The back of an open ambulance

Shared digital care records mean care home staff, paramedics and hospital emergency department staff know patients’ health and care wishes.

The stats

Over 115,000 Londoners already have a digital urgent care record

Thousands of Londoners will have a greater say over their care and treatment under a £200,000 drive to increase the use of a shared urgent digital care record for ambulances, emergency departments and other urgent care services.

The NHS’s Health Innovation Network (HIN) has won funding to roll out Coordinate My Care (CMC), which ensures health and social care professionals have access to patients’ urgent care plans. Covid-19 has brought into sharp focus the need for patients to set out how they want to be cared for with many preferring to stay at home rather than go into hospital.

Gloria Goldring created her own CMC care plan after a stressful end of life experience when her husband David was critically ill at a care home. He suffered from dementia and despite both agreeing that he did not wish to be resuscitated in a critical emergency, Gloria was told by paramedics that without paperwork to prove his end of life wishes, they would resuscitate David in the ambulance if needed.

“It was a big shock to me because this was something David and I had discussed many years ago and I just felt completely at a loss’, said Gloria Goldring.

Fortunately the trip to the hospital was just five minutes, David did not deteriorate and after Gloria explained to hospital staff that David had said he did not want to be resuscitated, this wish was accepted.

“So when CMC was introduced as a way to be able to flag this up I thought this was absolutely essential for people to understand. I think there is no doubt if we had a plan it would have been flagged up. This would have lessened the stress that I was under because I was in a very terrible state.”

Having already supported over 115,000 Londoners to date, a Coordinate My Care plan puts the patient at the heart of planning their future medical care. The care plan is designed to share the most important, up to date clinical information about the patient, including who to contact in an emergency. This information is then shared with all the health and social care professionals involved in treating them, such as 111, out-of-hours GPs, the London Ambulance Service and hospital emergency departments.

“Helping patients across London to better express their wishes about their care is very important at this time. We are extremely pleased to have this opportunity to work with Coordinate My Care and our NHS and care system colleagues to not only improve the quality of digital urgent care records but speed up the adoption and spread of this technology. ”Zoe Lelliott, Chief Executive of the HIN

The HIN will work closely with NHS and care system colleagues across London to identify a project in each of the five Sustainability and Transformation Partnerships (STP) areas to accelerate the adoption of CMC to match local priorities and address local opportunities. The scheme will fund local clinicians to focus on championing CMC with their peers and clinical colleagues and help to embed CMC in local care pathways and processes.

Zoe Lelliott, Chief Executive of the HIN, said:
”Helping patients across London to better express their wishes about their care is very important at this time. We are extremely pleased to have this opportunity to work with Coordinate My Care and our NHS and care system colleagues to not only improve the quality of digital urgent care records but speed up the adoption and spread of this technology.

“HIN seeks to speed up spread and adoption, so where innovations like digital urgent care records have been shown to be effective, we believe that it’s important to work with our NHS and care colleagues to adopt this technology to better meet patients’ needs.”

Professor Julia Riley, Founder and Clinical Lead for Coordinate My Care, said:
“As the coronavirus pandemic continues, we are hearing that many patients and families are talking about difficult futures, challenging decisions and appropriate treatments. This partnership with the Health Innovation Network means that health care services across the community will be supported to encourage increasing numbers of patients to have a digital CMC record, to ensure their wishes are recorded, to better their outcomes and to support the urgent care services.”

Find out more about our work with CMC

See the webpage for more on CMC

Click here to see the webpage.

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Get in touch with our Healthy Ageing team.

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New online video training for care home staff

New training video supports care home staff to detect deterioration

Wessex and the West of England Academic Health Science Networks (AHSNs), funded by Health Education England, have collaborated to produce a series of free videos and e-learning materials to support staff working in care homes to care for residents who are at risk of deterioration.

As recognised in a recent paper supported by North East and North Cumbria AHSN, identifying acute illness including sepsis amongst older adults in care homes can be difficult and opportunities to initiate appropriate care may be missed, if illness is not recognised promptly.

The short videos describe how to take measurements from residents correctly (such as blood pressure and oxygen saturation), spot the signs of deterioration, and prevent the spread of infection.

You can also access the films as part of the full training on Health Education England’s e-Learning for Healthcare (e-LfH) Hub (, an educational web-based platform that provides quality assured online training content for the UK’s health and care workforce, from this link.

Natasha Swinscoe, national lead for patient safety for the AHSN Network said:

‘Patient safety is a guiding principle for all AHSNs. Our care homes report highlighted numerous successes that AHSNs have had working with care homes across the country. Collectively, these have the potential to save many lives and tens of millions of pounds.’

Guidance for care home staff to register for an account

To register for e-Learning for Healthcare, visit

Select the ‘Register’ button. Select the option ‘I am a care home or hospice worker’ then enter your care home / hospice name or postcode and select it from the options available in the drop-down list. Finally enter your care home / hospice registration code and select ‘Register’. You may need to see your employer to get this code.

If your employer does not have a code, then they need to contact the e-LfH Support Team. The Support Team can either give the employer the registration code or arrange a bulk upload of all staff here.

Detailed instructions on how to gain access are available here and a quick start guide to the e-LfH hub available here.

Guidance for Care Homes: Suspected Coronavirus Care Pathway

Guidance for Care Homes: Suspected Coronavirus Care Pathway

The NHS London Out of Hospital Cell, London Clinical Networks, London Directors of Public Health and Adult Social Care, Health Innovation Network and Public Health England have collaborated to provide resources to assist the care and support vulnerable adults receive during Covid-19. 

The practical guidance has been designed to complement, not replace, local guidance and professional judgement. We are actively working on other resources which will be updated to align to national and regional guidelines once published. 


Advice to Care Homes on Covid-19, please click here.

Care Home resource pack, please click here.

Guide for care homes on saying “goodbye”, please click here.

If you have further questions relating to the above resources, please contact the London Clinical Networks in the first instance by emailing 

Volunteer Support for Care Homes and Care Home Staff now available

Volunteer Support for Care Homes and Care Home Staff now available

A new organisation of volunteer health and care students has offered support to care homes and care home staff through a HIN pilot scheme.

HealthSHIP (Health Students Helping in Pandemics) are mostly health students (i.e. nursing, physio, occupational therapy, medical) with valid DBS certificates, and free time on their hands who are keen to support NHS and social care staff with everyday needs (errands, childcare, pet care, grocery shopping, admin, non-clinical tasks, etc). The scheme is nationwide – it’s free, quick and easy, representing 87 universities and over 1,100 users.

HealthSHIP are keen to support Care Home Pioneer staff with any shopping, errands or help for their own families. In addition, care homes wanting volunteers to volunteer in their care homes can also request help – local medical students will volunteer to support if they can. The Health Innovation Network is helping to coordinate this pilot.

To register for the scheme, care home managers should:

1) Make an account for your care home on with your email and post tasks/roles you need help with. This would then prompt medical student volunteers to respond to the requests and then become volunteers of the care homes / care home staff.

2. Distribute the HealthSHIP website to your care home staff members who can sign up in a personal capacity and request help for their personal lives. You will need to email HealthSHIP with the personal email addresses of care home staff who want to register, so they can be verified.

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Maintaining Activities for Older Adults during Covid-19

Maintaining activities for Older Adults during Covid-19

Click here to watch the YouTube video to understand the needs of people living with dementia during the Covid-19 pandemic. The Activities Guide below will signpost you to excellent activities suitable for such population.

This guide to online resources for those providing care for people with dementia, is a resource that Health Innovation Network has compiled in collaboration with CHAIN members.

Activities for Older Adults During Covid-19 – aims to support the provision of free to use dementia friendly activities for older adult’s in mental health inpatient settings, Care Homes, supported housing and to those living in their own homes during the national response to Covid-19. You can download using the link below. Please share this guide with your colleagues and other relevant organisations.


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A tale of my grandfathers and the revolution in cardiovascular disease prevention

A tale of my grandfathers and the revolution in cardiovascular disease prevention

Laura Semple, Programme Director for Diabetes & Stroke Prevention at Health Innovation Network, reflects on how new prevention techniques might have changed her grandparents’ lives.

I’ve often wished I’d had the chance to meet my grandfathers, Gerry and David. They were both fascinating and spirited people, who led interesting lives. Gerry travelled the world, had a successful career in industry and loved fishing for trout in the Welsh countryside. David worked in finance for London Transport and enjoyed vintage cars.

Sadly, I didn’t get to meet them because, like many people of their generation, they died too soon from cardiovascular disease in the 1970s and early 1980s.

This part of my family history is far from unique. It’s also a big reason why I find it so rewarding to be part of the movement of committed people working to prevent cardiovascular deaths in this country. February is National Heart Month and I’m thoughtful about the real progress that we’re seeing in south London in this area.

One of the main drivers of cardiovascular disease in the UK that Gerry and David grew up in was a lack of understanding around the impact of certain foods and other lifestyle aspects on heart health. It was very common to eat a high fat diet and the true scale of tobacco-related harm was not yet understood. But since the 1970s we have gained a rich understanding of the impacts of diet, exercise, tobacco and medication on heart health.

What’s more, we now have risk models, which enable us to accurately predict how likely it is that someone will have a heart attack or stroke in the next 10 years, simply by knowing their BMI, blood pressure, cholesterol and blood glucose measurements today.

This all makes me wonder just how different it could have been for Gerry and David. Not only are we now able to offer preventative care that extends lives, but crucially these are also improving the quality of those lives.

At its core, most of our work is really about giving Londoners the support they need to live full lives without the burden of diabetes and cardiovascular disease.

The first success to highlight on the prevention front is south London’s contribution to the Academic Health Science Network’s national stroke prevention programme.

Atrial Fibrillation (AF) is one of the most common types of irregular heart rhythm and contributes to one in five strokes. If Gerry and David had been born 20 years later, there’s a good chance that they could have been two of the more than 4,500 additional south Londoners whose AF has been newly detected since 2017.

The latest national stroke audit data shows that in the two years to March 2019 there were approximately 150 fewer AF-related strokes in south London than would have been expected from the previous years’ data. This is 150 Gerrys, Davids, Simones, Ritas, Mohammeds, and many others, who are still thriving as a result. We’ve recently published the results of our innovative work in improving AF detection through mobile ECG devices here and an ongoing pilot of 14-day ECG patches on page 12 of Cardiac Rhythm News January 2020 here.

Then there’s diabetes.

This is a major driver of cardiovascular disease and it’s simply astonishing how much our experience and understanding has transformed since Gerry and David were alive. Back in the 1960s and 1970s, we were not as good at detecting type 2 diabetes, so some people lived with the condition for many years without a diagnosis, which in itself increased their risk of preventable ill health.

In general, there was far less freedom and choice for people with diabetes in how they lived their lives, with many being told to stick to rigid set diets.

But in 2020, we believe in giving people with diabetes as much freedom as possible to live the lives they want, without diabetes getting in the way. South London has a formidable partnership of colleagues committed to minimising the impact of diabetes on citizens’ lives. Together we represent 12 clinical commissioning groups, 12 local authorities, seven acute hospitals, two universities, the King’s Health Partners Institute of Diabetes, Endocrinology and Obesity, the Applied Research Collaborative, several industry partners and community organisations like the Wandsworth Community Empowerment Network The last two years has seen a major focus on type 2 diabetes prevention, with over 30,000 south Londoners referred to the NHS.

I’m curious as to what Gerry, David and their friends might have chosen if they had had access to Diabetes Book & Learn, a radical move to scrap the previous postcode lottery of self-management support for people with diabetes. In this new system, south Londoners are learning how to live well with diabetes at a time and place that works for them in their busy lives, with different languages, digital options, evening and weekend courses and telephone coaching all available.

Would Gerry and David’s employers have supported their access to diabetes education through the learnings of our Think Diabetes report?

People with type 2 diabetes are also increasingly taking charge and setting the agenda for their doctors and nurses in the innovative You & Type 2 programme in primary care.

Would Gerry and David’s employers have supported their access to diabetes education through the learnings of our Think Diabetes report? This was supported by former Labour Party deputy leader Tom Watson. Many forward-thinking employers are using the recommendations in this report to offer support directly in the workplace.

At its core, most of our work is really about giving Londoners the support they need to live full lives without the burden of diabetes and cardiovascular disease. Healthy living is far from easy. People need holistic and non-judgemental support and this is why the offer of psychological support is built into Diabetes Book & Learn and many other new services.

There is a great deal more to do to prevent cardiovascular disease and exciting plans are afoot to do even more to tackle the longstanding health inequalities in our region. For now, I’m asking everyone who has played a role in the great progress so far to take a moment this heart month to remember the strides we have made together and renew our energy to take this to the next level.

If you are keen to join the fantastic team of people saving lives by preventing cardiovascular disease in south London please visit our webpages on diabetes and cardiovascular.  Alternatively, get in touch with me on This year we will be focussing on cholesterol and blood pressure as well as continuing to support our members with AF detection and improvements in diabetes care. The more collaborators we have, the more lives we can save.

I know that Gerry and David would be only too happy to see that things are different and getting even better, for the generations who came after them.

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NB: Gerry and David are not the grandfathers’ real names.

‘Travel to learn, return to inspire’

‘Travel to learn, return to inspire’

Health Innovation Network’s Director of Operations, Rebecca Jarvis, is currently in Japan as part of her Churchill Fellowship exploring alternatives to care homes for older people.

Earlier this year, I was awarded a Churchill Fellowship to explore alternatives to long term institutional care for older people. I specifically chose to focus my research on this area because we have an ageing population in the UK with increasing demand on care services. Most people say they would not want to live in a care home when they become very old but they do not consider what the alternative could be, let alone actively plan for it. They carry on living in their own home which is maybe bigger than they need, but full of memories which are hard to let go of. And then crisis hits – a bad fall, or a partner dying and suddenly they can’t manage on their own, or make it to the upstairs loo, and then what? The hospital is desperate to free up the bed for the next patient, families and friends cannot provide around the clock care and suddenly there is pressure to move into a care home.

I selected Japan and New Zealand the two destinations for my Fellowship as Japan is a super-ageing society with 28 per cent of the population aged over 65, expected to rise to 38 per cent by 2015. Since the introduction of the long-term care insurance system in 2000, a range of community based alternatives to institutional care have been developed. New Zealand has a well-developed retirement village sector with some of the most advanced regulation and legislation in the world.

But this is not all about us learning from Japan. When we hosted a delegation from the International Longevity Centre (ILC) in Japan in August this year we were able to reciprocate the learning and used it as an opportunity to showcase some of the great initiatives underway in south London to support older people to remain physically and mentally active. The delegation was particularly interested in visiting reablement services, such as the Bexley reablement team where they have demonstrated particularly impressive outcomes in terms of reducing risk of frailty, and the Nelson Health Centre in Merton where the HARI (Holistic Assessment, Rapid Investigation) team of nurses, physiotherapists, occupational therapists and pharmacists help people recover from falls and other injuries / illnesses, reducing the number of hospital visits by an impressive 50% in their pilot year alone. When it was my turn to be hosted by the ILC as part of my visit to Japan, it felt like meeting up with old friends.

On the surface, we might seem like two very different countries, but when you reflect more closely the UK and Japan actually have more in common than we think. Geographically, both are ‘island countries’ on the edge of a large continental landmass. Politically, both have constitutional monarchies and both have a closer relationship with the USA than their European or Asian neighbours. And population-wise, both countries are ageing societies which, although this is more acutely observed in Japan, means that both countries are facing significant pressures on their health and care systems.

Japan is also experiencing a declining birth rate which is resulting in what they call a ‘piggy back’ situation; essentially meaning that where previously there have been two working age adults to support one older person, there will soon only be one working age adult to support one older person, meaning economically it is more crucial than ever before to ensure that the right provisions are being put in place accommodate for this.

Whilst the problems are similar in both countries, we are tackling them in different ways. For example, the Japanese health and care system has yet to make use of social prescribing, something that has increased in popularity in the UK as a way of addressing the ‘non health’ needs that were often raised by patients when they went to their GP. This was something our Japanese delegates were especially keen to hear about. Also, unlike the UK, the voluntary sector is very different in Japan and they don’t have large national charities providing services and support. A talk by Bexley councillors, commissioners, and people working for the Bexley voluntary service council, explained to the delegation from Japan about the massive impact that even a small charity could have in terms of the support it provides to vulnerable people.

Instead, Japan has the Long Term Care insurance system, introduced in 2000, and which everyone pays into from the age of 40 and as such a range of different models of community based care have been funded to support people in he own homes and communities. I have been fortunate enough to witness some of these initiatives first hand, such as the Silverwood Ginmokusei in Chiba Prefecture, the closest I’ve seen to a true alternative to a residential care home, providing accommodation for older people, many of whom have dementia and care needs, centred around a community space and an appealing restaurant, literally jutting out into the community. Residents work in the restaurant and sweet shop, and members of the community regularly drop by for lunch and the primary school kids drop in after school on their way home.

I also visited what is described as a small-scale multifunctional nursing home called Okagami in Kanagawa Prefecture. It provides support for people who have care and nursing needs but want to keep on living in their own homes. The facility looks like a family home in a residential area. There are six small rooms around a communal area. The clients can receive a range of support from a short stay in one of the six rooms, taking part in a group activity at the day centre, using the bath or receiving care and nursing support at home. The real benefit of this kind of facility is the flexibility it brings. Some people register as clients but only use the home care service or day care service. One client is over 90 and wants to continue living on her own in her own home, but she feels a bit nervous about it, so stays overnight at the centre from Monday to Friday and goes home at weekends. Many people use this facility as a safety net. It’s there for them in case they need it and it can respond flexibly to their needs. I didn’t imagine that I would see something that could support people with such severe care and nursing needs to continue to live in their own homes. There is no doubt that if it wasn’t for Okagami, many of these people would need to be in a care home.

There are many similarities in our approach as well. Professor Yoko Matsuoka from Kasei University in Tokyo eloquently described the paradigm shift in thinking in both countries, as moving from an approach of ‘doing for’ and ‘providing services’, to ‘doing with’ and generating solutions with the community. Both countries understand that older people themselves have a wealth of experience and skills which can they can contribute to support people to age well.

It is really fascinating learning about the Japanese health and care system, and how they are not only coping with, but embracing their “super ageing” population. Next week I will be leaving Japan for New Zealand to start the second leg of my Fellowship, which has one of the highest proportions of older people living in retirement communities in the world. I am particularly interested in why New Zealanders choose to move into a retirement village community and what their expectations are of these initiatives.

The Churchill Fellowship slogan is ‘travel to learn, return to inspire’. I am learning so much about alternatives to long term institutional care for older people on my travels and am looking forward to sharing what I’ve learn when I get back. It would be fantastic if we could adopt some of these good ideas from overseas in south London. After all, as an Academic Health Science Network, we are in a good position to try something new.

Read more about Rebecca’s experiences in Japan and New Zealand by signing up to her blog.

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The new GP contract didn’t mention innovation once. Yet the space it opens up for innovation is exciting, and we should seize it

The new GP contract didn’t mention innovation once. Yet the space it opens up for innovation is exciting, and we should seize it

Dr Caroline Chill, Clinical Director for Healthy Ageing at Health Innovation Network looks at the potential of the new contract to support innovation.

I’ve worked in primary care for over 30 years, and have been involved in leadership and innovation for most of them. GPs have a history of being innovative with the early coded electronic health record systems being a prime example. In recent years, it has felt like this innovation has been stifled by increasing workload, staffing pressures and ever changing contractual requirements. I’ve seen innovation talked about in countless different ways and these days it seems to me that policy makers are falling over themselves to describe initiatives as ‘innovative’ or to talk about the potential to improve care through innovation but with less commitment to support the delivery of innovation in practice. So, I was fascinated to see how this would be expressed in our new GP contract which to my surprise did not mention the word ‘innovation’ at all. Not a single mention, despite the contract being extremely innovative.

An obvious area relates to support for Primary Care Networks and additional staffing. The aim of Primary Care Networks is to connect the primary care teams to help deliver more integrated and comprehensive local services, to allow new models of care to emerge and to support higher levels of self-care. From 1July, 1,259 Primary Care Networks become operational and backed by nearly £1.8 billion funding over five years with most of England’s nearly 7,000 GP practices participating.

Additionally, the interim NHS workforce plan and dubbed the “People Plan” was published in June.  This focuses on three key areas – recruiting more staff; making the NHS a great place to work; and equipping the NHS to meet the challenges of 21st century healthcare.  It re commits the government to delivering 5,000 full time equivalent GPs “as soon as possible” as well as nearly 6,000 extra nurses, and the creation of “nursing associates” offering a career route from care support into registered nursing.

The GP contract acknowledges the fact that the additional staff we need in general practice will not come from doctors and nurses alone. The money available through the contract can be used to help recruit a much broader range of professionals – Initially the scheme will meet 70% of the costs of additional clinical pharmacists, physician associates, first contact physiotherapists, and first contact community paramedics; and 100% of the costs of additional social prescribing link workers.

I think it will be down to the primary care networks to find innovative ways to recruit, train, support, mentor and part fund these new roles. This is no simple task as the existing training and skills of these professionals will need to be strengthened and adapted for working in community settings, where there is less supervision and where patients need holistic care, encompassing multiple physical, social and psychological issues.

I believe GPs will rise to this challenge and seize the opportunity. . It could be the beginning of a new, more modern and holistic way for patients to experience general practice.

Increasing the numbers of physiotherapists and other community-trained staff could lead to another important shift. Take MSK as an example which includes chronic knee, hip and back pain, has a major impact on an individual’s quality of life and society. It is the second most common reason for GP visits, accounts for around 25% of all GP consultations and is estimated that 9.3 million working days are lost in the UK to MSK problems.

An intervention that relieves chronic joint pain, called Joint Pain Advice , already exists and can be delivered by a wide range of professionals and lead to lasting improvements in pain. The model focuses on reducing reliance on painkillers through exercise and education. Trained professionals, who could be physiotherapists, community health trainers, or others provide a series of face-to-face consultations, working collaboratively with people with hip and/or knee osteoarthritis and/or back pain, focusing on supporting self-management. The programme consists of up to four 30-minute face-to-face consultations between the advisors and people with hip or knee osteoarthritis (OA) or back pain. Patients attend an assessment where they discuss their lifestyle, challenges and personal goals and then jointly develop a personalised care plan that gives tailored advice and support based on NICE guidelines for the management of OA. They are then invited to attend reviews after three weeks, six weeks and six months to access further tailored support and advice. This has the potential to reduce pressure on existing physiotherapy services and potentially reduce demand for GP follow up consultations.

To date, more than 500 patients have used the service led by physiotherapists. In a previous pilot in Lewisham, south London, they reported less pain, better function and higher activity levels. A high satisfaction rate was achieved which included reduced BMI, body weight and waist circumference and has led to fewer GP consultations, investigations and onward referrals.

In addition to the patient benefits, for every £1 spent on the programme there is a saving to the health and social care system of up to £4, according a Social Return on Investment (SROI) analysis.

Why not embed this training into these new roles? This could genuinely help deliver one of the aims of PCNs to empower people to self-care and improve the quality of life for people living with MSK pain. This one example could radically change the approach for addressing the needs of people living with MSK pain helping them to become fitter, more active and more empowered,  provided that the additional funding for primary care staffing does not result in reduced provision in other sectors.

Primary care will find countless other ways of using new staff to do more in primary care. While this doesn’t magically reduce our workload in practices, it has the potential to shift it and makes it easier for patients to access a broader range of professionals in community settings without the need for referrals to hospital.

These initiatives alone will not be enough to completely transform and modernise primary care but they are a great starting point. Change is easy to talk about but difficult and complex to enact. Even innovations that will lead to significant savings will often require upfront investment of resources, time and goodwill. The introduction of state based indemnity is very welcome to help retain experienced GPs, however,  changes to pension contributions and tax implications may have an equal and opposite effect impacting  the number of sessions doctors are choosing to work.

For me the key headlines which make the new GP contract so innovative and exciting are the significant increased staff funding, support for the development of Primary Care Networks, a five-year timeline and introduction of state based indemnity.  What we now need is the time and space to deliver.

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