HRH The Prince of Wales Award for Integrated Approaches to Care

Improvements in treatment and care mean an increasing number of patients are living with long-term conditions. While these advances are very much welcome, they often lead to an increase in demand on health and care services. This category seeks to recognise nurses whose work is reducing the burden on the health service by preventing ill-health and/or offering truly holistic care to patients who have long-term conditions or complex needs. This prestigious award, which was established and named for the then Prince of Wales in 2014, is open to individual nurses or teams working in the NHS or independent sector. It seeks to recognise nurses working in any setting who have collaborated with other organisations, such as those from the voluntary and/or third sector, to promote public health and prevent disease and/or manage long-term conditions in a holistic and integrated way that improves patients’ quality of life and independence.

Barking, Havering and Redbridge University Hospitals NHS Trust
Patients know less to patients know best – a collaborative approach

North East London has a richly diverse population of around two million residents, with significant health inequalities and some of the fastest demographic growth in the country. Barking Havering and Redbridge University Trust(BHRUT) serves around 40% of this population and is looking to rapidly improve its digital capability to meet these health demands and transform patient and workforce experience. Barts Health deliver care to the 2.5 million people of East London and beyond with more than 60 languages spoken across the population. The primary issue was the digital divide in healthcare, where many patients lacked access to their health information and effective communication with their healthcare providers. This gap limited patient engagement, hindered chronic disease management, and created inefficiencies in healthcare delivery. Approach: There are 2 Renal Units in BHRUT managed by Barts Health NHS Trust namely Queens Renal Unit and Redbridge Renal Unit. We use the 2 units as a pilot. Patients here are using a Patientview now replatformed as Patients know best. The good thing is, Renal dialysis patients can use the PKB in its full functionality. But the uptake of PKB registration as at its lowest. 14 out of 108 patients registered in Patients Know Best (PKB) in Queens Renal Unit and 22 out of 116 patients PKB registered in Redbridge Renal Unit. So we need to do something. To resolve this, we developed an initiative by using Patients Know Best aimed at improving access, engagement, and communication. We run roadshows, write articles, create posters and leaflets, speak to patient groups and charities in the community, promote PKB in the Trust intranet and internet, clinical engagements in all departments. We identifed patients who can be a digital champion and be a PKB ambassador. “Without patient involvement at every level it would be misdirected and irrelevant."

Blackpool Teaching Hospitals NHS Foundation Trust
Early parenthood service – supporting families to be the best they can be

Blackpool has the highest rate of Children in Need and Looked After Children in the country, with the rate for those under the age of one being over four times higher than the national average. The Early Parenthood Service (EPS) was designed as a response to this and the decommissioning of Family Nurse Partnership (FNP) in order that the needs of a broader population could be better met, particularly those expecting parents with: Learning difficulties Difficult experiences in their own childhood and may be care experienced. Had children who are no longer in their care. Are experiencing vulnerabilities and whose lifestyle may pose a risk.The aim is to support Parents to be the Best They Can Be, by providing consistent and intensive support utilising a tool kit of evidenced based interventions throughout the antenatal period until the baby is up to three months old. EPS supports parents who may go home with their baby and those born into care. We considered recommendations of research, independent reviews, child safeguarding practice reviews, local information, and data to design a bespoke service integrated into the Blackpool Start for Life offer. A shared goal enabled a smooth and rapid development of a complex service. Putting the baby and their family at the centre enabled challenges to be considered as opportunities for growth and learning. EPS has been commissioned initially until 2027. 59 families have been referred to date, with amongst them 4 babies at significant risk of being removed have gone home with their parents. 4 families have been supported whose babies were born into care. We are currently working with 10 families in pregnancy whose babies are at significant risk of being born into care. Future plans are to evaluate, adapt, expand and integrate further into the Blackpool Partnership offer to families.

DHU Healthcare
Making preferred place of care and death a reality

In 2021, Derbyshire Clinical Commissioning Group (CCG) initiated a proof-of-concept pilot project. The Palliative Care Urgent Response Service (PCURS) cares for people who wish to remain at home, despite their urgent palliative health care needs. Responding to a crisis, it provides one-off and ad hoc visits to help keep patients at home and out of hospital, with forward referral to other teams for ongoing care needs provision. The PCURS was developed for the adult population and staffed with adult-trained nurses and practitioners. Since its’ inception over 3500 interactions have taken place. The only admissions in this period have been for palliative care emergencies, sepsis or when patients have changed their mind about their preferred place of care/death, making it an effective and cost-saving service. In 2022, the Nottingham/Derbyshire paediatric services approached the PCURS to ask for our support by extending care to children across Derbyshire. Unfortunately, due to staffing issues, the Children’s Community Nursing Service couldn’t support out-of-hours and at weekends to give dying children and families the option to die at home. This collaboration has seen 10 children die at home in their preferred place of care and been actively involved in supporting 5 of them to achieve this over the last 18 months, allowing over 300 more children to have a choice in where they die. In addition to this, the PCURS is now looking to extend its reach to prisons and is also looking at collaborative working with East Midlands Ambulance Service to further support patients to stay at home.

Newcastle upon Tyne Hospitals NHS Foundation Trust
Addressing barriers to successful diabetes transition in children and young people

NUTH provides care for about 300 young people aged 16 to 25 with type 1 diabetes. In 2021 National Paediatric Diabetes Audit results reported mean HbA1c to be been static, particularly compared to other units in North East England. Internal audits show 46% of children and young people (CYP) live in the bottom three IDACI (deprivation) postcodes. High HbA1c strongly correlate with deprivation. For HbA1c of over 86mmol/mol, 67% live in bottom three deprivation deciles. Local audit in 2021 showed 70% of CYP attended 3 or more clinics/year in the paediatric service falling to 36% in the first year of young adult clinic. The majority of DKA admissions in young adults ≤25 years were from the lowest IDACI postcode with 60% of admissions linked to insulin omission and 20% to alcohol use or illicit drugs. The NE young persons advisory group (YPAG) highlighted the need for more holistic transition with support for social issues such as housing, psychological support and better joint working between paediatric and adult services. Clinics have been expanded to create more flexible access for young people. A University clinic on campus was started in September 2023 to provide easy access to students and a MDT/keyworker programme was established. Texting communication service for young people has been implemented. Since December 2022 the MDT has had 115 referrals for a range of reasons from clinic non-attendance, DKA admission, high HbA1c, hypoglycaemia and psychological distress. Time from referral to MDT to contact by the team has reduced from 60 days to 8 days from December 2022 to August 2023. We plan to analyse the impact of social deprivation and further consider how to improve equity of access as well as expand the service to those with type 2 diabetes.

NHS South Yorkshire Integrated Care Board and West Yorkshire Integrated Care Board
Creating, developing and sustaining nurse and carer partnerships across South Yorkshire

Our highly skilled primary, community nurses strive to improve enhance and deliver complex support in a timely way to our population of unpaid carers across England. The value of unpaid care is equivalent to a second NHS in England and Wales, with social and nursing care professionals struggling to create the necessary time and capacity to spend with their citizens across the life course. This creates disjointed community teams experiencing a ‘crisis of care’ and critically impacts upon timely access to quality care for unpaid carers that is desperately needed within our localities, at regional and national levels. Our dedicated Unpaid carers are challenged to care for relatives who have complex multimorbid long term conditions, encompassing illness, disability, and mental health issues. The burden of caring responsibilities is growing. As the workforce closest to their communities, our primary care nurses share a long history of relational and therapeutic care, engaging and connecting with carers on an individual level. There is a critical imperative to formalise that partnership work to create ‘upstream’ preventative planned and timely services, that allows for equity and co production to enhance unpaid carers mental and physical wellbeing. Primary and community nursing teams led and collaborated with carers to establish three carers’ roadshows across Yorkshire. This sustainable comprehensive and flexible community model is now in its second year. Over the course of three half days in 2023, Barnsley Leeds and Sheffield integrated care systems delivered a total of 2,310 appointments and developed critical conversations with Carers and their families, to improve timely access to quality care and services. Sixty-five health and care organisations participated in the three roadshows across Yorkshire, with 227 preventative health checks initiated and completed by thirty nurses with student nursing teams. A model of planned community care, at place spread and scale.

Practice Plus Group
Offering holistic care via integrated care pathways

Often, patients in prison have suffered from health inequalities and deprivation. They present with multiple and complex needs which are often interwoven, and require tailored, consistent and reliable care. However, the nature and volatility of prisons means the potential for unplanned healthcare incidents is high. This creates disruption for planned clinics and routine appointments, leading to delays in care. The integrated care pathway (ICP) aimed to address both of these concerns: offering a holistic and person-centred approach to care; while helping to minimise the impact of unplanned incidents on general healthcare provision. The ICP roll out (London) involved the creation of multi-disciplinary team (MDT) pathways for early days in custody (EDIC) and unscheduled care (UC) comprising paramedics, triage nurses, mental health, and substance misuse practitioners. EDIC uses combined expertise to assist in the early identification and treatment of a patient’s needs, offering a holistic approach to healthcare from the moment of arrival. Meanwhile, UC provides care during unplanned incidents, helping alleviate the impact upon planned care (PC). This commitment to maintaining PC ensures consistency and improved outcomes for those with long term or complex conditions, whose care can be planned and managed effectively – preventing deterioration and unnecessary onward referrals. Practical implementation of ICP posed challenges, and required a phased approach across sites. This allowed for the thorough integration of each pathway before expanding further. Delays in system improvement and recruitment resulted in slower progress than anticipated. Moreover, governance structures necessitated broader support from national entities. However, despite this, ICP is now live in seven sites. In future, we aim to collect evidence of the longer-term impact of ICP for patients who remain within prison, and also post-release. We plan to roll out similar initiatives to support our ageing prison population – providing pathways for older persons d end-of-life

Sheffield Teaching Hospitals NHS Foundation Trust
Nurse-led late effects screening service

Modern cancer management is an impressive medical success story. The goal of treatments maximises efficacy and minimises toxicity. Trade-offs include co-morbidities, impacting quality of life. Late effects may occur weeks, months or even decades later, can affect any system, may be physical, emotional, social or financial and include second cancers. The earlier late effects are identified, the sooner and more effective the intervention. Cancer nurses are ideally placed to work holistically to assess and screen for potential late effects and patient concerns. We have established a Sheffield Nurse-led Late Effects service to do just this. A key senior nurse leader worked collaboratively with multi-professional colleagues across multiple specialties to extend an established paediatric service into haematopoietic stem cell transplantation by implementing international guidelines, the first in Europe. The appointment of a dedicated Clinical Nurse Specialist embedded care into pathways. A further nurse-led late effects clinic was established within oncology focusing on adults of fertile age and survivors of solid cancers. Whilst these services grew, novel therapies were developing in parallel and presenting with their own novel toxicities. A more recent opportunity for a further senior nurse appointment enabled the transferability into immunotherapy late effects. Oncology faces significant challenges with increasing demand, an overstretched workforce, growing elderly demographics. Within this context, late effects services never represent burning platforms. We have persisted by raising the profile of our work and advocating for patients with evidence, tenacity and dedication. We are currently writing a late effects strategy for the regional cancer alliance. We have extending our Community of Practice working with radiography colleagues to pilot a Pelvic Radiation Late Effects Clinic and within haematology, recruited a Clinical Nurse Specialist to support a Late Effects Clinic for Multiple Myeloma. A successful research grant will develop a digital monitoring pathway for immunotherapy late effects.

Singing Mamas
Singing on prescription for maternal mental health

NHS nurse Kate Valentine set up 'Singing Mamas' in 2010. We're a national non-profit movement for maternal mental wellbeing. We exist because suicide is the leading cause of death for pregnant women and women with babies under 1, and because group singing is clinically proved to reduce post-natal depression (See British Journal of Psychiatry). Kate has trained more than 200 women across the globe to deliver the Singing Mamas approach in their own community and face-to-face groups now reach thousands of women and children every week across 8 countries and 50 UK local authorities. In 2023 Singing Mamas piloted a digital version of the approach in partnership with Liverpool Women's Hospital and funded by Arts Council England. The pilot engaged a steering group made up of midwives, health visitors, GP's, social prescribers and mothers with lived experience to co-create a series of pre-recorded digital Singing Mamas episodes. The programme was then prescribed to identified women via perinatal services and tested with 84 women. External evaluation was undertaken by Dr Rowena Hay and recommendations created. Phase 2 of the pilot took place in Kent built on these recommendations by creating a listening album alongside video episodes, including volunteer outreach visits across 4 hospitals and involving a social media campaign to support self-referrals. It reached 621 women who went on to access content on the website and more than 1,000 women who listened to the album online. We are currently seeking funding for a national rollout of the phase 2 model.

Stow Healthcare, University Hospitals of Leicester NHS Trust and Care England
The Decaf Project

Could introducing decaffeinated drinks reduce falls associated with toileting? This was the question first explored by University Hospitals Leicester in 2021 and taken up in social care by trade association Care England and elderly care provider Stow Healthcare in 2023. Caffeine has a diuretic effect, impacting the bladder and bowel and increasing the urgency of using the toilet. This may be a contributing factor to falls, particularly among elderly or infirm people who often have limited mobility and a higher prevalence of incontinence than the general population. In this innovative cross-sector learning opportunity, the three organisations operationalised a unique trial focused on a low/no cost innovation to improve lives and potentially reduce the significant cost to the NHS associated with fractures caused by falls (£4.4bn per annum). UHL and Stow Healthcare engaged staff and participants with both blind taste testing and health information around the potential health benefits of reducing caffeine intake. This resulted in a high take up of decaffeinated products – 89% of Stow Healthcare’s 350 elderly residents chose to take part in the trial. In both settings, caffeinated products always remained available upon request, with decaf becoming the default option. UHL’s trial saw an initial reduction of 30% in falls occurring on the way to the toilet, eventually dropping by 61% compared to pre-trial by Autumn 2023. In Stow Healthcare’s care homes, toileting-falls reduced by 35% compared to pre-trial data. Both organisations are now recommending decaf as the default option. Challenges have included accurately identifying falls associated with toileting, which can be more complex in those unable to vocalise reasons for their fall, and sharing information effectively to engage participants and staff. Enthused by the excellent results, Care England, UHL and Stow Healthcare are promoting their work nationally to engage ICBs, acute settings and social care providers.

Tenovus Cancer Care
Cancer Callback

We proudly nominate the Cancer Callback service for its rapid expansion and transformative impact on cancer care across Wales. Developed by Tenovus Cancer Care, this nurse-led intervention provides a lifeline to individuals undergoing systemic anti-cancer therapy (SACT), offering crucial support and proactive monitoring throughout their treatment journey. The service's unique approach operates within Service Level Agreements with NHS partners and involves patient referrals from health professionals. By complementing and supporting the NHS, the Cancer Callback service empowers patients with direct access to supportive proactive calls, ensuring their wellbeing and early identification of potential treatment toxicities. Reassuring NHS decision-makers of the quality and need for our service was a challenge we overcame. Through collaborative partnerships, we have successfully expanded the service's reach across five out of seven health boards in Wales in the last year. Negotiations are underway with remaining health boards to achieve pan-Wales coverage and discussions are developing with pharmacy teams providing an oncology service to ensure equitable access to patients receiving SACT. Despite the demanding schedules of our NHS colleagues, our dedicated team, under the leadership of Tenovus Cancer Care’s lead nurse, maintains regular communication with NHS managers. We provide them with comprehensive referral statistics and updates on the provision of our services. Encrypted nurse notes are also integrated into health board systems, facilitating prompt action on identified side effects or toxicities. To meet the growing demand, we have increased our nursing capacity and are poised for further expansion in line with our service offer plans. The Cancer Callback service exemplifies our commitment to enhancing cancer care, supporting patients throughout their treatment journey, and reducing the burden on the NHS.

The Walton Centre NHS Foundation Trust
Keeping women with epilepsy safe: preconception to motherhood

This project is co-developing and piloting a national service specification for epilepsy preconception care to motherhood toolkit with primary care, maternity and epilepsy service providers in the North West. The goal is to improve the outcomes of preconception care for women with epilepsy for safer pregnancy and motherhood. The rationale for this project is the evidence of health inequalities for women with epilepsy entering pregnancy unaware of the risks of poorly controlled epilepsy and their increased risks of maternal death, including a tenfold increased risk of sudden unexpected death in epilepsy (SUDEP). The NW was selected due to the high prevalence of epilepsy (second highest region in England), diverse population (including numerous areas of deprivation and its correlation to epilepsy) and geographical footprint of rural and urban regions. The project objectives developed in collaboration with patients and public involvement and engagement involved patient co-research, completing a staged mix-method online Delphi with consensus meetings to establish the essential content of preconception care for women with epilepsy. The implementation phase of this project is in collaboration with Epilepsy Action (a national voluntary organisation representing people with epilepsy) and NW Maternity Services. Service mapping has supported networking across the NW and sharing experiences between primary care, maternity, and epilepsy service providers, as well as national leads of epilepsy patient organisations, including Young Epilepsy and SUDEP Action. Completing Gap analysis of local service specifications and resources to triangulate with national guidelines and agendas, including RCOG, NICE, MBRRACE, and the CYP Transitional Care Bundle. Links with local services have facilitated service user engagement and clinical listening events, including capturing young voices. The final stage is co-developing a minimum service specification and tool kit for preconception care to motherhood with extensive stakeholder participation and patient voice to pilot tests across NW before a national roll-out.