Joining the Dots’ in Bristol – A collaboration between AWP MH Trust and Otsuka Healthcare Solutions (ARCHIVED)

“Joining the Dots” uses technology to enable community mental health services to work in a more joined-up way by helping to predict unplanned care risks earlier and empowering service users with tools for co-producing their own care plans. Following a change in the way community services were being delivered, Otsuka Health Solutions and Bristol Mental Health worked together to support service users and staff to use the data available to them to improve care.


  • From start: Yes
  • During process: Yes
  • In evaluation: Yes


  • Peer: Yes
  • Academic: Yes
  • PP Collaborative: Yes

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What We Did

“Joining the Dots” uses technology to enable community mental health services to work in a more joined-up way by helping to predict unplanned care risks earlier and empowering service users with tools for co-producing their own care plans. Following a change in the way community services were being delivered, Otsuka Health Solutions and Bristol Mental Health worked together to support service users and staff to use the data available to them to improve care in three main ways:

1. Care Pathway Tool – a recovery focused digital platform which empowers service users to work with staff and carers to co-produce care plans, improving their experience and reducing the need to repeat their story multiple times. The aim was to enhance overall health and wellbeing by supporting a service user to understand warning signs, map their support network and plan to do more of the things that keep them well.

2. Risk Profiling Approach – Through exploring large quantities of information OHS have developed a risk propensity algorithm which helps to identify service users who are most likely to have a crisis or relapse and therefore require higher levels of skill and resource.
A collaborative project team (including patients and frontline staff) worked together to develop the Management and Supervision Tool (MaST) which improves understanding of the caseload requirements and the skills and resources needed to meet service user needs.
The risk profiling approach is used in combination with complexity factors to provide a clear view of the numbers of service users requiring higher levels of intervention from staff with more clinical knowledge or experience and those who might be prepared for discharge.

3. System Dashboard and Pathways Approach
The system level approach included two pieces of work:
• The system dashboard was built on the requirements of the 14 services involved in delivering mental health care. Each service identified up to 9 Key indicators across the 5 CQC domains. These were built into a dashboard that enabled services to easily monitor performance, capacity, and flow through the service. It provided an understanding of system dynamics and was reviewed in operational meetings
• The pathways approach underpinned the system’s understanding of the journey for different diagnostic groups through the services. The analysis highlighted key differences across pathways, with the aim of identifying the best outcomes and areas of inefficiency within the system.

Wider Active Support

The reason these digital solutions reflect the requirements of healthcare workers and people who use services is because of the collaboration between multiple groups including Avon and Wiltshire Mental Health Partnership Trust (AWP), Rethink Mental Illness, Otsuka Health Solutions and Bristol Mental Health (which is itself a collaboration between AWP, Second Step, Missing Link, Nilari, Richmond Fellowship, St Mungos).

We achieved the active support through:
• A Joint Project Board held monthly with broad representation from the groups to review progress and help make decisions about the project
• Whole System events were held twice during the project so the wider community could learn about the project, ask questions and feel involved
• Involving people in the testing and evaluation of the solutions meant that staff and service users felt empowered to make changes and felt some ownership of the final products
• A service user and carer project group (11 people currently using services, carers, and people with lived experience) met fortnightly to support the project with activities described below in the co-production section.


Throughout the project service user engagement and coproduction has been a core element of the project with support from Rethink Mental Illness throughout 2016. Examples of service user engagement include:

• Integral part of the design groups for both the Care Pathway Tool and Risk complexity work
• Weekly service user group involvement taking responsibility for delivery of 2 substantial pieces of work:
1. development of an NHS funded animation on co-production
2. designing training to familiarise other service users with the digital care planning approach)
• ‘You said we did’ feedback loop to demonstrate the difference made by service users
• Holding regular and routine design meetings with service user consultants and healthcare workers to ensure that the language and functionality of the end product reflects the users expressed needs.
• Presenting the values of collaborative working at a system wide event which allowed service users across Bristol to showcase their contribution to wider Trust members, and demonstrate the immense value that adopting a coproduction approach adds.
This approach has been recognised outside of Bristol at a national level with:
• An NHS England Community engagement award – this has provided a grant award to develop an animation which showcases the approach to developing digital tools in co-production (to be released shortly through the Rethink and NHS England website)
• Members of the service user group speaking about the benefits of co-producing digital solutions at two separate conferences led by Human Rights Foundation and Social Care Institute of Excellence
• In June 2016 two focus groups were held to gain feedback from service user involvees on their experience of co-production which helped shape the work in the latter half of the year. The report helped identify areas of development as well as highlighting the huge amount of value that both service users had personally gained from being involved.

We have forged close relationships with all stakeholders throughout the project development, placing them at the centre of the design. This was to ensure that we heard stories and use cases from service users, healthcare workers, managers and senior leaders within the organisation, Service User representatives at Bristol CCG, and representatives of special interest groups at national level. We also worked with organisations within Bristol who sit on the margins of direct care delivery such as independent networks and healthcare academics to widen our feedback network.

The approach has centred on the following 5 steps:
• Listen to staff and service users describe their experiences
• Develop and prioritise staff and service user stories
• Design and develop a solution
• Seek feedback from end users
• Review, adapt, design and develop

We regularly reviewed the impact that service users felt they were having on the project which pulled out some great experiences
One of our service users involved in the project team having never used a tablet device came in smiling to one of the meetings proud to be the owner of his own android device. The exposure he had had to technology from being part of the project team had given him the confidence to go out and purchase his own tablet enabling him to feel more connected to friends, family and information.

There have also been many stories about the difference it has made to people involved in the project.

One particular quote from a service user on our project team shares their experience:
‘It makes you feel that your views and your opinions count and they’re being listened to and thought about. I think that it’s been very uplifting for everyone in the group and it raises your self-esteem because you still do feel that you’re worthwhile and somebody cares’

By taking this approach we were able to rapidly develop solutions based on service user and staff needs, test the interpretation and get rapid feedback on early prototypes.

The approach also helped develop a team of solution advocates that could champion the use in practice

Looking Back/Challenges Faced

As with any project there were some exciting challenges to overcome in order to deliver the project.

1. Balancing the fantastic willingness from service users and staff to become involved in the project with day to day work and existing commitments. This meant it was sometimes difficult to find times to get everyone together
• We overcame this by varying our style of communication often collecting feedback through one to one conversations, focus groups and telephone conversation. If we were to do it again we would build a bigger network and explore innovative ways to keep people involved at a time that suits them without the need to travel

2. Demonstrating health outcomes and whole system impact in a short period of time was difficult
• We tackled this challenge by running a number of focus groups, 1:1 interviews and formal evaluation. This enabled us to capture impact on individuals and the value to service users and staff in helping them to co-produce care plans

3. Integration with other IT systems
• An on-going challenge was the ability to draw in information from a number of different systems used by different organisation delivering services. We minimised the impact of this by working closely with service leads to increase understanding, pulling data where we could through an automated feed and filling gaps with a simple manual process


The first 18 months has enabled us to co-develop solutions based on the needs of service users and front line staff.

The next 12 months we will start to share this work in other parts of the UK enabling us to continue to grow and develop a solution that meets local needs:
• We have already started to share experiences with other Mental Health Trusts
• We are testing the transferability of the algorithm with support from a team at Kings College London
• Continue to work with rethink to ensure approach to co-production is robust
• We will take the proof of concept and apply for a number of innovation funds to help with diffusion across the NHS

Evaluation (Peer or Academic)

Joining the Dots has been reviewed in a number of ways to evaluate the impact of the project on services:

1. CLAHRC West (Collaboration for Leadership in Applied Health Research and Care) – Formal evaluation carried out through the national institute for research reported in December 2016
2. Interviews with Service users by an Independent Researcher to explore improvements in experience
3. Rethink Mental Illness report on coproduction and impact



Overall, the OHS approach and development of solutions has been reported to be valuable within Bristol Mental Health and positive results have been observed in the adoption of risk analytics to inform and provide structure for important service development programmes such as the skill mix review and triage and access project.

Summary of CLAHRC evaluation report
• Change in referral to assessment and referral to treatment – reduction in RTA and RTT times of approximately 14 days
• Improvement in allocation of appropriately qualified care coordinators – 26% increase in the chance of allocation of a care coordinator appropriate to the level of risk
• Accuracy of the risk profiling in identifying high risk service users – in a retrospective data review, 65% crisis events had been profiled in the highest risk category. In a clinical case review exercise, clinicians reviewed 97 records – 4 people subsequently relapsed and 3 of these had been identified as the highest risk using the algorithm. On going improvements to the risk profiling work have already started to improve accuracy further..
• Care Pathway Tool – staff interviewed reported that the tool was valuable in sessions with service users by adding structure and visual materials that helped facilitate conversations. The ability for staff to produce progress notes with service users was felt to not only enhance the quality and transparency of the these notes but also save time in carrying out routine administrative duties
• Effectiveness: The main benefits of both tools seemed to be efficiency. The Care Pathway Tool taking less time, increasing time with service users and enabling mobile working Profiling analytics may have helped referral to treatment times and appropriate allocation of staff (qualified/unqualified).
• Responsiveness: The CPT seemed helpful in particular for service user led care planning and enhancing the discussions to include things that were helpful but that the clinician may have missed. The inherent ‘power balance’ in the interview-notes-opinion process seemed to be improved through joint completion of the CPT.

Service User Interviews (carried out by Healthcare Research Partnership)
Overall experiences of using the Care Pathway Tool were positive.
The benefits of a digital tool became obvious quickly, providing a visual and easily accessible method of recording and sharing information in a succinct and inclusive way, with the potential to reduce repetition.
The tool enables documentation of personal information, promotes transparency and encourages ownership of a care plan. As a working tool that can be changed iteratively, the tool gives the service user greater control over the management of their care plan and should have a positive impact on trust between service users and healthcare workers. For the above reasons, all service user involvees would happily recommend the Care Pathway Tool to friends or family.



We are a small team but try to share our work by speaking at conferences and sharing case studies. Last year we received a commendation from HSJ awards for ‘Innovation in Mental Health’ and a ‘Community engagement grant for co-production’ with service users from NHS England.
We also presented a poster at the NIHR MindTech conference and ran a workshop at NHS Health and Care Innovation Expo 2016.
In 2017 we plan to step up our sharing of positive practice and lessons learnt by:
• Providing a website to give people easy access to the work that’s been done
• Presenting at a number of conferences including Innovation Expo 2017
• Working with the Positive Practice collaborative and inclusion in the directory (hopefully)
• Working with Academic Health Science Networks
• Expanding the roll out of the solution through work with new partners and Mental Health Trusts
• Submitting case studies to be included on the Mindset Quality Improvement website.

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