Plenary presentation at the 2020 annual meeting for Wales School for Primary & Emergency Care Research (PRIME Centre Wales)

1. Making an impact in primary and
emergency care through PRIME
Centre Wales research
Helen Snooks
Associate Director PRIME Centre
Wales, Swansea University

2. Overview of presentation
• Why is impact important?
• Timescales for impact - a note of caution
• Domains of impact
• Impact Case Study: Avoiding unintended consequences of healthcare
intervention – story of predictive risk stratification research and policy
impact in Wales
• Examples from around PRIME Centre Wales
• Towards zero patient harm in healthcare
• Seal or varnish?
• Welsh code breaker – making visits to the GP safer
• When should I worry? – management of respiratory tract infections in
children
• PHED Data – linking pre-hospital and emergency department patient
records
• Celebrating success 

3. Why is impact important?
• Research Excellence Framework (REF)
• Income
• Reputation/prestige
• Attracting funding
• Recruitment
• Skilled staff
• High quality students
• Job satisfaction
• Being accountable for use of public funds

4. Impact timescales
• Rarely overnight!
• Usally a long process
1. Gaining research funding (1 – 2) years
2. Delivering trial or other study (2 – 5 years)
3. Publishing findings (1-2 years)
4. Wider dissemination to influence policy makers, guidance groups,
practitioners
• PRIME Centre Wales supports the whole process, particularly stages
1, 3 and 4 which fall outside project funding, when researchers are
contracted to work on that project
• PRIME Centre Wales has supported publication and dissemination
stages of projects undertaken previously as well as initial stages of
new projects

5. Domains of impact

6. REF 2020 Impact Case Study
Avoiding unintended consequences: A large scale
evaluation halted national rollout of predictive risk
stratification in primary care in Wales
Background
• Ageing population
• Increasing burden of chronic conditions
• Unsustainable level of emergency
admissions
• Predictive risk stratification of general
practice populations was widely
promoted as a new approach that
would assess and care for the whole
person proactively, to prevent
emergency episodes and admissions,
rather than reactively, following crises

7. Research
Use of linked anonymised data in research
• Funding - MRC/Wellcome Trust (CIPHER/FARR/HDR UK):
£7,376,942
Chronic conditions management policy evaluation
• Funding - Welsh Government: £304,897
PRISMATIC trial
• Funding - National Institute of Health Research (Health Services and
Delivery Research): £691,101
Emergency Admission Risk Prediction implementation survey
• Funding - Swansea Bay University Health Board: £18,000

8. Dissemination – key papers
1. The SAIL databank: linking multiple health and social care datasets. Lyons RA, Jones KH, John G, Brooks CJ,
Verplancke J-P, Ford DV, Brown G, Leake K. BMC Medical Informatics and Decision Making. 2009;9(1):3
2. Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial.
Snooks H, Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans BA, Farr A, Fitzsimmons D, Heaven M, Howson H,
Hutchings H, John G, Kingston M, Lewis L, Phillips C, Porter A, Sewell B, Warm D, Watkins A, Whitman S, Williams V,
Russell I. BMJ Quality & Safety 2019;28:697-705.
3. Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC). Snooks H,
Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans B, Farr A, Fitzsimmons D, Harrison J, Heaven M, Howson H,
Hutchings HA, John G, Mark Kingston, Leo Lewis, Ceri Phillips, Alison Porter, Bernadette Sewell, Daniel Warm, Alan
Watkins, Shirley Whitman, Victoria Williams, and Ian T Russell. Health Serv Deliv Res 2018;6(1).
4. Predictive risk stratification model: a progressive cluster-randomised trial in chronic conditions management
(PRISMATIC) research protocol. Hutchings HA, Evans BA, Fitzsimmons D, Harrison J, Heaven M, Huxley P, Kingston
MR, Lewis L, Phillips CJ , Porter AM, Russell IT, Sewell B, Warm D, Watkins A and Snooks HA. Trials 14, 301 (2013)
doi:10.1186/1745-6215-14-301 Estimated 2*
5. It could be a 'Golden Goose': a qualitative study of views in primary care on an emergency admission risk
prediction tool prior to implementation. Porter A, Kingston MR, Evans BA, Hutchings H, Whitman S, Snooks. BMC
Fam Pract. 2016 Jan 6;17:1. doi: 10.1186/s12875-015-0398-3.
6. Emergency Admission Risk Stratification in UK primary care: national survey of access and use. Kingston M,
Hutchings H, Griffiths R, Porter A, Russell I, Snooks H. Accepted by BJGP subject to response to reviewers’ comments

9. Impact
• National rollout of a web-based risk stratification tool for use by
General Practitioners was halted following the results of Swansea
University’s PRISMATIC trial.
• Introduction of the software led to unexpected increases in
emergency admissions, days in hospital and costs.
• Patients in Wales have benefited from avoided additional
emergency admissions (27,690 annually) and days spent in hospital
(75,815 annually) and cost savings for the NHS (£201 million
annually).
• Close working between academics and policy makers in Wales
enabled the avoidance of implementation of an intervention that did
not have an evidence base of effectiveness, and which in practice
had unintended adverse consequences for patients and the NHS.

10. Evidence of impact
National survey findings (published)
14% of practices in Wales have access to emergency admission
predictive risk tools compared to over 80% across the UK
Letters from Welsh Government
- at outset of trial
“The outcome of the evaluation will inform future use of the PRISM
tool. Until then, Welsh Government will not promote its use more
widely.”
- following publication of results
“ trial results indicated that effects were unanticipated and in the
opposite direction to those sought. The work concluded that caution
needs to be exercised in using predictive risk tools at an individual
patient level to support clinical decision making. This is a useful piece
of research for consideration in decision making and planning. As a
result, the PRISM tool was not rolled out more widely in the Welsh
health system.”

11. Andy Carson-Stevens, lead for patient
safety work package at PRIME Centre
Wales, co-chaired roundtable
discussions on the measurement,
reporting, learning and surveillance of
patient safety with experts, policy
makers and Ministers of Health at the
World Health Organization to
prepare a Global Patient Safety
Action Plan (2020-2030)

12. ‘Seal or Varnish?’ dental study
received prestigious award
2019
Professor Ivor Chestnutt, primary dental
care lead from PRIME, was awarded the
2019 International Association of Dental
Research (IADR) award for best paper
published in the Journal of Dental
Research.
‘Seal or Varnish?’ found that applying
fluoride varnish to children’s teeth is just
as effective at preventing tooth decay as
the alternative method of sealing teeth
and could save the NHS money.
“This award demonstrates that
we have the capacity in Wales to
conduct impactful research that
has implications for dental
prevention, not only locally, but
across the world.
This work was facilitated by close
collaboration between the NHS
and Cardiff University and is just
recognition of the tremendous
efforts of a large team of clinical
and research staff, in seeing the
work to completion."

13. Thousands of patient safety incident
reports are logged in the National
Reporting and Learning System: a huge
database made up of files sent in from
every NHS organisation in England and
Wales.
Dr Andrew Carson-Stevens, lead for
patient safety research in PRIME Centre
Wales, is working to spot and eliminate
patient safety incidents in primary care.
“We developed a library
of words so doctors and
nurses can pick a code to
describe what happened
and also what the
outcomes were for the
patients. And those three
things were more than
enough for us to be able
to start looking for
priorities”
Dr Andrew Carson-
Stevens
The Welsh ‘code-breaker’
making our visits to the
GP safer

14. Health & Care Research Wales
Impact Award:
‘When should I worry?’
2017
The ‘When should I worry? information
booklet was developed by former PRIME
work package lead Dr Nick Francis on the
management of respiratory tract infections in
children, for use in primary care consultations
and training for clinicians on communications
skills.
The booklet and training were rapidly taken
up in the NHS and abroad, widely used in UK
primary care and internationally:
o >140,000 website views
o >279,000 booklets purchased

15. Pre-Hospital Emergency
Department (PHED)
Data Linkage Project
Data linkage across ambulance
services and acute trusts: assessing
the potential for improving patient care.
NHS England took up the findings to
help shape the development of the new
Ambulance Data Set, which will
standardise and link data nationally,
and will be rolled out across all
ambulance services and emergency
departments across England by 2022.

16. Celebrating success – PRIME Centre collaborates
closely with impact award winning SAIL databank 2020