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This study assesses the perceived impact and benefits of Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring intervention for health and social care providers, patients and the health system in Northern Ireland. Having access to a specialist, a space to share experiences, and being able to disseminate up-to-date best practice were all cited as improving provider knowledge as well as improving quality of care for patients. Healthcare providers reported being more confident in managing patients and that relationships had been improved between different levels of the health system. ECHO was described as improving access to education and training by removing geographic and time barriers. This is one of the first studies to qualitatively analyse impact across a number of different clinical and social care ECHO networks. The results strongly indicate the perceived benefit of ECHO in improving provider, patient and health system outcomes such as increased healthcare provider knowledge and confidence to manage patients at primary levels of the health system. This has implications for future service design, particularly within the context of COVID-19 in which virtual and online training is necessitated by social distancing requirements.

Introduction Project ECHO (Extension for Community Healthcare Outcomes) is a tele-mentoring programme that uses video-conferencing technology to deliver, evidence-based education from specialists and case-based learning with peers. The Health and Social Care Board in Northern Ireland identified Project ECHO as a methodology to implement change. The vision was to engage with medical professionals to develop communities of practice, enhance knowledge, skills, and ultimately improve patient/client care. Project ECHO networks were established with a specific focus on (neurology, gynaecology, musculoskeletal, dermatology, ENT, cardiology, diabetes, and gastroenterology), along with a ‘GP support’ network. Network participants identified topics to be included within their curriculum ensuring a tailored approach to education delivery. Participants set the network objectives and the outcomes they hoped to achieve. ECHO sessions were held monthly and each network typically delivered nine sessions. Method Participatory monitoring and evaluation was used to identify outcomes for ECHO network participants. Evaluation surveys were issued after the final session. Results 361 medical professionals attended at least one ECHO session across the networks outlined above. 36% (131/361) responded to the evaluation survey. Results indicated participants valued access to education from specialists, to ask questions directly, and seek advice from secondary care colleagues. Participants reported knowledge of conditions and symptoms, confidence and capacity to treat patients in primary care increased. Improvements in relationships between primary and secondary care were also reported. Benefits reported by ‘GP Support’ included the ability to get advice from experienced colleagues, and that topics covered in the sessions were not usually covered in training for GPs. Also, joining the sessions remotely was a frequently cited as a benefit and to be a productive use of time. Professional isolation was reduced and satisfaction was increased. Conclusion Project ECHO is an ideal methodology for not only delivering education and advice to medical professionals but also as a mechanism for support in an isolated profession.

Background Palliative care requires an integrated, multidisciplinary approach and involves a range of specialities. Despite increasing demand, limited resources are often available to deliver high quality palliative care education and support that is tailored to meet the needs of healthcare professionals. Project ECHO (a tele-mentoring programme) could overcome this gap by using video-conferencing to deliver best practice guidance and education from specialists, and case-based learning with peer discussion. Five ECHO networks in Northern Ireland were established (Cardiology/Heart Failure, District nurses, Community pharmacy, Paediatrics, Marie Curie registered nurses). Participants set the curriculum, network aims and objectives, which included increasing participants’ palliative care knowledge and skills, enhancing confidence, building relationships, and facilitating peer support. 45 ECHO sessions were delivered across five networks between 2018-2019 with 194 participants attending ≥2. Aim The aim of evaluation was to identify if each network achieved its objectives. Methods Retrospective online survey issued to participants after the final ECHO. Results 27% (60/224) registered participants responded. ECHO was identified as a suitable model for education delivery and valued for case-based learning. Each network met their objectives: increased knowledge and management of palliative care patients. ECHO was identified as a suitable model for delivering education and the opportunity for case-based learning was valued. Impacts on practice included improvements in, inter-agency working, networking, communication with patients and families, confidence to make clinical decisions. Professional isolation was also reduced. Barriers to participation included time restraints due to staff shortages or workload. Conclusion Project ECHO may be ideal for delivering palliative care education and support across multiple settings. However, protected time for participation is recommended.

Introduction The Health and Social Care Board identified Project ECHO as a methodology to implement change. The aim was to develop the knowledge and skills of health and social care professionals, transform service delivery, and ultimately improve patient care. Up to 38 ECHO networks across a variety of settings (e.g. palliative care, ophthalmology) were established between 2018-2020. Aim The aim of this study was to use the Consolidated Framework for Implementation Research (CFIR) to guide assessment of the outcomes and impacts, and explore the factors which influence success across different contexts. Methods Qualitative study; key stakeholders including high and low attenders, and hub members were purposively invited to participate in a semi-structured interview; interview schedules guided by the CFIR method utilised for data analysis. Results 28 stakeholders participated. Network purpose varied across contexts, (i) provision of education and support to isolated practitioners; (ii) support practical implementation of strategies/guidelines across sites, (iii) support cross sector working, (iv) build capacity of GPs to manage patients on waiting lists, (v) transform and provide ongoing governance of a new service. Impacts on participants included increased knowledge of conditions and symptoms, increased confidence to treat patients, and increased capacity to manage patients in primary care. Improvements in relationships between primary and secondary care, and across sectors were also reported e.g. improved understanding of regional strategies, service initiatives and referral pathways. Impacts at service level were reported. Conclusion Project ECHO is an ideal methodology for not only delivering education and support to health and social care professionals, but also as a mechanism for delivering service change. CFIR is a useful framework for identifying pre-conditions which should be met before a network is operational to ensure success and sustainability.

Background There is a need for high quality palliative care education and support, but often limited resources are available. Project ECHO™ (Extension for Community Healthcare Outcomes) is a tele-mentoring programme which could overcome this gap by using video-conferencing technology to deliver: Evidence–based, best practice guidance and education from specialists; Case–based learning with opportunities for questions and discussion with peers. Five ECHO™ networks in Northern Ireland (NI) delivered palliative care education and support: Cardiology/heart failure; District nurses; Palliative care pharmacy; Paediatric palliative care; Marie Curie registered nurses. Network participants identified educational topics for their curriculum, and set network aims and objectives. Objectives included increasing participants’ knowledge, skills and confidence in palliative care related areas, improving collaboration, and facilitating peer support. Network leads were responsible for evaluating how well objectives were met. Aim To evaluate how successful each ECHO™ network was in achieving it aims and objectives. Methods Retrospective online survey designed specifically for each network issued to registered participants after the final ECHO™ session. Results Across the five networks, 45 ECHO™ sessions were delivered with 194 participants attending at least two. 27% (60/224) registered participants across each network responded to the survey. Overall, each network was successful in achieving its aims. The majority of participants reported increased knowledge and confidence in relation to the areas assessed. ECHO™ was identified as a suitable model for delivering education and the opportunity for case-based learning was valued. Direct impacts on practice included improved inter-agency working and networking, improved communication with patients and families, and improved confidence to manage similar cases in the future. Barriers to participation included time restraints due to staffing issues or workload. Conclusion Project ECHO™ may be an ideal methodology for delivering palliative care education and support to a range of practitioners. However, protected time for participation is recommended. Funders Health and Social Care Board NI/Hospice UK.

Background The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses the support needs of family carers. This carer-centred approach involves a change in practice from a practitioner to carer-led process of assessment and support. Training is needed to help practitioners transition to this new way of working, and implementation support is required at an organisational level (Austin, Ewing & Grande, 2017; Diffin, Ewing, Harvey & Grande, 2018; Diffin, Ewing, Harvey & Grande, 2018). An online training and implementation toolkit was therefore developed to provide accessible and structured guidance on how to implement and embed the CSNAT intervention. Aim To explore the feasibility and acceptability of delivering implementation training through an online format. Methods The online toolkit has two learning components: (1) Individual: knowledge for practitioners to use the intervention, (2) Organisational: to assist a project team to plan, pilot and sustain implementation. Five UK palliative care services participated; 2–4 practitioners from each completed the toolkit. Online survey administered upon completion of each learning component for feedback on content, followed by telephone interview. Results Fifteen practitioners completed ‘Learning component 1’ survey, 14 completed ‘Learning component 2’ survey, and 13 were interviewed. Feedback on content was positive. The most enjoyable aspects were the practical examples and the key steps to implementation being clearly detailed. The suitability of online learning was influenced by resource availability, the nature/size of the team, and individual learning styles. Variation in location of completion (work/home or both) was partly explained by availability of IT equipment, space, and time within the organisation. Whilst the majority of participants saw the value of online learning, some preferred face-to-face delivery, and so blended learning to include group discussions was deemed appropriate. Conclusions Whilst online learning is welcomed by practitioners, organisations need to give it the same priority as attendance at face-to-face workshops and ensure sufficient resources are available to enable completion. Blended learning may help accommodate different learning preferences. Funder NIHR CLARHC Greater Manchester.

Background The Carer Support Needs Assessment Tool (CSNAT) intervention comprises an evidence-based comprehensive tool incorporated into a person-centred process of assessment and support for carers of people with life-limiting conditions. It was developed from a programme of research, subsequently implemented across practice settings (community, hospital, hospice). The CSNAT’s impact nationally and internationally is substantial: 87 UK services are licensed to use the intervention, the tool has been translated into 13 languages, and is used in 27 countries. Aim To draw on the CSNAT intervention programme of research to illustrate why carer assessment needs to be comprehensive and person-centred, how this represents a change in practice, what difference it makes, and how this change in practice can be implemented. Methods/results We will draw on three aspects of the research programme: An overview of development, validation and initial implementation of the CSNAT: a qualitative study with 75 bereaved carers (01/2008–12/2008) identified the 14 support need domains that constitute the CSNAT; a survey of 225 current carers (04/2009–06/2010) established CSNAT’s content and criterion validity; implementation studies with 29 practitioners in two hospices (08/2010–12/2010; 01/2011–04/2012) identified use of the CSNAT as a significant change in practice and the importance of adopting a person–centred approach. Two cluster randomised control trials of the CSNAT intervention (UK: n=681 carers; 05/2012–11/2014); (Australia: n=322 carers; 03/2012–02/2014) showed a reduction in caregiver strain in current carers, and lower early grief and better physical/mental health in bereavement. A national implementation study in 36 organisations (11/2013–09/2014) and a hospice case study (11/2015–12/2016) provided key insights into practitioners’ training needs and vital organisational structures/processes needed to embed the intervention in practice, to underpin a CSNAT intervention Training and Implementation Toolkit. Conclusion This paper identifies the evidence base for the CSNAT intervention and lessons learnt about delivery of comprehensive, person-centred carer assessment and support for family carers.

Background Barriers and facilitators to implementation of comprehensive person-centred assessment and support within palliative care have been identified (Ewing & Grande, 2018). To address the challenges, an online toolkit was developed to provide organisations with structured implementation guidance for the Carer Support Needs Assessment Tool (CSNAT) intervention. However, feedback from practitioners undertaking previous face-to-face CSNAT intervention training and from online toolkit participants highlighted the benefits from follow-up support calls with the opportunity to ask questions and problem solve with their peers, the opportunity to build networks with other organisations completing the training, and having a point of contact to ask questions (Diffin, Ewing, Rowland, Grande, 2018). Currently there is no method for providing this additional support. Project ECHO™ (Extension for Community Healthcare Outcomes) is a tele-mentoring programme which uses video-conferencing to deliver best practice guidance and education from specialists, and case-based learning with opportunities for questions and discussion with peers, and therefore could overcome this gap. Aim To identify if Project ECHO™ could be used to establish a community of practice and support implementation of the CSNAT intervention. Methods and results We will draw on the CSNAT implementation evidence base to illustrate the importance of supporting practitioners to gain knowledge about how to use the CSNAT in practice, and enhance their confidence in carrying out assessments. In addition, we will reflect on the implementation support needed at an organisational level, to include practical guidance and opportunities for peer support. In turn, we will highlight how Project ECHO™ could be used to help overcome identified gaps in support through reflection on the core benefits of this methodology to include a curriculum identified by the network participants themselves, case-based learning, and the ability to join remotely. Conclusion This paper identifies how Project ECHO™ could be utilised to establish a community of practice to support implementation and embedding of comprehensive person-centred assessment and support for family carers into everyday practice.

Background Communication between young people (YP) with life-limiting conditions and healthcare professionals (HCPs) can be challenging, particularly during transition from children to adult services.1 Personal-health records (PHRs) have the potential to increase YP’s selfadvocacy2 yet have not been evaluated thoroughly with this population. Aim Use realist evaluation to test and refine a programme theory on how PHRs are thought to work with YP with a life-limiting condition. Methods Qualitative study informed by realist evaluation. YP aged 16–24 years old living in Northern Ireland with a life-limiting condition were invited to use a PHR; semi-structured interviews conducted at three, six and nine months to examine acceptability and use. Framework method used for analysis. Results Eight YP and two parents (on behalf of child) participated. 4/10 used the PHR; reasons included: (i) to help organise their care, (ii) feel more confident with communication, (iii) reduce the need to repeat details about condition(s)/medications, and (iv) manage health care when aspects of their lives were changing. PHR use depended on the level of need, desire for autonomy/self-management, and whether it brought benefits over how they currently managed their condition. Two additional contextual considerations which influenced PHR use were identified (i) YPs previous experiences in communication with HCPs, and (ii) the timing of the introduction of the PHR. Conclusion PHRs may be useful for YP who wish to become more independent over management of their healthcare but should be targeted towards those who identify a need, and their usage supported by HCPs. Funder Marie Curie.

Background Despite increasing demand, limited resources are often available to deliver high quality palliative care education. Project ECHO is a tele-mentoring programme that could address this disparity by using video-conferencing to deliver (i) best practice guidance and education from specialists, and (ii) case-based learning with peer discussion1. Five ECHO networks in Northern Ireland delivered palliative care education and support (Cardiology/Heart Failure, District nurses, Community pharmacy, Paediatrics, Marie Curie registered nurses). Participants set the curriculum and network aims and objectives, which included increasing participant’s palliative care knowledge and skills, enhancing confidence, improving collaboration, and facilitating peer support. 45 ECHO sessions were delivered across five networks with 194 participants attending ≥2. Aim Identify if each ECHO network achieved it aims and objectives. Methods Retrospective online survey designed for each network administered after final ECHO session. Results 27% (60/224) registered participants across each network responded. Overall, each network achieved its aims and objectives with participants reporting increased palliative care knowledge and increased confidence in managing end of life care scenarios. Benefits included case-based learning, professional networking, and avoidance of travel to access education. Participants reported improved communication with patients and families, and improved decision making in relation to patient care. Time restraints due to staffing issues or workload were identified as barriers to participation. Conclusion Project ECHO may be an ideal solution for meeting the demand for palliative care education across multiple settings. To ensure practitioners fully benefit, protected time for participation is recommended. Funders Health and Social Care Board/Hospice UK.

Community nurses play an important role in providing palliative care and support for patients and carers at home. The Carer Support Needs Assessment Tool (CSNAT) provides practitioners with an evidence-based comprehensive tool to use with carers in palliative home care. As a practice tool, the CSNAT uses a person-centred approach—that is, the process of carer assessment and support is facilitated by practitioners but is carerled. In this paper, the CSNAT research team provides an overview of the development of the tool and the benefits for both carers and practitioners arising from using the CSNAT as a person-centred approach in practice. The authors outline the five stages of the CSNAT approach to assist practitioners wishing to implement the CSNAT in practice.

Background: The Carer Support Needs Assessment Tool (CSNAT) intervention is an evidence-based, person-centred approach to carer assessment and support within palliative care. As such, it requires a change in practice from a practitioner- to a carer-led assessment and support process. A paucity of studies have investigated factors affecting implementation of evidence based interventions within palliative care. Objectives: To examine differences between high and low adopters of the CSNAT intervention in terms of practitioner attitudes to the intervention and organisational context.Methods: Phase IV study of implementation of the CSNAT intervention at scale in 36 UK palliative care services over six months. Survey at baseline and six months of practitioners at implementation sites, informed by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework. Survey tools: (i) questionnaire to assess attitudes to the CSNAT intervention; (ii) Alberta Context Tool (ACT) to assess organisational context. Monthly data on intervention use enabled service classification as ‘high’ or ‘low’ adopters. Results: 157/462 surveys returned at baseline; 69/462 at six months. Compared with ‘low’ adoption services, ‘high’ adopters were more likely to be hospice at home and day services; have a higher ratio of internal facilitators to total staff numbers; and higher scores for ACT ‘informal interactions’ denoting more discussions about care between colleagues. Both had similarly positive attitudes to the CSNAT intervention pre-implementation, but by six months ‘low’ adoption services developed significantly more negative attitudes; while in ‘high’ adoption services attitudes mostly remained the same/improved.Linking evidence to action: Implementation may be more successful for services that offer regular opportunities to use the intervention in practice, have sufficient levels of facilitators, stimulate more staff discussion, and encourage maintenance of positive motivation. Implementation of person-centred interventions needs to plan for such factors. This has informed an implementation toolkit for the CSNAT intervention.

It is important to ensure regional variances are considered when setting future end-of-life research priorities, given the differing demographics and service provision. This project sought to identify end-of-life research priorities within Greater Manchester (United Kingdom). Following an initial scoping exercise, six topics within the 10 national priorities outlined by The Palliative and end-of-life care Priority Setting Partnership were selected for exploration. A workshop involving 32 healthcare professionals and a consultation process with 26 family carers was conducted. Healthcare professionals and carers selected and discussed the topics important to them. The topics selected most frequently by both healthcare professionals and carers were ‘Access to 24 hour care’, ‘Planning end-of-life care in advance’ and ‘Staff and carer education’. Healthcare professionals also developed research questions for their topics of choice which were refined to incorporate carers' views. These questions are an important starting point for future end-of-life research within Greater Manchester.

BackgroundParents of infants admitted to the Neonatal Intensive Care Unit (NICU) are at risk of psychological distress and NICU-related stress. However, parents of infants admitted to NICU for cardiac surgery are an under-researched population.AimsIdentify levels of NICU-related stress, and levels of psychological distress, reported by parents of infants admitted to the NICU for cardiac surgery.Study designObservational study.Subjects69 parents of infants admitted to the NICU for cardiac surgery (cardiac group) and 142 parents of healthy infants (control group).Outcome measuresQuestionnaire packs provided to parents prior to discharge (time-point 1), and at six and 12 months corrected age included: Hospital Anxiety and Depression Scale, Coping Inventory for Stressful Situations, and Family Support Scale. The Parental Stressor Scale:NICU was administered to the cardiac group at time-point 1.ResultsThe cardiac group reported (i) that parental role alteration was the most stressful aspect of the NICU and (ii) higher scores for anxiety and depression than the control group at all three time-points, with the highest levels reported during the NICU stay. Correlation analyses indicated (i) stress associated with the sights and sounds of the NICU, and the appearance and behaviour of the infant in the NICU, had a significant positive association with anxiety and depression, and (ii) a significant negative relationship between anxiety and task-focused coping.ConclusionsAn individualised parent-targeted intervention aimed at reducing stress associated with the NICU and enhancing task-focused coping style may help to reduce levels of anxiety and depression within this group of parents.

Previous research with parents of preterm and low-birth weight infants admitted to the Neonatal Intensive Care Unit (NICU) has indicated the following: (i) parents are at risk of experiencing stress associated with the NICU environment; (ii) parents are at risk of short- and longer-term psychological distress; and (iii) the family is at risk of longer-term stress and strain. However, parents of infants admitted to the NICU for surgery are an under-researched population. This paper provides an overview of the current literature in relation to this issue. The results highlight the paucity of research conducted with parents of infants admitted to the NICU for surgery. A number of gaps and limitations were also identified in the current literature, including a lack of examination why some parents cope better than others, and a focus solely on parents of preterm and low birth weight infants. To conclude, further research with parents of infants who had surgery in the first few weeks of life is needed. Such information could help inform clinicians caring for these infants and their families, and would enable identification of those parents and families most at risk.

Background The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses family carer support needs towards end of life. This person-centred approach involves a change in practice from a practitioner – to carer-led assessment process. Numerous policies recommend carers’ needs should be addressed yet there is little guidance on how to achieve this within palliative care. To address this gap and assist a change to a carer-led process, an implementation strategy for the CSNAT intervention was developed, of which facilitation is key. Aims Investigate components of facilitation associated with successful implementation of the CSNAT intervention across a range of palliative/end-of-life care services. Methods Qualitative: Interviews three and six months post-CSNAT implementation with 38 practitioners with the role of CSNAT ‘champion’ (internal facilitation) in 32 services. Researcher field notes collected from teleconference support sessions with ‘champions’ (external facilitation). Results Successful implementation of the CSNAT intervention was associated with: utilising a teamwork approach to facilitation; the ‘lead champion’ having a leadership role in the service e.g. team manager; presenting a clear rationale why a change in practice was needed; reviewing progress and making changes to overcome identified barriers; ‘champions’ having good communication skills and authority to make changes. Larger services faced more barriers to facilitation e.g. difficulties with providing training to all staff and less frequent opportunities to review progress as a team. Aspects of context which constrained facilitation included the need to establish a new carer record, and organisational changes e.g. budget cuts, and a culture focused on the patient. In contrast, support from management was one aspect of context which assisted with facilitation efforts. Conclusions In addition to managerial support, establishing a team of practitioners to lead facilitation of the CSNAT intervention and regularly review implementation progress, is vital for implementation success. This study was funded by Dimbleby Cancer Care.

Introduction End-of-life (EoL) care is an under-researched area. It is vital to focus on the priorities that are likely to bring the most benefit to patients, carers, and their families. This project set out to identify the EoL research priorities of healthcare professionals (HCPs) and carers in Greater Manchester. Approach Following a scoping exercise of EOL services in Greater Manchester, comprising of semi-structured interviews with HCPs, CLAHRC GM identified six topics within the 10 national EoL research priorities outlined by PeolcPSP. The topics identified were those that we have the capability to deliver research in: Education and knowledge for staff and carers Access to 24 hour care and support Equitable Access Advance care planning Care at home Continuity of care CLAHRC GM held a priority setting event to consult with 32 HCPs and also held separate consultations with 26 carers facilitated by local carer groups from Manchester, Salford, and Bury during which HCPs and carers were asked to select their important priorities from the six topics. Outcomes Combining carer and HCP responses, the topics of shared priority were: Advance care planning (62% carers, 56% HCPs) Access to 24-hour care (65% carers, 50% HCPs) Education and knowledge for staff and carers (73% carers, 34% HCPs) Whilst all topics were generally viewed as important by carers, there was more emphasis placed on training and education as the main priority whilst HCPs focused more on advance care planning. HCPs also identified important research questions within their chosen topics. Next steps The shared priorities will be used to develop the research questions identified by HCPs and, through further carer input, will shape the EoL research delivered across Greater Manchester over the next few years.

IntroductionPatient-held records (PHRs) are proposed to improve communication and coordination of care amongst young people with life-limiting conditions their families and health professionals. However implementation of PHRs has proved difficult due to technical organisational and professional barriers.1AimsTo identify the factors which help or hinder the use of PHRs by young people with life-limiting conditions.MethodSystematic realist review. Literature was sourced from six databases: Medline Embase CINAHL PsychInfo The Cochrane Library Science Direct (from 1946 to December Week 1 2016). The web was searched to identify grey literature. Articles were sourced from reference lists of included studies. Data were extracted using a standardised data extraction form. Two reviewers completed data extraction and synthesis. Methodological rigor was assessed using the relevant Critical Appraisal Skills Programme (CASP) tool.ResultsNine articles were included each reporting on a different PHR. Young people (and/or parents/carers) with conditions of higher severity requiring ongoing care more medications and frequent appointments with multiple providers were more engaged with the PHR. Service providers need sufficient knowledge about the PHR and organisations need to ensure staff can see the benefits of using the PHR for implementation success. Mechanisms triggered by the PHR included improved self-advocacy and young people becoming empowered to self-manage their condition.ConclusionClear definitions of which young people would benefit from using a PHR must be established in order to direct resources accordingly. These definitions will help inform which organisations and service providers would see the most reward from PHR implementation.Reference. Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health records: A scoping review. Journal of American Medical Information Association2011;18(4):515–522.

IntroductionThe Carer Support Needs Assessment Tool (CSNAT) intervention requires a change in practice to a carer-centred process of assessment and support.1-3 An online toolkit was developed to guide palliative services through the process of implementing the CSNAT intervention.AimsExplore the feasibility and acceptability of delivering implementation training through an online toolkit format.MethodsThe online toolkit has two learning components: (1) Individual: knowledge for practitioners to use the intervention; (2) Organisational: to assist a project team to plan pilot and sustain implementation. Five UK palliative care services participated; 2–4 practitioners from each completed the toolkit. Online survey administered upon completion of each learning component for feedback on content followed by telephone interview.Results15 practitioners completed ‘Learning component 1’ survey 14 completed ‘Learning component 2’ survey and 13 were interviewed. Feedback on content was positive. Online learning suitability was influenced by resource availability the nature/size of the team and individual learning styles. Variation in location of completion (work/home or both) was partly explained by availability of IT equipment space and time within the organisation. Whilst the majority of participants saw the value of online learning some had a preference for face-to-face delivery and so blended learning to include group discussions was deemed appropriate.ConclusionsWhilst online learning is welcomed by practitioners organisations need to ensure sufficient resources are available to enable completion and that it is given the same priority as attendance at face-to-face workshops. Blended learning may help accommodate different learning preferences.FunderNIHR CLARHC Greater ManchesterReferences. Ewing G, Grande G. Development of a Carer Support Needs Assessment Tool (CSNAT) for end-of-life care practice at home: A qualitative study. Palliative Medicine2013;27(3):244–56.. Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study. Journal of Pain and Symptom Management2013;46(3):395–405.. Ewing G, Austin L, Diffin J, Grande G. Developing a person-centred approach to carer assessment and support. British Journal of Community Nursing2015;20(12):580–4.

Objective.To examine the pattern of disease severity in patients with rheumatoid arthritis (RA) at presentation to the Norfolk Arthritis Register (NOAR) over 20 years.Methods.NOAR is a primary-care–based cohort of patients with recent-onset inflammatory polyarthritis. At baseline, subjects are assessed and examined by a research nurse. The Health Assessment Questionnaire (HAQ) is administered and the DAS28 (28-joint Disease Activity Score) is calculated. Information is collected on disease-modifying antirheumatic drug exposure. In this study, patients (symptom duration of < 2 years at baseline) were grouped into 4 cohorts (Cohort 1: 1990–1994; Cohort 2: 1995–1999; Cohort 3: 2000–2004; Cohort 4: 2005–2008). The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 criteria for RA were applied retrospectively at baseline. Regression analyses were used to examine whether calendar year of presentation to NOAR was associated with baseline HAQ and DAS28 scores. Potential confounders included age at symptom onset, sex, rheumatoid factor, and anticyclic citrullinated peptide antibody positivity.Results.A total of 1724 patients met the ACR/EULAR 2010 RA criteria at baseline. Unadjusted mean DAS28 scores decreased over time. Calendar year of presentation to NOAR was significantly associated with lower DAS28 scores over time [Y = 4.51 + (–0.56 × year) + (0.44 × year2)]. Although unadjusted median HAQ scores increased over time, calendar year of presentation to NOAR was not significantly associated with HAQ scores [Y = (1.1) + (0.023 × year) + (0.05 × year2)]. Similar results were observed in each subpopulation of patients.Conclusion.While baseline disease activity has lessened slightly over time, there has been no improvement in baseline levels of functional disability.

Background The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses family carer support needs towards end of life.1–3 This person-centred approach involves a change in practice from a practitioner- to carer-led assessment process. Numerous policies recommend carers’ needs should be addressed yet there is little guidance on how to achieve this within palliative care. To address this gap and assist a change to a carer-led process, an implementation strategy for the CSNAT intervention was developed, of which facilitation is key. Aims investigate components of facilitation associated with successful implementation of the CSNAT intervention across 36 palliative care services. Methods Qualitative: Interviews three and six months post-CSNAT implementation with 38 practitioners acting as CSNAT ‘champion’ (internal facilitation) in 32 services. Researcher field notes collected from teleconference support sessions with ‘champions’ (external facilitation). Results Successful implementation of the CSNAT intervention was associated with: a teamwork approach to facilitation; the ‘lead champion’ having a leadership role in the service e.g. team manager; presenting a clear rationale why a change in practice was needed; reviewing progress and making changes to overcome identified barriers; ‘champions’ having good communication skills and authority to make changes. Aspects of context which constrained facilitation included the need to establish a new carer record, and organisational changes e.g. budget cuts, and a culture focused on the patient. Management support assisted with facilitation efforts. Conclusions Establishing a team of practitioners to lead facilitation of the CSNAT intervention and regularly review implementation progress, is recommended to help ensure implementation success. References Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study. J Pain Symptom Manage 2013;46(3):395–405 Ewing G, Grande G. Development of a Carer Support Needs Assessment Tool (CSNAT) for end-of-life care practice at home: A qualitative study. Palliat Med 2013;27(3):244–256 Ewing G, Austin L, Diffin J, Grande G. The Carer Support Needs Assessment Tool: A person centred approach to carer assessment and support. Br J Community Nurs 2015;20(12):580–584

Introduction End-of-life (EoL) care is an under-researched area. It is therefore vital to focus on priorities that are likely to bring the most benefit to patients, carers, and families. Aim This project aimed to identify EoL research priorities of Healthcare Professionals (HCPs) and carers in Greater Manchester. Methods Following a scoping exercise of EOL services in Greater Manchester, CLAHRC GM identified six EOL local research topics for further exploration within the 10 national priorities outlined by PeolcPSP. Education and knowledge for staff and carers Access to 24-hour care and support Equitable Access Advance care planning Care at home Continuity of care CLAHRC GM held a priority setting event to consult with 32 HCPs and separate consultations with 26 carers facilitated by local carer groups from Manchester, Salford, and Bury. Carers and HCPs selected their priorities from the topics. Results Combining carer and HCP responses, the topics of shared priority were: Advance care planning Access to 24-hour care Education and knowledge for staff and carers Whilst carers emphasised training and education as the priority and HCPs focused more on advance care planning, it was clear that all topics had importance to both groups. HCPs also identified important research questions within their chosen topics. Conclusions This study provides successful procedures for engaging with stakeholders to develop local priorities to guide EoL research of relevance to HCPs and user representatives. Reference Brereton L, Ingelton C, Gardiner C, et al . Lay and professional stakeholder involvement in scoping palliative care issues: methods used in seven European countries. Palliat Med 2016

Background The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses family carer support needs towards end of life. 1–3 A paucity of studies has investigated how to successfully implement evidence based interventions within palliative care. Aim Investigate how staff attitudes and organisational context affect implementation of the CSNAT intervention in palliative care. Methods 36 UK palliative care services participated. Staff surveys measured attitudes and context prior to, and six months after the implementation began including (i) a questionnaire assessing staff attitudes to the CSNAT; (ii) The Alberta Context Tool (ACT) assessing organisational context. Data on use of the CSNAT intervention were collected over six months; services were classified as ‘high’ or ‘low’ adopters on this basis. Relationships between service characteristics, aggregate data on staff attitudes and organisational context, and level of adoption were analysed. Results 157/462 surveys were returned at baseline and 69/462 at six months. Level of adoption depended on service type. ‘High’ adopters had a higher ratio of intervention ‘champions’ to total staff numbers and higher scores for ACT ‘informal interactions’ (e.g. more discussions with colleagues about patient care), compared to ‘low’ adopters. Both groups had similarly positive attitudes to the CSNAT intervention pre-implementation. By six months attitudes for ‘low’ adopters were significantly more negative, but remained similar or improved for ‘high’ adopters. Conclusions Ensuring successful implementation of complex interventions within palliative care requires consideration of the organisational context, service type, strategies for maintaining positive staff attitudes over time, and the use of intervention ‘champions’. References Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study. J Pain Symptom Manage 2013; 46 (3):395–405 Ewing G, Grande G. Development of a Carer Support Needs Assessment Tool (CSNAT) for end-of-life care practice at home: a qualitative study. Palliat Med 2013; 27 (3):244–256 Ewing G, Austin L, Diffin J, Grande G. The Carer Support Needs Assessment Tool: A person centred approach to carer assessment and support. Br J Community Nurs 2015; 20 (12):580–584

Background Relatively few studies have assessed sustained remission over a follow up of more than three years and at multiple time points to identify predictors and consequences of remission in patients with inflammatory polyarthritis (IP) and its subset rheumatoid arthritis (RA). Objectives To assess: i) which baseline clinical and demographic factors are associated with achieving persistent remission (PR), intermittent remission (IR) or never achieving remission (NR) in patients with IP and ii) the association between achieving PR, IR or NR on functional disability progression. Methods Patients aged >16 yrs with recent onset IP (≥2 swollen joints lasting for >4 weeks and symptom duration Results 868 patients were included in this study; 65.8% female, mean age at symptom onset 55.9 (SD 14.6) yrs and median disease duration 6.5 [IQR 4.1 to 11.1] months at baseline. The number (%) of patients achieving NR, IR and PR was 471 (54.3), 296 (34.1) and 101 (11.6), respectively. In univariate analysis, female sex, higher number of swollen or tender joints, satisfying the 2010 RA criteria, higher HAQ and DAS28-CRP scores, having at least one comorbidity, being hypertensive, depressed or obese at baseline were all associated with lower odds of being in a higher remission group (fig 1). Female sex, higher number of tender joints, CRP, DAS28, HAQ, time from symptom onset to starting DMARD treatment and being hypertensive at baseline were independently associated with lower odds of being in a higher remission group in a multivariate model. IR and PR were associated with a reduced HAQ score compared to NR (referent), adjusted β (95% CI) for IR and PR -0.51 (-0.60, -0.43), -0.85 (-0.98, -0.72) respectively, p Conclusions Only 11.6% of patients achieved PR during a five year follow up. As well as clinical and demographic factors, comorbidities at baseline were significantly associated with reduced probability of remission. Benefits of remission in terms of improved functional disability were seen, supporting the “treat to target” strategy. Acknowledgements This work was supported by GlaxoSmithKline and Arthritis Research UK. Disclosure of Interest None declared

Background Previous research has suggested that the severity of rheumatoid arthritis (RA) has decreased over time. Objectives To examine the pattern of disease severity in patients with inflammatory polyarthritis (IP) at time of registration into the Norfolk Arthritis Register (NOAR). Methods NOAR is a primary-care-based cohort of adults with recent onset IP (≥2 swollen joints lasting for >4 weeks). Disease related information collected at baseline includes 51- swollen and tender joint counts, HAQ, and DAS28. Blood is collected and C - reactive protein (CRP), Rheumatoid Factor (RF), and Anti-Citrullinated Peptide Antibodies (ACPA) are measured. In this study, patients with a symptom duration of Results In total 3045 patients were evaluated: Cohort 1=1022; Cohort 2=883; Cohort 3=631; Cohort 4=509 (Table). Calendar year of assessment was a significant predictor of lower DAS28 scores over time for the total sample (adjs= -0.0007, 95% CI -0.001, -0.0001), and each sub-sample, indicating improved disease activity over time. Within the total sample, and the DMARD naive sub-sample, there was a significant effect of ‘Cohort’, and a significant ‘Calendar year by Cohort’ interaction indicating the rate of change in DAS28 scores over time differed between cohorts. Calendar year of assessment was not a significant predictor of HAQ scores for the total sample (adjs=0.0002, 95% CI -0.0002, 0.001), and was also a significant predictor of increased HAQ scores for the sub-sample who met the ACR/EULAR 2010 RA criteria, indicating no improvement in functional disability over time. Conclusions Baseline disease activity has decreased over time and may not be solely attributable to the increased use of DMARDs. However, there has been no improvement in levels of functional disability. Acknowledgements Funded by Arthritis UK and GlaxoSmithKline Disclosure of Interest None Declared

Background The prognosis for patients with inflammatory polyarthritis (IP) varies and it is difficult to identify at onset which patients will ever achieve remission. Objectives To examine the disease characteristics at i) baseline and ii) five years of patients who persistently, intermittently, or never achieve remission within the Norfolk Arthritis Register (NOAR) over five years. Methods NOAR is a primary-care-based cohort of adults with recent onset IP (≥2 swollen joints lasting for >4 weeks). Disease related information collected over 5 years includes 51- swollen and tender joint counts, HAQ, and DAS28. This study included patients recruited between 2000 to 2004 with a symptom duration of Results Group NR had the highest disease severity at baseline (Table). Group PR were significantly more likely to be on DMARDs at baseline, but the duration on DMARDs at baseline did not differ significantly between groups. Patients with higher HAQ scores (adjs=0.44, 95% CI 0.07, 0.80) or DAS28 scores (adjs=0.47, 95% CI 0.26, 0.68) at baseline, were more likely to be in the IR or NR group. There was a significant effect of remission group on 5th year HAQ scores (p Conclusions A small proportion of patients achieved persistent remission, and patients in this group were more likely to have had DMARD treatment at baseline. Acknowledgements Funded by Arthritis UK and GlaxoSmithKline. Disclosure of Interest None Declared