Wednesday, October 14, 2015
Evaluation of the Multi-Systemic Therapy Social Impact Bond
Evaluation of the Essex Multi-Systemic Therapy Social Impact Bond
Essex County Council (ECC) Family Operations Service currently provides access to Multi-Systemic Therapy (MST) to young people who meet the referral criteria. This service is aimed at supporting young people and their families where there is a risk of a young person entering care (which also includes young people remanded into custody), and has the intention of keeping the young person within the family home whenever it is safe to do so. This service is being funded via a Social Impact Bond (SIB) and is being delivered by an external provider.
In 2013 OPM were commissioned to deliver a three-year independent evaluation of the MST SIB, using funding from Central Government.
The evaluation will generate:
- A replicable methodology for capturing any value added by the SIB
- Recommendations for improving the delivery of MST through a SIB in Essex
- Recommendations for improved future working of SIBs.
The evaluation involves capturing both qualitative and quantitative data. This is the first of two interim reports and presents the findings from the first eighteen months of evaluation activities. The evaluation will run until March 2016, culminating in a final summative report.
Wednesday, October 7, 2015
‘Quality of death’ – national success vs local variation
Most of us are familiar with the concept of ‘quality of life’ when thinking about a neighbourhood, city, or country. ‘Quality of death’, on the other hand, isn’t something we regularly talk about. However, a recent report has been in the news this week for doing just that.
The latest Quality of Death Index has been released comparing the quality of provision around care for those at the end of life in 80 different countries.
Happily, if that’s the right word, the Index ranks the UK as highest in the world for its quality of death, citing comprehensive national policies, extensive integration of palliative care into the NHS, and strong hospices as reasons behind this.
Certainly in our own work we have come across many examples of good practice, and innovative and effective approaches. Most recently at OPM we were able to visit Trinity Hospice, as part of our current evaluation of the Wandsworth Care Coordination Centre, to see what ‘quality of death’ can really mean in practice.
From our research we’ve found that key ingredients to this include:
- Joined-up working between professionals and services
- Clear pathways to enter end of life care
- Consistent guidance and frameworks, with good monitoring of whether they are being adhered to
- Specialised training for professionals involved
- A holistic approach to people’s needs at end of life
- Clear quality standards
However, although it’s great news the UK ranks top in the Quality of Death Index, the authors acknowledge that there’s clearly still room for improvement, which is reflected in our own research, as well as recent case reports from the Parliamentary Health Service Ombudsman.
For instance, the nature of the service landscape for end of life care, which the Index doesn’t take into account, is something we have found to be an important factor in influencing how a person spends the last months and weeks of their life. Often, many different services from across health and social care can be involved in a person’s last days. Where these work in a joined-up manner it can make a huge positive impact, but where this is not the case, people can experience delays, poor communication, and inadequate care.
All too often there can also be huge variability between and even within different areas for how easily people can access end of life care, the nature and quality of care they receive, what location they spend their last weeks in, and, not least, whether they have to pay anything for it.
Perhaps what we need is something similar to the Quality of Death Index for within the UK, to make clear the wide range of experiences people are having in different parts of the country. Of course, this idea would still need a lot more development to make sure it supports improvement rather than just singling out areas for criticism. But done successfully, this would enable us to better identify and share the excellent practice that we know is happening in many areas already – and ultimately improve our quality of death even further.
Friday, May 1, 2015
Patients in control: ‘assume it’s possible’
Imagine walking into a GP surgery. For most of us, the first thing we normally face is a reception desk with overworked staff fielding phone calls in front of long queues of waiting patients.
What would happen if you took the reception desk away? Can you picture the waiting room as a place to talk to healthcare advisers, to find out about different wellbeing programmes without needing to necessarily even see a GP? The experience might feel something like going into an Apple Store and being greeted with a friendly smile and an iPad to search for options.
This is one of the latest ideas from the Bromley-by-Bow centre – reimagining the waiting room as a space to actively engage with patients, rather than a space where people are passively processed.
Operating in one of the most deprived areas of Tower Hamlets, BBBC is a pioneering community organisation – a vibrant hub with a café, arts workshops, offices, a nursery, garden, GP surgery and officers from the local housing association. The programmes that they run include helping people with long term conditions to take control of their lives, learn new skills, supporting people to find work and establishing social enterprises. The GP surgery (along with five others in the local area) refers patients to BBBC programmes through social prescribing.
The philosophy underpinning this approach is not necessarily new or unique – The Marmot Review into health inequalities emphasised a social understanding of health, and more recently Dr Atul Gawande dedicated one of his Reith lectures to the importance of medicine shifting from a focus on health to wellbeing. There is also evidence from social prescribing pilots elsewhere in the UK of the success of the approach. But the BBBC has put a wellbeing approach into practice and made it sustainable – based on an unswerving belief in the power of stronger, and more networked communities, and people’s capacity to achieve their goals and raise their aspirations.
OPM worked with the Bromley-by-Bow Centre (BBBC) to create a commissioning simulation as part of the South East CSU Person-Centred Care project. This aimed to explore the tools and knowledge that CCGs might need to confidently commission programmes and services that put patients in control. Participants had to imagine they were at a Commissioning Challenge event for a fictional CCG – although not dissimilar to what some CCGs are already doing. At our event, commissioners, patients, local authority representatives, clinicians and voluntary sector providers had come together, to work up an idea on how to reduce Type 2 diabetes and heart disease through a living well programme.
Simulations always risk being slightly contrived, but the aim was to go beyond commissioners’ usual environments, draw inspiration from the setting and think about how to join the dots between different organisations in local areas – all of whom could have something to contribute to a wellbeing approach that puts patients in greater control of their health.
What did we learn?
Creating the space for CCG commissioners to come together with local organisations and patients is essential to understand what each has to offer. Patients in control programmes will rarely sit in isolation – they are part of a menu of options, and commissioners need to think across the local system.
We found many examples and case studies of programmes that could be described as putting patients in control. But commissioning these are not yet the norm.
Participants talked about the importance of CCGs being less risk averse – finding ways to challenge entrenched cultures, and influence others internally and externally. This is not an easy task in a time of tight budgets and long lists of priorities.
Within this context, being able to demonstrate impact and outcomes is vital – we have blogged about measuring impact in the context of commissioning earlier on in this blog series on person centred care.
Despite these challenges, overall, we found that there is real desire amongst CCGs to use the commissioning process to ensure that there are person centred approaches in place. As one participant in the simulation said: ‘The aim should be for a Bromley-By-Bow Centre in every local area…’
In the words of the Centre itself: ‘assume it’s possible’.
This is the third in a series of blogs to be published following the development of a set of online tools and resources by OPM in support of the person-centred care agenda for South East Commissioning Support Unit. The first is entitled: Person-centred care: putting patients in control and the second: Person-centred care: measuring impact.
Tuesday, April 7, 2015
Person-centred care: measuring impact
A key concern within integrated, personalised care is demonstrating the changes or impacts achieved. The aims are long term, reshaping the way that care is delivered (and received) and will take time to embed and filter through to improved health outcomes for patients.
So what evidence can commissioners, and others, show in the short term to demonstrate that their initiatives are working?
Quite simply, they can show that they are changing the way that healthcare is being experienced by patients. If commissioners can show that consultants, nurses, patients and carers are changing the way they interact, they can show that their programme is, in the short term, moving in the right direction. This is the first step in achieving change and builds an evidence base on which longer term outcomes can be attached.
So how do you demonstrate change?
Commissioners we spoke to told us that it can be really valuable to show what the changes to service usage actually look like on the ground. Showing the different ways that patients are being involved in their own care or decisions around their care can be really powerful. This could be patients perceiving the importance of self-managing their own care or being invited by the clinician to help decide between several treatment options.
OPM have already contributed to work carried out by the Health Foundation, reviewing approaches to measuring whether person-centred care is taking place. Our work for South East Commissioning Support Unit built on this work and focused on identifying measures for two specific areas: Shared Decision Making and Self-Management. These measures, for example the SHARED Scale and Patient Enablement Instrument, allow commissioners to demonstrate in a very tangible way that patients are playing a more active role in their care. By contributing to decisions about what care is appropriate for them, and taking a role in managing their own care, patients are moving away from a deference to, and dependence on, primary care practitioners.
We produced a searchable database of tools which can be used to demonstrate that interactions and relationships between patients and health care practitioners are changing, in specific and real ways. We shared these resources with commissioners and health care providers across three workshops to enable them to start using the tools.
We found that commissioners really appreciated this type of support. When we shared our database, and a framework for integrating it into project implementation, commissioners told us that it:
- helps them connect those doing the strategic thinking with the changes actually taking place on the ground
- helps them apply a strategic approach across multiple programmes, capturing data to compare between programmes and report consistently across a wider programme of work
- gives them the confidence to select validated measures which they can recommend for use within projects
- helps them provide clear guidance to providers about the measures that should be included within their programmes.
This positive feedback gives us confidence that this is a tool that will genuinely add value for commissioners. Participants that came to our demonstration workshops told us that in partnership with the tools for person-centred care , they have a solid foundation for implementing more robust programmes that create both impact and learning for the future.
We encourage all those working in this area to share their experience. It’s a new field of working and our workshops showed that everyone is keen to learn what works from those who are implementing change on the ground.
This is the second in a series of blogs to be published following the development of a set of online tools and resources by OPM in support of the person-centred care agenda for South East Commissioning Support Unit. The first is entitled: Person-centred care: putting patients in control and the third: Patients in control: ‘assume it’s possible’.
Wednesday, April 1, 2015
Introduction of the new Care Act
The launch of the new Care Act today marks the biggest set of changes to adult social care legislation since the formation of the NHS in 1948.
At OPM we’re really looking forward to seeing the impact of this policy in practice, having delivered a variety of projects for different clients in this area. Last year we worked with the Department of Health on a system-wide event exploring the impact of the Act on residential care markets, with an eagerly anticipated report in the works. More recently Hertfordshire County Council (@HertsTraining) tweeted pictures from the launch workshops for the toolkit we’ve developed with them which uses case scenarios to support social workers in the new ways of working the Act requires.
Tuesday, March 31, 2015
A guide to economic assessment in nursing: new pamphlet published
RCN publishing have brought together five articles, which were originally published in Nursing Management, to form one standalone guide to economic assessment in nursing. The articles were written by OPM director Dr Chih Hoong Sin and RCN’s research and innovation manager, Dr Ann McMahon and cover:
- the principles of economic assessment
- ways to apply these in practice
- a number of tools and templates
- suggested ways to put monetary values against different costs and benefits
- and concludes with seven approaches to conducting economic assessments.
Together they offer readers a step by step guide to critically examine economic assessments in the context of nurse-led service innovation, and include exercises to help readers put their new knowledge into practice. However, despite the fact these articles were written with a nursing readership in mind, they are designed to be accessible to all novices in economic assessment, and the principles, tools and procedures are also relevant those outside the nursing field.
For more information, or for a hard copy of the pamphlet, please contact Lawrence Finkle OPM’s Communications Officer on email@example.com.
Tuesday, March 31, 2015
Person-centred care: putting patients in control
In England, more than 15 million people have a long term condition. Improving the treatment and management of long term conditions (LTCs) is one of the most important challenges facing the NHS. This requires a shift towards models that are proactive, holistic and preventive where people with LTCs are encouraged to play a central role in managing their care.
Working with rather than doing to
The Health and Social Care Act (2012) requires CCG Boards to promote the involvement of patients, their carers and representatives (if any) in decisions which relate to the prevention and diagnosis of illness, as well as their care or treatment. As recognised by, amongst others, Nesta: people living with long-term conditions face significant challenges, but they also have strengths and abilities including the capacity to manage their own health, given the right support.
While the benefits of person-centred care are increasingly recognised, changes to practice remains patchy and inconsistent (Nesta). King’s Fund (2013), amongst others, argued strongly that encouraging better support for self-management and better use of community assets could create greater value at a cost lower than is possible with the current fragmented network of services. Their call is that CCGs will need to be ambitious if they are to change traditional ways of working and realise the benefits in terms of better outcomes and greater value for money.
Supporting patients to be more active and engaged in their own health
OPM has been commissioned by South East Commissioning Support Unit to develop an online menu of resources – toolkits, training and support, to help commissioners develop transformational models of integrated, personalised care co-designed with patients and carers to better manage long term conditions, reduce emergency admissions and promote prevention.
One of the resources is a an online searchable directory to support self-management, bringing together a useful selection of well known evidence-based tools to encourage and support patients to manage their own health through, for example, shared decision making, social prescribing and personal health budgets.
A directory of online resources alone won’t develop the culture, systems and processes to make the vision of patients in control a reality. To truly put patients at the centre of their own care, attitudes and practice of commissioners, clinicians and patients need to change. It will also require capacity building efforts and CCGs identifying what might provide the most value in their local area.
Creating a better understanding of local offer to support person centred care
Support may not be confined to those normally supplied by traditional health services. To be useful in a local context, GPs and other clinical staff need to have a much better understanding of what’s available locally to support patients in managing their own health and care. Commissioners should be encouraged to work with their local partners (NHS, voluntary and community sector organisations or private sector) to map local social prescribing options in any local area.
Islington is one area where there has been a concerted effort over a number of years to support patients to take a more active role in their care. Islington was a pilot site for the Co-creating Health programme to transform local diabetes care. As one of the first wave national integrated care and support pioneers, Islington have been working with people who have long term conditions such as COPD and diabetes to develop self-management plans, looking at their goals and wishes around care. This has involved more referrals to self-management support programmes, and longer appointments to ensure that better conversations take place in primary care. Islington also recognised the need for greater collaborative working across the area, and one approach has involved commissioning a VCS organisation to run a Health Navigator service that identifies and signposts to different sources of support locally to help improve patient quality of life and maintain independence, in turn delaying the need for more intensive health and social care services.
“Across the country colleagues are embarking on similar projects based on the evidence that shows what a difference person centred care makes to people’s lives… The challenge for commissioners is to respond to this and work with colleagues inside and outside of NHS structures to move person centred care in to the mainstream of healthcare provision.” Dr Katie Coleman, a GP and Vice-Chair of Islington CCG
So, to put patients in control of managing their own health and care there is a clear role for community services and self help. This requires identifying a portfolio or menu of local services for people to choose from, and a willingness on the part of commissioners to fund non-traditional services.
This is the first in a series of blogs to be published following the development of a set of online tools and resources by OPM in support of the person-centred care agenda for South East Commissioning Support Unit. The second is entitled: Person-centred care: measuring impact and the third: Patients in control: ‘assume it’s possible’.
Tuesday, March 3, 2015
Chih Hoong Sin interviewed for HSJ Workforce Supplement
Chih Hoong Sin, OPM’s Director for Evaluation, Research and Engagement has been interviewed for the latest Health Service Journal (HSJ) Workforce Supplement on the benefits of Specialist Nurses.
Chih Hoong was among a select group of patients, researchers, academics, healthcare managers and those working in charities and patient support groups – as well as nurses themselves – who were asked to share their perspectives on the difference specialist nurses can make.
Some of Chih Hoong’s thoughts are featured in the ‘How specialists can help you’ and ‘Meaningful efficiencies’ sections which are available to view here.
Monday, February 9, 2015
Social care has a role in preventing hate crime, it’s not just a criminal justice issue
A multi-agency hate crime care pathway will raise much-needed awareness of the issue, says Dr Chih Hoong Sin
In an article published in Community Care in June 2014, I argued that it is important for care agencies to recognise their role in preventing hate crime, and not to see it purely as a criminal justice issue. In a subsequent blog for the International Network for Hate Studies, I said that health and social care agencies can play three critical roles in relation to hate crime:
- To provide treatment and support to hate crime victims.
- To help prevent hate crimes by identifying and acting on the early indicators of repeat victimisation.
- As potential offenders, particularly in institutional care settings.
In the latter half of 2014, I started working with Leicestershire Partnership NHS Trust and its partners on developing a hate crime care pathway. Leicestershire has been at the forefront of efforts to respond to the challenge of getting health and social care services to acknowledge their multiple roles in relation to hate crime. It is heartening that others, such as NHS Greater Glasgow and Clyde with Glasgow City Council and Police Scotland, have a similar commitment to develop joined-up approaches. There is a real desire to learn and share which is why I want to describe some of the key steps we have been taking in Leicestershire and explain the rationale behind the approach.
You can read the full version of this article on the Community Care website.
Tuesday, February 3, 2015
The NHS financial crisis: E-QIPP-ing the nursing workforce with the skills to drive quality and efficiency improvements
It seems that not a week goes by without some form of media headline trumpeting the scale of the financial crisis confronting the NHS. NHS finances is a major issue requiring urgent and sustainable solutions. In the past few years, the National Audit Office repeatedly questioned the sustainability of savings made to date. The easiest savings have been made – through a pay freeze for public sector staff, reductions in the prices paid for healthcare, and cutting back-office costs. Yet these savings have yet to be driven by fundamental service transformations at scale. The latest report by the Public Accounts Committee underlines the depth of the problem, pointing out that the proportion of NHS trusts and foundation trusts in deficit increased from 10% in 2012-13 to 26% in 2013-14. According to the regulator Monitor, the problems are particularly bad for hospitals, with 80% of acute foundation trusts reporting a deficit half way through the current financial year.
More worryingly, there is evidence that ‘cuts’ may be conflated with ‘savings’. This reflects the lack of a whole system approach in looking at how we make decisions about resource allocation. After all, the Mid Staffordshire NHS Foundation Trust Public Inquiry has shown how the Trust Board’s focus on short term cost control contributed to a range of adverse impacts on the quality and safety of care, that have longer term financial (and other) implications.
In relation to nursing, a study published in the British Medical Journal indicated that reducing cost through shedding or not replacing frontline nursing staff impacts on the quality and safety of care that, in turn, have implications not only on patient outcomes but also on the financial costs to the health and social care system.
Putting NHS finances on a sustainable footing requires not only different ways of doing things, but also new skills. While it has been estimated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK, to date little has been done to harness this potential. As the largest professional group within the NHS, nurses play a critical role in delivering services and innovations in a way that achieves clinical outcomes and patient satisfaction, and will be vital in helping the NHS meet its quality and efficiency challenge. However, nurses often lack the skills to formulate and put forward arguments about the economic impact of what they do, over and above the clinical outcomes they contribute toward achieving. Nurses and other healthcare professionals often feel like they are reacting to, rather than driving efficiency initiatives.
OPM developed a programme aimed at building the capability of nurses and other members of the public service workforce to be able to generate evidence of the costs and benefits of various services in order to inform ongoing service improvements. Since 2013, OPM has been delivering this programme to cohorts of nurses in partnership with the Royal College of Nursing (RCN), with generous funding from the Burdett Trust for Nursing. Evidence to date shows how trained nurses contribute proactively to the Quality, Innovation, Productivity and Prevention (QIPP) agenda – in many cases helping to generate ‘cashable’ savings.
For example, a nurse in Scotland produced an economic assessment that showed how her heart failure nurse liaison service helped reduce both hospital admission rates and lengths of stay per admission, while also reducing demands on other professionals’ time. She was able to calculate efficiencies of around £454,928 per year, representing a return on investment of £489 per patient. More importantly, based on the evidence, she was able to make recommendations for where there may be further scope for increasing efficiencies. She identified that by improving part of the patient referral pathway, the service is likely to generate additional efficiencies, the potential return on investment rising to between £671 and £779 per patient per year. Based on this evidence, she was able to mobilise other colleagues and senior management to effect service re-design in a way that secures both quality and efficiency. This is testament to how an empowered workforce, with the right skills, can help the NHS meet its financial challenge while maintaining a clear focus on high quality care.
The Public Accounts Committee noted that radical service reconfigurations require “significant upfront investment”, and that this will become increasingly difficult with less money available for such investment as more NHS organisations move into deficit. Equally, a case may be made that securing a sustainable financial future for the NHS requires not only investment in services and service transformations; but also investments in the workforce to be able to drive meaningful change ‘on the ground’. Valuing public services means valuing our public service workforce, and seeing them as part of the solution.
Note: The programme is currently being delivered to cohorts of nurses in England, and there are still a few places available. More information about the programme, and the process for registering an expression of interest to participate, is available from the RCN website. ‘A guide to economic assessment in assessment in nursing’ supports the provision of RCN and OPM training in how to perform economic assessments and use economic evidence to demonstrate the value of nurse-led innovation.