Realistic Medicine and Value Based Health and Care Casebook

Innovation and Improvement

Supporting a culture of innovation and improvement will help us to make the changes that are needed happen.

Value Based Health and Care has its foundations firmly in the practice of evidence based medicine. That means not only must we adopt the best international evidence available but when delivering health and care services, we must also apply sound clinical judgment and empower people by truly understanding what matters to them.

By practising Realistic Medicine, by embracing continuous improvement and by innovating, we will deliver better value care.

The case studies that follow demonstrate how we can improve and innovate to deliver Value Based Health and Care.

Delivering a Person Centred Scottish National Service for GEPNET

Scotland’s National Service for treating people with progressive gastroenteropancreatic neuroendocrine tumours (GEPNET) was established in 2019. It follows the principles of Realistic Medicine, focusing on a personalised approach to care through shared decision making, reducing unnecessary interventions, and tackling unwarranted variation in care. By personalising care and fostering collaboration, we aim to achieve the outcomes that matter to the people we care for while minimising harm and waste.

GEPNET focuses on providing:

A Collaborative, Safety Focused Approach – The service is built on close collaboration with a multidisciplinary team, particularly the Nuclear Medicine Team, to ensure continuity of care and agreed standards. The Nuclear Medicine team follows national standards for diagnostics and therapeutics, adhering to NHS Greater Glasgow and Clyde (GGC) health and safety policies through local procedures and protocols. Its compliance is externally reviewed by the European Neuroendocrine Tumour Society (ENETS) Centre of Excellence accreditation, requiring annual data submissions and in-depth audits every five years, with the last review conducted on 4th October 2024, which confirmed standards were met.

Several Standard Operating Procedures (SOPs) have been developed to safeguard patient safety and maintain consistency in care delivery. These SOPs include criteria for referral, ensuring that decisions about fitness for treatment are based on clinical evidence, minimising radiation risks, and monitoring heart and kidney function. This careful attention to evidence based practice helps ensure patient safety and reduces treatment risks for the people we care for, which reflects the Realistic Medicine ethos of avoiding harm and unnecessary variation in treatment by underpinning guidelines on a strong medical evidence base, national standards for radiation protection, individual preferences and clinical judgement.

Shared Decision Making and Personalised Care – Patient selection is conducted during the West of Scotland multidisciplinary team (MDT) meeting, where joint decision making plays a key role. The MDT carefully reviews each patient’s case, ensuring that treatment decisions are made collaboratively and in line with the people’s needs and circumstances. This process empowers people to be at the centre of their care by giving them the opportunity to consider the benefits and risks of their treatment options.

People are invited to meet with the Consultant responsible for their treatment and a dedicated Nurse Specialist. During these consultations, people receive comprehensive information about their treatment options, ensuring they can make informed decisions. This approach is a cornerstone of Realistic Medicine and is the foundation of the personalised care we provide. Our approach ensures that the people we care for are active participants in their treatment journey.

Ongoing Support and Coordination – Throughout the five month treatment, our dedicated Nurse Specialist plays a crucial role in providing ongoing support, clinical assessments, and information to the people we care for. This ensures that people feel informed and supported at every stage of their care. Additionally, the Nurse Specialist coordinates with the person’s local consultant and GP to ensure continuity of care and effective management of their overall health. This collaboration reduces unnecessary hospital visits, improves communication between health and care providers, and enhances the overall experience for the people we care for. Simply put, kind and careful care is delivered through this approach.

So, what is the impact of delivering this care?

Measuring Patient Experience and Outcomes – Patient-Reported Experience Measures (PREM) and Patient-Reported Outcome Measures (PROM) are collected for all of the people we care for.

The PREM is based on the Scottish Government/Macmillan Cancer Patient Experience Survey, while the PROM uses the validated EORTC Quality of Life Questionnaire with a GEPNET-specific appendix. These tools provide valuable insights into patient satisfaction and quality of life, ensuring that the service continually improves and evolves in response to the needs of the people we care for.

The following are examples and outcomes of PREM questions:

1.Did you feel involved in making the decision to start treatment? 90% of patients responded positively to this question with 10% stating they didn’t remember.

2.Overall, did you feel you were treated with respect and dignity while you were attending the Beatson for treatment? 100% responded positively.

Impact on Patient Wellbeing – The PROM and PREM data consistently show high levels of patient satisfaction, with many people reporting an improvement in their quality of life after treatment. While some people do not experience a marked change in their physical wellbeing (as many are not clinically unwell), a significant reduction in anxiety and improved quality of life are frequently reported. This focus on improving not only physical outcomes but also psychological wellbeing highlights our commitment to treating the whole person – which is central to practising Realistic Medicine

Scotland’s National Service for GEPNET is an exemplary model of Realistic Medicine in action. Through collaboration, shared decision making, and a commitment to personalised care, the service places people at the heart of their treatment journey. By continually using people’s feedback and outcome measures to guide care improvements, the service remains responsive to the needs of the people we care for, ensuring that care personalised to what matters to them. This approach not only improves quality of life but also embodies the practice of Realistic Medicine.

NES Value Based Health and Care Case Study

In 2019, the Citizens’ Jury on Shared Decision Making released a report recommending that all health and care professionals receive training in shared decision making. This training should focus on skills such as active listening, people skills, power-sharing, and awareness of hierarchical challenges. This recommendation directly influenced the development of the Value Based Health and Care (VBH&C) Action Plan, with Action 1 committing the Scottish Government and NES to work with NHS Boards, education providers and wider partners to inform the education, training and tools to support delivery of kind and careful care, and the day-to-day practice of Realistic Medicine.

The Auditor General has recommended that Scottish Government and NHS Boards work together to deliver the VBH&C Action Plan.

To create effective Realistic Medicine learning resources, NES have engaged with Subject Matter Experts (SMEs) across various professional groups and health and care systems through the Realistic Medicine Network. This has ensured the development of high quality, evidence based educational materials that adhere to best practices and accessibility standards. NES has also implemented a communication plan to widely share and promote these resources through key networks, including the Realistic Medicine Network, professional bodies, and Higher Education Institutions (HEIs).

Training Products

Working closely with Scottish Government and Subject Matter Experts, NES developed a suite of training and education products, accessible via the TURAS platform through QR codes or direct links.

Figure 15.

• Realistic Medicine resources include: eight animations, five Sway presentations, and two eLearning modules designed for both the existing and future workforce.
• VBH&C Finance Toolkit tailored for finance professionals.
• Managing Risk resource, currently in development.
• Ongoing collaboration with multiple HEIs to integrate VBH&C and Realistic Medicine content into undergraduate and postgraduate curricula, including midwifery, allied health professions (AHPs), and pharmacy programmes.
• Lecturer’s slide pack shared with HEI faculty to facilitate the inclusion of Realistic Medicine and VBH&C content in existing courses.
• Integration of Realistic Medicine and VBH&C content within NES directorates and training programmes.
• Inclusion of Realistic Medicine and VBH&C topics in the Non-Executive Induction Programme.
• Quarterly data reports distributed to health boards detailing the uptake of NES Realistic Medicine training resources.

Uptake of NES Learning Resources

The Realistic Medicine Network and NES actively promote and monitor the uptake of its learning resources. Key engagement strategies include:

• Circulating national and local level data reports.
• Distributing newsletters and flyers.
• Promotion at conferences.
• Promoting training via various courses.
• Social media.
• Encouraging signposting via NES and Realistic Medicine networks.

Scottish Government also reinforces the importance of training by incorporating its promotion into the Chief Medical Officer’s annual report and making it a requirement in NHS Boards’ local RM action plans and Annual Delivery Plans.

In January, the Scottish Government conducted a survey to assess health and care professionals’ perceptions of Realistic Medicine. Over 1,800 professionals responded, with 50% identifying a lack of training as a major barrier to practising Realistic Medicine. This is notable, and highlights the absolutely crucial role that developing the right training and education tools has in supporting our health and social care professionals to achieve the outcomes that matter to people.

However, the survey also revealed that while only 13% of respondents had completed Realistic Medicine training, 57% of those who had, reported increased confidence in applying Realistic Medicine principles.

If health and care professionals aim to deliver kind and careful care effectively, engaging with the training available on TURAS is essential. Increasing awareness and accessibility of these training resources remains a priority for NES, NHS Boards, and Health and Social Care Partnerships (HSCPs) to ensure that health and care professionals feel supported in their learning and practice.

KIDZMEDS

Liquid medications taste bad, are tricky to manage around day-to-day life, are expensive and have a negative environmental impact. However, the majority of children are prescribed liquids as routine despite pill-swallowing being a life skill that is easy to learn from the age of 4 or 5 years.

Kidzmed Glasgow is an initiative to support children and their families to learn to swallow pills and to assist health and care professionals to consistently review children’s medication and switch from liquid medications when possible. It builds on success of the original Kidzmed project in the Great North Children’s Hospital, Newcastle which has won the NHS Sustainability Award, the Health Service Journal Value Award for Pharmacy and Optimisation and the Bright Ideas in Health Award.

The Glasgow project took place in the paediatric Cystic Fibrosis (CF) clinic, where the majority of children are on multiple medications which are vital for their health. The CF QI team developed a data collection sheet used in each clinic over 4 months.

Almost 100 children aged 4 years and over had a medication review. Many children with CF are taught to swallow tablets around school age to facilitate the use of Creon capsules at school, as these enzymes are required every time they eat. Despite this, almost a third of the children reviewed were able to either switch at least one medication from suspension (as they could already swallow pills) or were eligible to learn to swallow pills

”Pill switching packs” to facilitate the process for those who needed to learn the skill of pill swallowing were produced with support of Glasgow Children’s Hospital Charity (GCHC).

So far, there has been a 100% success rate with the packs with most families happy to learn at home. When learning at home was more challenging, for example, when parents themselves have difficulties swallowing pills, the hospital based play team offered support. Teaching children to swallow pills often only takes from a few minutes to half an hour.

Our project has had very positive feedback from patients and families with one parent commenting, “It’s like a weight lifted that I didn’t know we had. Life is so much easier without so many liquid medicines to contend with daily.”

The switch to kids being able to take tablets has several advantages.

• Convenience: pills eliminate the need for refrigeration and are easier to carry.
• Independence: for school-aged children, tablets simplify routines when they aren’t with their parents or carers.
• Cost-effectiveness: tablets are often much less expensive and more widely available.
• Accuracy: pill dosing is more precise.
• Sustainability: reduced packaging helps the environment and reduces waste.

This initiative has now expanded to other hospital departments, including haematology/oncology, where it could be particularly transformative for children using nasogastric tubes for liquid medication. Many large syringes of medicine could be replaced with just a few pills, potentially leading to the removal of NG tubes, when not needed for nutrition.

One month of oncology patient’s medication

Equivalent medication in tablet form

The challenge now is to understand the barriers to prescribing tablet medication across the hospital and to use this knowledge to develop education and training programmes for staff.

Beyond the hospital, the aim is to reinforce a broader societal opportunity across Scotland: teaching pill swallowing techniques to adults and children alike, improving patients and families quality of life, decreasing the environmental impact of medications and saving the NHS significant resources.

Kidzmed Resources

KidzMed - elearning for healthcare

Teaching your child to swallow tablets: Healthier Together

Quality and Value Improvement Skills Courses (QVIS) at NHS National Services Scotland

Implementing Value Based Health and Care requires knowledge and skills. NHS Services Scotland (NSS) developed a quality and value improvement skills (QVIS) training course to build capacity and capability in quality and value improvement. Participation in the course came with the expectation of working on live projects and incorporated organisational sponsorship and line manager support. The course supported NSS’s purpose of providing national solutions to improve the health and wellbeing of the people of Scotland and was aligned to their strategic priorities.

Two QVIS courses have been completed since 2023 involving 28 participants. Course delivery was hybrid, in-person / virtual employing varied training formats: lecture/information transfer, demonstration and modelling, practice exercises, exercises in application, coaching and review.

Importantly, formative and summative evaluation were incorporated into the course design from the start. The second QVIS course was modified to incorporate learning from the first course. Tight and specific learning objectives underpinned every session. All bar one participant completed the course and presented their experiences, learning and journey to their peers, executive leaders, sponsors and line managers at a course celebration event.

The Kirkpatrick Model is a framework used to evaluate the effectiveness of training in the QVIS course across four levels: reaction, learning, behaviour, and results.

Participant response was overwhelmingly positive with 100% satisfaction (73% highly satisfied, 27% being satisfied). Self-evaluated change in knowledge and confidence showed significant improvements.

Participants on the NSS Quality and Value Improvement Skills course applied their learning to projects they were involved in delivering. Two projects demonstrated highly impactful changes (Kirkpatrick Level 4) with significant and sustained transformations in quality and value which is a huge achievement after such a short time. All projects have contributed to furthering understanding and testing changes against NSS’s four strategic goals of service excellence, financial sustainability workforce sustainability and climate sustainability.

Example project undertaken by participant of the QVIS course:

QVIS Project: Enhancing Efficiency in National Procurement Operations

This project focused on addressing lower-value health and care services within National Procurement activities at NSS, specifically related to warehouse stock management and processing at the National Distribution Centre. The aim was to improve the efficiency of processing essential healthcare equipment and goods before distribution to health and care locations across Scotland.

The project team utilised quality improvement methodologies to analyse and optimise existing processes. They began by mapping current workflows using paper exercises and direct observations in the workplace to understand how tasks were carried out in real-time. A thorough analysis was conducted to identify inefficiencies such as unnecessary movements, delays, transport issues, and ineffective use of human resources. The team designed a new process that eliminated “non-value” steps and involved frontline staff in co-creating key changes to ensure practicality and operational alignment.

To validate improvements, the team tested changes both virtually and in real-world scenarios, evaluating their impact before full implementation. They continuously monitored and refined processes based on feedback and performance data to ensure the improvements were sustainable.

The project resulted in significant efficiency gains and improvements in warehouse operations. The team achieved a 63% improvement in the throughput of “lines” (individual items of medical goods), while increasing
the warehouse capacity by 35%, which allowed for a 64% rise in the number
of products stored.

Additionally, the team freed up racking space, reducing storage constraints, and reduced the number of movements of goods, leading to improved safety and a calmer work environment for staff. The reliance on contingency staff was also greatly reduced, leading to significant cost savings. Furthermore, the team successfully minimised waste and variation, aligning with NSS’s strategic goals of service excellence, financial sustainability, workforce sustainability, and climate sustainability.

Overall, the project greatly improved the value of healthcare services by ensuring that essential medical supplies reached people more efficiently. It also enhanced workplace conditions for staff, ultimately contributing to better value care for the people we serve.

All projects were aligned with the principles of Realistic Medicine including reducing harm / waste and unwarranted variation, managing risk and, of course, becoming improvers.

Interval evaluation (structured interviews with both line managers and participants, six or more months after course completion) illustrated positive development in thinking, habits and behaviours of participants.

"Before I would have collected lots of data if there was a problem, now I only collect the data that is needed."

"They now take a step back and find the real problem and work through that."

"I have confidence to take on a problem and not ‘winging it’."

Evaluation of projects and participants not reaching Level 4 Kirkpatrick impact highlighted the following themes: having an unclear description of the problem or opportunity, having preconceived solutions, having a predetermined 100% correct plan, looking too far ahead or too wide with their ambitions, moving directly and too soon to implementation, planning a (usually virtual or computer-based) educational intervention. It is recognised that understanding what worked less well is as powerful as understanding the conditions for success in delivering improvements in quality and value with the QVIS course.

The NSS Quality and Value Improvement Skills Course has been a successful intervention in supporting the adoption of Realistic Medicine and Value Based Health and Care. It equips participants with the attitudes, knowledge, and skills needed to deliver these approaches at NSS. Impact was significant and further interventions are planned in pursuit of accelerating and strengthening the positive results. In 2025, there are plans to offer modified QVIS courses, including one focused exclusively on “describing the problem/opportunity”. Additionally, specific Value Based Health and Care offerings will be available, along with bespoke programs for engaged leaders and teams aiming to drive system improvements and enhance VBH&C.

GIRFE – The Team Around The Person Toolkit

The Scottish Government has co-designed Getting It Right For Everyone (GIRFE) with place-based pathfinders and people with lived experience across Scotland. GIRFE is a multi-agency approach of support and services from young adulthood to end-of-life, focusing on health, social care and wider public services. Pathfinders were selected to pilot and co-design the national practice model with partners from health and social care partnerships, alongside people with lived experience

Realistic Medicine is aligned with the principles of GIRFE, putting the person at the centre of all decision making with a joined-up, coherent and consistent, multi-agency approach. A GIRFE design school helped pathfinders to prepare for co-design work and engage with people with lived experience on a specific policy area, problem exploration, or redesign challenge. One of these areas is support of people with alcohol and drug services.

The GIRFE “Team Around the Person” toolkit has been published to facilitate better support planning conversations, based on shared decision making. The person-led and human rights-based approach promotes access to support for people who may, or may not otherwise, encounter frontline services.

Figure 16.

Embedding GIRFE more widely has now also been included as a requirement in NHS Board annual delivery plans for 2025-2026. In January 2025 we held a series of drop-in sessions for Health and Social Care Partnerships (HSCP’s), Local Authority and Health Board staff to attend to consider how they can plan to embed GIRFE.

The first iteration of the GIRFE Team Around The Person Toolkit, and tailored support and advice, is now available to assist organisations across Scotland to embed GIRFE. A copy of the “Team Around The Person Toolkit” can be obtained by contacting the GIRFE policy team (GIRFE@gov.scot). An online link for the toolkit will be available from the GIRFE Scottish Government policy webpage in due course.

People in Alcohol and Drug Services - A GIRFE Case Study

GIRFE pathfinders applied tools within the toolkit to Sean, an individual who had complex care needs, having sustained a head injury, and a fractured spine resulting in paraplegia. Sean has a history of drug and alcohol dependency, self-harm and seizures which resulted in fifteen admissions to hospital between May 2023 to May 2024. Sean was discharged from hospital in May 2024 following treatment for severe pressure ulcers, bone infection, and severe anemia.

On discharge from hospital, Sean had no tenancy, clothes, furniture, no access to funds, and no referrals were made to relevant community disciplines. Sean was also socially isolated and had no involvement in wider social and community networks. Pathfinders applied the “Team Around the Person” toolkit. This consisted of involving Sean in conversations within “Team Around the Person” meetings. This provided Sean and the professionals involved to share information and develop a clear understanding of how Sean would like to be supported, as well as collective decision making during meetings.

The “My Team” tool and GIRFE principles were also applied, and this took the form of weekly locality meetings co-chaired and facilitated by Clinical Nurse Manager and Principal Social worker. There was representation from social work, intermediate care team, community nursing, Allied Health Professionals, hospice, housing services, enablement, care at home, Mental Health Addictions team and General Practice. Sean was also included within these meetings.

The Co-Ordinator Tool supported the care plan for Sean. The My Plan Tool was used to support the development of a care plan for Sean which took into consideration his wishes and what mattered to him most. Sean trusted that his choices would be respected as he was listened to, understood and involved in the decision making process. As a result of including Sean in conversations around his care and support, and using the tools within the GIRFE toolkit, he now has regular support from the community nursing team and social work to meet his health and social care needs.

The outcomes demonstrated by our pathfinder in applying the GIRFE “Team Around the Person” toolkit highlight the benefits of using the toolkit to apply a person centred and preventative approach. This applies a “whole life” approach when making decisions about this individual’s health and social care as well as support put in place to assist with personal care and daily living. The toolkit provided a framework for the professionals to have conversations with Sean and devise a robust and preventative plan of care and support.

Since applying the “Team Around the Person” toolkit Sean has had only one 24-hour stay in hospital, not for self-harm or seizures, but related to another acute health condition. Due to having a consistent team of professionals involved in his care, guided by the “Team Around the Person” toolkit, Sean now engages with his plan of support and substance misuse programme. In applying the GIRFE principles to his care plan Sean is also no longer confined to his home and can access local amenities independently. He is in contact with his family members and enjoys participating in regular social interactions. When Sean was asked about the support, he has around him, since the toolkit was applied by the professionals involved in his care, he said, “I have got my life back and never felt so safe.”

iSIMPATHY

Polypharmacy (the use of multiple medicines) represents a public health challenge as growing numbers of people live with multiple long-term conditions. Medication is the single most common healthcare intervention generating the third highest cost of health expenditure. Studies suggest up to 17% of all unplanned hospital admissions are attributable to medicines related harm, half of which are preventable.

Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years (iSIMPATHY) was a three-and-a-half-year European Union-funded project, funded through the Special EU Programme Body in Northern Ireland, Scotland and the Republic of Ireland and led by Scottish Government.

The iSIMPATHY project sought to ensure the optimal and most sustainable use of medicines for people by delivering pharmacist-led, 7-Steps personalised medicines reviews and embed a shared decision making approach to polypharmacy management.

Key Actions

Patient Reported Outcome Measures (PROMs) accessed via a public-facing app recorded peoples’ experiences before and after medicines reviews and were a key component of the shared decision making process during consultations.

Reviews took place in different settings including hospital in-patient, out-patient and GP practices. 6,481 patients participated with the average age of 72 years. An average of six long-term conditions were recorded per person. Project pharmacists made an average of 11 interventions per review which included patient education, medicines reconciliation, medication changes and monitoring.

Impact

The evaluation highlighted several key benefits:

• Interventions made were graded for clinical significance.
  • 82% classified as clinically significant.
  • 968 (4%) classified as potentially preventing major organ failure, adverse drug reactions or incidents of similar clinical importance.
• 94% of interventions recommendations were accepted.
• The average number of medications reduced from 12 to 11.
• 92% of reviews resulted in more appropriate medication use, therefore decreasing the likelihood of medication-related harm.
• Inappropriate medications were stopped (i.e. deprescribed), reduced or altered to improve appropriateness.
• There was an average gain of 7.4 Quality Adjusted Life Years (QALY) per 100 patients. (One QALY = one year of life in perfect health).

Through PROMs, people reported:

• large improvements in understanding, with over 90% reporting that they fully understood their medicines and potential problems with medicines, compared with 16% pre-review.
• reduced side-effects (64% experiencing side effects pre-review, reducing to 38% post).
• improved ability to perform their usual activities.
• improved medicines adherence.
• decreased pain, discomfort, anxiety and/or depression following reviews.

Conclusion

Medicine reviews improve outcomes, care and patient safety whilst delivering significant benefits to the wider health and care system, including reduced pressure on the system by preventing emergency hospital admissions, cost savings and waste reduction.

This person-centred approach results in measurable positive change in people’s daily lives and across health and care systems.

Data-Driven Improvement: Reducing Fresh Frozen Plasma Wastage at Ninewells Hospital

Fresh frozen plasma (FFP) is a valuable but finite resource, manufactured from blood donations and rich in clotting factors. While essential in managing major bleeding, its indiscriminate use can lead to unnecessary transfusions, increased patient safety risks, and resource wastage.

The Scottish National Blood Transfusion Service (SNBTS) provides blood banking at Ninewells Hospital, Dundee. Inventory management is supported by the SNBTS blood bank dashboard, which displays performance against nationally agreed key performance indicators (KPIs). Appropriate use of blood is essential to maintaining the blood supply chain and ensuring the best possible outcomes for people.

A dashboard review demonstrated that FFP wastage at Ninewells Hospital consistently exceeded the KPI of 20%, prompting a deeper investigation into its causes and the development of targeted improvements.

By embodying the principles of Realistic Medicine and Value Based Health and Care, making blood transfusion safer, smarter, and more sustainable, this project aimed to reduce FFP wastage to <20% by June 2024. The team focused on ensuring that every donation served a genuine clinical need, cutting waste without compromising care. An evidence based approach refined clinical practices, preventing unnecessary transfusions while maintaining safety. Collaboration was key. Working with obstetric teams, the major haemorrhage protocol (MHP) was redesigned to prioritise both better outcomes for people and better resource stewardship.

Quality Improvement (QI) methodology was employed to better understand the problem. Transfusion laboratory staff highlighted MHP activations as a potential source of waste. MHPs support provision of blood components to bleeding patients. Upon activation of the MHP, four red cell units and 4 FFP are issued. MHPs were reviewed, identifying the obstetric team to be the most frequent users of the MHP.

A review of obstetric MHPs demonstrated most FFP ordered was not transfused, suggesting existing MHP arrangements were leading to FFP waste.

A literature review demonstrated that most women suffering post-partum haemorrhage do not have a coagulopathy, and that therefore FFP transfusion is not indicated. A multidisciplinary team was assembled to develop change ideas and a subsequent implementation plan, aiming to reduce unnecessary FFP waste, in a safe manner. An MHP was in place which was not suitable for obstetrics: at each MHP activation, there was significant chance of FFP waste indicating that FFP was deemed to be a low-value intervention in this context. Change ideas focused on safely changing the practice of ordering of blood components during MHPs in obstetrics, improving resource usage, reducing a low value intervention and reducing waste. A new obstetric MHP was developed, communicated and launched, issuing four red cells at initial activation. FFP could be requested for specific clinical concern or after four red cells had been transfused.

A new obstetric MHP was introduced on 28 February 2024. FFP waste reduced following this and stabilised at ~15% since September 2024: the project had achieved its aim. There have been no clinical incidents concerning delayed FFP transfusion.

Figure 21: Quarterly FFP wastage before and after change implemented 28 Feb 2024

Figure 22: Median FFP wastage before and after change implemented 28 Feb 2024

This project demonstrates how a Realistic Medicine approach can drive meaningful change by combining data-driven decision making with clinical collaboration. By refining the major haemorrhage protocol to align with people’s needs, the team successfully reduced FFP waste below 20%, achieving its aim of optimising the use of this valuable resource while maintaining patient safety. The success of this initiative highlights the power of multidisciplinary teamwork, evidence based practice, and resource stewardship in delivering high-value, sustainable healthcare. With similar quality improvement methods, other blood components and clinical processes could also be optimised, delivering higher-value care and system efficiencies.