The Special Care Dental team from Furness and South Lakes have been highly commended in the National Oral Health Awards in the Best Care of Nervous Patients category for the development of an anxiety management pathway based on psychological treatment approaches.

The CLIC Engaging for Improvement (E4I) Scheme focused on designing a new pathway for patients in Cumbria that require specialist dental treatment. The pathway uses cognitive behavioural therapy techniques (CBT) to help patients who suffer from extreme dental anxiety.

Sue Mchugh, Clinical Lead Dentist, and Emma Apsden, Dental Nurse, at NCIC from Kendal Dental Clinic, initiated the project.

Sue said:“We receive many referrals for patients with extreme dental anxiety who in many cases have severely neglected mouths. Some of these patients have endured extreme pain and embarrassment in what they see as a reasonable alternative to visiting a dentist.

“Traditionally, many of these patients would be offered sedation for a course of treatment and only revisit us when in pain. We felt that we could offer a more appropriate alternative by accessing more psychological treatment. We signed up to a 6 day CBT course and decided to set up an anxiety management pathway for patients. We were totally focused on what we wanted to achieve and wanted to demonstrate a viable alternative to sedation.”

A pilot study was created using CBT techniques for a selection of patients. Anxiety scores and attendance rates for these patients were measured before and after treatment and then compared to those treated with sedation.

Emma said: "We saw anxiety scores dramatically decrease for all patients in the pilot group but patients attending for repeat sedation all had anxiety scores similar to, or even higher than when they initially attended. We also had a 100% attendance rate from the start through to completion of treatment for these patients compared to a 27% failure rate for sedation patients.”

One patient who took part in the study said: “Sue and Emma were absolutely brilliant. By the time I had finished my treatment I was actually looking forward to coming to appointments. I would find myself leaving with a big smile on my face because I was so happy with the way I had been treated. I feel happy with my mouth for the first time ever which has impacted on me positively. I want to look after my dental health now because I can see the positive effects that come from it.”

Sue adds: “We have taught people that it is ok to be anxious but that they are in control; by responding to their individual needs we have left them feeling empowered to deal with something that has overshadowed their lives for many years. From a service delivery point of view, the sense of achievement is indescribable. Teeth are teeth, but to help somebody who is so afraid and to make them feel valued is the greatest feeling any clinician can have.”

Natalie Carman, Clinical Director, Dental Services added: “This is an inspirational project and an excellent example of integrated care in action. I am proud to be working with those who care so passionately for the patients we see.”

To find out more about Engaging for Improvement, please go to:  

By Sheila Marsh | Head of Library & Knowledge Services | North Cumbria Library & Knowledge Services

The concept

The idea was first floated back in 2017 when CLIC, Library Services and the Head of Nursing talked about the need for a place close to the wards where staff could go for training courses and which they could use for their learning and development.

This eventually led to a project to create a learning and improvement hub - using an alcove in the staff restaurant - at the Cumberland Infirmary, Carlisle. This would give the library, Learning and Development, and Improvement teams a presence in the hospital. From our point of view this would also add to our growing network of learning spaces. The hub would also offer an opportunity for the service to support improvement and organisational-development (OD) initiatives and work together more with our trainers and staff. The aim was to create a flexible learning space to host small workshops and drop-in sessions and allow staff to access PCs for research and eLearning, thereby helping to develop and support a stronger learning culture across the organisation.

The consultation

We consulted with a wide variety of staff and stakeholders to get their views and find out what they wanted from the hub. We got almost 200 responses with the overwhelming majority supporting the idea. Using the Plan, Do, Study, Act (PDSA) model CLIC & Trust trainers also tried out the space running Rapid Process Improvement Workshops (RPIWs) with clinical teams with just temporary partitioning.

Trainers, clinical and non-clinical staff all responded. One of the most important things people told us was that they wanted the hub to be in the hospital and accessible to all staff.

The consultation used a variety of methods including:

  • An online survey
  • Face to face
  • Trust news
  • Print copies of the survey available in the library
  • An evidence-gathering event in the canteen
  • Ward walking
  • Stakeholder-group meetings
  • Targeted emails

The need

When we asked staff and trainers about the barriers to learning we found that:

  • Staff were often too busy and had very little time to access the library and training facilities which were some distance away from the wards and hospital
  • Staff found it difficult to access PCs and find a ‘space to learn’ in their own work area
  • There was an acute shortage of training rooms and facilities at the Cumberland Infirmary site in Carlisle
  • There was a strong desire from CLIC, Trust trainers and librarians, to increase their visibility across the hospital and improve their engagement with staff 

The Benefits

Developing the Learning and Improvement Hub close to the clinical area has the potential to save staff time, as well as increasing the time - and improving the quality and opportunities -they have to learn and develop. In turn the expectation is that this will help improve staff morale and contribute to the Trust’s efforts to be a ‘Great place to work’ and, in the long term, result in the development of a stronger learning culture. West and Dawson have shown that this can result in improved patient care and outcomes.

Other benefits include:

  • Helping meet the need for additional learning / training facilities of the current & future workforce
  • Better use of the space in the staff restaurant
  • Supporting greater sharing and inter-professional learning
  • Greater visibility and presence for Library, Learning & Development, CLIC and the Improvement team within the hospital
  • Increasing visibility and transparency with public and patients

The Bid

After the consultation we made a successful bid to Health Education England North’s Library Development Fund. Anna Stabler – the Deputy Director of Nursing, Midwifery & AHP’s at the time - agreed to sponsor our project. We submitted it and it was accepted on to the Trust’s and CLIC’s Engaging for Improvement programme (E4I) in 2018.

The risks and challenges

These included:

  • Finding a vacant space and getting approval to use it
  • The expense of converting the area
  • Complexity of PFI hospital and the need to work through the approval processes
  • Ownership and management of the hub as it is a separate area some distance from the library
  • Ensuring appropriate usage, i.e. for learning and research, rather than for meetings

The process and methodology

The success of any improvement project lies in the engagement and involvement of the right people from the start. The Engaging for Improvement programme focuses on identifying an idea for change, making sure that the right information is gathered to understand and support your change and then helping you to engage with your own team and wider stakeholders. Your sponsor is vital to the success of your scheme and helped us overcome some of these risks and barriers we met along the way.

The E4I approach is a six-step approach designed to be worked through over 20 weeks. However the principles apply equally to smaller- or larger-scale projects that will take less or more than the recommended time. The development of the Learning and Improvement Hub took over two years from the initial idea to its completion.

The E4I programme has been developed by the Trust and CLIC from the experience of similar improvement programmes, such as, Listening into Action and the continuing development and spread of CLIC’s Cumbria Production System. This brings together tried and tested tools that are part of CLIC’s improvement and transformational model.

The project used continuous improvement tools, such as, driver diagrams and project templates, (i.e. A3 plans, highlight reports, project summaries, mission templates, stakeholder mapping, etc.) and helped guide us when we organised a stakeholder engagement event. We surveyed staff and trainers gathering both quantitative and qualitative information.

The Stakeholders

  • PFI HMC and Interserve their service provider
  • Trust Estates
  • Finance
  • IT
  • Trust Communications Team
  • Trust Senior Management Team
  • Designers /Suppliers
  • Learning and Development (L&D) team
  • Clinical staff representatives
  • CLIC 
  • Engaging with Improvement Programme lead and facilitator
  • Knowledge Support Librarians and other Library staff

Outline plan and milestones

Key milestones included:

  • Engage with stakeholders and get approval to go ahead (i.e. PFI, Trust Finance and senior management team)
  • Submit project proposal for the first wave of the Trust’s Engaging with Improvement Programme
  • Look at design options and costs
  • Identify other costs with service provider related to change of usage (i.e. security, ventilation, health & safety, etc.) and follow process for submission of minor works
  • Agree and follow a programme of work
  • Launch with all stakeholders
  • Continue to promote, evaluate and improve

Opening and Launch

In the lead-up to the official launch on the 1st November 2019 we set-up an Outlook calendar for staff to view the Hub’s availability and make bookings. The month before the launch we held induction sessions with the trainers showing them how to use the IT facilities and introduced them to the final version of the Hub’s standard operating procedure - which they helped us put together - about the day-to-day running of the Hub.

What have staff and trainers said so far?

The Learning Hub is fantastic ... so great to see all the plans come together

Love the bright environment ... it is so conducive to learning

Excellent space! Efficient, clean and welcoming. Well done!

Reflections and lessons learnt

It is still early days, however it certainly feels like the Library Service has increased its profile and the Hub has demonstrated just how serious we are about supporting the personal development of staff and the wider organisation’s quest to become a learning organisation. It has also offered many learning opportunities for  us. We have all become more familiar with using and applying the Cumbria Production improvement tools and developed much closer working relationships with CLIC and the other trainers. We are now in the evaluation phase, so will see if usage and feedback reflects this.

One of the most important lessons we learnt was to spend as much time as possible consulting and engaging with staff and stakeholders to gather evidence. It's also really important not to rush ahead with the project.

We also discovered that developing a learning facility in a clinical area is entirely different from developing one in your library or another non-clinical area. Decisions about security and access, infection control, cleaning and life-cycle all need to be agreed beforehand.

Starting the consultation as soon as possible, as well as continuing to engage with staff and stakeholders throughout the project so they are kept on board and up to date, is absolutely essential.

The Hub before and after its redevelopment



We would like to acknowledge Health Care Libraries North, Health Education England and Doughty Charitable Trust fund of Consultants at the Cumberland Infirmary, Carlisle for funding this project.

By Ruth Parker, Improvement and Development Practitioner with CLIC

The merger in October 2019 of Cumbria Partnership NHS Foundation Trust (CPFT) and North Cumbria University Hospital Trust (NCUHT) brought together the Patient Experience team from (CPFT), Patient Advice and Liaison Service and Complaints from (NCUHT) into one team. 

Alison Budd Director of Nursing and Quality suggested a Rapid Process Improvement Workshop (RPIW) would be a great opportunity for the 3 teams to work together to develop and better system of working to improve the service to patients their family and carers. The RPIW week would be supported by CLIC.

The week of 18th October began with a full day of training, to equipped the team members with all the tools they needed to make real and lasting change. 

Trust staff rallied to support the week with encouragement and assistance coming from clinical staff, consultants, matrons, allied health professionals and nursing staff who were keen to help our team develop a new way to work.

Patient representative Sue Gallagher, contributed invaluable knowledge from a patient’s perspective.

The week was supported by Nikki Bridson, Business Manager, Quality and Nursing who offered ‘outside eyes’ and kept the focus for us all. 

We looked at how the teams currently work and how they would like to work in the future. They suggested 69 ideas for improvement and wrote 24 A3 project plans to make changes. The team have identified who will work on each of the A3 project plans and now come together once per week for 10 minutes to demonstrate progress.

One of the first tasks the team undertook was to re-write the letters which are sent to patients on the receipt of a complaint. Sue was able to give assistance in this, making the letters seem less formal and helping by suggesting what about the process would be key for patients and families.

A smaller group worked together with Liz Klein to redesigned a process to resolve issues for patients at the bedside, with a clear escalation to someone who would assist in resolving issues early.

The team is developing a communications strategy to improve its visibility in the trust and to encourage patients to make any concerns known, in line with the new focus on all staff being able to resolve issues locally.


The RPIW brought the 3 teams together and they quickly left their old organisational ties behind to begin working closely on taking the best from both organisations, bringing in some new ideas.

The RPIW week was the beginning of the improvement journey. CLIC will continue to support the team over the next 30, 60, 90 days to make the exciting changes identified during the week become a reality, improving the care for patients and job satisfaction for staff.


If you would like more information on a RPIW with the CLIC team, please contact: 

For more information on A3s and other improvement tools, please go to the Cumbria Production System Toolkit.


Happy New Year! 

If you’re looking for a New Year’s resolution that you can action today, look no further as you’re in luck. If you want to get fully up-to-date with the latest clinical evidence and guidance, then book a spot on our GP Update Course! 

Delivered by Red Whale, the course is developed and presented by GPs who understand the day-to-day reality of general practice. The course offers lots of practical tips and techniques for you to take away and implement immediately.

Saturday 1st February 2020

Time: 9.30am - 4pm

Location: Lecture Theatre, Education Centre, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria, CA2 7HY

Price: £135 (£70 for trainees)

Book your place now on our dedicated GP Update (Cohort 12) event page.

Innovation in Education Category, Sponsored by Health Education England North East

1st place - Development of Integrated Competency Hubs – Cumbria Partnership NHS Foundation Trust

During clinical skills workshops, it became apparent that community-based staff were struggling with clinical skills training due to the geography and infrastructure of the Cumbria region, which often results in long journey times between community work bases and the two acute hospitals. In response to this, Integrated Competency Hubs have been developed, with Hub Co-coordinators matching the skills required by the community-based staff member with the relevant patient attending for treatment. In this way, staff have accessible provision for maintaining competency, which improves staff wellbeing and ultimately improves the patient experience.

The Innovators:

Debra Sargent, Clinical Education and Workplace Learning Facilitator

Sue Harper, Clinical Education

Sheena Bleasdale, Clinical Manager

Jen Riera, Ward Sister, Maryport Hospital

Cumbria Partnership NHS Foundation Trust