Evaluation of a New Care Model: Morecambe Bay PACS Vanguard

Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Contents 8 Executive Summary This report has been commissioned by Bay Health and Care Partners, through NHS England Vanguard funding. The report has been produced by Health and Social Care Evaluations (HASCE) at the University of Cumbria. Report authors: Dr Tom Grimwood, Dr Lorna Bell, Dr Uschi Maden-Weinberger, Dr Sarah Skyrme, Pam Hearne, Clare Robinson, Aleksandra Palazsczuk Contact details: [email protected] Health and Social Care Evaluations (HASCE) University of Cumbria, Bowerham Road, Lancaster, LA1 3JD 2 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard 1 Introduction 1.1 Overview 1.2 Better Care Together: A Brief Narrative 1.3 The Evaluation of Better Care Together: A Brief Narrative 12 12 12 14 2 Evaluation Methodology 2.1 Assessing Change, Outcomes and Impact 2.2 Understanding Cause and Efect in a New Care Model 2.3 Sampling strategy 2.4 Data Analysis 2.5 Outcomes Survey 2.6 Ethical Considerations 2.7 Limitations, Issues and Adjustments 2.8 Discussion and Summary 17 17 19 23 25 28 28 29 31 3 Evaluation Workshops 3.1 Workshop One: Evaluating Better Care Together 3.2 Workshop Two: Whose Knowledge? What Evidence? Which Data? 3.3 Workshop Three: Evaluating Cultural Change 32 32 33 34 4 Findings 4.1 How the Findings are Presented 4.2 Coniguration of Hypotheses 35 35 36 5 Contexts Evaluation Question: What is the context in each vanguard into which new care models have been implemented? 5.1 Thematic Overview 5.2 Geography and Demographics 5.3 Skill Supply 5.4 Previous Interventions 5.5 Organisational Cultures 5.6 Availability of Resources 5.7 Discussion and Summary 38 38 6 Mechanisms Evaluation Questions: What key changes have the vanguards made and who is being afected by them? How have these changes been implemented? Which components of the care model are really making a diference? 6.1 Thematic Overview 6.2 Integrated Working 6.3 Integrated Care Communities 6.4 Cultural Change 6.5 Discussion and Summary 7 Resources Evaluation Questions: What is the change in resource use and cost for the speciic interventions that encom pass the new care models programme locally? How are vanguards performing against their expectations and how can the care model be improved? What are the unintended costs and consequences (positive or negative) associated with the new models of care on the local health economy and beyond? 7.1 Overview 7.2 Economic Evaluation 7.2.1 Workstream: Elective Care 7.2.2 Workstream: Out of Hospital Local Evaluation of Morecambe Bay PACS Vanguard 38 39 42 43 45 47 48 50 50 50 52 60 67 74 76 76 76 76 77 88 12 Month Report 31/10/2017 - 3 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Contents: List of Tables and Figures 7.3 Qualitative Analysis of Changes in Resource Use 7.3.1 Thematic Overview 7.3.2 Distribution of Funding 7.3.3 Non-inancial Resources 7.4 Discussion and Summary 8 Outcomes Evaluation Questions: What expected or unexpected impact is the vanguard having on patient outcomes and experience, the health of the local population and the way in which resources are used in the local health system e.g. equality? 8.1 Thematic Overview 8.2 Preventers 8.2.1 Insuicient Metrics 8.2.2 Staf Attrition 8.2.3 Disengagement at Key Points 8.2 Types of Outcomes 8.2.1 Positive Outcomes 8.2.2 Negative Outcomes 8.2.3 Outcomes for Patients and Citizens 8.3 Discussion and Summary Table 1 Summary of Challenges for Delivery and Evaluation of BCT 15 Figure 1 Better Care Together Logic Model 2016/17 18 Figure 2 Top-down approach to cause and efect 20 Figure 3 Ground-up approach to cause and efect 21 Figure 4 Realist Feedback Loop 22 Table 2 Evaluation sample size to date 24 115 117 118 119 120 122 123 132 133 142 Figure 5 Levels of Qualitative Analysis 25 Figure 6 C-M-O Coniguration of Themes 26 Figure 7 Programme Overview Template 27 Table 3 Coniguration of Hypotheses 36 Table 4 Outcomes and Potential Measures 37 Figure 8 Contexts - Thematic Diagram 38 Table 5 Summary of Geography and Demographics of Morecambe Bay by ICC 40 143 143 Figure 9 Mechanisms - Thematic Diagram 50 Figure 10 Integrated Working - Thematic Diagram 52 Figure 11 Integrated Care Communities - Thematic Diagram 60 Figure 12 Cultural Change - Thematic Diagram 67 Table 6 Cost per outpatient irst attendance: BCT-wide 78 Table 7 Cost per outpatient irst attendance: Barrow Town 78 Table 8 Cost per outpatient irst attendance: Bay 78 Table 9 Cost per outpatient irst attendance: East 78 Figure 13 OP 1st Attendance Cost: BCT 80 104 104 106 110 113 115 115 9 Active Ingredients of a New Care Model Evaluation Questions: What are the ‘active ingredients’ of a care model? Which aspects, if replicated elsewhere, can be expected to give similar results and what contextual factors are prerequisites for success? 9.1 Overview 9.2 Leadership 9.3 Communication 9.4 Cultural Change 9.5 Necessary Tensions to Negotiate 143 143 145 148 150 10 Recommendations 10.1 Improve data reporting techniques and strategies 10.2 Improve strategies for demonstrating change 10.3 Consider the Role of Leadership, Communication and Cultural Change 152 152 152 153 Appendix One: Semi-Structured Interview Schedule 154 Figure 14 OP 1st Attendance cost since vanguard: BCT 80 Appendix Two: Survey Design 155 Figure 15 OP 1st Attendance Cost: Barrow Town 81 Appendix Three: Focus Group Schedule 160 Figure 16 OP 1st Attendance cost since vanguard: Barrow Town 81 Appendix Four: World Café Discussion Summaries 161 Figure 17 OP 1st Attendance cost: Bay 82 Appendix Five: Evaluation Methods for Speciic Gaps in BCT Data Evaluating Collaboration Evaluating Engagement Evaluating Localised Metrics across Areas Evaluating Clinical Quality Improvement 168 168 169 170 171 Figure 18 OP 1st Attendance cost since vanguard: Bay 82 Figure 19 OP 1st Attendance cost: East 83 Figure 20 OP 1st Attendance cost since vanguard: East 83 Table 10 Cost per outpatient follow-up attendance: BCT-wide 84 Appendix Six: Outcomes Survey – Key Findings Introduction Engagement with ICCs Understanding of ICCs 172 172 172 173 Table 11 Cost per outpatient irst attendance: Barrow Town 84 Table 12 Cost per outpatient irst attendance: Bay 84 Table 13 Cost per outpatient irst attendance: East 84 Appendix Seven: Social Media Announcements and ED Attendance 174 Figure 21 OP Follow up Attendance cost: BCT 85 4 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 5 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Figure 22 OP Follow up Attendance cost after vanguard: BCT 85 Table 25 Non-Elective Bed days cost: East 99 Figure 23 OP Follow up Attendance cost: Barrow Town 86 Figure 45 Non-Elective Bed days cost: BCT 100 Figure 24 OP Follow up Attendance cost after vanguard: Barrow Town 86 Figure 46 Non-Elective Bed days cost since vanguard: BCT 100 Figure 25 OP Follow up Attendance cost: Bay 87 Figure 47 Non-Elective Bed days cost: Barrow Town 101 Figure 26 OP Follow up Attendance cost after vanguard: Bay 87 Figure 48 Non-Elective Bed days cost since vanguard: Barrow Town 101 Figure 27 OP Follow up Attendance cost: East 88 Figure 49 Non-Elective Bed days cost: Bay 102 Figure 28 OP Follow up Attendance cost after vanguard: East 88 Figure 50 Non-Elective Bed days cost since vanguard: Bay 102 Table 14 ED Attendance cost: BCT-wide 89 Figure 51 Non-Elective Bed days cost: East 103 Table 15 ED Attendance cost: Barrow Town 89 Figure 52 Non-Elective Bed days cost since vanguard: East 103 Table 16 ED Attendance cost: Bay 89 Figure 53 Change in Use of Resources - Thematic Diagram 105 Table 17 ED Attendance cost: East 89 Figure 54 Outcomes - Thematic Diagram 115 Figure 29 ED Attendance cost: BCT 90 Figure 55 Preventers - Thematic Diagram 117 Figure 30 ED Attendance cost since vanguard: BCT 90 Figure 56 Outcomes - Thematic Diagram 122 Figure 31 ED Attendance cost: Barrow Town 91 Figure 57 ED Attendances - Total Incidents by ICC, 2014-17 123 Figure 32 ED Attendance cost since vanguard: Barrow Town 91 Figure 58 ED Attendance - S Cumbria ICCs per 1000 population 124 Figure 33 ED Attendance cost: Bay 92 Figure 59 ED Attendance - N Lancs ICCs per 1000 population 124 Figure 34 ED Attendance cost since vanguard: Bay 92 Figure 60 ED Attendance by Age – S Cumbria per 1000 population 125 Figure 35 ED Attendance cost: Bay 93 Figure 61 ED Attendance by Age – N Lancs per 1000 population 126 Figure 36 ED Attendance cost since vanguard: East 93 Figure 62 Outpatient Appointments - S Cumbria ICCs per 1000 population 126 Table 18 Non-Elective Admissions cost: BCT-wide 94 Figure 63 Outpatients Appointments - N Lancs ICCs per 1000 population 127 Table 19 Non-Elective Admissions cost: Barrow Town 94 Figure 64 Inappropriate OP appointments - S Cumbria per 1000 population 128 Table 20 Non-Elective Admissions cost: Bay 94 Figure 65 Inappropriate OP appointments - N Lancs per 1000 population 128 Table 21 Non-Elective Admissions cost: East 94 Figure 66 Advice and Guidance: Total Conversations BCT-wide 129 Figure 37 Non-Elective Admissions cost: BCT-wide 95 Figure 67 Advice and Guidance: Total Outcomes BCT-wide 130 Figure 38 Non-Elective Admissions cost since vanguard: BCT-wide 95 Figure 68 Leadership as an Active Ingredient 144 Figure 39 Non-Elective Admissions cost: Barrow Town 96 Table 26 Aspects of Communication in an NCM 146 Figure 40 Non-Elective Admissions cost since vanguard: Barrow Town 96 Figure 69 Schein’s Model of Organisational Culture 148 Figure 41 Non-Elective Admissions cost: Bay 97 Figure 70 Necessary Tensions within an NCM 150 Figure 42 Non-Elective Admissions cost since vanguard: Bay 97 Table 27 Nuield Trust’s Personalised Advice Template 170 Figure 43 Non-Elective Admissions cost: East 98 Table 28 Modiied Template for Localised Data Collection 170 Figure 44 Non-Elective Admissions cost since vanguard: East 98 Table 29 Shortell et al.’s Dimensions needed to achieve clinical quality improvement 171 Table 22 Non-Elective Bed days cost: BCT-wide 99 Figure 71 Comparison of ED Attendances in relation to social media announcements 177 Table 23 Non-Elective Bed days cost: Barrow Town 99 Table 24 Non-Elective Bed days cost: Bay 99 6 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 7 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Executive Summary • Introduction This report discusses the indings from the irst 12 months of the Health and Social Care Evaluation (HASCE) project to evaluate the New Care Model (NCM) programme delivered by Morecambe Bay PACS Vanguard, Better Care Together (BCT). This evaluation, commissioned by the Bay Health and Care Partners, sets out to answer speciic questions set by the national New Care Models Team (NCMT). It does this via qualitative data collection and analysis on programme processes and outcomes and a health economics evaluation of resource use and outcome, triangulated with quantitative data provided by University Hospitals Morecambe Bay Trust (UHMBT) Business Intelligence team. The ambition of the NCM requires a more nuanced approach to cause and efect than simple measures of frequency and correlation, as these would be unlikely to capture the speciic kinds of change, and the incremental progress this may involve. Consequently, this evaluation is based on a realist approach. This approach assumes that physical and social systems are ordered, yet ininitely complex. Realist evaluation analyses programmes and intervention in terms of their contexts, mechanisms and outcomes. This produces testable hypotheses on who a programme works for, in what context, and why; as part of an ongoing cycle of evaluation. There were a number of challenges concerning the delivery of BCT itself and how this related to the possibilities of its evaluation. The lack of clear and consistent criteria for ‘what success looks like’, the size and shape of particular interventions, where BCT ‘begins’ and ‘ends’ in terms of inclusion of activities, and identifying the speciic contribution of vanguard resources to existing interventions in relation to other funding sources were all identiied as problems for the evaluators to overcome. BCT is being implemented in a complex context. Based on the data collected for this evaluation, the following points highlight the most prominent afective aspects of this, which have a direct bearing on the outcomes and impact of the work of the NCM: • • • Geographical, demographic, historical and organisational features are interacting with the availability of resources to both enable and disable the programme. The geographical location and distance between services was also identiied as afecting staf retention and recruitment. High staf turnover rates and recruitment diiculties were reported for a variety of roles and participants expressed frustration about the lack of capacity in care teams to implement the NCM. This problem re-emerges later in the process with regards staf attrition. Attitudes towards the NCM and engagement with it were afected by perceptions and experiences of previous interventions. Organisational cultures emerged as another important contextual factor, as well as the availability of resources. Overall, the indings suggest that the most positive accounts of change taking place within the NCM are with regard ground-level, localised responses to perceived gaps in services. Related to this localised activity, participants highlighted the need for ‘incremental approaches’ to change. It was, however, less clear within the data how these approaches map on to the larger-scale changes in the BCT logic model. • • Successful Multi-Disciplinary Team working. Care Navigators and other roles which worked lexibly between the ‘gaps’ in service provision. Where structures were already in place to support partnership working (e.g. commissioning structures allowing sub-contracting), progress was more straightforward. Participants consistently referenced improved and more open lines of communication as the main mechanisms for change. Conversely, the main obstacles to change tended to focus on structural and strategic issues. These were thematised as: • • • • • • Short-term funding and project-based approaches to change. The length of time many of the changes were taking to implement. The length of time that the machinery of BCT was perceived to require. Information Governance and Information Technology. A perceived lack of support from leadership. A lack of a clear sense of what BCT was, and its direction of travel. Reductions in costs can be shown via reductions in hospital attendance and bed days during the period of vanguard funding. This is based on intermediate data of overall hospital and outpatient activity to evaluate the potential inancial impact on the healthcare system. • Findings • • • • Changes around improved communication and dialogue between organisations, facilitated by the roles aligned with the vanguard funding, appear to be making important progress in some areas of Morecambe Bay. The main enablers for change were thematised as: • • • • While these are a good indicator of overall performance of BCT as a whole and individual ICCs, the link between individual interventions and these metrics is tenuous and, as the target populations of the interventions are small, their efects might not be noticeable on the larger scale metrics. The igures presented within this economic analysis represent resource use and associated cost only, in other words, outputs. However, identifying the appropriate data for capturing progress remains a major challenge. Qualitative data highlighted a range of non-inancial inputs which were key to the delivery of the NCM. Changes in non-inancial resource uses were very apparent from participants’ interviews, based on localised arrangements around what have been previously perceived to be systemic problems or gaps in service. The qualitative data raised an important question regarding the extent to which a return on investment, and the general efectiveness of a programme, will vary depending upon existing assets and skills within a team or area. A number of negative themes emerged around the distribution of funding. Certain themes, such as around the commissioning structures themselves, are embedded diferences between primary and acute care. Others centre on the transparency of decision-making around funding, the communication of capacity issues to management and the tension between the freedom to develop new ideas at local levels, and a perceived lack of steer or support from middle management up to higher tiers. The priority for the vanguard was often perceived to be on inancial eiciencies, and achieving a reduction in outpatient appointments in particular, rather than the creation of improved patient pathways. Participants suggested that current reporting measures were currently not accurately capturing valuable changes occurring at ground level. The methods for gathering localised data are inconsistent, and this risks missing important contextual factors that are key to the success of interventions, and ensuring successful scaling up across the Bay area. 8 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 9 Health and Social Care Evaluations (HASCE) Higher-level metrics report positive trends at certain points within the programme. However, the current structure of data reporting does not allow changes to higher-level metrics to be linked to the changes which BCT has implemented in a methodologically sound way. • • • • • The data suggests that localised successes are not currently being translated into wholescale change’ largely due to the variations in scale of many of the initiatives evaluated, and the low numbers of patients and citizens involved at this stage. It is important to note that many of the incremental changes which have been identiied by staf were also identiied by patient groups as either already taking place, or addressing clear gaps in service. This suggests that many of the qualitative themes around the changes the NCM has introduced have the potential to link up with patient expectations and improve the quality of care. While some preventers of positive outcomes link back to contexts outside BCT, participants highlighted several reasons for stakeholders becoming disengaged in the process of delivering the NCM; many of which were linked to the lack of clarity around outcomes, and, related to this, a lack of visible progress. Health and Social Care Evaluations (HASCE) There is a need for the programme to consider the roles of leadership, communication and cultural change in its delivery. • • In order to address the negative themes around these, it is recommended that the programme introduces more transparent ‘feedback loops’ within its structure. Communication across organisations at ground level was reported as one of the key successes of the NCM. There may be some useful learning points and good practice from these successes which can support communication at strategic level. Following the evaluator’s interim report on 18/04/2017, evaluators and commissioners started discussions concerning the next stage of the evaluation and the most beneicial areas to focus on. This led to the identiication and recommendation of three speciic areas which would inform both the tail-end of the irst twelve-month project, and the continuation of the evaluation project across 2017-18. These were the development of Integrated Care Communities (ICCs) in Barrow Town, Bay and East; and the evaluation of a speciic intervention within each of these: from the Respiratory pathway (Barrow Town), Paediatrics pathway (Bay) and Frailty pathway (East). This suggests that work on identifying more immediate and incremental outputs and outcomes of the NCM, coupled with a clear sense of how these relate to its larger-scale strategy, may well address many of the preventers which participants reported. It is also of note that the outcomes identiied in the data relect a number of outputs and outcomes on the 2016/17 BCT logic model. However, these are not systematic: the data collected and analysed does not identify a number of outputs and outcomes for Year 1-2, whereas some of the longer-term outcomes (3-5 years) are being mentioned. This suggests that the logic model is not featuring at the core of delivery. Recommendations The evaluation recommends that improvements can be made in the data reporting, particularly to include addressing gaps raised by the evaluation. This will enable the NCM to demonstrate more robustly the efects of the changes it is delivering. This work would be chiely around mapping outputs from speciic interventions in a clear and systematic way at the planning stage of delivery. This would allow more localised measures (whether quantitative or qualitative) to scafold up to the higher-level outcomes, and visible change to become apparent earlier within the NCM delivery. This includes: • • Consistent and methodologically robust data collection around incremental change to target populations, with a more consistent approach to mapping inputs for interventions and activities, along with timescales (based on contextualised factors such as existing community assets and relationships), which can then be compared against outcomes. Speciic data to track for individual interventions on patient level, including input as well as output data which covers enough breadth to measure the impact of the intervention on a patient level. The evaluation recommends that a wider evaluation strategy for the delivery of the NCM is produced to map diferent elements of data reporting according to strategic criteria for success. • • A recurring theme for participants has been problems with identifying what ‘Better Care Together’ is, in terms of inclusion/exclusion criteria, measurable outcomes and ‘what success looks like’. It is important that the outcomes of the programme are clearly aligned to a range of evidence sources, and that outcomes are falsiiable: in other words, that outcomes are able to demonstrate evidence of any lack of success as well as success so that obstacles to delivery can be identiied more quickly. 10 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 11 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 1 Introduction 1.1 Overview The BCT strategy document was published in February 2015 by Bay Health and Care Partners, stating: This report discusses the indings from the irst 12 months of the Health and Social Care Evaluations (HASCE) project to evaluate the New Care Model (NCM) programme delivered by Morecambe Bay PACS vanguard, Better Care Together (BCT). This evaluation, commissioned by the Bay Health and Care Partners, sets out to answer speciic questions set by the national New Care Models Team (NCMT), through qualitative data collection and analysis of programme processes and outcomes, a health economics evaluation of resource use and outcomes, and triangulated with quantitative data provided by University Hospitals of Morecambe Bay Trust (UHMBT) Business Intelligence team. As well as theorising the main successes of the current vanguard programme, this work will support future evaluation by identifying key perceptions, variations and outcomes that can potentially be tracked to evidence the programme’s longer-term impact. This report provides an analysis and indings of the evaluation work since it began in October 2016, discussion of the emerging responses to the commissioned evaluation questions, and information on how the evaluation will proceed over the next 12 months. As the Health Foundation rightly note, evaluation is ‘conducted in a spirit of discovery rather than management or monitoring.1 This evaluation was commissioned with a speciic instruction not to conduct a workstream-by-workstream evaluation, but to gather a picture of changes being made, outcomes afected, successes and obstacles across the whole NCM. This is due to the unique challenge of evaluating the BCT programme, which involves unpacking the complexity of a transformative and evolving programme, requiring collaboration across a range of sectors and wider communities – between NHS organisations, local authorities, the third sector and other local partners, as well as patients and the public. 2 As such, this is a complex, multi-faceted evaluation which has required iterative development in response to the delivery of the programme itself. This report is not an attempt to map all activities within the vanguard site, but, in response to the NCMT questions, identify the key contexts, changes, outcomes and ‘active ingredients’ at work in the NCM. 1.2 Better Care Together: A Brief Narrative The BCT programme started in 2012 as a review of health services across Morecambe Bay by Bay Health and Care Partners. This partnership of 11 (now 10, following boundary changes to the two Clinical Commissioning Groups) initiated the review as a response to both the increasing number of challenges for health care provision (including an ageing population, an increase in complex and long-term conditions, and an increased demand on resources), and speciic problems within Morecambe Bay Hospitals (including CQC and police investigations). As such, while the focus of these problems tended to fall on the hospitals, some of the root causes of these issues began in primary, community and social care. Furthermore, a number of inancial pressures were increased due to the geography of Morecambe Bay, with a dispersed population leading to duplication of services in some areas, and gaps in services in others. 1 The Health Foundation. Evaluation: what to consider. (2015), p.30 2 Foot. C, Gilburt. H, Dunne. P, Jabbal J, Seale B, Goodrich J, Buck D, Taylor J. People in Control of their own Health and Care: the State of Involvement. London: The King’s Fund (2014). Available at: www.kingsfund.org.uk/publications/people-control-their-own-health-and-care At the heart of our Strategy is a “population” based approach to promoting wellbeing and providing care in which people and their needs are the focus rather than processes and buildings. Responsibility for health and care will become a true partnership between the people needing to access services and those who provide them.3 The only way that we can guarantee great care within the realities of the budgets available to us is to focus our support and resources on people, not buildings and by providing care as close to home as possible. 4 Covering, at that time, 2 hospital trusts, 2 Clinical Commissioning Groups, 2 foundation trusts, 2 GP federations , 1 ambulance service and 2 County Authorities, the strategy placed the Triple Aims at its centre as its ‘guiding compass’: • • • improving population health; improving the individual experience of care; reducing per capita health and care spend. Coinciding with this strategy document, the NHS Five Year Forward View was published in 2014. This presented a wide- ranging strategy plan for NHS England to address the challenges facing NHS over the next 5 years, which include: • • • changes in patient health needs (e.g. chronic conditions) and treatment preferences (e.g. greater patient involvement); changes in treatment technologies; changes in health services and funding structures. Resonating strongly with the BCT strategy, the Five Year Forward View suggested that if no sustainable strategies are introduced, there will be progressively widening gaps between health and wellbeing, care and quality as well as funding and eicacy. Consequently, the strategy proposed three main pillars for its implementation: establishing new relationships with the patients and communities, introducing of NCMs and implementing innovative models of support strategies. The Five Year Forward View emphasises the key role of empowering and mobilizing communities in active involvement in the healthcare process: for example, supporting service users in health management via engaging in healthy lifestyles, making informed treatment choices, self- care, education and engagement in health-related community initiatives; as well as increasing the control patients have over the care process, including place, mode and nature of the treatment they receive. These shifts in care are underpinned by improvement of quality and access to the information as well as enhancement of information management systems within and between healthcare settings. The strategy document identiies this as a gradual process of collective change, involving both NHS organisations and partnerships with the charitable and voluntary sector, as well as community volunteering programs that make contribution to the provision of health and social care. At the same time, the Five Year Forward View recognised that traditional division between primary, secondary, mental health and social services often precludes the provision of personalised and coordinated care. As a result, NCMs were developed to act as a blueprint for the future NHS. 3 The Better Care Together Strategy for the Future for health and care services in Morecambe Bay. (2015) https://www.uhmb.nhs.uk/iles/bct-publications/Better-Care-Together-Plan.pdf p.6 4 The Better Care Together strategy the future for health and care services in Morecambe Bay (2015), p.11 12 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 13 Health and Social Care Evaluations (HASCE) As part of the NCM programme, in 2015 50 vanguards sites were selected to deliver NCMs through funding from the NHS Transformation Fund. BCT was selected as an Integrated Primary and Acute System (PACS) vanguard, although it included elements of the Multi-Speciality Community Providers (MCPs) model of care. The focus of the PACS model is twofold: to improve primary and acute medicine, and to develop preventative community- based services. The PACS model uses risk stratiication and population-based analysis in order to design services tailored to individual needs, and identify groups that need specialised care. 5 These needs are then addressed through redesigned patient care pathways, patient empowerment, strong collaborative networks with community assets, and redeined workforce roles where appropriate to improve resource deployment and respond to the needs of local communities. Health and Social Care Evaluations (HASCE) Area Strategic Speciic issue for evaluation Resolutions for evaluation The scope and boundaries of BCT as an entity are often unclear. Diiculty for participants in identifying what part of their work is ‘vanguard’, ‘BCT’ or something else. This report identiies gaps in data and suggests methods for addressing them. Difering understanding and little consensus between senior staf as to the nature and purpose of BCT. 1.3 The Evaluation of Better Care Together: A Brief Narrative The evaluation approach followed a realist methodology (see below, Chapter 2), and initially planned to spend the irst half of the project gathering qualitative data from across the vanguard funded activities. This would provide the evaluation with general hypotheses around the changes and outcomes taking place in the NCM. In the second half of the project, the evaluation would focus in on speciic interventions and areas for a more detailed and nuanced account of what was working for who, and why. This would be triangulated with larger-scale data from both the quantitative reporting metrics carried out by UHMBT Business Intelligence, and a large-scale survey conducted across Morecambe Bay by the evaluators. Speciic issue for NCM delivery No clear timescale for when changes are expected to take efect. Structural Pathways lack speciic output metrics; over-dependency on high-level outcome data e.g. ED Attendance. Information Governance processes has been slow to be put in place. As Table 1 on the right identiies, however, there were a number of complications concerning the delivery of BCT itself and its capacity to undergo a signiicant evaluation of this kind. These challenges were identiied from a number of sources: through monthly meetings with the BCT Research and Evaluation Group (REG), conversations with staf and stakeholders, discussions within the evaluation-led workshops (see Chapter 3), and qualitative data collection. These challenges, in turn, lead to practical diiculties being raised for the evaluation; these are detailed, alongside the routes taken by the evaluation team to ensure gathering an evidence-base for NCM delivery continues to move forward. Pace of change is slow: several interventions and pathways still taking shape at the time of the evaluation. Successful interventions involve very small numbers. It should be noted that it is understood that a number of very similar challenges are being reported by vanguard sites across the United Kingdom, and, it may be argued, that some are to be expected for ambitious large-scale change programmes. Lack of a clear and consistent criteria for ‘what success looks like’ and benchmarks to evaluate outcomes and impact from. Diiculty in tracking patient low and identifying key enabling or disabling points within pathways and interventions. Diiculty in identifying inputs to an activity (e.g. resource) to match against outputs. Challenges in locating up-todate documentation around pathways and interventions.6 Lack of access to quantitative data for irst eight months of project. This report establishes general contexts, mechanisms and outcomes of NCM. The next 12 months will concentrate on more focused pathways and areas. The evaluation examined generative causality as a way of capturing change and impact in the absence of clear or appropriate baselines and targets. Diiculty in working back from high-level outcome metrics to speciic interventions – cause and efect diicult to demonstrate (see below, section 2.2). Following the interim report on 18/04/2017, evaluators and commissioners started discussions concerning the next stage of the evaluation and the most beneicial areas to focus on. This led to the identiication and recommendation of three speciic areas which would inform both the tail-end of the irst twelve-month project, and the continuation of the evaluation project across 2017-18. These were the development of Integrated Care Communities (ICCs) in Barrow Town, Bay and East; and the evaluation of a speciic intervention within each of these: from the Respiratory pathway (Barrow Town), Paediatrics pathway (Bay) and Frailty pathway (East). Cultural 5 https://www.england.nhs.uk/wp-content/uploads/2016/09/pacs-framework.pdf Challenges in identifying meaningful outcomes. Numerous historical and geographical contexts afect the delivery of BCT across Morecambe Bay. BCT is delivered alongside other changes at both local and national levels. Some lack of engagement due to change fatigue. Concern that evaluation may not be seen as ‘independent’, and this may afect engagement. The evaluation used emerging themes from qualitative data to inform the contextual analysis. Workshops provided open spaces for input and discussion of the programme in an independent space. 6 ‘Documentation’ here refers to intervention/pathway diagrams or narratives, lists of staf engaged, PDSAs, 14 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 15 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 2 Evaluation Methodology Area Evidence Speciic issue for NCM delivery Speciic issue for evaluation Resolutions for evaluation The apparent lack of (or provision of) overarching evaluation strategy, or evaluation criteria for assessing success of pathways. Given the complexities, inconsistency in data availability and challenging landscape, expectations from commissioners can be ambitious. The report suggests evaluation criteria for areas moving forward. Lack of review and critique of internal evaluations (e.g. PDSAs). Inconsistent data reporting for comparison across areas/interventions. Information regarding existing or contemporaneous evaluation work, either external or internal to BCT, was not shared with the evaluators. Evaluation is often left to the end of delivery of interventions, rather than embedded from the start. There appears to be a tendency to rely on, and trust, anecdotal evidence of change rather than rigorous qualitative analysis. As part of the 2017/18 evaluation, the evaluators will deliver training to BCT staf around embedding evaluation into programme delivery. Risk of duplication of evaluation activities. Diiculty in detailed comparison across areas. Difering expectations from participants and stakeholders about the vanguard evaluation itself. Lack of engagement, or reluctance to engage, by participants in some areas of delivery. u Table 1 Summary of Challenges for Delivery and Evaluation of BCT 2.1 Assessing Change, Outcomes and Impact HASCE were commissioned by Bay Health and Care Partners to undertake a qualitative evaluation of the NCM, and, where appropriate, have triangulated our indings with other sources in order to assess change, outcomes and impact of the vanguard site. The indings in this report are based on ive sources in particular: • • • • • Perceived change reported by participants in qualitative research; Patterns of change suggested by quantitative data prepared by UHMB Business Intelligence for NCMT quarterly reports; Responses to an online survey of three ICCs; An economic analysis of cost-saving in relation to hospital attendance; Stated outputs and outcomes on the 2016/17 BCT logic model (see Figure 1 below).7 Qualitative analysis plays a key role in understanding and informing the development of the NCMs. The ‘new’ aspects which these care models bring pose a number of challenges to existing forms of data collection and measures. The scope of BCT, across an area as diverse as Morecambe Bay, brings a vast range of variables: some of which may directly afect the causal processes at work in the programme’s delivery, some indirectly, and some not at all. As such, there is a clear need for attending to what Miles and Huberman call ‘local causality – the actual events and process that led to speciic outcomes. 8 This evaluation is based on a realist approach.9 This approach assumes that physical and social systems are ordered, yet ininitely complex. As such, no amount of observation or measurement will allow a complete understanding of their organisation. Instead, the realist approach analyses programmes and intervention in terms of their contexts, mechanisms and outcomes. This produces testable hypotheses on who a programme works for, in what context, and why; replacing overlyreductive outcome studies with an ongoing cycle of evaluation. 7 For the next stage of the evaluation, the evaluators will use the updated 2017/18 logic model. As this was inalised late in the timeframe of the irst stage of the evaluation (and therefore would not have been in circulation when a large part of the data collection took place), it is not considered in this report. 8 Miles, M.B. and Huberman, A.M. Qualitative Data Analysis: A Sourcebook of New Methods. Thousand Oaks: Sage (1984), p.132 9 See Pawson & Tilley, Realistic Evaluation. London: SAGE (1997). The following report provides: • • • • • A detailed account of the qualitative themes and conigurations in response to the NCMT questions, triangulated with quantitative outcomes where appropriate. A general map of hypotheses regarding cause and efect across the NCM as a whole, which will inform the next stage of evaluation of speciic interventions and ICCs. An economic analysis of cost reduction, which establishes the foundation for the next stage of evaluation around three speciic ICCs. A summary of the ‘active ingredients’ of the NCM that have emerged to date in the course of the evaluation. The report can be read alongside the quarterly reports of quantitative metrics provided to the NCMT by UHMBT Business Intelligence. 16 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 17 Context: large geography with large travel distance – sub-scale services (clinical safety, service resilience, specialisation, efficiency, recruitment and retention); diverse population groups with specific needs requiring tailored services ; strained relationships between providers with silo working Inputs Activities Women & Children - Vanguard funding £4.73m (2016/17 non-recurrent) - New Care Model Team – central support providing expertise: - Leadership coaching Financial/benefits modelling Guidance on PACS/ accountable care Shared learnings from elsewhere External expertise: CLIC, AQUA, NHS NW Leadership Academy, NW Coast AHSN, University of Lancaster, University of Cumbria, staff released from partner organisations to develop and deliver Volunteer organisations involvement Community mobilisation – population engaged and delivering codesign/co-production Planned Care (in hospital and community based) - Referral & pathway support (advice & guidance, PIFU, referral support) Integrated planned care pathways redesign - Out of Hospital: four elements working together linking with the whole system - Enablers: Integrated IM&T business intelligence/analytics, localised care guides, Workforce culture, skills & competencies redefinition/ mapping, OD, Estates, Finance, Comms/ Engagement Integrated Children’s Services providing place based care with integrated teams across acute/primary/community care Integrated Maternity pathway (multi agency care from pre conception to postnatal/ transition care) 12 Integrated care communities Integrated urgent care Community Specialist Services Self-care and Community Engagement Millom Model Palliative Care Accountable Care Development of population health approach • Common platforms development (IMT etc) • System wide cost reduction projects • Staff & public engagement • Outcome based payment models Intermediate Outputs 1-2 years Integrated working and communication across all services and sharing of care plans Upskilled and redesigned workforce focusing on skills & competencies needed to drive improvements and practice population health approaches Communication and engagement with the patient/carer about their care and future service redesign. Standardised, efficient and evidence-based approach, agreed processes with up-todate service information and guidelines ensuring patients receive the right care, at the right time in the right place. A defined and established ACS common platform Development of outcome based incentive/financial payment system aligned to improving population health outcomes across the ACS. June 2016 Rationale: The region faces multiple issues: a) growing deficit, b) S&Q: History of quality and safety issues (CQC), c) complaints about difficult access to services, d) problems with clinical population outcomes and inequalities - unique geography will require bespoke solutions that may be very different from elsewhere Improvement in the quality of care that the patient receives. Improved staff and patient satisfaction ratings, with increased awareness of different patient needs and the correct responses. Improved management of people with Long Term Condition’s (LTC’s) Impacts 5 years + Long term outcomes 3-5 years Intermediate Outcomes 1-2 years Reduction of 25 outpatient appointments. Closure of 2 wards 50% reduction in MFFD Improved mental health services - Closing inequality gaps - Improved health of babies and children ultimately leading to a healthier adult population - Economic benefits of a healthier population Improved education of prevention and self management of population, with a large proportion of patients with LTC’s with a self care package. Improved Outcomes & Experience of Care Improved learning across health professionals and organisations People empowered and informed to choose best community resources for their needs ensuring they are looked after at or near home when appropriate, therefore reducing unnecessary patient journeys. People get access to the right service at the right time all the time Reduce the cost per capita of the current system Improved Population Health Service users , carers and families experience “one” joined up excellent service consistently delivered by “one team” Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard u Figure 1 Better Care Together Logic Model 2016/17 18 - 12 Month Report 31/10/2017 Logic Model: Morecambe Bay, Better Care Together A community who are engaged with co-production and invested in the current and future health of the population Financial Sustainability Achieved through integration and development of an Accountable Care System Quality & safety - Shared decision making and patient involvement in care pathways is common place across the Bay area. Advanced level of an ACS style organisation that optimises the use of a common platform Universal application of population based medicine and population health approach to planned care and WACS services across all communities Reduction in cost per capita of the current system Advanced development of outcome based incentive/financial payment system aligned to improving population health outcomes Excellent recruitment & retention rates Broader Dividend - Environmental (reduced journeys) Educational (learning to other parts of the NHS and beyond) Assumptions: BCT Business Case approval, financial settlement around the 5 year forecast stays in place, sociodemographics will develop as projected; population inputs/changes in behaviour will progress as expected 2.2 Understanding Cause and Efect in a New Care Model Health and Social Care Evaluations (HASCE) Evaluation Question: What is causing the outcomes demonstrated in particular elements of the programme, systems, patients or staf? How will the attribution of outcomes within the vanguard be assessed? This section describes the approach which the evaluation has taken to ascribing cause and efect: an area that presents considerable complications, both for NCMs in general, and for BCT in particular, due to both the complexity of the programme, and the factors described in Table 1 above. What follows is a more technical account of our methodology that was presented in the evaluation narrative above (section 1.3). This describes the rationale for the evaluation design, and an explanation of what this approach ofers above other approaches. A summary of the overarching points is provided in Section 2.8. Large-scale change programmes such as BCT will almost inevitably face tensions between high-level outcomes to evidence change (e.g. lower numbers of ED Attendance, Elective Bed-days, etc.) and the evidence of interventions being implemented ‘on the ground’. For example, as Chapter 6 suggests, while change in practice at a local level could often be demonstrated there may be no direct pathway from this change to a high-level outcome; this must result in no more than a generalised correlation. Conversely, while the vanguard site was supported with a logic model, this tool did not feature in the content of the data collection (that is, participants in the evaluation did not reference the logic model when discussing changes or outcomes). This results in signiicant challenges in pinpointing systematic progress of the NCM.10 This tension between the ground-level and high-level can result in two diferent approaches to identifying change and its causes, summarised as ‘top-down’ and ‘ground-up’. In Figure 2 below, a ‘top-down’ approach is represented. This begins by looking at high-level quantitative frequencies, and correlates changes at this level with localised interventions. 12 Month Report 31/10/2017 - 19 10 For example, on the 2016/17 logic model, ‘Community Mobilisation’ is listed as an input, but examples of this have occurred at diferent paces and levels across the Bay area. Reports of community events are not always clearly located within the larger theory of change, and as such what they enable and how they progress (i.e. whether they are an input, activity or output) can be diicult to identify (see, for example, http://www.bettercaretogether.co.uk/uploads/iles/Kendal%20Integrated%20Care%20 Community%20Case%20Study.pdf ). Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) • High-level Metrics, e.g. ED Attendance • • • • Reports from local delivery, varying in content and method u Figure 2 Top-down approach to cause and efect Successful pilot interventions within BCT (such as the Frequent Attenders pilot in Bay ICC) have typically worked with low numbers of patients and/or citizens, when compared to the population of the Morecambe Bay footprint as a whole, or even individual ICC populations. The larger metrics are often too abstract to track the kinds of changes the success of the NCM depends upon. For example, even though high-level outcomes are, in practice, improving, this may not carry with it the longer-term cultural change envisioned by a New Care Model. When assessing cause and efect in a complex programme such as BCT, identifying the most appropriate data to compare for successive causality can become speculative and contestable. Measuring ‘inputs’ and ‘outputs’ may risk missing the diferent elements that have to work together – often in iterative and mobile ways – within complex health interventions. For all of the points above, there is a gap in the data at the ‘middle range’ (represented in Figure 2 by a box with an ellipsis), where key data to bridge small-scale data and large-scale outcomes is not present. With these limitations in mind, it is useful to note that during the evaluation, a number of interview participants voiced concerns and criticism over what they consider to be a top-down approach to change. These concerns can be summarised as a perception that focussing on high-level outcomes is likely to miss the more nuanced changes taking place within the NCM. In contrast, to the approach above, Figure 3 is a ‘ground-up’ approach to mapping cause and efect, which this evaluation aimed to deliver. The beneit of such an approach is that it allows population-wide changes to be identiied straightforwardly, by mapping general trends, savings and improvements across the health economy. It has the added beneit of providing metrics that can be shared across pathways (for example, reducing hospital bed-days is a key part of all BCT activities). High-level Metrics, e.g. ED Attendance 11 This model also tends to privilege a ‘successionist’ model of causation; in which causation itself is unobservable but is identiied by observing two or more sets of (successive) data, and inferring a correlation between them. For example, the frequency of ED attendance pre-vanguard funding can be compared to the frequency post-funding. If the frequencies are signiicantly diferent, then a correlation emerges between vanguard funded initiatives and ED attendance, which can then be tested further. The beneit of this approach is its relative straightforwardness in identifying change and impact; hence, its usefulness for strategic overviews of programme efectiveness. Structured pathway mapped to NCM strategy There are, however, limitations in this model. In terms of BCT, problems arise when attempting to ascribe changes in the high-level data to ground-level activity. Speciically, the causal relationship between ground-level activity of speciic interventions and broader changes to populations cannot be reliably established, for several reasons: • While high-level metrics can identify the success of well-deined pathways, they do not show the decision-making processes by individuals or groups which lead particular mechanisms to result in particular outcomes. As a result, there is no reason to accept that local interventions had an efect on the metrics any more than other interventions, or external inluences.12 11 Pawson and Tilley, Realistic Evaluation pp.32-3; Maxwell, J. A Realist Approach for Qualitative Research. London: SAGE (2012), pp.36-7 12 For example, one inluence on ED attendance external to the work of BCT could be social media announcements posted throughout 2016 and 2017 by UHMBT, advising the public against attending A&E. The efectiveness of these announcements as an inluence on BCT’s high-level metrics can, however, be challenged; see Appendix Seven. 20 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Multiple local datasets based on speciic intervention models u Figure 3 Ground-up approach to cause and efect Here, the expected causes and efects are mapped out prior to delivery and data is tracked up from local contexts to demonstrate what efect they should have on the higher-level metrics. Thus, as well as concentrating on service integration or redesign, there is a clear low of data which links delivery activities to the outcomes used by the BCT delivery group. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 21 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Because the ground-level changes focus on the choices and decisions that staf and citizens make within speciic pathways (for example, a GP’s decision on whether to refer to a hospital consultant), this suggests a model of causation which is more ‘generative’ which can be summarised, thus: Actors and society have potential mechanisms of causation by their very nature. Change occurs when interventions, combined with the right contextual factors, release the generative mechanisms.13 The generative causality model, then, sees causation as something real and identiiable and this is important to help understand our approach to the evaluation. Our selected methodology of realist evaluation is focussed on what mechanisms, in which contexts, allow change to happen and produce clear outcomes. When we map the complexity of a programme onto this context-mechanism-outcome (C-M-O) template, it facilitates the understanding/identiication of how causation occurs (and this causation, as in the model above, should be real and identiiable). This realist method, described above, was chosen for this evaluation for two primary reasons: • • It allows the complexities of interventions to be examined and evaluated, as part of an ongoing cycle of hypotheses-testing. It is possible for a C-M-O template to align qualitative themes with quantitative outcomes. In this way, it works by ‘scafolding’ evidence of cause and efect from the ground up to the higher-level reporting metrics, and in doing so complement and support them (rather than replace them). It provides a way of improving qualitative data collection and analysis. One problem the evaluators faced was attempting to discern NCM achievements from aspiration, largely due to the slow pace of implementing change to frontline delivery. However, through the use of ongoing feedback loops (see Figure 4) qualitative data collection can be reined and structured as the NCM continues to develop. 2.3 Sampling Strategy The sampling strategy forms a key part of developing a clear cross-sectional view of the delivery of the NCM. Given the size of the programme, it was clear that the evaluation must begin with a purposive sampling strategy – that is, gathered with a purpose in mind, as opposed to a random sample of participants. In this case, the sample comprised a range of individuals speciically selected for their various roles, knowledge and experience of the programme in order to capture a full range of perspectives. Scoping meetings between the evaluation team, commissioners and work-stream project leads, facilitated the identiication of ‘sample routes’ through particular projects. The evaluators then approached named project and clinical leads and from there followed a chain-referral (or ‘snowballing’) approach. This allowed researchers to move from the strategic level of delivery to the interface between staf and patients. A purposive sampling strategy inevitably entails that not all views will be captured within the process data (due to time and resource constraint). However, this approach is not designed to audit BCT as a whole, but rather identify emergent themes around the contexts, mechanisms and outcomes of projects which could be used to identify causal factors for success, and carry into future implementation. As well as enabling data to be collected from the ‘ground up’ and the ‘top down’ of the programme, the evaluation design aimed to collect data on both the successes of the programme, and understand why aspects of the programme may have taken longer to deliver, or not been delivered. By tracking the delivery of activities from the strategic and planning level to the frontline delivery and patient or citizen responses, the evaluation aimed to capture ‘cross-sections’ of structural, cultural, strategic and technological changes to the delivery of care. Based on project documentation provided by the commissioner, and initial discussions with workstream leads, the initial areas of sampling were selected: • Elicit programme theory • • Revise hypothesis. The programme works under conditions A,B,D,E,F u Figure 4 Realist Feedback Loop Formulate if-then hypothesis. The programme theory works under the conditions A,B,C Design test of the hypothesis. Collect data on conditions Projects already in delivery involving clinical staf, project staf and patients: Respiratory; Self-Care; Advice & Guidance; Women & Children’s Pathways Launch; Ophthalmology. Projects in development involving clinical and project staf. In particular, we were interested here in projects that had taken longer to implement, and what the perceived reasons for this might be: Children’s Alternatives to Admissions (A2A); Muscular-skeletal (MSK). Development of Integrated Care Communities (ICCs) involving community/clinical staf (e.g. case managers and care coordinators), project staf and citizens. During the irst six months of the evaluation it became clear that a number of projects were not at the stage of development expected based on programme documentation from the evaluation commissioning stage. As can often be the case with this approach to sampling, some routes did not develop a full referral chain, due to either lack of engagement, or changes to delivery plan: participants were often reluctant to engage around projects that had not delivered a successful outcome, while some staf were not available to discuss certain projects. Conversely, other routes developed more widely than had been anticipated: for example, the interest and involvement of non-NHS organisations in the NCM. The data collection was initially guided by four elements based on the BCT programme design: Outcomes and Experience of Care; Quality and Safety; Cultural Change and Sustainability. These form the template for data collection activities (see Appendix One). All interview schedules covered these themes in their questions, although, dependent upon the participant’s role within BCT as well as how developed the activity was, some took a more central focus than others (this is discussed in Chapters 6-8 below). 13 Marchal, B., van Belle, S., van Olmen, J., Hoerée, T. and Kegels, G. Is realist evaluation keeping its promise? A review of published empirical studies in the ield of health systems research. Evaluation 18: 2, pp. 192-212 (2012). P.202 22 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 23 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) This initial sample was based on staf and stakeholders. The original evaluation design was to track projects from planning to delivery, and impact on patients and citizens and so the latter months of data collection were focussed on these groups and their perceptions or experience of the programme delivery. Because many aspects of the programme had not reached the stage anticipated when the evaluation was commissioned, participants from service delivery and management voiced a number of concerns that patients would not yet be feeling the efects of interventions. This led to a redesign of the sampling of patients and citizens in the second half of the evaluation. Patient and citizen representation was taken from focus groups. The sample for these was identiied following discussions with the evaluation commissioners regarding the 2017/18 evaluation. As a result of these discussions, the evaluators initially contacted patient participation groups and voluntary organisations which were either a) involved in one of the three pathways which form the focus of the second stage of evaluation: respiratory, paediatrics and frailty; or b) active within one of the three ICCs selected as a focus: Barrow Town, Bay and East. 2.4 Data Analysis Data was collected from interviews with staf and stakeholders, and focus groups held with patient groups. The interview and focus group data was analysed initially for themes, which were then categorised as ‘basic’, ‘organising’ or ‘global’. As Attride-Stirling notes, this approach does not initially ‘aim or pretend to discover the beginning of arguments or the end of rationalizations; it simply provides a technique for breaking up text, and inding within it explicit rationalizations and their implicit signiication.’14 Basic themes grouped together under shared assumptions can be identiied by an organising theme, and likewise global themes can be broken down into constituent organising themes, as illustrated in Figure 5: Basic Theme Focus groups have been ongoing between September and November 2017. This report includes analyses of data collected from 34 participants. The emphasis of the focus groups was on understanding what the patient experience has been of the BCT initiatives under evaluation, and what factors have been most afective in this, covering: Basic Theme • • • Attitudes and feelings towards the healthcare system, in particular relation to respiratory, frailty or paediatric pathways and the changes that these interventions have brought; Organising Theme Basic Theme How their access to care has or has not changed during the course of the programme; Changes in expectations of care from their local health providers. The focus group schedule can be found in Appendix Three. Basic Theme For the 2017/18 evaluation, speciic patients who have been through the selected interventions will be contacted for interviews and/or focus groups. As this data has yet to be collected, the focus groups with patients and citizens aimed to provide a general narrative in relation to the contexts, mechanisms and outcomes of BCT in these particular areas. This will form the foundation of the analysis of impacts on patients and citizens during 2017/18. Basic Theme Participant Background Data Collection Method Number of Participants (up to 30/10/2017) Clinical Semi-structured interviews 24 Project Semi-structured interviews 24 Local Authority, Third Sector and other non-NHS Semi-structured interviews 6 Patient/Citizen Focus groups 34 Global Theme Following on from these focus groups, a more detailed analysis of patient and citizen experiences that have been directly involved in BCT interventions or activities will form part of the 2017/18 evaluation work. Organising Theme u Figure 5 Levels of Qualitative Analysis Initial analysis of the interview and focus group transcripts produced over 500 pages of basic themes, which were then grouped into organising themes, and then more general, global themes. Alongside this category based analysis, the researchers also applied a connective analysis, which involved identifying themes within participant narratives as ‘enabling’ or ‘disabling’. This aimed to capture how change was developing within the often complex and unfolding NCM contexts. Some themes were also labelled ‘ambivalent’, typically where themes emerged around possible future events or changes which could not reliably be seen as enabling or disabling yet. 14 http://utsc.utoronto.ca/~kmacd/IDSC10/Readings/text%20analysis/themes.pdf u Table 2 Evaluation sample size to date 24 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 25 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) In order to propose cause and efect to the changes taking place within the NCM, the themes were analysed and arranged into context themes, mechanism themes and outcome themes. This facilitated in-depth analysis of each emerging theme, as well as the hypothesising the connections which would suggest causal links between themes. A beneit of the application of this C-M-O template is that it can use diferent forms of data, and it has been used in this way here. The bulk of our evaluation data collection focused on semi-structured interviews and focus groups; responses from these are most likely to focus on mechanism themes. Context and Outcome themes, meanwhile, can be aligned with quantitative data to support the cause and efect suggested in the qualitative indings. In principle, this method can produce hypotheses around what mechanisms carried out in what contexts are causing particular outcomes to occur (see Figure 7). Mechanisms taking place in particular contexts produce outcomes Contexts Mechanisms Outcomes Themes around elements that are external to the intervention, and may have an inluence on the outcome. Themes around elements which have the power to initiate an event which would not have otherwise taken place. Themes arising from elements produced directly from the application of the mechanism to certain contexts. u Figure 6 C-M-O Coniguration of Themes u Figure 7 Programme Overview Template Positive outcomes feedback into enabling contexts for further programme development In determining what should be seen as a context or a mechanism, we followed Marchal et al. in considering context to be elements that are ‘external to the intervention, present or occurring even if the intervention does not lead to an outcome, and which may have an inluence on the outcome.’15 However, it should be understood that this ordering is always hypothetical rather than a direct representation and, so, while it is very useful in this type of evaluation, alongside it the evaluation team must make informed decisions on how the data is themed and ordered. Mechanisms, meanwhile, are particular things which have the power to initiate an event which would not have otherwise taken place. ‘Integration of services,’ for example, can be understood as a strategic mechanism for BCT, because it initiates several of the outcomes of the NCM.16 In this project, the validity of the data analysis was established through dialogue with the Research and Evaluation Group (REG), three workshops run for stakeholders (see Chapter 3), and an Outcomes Survey (see below, section 2.5), as well as a number of informal conversations with stakeholders in and around the evaluation. The data analysis will continue to be tested and modiied in the 2017/18 evaluation work, by focusing on a smaller number of speciic interventions. Outcomes, meanwhile, should describe events which are produced directly from the application of the mechanism to certain contexts. Outcomes, in this sense, are not simply proof that a programme ‘works’, but are used to test whether the hypothesised connection between contexts and mechanisms is reliable. 15 Marchal et al., Is realist evaluation keeping its promise? P.207 16 Crucially, mechanisms can take a wide range of forms. Thus, integration of services is a strategic mechanism which can be broken down into a number of constituent parts, which may include psychological mechanisms (e.g. trust between individuals working within diferent services), social mechanisms (e.g. the enabling of discussion which ensures successful integration), technological mechanisms (e.g. data sharing), and so on. 26 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 27 Health and Social Care Evaluations (HASCE) 2.5 Outcomes Survey In the initial evaluation plan, a large-scale outcomes survey was planned which would provide a means to testing the hypotheses around the changes efected by the New Care Model. As documented in Table 1 above (section 1.3), the evaluation has experienced a number of challenges in data collection, following changes to programme delivery, variations in timescales across diferent interventions and workstreams, and no clear consensus between stakeholders around what success would look like. As is to be expected in an iterative evaluation project, there have been changes in the initial evaluation data collection strategy, and this also raised questions as to the appropriateness and usefulness of an outcomes survey at this point of the Care Model’s delivery. These questions were informed by the following concerns: • • • • The reach of the survey was likely to be limited; discussions with the BCT communications team suggested a igure of c.250 people may be likely to engage with a general survey. The data collected suggested very strong themes, which, the evaluators felt, were unlikely to be modiied by a larger survey. The qualitative data suggested that the most signiicant changes occurring were routed in speciic relationships at an individual level. It would follow, therefore, that localised analysis of causation would be more beneicial than a more overarching, general view. Because BCT operates within a range of other contexts, a large scale survey would risk missing key details, rather depth, quality and robustness of data would be better achieved via diferent means to facilitate participant reporting on speciic BCT outcomes (rather than more general perceptions of care) – for example, an explanation of what a workstream has achieved to date. In response to these concerns, evaluators distributed a smaller-scale survey (see Appendix Two), within the three ICC sites for the 17/18 evaluation, in place of a large outcomes survey. The smaller-scale survey was aimed at staf in primary care, social care and the voluntary sector, based on those involved in, or afected by, interventions currently in place within each ICC. The distribution followed a cascading strategy, beginning with ICC leads and core teams and was available to complete online for ive weeks in September and October 2017. The surveys focused on two key outcomes, based on the qualitative indings: the extent to which there is a shared understanding of roles and responsibilities within the ICC, and the level of engagement/disengagement that participants report for the appropriate BCT workstreams. The surveys used a combination of attitudinal Likert scales and open-box responses to provide quantitative and qualitative measures for these themes. The response rate was very low, with only 13 surveys being completed. While this cannot be considered as a representative sample, analysis of the survey responses provides some additional and valuable insight into experiences of the ICCs. These indings have been summarised in Appendix Six and are to form the basis of further qualitative work in the 2017/18 evaluation during which a second survey will be distributed, with the aim of increasing participation, particularly across GP practices and community groups involved in the ICCs. 2.6 Ethical Considerations Health and Social Care Evaluations (HASCE) It was of vital importance to the evaluators that anonymity of participants needed to be preserved. In the indings presented in this report, quotations from participants have been double-coded in order to prevent any contributions being traced back to individuals. Interviewees are thus labelled INT001, INT002, etc., and focus group participants are labelled PARTICIPANT 1, PARTICIPANT 2, etc. Where appropriate, text from quotes has been redacted where information, or a combination of information, may identify a participant. 2.7 Limitations, Issues and Adjustments The realist approach to evaluation is entirely appropriate to this type of project however, one limitation is that the model has a dependence on clear programme ‘theories’ being apparent from the outset of delivery, particularly within health systems.17 Similarly, the ‘ground-up’ model described in section 2.2 and 2.4 is an ideal schema, whereby the clarity of cause and efect depends very much on the clarity of the programme structure. In practice, it can be diicult – and not always useful – to decisively separate themes out as ‘contexts’ or ‘mechanisms’; this is made easier when clear outcomes are identiiable, but given the iterative nature of much of the BCT programme, this was not always possible. • To address this, the initial context-mechanism-outcome coniguration was adjusted to a wider set of categories; these allowed the ongoing and iterative nature of change mechanisms to be accurately represented, as well as the complexity of the systems they were placed within. The conventional realist coniguration was expanded to represent context, enabler, disabler, mechanism, preventer and outcome. A key challenge in the work here was the apparent lack of consistent documentation on, for example, intervention/pathway maps, inputs and resource use, and localised outcome data. Instead there appears to be some reliance on anecdote and ad hoc feedback. It is likely that this situation has arisen from a number of relevant contextual factors, but it should be noted that from the perspective of an independent evaluation, it does pose challenges for a system-wide ground-up, qualitative approach. Identifying clear outcomes proved to be a diicult task for the evaluators with a range of complications; some outcomes were yet to appear, others are not currently reported in a consistent form, while some are too broad to attribute to speciic changes within the programme itself. For example, certain Integrated Care Communities (ICCs) are described in the data as ‘more developed’ than others, but it is not clear if these align to speciic metrics or KPIs, and whether these might be comparable across all ICCs. • • In response to this, the evaluators have drawn out some of the key themes around success and outcomes in this report which may help to support the development of more robust, and locally-sensitive, metrics. The evaluators used quantitative metrics to triangulate outcome indings, and use these to identify further areas for analysis. In order to adjust for this, data collection took on more of a scoping function, in order to understand the realistic state of the programme. 17 See Julnes, G., Mark, M., and Henry, G. Promoting Realism in Evaluation: Realistic Evaluation and the Broader Context. Evaluation 4:1 483–504 (1998). The evaluation adhered to an ethical code of research conduct throughout the project. Where appropriate, data collection and analysis was approved by the University of Cumbria’s Research Ethics Committee. When undertaking focus groups with patients and citizens, participants were not asked about speciic conditions or treatments, in a way that might involve divulging personal information. They were, instead, be asked about their experience of the speciic changes brought about by the New Care Model. 28 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 29 Health and Social Care Evaluations (HASCE) In addition, a further challenge to the evaluation rollout is the wide variation in levels of engagement with the project, as well as access to relevant and up-to-date documentation. In some cases, the ‘projects in development’ sampling route did not generate enough participants to warrant pursuing. In other cases, there was little enthusiasm amongst participants for discussing projects that had not been deemed successful. • Adjustments were made to the original sampling strategy: the ‘projects in development’ sample route was merged with an additional route engaging a broader range of non-NHS stakeholders in service delivery. As well as these ‘ground-level’ challenges, a more strategic issue is that there appears to be no overarching evaluation strategy for the programme. This is problematic, particularly given the large scale and scope of the project, the latter being diicult to pinpoint exactly. Most critically, the lack of strategy entails that there was the possibility of multiple research and evaluation activities (for example, PDSAs) were taking place around Morecambe Bay with risk of duplication or lack of shared learning. A strategy in place may also have helped manage expectations as to what this evaluation project would be able to deliver with the time and resources available. Given the challenges noted above, this twelve-month report presents indings, but also a number of gaps in data which the evaluators feel are signiicant in being able to identify what outcomes are coming from the vanguard site, and how these are being caused. The limitations and adjustments have guided the development of a second stage of evaluation in 2017/18, where smaller, more clearly-deined activities will provide a focus for answering the NCMT questions. Health and Social Care Evaluations (HASCE) 2.8 Discussion and Summary The ambition of the NCM requires a more nuanced approach to cause and efect than frequency and correlation, as this is unlikely to capture the speciic kinds of change, and the incremental progress this may take. • • • • Measuring start points and outcomes does not capture the diferent mechanisms that have to work together in order to link the two in complex health interventions. In its current form, the quantitative data reported to the NCMT is not connected to clear models of inputs, outputs and outcomes. For this reason, the commissioners have been clear from the project’s inception that the evaluation should involve a whole programme approach, rather than a workstream-by-work-stream study. This approach entirely beits the ethos of the BCT programme. At the same time, problems can arise when there is ambiguity over key boundaries for the evaluation: in particular, the size and shape of particular interventions, where BCT ‘begins’ and ‘ends’ in terms of inclusion of activities, and the speciic contribution of vanguard resources to existing interventions in relation to other funding sources. The evaluators initially used the realist approach of coniguring context, mechanism and outcome in order to explain the changes taking place. However, several factors complicated this approach. • • Due to the size and scope of BCT, there are a number of diferent timescales for delivery for projects. In some instances, it appears there is a lack of a clear timescale for expected outcomes. This has led to adjustments in the original evaluation approach. The lack of clarity around speciic mechanisms, and the complexity of the systems they were placed within, led the evaluators to modify and expand their categories in order to represent the change process, to context, enabler, disabler, mechanism, preventer and outcome. The absence of an overarching evaluation strategy embedded within the delivery of the NCM is considered to be problematic. • • This means that there has been the risk of duplication of evaluation activities, and difering expectations from participants and stakeholders about the vanguard evaluation itself. The lack of clear and consistent criteria for ‘what success looks like’ makes evaluation fundamentally diicult. At the present time, localised qualitative data plays a key part in identifying the contexts, changes and outcomes of the NCM. Much of the evidence of change in relation to the speciied outputs of the BCT logic model currently resides in qualitative work. Following the production of the interim report (April, 2017), the evaluation and commissioners discussed how sampling routes could be focused and reined in order to address the main problems the initial evaluation faced. This has shaped the commissioning of the second stage of the evaluation, whereby the focus will be on three ICCs and three speciic pathways. • 30 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard The evaluators are therefore presenting here general indings around the NCM with more detailed analysis of speciic interventions to follow in the next 12 months. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 31 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 3 Evaluation Workshops The evaluation project was two-tiered: alongside its frontline evaluation activities, the evaluators also delivered three workshops over the 12-month period. These were designed so emerging indings could be fed back to stakeholders, and which a) allowed the evaluators to modify and reine our data collection in dialogue with those involved in delivering the care model and b) sought to establish a foundation for ongoing evaluation amongst stakeholders once the NCM evaluation had inished. HASCE presented these workshops with support from the Bay Learning and Improvement Collaborative (BLIC). 3.1 Workshop One: Evaluating Better Care Together The irst workshop took place on 21st February 2017, and brought together stakeholders from health, social care and the third sector to discuss the ways the progress and impact of BCT is evidenced and valued. The event utilised an Open Space format, where participants were encouraged to identify ‘conversations’ that mattered to them around BCT. Each conversation was given a separate discussion space, and participants were free to join and exit conversations as they wished. The initial aim of the workshop was to discuss and develop ideas on how evaluation could be embedded successfully at the core of BCT, both now and in the future. There was a sense, from the conversation topics put forward, that the question of evaluation had to proceed from some more fundamental discussions around, for example, improving communications, as well as examinations of broader issues such as territorialism around roles and funding. The conversations had the following headings: • • • • • • • • • • • • How do we establish trust between stakeholders? Do we have a sense of where we are going? How do we redistribute resource without afecting service? Making children’s voices heard in an Adult/BCT world Empowering people to diagnose cancer How do we make the important measured, and not the measured important? What does integrated IT look like? How can people learn/share/develop the population health initiative? What are the design principles that underpin all we do? Is a clinically led NHS achievable? How do we optimise the assets of individuals, communities and partners, including elected politicians at all levels of government? Cultural change amongst BCT stakeholders The discussions were captured on ‘harvesting sheets’, which were made available on the evaluation website designed for this project.18 While the purpose of the workshop was not necessarily to produce consensus, it was notable that a number of key themes started to appear across diferent conversations, these comprised: • • • • Having the right people ‘around the table’ for decision-making (at every level), and ways in which this might be achieved; for example, how we know who the ‘right’ people are, and how accessible the table might be for them. Whether the balance of priorities for BCT was appropriate, both in terms of the focus of care, and in terms of who leads this focus. The signiicance of relationships and personalities to programme success. The importance of case studies, stories from the ‘ground up’ and qualitative evidence of what works, in order to help continue to shape the delivery of BCT. It was interesting to note that these themes relected a number of emerging indings from the process evaluation at that point, speciically around the importance of ground-level qualitative data, and questions around ‘what success looks like’ at the end of the programme. 3.2 Workshop Two: Whose Knowledge? What Evidence? Which Data? The second workshop took place on 23rd May 2017 with the purpose of the workshop of discussing the creation, collection and use of data from across health providers, support services and the community to support the NCM. The workshop was attended by some 33 delegates19 from across BCT including clinical and non-clinical staf and representatives from local authority, public health, third sector and NHSE. As previously, the workshop used an ‘Open Space’ format which provided opportunities for participants to suggest topics and questions for discussion around the data that is being collected across the whole of BCT, and how it might be used to evidence success. The day began with an update from the evaluation team on the current evaluation. There followed the Open Space format, where participants were encouraged to discuss and develop ideas on how evaluation can be embedded successfully at the core of Better Care Together, both now and in the future. These conversation topics were suggested by participants, and individuals were free to attend, contribute to and move in between those conversations. The agreed conversations were: • • • • • • • • • • • • • People using the Third Sector What would success mean to the patient? What is an appropriate metaphor to convey the BCT vision? How do we remove fear of change? Ensuring equity, governance & challenge How informed are the public about NCM? Addressing equality and diversity How do we measure success in BCT? How do we challenge the Postcode Lottery? How do we mainstream ideas? Patient empowerment & citizenship How do we shift/transfer resources in line with the BCT strategy? Improving staf engagement From the evaluator’s perspective, there were a number of interesting themes emerging from discussions; two of the most prominent themes concerning evaluation speciically were: • • How organisations could assess the success of collaboration, across sectors and geographies (e.g. primary and secondary care, voluntary sector). The importance of efective communication. The BCT evaluation website provided some further information for participants on the main methods of applying evaluation to these areas.20 This information is summarised as part of Appendix Five. 19 Over 60 were registered for the event; unfortunately, a major traic incident on the day of the workshop led to many delegates being unable to attend. 20 https://v3.pebblepad.co.uk/spa/#/public/94jgbwjbdRgs6xg3qyR9d4p37W?historyId=CCkBWc0A5q&pageId=94jgbwjbdRgs9hg t946xq7MGmr 18 https://v3.pebblepad.co.uk/spa/#/public/94jgbwjbdRgs6xg3qyR9d4p37W?historyId=CCkBWc0A5q&pageId=94jgbwjbdRg s94Gz38xdzfp7gc 32 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 33 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 4 Findings The key point arising from these themes was that a deinition of successful engagement or successful communication was fundamental to evaluating success. However, diferent contexts may involve a diferent deinition of success. As such, attempting to use a universal category such as ‘efectiveness of public engagement’ must be accompanied by a clear articulation of the time and space that engagement takes place within, so that success can be compared across them. For example, it was noted that attention must be paid to how, where and when questions are asked, and how this might implicitly ‘shape’ the responses, as well as the conditions determining the ‘efectiveness’ of an engagement. Likewise, there was a discussion of how engagement in evaluation needed to show results – feeding back on a process needed to have a visible efect (whatever that might be) in order for it to be worthwhile; otherwise, participants may be less willing to engage at all. It was considered these will all afect the success of an evaluation. 3.3 Workshop Three: Evaluating Cultural Change In the initial evaluation proposal, a third workshop was planned which would follow the establishment of multiple new pathways, to provide a context for discussing issues around cultural practices, barriers and solutions, which would then contribute to thinking around the longer-term sustainability of the NCM. While delivery had not reached this stage, the workshop on cultural change was nevertheless felt to be timely. The workshop took place on 19th September 2017, with the purpose of discussing the evaluation of changes in the culture of healthcare provision within the BCT programme. The workshop was open to staf in primary and acute care, community teams, third sector organisations and patient representative groups and was attended by 60 delegates from across BCT including clinical and non-clinical staf and representatives from local authority, public health, third sector and NHSE. This workshop was run as a World Café model, to provide opportunities for participants to discuss pre-selected topics and questions around cultural change. The wide range of views from across the health economy, helped to articulate the key successes, and main obstacles, to the kinds of cultural change which Better Care Together aims for. 4.1 How the Findings are Presented Because of the complexity of the NCM, it can be challenging to isolate variables afecting individual aspects of change. At the same time, evaluation requires a degree of abstraction in order to ‘make sense’ of the work of the programme. In order to present this in as coherent a way as possible, the evaluators have presented their indings in three ways: • • • First, as overarching mechanisms in the coniguration table detailed in section 4.2 below. This coniguration forms the basis of the evaluators’ responses to the research questions set out by the NCMT. Each question is mapped to one of ive headings: contexts, mechanisms, resources, outcomes and active ingredients. Within each of these chapters (with the exception of Chapter 9), the main headings from the coniguration table are then broken down into thematic overviews, to illustrate their component enabling and disabling themes. These themes are then detailed in a narrative response, which forms the substantial part of each chapter. The narrative responses attempt to show the generative causality within the context of service delivery. Findings are discussed and summarised at the end of each chapter. It is important to note that the evaluation was not tasked with (and was not encouraged to deliver) a pathway-by-pathway audit. The subject of this report is an analysis of why certain changes have happened where others have not, what components of the NCM have been most efective in contributing to positive change, and how similar the enablers and disablers have been across workstreams, pathways and interventions. After an opening presentation from Dr Alex Gaw, Chair of the BCT Research and Evaluation Steering Group, and Dr Tom Grimwood, Lead of this evaluation, on cultural change and evaluation, participants were asked to join one of seven tables. Each table was tasked with a speciic question around cultural change in BCT. Groups had 30 minutes to discuss the question and populate a harvesting sheet, before moving on to a diferent table. There were four rotations in the course of the day. To conclude, a plenary discussion was held, where the most prominent questions from the day’s table discussions were put to a panel of senior igures. The harvesting sheets were structured to elicit more focused responses than those of the irst two workshops as evaluators were keen to understand how participants viewed the successes of BCT to date, and what they envisaged as the main obstacles to success. The harvesting sheets from the workshop are presented in Appendix Three. In many senses, these provide a clear snapshot of the state of BCT at the current time. When read in conjunction with the evaluation analysis (Chapters 5-9), they serve to support a number of the indings. 34 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 35 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 4.2 Coniguration of Hypotheses Contexts Disabling Mechanisms Enabling Mechanisms Overarching Mechanisms The coniguration table presents a schematic view of the development of the NCM. The entries in the table refer to broad themes, which are discussed in detail in Chapters 5-9. The table is to be read from left to right, beginning with the contexts for NCM delivery, across to the outcomes currently being evidenced, or identiied as prospective outcomes for the work being done. Preventers Outcomes Community mobilisation Improved self-care in citizens Care coordination Geography and Demographics Integrated Care Communities Localised solutions through lexible working Staf attrition Improved use of technology Time needed for development The outcomes column is supplemented below with possible measures to evidence their success. As Chapter 8 details, not all of these measures are currently active, and their development forms part of the report’s recommendations. While a range of tools for measuring these forms of outcomes exist, there is no single measure which will demonstrate the efectiveness of the changes BCT is implementing; and the coordination of a range of measures will be the best way of assessing outcomes overall. Care planning Dialogue and communication Non-inancial resources inc. upskilling Previous Interventions Each overarching mechanism for achieving these outcomes is preceded by smaller mechanisms which occur before the broader mechanism take place. These are either enabling (ingredients for success) or disablers (obstacles to be overcome). In some cases, disabling and enabling mechanisms will be in play simultaneously (where they appear next to each other on the table); in others, it is theorised that an obstacle will prevent the enabler emerging. In between the broad mechanisms and outcomes are preventers: these occur after the mechanisms have been instigated, but prevent full outcomes being reached. Improved quality of care Skill Supply Availability of Resource Patients receive appropriate care in an appropriate place This allows for outline hypotheses to be drawn across the contexts, mechanisms and outcomes of the programme, taking into account the interrelation of diferent themes. Clarity, perceptions and balance of distribution of funding Outcome Integrated working Non-sustainable change Insuicient metrics Enthusiasm for change Improved self-care in citizens Improved quality of care Non-sustainable change Incremental change ‘Joined-up’ care for patients Organisational Cultures Cultural change Pace of change Broader understandings of wellbeing Lack of clarity around BCT – vision, leadership and decision-making u Table 3 Coniguration of Hypotheses Disengagement at key points Improved patient satisfaction ratings Qualitative feedback from ICCs Existing pathway-speciic care quality measures Visible progress (at high-level and local levels) BCT as a disabler for long-term change Sustained reduction in non-elective admissions in areas of self-care projects Qualitative feedback from ICCs Patients receive appropriate care in an appropriate place Reduction in costs Potential Measures Reduction in re-admission rates for speciic pathways Improved patient satisfaction ratings for speciic pathways Lack of improvement (qualitative and/or quantitative) and progress in pathway implementation against speciied and contextualised timescales Reduction in cost per capita Reduction in costs Measures of non-inancial resource (e.g. time); improved use of shared resources Improved high-level metrics (BCT quarterly reports) Visible progress (at high-level and local levels) Overcoming organisational barriers ‘Joined-up’ care for patients Measures for incremental and qualitative change and local levels (see Appendix Six) Patients tracked through speciic pathways Qualitative feedback from staf and patients Evidence of shared decision-making Overcoming organisational barriers Evidence of good communication and engagement (see Appendix Six) u Table 4 Outcomes and Potential Measures 36 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 37 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 5 Contexts Evaluation Question: What is the context in each vanguard into which new care models have been implemented? 5.1 Thematic Overview NCMs are complex programmes that are being implemented within complex systems, and each system has a context that is shaped by unique local historical, demographic and organisational factors. These contexts are aspects which exist regardless of the programme itself, but nevertheless afect its implementation and success, so identifying its key features is necessary to understand the conditions for delivery. For the purposes of this evaluation, contexts were identiied using the VICTORE model, 21 which has been developed within realist evaluations to map contextual factors. This has been used to inform the analysis of the data collected in Stage One of the evaluation of the NCM. A narrative of these indings is presented below. 5.2 Geography and Demographics The geographical features of Morecambe Bay comprise key enabling and disabling contextual factors, as would be found in any geography. Morecambe Bay covers a geographical area of 1,800km2, which is double that of the average Trust nationally, but its 365,000 population is smaller than that of some urban areas.22 The distance between services, and from major city hospitals, is recognised as a key challenge to BCT.23 The challenges associated with low population density with diverse, and sometimes isolated, communities were commonly cited by participants in their descriptions of the NCM. BCT has used GP practice populations across south Cumbria and north Lancashire to divide its footprint into 12 Integrated Care Communities. These communities cover geographical and demographically distinct populations, such as the industrial Barrow-in-Furness in South Cumbria, the picturesque villages of the South Lakes and the city of Lancaster. Participants described the implications of these diferent health and social care needs of these communities on the provision of care, for example: My ICC has two geographically quite diferent areas. We’ve got the South Lakes and Ambleside, Windermere, versus the Grange Peninsula. So that’s a potential issue for my ICC, that they are two quite diferent areas geographically and demographically, with diferent challenges. So the Grange Peninsula has a lot of nursing homes and an ageing, frail population, and then the Lakes tend to have more aluent and holiday maker, temporary residents. (INT050) 21 This model categorises contextual data in terms of Volitions (the choices available to stakeholders), Implementation (the chains of resources, responsibilities and governance involved), Context (demographic concerns, on both micro and macro levels), Time (previous histories of interventions within the locality), Outcomes (the monitoring systems available), Rivalries (the pre-existing policy landscape in which the intervention is embedded) and Emergence (the potential efects and unintended consequences of the intervention). 22 University Hospitals of Morecambe Bay. Summary of our Five Year Strategic Plan 2015-2020. (2015) https://www.uhmb.nhs.uk/ iles/bct-publications/NHS-M-Strategy-Plan-2015.pdf 23 The Better Care Together Strategy for the Future for health and care services in Morecambe Bay. (2015) https://www.uhmb.nhs. uk/iles/bct-publications/Better-Care-Together-Plan.pdf u Figure 8 Contexts - Thematic Diagram 38 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 39 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) These needs and other demographic characteristics have been well documented elsewhere and therefore a detailed analysis is not repeated here. A summary is however presented in Table 5 below to highlight the key features of Morecambe Bay by ICCs. 24 ICC Population Millom 11,767 27,372 • • • • • • Barrow 33,774 (proile based on ‘Barrow Other’) Ulverston, Dalton and Askam • • • • 25,400 • • • • Grange and Lakes 31,854 Population Kendal 36,826 Key Features • • Alfred Barrow ICC • • • • Higher than average older population (24% compared to English average of 17.2%) East 32,313 Life expectancy for males (78.3) and females (81.3) is lower than the English average (79.5 and 83.1 respectively) 5.5% are unemployed, higher than the English average* Carnforth 14,920 Life expectancy lower for males (76.9) and females (81.2) than nationally Located in South Cumbria, includes coastal areas Higher than average older population (25.3% compared to English average of 16.9%) 5.0% are unemployed, higher than the English average * Bay 70,097 South Cumbria, on edge of the Lake District 3.5% are unemployed, lower than the national average* Queen Square 13,642* Life expectancy higher for males (80.7) and females (84.7) than nationally Located in South Cumbria, includes Lake District villages of Grasmere, Ambleside and Windermere Higher than average older population (31.3% compared to English average of 16.9%) Lancaster 54,630 Low unemployment rate (0.8%)* Higher life expectancy for males (80.7) and females (84.7) than the English average Garstang 24 Sources: all data for Cumbria ICCs: ICC Proiles, 2017, Cumbria Intelligence Observatory; data for Lancashire ICC s: Clinical Commissioning Group Proiles, 2015, Lancashire County Council, unless indicated with *. All data indicated with an * is from PHE’s National General Practice Proiles. • • • • • • • • Life expectancy lower for males (76.9) and females (81.2) than nationally 24.1% are aged 65 years and over, higher than the national average • • • • Located in South Cumbria, includes coastal areas Higher than average older population (20.5% compared to English average of 16.9%) • • • • A coastal area in South Cumbria, on the edge of the Lake District 5.4% are unemployed, higher than the English average of 4.4%* Key Features 18,192 • • • • • • • • • • • • South of the Lake District in Cumbria Higher than average older population (23.6% compared to English average of 16.9%) Low unemployment rate (1.6%)* Life expectancy for males (80.7) and females (84.7) is higher than the English average Located in South Cumbria, incorporates a small part of the Yorkshire Dales National Park Higher older population (30.2%) than national average Low unemployment rate (1.6%)* Life expectancy higher for males (80.7) and females (84.7) than national average A rural and coastal area on the boundary with South Lakes 26.4% of the population is aged 65 years and over* Low unemployment rate (0.0%)* Life expectancy higher for males (80.4) and females (84.4) than national average Includes the coastal areas of Morecambe and Heysham in Lancashire 21.2% of the population is aged 65 years and over 3.9% unemployment rate* Life expectancy is lower for males (76.1) and females (80.9) than the national average Located in the city of Lancaster 18.4% of the population is aged 65 years and over* Unemployment rate lower than national average (2.9%)* Life expectancy is lower for males (78.5) and females (82.8) than the national average* Includes the city of Lancaster and surrounding rural areas Only 13.4% of the population is aged 65 years and over* Low unemployment rate (1.5%)* Life expectancy is lower for males (78.2) and females (82.1) than the national average Rural area that covers parts of Garstang, Catterall and Calder 27.0% of the population is aged 65 years and over* Low unemployment rate (1.6%)* Life expectancy of 79.6 for males and 83.2 for females is comparable to the national average u Table 5 Summary of Geography and Demographics of Morecambe Bay by ICC 40 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 41 Health and Social Care Evaluations (HASCE) Although some ICCs have a higher proportion of older people than others, an ageing population with complex and multiple needs was recognised as an increasing source of pressure on health and social care in all areas. For participants, there was a direct link between social isolation and care needs; in the absence of regular social contact, there was an increased dependence on services. Furthermore, it was believed that needs may not be recognised until an acute care admission was required. For others, the rurality of some communities, and the perception that transport links are poor, created a more general sense of isolation. I think a lot of the problems with the vulnerable people in Kendal, who do feel a bit isolated, it’s to do with transport really, a lot of it. Especially for the people in the outlying villages, because the public transport is poor. So if something could be thought about to help people get to places, that would go a long way into helping people’s health improve, because they’d feel able to go to things and engage, rather than being isolated where they live. (INT007) The geographic isolation was also described as afecting adults of a working age. Some of the more isolated communities were perceived to have complex social and economic needs: Unemployment is a massive issue; drug use is a massive issue; poverty is an issue. You know, all the issues of deprivation really. (INT010) Despite the challenges presented by the geography, remoteness also facilitated the adoption of more creative working practices. Millom’s location, which was ‘30 miles from each large town’ or ‘in the back end of beyond’ (INT051), meant that diferent working practices had to be adopted. Its isolation has always meant that we’ve had to do things diferently to everywhere else. So, we’ve always been, to some extent, more self-suicient, because we’ve had to be. Because you know, we are an hour away from most of the big hospitals at Whitehaven and Barrow. (INT052) 5.3 Skill Supply The retention and recruitment of staf was commonly described as a factor afecting both the set up and delivery of the NCM. High staf turnover rates were reported across a wide range of roles, including commissioning, management and clinical. Furthermore, the geographical location, and the relative isolation of some communities, created recruitment diiculties; one remote area was described as being seen ‘as a bit of a backwater’ professionally (INT057) and as a result, there had been six Consultant Geriatric vacancies at one time. Another participant described how there was an increasing move to sessional and lexible working within general practice, but the remoteness of areas such as Millom restricted the ability to achieve this: We’ve still got massive problems trying to recruit and that again is a geographical problem, is that the way the General Practice has become structured, with a lot more part-time Doctors working, a lot more sessional Doctors working, because they want much more lexibility. Which is ine if you’re living in the middle of Manchester, you’ve got much more options, but if you’re a doctor as well, or a nurse and working, whereas if you’re in deepest, darkest Cumbria, if you’re in Millom, you’re stuck. (INT052) In addition to rurality and distance from other services, the reputation of Morecambe Bay was also cited as a challenge to recruitment. As one participant described, the Trust was perceived to have been ‘dragged through the mill. That doesn’t help us when we try and recruit.’ (INT024). Recruitment challenges were perceived across general practice, nursing, and specialisms such as paediatrics and psychiatry, and allied health professionals. Outside the NHS, home carers were reported to be in short supply with an accompanying reliance on a temporary workforce. Health and Social Care Evaluations (HASCE) Participants described their frustration at the capacity of care teams and their ability to implement the NCM. Staf shortages were seen as a challenge in the shift from hospital to the community, and integrated care more generally. I don’t think in the current climate of inancial and human resources, that it is possible to transfer care to the community, unless something drastic is done…nothing is going to work. They might as well stop the programme, stop wasting more money and get back to actually doing the job that they should be doing. This cannot work unless they ind more social care, and they ind more people to provide primary care or community care. (INT025) …there’s not enough home care. People have been stuck in the hospital because they can’t get home...It’s very rural. You can’t get people to work. (INT048) I think there’s a lot of cynicism amongst GPs who are thinking, “yeah, yeah, you want to bring everything out into the community but we don’t even have enough GPs to do the work that we’re doing at the moment, or community staf, or District Nurses, or anybody else in the community to do the work.” It all feels a bit implausible. (INT029) Despite staf shortages, one NCM initiative was able to develop after physiotherapists across the Morecambe Bay footprint were identiied as having under-utilised skills. These physiotherapists were over-qualiied for their job (for example, they had a PhD or Masters level qualiication) and were able to use their skills in a musculoskeletal project. The Commission for the Future of Primary Care suggests such upskilling is necessary to increase the capacity of primary care teams, and in turn enable them to respond to the demands of NCMs. 25 5.4 Previous Interventions Because those involved in the design and implementation of a programme are active rather than passive participants, their actions are informed by their choices and preferences (their volitions). For the NCM to succeed, stakeholders are required to engage with the process of change, however, the interview data indicates that willingness to engage varied. Perceptions and experiences of previous interventions are an important factor here. The NHS has been subjected to change for decades and more locally, Morecambe Bay has its own portfolio of transformation programmes, some of which are running concurrently with the NCM. The vanguard status was awarded in March 2015, but the Better Care Together programme was set up in 2013. Other relevant transformation programmes which either border or cross into BCT’s area include the Success Regime in West, North and East Cumbria and the Sustainability and Transformation Plans for North Cumbria and for Lancashire and South Cumbria. The Morecambe Bay Investigation of maternity services was also cited as an important catalyst for change by participants. Participants reported that this on-going cycle of change had created cynicism or negativity amongst staf and other stakeholders: There is always, depending on individual personalities, there are always people that are more frightened than open than others, to changes. And to be quite honest, the NHS has seen so many changes. It’s a constantly changing beast, so sometimes the staf are quite cynical and quite a lot of the time, quite rightly so, about changes in the NHS because there are so many changes on regular occasions that people do sense that this is just another one, just another change and we don’t really know what’s in it for us. (INT062) There’s always going to be issues with staf…you have to try to communicate with staf to say that yes, change is happening, but often people can associate change negatively rather than positively. The automatic reaction is that something is changing and so something negative is going to happen to us. (INT053) 25 Primary Care Workforce Commission. The Future of Primary Care: Creating Teams for Tomorrow. (2015) Available at https://www.hee.nhs.uk/sites/default/iles/documents/WES_The-future-of-primary-care.pdf 42 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 43 Health and Social Care Evaluations (HASCE) For others, who had been involved in similar interventions previously, the NCM was a source of frustration and they questioned why yet more of their time was required to set up the same process again. Muscular-Skeletal (MSK) care is one example of this; participants reported setting up a Steering Group in 2015 in response to what was perceived to be poor provision. If you’re talking about the time that people have inputted into the project, it’s been very poor use of our time, because this is about the third time we’ve been around the houses doing the same thing and coming up with the same results. (INT029) Participants also described how difering views of Steering Group members shaped the development of the project: The initial phase of that Steering Group development involved an awful lot of discussion between what were quite disparate areas, in terms of the vision. It took longer than expected to develop an agreed vision. To be honest with you, we’ve still got some difering views on how these services should be developed. (INT039) For others, their ability to engage with the NCM was constrained by the ongoing measurement of their performance against previous KPIs: Our commissioning arrangements don’t support it [change], because I’m still held to deliver on previous KPIs. So, if we can’t double run, the only way we can do it is to move our deck chairs. But if I’m held to deliver on previous KPIs, I can’t move my deck chairs in the way that I need to, to enable that change to happen. (INT043) In contrast, other previous initiatives appeared to facilitate the NCM. In Millom, an alliance was formed in 2014 in response to the threatened closure of the local hospital. The Millom Alliance brought together the Millom Action Group (which represented the local community), a GP practice, Cumbria Partnership NHS Foundation Trust, University Hospitals of Morecambe Bay NHS Foundation Trust and South Cumbria Clinical Commissioning Group (www.millomalliance.nhs.uk). In doing so, the relationships and connections required by the NCM were already in place: Millom’s quite diferent to a lot of the other ICCs in that the Millom Alliance has been in place prior to the ICC, really. So we’ve got the Community Health Action group and the community are really involved in the work that we’re doing and really on board with that. (INT054) Health and Social Care Evaluations (HASCE) 5.5 Organisational Cultures There was a strong feeling amongst participants that a departmentalised culture was prevalent across BCT partners and was a key disabler. For some, this related to the organisational structure of the NHS. The approach to commissioning was attributed with the creation of a fragmented service and even competition between primary and acute care providers: …[the] NHS has been set up over the years, is to build teams in silos. So you have a community team, and even within a community you can have diferent parts, or diferent community teams that are commissioned separately, that have diferent responsibilities, separate targets, separate KPIs. So consequently, when the commissioning system is set up like that, when you commission services, you inevitably commission services which are going to be fragmented. (INT022) The divide of diferent organisations who are meant to compete, and who are meant to purchase care from each other, isn’t a recipe for trying to make people get on. (INT024) More generally, it was felt that the number of partner organisations, and their operation across county boundaries, compounds the complexity of BCT’s delivery. For example, each organisation has a procedure for data collection and therefore the data that can be collated to evidence the success of the programme varies: There's lots of barriers to change. The culture is a barrier to change, I suppose the fact that we're having to wipe away years of splits between diferent parts of the NHS. We're working with 11 diferent partners, all of which are statutory organisations, all of which have their own agendas. We are having to remove all of those and come to agreements about how people will work together. (INT016) So, there are 14 [sic] major players, statutory bodies in the area, in the patch, that all employ staf and have diferent responsibilities. And so, the only unifying point is UHMBT, as the acute Trust… (INT056) We're sat here to try and reduce admissions and we know we're here to try and reduce excess bed days. How can we do that with BCT? What can BCT bring to the table to help the social aspect, that the NHS is not in control of? That's our frustration. (INT047) Similarly, collaborative networks were reported to have been established for Women and Children’s Services workstream (WACS) before the NCM was introduced: The work had started before there was ever such a thing as BCT, that we had come together across a wide range of stakeholders, including third sector, including local authority, including acute and community and primary care – and worked up a model of the best way to deliver healthcare for […] women and children. This work was already underway when BCT came along and absorbed it. (INT013) Understanding the function and role of partner organisations is an important factor here; it is this understanding that appears to have created an enabling context for NCM. This theme is discussed further in Chapter 6 and 7. 44 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 45 Health and Social Care Evaluations (HASCE) Participants highlighted the CCG boundary changes as a further source of complexity. In 2017, a new Morecambe Bay CCG covering North Lancashire and areas of South Cumbria, and reconigured North Cumbria CCG were established. It is apparent that there were mixed feelings on this change; although some welcomed the fact that the CCG footprint would now mirror that of partner organisations), others were concerned about the administrative implications of the move. For example: …it makes sense in that three hospitals now are a lot more linked to one CCG. I suppose with that there are some concerns about, is that going to add value to BCT or is it going to detract away from it, because are people going to spend the next year sorting out the admin and process for the boundary change? (INT027) More generally, the slow and complex interaction between BCT partners was a source of frustration. There was a perception that decision making was slow, with agreed actions from one group being referred to another for approval. For the voluntary sector in particular, the slow and complex interaction between BCT partners was a challenge to their way of working: I’ll be honest, I struggle to see how I it in with the primary and acute Care, because we’re not – I think the voluntary sector… to be able to sit at a strategic level and I think it’s a very slow process for us to be involved in that very strategic level. (INT028) The frustration experienced by the voluntary sector was echoed by other participants and attributed to the complexity of the BCT governance arrangements: I think they get very frustrated with us, because they can see what needs changing but there’s so many diferent partners that have to be engaged in Morecambe Bay, it makes it really, really diicult. (INT019) A key and overarching theme here is the understanding of the diferent roles and functions performed by diferent organisations, and the teams within them. For example, in discussing the approach to re-enablement, one participant described how lack of awareness afected services: So there might be a reacting or a re-enabling team, and lots of social care type teams, but then they seem to miss out the housing link quite often, or the Home Improvement Agency, which has the handyperson who can do small jobs and adaptations in people’s houses to keep them independent, or to make sure they’re not going back into an unsafe house. We struggle to get connected into the right people at the hospitals, to try and make that happen. (INT027) An understanding of the respective roles of partners was required to enable the formation of relations built on trust, which was considered necessary for the development of the NCM: I think there’s been a lot of broken relationships - people not trusting each other. And without trust you can’t progress. That trust is now building. It’s not there in all avenues but it is building. (INT006) The organisational culture is therefore a key contextual factor shaping the NCM’s implementation. Individual working practices and cultures are also important here; NCM requires a new way of working, and an individual’s willingness to engage with it is afected by a fear of the unknown (a risk averse culture) and the perceived threat to their role. To facilitate engagement, and overcome the fear created by the transformation process, participants described a need to irst establish ‘proof of concept’: There are always barriers to change. People’s reluctance to work diferently, people’s reluctance to give up what is familiar, people’s conidence in an existing system. And reluctance to take on what may be perceived to be untried or an untested system … When we’re asking people to work diferently, … sometimes [there are] many years of work that they have to unlearn … “You want me to change 20 years of working practices and do it a diferent way. So, are you saying that for the last 20 years I’ve been doing this wrong?” And that’s not always a message that people like to receive. Therefore, people can resist change and value, sometimes value eiciency of process more than outcome for patients. (INT013) 46 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Because at the moment the ICC is a theoretical concept because they are not an entity as such. So in order to fully prove the concept, we need to make sure that all of the organisations involved feel quite safe and secure, that they’re not going to be put at risk. (INT062) …we had some excellent people called case managers and care navigators. We had those roles appointed within our ICC. Initially, like everything else new, people were sceptical and they didn’t know how to use them. The people who were appointed didn’t know how they could make a diference, or what their role was or how they could do it. … No one likes coming in to a thing which is uncertain. So, if you decide to go down a route and make a change, then you just have to make it and sit back and let it work. It will take time, but unless you do that, you’re not going to see the change. (INT025) 5.6 Availability of Resources The NCM has been developed in a period of austerity, in which the NHS, social care and third sector partners have all faced signiicant inancial pressures. For example, at the time of writing the Better Care Together Plan (2015), the University Hospitals of Morecambe Bay Trust had a £26.3 million deicit that was expected to increase in future years. Participants described how services had been realigned or even “retrenched” in response to such pressure, which in turn afected their ability to engage with the NCM. Changes to funding for Health Visitors and School Nurses were cited as one example of this: The changes in the County Council funding of Public Health Services, so the Health Visitors and School Nurses, are really beginning to take efect and they’ve, they’ve just not been able to engage as much in the children’s or maternity developments, because they’ve been going through a period of intense negotiation with the County Council about what they’re being commissioned to do. (INT019) The demand for social care, and the ability of social services to respond it, was also reported to afect the ability to deliver integrated care: Obviously, the other big drawback at the moment is the stresses and strains that the Social Services are undergoing. That’s a big barrier, because we can’t put in the care that we need at an appropriate time, because of this restriction on accessing Social Services. (INT055) Indeed, increasing service demands were reported to afect health and social care staf from both public and voluntary sector organisations, which in turn limited their ability to engage with the NCM. For example, senior staf in the voluntary sector were unable to attend every strategic meeting and in the NHS, healthcare professionals found the NCM’s requirement to carry out duties and responsibilities that were additional to their ‘day job’ a challenge: Although people really want to be able to be involved with improving services moving forward, there isn’t always capacity, within the job plan to be able to do it. And you hear that across the whole health system. (INT001) I’m not sure that it’s been a barrier, but I think it’s been a hindrance in that the people that are working on the vanguard have all got day jobs and other jobs that we do. The clinical leads and all of us, we’ve just got a set amount of time to dedicate to the vanguard work and sometimes there’s a pull between the day job and other work you need to do. That’s been a bit of a hindrance and I think we could have maybe moved faster if we could have had dedicated staf who were just doing this work. It isn’t always possible to concentrate on the things we want to do at the time that we want to do it. (INT015) I think releasing clinical staf and clinical duties is the biggy. Biggy, big, biggy. You know, because they are busier than they’ve ever been, and we’re asking them to take time out to think about how the system could change. (INT058) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 47 Health and Social Care Evaluations (HASCE) The lack of ‘vanguard funded time’ was a key issue here and as one participant described, engagement was often dependent on ‘goodwill’ (see Chapter 7 on resource use). Furthermore, where, roles were funded, the short term nature of the vanguard funding meant that they were ixed term posts. The priority for the vanguard was also perceived to be on inancial eiciencies, and achieving a reduction in outpatient appointments in particular, rather than the creation of improved patient pathways. Because … the whole focus of the programme was not … necessarily about improving care, although there was obviously an element of that. How it was presented was “How you are going to reduce outpatient appointments.” Not about, “How you look at the holistic health of the population of Morecambe Bay and Barrow, etc. and let’s look at improving that.” (INT020) The focus on cost-efectiveness was cited as another factor contributing to willingness to engage with the BCT programme: I think the programme shot itself in the foot at the very start when they set it out, what needed to happen. And I think instead of it being our programme, that they looked at increasing the health of the population. I think it very quickly focussed down to saving money. And I think that really put a lot of people’s backs up. (INT020) The availability, or lack of, more practical resources also emerged as a key contextual factor. For example, the physical space available in Morecambe Bay to deliver the NCM was cited as a disabler for the MSK project. There was a shortage of rooms in which the new service could be provided while GP practices in some areas were located in historic buildings that were considered non-compliant with accessibility requirements. However, another participant felt that there were buildings available for use within the voluntary sector, they were available free of charge but not thought to be fully utilised. IT systems, and information governance procedures that determined access to IT, were identiied as a complex disabler. Again, the number of BCT partners and their operation over county boundaries, was identiied as a compounding factor here. One participant described the diiculties this created in accessing patient records: BCT is obviously about a system-wide approach, but our individual organisations don’t allow us to deliver Better Care Together. So, the barriers if anything are the organisational constraints. Information governance is a killer. I’ve got into so much trouble, because you say it’s the right thing to do and therefore we should be sharing, but NHS England have come and said, here’s some money, with your vanguard status, deliver BCT. It’s such a great idea, we can learn from it. But what they haven’t done is set the permissions level to say, on this occasion, don’t worry about IT between organisations, that can be taken out, you can treat this as an open book. For me, the barriers have been the information governance, the technology systems that have got absolutely no way of speaking to each other. You pull of system data on the same patient population, you’ll deinitely get two diferent answers. Without a shadow of a doubt, you will not be able to marry that up. (INT061 5.7 Discussion and Summary The NCM is being implemented in a complex context. Based on the data collected for this evaluation, the following points highlight the most prominent afective aspects of this, which have a direct bearing on the outcomes and impact of the work of the NCM: • Geographical, demographic, historical and organisational features are interacting with the availability of resources to both enable and disable the programme. 48 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) • • • • Morecambe Bay covers a large geographic area with a relatively sparse population (compared to other Trusts nationally). The distance between services and the geographical isolation of some communities is a challenge to the NCM. The 12 ICCs cover geographical and demographically distinct populations, which all have diferent health and social care needs. Although some have a higher proportion of older people (and Grange and Lakes the highest), an aging population with complex and multiple needs was an increasing source of pressure in all communities. Participants described how experiences of isolation afected the need for health and social care. Those without social and family networks were more dependent on services. Adults of a working age were also afected by isolation; the remoteness of some communities created complex social and economic needs, such as high unemployment rates. In this way, the demographics of the area form a key context of the delivery of the NCM. However, geographical isolation was also thought to provide opportunities for more community mobilisation, such as the creative working practices which had already emerged in more remote communities such as Millom. The geographical location and distance between services was also identiied as afecting staf retention and recruitment. High staf turnover rates and recruitment diiculties were reported for a variety of roles and participants expressed frustration about the lack of capacity in care teams to implement the NCM. This problem re-emerges later in the process as well (see Chapter 8). Attitudes towards the NCM and engagement with it were afected by perceptions and experiences of previous interventions. • Repeated cycles of change in the NHS, together with other transformation programmes, had created cynicism or negatively amongst staf and stakeholders. Other participants were frustrated about the need to invest more time in a project that was perceived to be the same as a previous intervention or that their ability to engage was hindered by the monitoring of performance against historical KPIs. • In contrast, previous interventions also served to facilitate the delivery of the NCM in some areas. For example the collaborative networks established in Millom and for WACS were both cited as enabling factors. Organisational cultures emerged as another important contextual factor. • Where working practices were departmentalised, such cultures were a key disabler. Participants described how the restructuring of the NHS in recent decades had created a fragmented service that had a competitive approach to commissioning and diferent funding approaches. • The number of BCT partners, and their operation across county boundaries, was perceived to have created complex and slow delivery processes. An understanding of the diferent roles and functions of each partner organisation was required to enable the formation of more efective working relations. • Individual working practices and cultures was also identiied as afecting the implementation of the NCM. For some, the transformation process was perceived as a threat to their role or a source of anxiety. Participants described how the NCM had to irst establish proof of concept to facilitate engagement with it. The availability of resources also shaped the NCM’s context. • The inancial pressures faced by partners, and increasing demands on their services, were described as a challenge – particularly given the lack of ‘vanguard funded time’ for some. • Other resources, including a perceived lack of physical space to deliver new or diferent services in the community and the use of diferent IT systems across Morecambe Bay, were also described as increasing the complexity of the NCM implementation context. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 49 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 6 Mechanisms Evaluation Question: What key changes have the vanguards made and who is being afected by them? How have these changes been implemented? Which components of the care model are really making a diference? As noted in Chapter 1, a full review of all changes the vanguard made is not possible for a number of reasons; not only would the scope of the evaluation always be limited by time and resource, but the scope of BCT itself under-deined, as noted above, and the speciic vanguard inputs were not clearly identiiable. Nevertheless, it was notable that, even with a wide-ranging data collection strategy, the responses of participants relected a number of very consistent themes around the changes being made by the introduction of the NCM. A fuller discussion of some of these themes is given below in Chapter 9. The key changes being made within the vanguard, as participants described them, fell under three main headings: more integrated working across the Morecambe Bay area, the development of Integrated Care Communities (ICCs), and cultural changes (both within and across organisations, within approaches to activities and within citizens). Across the piece, the changes show an emergent picture of a programme in which a number of relatively small-scale pilots have been implemented, often addressing localised problems with solutions built on the assets of the local community and/or local service providers. Where the approach has been more dependent on system change, interventions have typically struggled. Participants frequently cited the length of time it has taken to generate shared Information Governance protocols and Information Technology services which, at the time of many of the interviews, were seen as the main disablers for progressing many of the pathways. 6.1 Thematic Overview The following sections provide a more detailed narrative of each of these key headings. u Figure 9 Mechanisms - Thematic Diagram 50 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 51 Health and Social Care Evaluations (HASCE) 6.2 Integrated Working Health and Social Care Evaluations (HASCE) Within the overarching theme of integrated working, the changes participants tended to describe could be captured in one or more of the following: • • • Addressing gaps in services within a local area (for example, lack of attention to broader issues which may be afecting a citizen’s health, which current services were not addressing; Lack of joined-up work between acute, primary and community services); Service redesign in order to treat patients in an ‘appropriate place’, moving certain services that had previously been delivered in hospital to other locations and forms of delivery. A core context of the BCT programme is the perception of gaps in health provision across the footprint. Participants noted that the starting point for delivery was the inequality in provision of care across Morecambe Bay. In some cases this is due to disparity between localities, due to the rurality of the area; in others it is due to gaps emerging from the complexity of patient needs, and in others still it is due to the lack of community-based ‘mid-point services’ which bridge the gap between primary and acute care and prevent symptom escalation. We know it’s a service that’s needed because these patients are very complicated. Some are very complex and need a lot of input. Ten minutes, a ifteen-minute call from your GP isn’t eicient really, is it? (INT048) It’s about recognising that there’s a huge variability in both paediatric and maternity practise across the patch. (INT001). These needs were similarly relected by patient groups (see Chapter 8), who all raised the variation of care across the geography of Morecambe Bay, and that complex issues required more time with service deliverers, and sometimes alternative approaches to wellbeing. Not all participants were convinced that they were delivering a ‘new model of care’. The MSK project, for example, was set up to develop an intermediate service to deal with MSK problems without surgery in South Lakes like the one that already existed in North Lancs. In this sense, it was about introducing equality of care into the area. The basis of the scheme is to introduce what basically doesn’t exist at the moment, which is an intermediate service which lies between the trauma and orthopaedic service and the physiotherapy service. It’s in-between. It’s the muscular-skeletal service. So, it’s a gap in the market if you like. Currently in South Cumbria, we don’t have access to those skills…So, it’s not a brand-new model of care. It’s quite common in various guises elsewhere in the NHS… but it’s illing a gap in the market which we don’t currently supply. (INT039) The ophthalmology pilot, meanwhile, was set up in late 2016 based on work that had been underway for at least 18 months building on earlier local work. It allowed patients with cataracts and ocular hypertension, plus some paediatric patients, to be seen in the community by optometrists in their private practices. In the past when we’ve looked at service redesign, and I’m thinking nationally not just locally – very often we look at it as where our bit of the pathway starts…This model allows us to look at the patient journey from when they are irst identiied, out in primary Care, back out into primary Care. It’s a patient centred approach and allows the clinicians to better work together across the organisational boundaries. I think that its nicely within the BCT way of working. (INT042) In areas where the commissioning structures already allowed this kind of work to take place, change was considerably more straightforward than those where organisations did not have ready-to-hand structures in place. u Figure 10 Integrated Working - Thematic Diagram 52 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 53 Health and Social Care Evaluations (HASCE) It’s supported by the contractual model that they’ve used, in that lots of these services are commissioned across the country, where community optometrists provide a greater clinical work up, beyond their core contract service. (INT042) The main mechanism of change that transpired across the data was integration via the creation of Multi-Disciplinary Teams (MDTs), cross-organisation communication and education. Across the region and within diferent sectors of healthcare, participants reported higher levels of inter-organisational collaboration linked to operations of BCT. While many of the impacts of these were based on anecdotal evidence, participants suggested that integration eforts have been associated with more joined up service provision, shift of care to the community, and patients engaging less with acute and non-elective care and more eicient use of resources. Across all work-streams, frequent interactions between professionals from diferent ields has provided an opportunity to gain better understanding of individual roles, responsibilities and service developments, as captured below: We’ve started, doing some joint GP consultant clinics…the consultant has actually come out into the community, done the clinic in the GP practice…had a feedback session with the GP afterwards to discuss those cases. (INT001) One of the good things that has come out of BCT…you’ve had a lot more meetings of clinicians, across the organisation[s]. So you have a lot of GPs who have managed to meet with the acute clinicians, and it’s reassuring to know that you all think the same way, in terms of providing care for people in appropriate settings. (INT025). We’re all working together much more closely. (INT001) One of the ICCs did quite well in relation to the initially agreed outcomes and KPIs, is the East ICC…it’s because they have developed what we call the Multi-Disciplinary Team approach. So, they have got virtual MDT meetings on a day-to-day basis…led by one of the GPs and the Case Manager in that ICC…they talk…And they’re able to mitigate the impact of multiple intervention by various teams. (INT062) The main mechanism of change consistently identiied in the Women and Children’s Services workstream (WACS) has been system integration with multidisciplinary partnerships that appear across all professional levels of healthcare settings. Participants representing both the clinical and commissioning sectors provided numerous examples of multidisciplinary partnerships, that include but are not limited to: • • Liaison of GP lead with local ICCs, community-based children’s nursing teams and acute Trusts to review and divert unnecessary referrals; Partnerships between paediatric consultants and GPs in provision of specialised services in a community setting and collaboration of paediatric nursing teams with acute Trusts, public services and third sector to manage children with complex needs outside hospital care. However, BCT has not been a discrete entity in this sense; participants report there have been attempts to extend professional networks beyond BCT partnerships to facilitate system wide transformation and support embedment of BCT processes into mainstream service provision (for example, linking with Children’s and Young People Emotional Health and Wellbeing Transformational Programme). Health and Social Care Evaluations (HASCE) I think it its BCT really, really well because it is a completely diferent way of integrated working with community providers. It gives patients a lot of opportunity to be seen in the community rather than at the hospital. For this group from the start, we’ve really had a systematic approach to this, which I think has worked really, really well. So, we had a group of people together looking at what we could do diferently for our patients, who could do what, and really being able to put organisational boundaries and any organisational impact to one side, while we were doing all the planning. (INT030) At the same time, the layers of complexity that this kind of working can introduce was not welcomed by all participants. For instance, across a number of staf grades participants expressing ‘frustration’ with BCT and its complex processes for lack of continuous progress. This is likely to put strain on the relationships between key stakeholders, having impact on cross-organisational partnership and engagement at the individual level. For example: They [Blackpool provider] get very frustrated with us, because they can see what needs changing, but there’s so many diferent partners that have to be engaged in Morecambe Bay, it makes it really, really diicult. (INT019) As the Opthalmology pilot was rolled out though it was still seen as positive there were some issues with the community based optical practices being private which were overcome by focusing on patient care and what is in it for the practices. It’s created interesting challenges as well, because obviously, Optometrists generally operate as private enterprises, which again isn’t normally part of the NHS family. They come at it from a diferent perspective to some extent as well, so for them it’s more extending their business. That led to some interesting discussions. We kept getting it back to the focus of, “This is better for the patient and needs to be accessible to the patient. How can we ensure that’s going to happen?” (INT030) Conversations thus became a key theme for enabling change and overcoming the kinds of obstacles that partnership working could bring about. Right from the beginning, there’s been really good communication and engagement, so when I irst got involved was at an engagement event, where patients and other care providers, GPs and the Trust Commissions came together with Community Optical Practise Clinicians...That’s how the conversations started, and working from there, there have been regular workshops and communication low. (INT042) In certain staing groups where I’ve sat in on meetings, it’s just been an absolute pleasure, because they’re actually chatting away to each other and swapping ideas, and for the ones I’ve seen it’s been really beneicial. There’s still, because they are separate organisations, there’s still that, are you trying to take my job? Or, are you going to be in charge of me? (INT061) The thing I’ve really liked about it actually, more than anything, is improved communication between hospital Doctors and Eye Nurses, and Optometrists, because for years, the two have barely communicated. One of the irst things that shocked me when I started working, was how little communication there was between the hospital and primary care. (INT035) Sitting down together is incredibly powerful and productive. (INT010) Consistently across all workstreams, the data collected illustrated the main enabler of multidisciplinary partnerships as their development across multiple levels of workforce relationships, underpinned by shared values and understanding. Participants from the commissioning and provider sector identiied that the main values of partnership working were enhanced professional competence, increased opportunity to share knowledge and experience, facilitated communication and decision-making. 54 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 55 Health and Social Care Evaluations (HASCE) The Advice and Guidance initiative, for example, was seen as a key tool in the enabling of conversations between consultants in the hospital and primary and community care. Both clinical and project leads identiied the educational value of multidisciplinary partnerships between consultants and GPs. Increased competency related to partnership working was framed in terms of awareness of capacity and capability across diferent settings, which minimised unnecessary referrals to hospital. However, data analysis evidences that many of the communication strategies underpinning changes made by the vanguard were far more fundamental than an integrated IT system: We were blessed in that the Age UK building is next to the hospital, next to the care home and the GPs are in the same building. The communication is awesome. (INT061) I know our Case Management team in Ulverston…they work really well, but they do work within two GP surgeries that are together in one building, so they’re in the building with them. I think that makes for a much better relationship with the GP surgeries. (INT044) Some premises, you know, they’re all in the same building and that’s ine…But in many instances, that’s not true… [here] all of the GPs are in old Edwardian four-storey buildings that are not DDA compliant. (INT057) However, while increased communication was welcomed across a number of aspects, not all conversations were considered useful in the long-run. I’m not really in favour of big GP and Consultant meetings at a corporate level..I don’t think there’s any value really…My experience of the GP and Consultant meetings…was that you just sit in a room and talk about stuf, which really isn’t important on a day-to-day basis, about who pays for what and that sort of thing. That’s not of any interest really, to people who are doing the job. (INT023) If you’re talking about the time that people have inputted into the project, it’s been very poor use of our time, because this is about the third time we’ve been around the houses doing the same thing and coming up with the same results. So, a poor use of people’s time, which I think will be very costly. On the plus side, I suppose, the more times you go around the houses looking at the same problem, maybe you become sure that what you want to do is the right thing… (INT029) While this comment points to the need for some of the changes brought in by the NCM to take time to develop and grow, there is also a sense that conversations without a clear sense of direction can be costly in the longer-term. Similarly, participants raised concerns around the amount of talking that was perceived to be taking place: We’ve gone to meetings with regard to BCT for several months over the last couple of years, where we’ve gone there and we’ve heard exactly what we heard two years ago, again…Yes, there are reasons for that, but then why meet again, if there’s nothing new to say? Or why make a plan at one meeting, then have another meeting two months later and forget that you actually made a plan and then make another plan? (INT025) The extent to which the vanguard instigated and facilitated the conversations was not always clear although the extensive data analysis could identify some cases where the increase in conversations were linked directly to BCT initiatives. Participants also viewed the vanguard a inancial enabler to act upon existing and ongoing discussions taking place ‘in the last few years about what we need to do in health care in its broadest terms’. (INT029). This point is salient as a number of participants questioned the extent to which BCT was introducing change when many initiatives had been in development for some time; or, as others reported, BCT was viewed as a hindrance to carrying out longer-term service redesign. There were some negative views, for example, about how much time the integration of care was taking: 56 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) About three years or so ago … we were trying to put some stuf together for the CCG, to try and develop MSK care. That all came to a halt because then we were told, “No, you can’t do any more, it’s only going to be part of BCT and Vanguard”. Then I was one of the project group in the Vanguard project which started, it must be two years ago. X was initially the Project Manager for that and then we had another guy, and now we’ve got Y... (INT029) The data shows that other conversations are perhaps more political in focus, particularly around aligning the need for eiciencies within the health system with the shift to a more social model of care. These participants shared concerns about who was involved and engaged with the conversations within BCT, and the efects that representation might have on the overall direction it took: But also, there’s been a change also over the three years, there’s been a change in our relationship with the local authority. Not very positively, either. We do struggle -- at the very beginning we got a lot of buy-in, and then I absolutely understand the inancial diiculty of the local authority and county council wanting everyone to retreat and regroup and refocus. That changed our ICC to be about a health community, not about a health and social care community. (INT063) In particular, the relationship between the work of the ICCs and social care was often cited as a disabler that subsequently shaped the development of vanguard work. I think the only obstruction probably that I’ve found is the struggle with Social Care. That’s the biggest problem, takes up the most time. (INT047) I suppose you could say our shortfalls in Social Care often mean that we have to deal with admission as well, because there isn’t the support to keep somebody at home. I think around here, if Social Care was a better provision, people would stay in their homes more and there’d be less admission. (INT049) Others, meanwhile, cited an imbalance between staf on the ground and project managers. In this sense, the initiative of integrated care stumbled around the problem of staf recruitment. There’s no diiculty in inding Managers and Project Management people, but there seems to be a huge diiculty in inding people on the ground, Doctors and Nurses. … You have far too many people who know how to tell you what you should do, but actually no people on the ground to do it. (INT025) Another theme to emerge from analysis, which relects this tension between developing distinct, place-based services and wider systematic support, concerns the implementation of speciic forms of care plans. These manage key information on patients, but doing so in a way that is patient-centred, respectful and productive. On the one hand, the ‘ground-up’ approach has been instrumental to supporting the development of this form of care planning: When I irst started doing this job, we had these 10-page assessment forms. They were horrendous, you know: What are you eating? How’s your sleeping pattern? Really patronising. [Now] I go in, sit down, have a cup of tea and a bit of a chat and in and around that I’ll ask questions which will lead to the answers I need to get. (INT059) This resonates with activities in other projects and work-streams to work towards documentation practices that will support integrated pathways of care. However, this is clearly time-consuming, and not yet supported by lexible or real-time IT or IG systems: a point which is often cited as slowing or preventing the implementation of some integrated care initiatives. Once you’ve done a full assessment of somebody, you have a really good knowledge of how they are and how they function. And also, to prevent hospital admissions, once you can get these care plans in, then if they have a fall and an ambulance rocks up, then they have a really good idea holistically… it helps in their decision making of, do we keep this person at home… or do we have to have a hospital admission? (INT051) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 57 Health and Social Care Evaluations (HASCE) It appears that while staf can see the beneit of Care Plans, they feel IT issues are currently compromising how the plans are shared and agile working has not yet enabled real-time updating of the plans. Data analysis suggests that care plans take time to do and rely upon the care coordinator having the social and healthcare skills to identify need and to get to know patients. A number of care coordinators discussed ways in which they had developed a socially appropriate means of information gathering that observes patient dignity and the contextualised nature of each individual’s lifeworld. This information was felt by participants to be important in enabling a population-based approach that understands local context and need and can tailor interventions to this need: Now, that’s the diference about population health and well-being, isn’t it, that you’re actually thinking about needs, because you’d have the family assessment there as well. (INT063) We’re doing a lot with regards to Care Planning and we can’t access the Care Plan unless we go into a GP login and vice versa, to update it. (INT055) I do agree with Care Planning, but then Care Planning has to be quality Care Planning. You can have a Care Plan, but actually if it doesn’t give us any worthwhile information, actually, will it stop an admission? (INT053) However, some participants reported tangible signs of change as a result of the care-planning process: INTERVIEWER: Do you see that the activities that you are involved in are making a diference in care? INTERVIEWEE: I do, yes. Especially with the Care Planning. We’ve been integral in developing… a new Care Plan template. We’ve been integral in developing this… I feel it will be very important to give NWAS [North West Ambulance Service] access -- especially the evening and weekend service… to these Care Plans. (INT048) Despite this, the progress of Care Plan templates was unclear at a system-wide level according to data analysis. This lack of clarity is highly relective of many of the changes which participants reported positively on: once interventions, tools or practices were piloted, it was unclear how these were captured and assessed at programme level. For many participants, this lack of clarity is directly linked to the problem with scaling up interventions which, analysis shows participants believe, is centred on IT and IG. INTERVIEWER: Do you think it is reducing… hospital admissions, the new way of working? INTERVIEWEE: I don’t know if it is. I think there’s been issues again with the recording of our data, to determine whether that deinitely is the case or not. There’s been a lot of tweaks with how we record our input electronically. (INT044) Health and Social Care Evaluations (HASCE) It is a little bit diicult. There is a lot of overlap, so there’s an overlap with some of the ICC stuf, but also some of the stuf we’re doing is quite diferent. And we’re probably heading in a slightly diferent direction to some of what the other ICCs are doing. (INT052) For other participants, the theme of time simply concerned the length of time change had taken to deliver: The only thing that hasn’t gone to plan is the computer system, which hasn’t been a massive hindrance, but it would be useful for me to have it there, for me to review the information as it actually happens. …Now that was supposed to be happening by the end of March, but I’ve just been told that it’s not actually coming in until mid-May now. That’s been a bit of a stumbling block for me. (INT040) This was linked by others to the commissioning process, and the decision-making timetable: Unfortunately, with the NHS and with this CCG in particular, …you ind out you have funding for a project, two days before you have to submit the bid, and so basically what they do is write a “back of the fag packet” plan, submit then, hope you get selected. Sometimes you don’t, which is ine, nothing is lost. But if you do get chosen, God help you, because you don’t have a clue what you’re going to do, and you need to start doing it from next week. So, then you have this mad lurry of people trying to sit together and trying to work out … what it is you’re going to do. … And by the time you’ve got your act together, there’s two or three months left. And you’re never going to be able to show results. (INT025) The involvement and relationships between multiple stakeholders was also linked to the time delivery was taking, in particular by participants from primary care. Here, decision-making processes were not considered as enabling well-planned and coordinated evidence-based interventions, which may facilitate change on a deeper level allowing for a social and cultural change. Even in pilots which were reported as successful by participants, some longer-term implications emerged after the initial positive start. For example, in the Opthalmology pilot: In terms of Practices, the Optical Practices, some of them have felt their resources strained, because of the sheer number of appointments. They’ve found their clinics illing up and we have had one or two pinch-points in terms of delivery, because patients have tried to get a minor eye conditions appointment and can’t be seen at one Practice, so they try and signpost them to another Practice, who also can’t see them and signpost them to a third, because nobody has any free slots because it’s been popular. There’s been that level of resource diiculty. (INT040) So that’s one of the biggest focuses, as well, for next year. Having a common database and the ability to share patient data and referral, will most certainly be one of our biggest enablers. (INT062) The time that the changes were taking to implement was also a common theme to emerge in participants’ narratives. Typically this referred to how much longer than desirable delivery was taking to implement. A common narrative arose around areas where interventions were implemented on the back of longer-term discussions, existing relationships and partnerships. The Millom ICC, for example, is geographically isolated and has had to cope with the loss of the town’s former iron ore production, which was its main source of employment and income. Participants in the Millom area frequently reported to us a willingness within the community to work creatively and try new ways of working. At the time BCT was initiated, the Millom Alliance was already established, and has been shaped by a clear and urgent need for change, and by patient activism to address this need. On the one hand, this appears to have given Millom ICC something of a ‘head start’ in development but, at the same time, it was recounted that the change in strategy and delivery has posed its own problems for itting a NCM ‘on top’ of what was already in place: 58 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 59 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 6.3 Integrated Care Communities The ICCs are one of the key drivers of the NCM. In terms of the changes being delivered, ICCs are developing at diferent rates. This can be due to development taking more time, and being more diicult than originally envisaged; the number of meetings required in relation to the time that key partners have to attend; as well as the more structural fact that each area necessarily has diferent strengths and weaknesses according to the community’s assets, and the staf available: Each ICC, although we’re trying to run them on very similar models, against a core model, each one will become organic, as you say, and develop its own area of, I suppose, not specialism, but it will be speciic to that community. (INT057) Clinical skills As a result, while changes to clinical delivery (see 2.2.2.1) have reported small improvements which may lead to wider, systematic ones, participants from ICC projects typically begin with the task of widespread cultural change. In this sense, one change that has emerged has thus been the move to a person-centred approach to delivering the ICC strategy. As one project lead puts it: Non-clinical skills Care coordination Localised solutions We’ve not just been growing the ICCs, we’ve been growing people in the ICC to be the ICC. (INT058) Barriers to delivery Communication Communication between organisations Problems linking local need with system-wide change Lack of support Leadership and support Collective leadership Geographical and historical contexts Community mobilisation Community creation Integrated care communities Communication with citizens The sense that growing ICCs depends on ‘growing people’ resonates with the theme around the upskilling of staf as part of the NCM programme. However, the tension between allowing roles and people to ‘grow’ from the needs of the community, and investing resource to support this, has been present in a number of interviews. For example, some participants gave clear examples of how additional training supported the implementation of new pathways, and of feeling well-supported in developing these roles. For some care navigators/coordinators, though, there was a view that there had ‘been no support from management. We’ve just been left.’ (INT045). While being left to develop their roles was potentially enabling, where there were related disabling mechanisms – such as a lack of training or support, a regular turnaround of case managers who are in some cases leaving without being replaced, or some key roles were left unilled – the development of certain ICCs had stalled due to staing issues. The care coordinator and care navigator roles were highlighted as key successes in the work of ICCs. The positives have deinitely been the care navigators, and the amount of work they can take on board…It fulils a need and to a degree it prevents hospital admission…(INT055) The success of care coordination is frequently linked to the importance of localised practice. The CC’s all appear to have a good knowledge of their locale, services, and the needs of the residents and community, based on the data collected. I think you’ve got to have a good knowledge of the area, what there is around here. I’ve made myself known… (INT049) Communication is key…Personally, I’ve tried to network between the primary and acute sectors, going into the hospitals and doing all the things myself. Community mental health, going with the Social Worker. It’s integrating, building up a relationship, getting your face seen so people can put a face to a name, and things like that. Then you get a trust, don’t you? (INT048) I’ve worked here before for six years before I did this job. So, I would go into people’s houses and I knew them straight away…People are hearing about me. Sometimes the phone does not stop ringing, which is testament to the job itself and the lexibility that I have. (INT047) Because there was no deined pathway to start with, in some respects we’ve furrowed our own pathway…But that’s one thing I think needs further consideration, is setting us up - how we align really. (INT060) u Figure 11 Integrated Care Communities - Thematic Diagram 60 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 61 Health and Social Care Evaluations (HASCE) The key to successful care coordination emerged as the building of a therapeutic relationship with a citizen, which takes time. This relationship involved supporting with social signposting, liaising with the Third Sector, hospital appointments, care following discharge from hospital, and arranging appointments; and, for those further embedded within the community, carrying out holistic assessments and avoiding crisis and hospital admission. If somebody is starting to struggle at home, is starting to just go of their legs a little bit, they’ve just been discharged from hospital and are socially isolated, or even if the GP is just thinking that they don’t look as well as they used to, and they might need just a little bit of input at home. (INT045) The model of working was thus presented as highly lexible, both in terms of requirements within a single role, and the variations of role across ICCs. We have to be lexible and we have to develop. Staf tend to develop more autonomously. I have a colleague who is an AP [advanced practitioner]… our OT went on Maternity Leave … and she was never replaced. So, [name] worked with the trained OTs and… developed her role, so now she goes and she will do the lower level OT assessment…(INT051) This has raised a number of points around the skills, training and role proile that best suits a care coordinator or care navigator. On the one hand, clinical skills were seen as key to the role: Moving forward, it would be more beneicial if [regarding employing new CCs] it’s someone who has some background experience in health as well as the idea of what is out there in the third sector…a couple that have actually left at the moment… they’ve come from admin backgrounds…I think they’ve actually struggled. Whereas we’d look at identifying the risks and everything like that. (INT045) How they [care navigators] started of was very much non-clinical, but they are actually doing home visits and quite a lot of clinical work. They are also going to be part of putting the personalised Care Plans in place for the moderately frail patients. I think part of my role [case manager] in their support is to try and give them the best skills possible. (INT046) Whereas other participants suggested other skills were just as, if not more, important: communication skills, for example, were seen as crucial to both addressing some of the gaps in service (e.g. addressing the problems of social isolation, particularly for the elderly), and for liaising between diferent organisations to ensure joined-up care. From my perspective, there’s been quite a lot of, not sort of, Clinical skills... but the social skills… your communication skills have to be A1, because you’re there in that patient’s house and it’s their turf. (INT060) [as care coordinator they have] built up some really good relationships on a few of the wards and ring them at least three or four times weekly… you’ve got to be able to chat to people and cold call…we’ve built up some really good relationships with the hospital and the third sector. (INT059) And others who identiied project development as a further skill: I’m doing a lot of project development, which currently I don’t think is happening in other ICCs. So there’s three things, I’m hospital in-reaching, being proactive in the community with identifying vulnerable people and going out and assessing and trying to help them, then the project side of it to be proactive from a health point of view to prevent. (INT059) Health and Social Care Evaluations (HASCE) The lexibility of the role posed challenges in other areas, particularly around the similarity of roles to others in social care and the expectations this may give rise to in citizens. As one care coordinator describes: A lot of the times when I go in, they think I’m some kind of social worker, and I have to explain to them that I’m not a Social Worker. (INT045) A lot of the stuf the care navigators are doing, that’s really social care. … If social care were just properly resourced in the irst place, would we need care navigators? (INT014) Likewise, deining the success of care coordination is limited by the variation in roles; not just in terms of the locality they operate within, but also their employers and management. I think that’s become apparent with all the ICCs, that we’re all diferent, we’re all individual. Every community is diferent and I think because the care navigator role as well, we’ve all been diferently funded and diferently employed. (INT049) Care coordinators and care navigators emerged within the data as key actors in local successes of the NCM. In many cases, the broad outline of the role allowed them to introduce changes ‘upstream’ of patients being admitted to hospital: INTERVIEWER: … what do you think the key changes are that your role is making? INTERVIEWEE: Hitting patients upstream… I’m not an emergency service. So, it’s about identifying the patients soon enough to put things in place to prevent the hospital admission. (INT049) Data from and about care coordinators and care navigators highlighted how their role sits at the interface between some of the core strategies of BCTs, their implementation and their outcomes. Many of these changes were ‘ground up’ in nature, and took on a wide variety forms (qualiied nurses/advanced nurse practitioners/non-clinical) which allowed for the testing and reining of integrated care and ‘making it work’; often creating impromptu solutions around systems rather than through them. While there were many success stories around the ways in which these roles were implementing change, almost all noted that itting in a new, somewhat under-deined role caused problems for engaging with other areas of health delivery within the ICC. And the results of this latest project are showing that it’s been really successful. But yes, I really had to battle to be able to do it, because I think that they felt that wasn’t my role, yet I hadn’t been given a speciic job description…that’s probably been the only obstruction. (INT059) The focus on localised solutions enabled a good deal of enthusiasm for the changes the role was perceived to be making; but, as with other areas, tensions emerged between strategic directions and the notion of ‘localised practice’: I’ve struggled with that with BCT, because they’ve sort of got the heat maps, and it’s ooh, respiratory and that -- quite right and they’ve done some great work, but I’ve never felt that we have quite managed to join all the dots up. We don’t keep going back to say is this addressing the local health needs? (INT061) There is, then, an emergent tension between the localised delivery of care coordination and the demonstration of its efects, as well as how well it translates across ICCs. This can be illustrated by one care coordinator who captures the beneits of the lexibility of the role, as well as the problem of evidencing it: My appointments are half an hour, so I’ve got time to sit and talk to people…from a Mental Health perspective, I suspect that people get seen quicker, they get quicker treatment, they probably have better outcomes. I haven’t got any proof of that but I certainly know how many people I see and that it’s quite a lot of people. (INT051) 62 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 63 Health and Social Care Evaluations (HASCE) The problem of evidencing change was linked speciically to this emphasis on a ‘ground up’ approach. Likewise, this had raised some challenges for project managers and ICC lead roles in knowing how to steer the development of the teams. Project managers are working across organisational borders and managing newer ways of working that simultaneously it localised need, whilst also being expected to it with more generalised and sometimes inlexible NHS targets. Thus, there were some accounts of conlict with staf ‘on the ground’ who are working in lexible ways that may not have been clearly set-out in job roles or where there has been insuicient communication between managers and care coordinators. The data illustrates that balancing the tentative, exploratory nature of the development of ICCs with funding/inancial constraints and various IT/IG issues were felt to be limiting some outcomes. Most of the ICCs are driven by the staf, as in what we call the Core Teams. …The ICCs themselves don’t really have a deinitive goal, as such. They’ve been given the lexibility to develop ideas, … so it’s bottom-up rather than top-down. And that’s easier said than done, to a certain extent. (INT011) On the one hand, a positive view of leadership was portrayed as relecting a model of collective leadership: So what I’ve done is give my team, at whichever level, the permissions. And I’ve said, “As long as you don’t negatively afect the reputation of the organisation, it’s not costing us any more money and you have staf working within their professional capacities… then feel free to try it diferently… if it does work, then we need to be sharing that positive good working.” Because it’s agreed as a committee in efect. There’s that core team. (INT043) Try it, to see where you need to improve things or make changes. With any pilot project that’s the beauty of it really, that you ind out what the weaknesses are and then you try and make those changes. (INT046) But on the other hand, participant data suggests this did not always result in eicient ways of working. While the ‘try it and see’ approach has been well-received, there have also been problems reported around ICCs going ‘of course’ due to not enough steer. For example, in some ICCs, work relected the interests of individuals, rather than a population-based approach: Some of the work wasn’t actually targeted, so some of the risk stratiication and the kind of identiication of the priorities in each of the ICCs as to what particular group of patients they should focus on, hadn’t been done. …The work that was focussed on was very much around particular interests from the commission involved in those groups. And it wasn’t necessarily based on population need. (INT062) Others warned of a lack of sustainability if the ICCs became too detached from the overall strategy: In order for them [ICCs] to be able to achieve, and for us [hospital Trusts] to be able to achieve stuf, we’ve got to work closely…otherwise if we’re not careful, their concentration will be on something that might make a diference to them, but not a diference to the health economy overall. (INT022) A necessary tension emerged for each ICC between providing freedom and permission, whilst shaping these with a clearly-deined vision of the programme strategy. However, there were stronger criticisms of the lack of support given to ICCs in operational terms, both in terms of inance and management: There’s deinitely been adjustments along the way [to the role]… We didn’t really know exactly what we were doing…we’ve plodded on and tweaked things ourselves along the way and maybe -- there’s been a lack of support sometimes as well. (INT044) Health and Social Care Evaluations (HASCE) INTERVIEWER: Have there been any obstructions to change… INTERVIEWEE: … Not having any direct instruction, but then when I try to do something to make a positive diference, I’m prevented from doing it or not necessarily always prevented, but there’s a negativity towards some of the stuf I’ve been trying to do. But that’s more from middle-management, not my immediate GP surgery or my team. Certainly, not from the community. (INT059) In some cases, successful changes were identiied as happening in spite of a lack of support; but this also raised the problem of how this success might be recognised. One of our Managerial leads… admitted that she hadn’t supported us, but then we’ve had no support since… I know BCT is more than us. BCT is a big scheme, I’m well aware of that, but – and there’s a lot of diferent pockets of good work going on, but I feel quite chufed that we’ve got this far with the Care Plans. (INT048) The pressure on resources are mainly time pressure; IT not joined up so duplication of information input; and other services such as Social Services and Third sector not always being available or being in communication with ICCs. Some care coordinators reported to interviewers they were experiencing diiculty communicating with hospitals; hierarchical, organisational and bureaucratic barriers appeared to be making this problematic. The two quotes below illustrate that there is perceived to be poor coordination for the discharge of patients, due, in part, to the number of bank staf involved in day-to-day hospital care and poor links with hospital staf. I think the most diicult part has been our links with the RLI, to be honest. They’ve got discharge coordinators on each ward, basically. We link in with them and they’re really good, but they’re the busiest people I’ve come across… The only other people that I’ve found it diicult to engage with is the Social Workers in the hospital… I think they thought we were taking their jobs or whatever. (INT060) If you think about how many bank staf there are in the hospitals every day, working on those wards, that are responsible for discharging patients… it takes me two hours to get to know the patients and know the routine of the ward, just to do the medication round...To then have to think about having to put discharge plans in motion… (INT046) Interviewees noted the importance of personal relations was highlighted as a key enabler to overcoming these barriers. Such relationships also provided tangible evidence for many participants of change on a qualitative level. It’s been very successful in some parts, particularly where I’ve got to know a patient in my community that’s gone into hospital, if I know them really, really well then I can ring up and say, “I know that patient, that’s baseline for them, can they come home today?” And on a few occasions, that has happened, so I have made a diference in for a lot of things... (INT052) …just the communication from one room to another with the door between, has made a massive diference in the communication between the community Nurses and the GP, but also the hospital. We had no contacts at the hospital at all…now I’ve been into the hospital and we’ve got a designated person on each ward. (INT059) And we’re actually building up links with individuals, or teams of individuals, so that you can get things done a lot easier than trying to igure your way through the system. I think that’s one real positive that’s come out of everything. (INT060) Alongside the professional links between the ICCs and the hospitals (as well as with other organisations such as social care; see Chapter 7, Section 7.3.2), responding to the needs of the community is a key mantra of the ICCs, and the BCT logic model positions community mobilisation as an input to enable this aspect of the NCM. In some areas, this was reported. I don’t think there has ever been a time when the community has been as involved with the NHS as now. (INT061) 64 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 65 Health and Social Care Evaluations (HASCE) While ‘the community’ was discussed frequently by participants, there was no clear consistency over what speciically constituted the community or its ‘involvement’ (there was notable disparity across the ICCs on how successful ‘engagement’ events had been, which became a matter of some discussion at the 2nd workshop event), and how either of these related to aspects of the NCM such as population-based needs. Health and Social Care Evaluations (HASCE) 6.4 Cultural Change One of the most cited examples of community mobilisation was Millom. However, there was a strong sense of the ICC developing alongside and in response to community needs, as discussed above, which were identiied from a period of crisis when the area’s healthcare was perceived as under threat. Thus, what was begun in Millom developed from grassroots citizenship: new ways of working emerged from clearly deined moments of threat and crisis, which may be relected in the roles that have grown within this particular ICC. The nurse practitioner’s role is reported to have developed to be multi-skilled in key areas covering mental health and frail/elderly care. Likewise, the community paramedic’s role is responsive to community and GP need. These two roles are addressing key elements in BCT’s strategy – mental health/frail and elderly, taking the strain of GPs (the paramedic can undertake home visits and can treat lower-grade issues with patients in the surgery setting). Participants from this area highlighted that these developments were enabled by a) community groups being closely involved part of the process, rather than just reacting to changes imposed from above, and b) the mind-set developed as a response to the perceived threat of service closure facilitating a breaking down of some hierarchies and barriers to change. It could be argued that this is the ideal model for an ICC as it is shaped by local need, context, geography, and its socio-economic base. At the same time, a participant at the 2nd workshop mentioned that Millom is not a ‘real’ ICC as it came from direct citizen action and localised need, and works in collaboration with other organisations. While the roles that have emerged in local practice (such as the community paramedic) align with BCT strategy, other roles speciic to the ICC in Millom have experienced a challenging task in trying to it the BCT template onto an area that has already instigated its own changes and has built its own momentum: there are all these barriers like systems… I don’t think… we’ve really made any changes. (INT054) Thus, while community mobilisation provides one set of assets for some of the changes brought about by BCT, it would be unwise to attribute all outcomes of the Millom ICC to one context. While the role of community mobilisation provides one narrative of change, other ICCs have experienced problems in identifying themselves as a clear community, or the ‘clear moments’ where community need emerges: …the public event at East didn’t go particularly well, because there was quite a lot of professional public there. And members of local Parish councils, who actually took ofence at the fact that East ICC is ive practices who are very dispersed. And they didn’t think it was a community. (INT063) This is combined with, what appears from analysis, to be some resistance to change from healthcare professionals: I think healthcare professionals and myself included, ind it quite diicult to get their head around not being able to keep everybody on your caseload. You can’t see everybody all the time and be a support for everybody, you do have to try and take a diferent approach and encourage patients to self-manage. (INT046) Nevertheless, the East ICC was pinpointed by many participants (across BCT) as a success, primarily due to the willingness of service deliverers to communicate across organisations and utilise data sharing. In this context, where there is no ‘natural’ community in a geographical or social sense, the linking together of the community is dependent upon professional frameworks created by the ICC teams. u Figure 12 Cultural Change - Thematic Diagram 66 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 67 Health and Social Care Evaluations (HASCE) Across both the closer integration between primary and acute care, and the development of ICCs, a key change has emerged as the growing attention to the role that social, cultural, political and economic contexts have in people’s wellbeing has emerged. A number of diferent interventions and activities are premised on this mechanism for change. It's a diferent approach to perhaps coming with a clinical approach, where you've got to go out and do exercise half an hour a day. There are other aspects to being well, other than the physical health. (INT056) While this is supported by increasing clinical awareness of the ‘bigger picture’ of patient pathways (in particular for patients with complex needs), it also underlies the shift in approach to the overall delivery of care for community roles, such as care navigators: The question I want to ask people in my community is: What would you like [it] to be, to make it a better place to live and work? So it’s not just about health, it’s about everything. It’s about physical and mental well-being for the whole community, really. Because a happier community is a healthier community. (INT057) We’ve always been involved with holistic assessment, holistic treatment. We’ve previously been a long-term conditions team, the ethos of the new way of working is treating the patient as a whole, and not just the individual disease or illness. (INT55) This is often facilitated by patient-centred approaches, which shift focus to ‘individual stories and then improving individual lives’ (INT016): A lot of patients, social isolation has been a major issue… they really appreciate you talking to them for half an hour. They’ve got things of their chest... (INT044) To enact this shift to a broader understanding of wellbeing, cultural change was raised as a fundamental aspect of the NCM, most prominently in the Out of Hospital pathways. Part of it [self-care] is about an understanding of how we change our culture, not just the culture of our population in how they use NHS services, and how do they look after themselves and take responsibility, not just from a lifestyle perspective and how they live, but also in the way they use services and how they comply with treatment etc. (INT018) The shift to a holistic or social model of care (there was no one model referenced consistently), based on patient empowerment, had achieved consensus across most ICCs. [We are] trying to educate people to self-care, trying to improve physical health or prevent deterioration … It’s about physical and mental well-being… a happier community is a healthier community. (INT059) It’s about encouraging the community to take ownership and responsibility, to get involved. So, they might decide that having a choir would be good… it’s a diferent approach to perhaps coming with a clinical approach… (INT056) So the whole thinking behind it is, although loneliness isn’t a speciic health problem, it does contribute to their overall health and well-being. So therefore, if we can do anything at that stage to guide or signpost the person, to try and relieve that loneliness… their overall health will improve. (INT060) …one of the things that we’re inding… we thought we were going out to see people with multiple long-term conditions and it might be that… [But] it’s more that they live on their own and their mood’s a bit low and because they were never a good cook… and therefore they’re not eating properly… they’re not maintaining their wellness. (INT058) 68 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) The data suggested that there is a consensus and understanding about BCT’s focus on populationbased health rather than on a deicit model of health. This new way of working aims to address isolation, poor motivation and low mood via ‘social prescribing’ such as lunch clubs, choirs and walking/running groups. It engages with people in their lived contexts, taking a holistic approach through addressing the broader determinants of health such as loneliness, poor diet and inadequate exercise. It is not just treating the individual’s illness, but focusing on their overall health and wellbeing and identifying the inluence of local contexts and inequalities – unemployment, pollution, social capital, and the stratiication of health outcomes for populations. Via the data collected and analysed, this part of the new model appears to be understood consistently by those implementing it; although it is not always clear what evidence-bases have been used to guide the delivery of services in particular local areas. 26 Much of the success of this involves growing the notion of co-production. In the middle of 2017 (some eight months into the vanguard), one project manager relected on work across the whole of South Cumbria: I’m quickly coming to realise that to deliver BCT it actually meant that without co-production we were going nowhere. (INT061) The mechanisms for realising co-produced care are thematically similar across BCT, though often diferent in practice. In Carnforth, for example, the care coordinator is involved in project development, running cafes for speciic health complaints, and the project leads are asking the community what they want as the ICC is developing. This kind of activity was also reported in Ulverston and Dalton where: ‘it’s about encouraging the community to take ownership and responsibility, to get involved’ (INT056). In Millom, meanwhile, community assets such as ‘really good self-help groups’ (INT052) were identiied as allowing people to become better educated about illness. As above with population-based health, the ethos of co-production was well-understood; but its realisation was not always tangibly evidenced. Cultural changes were almost universally described as being ‘incremental’, because they involved both structural adjustments to referral pathways and improved communication with the public around health. As one clinician noted: Comparatively minor changes in things like smoking, eating, drinking habits, exercise, would have an absolutely massive impact on health care needs – far more than anything that we could do in terms of saving money. (INT022) The extent to which these smaller changes are able to be linked to visible ‘progress’ on strategic outcomes was a consistent cause for concern for participants, and raised again the problem of which metrics were driving change, and how much these might be focused on short-term hospital numbers: Actually, you suddenly realise, when you’re working out in the community… people will go into hospital that need to go into hospital… So, I think our lessons learned are, don’t just sign up and say, “Yes, I’ll reduce those beds,” because you might not be able to do that. But what you can do is, you can change the culture, you can change the communication, you can change your processes, you can get rid of waste, you can start to talk to people diferently. (INT063) You can’t make culture change happen in one inancial year. (INT025) 26 According to Realising the Value (2016), a social model of health combines a deep understanding of what matters to people, with excellent clinical care, timely data and sustained social support (p7). Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 69 Health and Social Care Evaluations (HASCE) One theme to emerge from data analysis was that changes in resource use and cost needed to be placed in the context of a broader timescale. This was driven by the understanding that ‘incremental changes’ would add up to larger reductions in cost, but that signiicant reductions were unlikely to be seen in the short-term, particularly in emergency care: You have to make step changes before signiicant improvements happen. So, for example, you could work really hard and reduce A & E attendances by ive per cent. That would not enable any change in the number of staf that you need at the front door…. It's one of the biggest challenges to it, is being able to make the step changes that are required to make some of the other things happen. (INT022). The changes so far have really been more about a mind set of trying to change people's thinking, and appreciate that everyone is just treading water … so far it's more about the planning and the thinking, rather than the actual, putting it properly, irmly into place. (INT050) We might not have improved our A & E targets, but do you know what we have done? We're changing the culture towards health and well-being. We're changing models where it makes sense to change models. (INT063) With my ICC so far the changes so far have really been more about a mind-set of changing people’s thinking, and appreciate that everyone is just treading water. But this is throwing people a lifeline and a potential opportunity to make a diference… it’s more about the planning and the thinking… (INT050) Some participants linked this to the problem of the ‘grand programme’ approach to change: I think if there's one learning point to come out of this, it's about how to manage change a lot more eiciently. One way of managing change is possibly to start not by having some grand project to change the whole of MSK and Trauma Orthopaedic referral pathways, but you actually start with little bits and then pick away at it, so you're gradually developing a new service, which I suppose is what we've ended up having to do to a certain extent. (INT029) …you can do all these little things that make a short-term diference, and we've proved that we can do that, but it doesn't solve the underlying problems. So, I think we've got a little bit of conlict where, from an ICC point of view and particularly from a CCG point of view… they want numbers and they want proof. Whereas actually, we're trying to… change the way health care is provided in [this ICC]. And that's not going to show itself for ive, ten years really. (INT052) Others, such as one Clinical Governance lead, noted the lack of documentation had been problematic in the integration of care (in this case, between hospital care and private sub-contractors): I think part of this came down to, they wanted this implemented asap. Everything had to happen yesterday, was what I understood, from when it was launched. Again though, I would say a much stronger training system for the Optical Practitioners would have been a good idea. None of it was terribly complex, but if nobody showed you how to use the computer system, you don’t know how to ind out where your invoices are raised, and which patients you’ve been paid for, then it gets stressful for people and that’s what I end up dealing with a month or two down the line. Essentially that could all have been dealt with by a properly written training document. (INT035) However, it appears that tensions arise between the available reporting metrics and the local community’s notions of improved care. The mechanism for change, in such cases, has involved project managers having to manage these expectations without damping enthusiasm: Their deinition of ‘improved care’, for them, or ‘improved patient experience’, is not necessarily the same as the deinition of the metrics that we’ve been given that we need to provide. (INT054) 70 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Further discrepancies emerged between patient participation that merely involves information exchange, and true engagement based on meaningful involvement, equal and reciprocal relationships with shared meaning and mutual understanding that leads to transformation of culture with change on both, attitudinal and behavioural level. For instance the ICCs have picked up on, “we must engage with the community”, but they’ve gone of having conversations rather than engaging with the community. There’s been an interest in doing it, but a lack of real knowledge of what they’re trying to do, or want to do. There’s still that, “We’re going to hold an event and we’re going to invite the community to come along, and we’re going to talk to them. We’re going to tell them what we’re going to do and we’re going to ask them what they want to do.” … That’s ine if you want a patient participation group, but that’s not community engagement.” (INT018) The concern with changing the culture of the public regarding their views of local health provision was clear, and many of the intended changes of BCT thus involve proactively working with at-risk populations ‘to empower them in decision-making now’ (INT002). However, how this decisionmaking is enacted is not always clear at the current stage, and neither is the extent to which proactive interventions and activities are being successfully rolled out. But whereas the notion of holistic care was discussed relatively consistently across staf, the notion of engagement and empowerment was less straightforward to discern. One of the areas that I think we need to look at is the patient engagement. There has been quite a considerable amount of patient engagement already, but it really is around when you’re redesigning a service, and certainly when you look at the minor eye condition service, which is demand-led, we need to somehow educate patients to turn up to the right place irst time. …Now we’ve got a service in place across Morecambe Bay, we need to make sure that we get a message out to patients so that they know where they need to turn up, so that they get the care they need. (INT042) Here, the language of engagement is equivocated with the language of education. In some areas, basic education was seen as the quickest route to addressing unnecessary ED attendance: What we found is… that young people and families do not know basic irst aid. So, there’s people coming in with nosebleeds… If we can educate young children for the future, and say, “Actually, you know what, go to the Pharmacist. You don’t need to go to A & E.” (INT043) One of the examples that we’ve got… are the sick plays… they’re going into schools or community areas and they’re doing a play called Big Sick Little Sick, and it’s about educating particular year groups…about when it’s appropriate to go to the Doctor, the Pharmacy, A & E and when they can look after themselves at home. And the hope is… the children will then go home…and educate their parents, indirectly, about when they can use A & E, or not. (INT056) However, the tensions between these areas – engagement, education, co-production and empowerment – were apparent across the data. In general, the need for all four aspects was seen as crucial, but how they itted into the development and delivery of the NCM was not always straightforward or clear. A majority of participants agreed that the key longer-term change was in the public perception of the health service; but how that was to take place, and what the structures for empowerment and decision-making were, or if they had begun to take place, did not present a consistent picture, and was notably often placed in the future tense. I think what’s happened gradually over the years, people have expected the health service just to provide for them… Whereas, this is about the Clinicians talking to people… it’s getting patients involved in decision making, empowering them to make the decisions. (INT056) It’s far too easy for some of the patients to call 111, or they call 999 and before you know it, they then hit the front door of the hospital. If we can get away from that and change the mind-set of people…to try and get people to think diferently about their own individual health care and their well-being. That actually, if we can then start to get them to use their local resources…then at that point, then we start to see these efects. (INT011) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 71 Health and Social Care Evaluations (HASCE) Given the tensions around cultural change as a mechanism, the number of varying accounts of what BCT actually ‘was’ became a distinctive theme which could both enable or disable change. The need for organisations to come together around a shared agenda was highlighted as the key to many successful examples of partnership working and multi-disciplinary teams. The extent to which such an agenda could be secured seemed to depend on the type of intervention. For pilots which involved structural adjustment – for example, the sub-contracting of services to businesses outside of the hospital – the purpose could be outlined very clearly: As demand and pressure within the NHS grows, particularly in Ophthalmology with an aging population, it becomes very quickly, very diicult to provide all of the services to all the people, particularly in hospital. As we all know, inances within the health service are tricky at best. So really the whole point of BCT, particularly the Ophthalmology project, is providing an appropriate healthcare system by an appropriate healthcare individual, and that doesn’t have to be a Consultant in hospital. That’s what BCT looks at, the whole pathway, particularly in Ophthalmology about what elements have to be delivered in hospital, and what could be delivered closer to home in people’s homes. (INT041) But this became less clear the further participants were from the hospitals: I know BCT… But I’m thinking, “What’s BCT?” From being in the hospital and going on the wards and meeting people, actually you see all the signs, you know that it’s there, but I don’t think it’s trickled down to primary Care. …Things might change once we go back to being Morecambe Bay. I don’t know. (INT059) I think BCT has become, it has become a body in itself, and it’s almost like, “This is a problem, but BCT will ix it.” And I keep saying, “But who do you think is BCT? We’re all BCT.” …And I do think that there’s a bit of friction between the -- and I don’t know who this amorphous blob of BCT is meant to be. It’s become quite a convenient catch-phrase. (INT063) In some cases, the programme is perceived as government’s latest project that “comes and goes” in the context of severe under resourcing and no perceived efects, which further contributes to wideranging apathy within NHS workforce. I don’t even know anything about it [BCT], very much, to be honest, is the truth. It doesn’t really impact on our day-to-day business. … It’s seen a little bit as another one of these initiatives which will come and go. (INT023) I think it’s lack of information and I think it’s a lack of understanding of what it actually is. (INT007) In other cases, the situation was more complicated: a care coordinator in East ICC said that they didn’t know what BCT ‘meant’; but was, however, comfortable that they knew what their role entailed, and could describe in terms which aligned to the BCT strategy. In this sense, the reasoning behind BCT may be more apparent than the actual ‘artefact’ of BCT. BCT has been described in more than one interview as a ‘beast’ that although provided processes facilitating change (‘It focused the minds of the key people’), has actually inhibited its scope and pace with its complex structures and bureaucratic procedures. Health and Social Care Evaluations (HASCE) What we do is being driven by us, it’s not being driven by BCT…We give a good quality of service, the patients…give us good feedback, they ind us very accessible and the GPs the same, I think. We’ve had an increasing number of attendances in A & E here, as everywhere else. I suspect we also have more referrals into our outpatient system. But we’ve actually got a falling number of admissions over the last couple of years, as I understand it… But I think some of the work we’ve been doing is contributing to that. (INT023) In these cases changes were perceived to be independent of the programme, and driven by external factors such as the scrutiny of Morecambe Investigation,27 which has been aligned with the BCT programme’s ambitions and principles. On this note, participants observed that communication about BCT had not been particularly good: BCT and Vanguard just seemed to appear from nowhere in late 2014 and we all thought, “Where’s all this come from?” That was a bit of a problem. I don’t think that anybody was aware that anybody had applied for it, or at least the people applying for it didn’t tell lots of folk on the ground, at the coal-face. So, it was all a bit, “What is this?” (INT029) This could result in anxiety both within and between organisations which cemented, rather than changed, organisational ways of working. I think a lot of hospital staf are potentially anxious, because if you know what we’re trying to do is reduce the bed base, reduce the outpatients’ follow-ups, move things into the community, well, what does that mean for my job? Am I going to lose my job as a result of this? And then you’ve got a great anxiety in the community, where you’ve got people who are working every hour they can, and putting everything they can into their jobs, and they’re thinking, well how on earth can I do more? So, there’s a real anxiety there. (INT006) In other contexts, resistance was linked to territorialism, such as in the MSK intervention: The clinical feedback is really good except for one or two GP Practices who stamped their feet and said, “No, we’re not having anything to do with it.” (INT029) Organisational barriers present a disabling context when, for example, the NCM reaches across diferent Trusts. Alongside this, working practices in service delivery are often shaped by the disabling context of existing ‘tribalism’ around organisations, or protectionism over roles. A combination of strong professional identity with the climate of economic austerity can raise suspicions over interacting with diferent sectors of healthcare, particularly for individuals in operational roles who are wary of increases in workload without appropriate resource support. This can afect decision-making and engagement. There will always be suspicion that you’re trying to either take over, or that they’re going to get the worst end of the deal or whatever. (INT022) 27 https://www.gov.uk/government/publications/morecambe-bay-investigation-report For example, one participant equated BCT with spontaneous change with a number of processes initiated before commencement of the programme and subsequently absorbed by its operational strategy: Much of this work, that is under the umbrella of BCT, is work that would be happening anyway I think sometimes, it’s been a little bit hampered by the bureaucracy of a structure like BCT. (INT008) 72 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 73 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 6.5 Discussion and Summary The main enablers for change were thematised as: Overall, the analysis suggests that the most positive accounts of change taking place are within ground-level, localised responses to perceived gaps in services. Changes around improved communication and dialogue between organisations, facilitated by the roles aligned with the vanguard funding, appear to be making important progress in some areas of Morecambe Bay. This resonates with Greenhalgh et al.’s28 observation that approaches to integration workwhen responses are imaginative and locally responsive rather than rigid, non-negotiableand driven by technology. Shortell et al. note there are issues and challenges in implementing the Five Year ForwardView. The irst is to allow time to build the relationships and cultures that enable GPs andspecialists to work together to improve care, ‘sustained efort will be needed to nurturecollaborative clinical practice and team working.’29 This is, in many ways, borne out byparticipants’ accounts of the changes that the vanguard has introduced so far. Related to this localised activity, participants highlighted the need for ‘incremental approaches’ to change. It was, however, less clear within the data how these map on to the larger-scale changes in the logic model. Participants suggested that current reporting measures were currently not accuratelycapturing valuable changes occurring at ground level. • As such, there is a gap between the organic, site-speciic development of ICCs andthe expectation for statistical data that will relect improvements which,realistically, may take much longer to develop. • • • • • Successful Multi-Disciplinary Team working. Care navigators and other roles which worked lexibly between the ‘gaps’ in service provision. Where structures were already in place to support partnership working (e.g. commissioning structures allowing sub-contracting), progress was more straightforward. Participants consistently referenced the opening of lines of communication as the main mechanisms for change. At the same time, some participants noted that ‘talking’ in and of itself can be problematic if structures do not contain efective feedback loops. There is a question around what one might reasonably expect a certain amount of discussion to produce. The main gaps in the data currently are: • • • Consistent and methodologically robust data collection around incremental change to target populations. A wider evaluation strategy to map diferent elements of data reporting according to strategic criteria for success. A more consistent approach to mapping inputs for interventions and activities, along with timescales (based on contextualised factors such as existing community assets and relationships), which can then be compared against outcomes. Incremental changes were described in terms of the larger outcomes which should emerge as a consequence in the future (e.g. reduction in ED attendance). This was evident in the number of participants who described mechanisms in terms of more aspirational than tangible outcomes, or comments about it being too soon to see real change in the system. However, these incremental changes are also outcomes; and can constitute evidence of visible progress needed to propel the programme forward. • • These changes are largely recorded in small-scale interventions and anecdote. This is valuable evidence of change, but needs to be embedded within larger structures of change where it can be scrutinised. Otherwise, it can be limited to ‘good news stories.’ For example, without an analysis of the non-inancial resources and existing community assets employed used, there are likely to be problems with rolling out small-scale pilots to the wider area using clear, contextually aware timescales for delivery. The main obstacles to change were thematised as: • • • • • Short-term funding and project-based approaches to change. The length of time many of the changes were taking to implement. The length of time that the machinery of BCT was perceived to require. Information Governance and Information Technology. A perceived lack of support from leadership. 28 Greenhalgh, T., Humphrey, C., Hughes, J., Macfarlane, F., Butler, C. And Pawson, R. How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London. The Milbank Quarterly, Vol. 87, No. 2, pp. 391–416 (2009). P.402 29 Shortell, S., Addicott, R., Walsh, N., and Ham, C. The NHS ive year forward view: lessons from the United States in developing new care models. BMJ 350, pp.1-3 (2015). P.2 74 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 75 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 7 Resources Evaluation Question: What is the change in resource use and cost for the speciic interventions that encompass the new care models programme locally? How are vanguards performing against their expectations and how can the care model be improved? What are the unintended costs and consequences (positive or negative) associated with the new models of care on the local health economy and beyond? 7.1 Overview The response to this question consists of two parts. The irst shows the results of the health economics analysis of BCT. The second presents the indings from the qualitative data on participants’ use of resources, and unintended costs and consequences on the local health economy. Overall, this part of the evaluation established that there are many gaps in available data to form a full response to the question. For example, without clear input data, the actual change in resource use was not possible to calculate. The data was also limited in this instance to UHMBT analytics, and therefore the savings and costs to the wider health economy was also not possible to calculate. Underlying this was the problem of many vanguard interventions were slow to deliver, which meant that attributing changes to outcome costs to the work of the NCM is highly speculative. The purpose of this economic analysis is, therefore, not to provide a deinitive answer to the question around costs and consequences of the NCM. Instead, the analysis below serves as a irst step in producing a more detailed economic analysis in the 2017/18 evaluation, which will focus on more speciic interventions (and their costs and inputs) within the Barrow Town, Bay and East ICCs. As such, the indings of this part of the evaluation form an important step in identifying how the change in resource use of the NCM can be more accurately calculated moving forward, both by establishing output baselines and identifying the key gaps in input data which will need to be illed before a fuller answer to the evaluation question can be provided. This is, in turn, informed by the qualitative analysis of resource use which provides an insight into the diferent variables involved in accounting for the ‘cost’ of the NCM. The overall indings, and how these can be used for evaluation moving forward, are discussed in the summary section. 7.2 Economic Evaluation The economic evaluation is based on the metrics developed for the Morecambe Bay Accountable Care System Integrated Performance Report (IPR). These metrics measure key performance indicators for the diferent workstreams in terms of patient activity. In this report, economic evaluations are given for two central workstreams, Elective Care (formerly Planned Care) and Out of Hospital. The metrics for the Elective Care workstream are Outpatient First Attendances and Outpatient Follow-Up Attendances, the metrics for Out of Hospital are Emergency Department Attendance, Non-Elective Admissions, Non-Elective Bed days and Bed Reduction (ward closures). In order to approximate a measure of cost-efectiveness of the vanguard interventions it is assumed, for the purpose of this evaluation, that intermediate outcomes like lower hospitalisation and reduced bed days for the Out of Hospital workstream and reduced attendance of outpatient appointments for the Elective Care workstream are a positive outcome in themselves, even if the direct link to health outcomes or health savings are more elusive. 76 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard For each of the metrics, igures for ‘cost per instance’ have been calculated. For the Out of Hospital workstream these are based on the most up to date igures from the National Schedule of Reference Cost 2015-2016. 30 For the Elective Care Workstream, the National Schedule of Reference Cost does not distinguish between irst and follow-up appointments. Therefore, in order to calculate per unit costs, igures were drawn from the National Tarif for 2015/16, 2016/17 and 2017/18. 31 Cost and number of instances have been used to calculate average “cost per unit” igures. Taking into consideration the market forces factor for Morecambe Bay, these then form the basis of cost calculations for the whole of the BCT area, as well as for the three ICCs that have been selected for the next stage of evaluation in 2017/2018 – Barrow Town, Bay and East. Data from the metrics have then been computed to enable inancial impact comparisons on two levels. On the one hand, a comparison is drawn between time periods before and after the onset of vanguard funding and, on the other hand, cost implications are compared based on actual incidence igures versus the calculated “do nothing” trajectory. The irst comparison gives an indication of the impact of the changes already efected through the new care model compared to the same time period a year previously, while the second looks towards the future by comparing the projected performance from the “do nothing” trajectory against the trend indicated by the data since the beginning of vanguard funding. In terms of timescales, the onset of vanguard funding is taken as October 2016. Year on year comparisons of actual activity are therefore made between October 2015 – September 2016 (‘before’) and October 2016 – September 2017 (‘after’). Comparisons between actual activity and “do nothing” trajectory start with the onset of vanguard funding (October 2016). Trajectories are available up to and including March 2018. In order to maintain comparability of trends between trajectory and actual data (available up to and including September 2017), we calculated the efect of the trajectory as a linear regression of the percentage change between actual and trajectory data since vanguard onset and then applied this efect onto the seasonality of the trajectory. This enabled us to project actual igures forward to March 2018, taking into account how the data is expected to move according to the seasonal efects shown in the trajectory. By doing so, we are able to include trend lines with the graphs, which indicate overall upwards or downwards movements in the data over the indicated periods. 7.2.1 Workstream: Elective Care The metrics for Elective Care distinguish between Outpatient First Attendance and Follow-Up Attendance, as these are afected by diferent changes within the workstream and also because they are associated with difering cost implications. 30 Department of Health. NHS reference consts 2015-2016. (2016) https://www.gov.uk/government/publications/nhs-reference-costs-2015-to-2016 31 NHS England. National Tarif. (2017) https://www.england.nhs.uk/resources/pay-syst/national-tarif/ Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 77 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Outpatient First Attendance The Tables show a two-way comparison: As outlined before, the National Tarif was used to calculate average per unit costs for outpatient irst attendances. As new igures are published on a yearly basis, the average per unit cost is diferent for the years 15/16, 16/17 and 17/18. This has been taken into consideration for the cost calculations. • Average cost per outpatient irst attendance: £212 (2015/16); £195 (2016/17); £209 (2017/18). BCT Cost actual Oct 15 – Sept 16 £30,234,990 Oct 16 – Sept 17 £29,016,021 Diference year/year -£1,218,969 Cost trajectory Diference actual/trajectory £29,071,955 -£55,934 u Table 6 Cost per outpatient irst attendance: BCT-wide Barrow Town Cost actual Oct 15 – Sept 16 £2,930,706 Oct 16 – Sept 17 £2,759,029 Diference year/year -£171,676 Cost trajectory Diference actual/trajectory £2,855,188 -£96,158 u Table 7 Cost per outpatient irst attendance: Barrow Town Bay Cost actual Oct 15 – Sept 16 £5,212,472 Oct 16 – Sept 17 £5,028,558 Diference year/year -£183,914 Cost trajectory Diference actual/trajectory £5,050,200 -£21,643 u Table 8 Cost per outpatient irst attendance: Bay East Cost actual Oct 15 – Sept 16 £2,835,432 Oct 16 – Sept 17 £2,732,300 Diference year/year -£103,132 Cost trajectory Diference actual/trajectory £2,763,549 -£31,249 • Down the column ‘Cost actual’ compares cost diferences between the year before the onset of vanguard funding (Oct 15 – Sept 16) and for the irst year of vanguard funding (Oct 16 – Sept 17). A highlight in green indicates a cost reduction due to reduced activity, i.e. a reduction in the number of outpatient irst attendances. Figures highlighted in red indicate increased cost due to increased activity. Table 6, for instance, shows that irst outpatient attendance cost reduced by ca £1.2m in the last year, compared to the year before. Across the row ‘Oct 16 – Sept 17’ compares cost diferences between actual cost and the calculated ‘do nothing’ trajectory during the irst year of vanguard funding. Again, a green highlight indicates a lower actual cost than the projected trajectory cost, a red highlight indicates higher actual costs against the trajectory. Table 6 shows that the actual cost last year was lower than the ‘do nothing’ trajectory by about £56,000. As can be seen in the tables, all year on year actual costs show a reduction, both for BCT as a whole and in each of the three selected ICCs, due to a real term reduction in irst outpatient appointments. Equally, all actual costs in BCT as well as the three ICCs were slightly lower in the last year than the ‘do nothing’ trajectory. The following graphs (Figure 13 – Figure 19) give an indication of trends within the actual data against the trajectories. For each of the four areas, BCT as a whole, Barrow Town, Bay and East two graphs are presented to indicate trends. The irst graph tracks actual data and “do nothing” trajectories from April 2016 – which is the starting point for the ‘do nothing’ trajectories – to the present date (September 2017) and computes trend lines for both sets of data. This allows for a comparison of upward or downward trends in the actual data against the trajectory. The second graph looks towards the future and takes the onset of vanguard funding (October 16) as the starting point and includes the projected trajectories up until March 18. In order to make the trend lines comparable, the actual data has also been projected forwards to March 18 on the basis of a linear regression of the percentage change between actual and trajectory data since implementation of the vanguard to account for the seasonality in the trajectory. Here, a word of caution needs to be issued with respect to the trend lines. While the trend lines are good indicators of whether there is a falling or rising trend to be detected in the longitudinal data, due to the limited amount of data points and the great variation of data within the respective time periods, the trend line should be taken as an indicator of a rising or falling trend only and the degree of incline or decline should not be taken to predict a certain data point on the graph in the future. In addition, there are not enough data points to make any statements about the statistical signiicance of the diferences in trends. In summary, BCT as a whole has been following the trajectory closely (Error! Reference source not found.3), with overlapping trend lines for actual and trajectory data. This indicates, that, overall, irst outpatient appointments have been increasing over the last year. Figure 14 indicates that this upward trend is also set to continue into the next year. Where the three ICCs are concerned, Bay and East are following the same trend as the overall BCT data, while Barrow Town seems to have been able to reverse the upward trend in irst outpatient appointments over the last year indicated in the trajectory into an overall downward trend, both in the igures to date (Figure 15) and in terms of future projections. u Table 9 Cost per outpatient irst attendance: East 78 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 79 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Barrow Town: OP 1st Attendance cost: actual vs trajectory to date BCT: OP 1st Attendance cost: actual vs trajectory to date £2,800,000 £2,700,000 £270,000 £2,600,000 £260,000 £2,500,000 £250,000 £240,000 £2,400,000 £230,000 £2,300,000 £220,000 £2,200,000 £210,000 £2,100,000 £200,000 £190,000 £2,000,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Apr May Jun Jul Aug Sep Cost Trajectory Cost Trajectory Cost Actual u Figure 13 OP 1st Attendance Cost: BCT Jul Aug Sep Cost Actual u Figure 15 OP 1st Attendance Cost: Barrow Town BCT: OP 1st Attendance cost: actual vs. trajectory since vanguard funding £2,800,000 £2,700,000 £2,600,000 £2,500,000 £2,400,000 £2,300,000 £2,200,000 £2,100,000 £2,000,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 14 OP 1st Attendance cost since vanguard: BCT 80 - 12 Month Report 31/10/2017 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Local Evaluation of Morecambe Bay PACS Vanguard Barrow Town: OP 1st Attendance cost: actual vs. trajectory since vanguard funding £280,000 £270,000 £260,000 £250,000 £240,000 £230,000 £220,000 £210,000 £200,000 £190,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 16 OP 1st Attendance cost since vanguard: Barrow Town Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 81 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) East: OP 1st Attendance cost: actual vs trajectory to date Bay: OP 1st Attendance cost: actual vs trajectory to date £500,000 £270,000 £480,000 £260,000 £460,000 £250,000 £440,000 £240,000 £420,000 £230,000 £400,000 £220,000 £380,000 £210,000 £360,000 £200,000 £340,000 £190,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cost Actual u Figure 17 OP 1st Attendance cost: Bay Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 19 OP 1st Attendance cost: East Bay: OP 1st Attendance cost: actual vs. trajectory since vanguard funding £500,000 East: OP 1st Attendance cost: actual vs. trajectory since vanguard funding £290,000 £480,000 £270,000 £460,000 £440,000 £250,000 £420,000 £230,000 £400,000 £380,000 £210,000 £360,000 £340,000 £190,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 18 OP 1st Attendance cost since vanguard: Bay 82 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 20 OP 1st Attendance cost since vanguard: East Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 83 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Outpatient Follow-Up Attendance In analogue to Outpatient First Attendance, the average per unit cost for Outpatient Follow-up Attendance has been calculated on the basis of the National Tarif, taking into consideration the Morecambe Bay market forces factor. The projected trajectory costs have been calculated on the basis of the 17/18 igures. Average cost per outpatient follow-up attendance: £127 (2015/16); £117 (2016/17); £105 (2017/18). BCT Cost actual Oct 15 – Sept 16 £42,845,313 Oct 16 – Sept 17 £39,127,001 Diference year/year -£3,718,312 Cost trajectory Diference actual/trajectory For BCT, as well as all three individual ICCs, costs for follow-up attendance have been reduced considerably (£3.7m) compared to the previous year. It has to be taken into consideration, however, that the unit cost per follow-up attendance is also lower in this year compared to the previous. For BCT as a whole and East, the cost, however, is slightly higher than the predicted ‘do nothing’ trajectory. Barrow Town and Bay show a decrease in follow-up attendance that is exceeding the trajectory. The following graphs also indicate a downward trend for the cost of follow up appointments for BCT as a whole as well as all three ICCs that follows the path of the trajectories very closely. Again, part of this would be due to the reduced unit cost of follow up appointments, combined with a reduction in activity. BCT: OP FU Attendance cost: actual vs trajectory to date £39,000,021 £126,980 £4,100,000 £3,900,000 £3,700,000 u Table 10 Cost per outpatient follow-up attendance: BCT-wide £3,500,000 £3,300,000 Barrow Town Cost actual Oct 15 – Sept 16 £4,201,041 Oct 16 – Sept 17 £3,741,515 Diference year/year Cost trajectory Diference actual/trajectory £2,900,000 £2,700,000 £3,777,271 -£35,756 £2,500,000 Apr May Jun -£459,526 Bay Cost actual Oct 15 – Sept 16 £7,654,135 Oct 16 – Sept 17 £6,932,742 Cost Trajectory Cost trajectory £6,996,798 -£64,056 Oct 15 – Sept 16 £4,075,128 Oct 16 – Sept 17 £3,793,473 Diference year/year -£281,655 Cost Actual BCT: OP FU Attendance cost: actual vs. trajectory since vanguard funding £4,000,000 £3,800,000 £3,600,000 u Table 12 Cost per outpatient irst attendance: Bay Cost actual Jul Aug Sep u Figure 21 OP Follow up Attendance cost: BCT Diference actual/trajectory -£721,393 East Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 u Table 11 Cost per outpatient irst attendance: Barrow Town Diference year/year £3,100,000 £3,400,000 Cost trajectory Diference actual/trajectory £3,200,000 £3,000,000 £2,800,000 £2,600,000 £3,755,171 u Table 13 Cost per outpatient irst attendance: East 84 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard £38,302 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 22 OP Follow up Attendance cost after vanguard: BCT Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 85 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Barrow Town: OP FU Attendance cost: actual vs trajectory to date £380,000 Bay: OP FU Attendance cost: actual vs trajectory to date £700,000 £650,000 £360,000 £340,000 £600,000 £320,000 £550,000 £300,000 £280,000 £500,000 £260,000 £240,000 £450,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cost Actual u Figure 23 OP Follow up Attendance cost: Barrow Town Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 25 OP Follow up Attendance cost: Bay Bay: OP FU Attendance cost: actual vs. trajectory since vanguard funding Barrow Town: OP FU Attendance cost: actual vs. trajectory since vanguard funding £700,000 £380,000 £360,000 £650,000 £340,000 £320,000 £600,000 £300,000 £550,000 £280,000 £500,000 £260,000 £450,000 £240,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 24 OP Follow up Attendance cost after vanguard: Barrow Town 86 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 26 OP Follow up Attendance cost after vanguard: Bay Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 87 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) East: OP FU Attendance cost: actual vs trajectory to date Emergency Department Attendance The average per instance cost for emergency attendance has been calculated on the basis of most up to date igures from the National Schedule of Reference Cost 2015-2016. 32 Taking into consideration the Morecambe Bay market forces factor, the per instance cost is based on igures for emergency departments (National Code 01) only, as this relects most closely the recorded activity data. This yielded an average per instance cost per ED attendance of £153. £390,000 £370,000 £350,000 £330,000 £310,000 £290,000 £270,000 BCT Cost actual Oct 15 – Sept 16 £13,914,333 Oct 16 – Sept 17 £13,300,784 Diference year/year -£613,548 Cost trajectory Diference actual/trajectory £13,495,337 -£194,552 Cost trajectory Diference actual/trajectory £1,764,944 -£69,844 Cost trajectory Diference actual/trajectory £2,557,248 -£57,908 Cost trajectory Diference actual/trajectory -£9,496 £250,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 27 OP Follow up Attendance cost: East East: OP FU Attendance cost: actual vs. trajectory since vanguard funding u Table 14 ED Attendance cost: BCT-wide Barrow Town Cost actual Oct 15 – Sept 16 £1,840,338 Oct 16 – Sept 17 £1,695,100 Diference year/year -£145,237 £390,000 £370,000 u Table 15 ED Attendance cost: Barrow Town £350,000 £330,000 £310,000 Bay Cost actual Oct 15 – Sept 16 £2,653,760 Oct 16 – Sept 17 £2,499,340 Diference year/year -£154,420 £290,000 £270,000 £250,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 28 OP Follow up Attendance cost after vanguard: East u Table 16 ED Attendance cost: Bay East Cost actual 7.2.2 Workstream: Out of Hospital Oct 15 – Sept 16 £643,968 The metrics for the Out of Hospital workstream are Emergency Department Attendance, NonElective Admissions, Non-Elective Bed days and Bed Reduction (ward closures). As with the Elective Care workstream, intermediate outcomes of these metrics like lower hospitalisation and reduced bed days are interpreted as positive outcomes in themselves, even if they cannot be linked directly to changes made through vanguard interventions. Oct 16 – Sept 17 £616,303 £625,798 Diference year/year -£27,665 £625,798 u Table 17 ED Attendance cost: East 32 Department of Health. NHS reference consts 2015-2016. 88 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 89 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) All year on year comparisons between 2015/16 and 2016/17 show slight decreases in overall emergency department attendance, signifying improvements in avoiding ED attendance. In addition to that, in BCT as a whole, but also in each of the three ICCs, the overall ED attendance igures were lower in the last year than the ‘do nothing’ trajectory. These postive trends are also visible in the graphs comparing trends in the data between actual cost and the trajectory, both to date and when looking at the projected data until March 2018: Barrow Town: ED Attendance cost: actual vs trajectory to date £180,000 £170,000 £160,000 £150,000 £140,000 BCT: ED Attendance cost: actual vs trajectory to date £130,000 £120,000 £1,300,000 £110,000 £1,250,000 Apr May Jun £1,200,000 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 £1,150,000 Cost Trajectory £1,100,000 Cost Actual u Figure 31 ED Attendance cost: Barrow Town £1,050,000 £1,000,000 £950,000 £900,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Barrow Town: ED Attendance cost: actual vs. trajectory since vanguard funding 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 29 ED Attendance cost: BCT £190,000 £170,000 BCT: ED Attendance cost: actual vs. trajectory since vanguard funding £150,000 £130,000 £110,000 £1,300,000 £90,000 £1,200,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 £1,100,000 Cost Trajectory £1,000,000 Cost Actual u Figure 32 ED Attendance cost since vanguard: Barrow Town £900,000 £800,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 30 ED Attendance cost since vanguard: BCT 90 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 91 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Bay: ED Attendance cost: actual vs trajectory to date £260,000 East: ED Attendance cost: actual vs trajectory to date £65,000 £250,000 £60,000 £240,000 £230,000 £55,000 £220,000 £210,000 £50,000 £200,000 £190,000 £45,000 £180,000 £170,000 £40,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Jul Cost Actual u Figure 33 ED Attendance cost: Bay Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 35 ED Attendance cost: Bay East: ED Attendance cost: actual vs. trajectory since vanguard funding Bay: ED Attendance cost: actual vs. trajectory since vanguard funding £65,000 £290,000 £60,000 £240,000 £55,000 £190,000 £50,000 £140,000 £45,000 £90,000 £40,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 34 ED Attendance cost since vanguard: Bay 92 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 36 ED Attendance cost since vanguard: East Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 93 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Non-Elective Admissions Non-elective admissions are deined as unplanned, often urgent admissions (often via A&E), generally understood to include at least one overnight stay on short notice because of clinical need or because alternative care is not available. The average reported spell cost of a nonelective inpatient admission (including excess bed days) from the National Schedule of Reference Cost 2015-201633 adjusted for the Morecambe Bay market forces factor is £2,263. BCT Cost actual Oct 15 – Sept 16 £86,459,878 Oct 16 – Sept 17 £81,062,925 Diference year/year -£5,396,954 Cost trajectory Diference actual/trajectory £82,187,813 -£1,124,889 In analogue to emergency department attendance, igures for non-elective admissions have reduced since vanguard onset compared to the previous year, resulting in a reduction in cost for BCT as a whole of over £5m, as well as considerable cost reductions in Barrow Town, Bay and East ICCs. Again, as with emergency department attendance, the cost of non-elective admissions have also been lower in the last year compared to the ‘do nothing’ trajectory, with over £1m diference for BCT as a whole. This downward trend is also relected in most of the trend lines comparing actual versus trajectory up to date and for the projected future costs, as demonstrated in the graphs below. Apart from Barrow Town ICC, where actual costs to date and future projections do not show an improvement against the trajectory, the ICCs and BCT as a whole show slightly better trends than the trajectories: BCT: NEL Admissions cost: actual vs trajectory to date £8,000,000 £7,500,000 u Table 18 Non-Elective Admissions cost: BCT-wide Barrow Town Cost actual Oct 15 – Sept 16 £9,827,660 Oct 16 – Sept 17 £9,313,988 Diference year/year -£513,672 Cost trajectory Diference actual/trajectory £7,000,000 £6,500,000 £6,000,000 £9,354,414 -£40,425 £5,500,000 Apr May Jun u Table 19 Non-Elective Admissions cost: Barrow Town Bay Cost actual Oct 15 – Sept 16 £17,231,783 Oct 16 – Sept 17 £15,665,875 Diference year/year -£1,565,909 Cost Trajectory Cost trajectory £16,172,355 Diference actual/trajectory Cost actual Oct 15 – Sept 16 £6,191,222 Oct 16 – Sept 17 £6,007,930 Diference year/year -£183,293 Jul Aug Sep Cost Actual u Figure 37 Non-Elective Admissions cost: BCT-wide BCT: NEL Admissions cost: actual vs. trajectory since vanguard funding -£506,481 £8,000,000 u Table 20 Non-Elective Admissions cost: Bay East Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 £7,500,000 Cost trajectory Diference actual/trajectory £7,000,000 £6,500,000 £6,000,000 £6,089,020 -£81,090 £5,500,000 Oct Nov Dec Jan Feb Mar Apr May Jun u Table 21 Non-Elective Admissions cost: East Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 38 Non-Elective Admissions cost since vanguard: BCT-wide 33 Department of Health. NHS reference consts 2015-2016. 94 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 95 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Barrow Town: NEL Admissions cost: actual vs trajectory to date Bay: NEL Admissions cost: actual vs trajectory to date £1,550,000 £1,500,000 £900,000 £1,450,000 £850,000 £1,400,000 £1,350,000 £800,000 £1,300,000 £750,000 £1,250,000 £1,200,000 £700,000 £1,150,000 £650,000 £1,100,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Apr May Jun 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cost Actual u Figure 39 Non-Elective Admissions cost: Barrow Town Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 41 Non-Elective Admissions cost: Bay Barrow Town: NEL Admissions cost: actual vs. trajectory since vanguard funding Bay: NEL Admissions cost: actual vs. trajectory since vanguard funding £900,000 £1,600,000 £850,000 £1,500,000 £800,000 £1,400,000 £750,000 £1,300,000 £700,000 £1,200,000 £650,000 £1,100,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 40 Non-Elective Admissions cost since vanguard: Barrow Town 96 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 42 Non-Elective Admissions cost since vanguard: Bay Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 97 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) East: NEL Admissions cost: actual vs trajectory to date Non-Elective Bed days Non-elective bed days relate to the length of stay of patients who have been admitted to hospital through emergency (non-elective) services. While the majority of admissions to hospital are elective patients (61% in the BCT area in 2016/17), they occupy only about 10% of bed days. In turn, 90% of bed days are occupied by non-elective patients, which means that reducing bed use for emergency admissions ofers greater potential to deliver an overall reduction in the use of hospital beds and associated cost savings. The average bed day cost has been calculated as £283, on the basis of the average cost of excess bed days in the National Schedule of Reference Cost 2015-201634 and adjusted for the Morecambe Bay market forces factor. £560,000 £540,000 £520,000 £500,000 £480,000 £460,000 £440,000 £420,000 £400,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cost actual Oct 15 – Sept 16 £54,993,976 Oct 16 – Sept 17 £51,531,947 Diference year/year -£3,462,029 Cost trajectory Diference actual/trajectory £53,637,566 -£2,105,618 Cost trajectory Diference actual/trajectory £7,087,720 -£358,948 Cost trajectory Diference actual/trajectory £9,161,657 £377,434 Cost trajectory Diference actual/trajectory -£395,440 Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory BCT Cost Actual u Figure 43 Non-Elective Admissions cost: East u Table 22 Non-Elective Bed days cost: BCT-wide East: NEL Admissions cost: actual vs. trajectory since vanguard funding £600,000 £550,000 Barrow Town Cost actual Oct 15 – Sept 16 £6,980,581 Oct 16 – Sept 17 £6,728,771 Diference year/year -£251,810 u Table 23 Non-Elective Bed days cost: Barrow Town £500,000 £450,000 £400,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 44 Non-Elective Admissions cost since vanguard: East Bay Cost actual Oct 15 – Sept 16 £9,340,695 Oct 16 – Sept 17 £9,539,091 Diference year/year £198,395 u Table 24 Non-Elective Bed days cost: Bay East Cost actual Oct 15 – Sept 16 £4,814,340 Oct 16 – Sept 17 £4,376,005 £4,771,444 Diference year/year -£438,335 £4,771,444 u Table 25 Non-Elective Bed days cost: East 98 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard 34 Department of Health. NHS reference consts 2015-2016. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 99 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) As can be seen from the tables above, there was a reduction in cost of non-elective bed days by just under £3.5m last year as compared to the year before and also registers a saving compared to the ‘do nothing’ trajectory. Barrow Town and East also indicate reduced costs, both in the year on year comparison and against the trajectory. In Bay ICC, on the other hand, costs for non-elective admissions rose last year compared to the previous year, as did actual costs against the trajectory. £750,000 This trend is also markedly visible in the comparative graphs below: £700,000 Barrow Town: NEL Bed days cost: actual vs trajectory to date £650,000 £600,000 BCT: NEL Bed days cost: actual vs trajectory to date £550,000 £500,000 £450,000 £4,800,000 £4,700,000 £4,600,000 £4,500,000 £4,400,000 £4,300,000 £4,200,000 £4,100,000 £4,000,000 £3,900,000 £3,800,000 £400,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Cost Actual u Figure 47 Non-Elective Bed days cost: Barrow Town Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Trajectory Barrow Town: NEL Bed days cost: actual vs. trajectory since vanguard funding Cost Actual u Figure 45 Non-Elective Bed days cost: BCT £750,000 £700,000 £650,000 BCT: NEL Bed days cost: actual vs. trajectory since vanguard funding £5,000,000 £600,000 £550,000 £500,000 £450,000 £400,000 £4,500,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 £4,000,000 Cost Trajectory Cost Actual u Figure 48 Non-Elective Bed days cost since vanguard: Barrow Town £3,500,000 £3,000,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 46 Non-Elective Bed days cost since vanguard: BCT 100 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 101 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Bay: NEL Bed days cost: actual vs trajectory to date East: NEL Bed days cost: actual vs trajectory to date £950,000 £530,000 £900,000 £480,000 £430,000 £850,000 £380,000 £800,000 £330,000 £750,000 £280,000 £700,000 £230,000 £650,000 £180,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Apr May Jun Jul Aug Sep Cost Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Cost Trajectory Cost Actual u Figure 49 Non-Elective Bed days cost: Bay Jul Aug Sep 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 Cost Actual u Figure 51 Non-Elective Bed days cost: East Bay: NEL Bed days cost: actual vs. trajectory since vanguard funding £1,050,000 £1,000,000 £950,000 £900,000 £850,000 £800,000 £750,000 £700,000 £650,000 East: NEL Bed days cost: actual vs. trajectory since vanguard funding £530,000 £480,000 £430,000 £380,000 £330,000 £280,000 £230,000 £180,000 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 50 Non-Elective Bed days cost since vanguard: Bay 102 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 Cost Trajectory Cost Actual u Figure 52 Non-Elective Bed days cost since vanguard: East Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 103 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Bed Reduction According to a recent report from The King’s Fund in England, the number of general and acute beds has fallen by 43 per cent since 1987/8, with the bulk of this fall being due to the closures of beds for the long-term care of older people. Medical innovation, including an increase in day-case surgery, has also had an impact by reducing the time that many patients spend in hospital. While the rate of decrease in bed numbers has slowed in recent years, there are opportunities to make better use of existing bed stock by preventing avoidable admissions, reducing variations in length of stay and improving the discharge of patients. 35 The efects of these eforts to make better use of existing bed stock are shown through the non-elective bed day metric above. The King’s Fund report continues: Today there are signs of a growing shortage of beds. In 2016/17, overnight general and acute bed occupancy averaged 90.3 per cent, and regularly exceeded 95 per cent in winter, well above the level many consider safe. In this context, proposals put forward in some sustainability and transformation plans to deliver signiicant reductions in the number of beds are unrealistic.36 7.3 Qualitative Analysis of Changes in Resource Use Short-term nature of funding Lack of capacity in the third sector Perceived lack of capacity Distribution of funding Lack of capacity in BCT Commissioning structures Distribution of resource to third sector Negative views of commissioning processes Change in use of resources For the BCT area, overnight general and acute bed occupancy averaged 85% since vanguard onset in October 2016, with a peak of 87.8% in March 2017. Compared to this, the average bed occupancy in the same time period the year before was 86%, with a peak of 89.2% in January 2016. This slight reduction in occupancy is achieved despite a reduction in available beds. Between October 2016 and July 2017, the average number of available beds dropped by 23, from 676 to 653, reducing available bed days from 20949 to 20232. With the average bed day cost calculated at £337 (taking into account the distribution of elective and non-elective patients at 10% to 90%, as discussed in the previous section), this suggests an overall saving through bed reduction of £241,291 for the BCT area. Lack of capacity in social care Lack of upskilling Lack of management support Lack of ‘steer’ 7.3.1 Thematic Overview As with all areas of qualitative analysis, interview data regarding resource use was organised thematically in order to identify patterns, regularities and signiicances in participant responses. A diagram of themes is presented below, followed by a narrative of the qualitative indings around resource use. Good links with social care Non-inancial resources Shared resource Partnership working 35 The King’s Fund. NHS hospital bed numbers: past, present and future. (2017) https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers 36 The King’s Fund. NHS hospital bed numbers. Use of the voluntary sector Savings made Use of untapped skills in the workforce Information sharing Enthusiasm for change and goodwill u Figure 53 Change in Use of Resources - Thematic Diagram 104 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 105 Health and Social Care Evaluations (HASCE) 7.3.2 Distribution of Funding While all participants were asked to discuss the changes in resources they had seen, few identiied tangible changes. Instead, the data analysis shows the issue of resources raised a number of deep concerns around the meaning of resource use to practitioners, including: • • • the distribution of funding and the decision-making behind it; diferent funding models for primary and acute care; how resource was translated into delivery, and the efect of funding structures ondelivery and morale. One of the major discussion points around resources was the distribution of the vanguard money, and of the BCT investments more generally. As the Figure 53 shows, all of the themes emerging under this heading were negative or reporting disabling mechanisms for change. A recurrent theme around funding related to its short-term nature, and the problems this raised for delivering sustainable change. According to many participants, the programme has been driven by short-term and non-recurrent funding with little or no preceding investment in afected services. This has been reported to contribute to disengagement of the workforce and generate outcomes that are vulnerable to reversal change, following conclusion of the programme. One of the bones of contention being the fact that we've been an ongoing stop-start because of funding. Even now we don’t know what's going on with it. (INT047) We’ve had several Project Managers, and that lack of continuity has not helped at all… it's a long-term project, it's a long-term aim, but the money is all short-term. So, we’ve only just found out that next year’s monies are there. And also that doesn't help with the work force, or with planning, or with what we might hope to achieve. (INT050) This was mentioned across a range of interventions, including MSK: The funding comes from vanguard for another six months. What happens after that, nobody knows. That uncertainty is certainly having an efect on the recruitment of staf into the service.We're sort of in a pilot phase, but nobody really knows what's going to happen. (INT029) In this context, an unintended consequence of vanguard funding was to introduce more, rather than less, uncertainty into areas of practice: But then, we get told that apparently at the end of February, the funding for the Telehealth is inishing…because it was only a pilot. And then it’s like, “Oh, well it doesn't matter, there'll be funding from somewhere else.” But it just creates uncertainty and then everybody is like, “Why are we bothering now with the Telehealth, if we're not going to be able to carry on with it?” (INT052) However, the importance of being able to trial new ways of working did provide a model for longerterm investment, and with it a belief that if the funding could be extended there would be further opportunities to backill the current volunteers’ posts and extend the service. This was seen in the MSK work: Once we get permanent funding we’ll be able to potentially recruit to the new session and backill the old ones. So, that’s part of the problem with doing things on a trial or test basis without permanent funding. We’ve not been able to recruit to the backill. (INT039) Health and Social Care Evaluations (HASCE) The delivery of the NCM sits not only within a complicated history of service improvement interventions in Morecambe Bay, but also alongside multiple and competing demands associated with both pre-existing BCT initiatives and wider NHS strategies. This was sometimes seen as a disabling context: To some extent, the vanguard award which came was a bit of a hindrance. Because we were trying to deliver the BCT strategy … [and] trying to serve the Five Year Forward View vanguard team expectations. In terms of resource, it was a limited resource we had from vanguard and there was competition between work streams for that scarce resource, which has been shrinking. And I think as the vanguard award shrunk, our ability to move things forward became inhibited. (INT009) About three years or so ago… we were trying to put some stuf together for the CCG, to try and develop MSK care. That all came to a halt because then we were told, “No, you can’t do any more, it’s only going to be part of BCT and vanguard.” (INT029) One of the added problems of vanguard-speciic resource was the perception that support for initiatives is tied to the project management structure of BCT. For example, it was noted in the previous chapter that at ICC level, many care coordinators had raised the ‘lack of steer’ from managers as something which could be potentially beneicial, but was also problematic in terms of the support available. In one North Lancs ICC, the care coordinator feels that while the GPs are onboard, middle-management could prevent the role holder implementing new ways of working and rolling out new ideas. Here, the measure of support is linked to the commissioning process: It’s middle management where I’m getting the blockers put on me… I’m presuming it’s because I’ve not been commissioned, or they’ve not been commissioned to provide this service. I don’t really know… but I’m being left to get on with it now because they’re seeing positive results. (INT059) In this sense, the ‘lack of steer’ can be interpreted positively (projects left to develop while they show positive results), as well as negatively (if more support is needed). In other areas, the lack of a leadership steer could lead to competing demands of several diferent managers: There’s an issue as well because we work for several GP surgeries. Some want some things and some want others, so it can be hard to determine that, let alone put it in place sometimes. So it’s just getting some consistency… even some of the paperwork we do, some of the surgeries want certain things doing… and then others aren’t so keen on it, so we don’t really know whether we’re doing it or not at times. There’s been an issue with not having a Case Manager and not having a very deinite Senior Manager to coordinate that, is part of the issue. (INT044) There were similar concerns raised around the capacity outside of BCT. As a clearly stated aim of BCT is to keep frail and elderly people out of hospital, social care forms a vital role in this. However, participants – particularly in South Cumbria – reported problems with capacity and funding in both statutory and third sector organisations. A number of participants noted that this was a key preventer in the successful delivery of the BCT strategy. All of the following quotes are from South Cumbria ICCs: We’re supposed to be a fairly short-term service, and bringing in other services to support. Sometimes the third sector isn’t there and even with either the NHS or the Social Services, it’s an issue of capacity a lot of the time… then that obviously keeps them on our caseload and possibly increases the risk that they will go into hospital in between, whilst they are waiting for services. (INT044) Being in post in the irst three months, we’d already saturated the third sector, the Age UK and Sight Advice because we’d blocked their referral services up. (INT049) 106 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 107 Health and Social Care Evaluations (HASCE) I’ve just been told recently to utilise Age UK’s befriending service and… apparently, the money has run out for that now, so the best they can do is maybe ofer a telephone befriending service, but again that’s not even guaranteed. (INT060) Well the clear directive is to try and reduce admissions…but I think that directive is slightly unattainable, because of the severe lack of Social Care… I think there are not the carers on the ground where we are, because we’re in a rural area. (INT047) They’ve got major issues with staf sickness, and just not enough Social Workers anyway, but obviously we need a lot more input and I don’t think we’re going to get it anytime soon. (INT044) I think the biggest strain on resources is Adult Social Care… we don’t even know who our Social Worker is. (INT047) This was also linked to the problem of general staf recruitment and attrition issues reported in the South Cumbria area (see Chapter 8): In the area where I work, there’s not enough home care. People have been stuck in the hospital because they can’t get home, because there’s no care agencies and there’s not enough care for the area. (INT048) Conversely, where links between social care and the ICC were stronger, participants were more conident of producing successful outcomes. …because we can never get Social Workers, one of the Social Care Workers showed her [an Assistant Practitioner] how to do re-ablement plans… She’s the most informed person to write these plans. So she passes them up to Social Work so we can work more collaboratively… to get people discharged. It’s an informal agreement, but as long as somebody does it. It’s okayed by Social Care. It works really, really well. (INT051) …we have really good links now with Social Services…we’ve got a Social Worker linked in to our ICC, so now if we have any social aspects that we need to clarify, it’s just a case of picking up the phone or emailing…likewise, with the voluntary sector as well, we’ve built up really good links with Age UK. (INT060) The number of demands on more senior staf in the public and voluntary sectors and how this impacted their ability to engage was also an issue: I tend to get invited to quite a few things, or I might get invited to have a seat at a certain meeting, but because there’s generally only me that’s got a portfolio for health and wellbeing, at a senior level, my problem is that I just don’t have the capacity to service everything. So, I have got a seat on the OOH implementation meeting, which is great. I’ve been to the occasional meeting, but they are about every month, and I just can’t make them all. (INT027) Alongside concerns around the capacity of Social Care and the Third Sector, there were also negative views expressed about the distribution of resource around BCT itself. There was a recognition that the time required for system change to be designed and take place placed a large demand on clinical staf. This can not only afect the delivery of changes, but also the way in which decisions are made at more strategic levels, as clinicians may be prevented from engaging in the conversations which, as reported in Chapter 6, have so far been crucial enabling mechanisms for the NCM: And the Clinicians we have are doing day-to-day service delivery. They don’t have protected sessions for other things, if you like. They’ve got patients to see. So, although I try and involve my Clinicians in the pathway development, because they’re the experts… you can’t get them around tables at Senior meetings. (INT043) 108 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) But much of the concerns around capacity came back to funding: There is no resource … I’m funded one day per week, how do you expect somebody to transform a whole health system in a day per week for six months. (INT054) INTERVIEWER: … Has there been any upskilling or role redesign involved? INTERVIEWEE: No, we’ve had no changes. There’s been no support from management. (INT045) In this context, the following observation from one South Cumbria ICC is key, as it raises the issue around the extent to which a return on investment, and general efectiveness of a programme, will vary depending upon existing assets and skills within a team or area. We were just left to make the service -- within the [ICC], we moulded it into the way that we thought would work better… it’s been hit and miss, but because of the skills that we have in the team… we’ve got some background in all areas… The GPs seemed happy with the way that there’s actually more of a service for our patients. (INT045) One of the problems associated with the localised responses which form the basis of many of the successes in BCT was the way in which resource use could be tracked from input to outcome. It was noted in the overview (Section 7.1) that identifying inputs into the resource chain was problematic. In part, this was attributed to separate commissioning structures at work within the programme: The acute Trust are on a tarif, [while] we’re on block. So, what happens is we get more and more work thrown at us for no additional money, no additional resource. So, if my District Nurses had 100 visits in one day, they’re going to end up with 130, but no more Nurses to do it. So all of that doesn’t lend itself to ensuring that we embed or change services. (INT043) BCT is a means of creating change, but change is very slow; “it feels like we are being sucked into the giant machine that is the healthcare system… as soon as you try to change something, you’re changing contracts, which are quite complicated.” (INT064) The task of bringing together ten diferent organisations as ‘Bay Health and Care Partners’ has also proved problematic at an operational level: BCT is obviously about a system-wide approach, but our individual organisations don’t allow us to deliver BCT. So, the barriers if anything are the organisational constraints… NHS England have come and said, here’s some money, with your vanguard status, deliver BCT… But what they haven’t done is set the permissions level to say, on this occasion, don’t worry about IT between organisations… (INT061) Likewise, the cohesion of the system-wide approach was challenged by competing programmes of work and performance indicators: Our commissioning arrangements don’t support it [change], because I’m still held to deliver on previous KPIs. So, if we can’t double run, the only way we can do it is to move our deck chairs. But if I’m held to deliver on previous KPIs, I can’t move my deck chairs in the way that I need to, to enable that change to happen. (INT043) Participants’ views that distribution of funding was problematic due to its temporariness was also linked to the decision-making structures and involvement of other care deliverers. This was perceived to interfere with some of the localised solutions which were being developed as part of ICC development, for example: We’re being told as ICCs, “You need to have free rein to identify -- because you know your population, you need to do what’s right.”…But when it comes to actually any decision making - any transparency over how much money is available, what it can be spent on, we don’t get given that…And often, the decisions that are made higher up are completely disjointed from what’s happening in the ICC. (INT054) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 109 Health and Social Care Evaluations (HASCE) This view of a disconnection between decision-makers and the lived contexts of the region was raised in a broader sense by a participant from the voluntary sector: The BCT strategy does really need to think about its wider partnership and what assets they can bring to making this a successful implantation. So, I think there is still mileage in making sure that they involve people and the right people. And I think there has to be a cleverer way of distributing funding as well. You know, we bring so much to it, but we virtually get nothing from it. (INT028) There were more positive notes, however, around improvements in the distribution of resources related to the growing evidence around the shift to a wider understanding of wellbeing (see Chapter 6): I think there’s an increased and improved understanding of why things like lunch clubs have had a value. Because lunch clubs just sounds like, well, why would anybody pay for that, why would anybody commission that? And the answer is, actually, for lots of reasons. And not about the food. (INT058) The work in the Opthalmology pathway, whereby certain conditions were contracted out to the private sector, was raised as a good example of managing relationships and communication between organisations: The model across in Morecambe Bay allows the Trust to sub-contract out to the Optical Practices, so the Optical Practices and the staf within them become the face of the Trust. … In other models, you’ve got a situation where the commissioners will potentially decommission from one organisation, to recommission with another. It immediately puts the provider organisations at odds, if you like. Almost thinking as businesses rather than clinical providers. The model across Morecambe Bay is really a good example of how clinicians coming together can support a better service around patients. (INT042) 7.3.3 Non-inancial Resources In contrast to the themes around the distribution of funding, far more positive themes could be identiied from the data collected around the idea that resources other than money were important and could be valued more when they are shared. The negative themes drawn from the analysis focus on management support, and the tension between the freedom to develop new ideas at local levels, and a perceived lack of steer or support from middle management upwards. The role of partnership working in utilising resources in a more eicient way was noted by a number of participants, particularly those from the voluntary sector. At the time of data collection, this was still felt to be in a nascent stage, but the possibilities that some of the BCT initiatives were ofering was promising: I think in the voluntary sector, and I think at community level, there’s a lot of resources that can be better utilised. So, there’s buildings, a lot of buildings that could be better utilised. And we are giving that. We are allowing people to share resources, share buildings, you know, share meeting spaces or main halls and so on, for nothing. And we give that for nothing, so it’s -- so we are giving stuf. (INT028) In some interventions, such as the MSK pathway, the intention was to utilise community resources, so that patients could be seen closer to home than the general hospital. However, practical issues and availability had led to what one participant described as a ‘hybrid’, whereby some clinics had been run in a health facility in Dalton, and others in Westmoreland General Hospital: We didn’t intend to run [the clinics] on a hospital site but that’s working well initially. Plan A was to use community facilities, and we’re still working on that as a next phase. We’re looking to introduce another ive clinics in the next inancial year, and we’re working on a couple of options. So yes, that’s a bit of a hybrid from the intended direction, it’s not quite turned out as we expected, really. (INT039) 110 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) It is important to note, though, that the ‘stuf’ referred to, though, is not just physical things, but knowledge, connections and relationships. I think people work with people and people that work in these very diicult communities, they know people, they know families, they know the hot spots, they know young people, they know local businesses. I mean they’re devalued in that really. They bring a lot of wealth and resources in that sense. (INT028) Also there was a desire to identify and share further resources towards their joint objectives, which built upon the work around identifying gaps in local health provision. We have used third sector a lot, and a lot of the time that is – not in place of Social Services, they still need that assessment – but sometimes it’s to sort of put something in in the meantime to make things a little bit easier. (INT044) I think it is about training and that awareness raising. We work [with], or we come across… ICC Practitioners, and these are Nurses that are working on the front-line in communities. And they quite often say, you know, “We’re a bit frustrated about what’s available in our community, and we’re frustrated about the referral pathway.” So, for example if they come across someone who needs to go on a food-related programme, on a diet programme or itness programme, you know, they want to know what’s available and how to make that referral. So, there’s a big need for them to have some kind of database, accessible database that they could -- even an app, maybe or something? You know, using technology far better than we are. (INT028) At the same time, there was recognition that more work on IG and technology was needed. For me, the barriers have been the information governance, the technology systems that have got absolutely no way of speaking to each other. You pull of system data on the same patient population, you’ll deinitely get two diferent answers. (INT061) One of the consequences of the programme delivery is the identiication of speciic gaps around IT and IG which have historically contributed to the architectural obstacles to integrated care. While this is a prominent problem reported by vanguard sites nationally, there are a number of localised solutions which participants have reported, including contracting staf on ‘honorary’ contracts at General Practices to assist with data access. In general, though, these were operational at local levels, rather than system-wide initiatives; and procedures for sharing data tended to vary according to the existing relationships between organisations. While there has been some progress in integrating IT and IG structures in the later half of 2017, these had not iltered through to the operational level of delivery at the point of data collection. The 2017/18 evaluation will explore some of the more recent developments around technology, particularly in relation to the Frailty pathway and its links with the Third Sector. A number of participants noted the relationship between successful pilots and interventions and the use of existing assets within a community. We were asking for an additional clinic a week, on top of local physio work plans. … The level of experience and knowledge and qualiication was exceptional. Two of the 14 have got PhDs in physiotherapy. Several were MSc. It was quite surprising in a way. I don’t think we’d realised the extent of the potential locally, which is untapped. That was from the three local providers, Cumbria Partnership, Lancashire North and Morecambe Bay Hospitals. So, that was really quite pleasing, that there’s a huge range of people who have obviously invested a lot of their own time in developing skills which weren’t being utilised. (INT039) I think what speciically also helped Ophthalmology is that with Optometrists, we already had a big cohort of community providers as our capacity available, which probably made it a bit easier for Ophthalmology than it will be for some of the other specialties, because they will be relying a lot more on already overstretched workforce in their area. (INT030) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 111 Health and Social Care Evaluations (HASCE) There was seen to be a positive use of higher-level skills that Optometrists had been trained in but hadn’t been using in their practices making their work more interesting and therefore them more likely to engage. Out in the Optical practise, Optometrists have their core contract, which allows them to do sight testing and provide services. Beyond that they have to refer in. So, if they identify an abnormality, they refer on to another level of care. Actually, that’s very frustrating for Optometrists, because they’ve got the skillset and they’ve got the equipment to do much, much more, but they haven’t got the contract in place to deliver that. What we’re allowing community Optometrists to do is to work within their core competencies, but do more for their patients. Once they’ve identiied there’s a problem, there is a lot more they can do to manage their own patients and do it very promptly. So, there’s a lot of job satisfaction comes from that. (INT042) Health and Social Care Evaluations (HASCE) In this way, mechanisms which enabled shared understanding of individual roles and competencies between primary and secondary care (such as the introduction of the Professional Pathways in Primary Care for paediatric assessment) increase conidence in service provision in alternative settings, and engage with the view, consistent across North Lancashire and South Cumbria, that historical divides between these areas are major barriers to wider system integration. Capturing the outcomes of these interventions in a meaningful way, however, is not straightforward. Finally, one of the main resources to igure as an enabler for change was the goodwill of those involved. It became apparent both from interviews and PDSA reports that a large amount of work in BCT projects was being undertaken based on goodwill and extra hours put in by staf. There was a distinct theme within the data that suggested while this was a key enabling mechanism, it was also a inite resource. The main thing is the lack of -- my time is funded, but when the surgeries, or the ICC member Practices, none of their time is funded… it has to be an evening meeting, so it’s, a lot of it is done on goodwill from member Practices… they have no funded time to think outside the box and to plan and therefore it’s all done on goodwill. (INT050) I think it’s positive for the profession too, because Optometrists are trained to do lots of things that they don’t get to do very often, because the NHS won’t pay them for it, and customers aren’t used to paying for it. So, it ills in a nice gap. (INT035) When people have already been working well beyond their employed time and giving discretionary efort, and trying to lag up that there’s a problem for decades. It becomes very diicult for them to believe that the cavalry has actually arrived, that this is actually a solution…Because you’ve made do and mended for so long, that if there suddenly is resource, then people are suspicious of it. (INT024) The following quote illustrates how one participant links the issue of resource through some key ICC themes: upskilling, communication, care plans and the ultimate aim of keeping people out of hospital. …it’s more down to communication and informing them of pathways and ways of more clinical working. If they’ve got a Care Plan, they need to be following it. It’s that kind of upskilling in the fact that, “Look, you need to know about these things that are coming out and you need to be using them and these pathways to keep people at home.” And that’s our agenda, to try and treat people more in the community than them going to hospital… It’s just highlighting that we need to think about changing the way we work and communicating better. (INT053) On this note, some participants noted the diverse knock-on efects of limited resources; in the example they gave, isolated patients who aren’t on a bus route may miss appointments and become unduly frail, which is coupled with the wearing-down of goodwill among staf who get involved in a service only to see it end can lead to low morale and cynicism. One of the key things is transport… if someone has a medical condition… their driving license is revoked...It can have a massive impact…The other side of it, is the fact that the service is there and then six - twelve months later it’s not there anymore. And you’ve really pushed it and got people involved with it and it’s just disappeared really. It’s all down to money, isn’t it? (INT060) This was characterised by the educational opportunities that multi-disciplinary teams provided: There’s been a kind of shared, education…[with] the consultant understanding better what the primary care is able to do. But also, primary care picking up education from the consultant’s viewpoint as well. (INT001) The positives have deinitely been …the fact that we have upskilled ourselves… with mobility aids and equipment, which is something that we would never normally have got involved in…to a degree it prevents hospital admission, because sometimes it can be a vital piece of equipment because somebody has fallen when they get out of bed irst thing in the morning. It could be something as simple as a bed lever, to hold on to. (INT055) The process of shared education is associated with a wider culture change where the professionals are required to bridge the traditional divides in knowledge and approach between clinicians working in community settings, and those in acute settings. In the case of the Advice and Guidance project, for example: 7.4 Discussion and Summary The aim of this section of the evaluation was to identify changes in resource use and cost for the speciic interventions and evaluating the vanguard’s performance against its expectations. • There’s a kind of growing realisation by the consultants that actually GPs are approachable and…they can learn a lot from each other and…similarly with primary care. Over time… barriers have built up between secondary and primary care, it feels that those barriers are now starting to come down. (INT001). • I think the more we bring people together, the more they learn about each other’s role and each other’s expertise, the more conidence they have in each other…that the other has a good understanding of the necessary clinical provision that is required for their patients. (INT013) • One of the advantages, where you start to have two teams working close together is, the next step is to say, “Well actually, let’s have a bit of rotation in that team.” And that means that if one person in one team is ill…then you’ve got a bigger group of people that you can use to cover that gap. (INT022) 112 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard The main challenge in answering these questions for this evaluation has been that much of the new care model is very much in the developing stages, and the above questions make extensive assumptions about the availability of data that does not yet exist in an evaluable form. Therefore, as the design of interventions was still in progress, we could not inalise evaluation methods at this stage of the NCM’s delivery. Because the interventions being put in place target relatively small populations, identifying the appropriate data for capturing progress remains a major challenge. A preferable dataset would be at patient level, linked across all care sectors. It has proved extremely diicult, however, to obtain data on this level. Without this data, we have used intermediate data of overall hospital and outpatient activity to evaluate the potential inancial impact on the healthcare system. While these are a good indicator of overall performance of BCT as a whole and individual ICCs, the link between individual interventions and these metrics is tenuous and, as the target populations of the interventions are small, their efects might not be noticeable on the larger scale metrics. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 113 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 8 Outcomes Furthermore, it is clear that the igures presented within this economic analysis represent resource use and associated cost only, in other words, outputs. Due to data availability issues, however, we were not able to include cost inputs in the economic analysis, which would have to be applied on a much lower level of individual interventions and include data about changes in staing structures, processes and the associated cost implications. • • As the qualitative data has shown, there are further non-inancial inputs which amount to a resource cost: for example, the amount of extra hours put in by staf to deliver pilot interventions, and the dependency on ‘enthusiasm and goodwill’ which needs to be represented in order to accurately identify the full resource impact of the NCM. • • • Speciic data needs to be obtained for individual interventions on patient level. Input as well as output data should cover enough breadth to measure the impact of the intervention on a patient level. Negative outcomes Outcomes for patients and citizens Where secondary care data is aggregated, attempts should be made to it the aggregated data to the target population as closely as possible. Furthermore, appropriate baselines for input and output data have to be identiied on intervention level. Ideally, this baseline data will take account ofgeneral underlying trends, in order to enable meaningful before and aftercomparisons. The programme deliverers may want to consider mapping existing community assets, BCT investment and social care igures in order to follow through theimpact of their outputs and outcomes on the health economy as a whole. The generally negative views over the distribution of funding link to several aspects around the NCM. Certain themes, such as around the commissioning structures themselves, are embedded diferences between primary and acute care. Others, however, centre on the transparency of decision-making around funding, the communication of capacity issues to management and the tension between the freedomto develop new ideas at local levels, and a perceived lack of steer or support from middle management upwards. Conversely, far more positive themes all involved constructive dialogue between diferent organisations, or within organisations or activities. • Disengagement at key points Positive outcomes Where linked patient data is not available, secondary care episodes might be picked up in primary care systems, if such data is entered and correctly coded. The qualitative data raised an important question regarding the extent to which a return on investment, and the general efectiveness of a programme, will vary depending upon existing assets and skills within a team or area. Because interventions are currently working in very localised ways, this data is not being examined consistently. Someparticipants cite existing or untapped skills as vital to the success of an intervention. • Staf attrition Types of outcome • • Insuicient metrics Preventers Moving forward into the next phase of the evaluation, the following points could address the disparity between the requirements of the economic evaluation and the currentavailability of comparable data: 8.1 Thematic Overview Outcomes In some cases, a measure for this might be as basic as ‘time’. A straight forward way of beginning such a measure of the time taken to implement delivery would be to collate meeting minutes and take from these numbers/roles of attendees, hours taken, and positive outcomes which can be measured and tracked against project timelines (to demonstrate any diferences between time resources needed at the earlier and alter stages of the activity). Evaluation Question: What expected or unexpected impact is the vanguard having on patient outcomes and experience, the health of the local population and the way in which resources are used in the local health system e.g. equality? Changes in non-inancial resource uses were very apparent from participants’ interviews. This speaks to localised arrangements around what have been previously perceived to be systemic problems or gaps in service. 114 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard u Figure 54 Outcomes - Thematic Diagram As discussed in Chapter 6, there was a strong sense across a signiicant proportion of participants that deining outcomes for the NCM was problematic. This was due to four clear reasons: • • • • The timescale it is likely to take for meaningful change to occur was longer than the amount of time that had elapsed; While positive change had occurred, the metrics currently being used by BCT to report outcomes were not capturing more tangible changes on the ground; Structural issues were preventing outcomes from being achieved (e.g. staf attrition); There was a lack of a clear sense of what the outcomes should ‘look like’ in terms of wholesystem change. While the vanguard was supported by a logic model (see Figure 1), this was not referred to substantially by any participant during the course of the interviews. At the same time, other outcomes (such as the Triple Aims37) were referred to, which served to complicate the sense of what the end goal of the NCM should be. 37 See above, Chapter 1 Section 1.2 Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 115 Health and Social Care Evaluations (HASCE) The themes identiied in the qualitative data were therefore organised into two categories: on the one hand, preventers which occurred chronologically after the mechanisms of change had taken place, but were causing activities to stall or end; and on the other hand, the diferent types of outcome that participants perceived to be happening (or expected to happen in the near future). Schematically, the emergence of preventers feeds back into the contexts for future delivery, which introduces more disablers into the system of change. Conversely, the emergence of visible successes can contribute to enabling contexts (such as improvements in relevant areas of population health in an ICC). Health and Social Care Evaluations (HASCE) 8.2 Preventers Cultural change Longer-term change As might be expected, the themes from these two categories arise from the interlinking of a number of themes identiied earlier in the C-M-O template. This interlinking is important for understanding the nature of both successful outcomes and preventers. For example, a preventer such as ‘staf attrition’ is clearly linked to earlier contextual themes around the historical problems of recruitment in the Morecambe Bay area. However, this is not the whole story: participants also linked attrition to the short-term nature of the funding, the amount of support from leadership, the lack of visible progress and anxieties about the future development of the NCM which may not currently be clearly articulated. In short, while the historical problem of staf attrition may be outside of the reach of a vanguard site to address, some other aspects of this preventer are. Insuicient metrics Sense of improvement Understanding costs Turnaround of staf Non-replacement of staf Staf attrition Preventers Project-based working Short-term funding Lack of support Unconvinced by BCT Lack of visible progress Insuicient metrics Changes in strategy/focus Lack of clear view of the future Disengagement at key points Lack of capacity Not ‘around the table’ u Figure 55 Preventers - Thematic Diagram 116 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 117 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 8.2.1 Insuicient Metrics 8.2.2 Staf Attrition A common feature of participants’ comments on outcomes was the problem of how to record the kinds of changes taking place within the NCM. One of the most consistent contextual themes to emerge was the problem of staf attrition as a key context for delivery. Some areas within the Morecambe Bay footprint have historically struggled to recruit to posts; while other participants commented on the short-term nature of the NCM contracts impacting on morale, quality and consistency of care, cohesion and trust. There are simple measures like looking at the number of admissions, length of stay, all of those sorts of factors…But, I don't think they necessarily relect on how eiciently that bit of the health economy is working. The more diicult bit is how do you measure the beneit of teams working together? How do we measure that; how do we get there? (INT022) A lot of the things we're doing are culture changes. That's part of the issue. We're actually trying to do things diferently. And the problem is that – what the CCG like are numbers. So, they want, “This month, you’ve accepted less Paediatric patients than you did last month. Tell us why, tell us what you’re doing.” But it doesn’t work like that, you know. We’re talking about whole model change. (INT052) The quote above captures a clinician identifying a clash between the demand for statistics as evidence of change, versus the evolution of change which is responsive, adaptive, and less statistically evident. For some participants, the long-term efect of the mechanisms being introduced provided an aspirational set of outcomes: I think that the activities that are going to have the greatest value, for instance education, children, that sort of thing that’s going to change the way people view their health care and the health service, that’s going to have the biggest impact in the long-term. It’s going to be of greatest value, but it’s equally not something that we can evidence right now. (INT054) But for others, there were already tangible outcomes taking place which they felt were not able to be evidenced at this point. For example, a care coordinator comments: So my appointments are half an hour, so I’ve got time to sit and talk to people. So certainly, from a mental health perspective, I suspect that people get seen quicker, they get quicker treatment, they probably have better outcomes. I haven’t got any proof of that but I certainly know how many people I see and that it’s quite a lot of people. (INT051) Given the importance of this kind of evidence, however, there is a clear need to identify whether cultural change is occurring, what may accelerate it and what may block it. Otherwise, problems will emerge (as some participants noted) with activities getting steered of-course from the main BCT strategy, progress not being visible (leading to frustration and/or potential disengagement), and progress not open to challenge. In other cases, evidence is available, but the complexity of introducing eiciencies in inance and resource is more complicated, and involves a more nuanced approach to metrics: I think it [BCT] is a more eicient way of working, I’m not sure that we’ve seen any cost beneit yet. We’ve seen reductions in non-elective admissions but that doesn’t mean to say we’ve been able to really take the costs out. In order to take the costs out, you’ve got to close wards or clinics or whatever, and we haven’t really been able to do that…because of the pressures on the system generally, and the backlogs that the Trust has got. (INT016) Despite investing a lot of money in these programmes, we haven’t got the staf. And recruitment is afecting everything that we want to do. (INT063) Case Managers have left, Nurses have left. You know, it’s been two years and they haven’t been replaced. And people have been quite nervous because the jobs have only been renewed for three months at a time […] And that’s why with the Case Management team across the county, so many people have actually left. (INT045) I’m one of the longest-serving members of staf here and I’ve only been here eighteen months. (INT057) When I irst started, I had a Case Manager and also a Band 5 Nurse. I’m a Band 4 so I’m non-clinical. I’m on my own. INTERVIEWER: The Case Manager? INTERVIEWEE: They left… [because of] Money and hours I think… she left after six months or so…. I had a Band 5 Nurse as well. She left. (INT049) At the moment, we are not a full team as such. There’s only me and my colleague, the care navigator. We haven’t had a Case Manager for well over a year now. That’s been a bit diicult… (INT044) Both clinicians and commissioners expressed concern about staf shortages and issues with recruitment and retention across the sector and its wide ranging impact on the continuity of care. From the perspective of the programme delivery, vacant positions in key areas and reliance on temporary workforce was identiied as considerably inhibiting the implementation and progress of the BCT strategies. I think it’s probably because there’s not enough staf to do it [integrate primary and secondary care]. I don’t think there’s a feeling of resistance from people not wanting to do it. We tried it for a little bit, with one of the Advanced Nurse Practitioners from the community, but it only lasted some weeks, before someone went of sick in their team, and they had to revert back to doing what they were doing before. (INT023) Others linked this to the short-term nature of funding: Staf are in post and even though they like the role, they like the job and they’re doing a good job, because they are not sure about the future and what’s in it for them long-term, they look at other opportunities. And we’re losing them half-way through the inancial year… But then that leaves the ICC in a vulnerable position. (INT062) We’ve had several Project Managers, and that lack of continuity has not helped at all… it’s a long-term project, it’s a long-term aim, but the money is all short-term. … And also that doesn’t help with the work force, or with planning, or with what we might hope to achieve. (INT050) Or uncertainty about the project itself: I think because the service was quite new when the Case Managers were put in post, they didn’t quite know what the service was going to be and there’s been a lot of change. I think that’s probably quite hard to adapt to. (INT046) 118 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 119 Health and Social Care Evaluations (HASCE) There’s been some new role exploration, which I think we’ve done less well than we should have done and we’ve developed some new posts, where I don’t think we’ve put the support in to people… and we’ve had a level of attrition and a lack of attraction about some of those new job roles. So, I think we’ve not done that as well as we should have done. (INT058) I’ve been close to leaving myself. When you’re struggling with a juggernaut uphill, it can be quite a battle. (INT048) 8.2.3 Disengagement at Key Points One of the key preventers identiied in the data was disengagement from practitioners. As with staf attrition, this theme brought together a number of sub-themes; some outside of the reach of BCT in and of itself, and others more clearly related to the delivery of the programme. In Kendal, for example, there was scepticism in relation to the programme, being described as a part of the cyclical change noted within the NHS framed as attempt to ‘reinvent the wheel.’ Some participants from district nursing services saw no value of the NMC, describing it as a project- based initiative that will inish, and then be reintroduced under a diferent policy-driven initiative. These perceptions described the NHS in general (rather than the NCM speciically), and are likely to be similar to those themes described in Chapter 5 on contexts. They re-emerge at this point in the programme, however, if the mechanisms have not separated themselves enough from previous interventions. This is entirely possible, as the following quote suggests: I’ve seen a lot of changes and a lot of initiatives, but this is the biggest potential driver for change that I’ve ever seen. I’ve always maybe been a little cynical on some of the management changes that the NHS has come along with, but I see BCT and ICCs as the biggest opportunity that has ever been presented for a radical shift to the beneit of all. (INT050) Participant data analysis also evidences a wide-ranging disengagement with the programme in the strategic delivery of the NCM: slow progress, continuous changes to approach and service strategy contributes to wider disengagement from key operational processes. Here, staf lose motivation and interest in the programme when they “see the banners but disconnect with the substance”: Classically when you have a wide-ranging involvement of operational staf in strategic thinking, and then nothing much happens in the next six months, there’s a high potential for staf to feel demotivated and disengaged from strategic processes…I think…the slow progress, the emergent circumstances that have led to diferent approaches, diferent strategies in the course of the BCT strategy, has probably disconnected the work force from what it’s all there for…I’ve heard reports that when you go onto a ward or…a community team, and ask about the BCT business, not many people on the ground really know much about it. They know the banners, they’ve seen all the publicity, but they don’t know the substance of what BCT is all about. (INT008) As discussed above in Chapter 7, the availability of clinicians to contribute to strategic meetings was also a preventer for outcomes taking shape: Even people who are meant to be on the Steering Group and the OOH group don’t turn up for the meetings. So if they’re not turning up for the meetings, they’re not having input and… we don’t know what they’re doing back in a Clinical setting, as to …what actions they’re making with regards to the changes that we’re trying to make…People are overworked, there’s not the capacity there to do everything that we need to do. (INT008) Health and Social Care Evaluations (HASCE) I know in [the ICC], where I usually work, the District Nurses weren’t invited to the ICC meeting initially. I couldn’t understand that…That doesn’t give out a good message, does it? (INT003) This theme of having ‘the right people around the right table’ emerged in Workshop discussions as well. Participants from primary care, for example, often saw BCT as lacking clarity outside of hospital contexts. The hierarchical organisational structures and bureaucratic processes were seen to considerably inhibit innovation and motivation to introduce improvement at a delivery level. For example, General Practitioners may be able to implement changes in their own practice quickly, but aligning this with BCT means that: it’s got to go to a meeting, then it’s got to go to a second meeting, then it’s a full business case, then it’s a third meeting and still no decision comes out, they get very frustrated and very reluctant to take part. (INT020) The disengagement from the programme is not limited to individual actors within the system but includes entire sectors of health and social care provision. This involves withdrawal of Public Health and Social Care, identiied to be a signiicant threat to the whole -system integration and multidisciplinary working. This has been attributed to the funding cuts in the local authorities having a direct impact on the service capacity and capability. We haven’t got a joined-up system with them. And there are some things that both County Councils are facing. Reducing - cuts in their budgets, which…a real threat to what we’re trying to achieve. Because we need that multi-agency working. I suppose we’re trying to achieve system change, but if one of the elements of that system is actually being withdrawn at the same time - we don’t even know what cards are on the table properly, to move them around. (INT019) Disengagement and withdrawal has not been limited to management structures, although frontline practitioners have attributed resistance towards the programme to the lack of understanding of underlying evidence, risk aversion and selective engagement of community- based services across ICCs at the commencement of the programme. Most General Practice is really worried that what this [BCT] efectively means is an increase in their work load. So, some of them are very, shall we say, perturbed that …some of these changes mean their work load could increase with no extra resource. Some General Practices just seem to have heads in the sand and just, “Nothing to do with me, not interested. (INT022) A further negative outcome was the doubts about how much people in the other sectors understood about the BCT work and agenda. This in turn linked to the sense – often coming from primary and community care – that the strategic direction of BCT had been too hospital-focused to date. Thus, while successful work has been done in creating eiciencies from the hospital side, the knockon efect on the community is harder to realise at the current moment. Participants expressed considerable misgivings about the overall strategic direction, the lack of clarity of the vision of BCT, and the decision-making processes at work. What would be really useful would be for the more senior, the very senior management team, to make a true decision as to how we take this forward. (INT062) I think within the NHS, we do a lot of project work, and people come in and support a project, then the project comes to fruition and those people withdraw, and it’s not fully sustainable. Some elements maintain, others may drop of. So somehow you need to maintain somebody to lead, to make sure it’s thoroughly embedded. (INT006) In contrast, participants from primary care and district nursing attributed the disengagement from the programme among speciic groups in part to the engagement strategy at the leadership level. Participants reported marginalisation from access to information and a sense of resentment due to selective involvement of certain professional groups. 120 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 121 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 8.2 Types of Outcomes 8.2.1 Positive Outcomes Statistical evidence Visible progress Anecdotal evidence Positive outcomes Overcoming organisational barriers Appropriate care in appropriate place Improvement in quality of care Increased awareness of patient needs Negative outcomes In terms of reporting on visible progress in the quantitative data, this report will not reproduce the work done by the quarterly reporting metrics supplied by UHMBT Business Intelligence. This has shown a signiicant decline in non-elective admissions and non-elective bed days, as Chapter 7 discussed. Instead, the evaluators looked at the quantitative data available to look for how outcomes might be identiied that would demonstrate the efect of the qualitative causes discussed in Chapter 6. This involved analysing the data by ICC area, in order to identify any notable diferences in outcomes between sites. Some outcomes of this form of analysis have been shown in Chapter 7, in terms of cost reduction. Looking here at ED attendance totals, we can note that the highest scorers are, perhaps somewhat predictably, those with the highest populations (Bay, Lancaster City, and the two Barrow ICCs). Problems with scaling up u Figure 57 ED Attendances - Total Incidents by ICC, 2014-17 Outcomes Problems with sustainability The visible progress of BCT can be organised into two distinct areas. On the one hand, quantitative data should demonstrate the efects of the NCM after 12 months as a vanguard (although BCT has existed for several years before this). On the other hand, as noted above, much of the more incremental progress was typically anecdotal, and many of the changes made qualitative in the irst instance. Lack of direction Shared outcomes Community mobilisation Patient empowerment Self-care Outcomes for patients and citizens Improved communication Appropriate care in appropriate place Continuity of care Awareness of BCT u Figure 56 Outcomes - Thematic Diagram 122 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Total incidents alone, then, will relect some obvious disparities between ICC populations. For a comparison between ICC areas, the following igures are based on total numbers per 1000 population. Comparing ED Attendance by ICC areas in this way allows us to see if any area is showing a signiicant diference in relation to others, which would in turn enable the qualitative changes within each ICC to be represented as outcomes. For visual clarity, the charts have been broken down into South Cumbria and North Lancashire ICCs, and the chart begins in 2014 to roughly coincide with the beginning of Better Care Together (rather than October 2016, when the vanguard funding began). This is a comparative chart, to look for diferences in regions; this is not to be confused with total frequencies, which are (somewhat naturally) far higher in the more densely populated ICC areas. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 123 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) One observation to make on these igures is that in South Cumbria, frequencies seem to separate with some regularity across the ICCs, whereas, with the exception of Garstang, there seems to be no separation between the frequencies of ICCs in North Lancashire. There may be several reasons for this. 38 For example, the higher scoring ICCs in South Cumbria are closer to Furness General Hospital, which has an A&E department, while Westmoreland General Hospital in Kendal has an Urgent Care Centre. Due to the overlapping boundaries of the North Lancashire ICCs, meanwhile, the distance between an ICC and Royal Lancaster Inirmary’s A&E is less straightforward to separate, which could be relected in the frequencies. Garstang ICC is an outlier for all hospital-based metrics, most likely due to its proximity to the Royal Preston Hospital (outside of the BCT footprint). An alternative explanation for the diferences in frequencies may be the age demographic within each ICC. If we compare ED attendances between 2014 and 2017 by age, then there is a clear diference per 1000 population between the Barrow ICCs and East, Grange and Lakes and Kendal for the age groups of 10-29 and 80-90+; both of which are the highest ED attenders on average across the piece. In North Lancashire, meanwhile, the age groups are more evenly distributed across ICCs. u Figure 58 ED Attendance - S Cumbria ICCs per 1000 population u Figure 60 ED Attendance by Age – S Cumbria per 1000 population 38 Chapter Two has discussed some of the methodological problems with working back from high-level outcomes to localised causes; these are all relevant in this case. u Figure 59 ED Attendance - N Lancs ICCs per 1000 population 124 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 125 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) u Figure 61 ED Attendance by Age – N Lancs per 1000 population u Figure 63 Outpatients Appointments - N Lancs ICCs per 1000 population A more decisive pattern emerges when we apply the same per 1000 population comparison to Hospital Outpatient Appointments. Again, we use data from 2014 in order to contextualise the outcomes appearing after October 2016, and the addition of vanguard funding. Per 1000 population shows that there is no clear diference between the ICCs in terms of numbers of overall outpatient appointments, and remarkably similar trends. The only outlier here is, again, Garstang ICC. With the same comparison run for inappropriate outpatient appointments (new OP appointments with an outcome of discharge/discharge (treatment complete), the picture is decidedly less clear: u Figure 62 Outpatient Appointments - S Cumbria ICCs per 1000 population 126 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 127 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) When comparing outcomes across ICCs, it would seem that participants (in both interviews and the outcomes survey) were justiied in suggesting that it is too early to see visible change on a broader level. The main diferences between areas of Morecambe Bay can still be attributed to contextual factors outside of the BCT. A more nuanced examination of the data could be undertaken (e.g. breaking down outpatient attendance by speciality, and monitoring those within vanguard workstreams). There would remain problems with this approach, however, when triangulated with qualitative indings. Not all activities within workstreams have become operational, which would make discerning the efect of vanguard activities from non-vanguard activities diicult. A form of projection for when workstreams would expect to see efects would also help to provide a stronger sense of how the outcomes related to vanguard activities. For example, there is a notable drop in ED attendance immediately following the vanguard funding; but this would clearly be far too soon for funding to realistically take an efect on patient activity. As the ICCs continue to develop, a more sophisticated system of lagging individuals who are within the scope of speciic interventions and pathways may be possible. Given that the main changes at work in the NCM are fundamentally about integrated care, this would be a more reliable metric for measuring both the success of the programme and the beneit of investment. A more straightforward alignment between qualitative changes and quantitative frequencies can be seen around the theme of dialogue, which was discussed in Chapter 6. The Advice and Guidance system, for example, which allows GPs to communicate with Consultants in order to assess whether patients need to be referred to the hospital, is one BCT initiative which shows how such conversations can have a signiicant efect on hospital admissions. u Figure 64 Inappropriate OP appointments - S Cumbria per 1000 population u Figure 66 Advice and Guidance: Total Conversations BCT-wide u Figure 65 Inappropriate OP appointments - N Lancs per 1000 population 128 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 129 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Some progress was seen simply in terms of overcoming organisational barriers, and evidence of engagement of diferent care providers and multidisciplinary partnerships between healthcare professionals. This integration has been reported to lead to a more consistent approach with established communication channels and more joined-up service provision. In particular, the setting of clear and agreed goals was paramount to the success of these conversations: I think we’ve had a lot of successes, we’ve got really good involvement from both community services and from the Trust and from primary care, and we feel that we’re really starting to make progress now in those areas. So, we’re having a lot more joint clinical discussions between consultants and GPs and they’re actually now trying to work towards the same goals. (INT001) And in others, this was linked to successes in organisational culture change: It will be at least another ive or six years before we’ve got that buy-in how we want it. But, we’re starting to see the “I can do”, instead of “that’s not my job.” (INT063) Participants often struggled to identify evidence of incremental changes on the ground that would show the success of interventions. This was most diicult in those areas aiming at proactive care, rather than the re-adjustment of existing pathways. Nevertheless, the importance of seeing change – whether this was able to be mapped on to higher-level metrics or not – was crucial to the enthusiasm for the project: The positive is that despite all the meetings, you can actually see movement and the development of something really exciting. The ACS, the accountable care system, if we can get to that stage and align as a system, then that would be absolutely fabulous. (INT061) u Figure 67 Advice and Guidance: Total Outcomes BCT-wide The igures above detail the total incidents and outcomes for the system (total frequencies are shown because this initiative is separate to ICC-speciic work). ‘Outcomes’ here refers to patients that would have been referred to Outpatients but, following the Advice and Guidance conversation, were managed elsewhere. On the one hand, looking at these igures from 2014-2017 suggests a narrative whereby closer working between primary care and hospitals is resulting in a reduction in Outpatients appointments. But at the same time, it should also be noted that following a relatively steady progression between 2014 and 2016, the results are visibly more volatile across 2017 (in particular the second half of 2017, where outcomes deviate from conversations). As before, there are a number of possible reasons for this, and to attribute causality reliably to the NCM it would be necessary to test hypotheses of change, based on the qualitative themes and quantitative metrics, rather than draw irm conclusions from the outcome igures alone. If the higher level outcomes are still in development, in contrast a number of participants could identify tangible outcomes of the work of BCT, but also noted that success – in particular success in proactive care and improvements in self-care, which would take longer to take an efect on hospital attendance – was based on incremental, small-scale change. It’s been very successful in some parts, particularly where I’ve got to know a patient in my community that’s gone into hospital, if I know them really, really well then I can ring up and say, “I know that patient, that’s baseline for them, can they come home today?” And on a few occasions, that has happened, so I have made a diference in for a lot of things, particularly for things like Mental Health it’s been brilliant. With that we’ve - actually what we’ve been able to do with that, we’ve been able to focus on some of the non-attenders. (INT052) 130 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Receiving healthcare at the most appropriate settings supports system eiciency via reduction of unnecessary admissions and duplication of services was identiied as a key improvement in the quality of care, both in terms of improving patient low and healthcare outcomes. We should be beginning to achieve a reduction in people needing to go to hospital, for things that don’t need to be done in hospital…And I suppose linked to the only going to hospital when you need to, is an element of getting what you need sooner, and where you are. So hopefully not progressing, but getting a quicker response that actually meets the needs. (INT019). A number of staf involved in MDTs noted that the increase in communication formed the bedrock of improved quality of care for patients: There’s also been the Orthopaedic surgeons who have been working on the project -- actually it’s quite interesting - they’ve changed the way they’ve viewed management of MSK problems… And that has been a great result that we never envisaged happening. (INT029) I think also it’s empowered a lot of the physios, because even the physios not working as part of the team know that it’s happening. The fact that their colleagues are working and seeing patients who would otherwise be seeing Orthopaedic surgeons is empowering to them as professionals. Feeling that what they do really makes a diference, which I think is excellent. (INT029) As has often been the case, due to the early stages of the some of the projects, the perception of improvement was balanced between evidence and expectation. Other participants raised the issue of how scalable some of the initiatives were (see below, 8.3), and there was a clear sense that in some areas MDTs had been far more diicult to set up than others, due to factors described above in Chapter 6. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 131 Health and Social Care Evaluations (HASCE) As the quantitative metrics above show, there has been a signiicant decline in non-elective bed days and non-elective admissions. While it is not possible, on the current data, to suggest a irm cause for these reductions, participants in primary care did note that mechanisms introduced by BCT were contributing to a wider range of possible outcomes for patients other than visiting the hospital. Well I would say we certainly have more options now, rather than admitting people. There are some other…provider teams…where you have access to a physiotherapist or an occupational therapist…The majority of the time they [older patients] were getting admitted for social reasons, because they were unstable, with nobody to care for them. Now you have other things that can step in and do that. And that’s part of us working together. (INT025) This corresponded to an increased awareness of patient needs: something enhanced by the success of MDTs and bringing in diferent professional viewpoints. 8.2.2 Negative Outcomes At the same time, the signiicance of the impact was not always guaranteed. In one workstream, the outcomes of the project were framed in terms of lack of anticipated outputs and impacts: observed changes were small in magnitude with no signiicant impact on the wider system transformation. The lack of wider impact of the programme was directly attributed to dysfunctional leadership. So I think there will be a few patients who will have had slightly quicker appointments, there will be a few patients who’ve had some interventions done slightly more quickly than they would have done, but I don’t actually think there’s a huge, wholescale change in the delivery of Cardiology services in Morecambe Bay. That’s not to say there couldn’t be, and I think if it was under a diferent guise, and a diferent way of framing the work, I think it could be diferent. (INT020) This theme linked to others raised around the project-based nature of the NCM. This raised a tension between the delivery of small-scale pilots, and the possibility of developing them into long-term sustainable and system-wide changes. One participant, for example, argued that the current developments remain largely vulnerable owing to the fact that they are still being seen as timelimited schemes as opposed to new approach to practice. There are quite a number of projects, that have been started and have been quite successful, but the question is: how do we scale those up so it becomes the norm across the whole of Morecambe Bay?...And they’re still seen as projects, rather than a new way of working. …I think there has been some progress… [But] whether that is sustainable is another matter. (INT018) As discussed above in Chapter 6, the principles of the NCM is present in much of the data; but the lack of milestone markers from beginning to an end can be a disabling factor in monitoring progress, and ensuring that initiatives produce outcomes within a given timeframe. What I think have probably let it down [is] the sense that, a nice piece of work would have a beginning, a middle and an end, and it does feel a bit headless, at the moment. (INT008) In this sense, the vanguard interventions remain localised solutions which struggle to be scaled up without further investment. ICCs pose a particular challenge, in this sense, because on the one hand the lack of direction associated with a ‘bottom-up’ approach is intentional and consistent with population focused care; yet, this kind of operational lexibility adds to complexity of the programme implementation, delivery and the sharing of good practice. Hence, one participant commented: 132 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) it needs to be more centrally coordinated […because] there was a disparity between [the two CCGs and the two OOH work streams] that they were two completely separate organisations going completely separate ways, with the hospital Trust in the middle trying to meet the needs of both, and potentially failing in all avenues. Then the various work streams that cross-cut everything and it just seemed to be a bit messy. (INT006) 8.2.3 Outcomes for Patients and Citizens Outcomes for patients emerged as a key theme within the staf interviews. It was not clear from the interview data how much evidence was being collected systematically by staf on patient responses to the interventions. In some cases, the improvements in patient care were assumed with reasonable justiication. In other cases, such as Opthalmology and some Paediatric interventions, initial patient feedback was from follow up phone-calls to patients by the co-ordinator. The responses from these (some of which are documented in PDSAs) are generally positive; although there does not appear to be a consistent approach to garnering patient feedback. Alongside staf views of what outcomes were, or would, be happening with patients and citizens, the evaluators held focus groups with patient groups. These focus groups were purposively sampled to relect the focus of the 2017/18 evaluation work. As such, they came from the three geographical areas that will form the focus of the 2017/18 evaluation (Barrow, Bay and East ICCs), and/or groups which would potentially be afected by the pathways under examination (respiratory, paediatric and frailty). While this resulted in a wide range of participants, there were some surprisingly consistent themes to emerge in response to the mechanism and outcome themes that staf and other stakeholders raised. The emerging themes are organised below. Patient Expectations, and Expectations of Patients Understanding patient expectations (in as localised a context as possible) is key to demonstrating the success of BCT. Patient expectations may well not necessarily coincide with clinical views. Alongside this, a condition of the longer-term success of BCT is the empowerment of patients and mobilisation of community resources (although, as discussed briely in Chapter 2, the role of this mobilisation is not always tracked in a theory of change). In general, both service deliverers and patients shared similar expectations about the outcomes of BCT initiatives. The fact that patients were seen closer to home and there were timely appointments, for example, were considered good outcomes by staf: In Millom we’re using telehealth, so they’re not having to do that really tough 50-minute journey on a bouncy road with one way in and one way out. (INT061) From a patient experience perspective, they don’t have to travel. As you know, we are a community quite wide reaching geographically, and that has its own challenges, which means that actually in reality, a patient can be seen in the high street down the road, rather than travelling to one of three hospital sites, in order to be seen and treated and to be sure that everything is okay. So from a patient experience perspective, I would say that’s a success. (INT041) They don’t have to travel to hospital and wait for hours to see a Consultant to have something minor dealt with. (INT035) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 133 Health and Social Care Evaluations (HASCE) The patient focus groups conducted tended to agree that while being treated out of hospital was preferable to inside, the time taken to wait for an appointment was a signiicant issue, and a recurrent cause of frustration. Some participants identiied being sent to diferent hospitals across the Morecambe Bay area, which could have costly travel implications. Others noted that travel had become a problem since General Practices merged and services were redistributed. PARTICIPANT 29: It’s getting an appointment at the right surgery. You’re by your house, where there’s a surgery and then all of a sudden, they’re all intermingled and they want to send you up to Heysham when I live at [redacted – 2.8 miles away]. It’s either two taxis there and back, two buses, because it’s too far to go on my scooter. They wanted to send me up to Heysham and I refused. This, in itself, is a separate causal factor from the NCM. But at the same time, in some cases key terms for the NCM, such as ‘integration of care’, were interpreted by patients as introducing unnecessary travel rather than reducing it, because the phrase was associated with the number of recent mergers of GP practices (this theme was also picked up in the Outcomes Survey – see Appendix Six). When asked what changes they had seen in local health provision, one participant noted: PARTICIPANT 16: Yes, they’ve all merged and we’ve got this massive conglomeration of doctors now, so I’ve heard of people having to go through to Lancaster [from Morecambe]. I’m taking my son this afternoon, I’m having to go to [redacted]. I’ve never been to that -- you know, it’s not far, it’s just having to go to a diferent place every time. That’s a big change. PARTICIPANT 9: Well it has seemed that I’ve been sent to more diferent places this last year. It’s becoming more of a thing. I was at Lancaster hospital myself, and there were a couple who’d come from Kendal and it had cost them £47 in a taxi. Then obviously they’ve got to go back, so it would cost them £100 to visit the hospital. In this sense, the ambition of patients being seen at appropriate times and in appropriate places was placed within a disabling context of service reorganisation. At the same time, patients with more complex needs also expressed a consistent willingness to travel out of area to address their care needs, suggesting that travel was not necessarily the biggest concern; whereas appropriate care was: PARTICIPANT 11: I go to Preston hospital quite a lot, under the care of a neuro-surgeon and I can honestly say I have waited at the longest 15 minutes in the past ive years… I really think that because it’s another teaching hospital and it’s out of our area, it comes under another body, doesn’t it? PARTICIPANT 7: My friend chose to go to Liverpool, or somewhere. Then you’ve got to get there, which can be traumatic sometimes, but you go to the best place for what you’ve got ailing you, perhaps. Patient Empowerment and Community Mobilisation A key reason that a more systematic, ongoing evaluation of patient views is an important issue for understanding what ‘works’ in the NCM is that one of the guiding principles of the vanguard site involves moving towards a more empowered and educated public. In line with the move towards a whole-person approach to care, with a focus on localised, population-based delivery, many participants raised the theme of patient empowerment. I think the patients really appreciate it. I think they’re made to feel individual and special and listened to… whereas if you come and see a Doctor, it is just about your medical problem. You get ten minutes, you know. When you go and talk to them, they can tell you everything that’s going on... (INT047) 134 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) I think more than anything it is empowering the patient. A lot of the patients didn’t know that this service was out there… some patients are just so relieved... “If I’m struggling, I know who to ring now.” And just me actually leaving that card, gives that person, the patient, the empowerment just to be able to contact us whenever they’re struggling. (INT045) This point about having a clear point of contact was also picked up in patient focus groups, with varying results: INTERVIEWER: It’s just getting to that point [of a single point of contact]? PARTICIPANT 9: It’s getting to that point, yes. Since then, I actually had somebody phone me yesterday and he said that my point of contact was going to be him. If ever I was worried about anything… it’s him I would speak to. That’s good... That you have got that contact with somebody who knows what’s going on. PARTICIPANT 17: There’s no continuity of care again. It puts you of ringing up, because you never know what time to ring up for an appointment, you never know what number to ring up for an appointment. You don’t know where you’re going to get sent. Patient empowerment, however, is complicated. Often, participants tended to group ‘informing the public’ with ‘empowering the public’. Educating the public about self-care, for example, is not identical to co-production of care; and this became a grey area in much of the data (see Chapter 6, Section 6.4). Conversely, the two comments above from care coordinators could well relect an improved service provision (which would link to the identiication of gaps within the system) and, a shift to a more social model of wellbeing. Conversely, the participants from self-help groups identiied these as key enablers of improving their health; one participant noted that they had had a COPD appointment rescheduled for the same date as their self-help group, and chose the group over the clinic. The consensus from all the focus groups indicated that community assets are important in meeting needs and these can address isolation, frailty and low mood; community groups/centres provide a focal point for support, these assets help foster friendship and can provide signposting to key resources. As one participant noted of their particular group “It’s like AA for breathing.” (PARTICIPANT 9) While the forms of care that the groups facilitated – very much in keeping with the broader understanding of wellbeing discussed in Chapter 6, Section 6.4 – were identiied as crucial to improving self-care: PARTICIPANT 2: …it’s isolating. When you’re ill, you can’t get out. PARTICIPANT 38: I live in a ground loor lat and last week I was struggling from walking from the bedroom to the kitchen. Because I lean forward, if I’m struggling to breathe I put my hands on something and I lean forward. It does seem to get my breath regulated. But there’s no one you can phone up when you’re feeling like that. It became apparent in several focus groups that support and information-sharing was perceived to be taking place in spite of some health services, rather than alongside it. In some cases, particularly around areas of mental health, gaps in services relating to aftercare, support and diagnosis had left patients isolated: PARTICIPANT 21: That’s when we get left to Google. Whereas a more common narrative across the focus groups was based on community assets: PARTICIPANT 14: Just go on Facebook and ask other parents that we know through the support groups that we mentioned before. That seems like the easiest option, then they give you advice and you take it from there. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 135 Health and Social Care Evaluations (HASCE) PARTICIPANT 15: I feel that the support I’ve been given is by charity organisations. … It was the charity organisation that helped me [redacted: with aspect of child’s condition]. Whereas that should have been the Consultant’s job. PARTICIPANT 15: There’s networking as well that goes on through schools, with your children. They go to similar schools and have similar diiculties. You’ve networked from there and then other parents have opened you up to other places, organisations that can help. INTERVIEWER: Yes, but I’m getting a sense that it’s very much removed from the healthcare system. It sounds like it’s – PARTICIPANT 17: They look after themselves. PARTICIPANT 16: They fend for themselves or network through friends and charities and the other community support, but the healthcare tends not to be joined up with all that. PARTICIPANT 15: I’m learning about it myself and I’ve had to go to charity organisations to learn about it and other parents who have a child with that same condition and I’m having to tell the health professionals about it when I’m still learning myself. I just got a diagnosis. There, he’s got that. Although some groups identiied clearer links: PARTICIPANT 2: We get speakers, sometimes from the hospital, the respiratory Nurse and the therapist. Even the Consultant on occasion. It is worth bearing in mind at this point that these groups were purposively sampled, but had not necessarily had direct contact with BCT initiatives. As such, these comments are not necessarily representative of the patient population. Rather, in terms of the delivery of BCT, these themes raise two speciic issues. Firstly, they conirm what a number of initiatives have already pointed towards regarding the need for better sharing of information and expertise to support citizens outside of clinical settings, and promote a broader understanding of wellbeing. Secondly, they suggest that this is not currently perceived to be happening, even if the ethos of BCT initiatives are resonating with patient concerns. PARTICIPANT 16: I don’t think a lot of doctors know, even though they’ve been to university and they’ve done their thing, I still think a lot of health professionals are uneducated about learning diiculties, autism, everything. It just seems to be like you’re having to educate a Doctor. PARTICIPANT 1: They admit to you, we’ll try this and then we’ll try that. Surely, they can go to somebody that is more experienced [in respiratory] than them and get a bit of advice. It is worth noting again at this point that these participants had not necessarily been part of speciic BCT pathways; in the 2017/18 evaluation, where patients who have been through BCT pathways will be interviewed, this will provide the potential for a clear comparison between the two groups. Communication and Time One of the main themes revolved around communication and the time available for clinicians to engage with patients. PARTICIPANT 8: I think that if you are listened to is really important. Especially for your irst consultation. PARTICIPANT 2: Enough time as well, to explain what your problems are, without being shoved out of the door. PARTICIPANT 5: I think just having time, not making you feel as if -- letting me say what I want to say. PARTICIPANT 24: …they don’t always listen to the patient. They think they know what’s best and they don’t know what’s best for that particular patient. 136 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Where participants had positive stories to tell about the services they had received, time and communication were crucial aspects of their experience: PARTICIPANT 6: All I’ve had has been good. I had a [respiratory] lare up once and the Doctor came the next day. He sat with me for ages and I said about dialling the numbers, you know. You can’t think straight when you’re trying to breathe, can you? He said, don’t bother about it, just dial 999. So, the next time I had one, I dialled 999 and the woman at the end was brilliant, because I couldn’t speak and I was just gasping, and she seemed to know what I meant, what I was saying. They must have been just around the corner, because within minutes they were there. That was brilliant. I can’t say anything detrimental. They were brilliant. Perhaps the largest frustration to emerge was with the time taken to get appointments: PARTICIPANT 3: Also, not waiting too long for your appointment [would be an improvement]. That’s another big thing, because it can work you up. INTERVIEWER: Have any of you noticed any changes in the way your care is being provided over the last year, or maybe over the last eighteen months? PARTICIPANT 41: Well I can’t make appointments. I can’t get appointments. (Sound of general agreement across the group) Some participants noted that the diiculty in getting seen in clinical settings could lead to being ‘put of’ trying. Instead, other services were utilised, such as pharmacists. PARTICIPANT 15: I feel reluctant to go, as well. Sometimes I will go to the chemist and just get what I need from the chemist and try that irst and try and put of going to the doctors, because you can’t get an appointment. In this sense, the work being done within the NCM to create more alternative or midpoint services, and address gaps in service provision which address patient-centred care, would seem to resonate with the concerns raised by the patient focus groups. There remains something of a communication gap, for these participants at least, between the move to a broader approach to health delivery (whereby visiting the chemist may well be more appropriate than visiting the GP), and the perception of a health system working against, rather than for, the patient. This theme is picked up below, under ‘Awareness of BCT.’ Continuity of Care Continuity of care was a consistent theme of concern throughout the focus groups. Frustration at the lack of consistency with care received underlay a number of pertinent issues for participants, including: having to see diferent doctors on each visit; having to repeatedly provide verbal account of health history or child’s disability; confusion about procedure for making appointments. This leads to stress, wasted time in the consultation and despondency with health services. Lack of aftercare after diagnosis of a mental health disorder also emerged as a highly emotive issue. Participants expressed the need to feel understood and cared for as a whole person. PARTICIPANT 27: You’re not a patient now. … INTERVIEWER: What do you mean, that you’re not a patient? PARTICIPANT 27: Well, you’re only a number, aren’t you? You don’t have the continuity of anything. You just go, and I don’t seem to be able to get anywhere. PARTICIPANT 26: You want your family Doctor back again. The idea of wanting ‘your family doctor back again’ was expressed by older participants; but while focus groups around paediatrics also expressed a need for a single point of contact, a number raised issues around the GP role, and the appropriateness of a generalist dealing with complex conditions. In some cases, this could lead to frustration: Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 137 Health and Social Care Evaluations (HASCE) PARTICIPANT 13: It’s like they [GPs] don’t listen to you either. You tell them and then they just sort of ignore you, and tell you what they wanted to tell you, rather than listening to what you’ve got to say to them. The need for a single point of contact was not, then, necessarily about returning to the model of a ‘family doctor’, but rather about enabling the quickest line of communication between patient and clinician as possible. This was supported by the widespread dissatisfaction from participants around having to recount their medical history at successive appointments; hence, continuity of care and seeing a clinician who knows their history was valued by some participants as a way of reducing anxiety. PARTICIPANT 27: You could get fobbed of with the locum, who doesn’t know any information about you. You’ve got to sit there and tell him everything. Whereas when you can go to see your own Doctor, he knows everything about you. You don’t have to keep going through it all. On this note, some questioned why patients’ records are not comprehensive – particularly when they are seeing more than one consultant or care provider; this raised queries about why IT does not enable a holistic recording of a patient’s care. The NHS has worked in silos, hence, services are not joined-up; an issue that BCT is attempting to redress but seems some way of iltering through to patient experience. PARTICIPANT 31: Does it not come up on their computer screen, because every time you go, they say, “What’s the matter?”, and I’m thinking, well look at your damn computer. …They don’t seem to know and you’ve got to explain it. I think, well why am I explaining when it should be there? PARTICIPANT 6: You walk in, they’ve got all your notes in front of them and then they ask you, when was the last time you had this test, when was the last time – as you say, we don’t have long in that appointment, and we’re recounting what they should already know. PARTICIPANT 1: I think one of the other things is, because when you go to see your GP, or possibly when you go to a Specialist clinic, it’s very rarely that they have your medical history… That’s ine if you’re quite young with it, but if you are an older person, you don’t -you’re stressed and you possibly don’t think of [aspects of your medical history]. PARTICIPANT 24: You have to explain everything to each person that you see. You have to go through it over and over and over again. If they read about you before you got to the appointment, you wouldn’t have to keep doing it. PARTICIPANT 6: Once you’ve got complex health needs, you need to see the same person, don’t you? Or you’ve got to go through the whole scenario with every doctor. PARTICIPANT 3: It’s the time on it as well, I like to see a doctor who listens to me, so that I could get all of it out. A single point of contact, and access to medical records, were seen by many focus group participants as key to managing complex and long-term conditions such as respiratory problems. Across the focus groups, participants showed an awareness that changes were taking place in Morecambe Bay to improve the situation, but the perception was that this was inconsistent: PARTICIPANT 1: Now, with this Better Care Together computer system, let’s face it, everything should be at the touch of a button. PARTICIPANT 33: I think people who’ve got a condition like ours should have an allocated Doctor and see the same Doctor all the time. I know it’s not going to happen but… PARTICIPANT 1: They should have and be able to access our complete medical record, to be able to see what our complete medical history is. PARTICIPANT 2: That’s what they’re working towards. And it is like that sometimes but not always. 138 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Likewise, participants across the focus groups expressed an enthusiasm for diferent services speaking to each other more, but did not report visible changes: PARTICIPANT 22: They don’t communicate with each other at all. At all. PARTICPANT 14: They don’t seem to have any information about your child and if they communicated with each other, they would know what you were going in for. You have to go to the doctors and then you get sent to hospital and you just have to explain it over and over again to ive or six diferent people. …By the time you’ve explained it ive or six times, you could have gone in straight away rather than waiting and explaining to someone else. Much of the concerns around the continuity of care regarded communication, both within primary care and between primary and acute care: PARTICIPANT 17: I’ve just had a medical procedure done, literally within the past few weeks. The hospital knew this appointment was coming up. My GP knew the hospital appointment was coming up, I knew the hospital appointment – I had made everybody aware of certain things that are in my background that are very valid and relevant to this appointment, that were very relevant. Yet, when I arrived at the appointment, the people that needed to know that information did not know that information. I had to tell them it there, face to face, again. It was embarrassing and I felt uncomfortable, I felt upset. Speciic Roles and Gaps in Services While patient groups discussed more ‘traditional’ roles of health delivery – surgeons, GPs, and so on – a number of discussions focused on the roles which sat at intermediate points between the community and the hospital. These did not map directly on to the pathways that this evaluation had examined (e.g. care coordinators, community physios), but a role which was recurrently highlighted positively was the pharmacist: PARTICIPANT 18: I do think that prescriptions have improved though. The fact that it’s always there at the chemist when you want it. You don’t have to really do a great deal. You don’t have to see the paper version anymore, do you? The participants reported success with using a pharmacist who could assess their needs and give advice and, in some cases, prescribe medication for them. There also seemed to be a sense of empowerment attached to this, in that the individual was able to access expert care themselves without going through the GP. The pharmacist can also take an overview of a patient’s medicine use and lag-up interactions between prescribed drugs; there were suggestions that GPs did not always spot this risk. Those with co-morbidities and polypharmacy usage can beneit from a review of their medicines and any drug interactions that could be harmful. This would ensure people gain maximum beneit with minimal harm and waste. 39 Other roles were discussed less positively, with concerns around empathy, expertise and communication raised around non-clinical roles: PARTICIPANT 3: I object to the receptionist asking you what the problem is… Not in a public area. Everyone is in the public area; everyone can hear the conversations. PARTICIPANT 7: I’m not happy to discuss my complications. PARTICIPANT 3: She wouldn’t know what to say as a reply anyway.’ PARTICIPANT 5: They ask too many questions. PARTICIPANT 1: [the receptionist phoned regarding concerns over the participant’s son having a high incidence of injuries due to playing sports] I was thinking the receptionist shouldn’t be discussing this with me, on the phone. I was absolutely furious. I don’t really don’t think she should have had access to that information at all. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 139 Health and Social Care Evaluations (HASCE) It is important to note that this theme is of interest, not because of the comments on receptionists per se, but rather how many of the tensions reported arose from communication issues, and a lack of explanation as to why or how interactions at earlier points may help to speed up appointments and treatments later on. While these responses allude to experiences of primary and acute care in general, there are implications for the ways in which BCT directs care to out of hospital areas, and how communication is handled in the process (particularly when citizens may be directed away from doctors). For example, in the shifting of clinics from the hospital to optometrists, a clinician raised the fact that a small number patients had raised natural concerns: There’s been a bit of uncertainty from some patients, saying how do they know the service is really as good. They’re so used to having to come to the hospital and wonder, “Why can’t I do that anymore? I trust them.” (INT030) Awareness of BCT A small number of participants could explicitly identify BCT, and those that could spoke positively about it (although for diferent reasons – some linked it to the ‘computer system’, others to an event where over-60s were surveyed). It became apparent that participants were experiencing at least components of BCT, but without necessarily realising. In some cases, such as the Walney Cottage community centre, the group had begun locally, but had since been incorporated into BCT. As such, some participants could identify the changes, at least in their intention: PARTICIPANT 3: It’s easier access to other services and pointing you in the right direction. PARTICIPANT 8: Like the doctors suggesting I came here [to the self-help group]? INTERVIEWER: Yes. PARTICIPANT 4: I think it’s a very nice place to drop into, as well. PARTICIPANT 8: You wouldn’t want to take a tablet, but the meditation and things like that help, it does a similar sort of job, in a way. Whereas others had experienced a move to out of hospital care, without identifying it as a systematic change: Health and Social Care Evaluations (HASCE) However, there remained a large number who viewed the lessening of referrals to hospital, and the subsequent perception of a decline of input from consultants, as part of a broader frustration and, in some cases, despondency with healthcare services, whereby participants felt that they had to take the lead with their own, or their children’s, healthcare. Indeed, one focus group was unanimous in agreeing that they had seen ‘deinite’ changes in local health delivery recently, but identiied this entirely in terms of the shutting down of a local service. Improved patient education would help support the changes BCT is implementing (as has been noted by staf during interviews), for example: clearer explanations to patients about why speaking to a receptionist, or telephone triage with a healthcare professional, are eicient means of managing time and resources. Education would also help some patients understand why they are being referred to an exercise or other support group as a means to address isolation, lack of exercise, poor diet, low mood. Patients attributed preventers to better care as the poor reputation of some hospitals (for example: ‘they won’t do it [operate on son]. I don’t know whether that’s because [Furness Hospital] were on special measures with kids and operations, but they won’t do it’ (Participant 1)); geographical isolation, and the problem of recruitment and attrition: PARTICIPANT 6: But the hospital said to me that they’re having a struggle getting the Specialists to actually come within borough, the people that they want. PARTICIPANT 1: It’s got such a bad reputation. PARTICIPANT 6: In Barrow, because it hasn’t got the theatre, it hasn’t got all this. They want to be somewhere near a big city. PARTICIPANT 4: Where it’s modern. PARTICIPANT 3: Newly qualiied doctors, they have to ofer them incentives to come here… PARTICIPANT 8: We’re having to go out of town for a lot of things now, because they haven’t got anybody here. How do you make it more attractive to people? PARTICIPANT 6: It might just be the geography of where Barrow is, as well. PARTICIPANT 8: It is, yes. Everybody seems to say it’s the back of beyond. It isn’t now you’ve got the roads. PARTICIPANT 3: With Lancaster being my nearest hospital, I still thought I’d see a Consultant every now and again there, but no, I don’t see any apart from my Doctor and COPD Nurse, unless obviously my chest is bad, I don’t see anyone at Lancaster [Royal Lancaster Inirmary] now… INTERVIEWER: Have any of you been given any sort of information sheets about new ways of working, or maybe seeing a Specialist Nurse instead of a Consultant? Have any of you been aware of anything like that? ALL: No. As noted above in the discussion of community mobilisation, participants were enthusiastic about the community assets they were part of. Some identiied this as a key change in the way they viewed their own health. PARTICIPANT 7: If somebody had said to me this time last year, you’ll be going to meditation, you’re going to do this and you’re going to do that, well I would just think I would be the last person in the world to say that I’ve sat there and done meditation, but I thoroughly enjoy it. PARTICIPANT 6: It’s lovely, isn’t it? PARTICIPANT 7: It’s fantastic, I love it. … PARTICIPANT 1: It’s brought us all together. We’ve all got new friends and a nice little group. 39 https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation 140 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 141 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 9 Active Ingredients of a New Care Model 8.3 Discussion and Summary As noted in Chapter 2, Chapter 7, and the quarterly reports to the NCMT, there have been changes to high-level metrics since the introduction of vanguard funding, particularly around non-elective bed-days and non-elective admissions. However, it is not possible at the current stage to link these in a methodologically sound way to the changes which BCT has implemented. As such, these changes are correlative, but more work is needed to understand why these particular metrics are showing these patterns, in terms of mapping out the interventions which have contributed to it. • • This work would be chiely around mapping outputs from speciic interventions in a clear and systematic way at the planning stage of delivery. This would allow more localised measures (whether quantitative or qualitative) to scafold up to the higherlevel outcomes, and visible change to become apparent earlier within the NCM delivery. Many outcomes were reported anecdotally. However, while in some cases this is unavoidable (for example, ad hoc patient feedback on a service), in other cases there are more detailed and locally nuanced themes which could be introduced, which provides deliverers with an ongoing evaluation of their work, and commissioners a stronger sense of what is working for who. It may be the case that the use of anecdote is due to insuicient recording techniques for the kinds of changes taking place (for example, the lack of clear evaluation criteria for qualitative change). The data suggests that localised successes are not currently being translated into whole-scale change. Given the variations in scale of many of the initiatives evaluated, and the low numbers of patients and citizens involved at this stage, this is perhaps not surprising. It is important to note, though, that many of the incremental changes which have been identiied by staf were also identiied by patient groups as either showing efects (the sense that being sent to a self-help group was preferable to ‘taking a tablet’, for example), or being areas where they felt the quality of their care could be improved (for example, improved IT systems). • This suggests that many of the qualitative themes around the changes the NCM has introduced have the potential to link up with patient expectations and improve the quality of care. These links must overcome the preventers currently in the delivery of the programme, however. While some preventers of positive outcomes link back to contexts outside of BCT (for example, the general level of staf attrition, the perception of areas of Morecambe Bay as ‘the back of beyond’, or time pressures on clinicians), other preventers are linked to the structure of its delivery. Participants highlighted several reasons for stakeholders becoming disengaged in the process of delivering the NCM; many of which were linked to the lack of clarity around outcomes, and, related to this a lack of visible progress. • • • This suggests that work on identifying more immediate and incremental outputs and outcomes of the NCM, coupled with a clear sense of how these relate to its larger-scale strategy, may well address many of the preventers which participants reported. It is also of note that the outcomes identiied in the data relect a number of outputs and outcomes on the 2016/17 BCT logic model. However, these are not systematic: the data collected and analysed does not identify a number of outputs and outcomes for Year 1-2, whereas some of the longer-term outcomes (3-5 years) are being mentioned. This suggests that the logic model is not featuring at the core of delivery. This may also be a signiicant factor for the number of participants who raised concerns about the structure, trajectory and overarching vision of the programme. 142 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Evaluation Question: What are the ‘active ingredients’ of a care model? Which aspects, if replicated elsewhere, can be expected to give similar results and what contextual factors are prerequisites for success? 9.1 Overview The ‘active ingredients’ of an NCM are not necessarily identiiable as contexts, mechanisms or outcomes by themselves. Instead, they appear thematically at various points across the whole spectrum of delivery. To respond to this question, then, the evaluators re-analysed the data for the most recurrent themes which appeared throughout participant’s responses, in order to identify the multi-faceted ways in which particular themes afected the success of the programme delivery. 9.2 Leadership Leadership is a theme which has emerged consistently, both implicitly and explicitly, throughout the data. There is a clear link between the perceived successes of the programme to date, and the importance of leadership at every level. As with other themes, the concept of leadership in a NCM is not straightforward, but rather arises from a matrix of interrelating concerns around strategic goals, expectations of particular models of leadership, and moves towards collective leadership models. Some of our ICCs have … got a bit of a shared model of leadership and not everybody’s looking to their door to tell them … to take the direction of travel and say, “This is what I would like you to do.” So, some of them are … much more: “Any of us can have a good idea and any of us can lead on this.” And others are a little bit more – using more traditional, kind of, hierarchy behaviours really. (INT058) We've been very well supported in the Trust, in terms of accepting that we should be left to get on with it to a degree, and not be handcufed by some of the traditional sort of things that might otherwise stop you. … So we've been supported in taking things forward in the way that we can see working. (INT023) In other cases, particularly clinical contexts, the importance of shared vision was paramount: We’ve got a good core of strong, kind of clinical leaders within the system, who all have that shared understanding and shared vision and I think that’s why we’ve been able to make the progress that we’ve made. (INT001) On the one hand, then, the model of leadership which forms a positive active ingredient to the programme is iterative, and context-dependent; as one project manager summarises: It’s a balance between keeping the energy and enthusiasm, but actually orienting people towards the fact that there’s something that we need that has to be delivered, really. (INT058) On the other hand, a common theme emerging across contexts suggests discrepancies between vision and strategy. For example, some participants from the Planned Care workstream discussed how a concentration on hospital appointments is not consistent with the wider assumptions of the programme. Participants from Self-Care projects raised their views that BCT held too much of ‘a medical model’ which was incongruent with the social and holistic activities needed to achieve the programme’s strategic aims: ‘Most of the things to do that do not sit within the NHS.’ (INT018) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 143 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) A strong picture to emerge from participants’ accounts was the notion that a top-down model of leadership was inappropriate for the changes being attempted. The problem which was noted most frequently was that participants perceived that the structure of traditional models of leadership remained (for example, around the distribution of funding), but – perhaps in order to facilitate a more localised set of responses to population-based health issues – the ‘leader’ was absent or unidentiiable. We see this most commonly in participants reporting a lack of support (this was, in places, also due to staf attrition rather than style of leadership), and in the Out of Hospital activities such as ICC development in particular. Where leadership was praised, meanwhile, it relected more of a collective leadership model. The exception was particular aspects of clinical leadership, which continued to relect a more traditional model of leader. The themes have been presented in this way here to highlight three points around the notion of leadership as an active ingredient: 1) While some participants discussed models of leadership in more detail (e.g. personalitytypes, speciic leadership structures, etc.), this could be construed as comments onmanagement, rather than leadership per se. Discussions on leadership in general focusedmore on the relationships rather than speciic ‘types’. 2) While the enabling mechanisms of leadership identiied by participants do present acertain ‘model’, what is notably absent on this list (and in the data overall) are strongexamples of overarching system-wide leadership. But, as discussed in Chapter 6, thefocus on incremental changes must be clearly related to a larger-scale model of changethat such increments can demonstrate an efect on. Otherwise, the gap betweenlocalised delivery and strategic change will remain. 3) It is also notable that while some of the disabling mechanisms are structural (e.g. theperception that change takes too long, due to the complexity of the NHS, or theperception that support was not being provided from further up the organisationalhierarchy), many of the themes of leadership revolve around issues of communication.Communication therefore forms the next active ingredient of the NCM. One participant from primary care suggested the current BCT leadership model was too far removed from the challenges and opportunities ‘on the ground’ and operating within complex bureaucratic processes that hinder meaningful change: I think what they need to do is to stop having so many new projects and people to manage projects. … What we need is much less political interference in what needs to be done. (INT025) The theme of leadership as an ‘active ingredient’ can be thematised in the following diagram, where the reported enabling aspects of leadership correspond with the reported disabling aspects: 9.3 Communication Enabling mechanisms Leadership Creating localised solutions to gaps in service delivery Multiple stakeholders involved in decisionmaking Disabling mechanisms Perception of a gulf between the ‘decisionmakers’ and service delivery Lack of transparency around decision-making processes Perception of ‘moving slowly’ ‘Try it and see’ Perceived lack of support at delivery level Small-scale incremental changes acheived The theme of communication emerged at every level of analysis, and good communication was a very clear ‘active ingredient’ for the delivery of the NCM. When we draw together all of the themes around communication from the interview data, it becomes clear that participants’ use of the term ‘communication’ is broad, and not limited to, say, a speciic communication strategy in the sense of publicity campaigns. Rather, communication is a multi-dimensional ingredient. As such, it is intrinsically connected to other aspects of the programme: in particular, leadership and the importance of relational working. As an active ingredient, the quality of communication will produce diferent efects depending on where it sits in relation to these other key themes. To illustrate the ways in which diferent aspects of communication have been identiied as important to the success of BCT, we have modiied from Shortell et al.’s work 40 on dimensions needed to achieve clinical quality improvement, and used the thematic analysis of the previous chapters to construct a matrix of the diferent aspects of communication. The table shows the four key forms of communication which emerged from the data, arranged from strategic to delivery level. Based on our analysis of the data, we hypothesise the likely results should one aspect of communication be under-developed in the delivery of the programme. 40 Shortell SM, Bennett CL & Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. The Milbank Quarterly 1998: 76: 4, pp.593-624. The table is reproduced in Appendix Five, Evaluating Clinical Quality Improvement. Lack of shared vision around outcomes and where BCT ‘leads to’ u Figure 68 Leadership as an Active Ingredient 144 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 145 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Leadership Clarity of strategy and direction x 0 Multidirectional feedback loops to inform decision-making x 1 Localised conversations between staf and organisations x 1 = Result 1 = Lack of direction, discussion without action, increased frustration and anxiety 1 1 = Disconnection between high level strategy and ground-level work 1 1 0 1 = Silo working, frustration over resource distribution 1 1 1 0 = Despondency over service delivery. Misinterpretation of integrated care 1 1 1 1 = System-wide delivery informed by localised integrated working 0 = absent; 1 = fully present u Table 26 Aspects of Communication in an NCM At the strategic end of communication, a strong view to emerge from interviews was that communication meant the low of information from the strategic level to the delivery level: If you're lower in the hierarchy, you get drip-fed bits and you might think, “It sounds okay, but what am I not hearing?” … I think staf do worry about what they don't know. “I’m being told this, but what are they not telling me?” There’s an element of distrust in the higher levels. (INT053) Trying to talk to 1400 staf, or communicate with 1400 staf, is really diicult. You will get some that are highly engaged and some that are so far of the spectrum that when you ask them what BCT is they’ll say, “I don’t know”. (INT061) I think some of the anxiety has come around when people have been through changes and pilots before, and they haven’t necessarily had all the communication, or something has worked and then it’s been stopped because of various things. (INT005) Local Evaluation of Morecambe Bay PACS Vanguard Relationships 0 Leadership Communication with patients and public 1 146 - 12 Month Report 31/10/2017 Enabling mechanisms around the theme of communication, meanwhile, allowed staf to understand the ‘bigger picture’, and their own roles in trying new approaches to delivery, and to situate individual’s practice concretely. Likewise, communication between health services and the public also focused on raising awareness of an individual’s needs and situating this in terms of the options available to them. Clear, accessible and transparent communication – ‘having that open and honest communication to be available to patients, staf and clinicians’ (INT005) – reduces anxiety about the envisaged changes and stimulates engagement with wider vision and strategy. For patients who might receive several visits in a day from health professionals, the NCM provides an opportunity for the same information to be collected in one visit, on the condition that communication is robust. Relationships Alongside this, though, was an emphasis on the importance of localised ‘conversations’ (whether formal, through MDTs, or more informal). In this sense, physical aspects of communication have emerged as important: ‘being down the corridor’ from colleagues, or simply ensuring there are enough car-parking spaces to enable meetings, for example. In this way, communication as an active ingredient also encompasses the ways in which IT systems and IG access can ‘speak’ to service deliverers, and how diferent stakeholders are related to each other through technological and structural means. While the availability of technology is key to the delivery of speciic projects (such as telehealth), several prominent themes have emerged where technology informs the communication of care: for example, using improved data systems to communicate patient needs across services, or using IT to access the right kind of data to communicate the success of particular initiatives. At the far end of the table lies communication with citizens and patients. In Chapters 6 and 8 the complications of co-production of care, engagement and education have been discussed. In the case of communicating with patients and citizens around the NCM itself, there was a view from both service deliverers and patient focus groups that expectations had to be managed carefully. This provided a context for some patient views on the changes taking place in the health system: PARTICIPANT 26: Your expectations haven’t changed though, have they? It’s not what we expect, it’s just what we get. It’s just getting further away from it. PARTICIPANT 28: It just takes longer to get to it. As one consultant described succinctly: Medicine is basically about management and communication. If you try to reduce that to people you don’t know, or whose communications are in a diferent language, or in a broken form of the language that the patient is communicating in, then it’s far harder for that to be a really high quality exchange, and for the patient to end up with good care, and to feel engaged with their care. (INT024) Whereas, when asked if people felt ‘kept in the loop about changes or developments in your care’ (or the care of your child), all focus groups to date responded ‘No.’ As a result, as Chapter 8 detailed, a number of the moves towards out of hospital care risked being misinterpreted as negative consequences of other changes within the health system. The hypotheses within Table 25 suggest that some aspects of communication are embedded within aspects of leadership, whilst others are embedded within relationships, engagement and coproduction. The former involves structural and strategic aspects, whereas the latter is often done without formal structures in place; but in areas where relationships were historically distant, or diicult to articulate, there was often anxiety. In short: while communication is an active ingredient of the NCM, it should not be thought of as separate from these other aspects. Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 147 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 9.4 Cultural Change The communication work needed to deliver the NCM was often rooted in attempts to change the culture of health delivery in the longer term. Cultural change igured as an important aspect of BCT throughout the data, and for many participants formed the ultimate long-term goal of the programme. In order to analyse how culture formed an active ingredient in the delivery of the NCM, we utilised Schein’s model of organisational culture. Schein’s model proposes that culture can be organised into three levels, which Schein labels ‘artefacts’, ‘espoused values’ and ‘basic underlying assumptions.’ Artefacts refer to the visible signs of culture – tangible, observable and quantiiable ‘things’ which demonstrate a particular culture is at work. Espoused values refer to the justiications for those ‘things’; the reasoning behind why a culture works in the way that it does. Finally, basic underlying assumptions refer to the unspoken rules and embedded beliefs which are often taken for granted, and rarely made ‘visible’, which form the deepest level of people’s beliefs and behaviours within a cultural setting. What people observe (see, feel, hear) Artefacts Observable/quantiiable Fairly straightforward to change Schein’s expectation was that cultural change in and across organisations occurs at a strategic level most easily, and takes longer to embed itself at the level of underlying assumptions. Conversely, culture change can emerge if there is a sea change in basic assumptions which causes the values and artefacts of an organisation to be re-thought. Current BCT delivery, however, is very strong on the espoused values behind cultural change. According to Schein, this is not the visible message of change, but rather the justiication or rationality behind it. In this sense, the principles of self-care, improving eiciencies, addressing gaps in local health provision and the long-term possibilities of a shift in health to out of hospital care, are common throughout the data. But as noted in Chapter 6 and Chapter 8, there is currently a noticeable lack of artefacts which would qualify or quantify these, though. As one participant summarised in June 2017: I think it's something that if people know what it's about, they understand the rationale behind it, but if you ask somebody whether they can see something tangible, I think people would struggle to answer the question. (INT037) Throughout the data collection, and during the evaluation workshops, many participants questioned the visibility of BCT, both in terms of how and where it was recognised across Morecambe Bay (in terms of documentation, distribution of information, identiication of individuals involved and so on), and the visibility of the message it was giving (i.e. what BCT actually was; see Chapter 6, Section 6.4). Why was this the case? In some senses, this problem was anticipated in a 2013 survey of staf and public views on potential new ways of ‘joining up’ care in Morecambe Bay, where the ‘Overall response to most of the out of hospital scenarios and principles was “good words, but can we deliver this?”’ The report summarised: What people are told Espoused values We used this to re-assess the qualitative data discussing cultural change, in order to identify where the basic themes could be placed on this model. Interpreting themes of cultural change through the lens of Schein’s scale raised some interesting and perhaps unexpected results. Most principles and concepts behind some scenarios are appealing and hard to argue against in principle; But general scepticism and some strong concerns around delivery, given views of what might be required and how this matches up to the current situation and previous experience; Many tangible factors were felt to be problematic or unaccounted for in the scenario/ principle descriptions.41 Culture Basic underlying assumptions What people take for granted Diicult to to uncover Diicult to change u Figure 69 Schein’s Model of Organisational Culture Within the current evaluation project, there emerged from the data a number of themes which could be identiied as preventing the translation of values into artefacts. Typically, these were identiied in the context of participants delivering localised solutions which were not translated into longer-term cultural changes, for example: • • • a perceived lack of support from middle management; a lack of multi-directional communication; silo working related to commissioning processes, IG and IT. If this explains some of the problems with translating the espoused values of BCT into artefacts, a further recurring theme throughout the data was that the work of BCT – and the ICCs in particular – was around ‘changing mind-sets’, which suggests that direct attention is being paid to the third level of Schein’s model, basic underlying assumptions. 41 Better Care Together Engagement report (2013) http://www.bettercaretogether.co.uk/uploads/iles/Engagement%20to%20date%20March%202017%20v0.01.pdf 148 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 149 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) It is perhaps not surprising that this work is not always accompanied by methods of capturing or representing such changes; such methods are, as Schein’s model notes, very diicult to do. However, while a number of participants spoke positively of the ways that underlying assumptions are changing, there remain a number of diferent perspectives underlying the delivery of the NCM which appear to sit in tension with one another. For example: • • • whether the NCM aims for an informed public or an empowered public, and what the possible diferences between the two are; whether the NCM should be clinically-led, project-led or community-based; who holds ultimate responsibility for change. This can be explored further through a more detailed analysis of integrated working (e.g. MultiDisciplinary Teams), and in particular how shared and conlicting assumptions are negotiated within integrated pathways. The 2017/8 evaluation will focus on this as part of its work. 9.5 Necessary Tensions to Negotiate A inal ingredient regards the key tensions which are, in many senses, necessary to the kind of changes which both BCT, and the Five Year Forward View, entail. Throughout the delivery of the vanguard, tensions emerged at both practical and conceptual level, chiely surrounding the scaling up of the changes being delivered. In the igure below, they are presented in terms of apparently contradictory themes which sit at either end of a continuum. Many of the concerns raised about the sustainability of the programme – in terms of whether funding would continue, whether staf would be retained, and whether long-term cultural change was achievable – were rooted in the apparent irreconcilability of these tensions. Delivering longterm sustainable work will, for example, always sufer frustrations from being based around smaller project-based initiatives, which are time- and resource-limited. At the same time, data also suggests that these tensions need to be negotiated – even if they cannot be fully resolved – in order to accelerate the delivery of the NCM. The question this raises, then, is what the ‘gap’ is which sits in between the two ends of each continuum, and prevents themes from joining together. While participants described a number of obstacles to achieving change (lack of time, complexity of IG and IT, and so on; as discussed earlier in this report), an analysis of how participants discussed these particular tensions suggests that the key gaps preventing are evidence base and multidirectional feedback loops in between localised practice and strategic decision-making. The lack of consistent data across the range of projects which form part of BCT tended to be perceived by participants as exacerbating the lack of a clear vision of the ‘endpoint’, or future of the NCM. This was also relected in workshop discussions (see Appendix Four). The Vanguard Value Proposition document for 2016/17 claimed that: the objective of the Research and Evaluation work is to ensure that evaluation becomes part of DNA and creates a virtuous learning cycle. 42 However, the sense that reporting measures were insuicient for capturing the work being done at localised levels was raised persistently in the data, and this was often connected to a perceived disparity between the long-term and short-term aims of the programme. 42 Better Care Together Vanguard Value Proposition, February 2016 Whole system change Localised activities Focus on eiciencies Evidence base and feedback loops Project-based work Long-term sustainable work Focus on ‘upstream care’ u Figure 70 Necessary Tensions within an NCM 150 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 151 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) 10 Recommendations While the NCM has been delivered across a large geographical area and involving a range of organisations, the indings of the twelve months of evaluations present a clear picture in terms of successes and obstacles. Based on our analysis of these indings, the evaluation concludes with the following recommendations: 10.3 Consider the Role of Leadership, Communication and Cultural Change There is a need for the programme to consider the roles of leadership, communication and cultural change in its delivery. • 10.1 Improve data reporting techniques and strategies While there were a range of interventions either planned or in process ‘on the ground’, these often struggled to link to the larger-scale, strategic views of Better Care Together. This can be addressed in two ways: improving data reporting, and improving the links between incremental changes and longer-term strategy. • • • • The evaluation recommends that steps are taken to address the gaps in data reporting, in order for the NCM to demonstrate more robustly the efects of the changes it is delivering. This work would be chiely around mapping outputs from speciic interventions in a clear and systematic way at the planning stage of delivery. This would allow more nuanced, context-speciic and localised measures (whether quantitative orqualitative) to scafold up to the higher-level outcomes, and visible change to become apparent earlier within the NCM delivery. This includes: • • In order to address the negative themes around these, it is recommended that the programme introduces more transparent ‘feedback loops’ within its structure. This would include feedback from organisations outside of the NHS, who are nevertheless key to the delivery of the NCM. Communication across organisations at ground level was reported as one of the key successes of the NCM. There may be some useful learning points and good practice from these successes which can support communication at strategic level. The public views solicited suggested that the aims of BCT were in keeping with public need, such as more personalised care. There are gaps, however, between service redesign and delivery and the understanding by the public of some of these changes. Some of this is due to the lack of clear indicators of incremental changes, educational attempts and general engagement with the public. Consistent and methodologically robust data collection around incremental change to target populations, with a more consistent approach to mapping inputs for interventions and activities, along with timescales (based on contextualised factors such as existing community assets and relationships),which can then be compared against outcomes. Speciic data to track for individual interventions on patient level, including inputas well as output data which covers enough breadth to measure the impact of theintervention on a patient level. Evidence from wider literature suggests that the best measure of complex changes to models of care utilise a range of methods and data sources. Appendix Five below outlines some recommended approaches that BCT might consider for redressing the gaps in data that this evaluation has identiied. 10.2 Improve strategies for demonstrating change Alongside more nuanced and contextual data collection, the programme would beneit from having a clear evaluation strategy which covers all aspects of delivery, and from this use a set of evaluation criteria which enables diferent interventions to be assessed. There needs to be evaluation criteria to link up small-scale changes with large scale. • • • • A recurring theme for participants has been problems with identifying what‘ Better Care Together’ is, in terms of inclusion/exclusion criteria, measurable outcomes and ‘what success looks like’. This needs to be addressed in order to avoid suspicions of the NCM being focused on inancial eiciency over and above improved population health. A large number of participants indicated that it was ‘too soon’ for results to be showing from the BCT activities. This suggests that roadmaps were not suiciently detailed to document incremental successes in the way that large-scale change requires. Ensuring that a theory of change, such as the BCT logic model, is aligned clearly to workstream reporting, will enable programme outcomes to be clearer, as well as routes to demonstrating efectiveness. It is important that the outcomes of the programme are clearly aligned to a rangeof evidence sources, and that outcomes are both speciic and falsiiable, so that obstacles to achieving them can be identiied more quickly. There has been notable tendency for participants to avoid open discussions of unsuccessful interventions, non-developed projects and the severe delays that some workstreams have experienced. However, obstacles to change are as key as successes for understanding how interventions can be scaled up to the wider Bay area. 152 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 153 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Appendix One: Semi-Structured Interview Schedule Appendix Two: Survey Design 1. How do you see [this activity/role] contributing to the New Care Model for primary andacute This short survey is about the introduction of integrated care communities (ICCs) into three areas across Morecambe Bay: Barrow Town, East and Bay. care? • • How does it it with the Better Care Together programme? Do you think it is doing this successfully so far? Why/why not? 2. To what extent do you feel [this activity/role] has been implemented as planned, so far? • • What changes have been made along the way, if any? What caused these changesto happen? (Was this, for example, a contextual issue, or an issue with design?) In what ways have the changes been beneicial? 3. What do you think the key changes [this activity/role] is making so far are, and to who? • • • • Is it focusing on particular groups of patients (or staf/services)? How ‘deep’ is the change, in your view? (Does it involve, for example, a change insurface behaviour, or a change in deeper, more embedded assumptions?) Are their obstructions to change? (How ‘deep’ are these obstructions?) How do you think people feel about the changes being made? (e.g. Who is enthusiastic? Who is anxious? The survey forms part of a larger evaluation of Better Care Together, which Bay Health & Care Partners have commissioned HASCE at the University of Cumbria to conduct. The survey should not take more than ten minutes to answer, and your responses will be used, alongside data from other evaluation activities, to inform the future development of ICCs across Morecambe Bay. Your survey responses will be anonymous and handled conidentially, and no individual will be identiiable from any outputs. You do not have to answer any question that you do not want to, and you can end the survey at any time. If you have any questions about the survey or the evaluation more generally, then please contact [email protected]. 4. What diference do you think this is making to the experience of care in the local area? • • • Is the more integrated approach enabling better quality of care? How? (e.g.Integrated Pathways) In what ways does [the activity/role] meet the needs of the local population?[which areas/ demographics is it aimed at, and is it reaching them?] Is it reducing/will it reduce admissions to hospital, in your view? 5. Have there been any unintended outcomes of the work on [this activity/role] so far? 6. What diferences do you think this is making to the staf delivering care? • • For example, is there any upskilling or role redesign involved? Has communication between services improved? 7. Have you seen any change in use of resources so far from [this activity/role]? • • Is this a more efective use/less efective use? Are there any particular strains on resources? 154 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 155 Health and Social Care Evaluations (HASCE) 156 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 157 Health and Social Care Evaluations (HASCE) 158 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 159 Health and Social Care Evaluations (HASCE) Appendix Three: Focus Group Schedule Health and Social Care Evaluations (HASCE) Appendix Four: World Café Discussion Summaries About your involvement with the health system Could you describe some of the things that are important to you when you are seeking healthcare support? • • • • • Kindness/politeness of staf? Time spent waiting at & for an appointment? Location of care e.g. at home, hospital? Journey time? Staf giving you time to ask questions? Additional needs (e.g. social) being taken into consideration? About changes in the health system Have you noticed any changes to the way care is provided by the NHS in your area recently/over the last year or so? • • • Has this made any diference to your experience of care? How has this afected your speciic needs [i.e. long-term conditions] Have the changes been positive or negative? If positive, what, and if not, what was missing? Would you say that your expectations for your own care have changed over the last year or so, in terms of the services that are available to you? • • In what way? What caused this change? Are you aware of Better Care Together? • • • • Do you have any experience of this new way of working? What are your thoughts on BCT as you understand it? E.g. Seeing a specialist nurse/physio etc. rather than a consultant? E.g. spending less time in hospital About co-design and communications How much do you feel involved in your own care? • • • Are you listened to by your care providers? Do you attend a support group? Online or telephone support? What are your experiences of communicating with healthcare providers? • • • Could you describe a good experience of communicating with a provider? What could improve communication? Are you kept ‘in the loop’ about changes or developments in your care? What would you do if you feel your needs are not being met? • • • Make a complaint? Try a diferent path for care support? Ask for advice on what to do? About a joined-up service In your experience, do the diferent health deliverers you are involved with communicate well with each other (e.g. about your care)? • Do you feel information is passed well between e.g. GP and hospital? Do you feel that you have a similar standard of care across diferent providers? • Hospital, primary care, third sector (if relevant) 160 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 161 Health and Social Care Evaluations (HASCE) 162 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 163 Health and Social Care Evaluations (HASCE) 164 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 165 Health and Social Care Evaluations (HASCE) 166 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Health and Social Care Evaluations (HASCE) Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 167 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Appendix Five: Evaluation Methods for Speciic Gaps in BCT Data Throughout the evaluation report, several areas have been raised as demonstrating gaps in data. These gaps were also relected in the evaluation workshop discussions. While there is no single and deinitive ‘answer’ for addressing these – every evaluation needs to be designed according to its context and purpose – the following methods were identiied during the course of the evaluation as starting points for addressing the gaps in data. They are listed here in the spirit of dialogue with those delivering BCT, in order to identify ways in which the quality of evidence around the successes of and obstacles to the NCM may be enhanced. Evaluating Collaboration One theme which emerged was around how organisations could assess the success of collaboration, across sectors and geographies (e.g. primary and secondary care, voluntary sector). Evaluation literature tends to agree that there are key areas for achieving positive outcomes: • • • • • Having a clear deinition of success; Deining success in a way that needs and perspectives of stakeholders are recognised; Transparency of communication; Attention to collaboration operations (structures, procedures, metrics), and their relation to non-collaborative operations; An increased capacity for collaboration amongst stakeholders as a tangible outcome. If this sounds straightforward, Norris-Tirrell nevertheless argues that ‘while an exponentially expanding set of researchers and practitioners conduct research, evaluations, and theory building reports, articles, and books on the topic of collaboration, the eicacy of the strategy remains murky.’ Perhaps this is in no small part due to the fact that ‘the success of collaboration depends on the situation, the actors, timing, and so on.’43 For this reason, much of the current evaluation research is case-based, as this allows evaluators to describes and analyse a situated collaboration in order to draw lessons for the future. But these can be time-consuming and, given that a case study is always a sub-set of a broader system, requires careful thinking around which cases to use. 44 In contrast to the case based approach, other evaluators have used structured surveys to measure the efects of collaboration. For example, Marek et al. have developed a ‘Collaboration Assessment Tool’. 45 The survey questions embedded within this tool may be useful starting points for thinking through what kind of data would evidence successful working across organisations and sectors. 43 (Norris-Tirrell 2012, p.4) 44 https://case.edu/ail/healthpromotion/ProgramEvaluation.pdf 45 Marek, L., Brock, D-J., Svla, J. Evaluating Collaboration for Efectiveness: Conceptualization and Measurement. American Journal of Evaluation, Vol. 36(1), pp. 67-85 (2015) Evaluating Engagement One of the most widely-used models for evaluating public engagement has been created by Rowe and Frewer. 46 This approach essentially breaks the success of engagement into two aspects: how participants are involved in the construction of the engagement, and how fair they perceive it to be. Rowe and Frewer describe this as ‘process’ and ‘acceptance’ criteria: Acceptance Criteria: • • • • • Representativeness: public participants should comprise a broadly representative sample of the population of the afected public. Independence: the participation process should be conducted in an independent, unbiased way. Early Involvement: the public should be involved as early as possible in the process as soon as value judgments become salient. Inluence: the output of the procedure should have a genuine impact on policy. Transparency: the process should be transparent so that the public can see what is going on and how decisions are being made. Process Criteria: • • • • Resource Accessibility: public participants should have access to the appropriate resources to enable them to successfully fulil their brief. Task Deinition: the nature and scope of the participation task should be clearly deined. Structured Decision Making: the participation exercise should use/provide appropriate mechanisms for structuring and displaying the decision-making process. [NB. This is sometimes rendered ‘structured dialogue’ if decision-making is not considered viable] Cost Efectiveness: the procedure should in some sense be cost efective. [NB. More recent versions of this model remove cost-efectiveness, as it is argued that participants would not have this kind of knowledge] By testing engagement around these headings, Rowe and Frewer have aimed to provide more ‘objective’ accounts of the success of engagement activities. However, they caution that engagement exercises have ‘been variously described as consensus conferences, deliberative conferences, citizen advisory committees, citizen advisory boards, focus groups, task forces, community groups, negotiated rulemaking task forces, community advisory forums, citizen initiatives, citizen juries, planning cells, citizen panels, public meetings, workshops, public hearings, and others.’ 47 But each of these may involve a diferent deinition of success. As such, attempting to use a universal category such as ‘efectiveness of public engagement’ has to be accompanied by a clear articulation of the time and space that engagement takes place within, so that success can be compared across them. For example, in the second BCT workshop it was noted that attention needed to be paid to how, where and when questions are asked, and how this might implicitly ‘shape’ the responses received, as well as the conditions determining the ‘efectiveness’ of an engagement. Likewise, there was a discussion of how engagement in evaluation needed to show results – feeding back on a process needed to have a visible efect (whatever efect that might be) in order for it to be worthwhile; otherwise, participants may be less willing to engage at all. All of these will afect the success of an evaluation. 46 Rowe, G. and Frewer, L. Evaluating Public-Participation Exercises: A Research Agenda. Science, Technology, & Human Values, Vol. 29 No. 4, pp. 512-556 (2000) 47 Rowe, G. and Frewer, L. Evaluating Public-Participation Exercise, p.550 168 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 169 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Evaluating Localised Metrics across Areas There are two caveats to using this as a template for evaluation, however. • One recurrent issue around ongoing evaluation was how to report on population-based and localised interventions, such as within ICCs, which would demonstrate success through nuanced or contextual changes that do not ‘travel’ well up to higher-level metrics. The following chart is a ‘personalised advice template’ presented by the Nuield Trust as part of their evaluation of the National Association of Primary Care’s ‘Primary Care Home’(PCH) programme. This was based on a dialogue between evaluator and programme to identify the diferent ways in which metrics could be identiied to make the programme aims tangible. 48 Four aims for the PCH Improve whole-population health and wellbeing Improve quality and experience of care for patients Improve utilisation and sustainability of local health and social care resources Improve staf experience Examples of ways to measure this Domains of measurement Population health and wellbeing Your current proposed measures: Additional measures you could use: Patient outcomes (including clinical and process measures) Your current proposed measures: Additional measures you could use: Patient experience Your current proposed measures: Additional measures you could use: Health and care activity Your current proposed measures: Additional measures you could use: Cost of delivering care Your current proposed measures: Additional measures you could use: Staf experience and engagement Your current proposed measures: Additional measures you could use: • First, the most important point for monitoring ‘ground up’ initiatives is that the reporting is formative; that is, it can feedback to the delivery in a meaningful and regular way to steer the progress of a pathway or intervention. This is one of the main beneits of localised measurements, as they should ideally be more immediately visible (and thus quicker to respond to) than the higher-level aims. Second, the success of the measures (be they qualitative, quantitative or mixed) must be open to review and challenge. Measures, like aims, must be falsiiable, which means that the measures chosen must be able to show not only successes, but also lack of success where necessary. For this reason, smaller-scale measures are best decided on through conversations with multiple stakeholders, which may include citizens or patients Evaluating Clinical Quality Improvement One of the main outcomes stipulated in the BCT logic model was improved quality of care. While there are obviously many evaluation methods for assessing quality improvement, Shortell et al.49 have provided a matrix of quality improvement which details the aspects needed to produce lasting organisation-wide impact. This tool can be useful for identifying how changes introduced are supported by wider aspects of a health system, as well as identifying the key enabling and disabling mechanisms such a change might need to address during planning and delivery. While this is not an evaluation method in itself, it provides a good starting point for locating the kinds of measures which may need to be reported on in order to provide a robust evaluation of system-wide change. Strategic x Cultural x Technical x Structural = Result 0 1 1 1 = No signiicant results on anything really important 1 0 1 1 = Small, temporary efects; no lasting impact 1 1 0 1 = Frustration and false starts 1 1 1 0 = Inability to capture the learning and spread it throughout the organisation 1 1 1 1 = Lasting organisation-wide impact u Table 27 Nuield Trust’s Personalised Advice Template The beneit of this template is that it insists upon tangible data for supporting what would otherwise be fairly high-level and generalised aims. Modifying this template may provide local interventions with a link to the more abstract aims of the BCT programme as whole.: Main aims – programme wide E.g. “Improvement in the quality of care a patient receives.” Examples of ways to measure this (qualitative or quantitative) – ICC speciic Domain of measurement pathway speciic Patient Outcomes Patient Experience ... ... ... ... 0 = absent; 1 = fully present u Table 29 Shortell et al.’s Dimensions needed to achieve clinical quality improvement Etc. u Table 28 Modiied Template for Localised Data Collection 170 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard 49 Shortell SM, Bennett CL & Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. The Milbank Quarterly 1998: 76: 4, pp.593-624 Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 171 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Appendix Six: Outcomes Survey – Key Findings Introduction As discussed in Section 2.5, to explore levels of engagement with BCT and understanding of its shared outcomes, staf from three ICCs were invited to complete a survey. The survey was available to complete online for ive weeks in September and October 2017. The response rate was very low, with only 13 surveys being completed. Despite these data limitations, analysis of the survey responses still provides some additional and valuable insight into experiences of the ICCs. The key indings emerging from this analysis are presented here. Engagement with ICCs All respondents felt that they had engaged with their local ICC at least to some extent, with the level of reported engagement varying across respondents. The survey asked respondents to indicate how engaged they were with their local ICC, where 1 indicated ‘not at all’ and 5 ‘very much’. Although six rated it as 2 or 3, no respondent provided a ‘not at all’ rating and, more positively, seven rated the impact as a 4 or 5. The small number of respondents prevents the identiication of patterns and relationships in the data (and respondents worked in only three out of the 12 ICCs which further limits its representativeness), but as would be expected, those with a job role directly linked to BCT (Programme and Project Managers) reported higher levels of engagement. Eight out of the 13 respondents were either a GP or Practice Manager, for them, perceived engagement appeared to relect their attendance at meetings or involvement in its interventions. For example, one Practice Manager reported that they attended all meetings and had been involved in the piloting of pathways and they therefore felt that they were ‘very much’ engaged with their local ICC. Only three respondents reporting lower levels of engagement provided additional information to explain their rating, one explained that they had not attended recent meetings, another stated that the ICC’s primary focus was on physical health, and a third felt that their involvement was restricted by broader issues. The impact of the local ICC on respondents’ day-to-day work and their delivery of services was also explored in the survey. When asked about the impact on day-to-day work, nine respondents rated it as either 2 or 3 (where 1 is no impact at all) and four provided higher ratings of 4 or 5. Where additional comments were provided (by nine respondents) to explain the impact rating, they were varied with each respondent citing a diferent factor or issue. For example, a respondent providing an impact rating of 2 stated that although they are invited and encouraged to attend meetings, their involvement requires time out of their practice. Another respondent, also providing a 2 rating, criticised the ICC for being “slow moving and too conceptual on the possibilities whilst lacking in simple achievable goals to drive forward.” More positively, those providing a 4 or 5 rating cited various examples of impact on their day-to-day work including the Wellness Hubs, prevention agenda, regular use of the care navigators and case managers, and increased signposting to other services. Fewer respondents thought that their local ICC had had an impact on the delivery of their services, with three stating that it had no impact at all, seven rating it as 2-3, and three as 4-5 (where 5 is a lot of impact). The survey also explored perceptions of impact on service users; only one respondent (who did not disclose their job role) stated that there had been a lot of impact, three thought that there had been no impact, and eight rated impact as either 2 or 3 (where 1 is none and 5 is a lot). The respondent stating that there had been a lot of impact thought that the ICC had brought about “greater access to services for patients”. One respondent stating that it had not had any impact on service users described how the merger of GP practices had been perceived negatively by patients “comments have included – intrusive and judgemental reception staf, don’t know what’s happening, unable to see the same doctor, herded through the system, loss of personalised service, increase in cancelled appointments with nurses.” Three other respondents (who provided a 1, 2 and 3 impact rating) all commented that services were still in the early stages and others stated that the ICC was “supporting communities to shape their own wellness. Lifestyle and behaviour choices etc.” and that care navigators and case managers were supporting complicated cases. Understanding of ICCs All but one respondent felt that they had at least some understanding of the aims of their local ICC, with seven stating that they understood them very well and ive that they somewhat understood them. However, when asked what its aims were, responses were varied and included reference to the triple aims, co-operative working practices, early intervention, sustainable and accountable health systems, and improved local services. In terms of their own role and responsibilities within the ICC, ive respondents stated that they understood it very well and eight that they somewhat understood it. Two of those respondents reporting high levels of understanding described what could enable help them to better fulil their role and responsibilities: Certainty over continuation funding beyond March 2018 and expansion of the ICC ofer through Community Services development. More enthusiasm & co-operation from other practices in the ICC. Those that somewhat understood their role and responsibilities or had no understanding at all were asked what would improve their understanding, three of whom provided a response. A range of diferent factors were cited, including: a perception that their responsibility related to supporting and promoting ICC activities only and that protected time away from the day job was needed; that it should be GP centric; and engagement with and input to ICC discussions. Understanding of the aims of the BCT programme overall were comparable to understanding of the local ICC’s aims. Out of the 13 respondents, eight somewhat understood them and ive understood them very well. Three of those with higher levels of understanding described the aims and although diferent descriptions were provided, all referred to increased collaboration and joint working to achieve improved care. Closer networking and joined up working were identiied as the most important changes to working practices brought about by the ICC (cited by four respondents out of a total of eight answering this question), however, two of these respondents were a Programme or Project Manager. Examples of this type of response included: “closer networking with other services” and “the ICCs have enabled services to integrate and communicate more efectively. Services are becoming joined up and the system approach better understood.” Another respondent stated that the ICC had led their team to refocus their work using asset based principles, two stated that it was too early for change and another felt that the ICC had not brought about any changes to their working practices. 172 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 173 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) Appendix Seven: Social Media Announcements and ED Attendance During the course of the vanguard funding, UHMBT used social media on speciic days to discourage the public from attending A&E departments. In some cases this was due to serious events (for example, a junior doctor’s strike on 21/04/2016; or following an outbreak of norovirus on 21/12/2016 and 06/01/2017 those with diarrhoea or vomiting were advised to not attend). In others, no speciic reason was given. In total, 28 social media messages were distributed between December 2015 and October 2017. A brief look at three months of ED Attendance across three years (to compare months where announcements were made, to those where there were none) shows no immediate efect on total numbers of attendance. In cases where numbers drop in the days following the announcement, it seems more likely that this is relecting seasonality (when compared to the same days in previous years). This remains a high level analysis, however. There may well be other efects that the announcements are producing which are not immediately realisable, and may be complimented by activities taking place within the BCT programme. The comparative igures are presented below. Days where announcements were made are highlighted in red; days without an announcement coloured blue. 174 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 175 Health and Social Care Evaluations (HASCE) Health and Social Care Evaluations (HASCE) u Figure 71 Comparison of ED Attendances in relation to social media announcements 176 - 12 Month Report 31/10/2017 Local Evaluation of Morecambe Bay PACS Vanguard Local Evaluation of Morecambe Bay PACS Vanguard 12 Month Report 31/10/2017 - 177