2017 Winning Projects – Teams

Dorset Multiple Sclerosis Service

 “This investment in ‘face to face’ training has been vital in establishing strong networks throughout Dorset with a positive and long lasting effect on patient care.”

The Dorset MS Service provides multidisciplinary expertise to over 1200 people with MS, providing timely, specialist, high quality evidence based care. The service has set up a rolling programme of MS Competency Based Training for their team and all healthcare services they link with in the community.  These sessions are domain based (e.g. DMD, Spasticity, Continence, Fatigue). Training extends to secondary care services such as the acute admissions ward, therapy departments and infusion units. Training is also provided to pwMS through MateS groups and MS Society branch meetings.

The team is based at Poole Hospital enabling access to secondary care specialists, investigations, planned admissions for therapeutic treatment, outpatient services and rehabilitation. The service has developed to ensure patients are seen in their home, workplace, or other appropriate community facilities; they have recently increased the number of clinics in community hospital and GP surgeries to reduce patient journeys. They ensure patients have access to all relevant information and provide a telephone helpline to enable weekday access to professional support and advice.

Staff have been flexible in their free time piloting a weekend training session on MS for children with a family member with MS outside school hours. This was successful and well received with further sessions planned.

 

MS Buddy Scheme, Wessex MS Therapy Centre

 “For many of these people stuck in their homes, a Buddy acts as a lifeline to the outside world.”

Carol Coates, a volunteer coordinator at the Wessex MS Therapy Centre recognised the social isolation and loneliness that many people with MS must contend with and created a bank of MS Buddies to visit people in their own homes. She worked tirelessly to identify suitable volunteers to become companions/MS Buddies, creating a training schedule together with policies and procedures. Carol successfully identified several members she felt were lonely or isolated and would benefit from a friendly visitor in their home.

She has worked closely with the volunteers to make sure that they are offering the right needs for the individuals they visit and is meticulous in finding the right match. MS Buddying is a very specific form of companionship and even though it offers no personal care Carol has made sure that volunteers can take their Buddy out and about. The Buddy is there to offer whatever support is needed, whether it’s just to have a chat, watch a film, or to help with tasks such as form filling.

For many of these people confined to their own home, a Buddy is a lifeline to the outside world, a friendly face who can devote all their attention to someone with MS in need of support.

Frimley Park Hospital MS Service, Frimley Park Hospital

 “The treatment agreements not only reinforce the importance of blood monitoring but allow for a trusting collaborative partnership with the patient. They empower patients with regards to their decision making and ongoing care.”

The team at Frimley Park Hospital felt it was important for patients to take some responsibility for their care and feel involved in the decision making process, which led to them developing ‘Treatment Agreements’ for all available disease modifying therapies. The Treatment Agreement is a one page document that is given to the patient at the point of consultation once a treatment decision has been reached and agreed.  The MS Nurse covers every aspect of the form, ensuring patient understanding. Feedback has been extremely positive with patients saying that they feel enabled to be included in the management of their disease.

Since the implementation of the treatment agreements adherence to blood monitoring has improved significantly. Patients understand the importance of these blood tests and contact the team, as outlined in the agreement, when they have had blood taken. These agreements have had a number of clear benefits including initial patient engagement, improved adherence to blood monitoring, patient empowerment and patients developing a greater understanding of the management of their disease.

 

Queen Elizabeth MS Team, Queen Elizabeth Hospital, Birmingham

 “The ethos of the MS team is to provide information and support prior to patients establishing Disease Modifying Therapies. By doing this, patients can make an informed decision regarding their treatment which in turn helps to promote adherence to therapy.”

The Queen Elizabeth MS team wanted to ensure information regarding DMTs is provided to all patients, and with this in mind developed discussion groups providing a one stop shop including screening and discussions around the therapies.  During the discussion groups screening is carried out with an indepth history taking to ensure PwMS are safe to proceed with therapy.  Information is provided including mode of action, possible side effects, monitoring and provision of medication. Frequently asked questions are also covered including holidays/travel, relapses/steroids, pregnancy and supplements/vitamins.  At the end of the discussion the team have a one to one with the patient to discuss their treatment option and concerns/questions.

The team arrange follow-up appointments for those who require more time for their decision process. These appointments also enable those who don’t like speaking in a group to ask questions. Questionnaires are sent to patients every 2 years to gain their feedback and to take on board any recommendations or suggestions they may have. Feedback has always been extremely positive with 99% reporting that they were provided with the right level of information.

 

Therapeutic Opportunities Team (TOPS Team), North Bristol NHS Trust

 “The important feature of this approach is ensuring the appropriate collection, storage and use of data derived from MS validated measures for physical and non-physical outcomes.”

The Therapeutic Opportunities Team (TOPS) is a collaboration between clinical and research MS specialists. The team comprises exercise scientists, orthotists and local gym and swimming instructors who combine research and clinical expertise to offer an interactive service based on a range of therapeutic opportunities to promote long-term symptom self-management.

Qualitative and quantitative outcomes including patient perceived value, attendance and continuation of different elements of the therapeutic package is collated and entered in the clinical notes. Local commissioners are provided with evidence of cost, value and impact of joint and individual interventions for single and group therapy approaches.

Regular team meetings and planning allow evaluation, development and revisions in practice. Using literature searches and evidence critiques the team keeps up-to-date with current research and legislation. This ensures continuation governance across NHS and community sites and allows amendments such as new rules for personal data and safeguarding for vulnerable adults to be implemented.

Neurological Examination Nurse Training Course, Salford Royal NHS Foundation Trust – MS Team

 “Learning is delivered in a structured and interactive way that gives nurses time for explanations from the neurologist and a deeper understanding of the more discreet problems of the patient with MS.”

The Salford team of neurological consultants and MS nurses have developed a bespoke course that educates and supports MS nurses throughout the country, in the delicate art of neurological examination. The Neurological Examination Nurse Training Course (NENTC) is designed to train nurses to assess patients’ sensory and motor responses and improve their ability and confidence in diagnosing and identifying warning signals earlier in CNS impairment, leading to better care and treatment for those with MS.

Over 200 nurses working with PwMS across a variety of healthcare settings have attended the acclaimed 2-day course. The outcomes indicated significant increases in the confidence of nurses to undertake neurological examinations which has had a positive impact on their clinical practice.

The course started in 2012 and has continued to be an immense success, now leading to the development of a Level 2 more advanced course.  It has flourished primarily because of the tireless efforts, dedication and passion of the MS team in Salford to improve patient care.

NHS Western Isles MS Service

 “The use of technology tailored to fit each individual’s needs has been instrumental in empowering patients to self manage and allowing them to have stress free consultations from their own homes.”

The NHS Western Isles MS Service has introduced a range of initiatives including Jabber VC for people unable to leave their own homes, enabling them to link into the advisory group, something which is extremely important in this rural setting. Jabber also facilitates consultations with mainland consultants to support rehabilitation and management of progressive MS. A texting service called Florence has also been introduced to remind patients of upcoming blood tests, and to do their pelvic floor exercises. Attend Anywhere, a replacement for Jabber, facilitates the introduction of a weekly rapid access (drop in) clinic to assess patients in their own homes or place of work, meaning that patients in Uist and Barra have equitable access to the service.

The sheer magnitude of the Western Isles means there are inevitably logistical issues in getting support to patients at times of need, with clinicians and patients having to travel significant distances by land, air and ferry, often in inclement weather. The introduction of VC has transformed the MS Service, with patients now able to see clinicians quickly and safely, wherever they live in the Western Isles.

Barts MS, Queen Mary University of London, Digesting Science

 “Digesting Science brings families affected by MS together. It reconnects them with their health teams and give them a safe space in which to talk about the condition in an environment where everyone understands.”

Digesting Science is a unique and exciting event bringing the science behind MS straight to families affected by the condition. Children aged between six and twelve learn more about MS treatments, symptoms and risk factors through fun activities. The event is engaging for young people, and communicates scientific concepts in an accessible way, but without being patronising. Each child receives a lanyard full of information, which they stamp as they complete activities. They can then take this home and educate their friends and teachers about their parent’s condition, increasing knowledge of the condition within the family’s immediate community.

Feedback from families who have attended the events has been fantastic. Parents find that they can discuss their condition with their children in innovative ways and in a relaxed environment. They also learn more about the condition themselves, re-engage with their health team and meet other people in the same situation.

Digesting Science is a collaboration between researchers, neurologists, teachers, parents with MS and designers, catering to all learning types and bringing together health teams, local support groups and families.

The events create a space where information about MS is easier for families to access: they learn through play whilst having an MS expert on hand to answer further questions.

BrAMS (Bristol and Avon MS Centre) Community Rehabilitation Service

 “This non-hospital based model of rehabilitation allows PwMS to exercise in the same environment as their peers and assist them to manage their long-term condition.”

The services developed in Bristol allow those people with higher level function to remain fit and avoid some of the common problems seen in early MS. Those needing more appropriate therapeutic strategies are also catered for through initial clinical assessment, routing them into gym based or aquatherapy sessions as appropriate. The aims for both these groups are avoidance of deconditioning, improved general and cardiovascular fitness and specific exercise modalities aimed at individual needs.

Creating a partnership with the County Council Leisure Centre has enabled use of the community facilities which helps to engage PwMS in exercise to improve their function. It is  based on clear understanding of their individual needs and guidance on how to approach exercise using the leisure centre facilities. These types of partnerships allow PwMS to exercise using gym equipment or swimming pool resources according to their individual needs, thus managing their specific symptoms.

There are now ten leisure centre instructors working in this partnership with an interest in MS enabling both individual training and general support for more disabled participants. Consequently this has expanded rehabilitation opportunities for PwMS under the guidance of the MS Specialist Physiotherapist.

Community MS Specialist Nurse Team, Northumbria Healthcare NHS Foundation Trust

 “Working across these services we strive to co-ordinate the physical, mental health and social care of our patients to ensure that management of their MS is optimised.”

The service began in 2006 with the appointment of an MS specialist nurse in rural North Northumberland. Prior to this, people affected by MS often had to travel 120 miles or more for appointments as they could not access specialist services locally. Following patient feedback, the Community MS Specialist Nurse Team established community MDT clinics with a consultant in rehabilitation and continence service colleagues, and in 2011 the service expanded offering community based MS Nurse Support.

The team hold community based nurse led clinics across the county in NHS and non NHS settings, as well as offering home visits and joint visits with consultants and HCPs to improve patient outcomes.

The team have worked tirelessly with patients and families to provide a service that is tailored to their needs. Together with local MS charities they rolled out a twice monthly evening outreach service.  In an informal setting people affected by MS can access a neurological physiotherapist, and MS nurse and complementary therapies and they benefit from social networking and group support.

September 2017 marked its 10 year anniversary and the service continues to be valued by patients and clinicians alike.

Community Neurology Service, West Norfolk, Norfolk Community Health and Care NHS Trust

 “This team and its members  are recognised throughout the Trust as being supportive of each other, progressive, innovative, resilient and cohesive.”

This highly specialist community neurological service, which encompasses specialist nurses, OTs, physios, a psychologist, speech therapists, and highly experienced therapy assistants offers holistic assessment, treatment, self-management,  maintenance, practical advice, and ongoing support to ensure those with MS and their families and carers are able to live and work to their maximum ability.

The team meet weekly to discuss complex patients in order to ensure coordinated care, and timely interventions for patients and families/carers, and team supervision is provided for learning, support and development of knowledge and skills.

The service offers a variety of treatments, interventions, assessments, advice and support dependent on patient need.  The team offer clinics, home visits and community based appointments in areas such as local gyms and swimming pools.

They encourage self-referral by patients to ensure they get advice and suppport when they need it, and where appropriate, expedite patient appointments to ensure safe care.

The service offers comprehensive, holistic and person-centered care, despite funding cuts. Patients are fully aware of the collaborative approach of the service and know they can contact anyone for advice/support.

MS Specialist Rehabilitation Team, West Midlands Rehabilitation Centre, Birmingham Community Healthcare NHS Foundation Trust

“The MS Team’s aim is to help their clients adapt to changes as their condition progresses and achieve the best quality of life and rehabilitation potential possible.”

The team provide rehabilitation assessment and support services for those with progressive forms of MS, as well as seeing a small number with relapsing remitting MS. They run multidisciplinary clinics where clients are assessed and client centred rehabilitation goals are mutually agreed. These actions are completed by the appropriate team member who can follow up with domicillary, workplace or leisure visits as required.

The MS Rehabilitation Team provides a ‘one stop shop’ for PwMS as they have access to other specialist services within the West Midlands Rehabilitation Centre. These specialist services range from spasticity management including intrathecal Baclofen implants, functional electrical stimulation management, communication services, specialist wheelchair services and orthotic services.

Patients also have direct access to counselling, psychology and speech and language therapy services. In addition they can refer to the team’s Patient Information Service for advice on financial, benefit and housing matters and their Carer Support Service.

All clients are provided with contact details for team members and are free to contact them at any time between appointments.

They also keep up-to-date with MS Trust and MS Society work so they can signpost clients to things that may be of interest.