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How Does Access to Community Health Services for Older People Vary Across the Midlands?Community health services provide invaluable support for older people with a range of health care needs. These services also keep local health systems working efficiently. Despite this importance, comparatively little is known about the scale and distribution of community services. The NHS may consequently fall short when it comes to monitoring and planning these services. Integrated Care Boards (ICBs) in the Midlands therefore commissioned this report, through the Midlands Decision Support Network, to better understand how access to community services varies across the region. We were asked to focus on services for older people (taken to be those aged 65 and over). We set out to investigate what could be said of community services in terms of their: Scale and concentration. How much care is provided? How has this changed over time? To what extent is care concentrated or distributed? Socio-economic distribution. Which population groups receive the most care? Effect on demand. (How) have changes in community services provision affected pressures in urgent care? The nature of these analyses was exploratory. Lack of existing knowledge, and expected problems with data quality, meant that we focused more on the question of what could be said, than on generating definitive answers and recommendations. Nonetheless, we see several implications of this work for Midlands ICBs.
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GP Practice productivity, efficiency, and continuity of careIn the previous two reports in this series, we showed that crude GP practice consultation rates, the average number of consultations per person per year, has been falling since 2012, whilst the need for consultations has been increasing. A substantial gap between need and supply has opened up, with significant consequences for patients and the wider health system. Almost half of patients now report difficulty getting through to their GP practice by telephone. Attendances at over-stretched emergency departments for conditions treatable in GP practices have increased. And there has been a rise in the number of emergency admissions to hospitals for ambulatory care sensitive conditions. The scale of the gap between need and supply is such that substantial GP recruitment must be the mainstay of any solution. But large-scale, national efforts to increase the numbers of clinical staff take time, and despite considerable efforts, the number of fully qualified, permanent GPs, the core of the primary care workforce, has fallen since 2015. Resolving this recruitment problem remains a key feature of national strategies for primary medical services. But given the pressing consequences of an under-supply of GP practice consultations and the intractability of the GP recruitment challenge, efforts to close the gap between need and supply have increasingly focused on productivity solutions. In this report, we explore the issue of GP practice productivity and efficiency; how it might be measured, how it has changed over time, the degree of geographic variation, and the relationship between productivity, efficiency, and continuity of care for patients. We draw heavily on three pieces of research carried out recently by the University of York, by the Strategy Unit in conjunction with the University of Birmingham and by the University of Cambridge and the INSEAD business school. Key Findings Analysis by the University of York suggests that cost-weighted productivity of primary medical services increased rapidly, by 2.3% per annum between 2004 and 2012. Since 2012 productivity growth has stalled. A cross-sectional analysis of GP practice productivity in 2019 and 2020, carried out by the Strategy Unit, suggests that there is little headroom for productivity growth within the service model that was prevalent at the time. The benefits of care continuity to patients, staff and health systems have been widely reported. But recent research by the University of Cambridge finds a positive relationship between continuity of care and the efficiency of a GP practice consultation. The time to a patient’s next appointment is increased if they are seen by their usual GP. As efforts to increase the number of GPs have faltered, attention has turned to reducing the gap between need and supply of GP practice consultations by improving input-output productivity. These efforts take many forms including division of labour and the delegation of duties to nurses and other healthcare professionals, remote consultations, extended hours, the diversion of low acuity cases to pharmacies, and the merging and federating of GP practices. These efforts to improve input-output productivity may be undermined by the absence of financial incentives to increase supply. They may also lead to unintended reductions in continuity of care which increases need and reduces supply. An alternative approach to closing the gap between need and supply of GP practice consultations would make continuity of care the primary objective. A strategy based on this priority would be a radical departure from current policy.
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The gap between need and supply of GP practice consultationsThis is the second in a series of three analyses of GP practice service provision. In the previous paper in this series, we showed that GP consultation rates, the average number of consultations per person, increased between 1995 and 2012, before falling steadily to 2019. Trends beyond this point become more difficult to interpret and the available evidence is not consistent. This is important contextual information for those keen to address patients’ concerns about access to GP services, but additional insight is needed before a grounded policy response can be settled on. Interpreting trends in supply, would ideally take place alongside data on trends in patients’ needs. In this paper we seek to answer two related questions. How have consultation rates changed over time relative to need? Are patients with a given level of need, more or less likely to receive a GP practice consultation now than they were in the past? and, If gaps between need and supply of GP consultations exist, do we see any evidence of displaced demand and failure demand elsewhere in the healthcare system? Our analysis covers the period from 2008 to 2019, and uses the primary care research database, CPRD Gold. Over this period there is close agreement between the various available data sources about trends in consultation rates. Supplementary analysis draws on data from the GP Patient Survey, the Emergency Care Dataset (ECDS) and Hospital Episode Statistics (HES) for admitted patient care. The final paper in this series considers GP practice productivity, efficiency, and continuity of care. Key findings The use of GP practice consultations increases with age and with levels of morbidity. Since 2008, the population has aged and age-specific morbidity levels have increased. This suggests that need for GP practice consultations has grown, whilst the average number of consultations per person has reduced. We estimate that in 2019, a patient was 12.2% less likely to receive a consultation than a patient with similar needs in 2012. An additional 36.6 million consultations (+13.9%) would have been required to meet needs in 2019 as they were in 2012. Patients are finding it increasingly difficult to contact and make a convenient appointment with their GP practice. It has become more common for patients to use emergency departments and urgent care centres to access care that would normally be delivered by GP practices. Hospital admissions for acute, and to a lesser extent, chronic ambulatory care sensitive conditions, had been rising prior to the pandemic.
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Long-term trends in GP practice consultation ratesGP practice consultations are, by some distance, the most common interaction between the NHS and the population it serves. During these consultations, patient’s acute conditions are diagnosed and treated, their long-term conditions are managed, preventative interventions are delivered, and referrals to secondary care are made. Patient satisfaction with access to GP practice consultations is a long-standing problem, but this issue has become more acute since the COVID-19 pandemic. Most consultation appointments are booked by telephone, but in a recent survey, 50% of patients reported difficulties getting through to their GP practice by telephone, up from 30% in 2018. One might expect that the NHS would have a detailed and comprehensive understanding of the levels, types, and distribution of this important service. Whilst there have been many advances in recent years, there remain important gaps in our knowledge. In this paper we explore the long-term trends in GP practice consultation rates. We use two research databases, Clinical Practice Research Datalink (CPRD) Gold and Aurum, to estimate consultation rates between 1995 and 2022. We consider all interactions between a patient and a healthcare professional: face-to-face consultations in the GP practice, consultations conducted by telephone, or using digital technologies, and visits made to the patient. We set our results alongside (1) estimates from other studies, (2) new data on GP appointment rates, (3) GP patient survey results, (4) information about the GP practice workforce and its workload, and (5) data on other important forms of GP Practice activity. Key findings Practice consultation rates, the average number of consultations per patient per year, increased steadily and for many years until 2012, corroborating results from earlier studies. Between 2012 and 2019, consultation rates fell, reversing the gains seen since 2008. As far as we are aware, this is the first study that highlights a fall in GP practice service levels over this period. From 2020, the two sources of data that we used to estimate consultation rates, produce substantially different results, with one showing continued reductions and the other showing rapid increases in consultation rates. Analysis of other sources of information fails to resolve the matter. Experimental data from NHS Digital suggests GP practice appointments have increased, but responses to the GP Patient Survey, and data on prescription and referral rates imply that consultation rates have decreased. That no clear consensus emerges from these analyses of post-pandemic trends, may indicate an issue with the primary unit of activity of GP practices, a patient consultation. For many years, this unit of activity had a clear and consistent meaning. Between 2008 and 2019, counts of consultations from different systems and sources provide similar results and similar trends. But the widespread adoption of remote consultations and digital technologies, the emergence of Primary Care Networks, and the rapid expansion of the allied healthcare professional workforce, have led to radical changes in service models. Future analyses of activity trends and equity of access may require the development of new activity units that better reflect the operations of modern general practice. This analysis, the first in a series of three, considers changes in the rate of consultations per patient per year. The remaining papers in the series will explore how rates of consultations have changed relative to patient need, the consequences of these changes on hospital activity, and changes in the productivity and continuity of GP practice service provision.
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A Picture of End-of-Life Care in EnglandWorking with Macmillan our analysis investigates who is more likely to experience poor outcomes associated with shortcomings in end-of-life care? Are there particular areas in England where those at end-of-life face significant challenges and how might the supply of services in an area be influencing these?
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Review of Ophthalmic Managed Clinical Networks (MCNs) in Staffordshire and ShropshireEyes on the prize: The development of managed clinical networks for optometrists and ophthalmologists. By creating new networks connecting optometrists and ophthalmologists, eye-care specialists are finding new ways to collaborate and share specialty knowledge to improve patient care. The Strategy Unit has conducted a review of two of these new managed clinical networks (MCNs), analysing the impacts of their collaboration and publishing their findings in an in-depth report. Managed clinical networks are self-supporting groups of professionals working together to ensure cross-speciality sharing of patients and expertise. The aim of the MCNs is to bring together primary care optometrists with local ophthalmologists within a geographical area. This way, knowledge can be shared on a local level whilst encouraging networking with neighbouring colleagues. The Strategy Unit were commissioned by NHS England to work with a medical retina MCN in Shropshire, Telford and Wrekin and a glaucoma MCN in Staffordshire and Stoke on Trent, to review their work so far and look at the opportunities the networks present. These new MCNs were established around the two different ophthalmology sub-specialities of medical retina and glaucoma because they contain high volumes of patients with scope for service improvement. Under the guidance of Local Eye Health Network Chair Claire Roberts and Local Optical Committee chairs, Paul Cottrell (Shropshire) and Irfan Ravzi (Staffordshire), a collaborative and supportive environment within which to learn and share best practice was created. Improving patient care has been the underlying drive for previous collaborations of this type and Ophthalmic MCNs are no different. They have given the chance for ophthalmologists and optometrists to get to know each other on a local level whilst starting to incorporate joint learning on both sides. For those who are mostly based in high street optical practice, the networks have led to more opportunities to focus on their professional development. One of the keys to success for the MCNs has been a culture of being able to ask questions and offer thoughts in meetings without fear of judgement. Using ‘Chatham House’ rules, where the identity or affiliation of the person speaking is withheld, participants have been able to have a safe, protected space to encourage learning. Through these types of meetings, ophthalmologists and optometrists can more readily identify interests, skills, and competencies, opening up new avenues for working and learning together. This review makes seven targeted recommendations for the successful scaling up of MCNs across the Midlands. As these MCNs grow they are well placed to provide an opportunity for shared learning and promote greater levels of knowledge and understanding to match continuing enthusiasm for collaboration.
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Learning about what works in urgent community responseNHS England commissioned the Strategy Unit at Midlands and Lancashire CSU and Partners Ipsos UK to conduct a multi-year, two-part evaluation of 2-hour Urgent Community Response (UCR). This national evaluation is the first of its kind to try to demonstrate the impact of an urgent at-home care service and will build evidence of what works best. This initial phase of the evaluation includes a process evaluation and report and an economic modelling tool (to be published shortly), which are the key outputs from the first year and a half of the evaluation. The final phase of the evaluation will be published in spring 2024 and include: key learnings from implementing UCR; proposals for policy changes to support Integrated Care Boards to understand what works best; an updated economic model; and an impact evaluation, which will focus on how UCR has met the needs of individuals and prevented further clinical deterioration as well as UCR’s impact on Urgent and Emergency Care. Background on UCR and the national evaluation The 2-hour urgent community response (UCR) standard requires all Integrated Care Systems (ICSs) to assess, treat and support people aged over 18 experiencing health and/or social care crises in the place they call home, including care homes, who are at risk of hospital admission. The service has been implemented across England since the first UCR ‘accelerator’ sites in 2020. Since April 2022, each ICS has been required to provide a consistent service from 8am-8pm, seven days a week across its full geography. UCR is central to the NHS Long Term Plan ambition to provide the right care, at the right time, to people closer to home – and remains a core element of strategies to manage winter pressures, recover from COVID-19 and further shift resources to home and community-based services. As set out in 2023/24 System Planning guidance, providers have been asked to increase referrals into UCR services, which should respond to the following nine clinical conditions, at a minimum: Falls Decompensation of frailty Reduced function or mobility Palliative or end of life urgent care Urgent equipment provision Delirium Urgent catheter care Urgent support for diabetes Unpaid carer breakdown The national evaluation of UCR is working with seven case study sites, selected to reflect a range of contexts and delivery models, to explore what works and provide learning for implementation across England. There is a process (qualitative) strand developing a narrative of the different approaches across the different stakeholders involved and an impact (quantitative) strand that will establish the difference the service makes on admissions. Despite UCR being implemented in every ICS in England, variation remains between how different clinical conditions are responded to and how local teams establish their service model. Part of this variation is because the seven sites that were evaluated built their UCR service from existing provision, which differed from site to site. This is expected in a relatively new service, which requires extensive joint working across service and organisational boundaries. The national evaluation will support an understanding of what works best within certain types of settings. Year one evaluation report The first report from the national evaluation of the standard for NHS England draws on findings from over 100 qualitative interviews with senior leaders, managers and front-line staff. It provides an overview of the seven different case study models and learning from their development and delivery to August 2022, with recommendations for ICS leaders and NHS England. Findings are focused on operational learning; key benefits and challenges for patients, carers, staff and the wider healthcare system; and recommendations for system leaders. Key findings include: Participating sites support the 2-hour waiting time standard for UCR and operating service model due to its perceived benefits in preventing deterioration among patients, reducing pressures on other health services, providing care in the community and enhancing cross-system working. The sites took different approaches to the way they set up their teams, data collection and use of resources to deliver at-home care within a two-hour timeframe. Rather than creating new UCR teams from scratch, the majority of sites worked to develop UCR services from existing teams, sometimes spanning multiple providers, and built on existing resources. This required partnership working across health and care to establish their UCR offer. The physical co-location of teams with other services and having weekly discussions to escalate cases was highlighted as a key facilitator of an integrated service. This enabled joint-working and the ability to build better relationships among staff, which resulted in improved communication and decision-making. Key areas in which sites have gone further than the national guidance include: Workforce and development (for example, unique or expanded job roles and duties or the introduction of specific UCR leadership roles and portfolios) Introduction of new technical resources, such as bespoke fully stocked service vehicles Investment in technological solutions for tracking available staff with appropriate skills to meet patient needs, enabling remote working and information sharing between providers The most common areas identified for improvement include: Strengthening links with 111/999 services and working with virtual wards Developing a consistent system-wide model at scale Improving data quality in order to document progress on key performance measures The evaluation team are continuing to work with the seven case study sites in 2023 as well as other providers as required to explore how provision has developed since the beginning of the evaluation. A quantitative impact evaluation will also be finalised by the end of the 2023/24 financial year. Economic modelling tool The team have developed an economic modelling tool that can help system planners and analysts understand the impact of UCR on finance and service-level activity, to support pathway modelling. It is accompanied by a user guide and five how-to videos. The model is based on a set of assumptions, using local and national figures, and compares UCR activity against a situation where there is no UCR service of any kind. The modelling tool and resources will be available here soon.
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How is growth in diagnostic testing affecting the hospital system?Our latest report published for The Midlands Decision Support Network presents a systems analysis that suggests, alongside benefits, the recent growth in diagnostic testing has had a substantial and adverse effect on the flow of patients through hospitals and on the timeliness of care that patients receive. MDSN Diagnostic Growth Report We find that growth in diagnostic testing has led to: Longer waits and overcrowding in emergency departments. A longer waiting list (and longer waits) for elective treatment. Longer stays in hospital and decreases in bed availability. These effects are sizeable; they are felt in both elective and emergency pathways; and, unaddressed, they will undermine patient safety. The key message of this report is that trade-offs are inevitable in our health system. All else being equal, an NHS that increases testing as fast as capacity allows will be more perceptive but less responsive than one offering minimal testing. The question is, what is the correct balance? What rate of diagnostic growth will secure the best overall outcomes for the population? It may be that the NHS will have to grow diagnostic services more slowly than it might wish, so that the growth is sustainable and better balances risks and benefits across the system.
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The NHS as an anchor institution: addressing fuel povertyThe number of households in fuel poverty in Staffordshire and Stoke-on-Trent (SSoT) is higher than the national average. As anchor institutions, NHS organisations can use their assets to influence the health and wellbeing of their local communities. The Strategy Unit was asked by the Midlands NHS Greening Board to evaluate a cross-sector initiative in SSoT to help alleviate fuel poverty using savings generated through solar panels on NHS buildings. The project is called Keep Warm, Keep Well. About the project In 2016, University Hospitals North Midlands (UHNM) partnered with South Staffordshire Community Energy Limited to raise funds (through a share offer) for solar panel installation on their hospitals. The savings from the panels are paid into a community fund. Patients from the hospitals with conditions that may be made worse by their home environment are referred to a local charity, Beat the Cold. A fee is paid for each patient who is referred, from the community fund. NICE guideline NG6 states that health providers should play an active role in reducing the health risks associated with living in a cold home. In Keep Warm, Keep Well, when a patient is discharged hospital staff identify whether that person is likely to be vulnerable to the cold and if action is needed to make their home warm enough to return to. Initially the project prioritised patients presenting with respiratory conditions, hypothermia, or frailty, as groups particularly vulnerable to living in cold or damp conditions. Where a person is identified as potentially vulnerable, their details are passed – with permission – to Beat the Cold, who can help them to access financial and other support to improve their home environment. The evaluation The evaluation took place in 2022 following a period of reduced referrals to Beat the Cold during the COVID-19 pandemic. The Greening Board, the project team at UHNM and its partners wanted to understand how they could make improvements to their processes, and demonstrate the impact of their interventions in the future. The Strategy Unit team found that: Staff rotation on hospital wards had made it difficult to maintain the profile of Keep Warm, Keep Well, leading to variable referral rates. As a result, Beat the Cold were planning to have a more regular presence at the hospital, to remind staff to provide patients with the offer of their support if appropriate In most cases, only clinical staff were able to make a referral to Beat the Cold. The evaluation found that other staff (for example, volunteers) could also be encouraged to identify potential referrals Patients could be encouraged to self-refer to Beat the Cold, signposted by hospital staff, rather than always needing to rely on a formal referral UHNM could work with community health providers to provide more avenues for identifying those who may benefit from Beat the Cold’s support. The evaluation also recommended some improvements to the data collection processes for the project, to support it to demonstrate its impact on patient outcomes and hospital admissions. The SSoT Integrated Intelligence Hub advised on this aspect. Keep Warm, Keep Well demonstrates an innovative approach to using NHS assets to affect the health of communities. It was awarded a High Commendation Award for contributing to Net Zero by the Health Services Journal in 2022. Options to expand the scheme are being explored, and this evaluation can help those involved to refine the approach.
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ICS intelligence functions – a toolkit to support the implementation of NHSE guidanceIn 2020, NHSE announced the expectation that ICSs should develop “shared cross-system intelligence and analytical functions that use information to improve decision-making at every level.” This expectation has been followed by more detailed guidance for health and care systems setting out: What an intelligence function is National enablers that can support their development How intelligence functions can help with decision-making; and What a good intelligence function looks like. Alongside this work, the Strategy Unit, with input from the Nuffield Trust, were commissioned by NHSE to create a toolkit to help ICSs introduce intelligence functions into their system plans. This toolkit provides a curated set of materials offering ideas, inspiration, and practical advice for getting started with an intelligence function that can be tailored to local contexts. The toolkit provides systems with: A clear description of different types of analyses systems can undertake, and the skills and resources they will need to execute them A set of actionable ‘tips for getting started’ with an intelligence function Available resources that can address some of the essential questions that will need to be explored as intelligence functions are developed; and A set of case studies describing how ICSs have already made progress in establishing their intelligence functions. This toolkit is another example of the Strategy Unit’s ongoing commitment to furthering the use of high-quality analysis across the NHS. For example, it should be considered alongside our recommendations for advancing the analytical capability of the NHS and its ICS partners. It is also clearly linked to our work with Decision Support Networks. The Strategy Unit is also organising the first national Health and Care Analytics Conference (HACA 2023) to celebrate and advance analysis as delivered by the NHS and local government across the UK.
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Strategies to reduce inequities in access to planned care: an Ethics Review for Integrated Care BoardsWe are delighted to present a report on inequities in access to elective care for the Midlands Decision Support Network (MDSN). Produced by Angie Hobbs - the world’s first Professor in the Public Understanding of Philosophy – this paper examines the ethical questions raised by our report outlining strategies for reducing inequity. Professor Hobbs looks at our suggested strategies with the eye of a professional philosopher, asking: what ethical tensions and issues might arise by following these strategies? How can they be overcome? Her headline finding is that all the strategies suggested in our work are viable from an ethical perspective. And she goes further, outlining a process for decision-making which – if followed with care, thoughtfulness and humility – should give Integrated Care Boards (ICBs) and hospital trusts confidence in making ethically thorny choices. This ethics review is a further significant addition to the case for addressing inequities. It follows: Our May 2021 report outlining the nature and scale of the problem of inequities in access to elective care. Our May 2022 report suggesting strategies for addressing the problem. The legal review from Hill Dickinson examining these strategies from a legal perspective. Work by University Hospitals Coventry & Warwickshire NHS Trust, who have shown that it is practically possible to implement approaches to addressing inequities. Research by our partners Ipsos demonstrating that it is possible to engage people in the sophisticated and tricky choices involved. Analysis cannot change practice. This requires others – ICBs, hospital trusts, policy makers – to act. But analysis can guide action and reduce barriers to it; and we believe the work outlined above presents a compelling case with some clear routes forward. The NHS is committed to addressing health inequalities. We see our work as an important element in helping it to do so, with Professor Hobbs’ ethics review offering a unique contribution to this conversation.
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Strategies to reduce inequalities in access to planned hospital proceduresOur new report guides Integrated Care Boards through the process of developing a credible strategy to reduce inequalities in access to planned hospital procedures. In our 2021 report for the Midlands Decision Support Network, we described how people living in more deprived areas have poorer access to planned hospital care than their more affluent counterparts. These deficits are widespread, substantial, and worsening. In this report, we move beyond describing and explaining the problem, providing practical support for those keen to address it. We start from the premise that inequities are not immutable. Tackling the issue will not be easy, but it is essential if the NHS is to be true to its founding principles. Efforts to date have clearly not been sufficient. Bolder action and more potent interventions are required. The report is primarily aimed at integrated care board (ICB) members. Is addressing inequities in planned hospital care a priority for your organisation? If it is, then we hope this report will help. How much additional care, and of what type, would be required to ‘level-up’ access to planned hospital procedures? Is levelling-up the only solution? What interventions exist that might help reduce inequities? How might an ICB go about setting its strategy? And once set, how should the strategy be monitored? These are the questions addressed by this report. Update 10th August 2022: To help ICBs and others, in taking the insights from this report into action, we have commissioned some further perspectives on the possible strategies described. The first of these is a publication from colleagues at Hill Dickinson which provides an up-to-date overview of the legal duties placed upon ICB decision makers in relation to reducing inequalities and then considers the range of possible strategies proposed in our report from that legal perspective. This paper will be followed later in the year by one that addresses the ethical dimensions of developing strategies to address socioeconomic inequalities in planned care.
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Benefits of Digital Social Care RecordsThe pace of change in the development and use of digital technology is astonishing. The use of such technology has been an essential element in the health and care services response to the COVID-19 pandemic. In many cases, the previously unthinkable became commonplace. Yet take up has been far from uniform. There are very mixed views across the health and care sectors on the power of digital technologies to improve the quality of care for people they support. Sceptics rub shoulders with enthusiasts. This translates into wide variation in use. In very general terms, the social care sector has been slower than health services to adopt digital solutions for capturing and sharing information about service users. Alongside challenges of implementing new technologies in their work, this can also partially be attributed to a potential lack of clarity about the exact benefits of doing so. To help clarify these benefits, we examined the evidence. We identified and analysed evidence on benefits for people receiving care and their support networks, for people delivering and managing social care, and for the wider health and care system. We also looked at specific factors that can help or hinder providers introducing digital social care records, as well as how benefits have been measured in the past. This work was completed as part of a wider project with our partners Ipsos for NHSX. NHSX is working closely with the social care sector, supporting them to realise the value of digital social care records - and give providers tools and solutions to help them make this digital transformation. We look forward to supporting these efforts in future, bringing evidence to bear on these important questions. Please get in touch with any comments or questions by emailing jane.greenstock1@nhs.net
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Dudley MCP Scenario AnalysisDudley is one of fourteen vanguard sites nationally developing the Multispecialty Community Provider (MCP) care model. The MCP involves the implementation of new organisational relationships that are intended to result in new system dynamics, incentivising the actions that can improve population health over the long term. The patient is at the centre of the MCP model of care. The MCP will bring together the services of GP practices, nurses, community health and mental health services, community-based services such as physiotherapy, relevant hospital specialists and others to provide joined up care in the community, improving outcomes and reducing demand. All this takes place in an uncertain context: the challenges facing NHS systems are headline news; NHS structures are frequently the subject of organisational change and new policy directives; funding allocations are determined on a relatively short term basis; and the impacts of the wider environment on the NHS and local health and care systems cannot be accurately predicted (e.g. how patterns of trade, competition and migration may change; what technological advances will be made and how the public will respond to them; how the supply and culture of the workforce will evolve). The Strategy Unit has been a strategic partner providing specialist support to the development and evaluation of the MCP, and the MCP Programme Board asked us to assist local stakeholders in exploring a range of plausible futures that could evolve over the intended fifteen year duration of the MCP contract. The aim of this work was not to predict the future but, through exploring a diverse set of plausible futures, to generate practical responses that would increase the effectiveness, resilience and agility of local plans, as well as providing additional assurance to regulators. Scenario work is best seen as an ongoing process: it builds social capital, provokes new insights and enables partners to explore challenging issues in a collaborative rather than competitive manner. This report is therefore only a staging post which: Describes the MCP strategy; Explores key features in the wider contextual environment; Presents three plausible future scenarios; and Records the shared learning that local stakeholders have already begun to generate following a workshop with a broad range of senior local leaders
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Evaluation of the Dudley New Care Models ProgrammeThe Strategy Unit led the evaluation of the Dudley Vanguard programme. This is the final system-wide report from that work. It draws on in-depth interviews with over 20 strategic level stakeholders from the Dudley system. The report looks at both the large-scale procurement process and the development of new services within the Vanguard programme. It provides an update on progress, but it also draws out lessons for both practice and policy. Readers wanting more information on the work we and our partners ICF and Health Services Management Centre did for Dudley should see the microsite we set up to house reports and disseminate lessons: https://www.strategyunitwm.nhs.uk/dudley-mcp
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Lessons from the Vanguard: Innovation and EvaluationThe problems facing health and care services are so well known as to be documented in the media most days. These problems arise from a mismatch between need and provision: a mismatch where there is no reason to assume fundamental change. So innovation – in both product and process – is needed. Yet innovation doesn’t just happen. It must be encouraged and nurtured. It must also be supported with evaluative tools and disciplines: evidence is needed to inform decisions as to whether innovations are scaled, stopped or refined. This short paper suggests that evaluation and innovation are two sides of the same coin. It was produced by Dudley Clinical Commissioning Group (CCG) and its partners the Strategy Unit and draws on Dudley’s experience as a ‘Vanguard’ site under the New Care Models programme.
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Scoping the Future (CRUK)The Strategy Unit was a partner in this project, led by the Health Services Management Centre at the University of Birmingham. The project was commissioned by Cancer Research UK to understand the capacity of endoscopy services to meet growing demand. The work included evidence collation, qualitative interviews with staff managing and delivering endoscopy services across England, quantitative modelling and analysis and triangulation of all the findings to make a series of recommendations. The findings were shared with the Independent Cancer Taskforce to inform the recently published cancer strategy.
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Integrated Impact Assessment for Major Hospital ReconfigurationThe Strategy Unit worked as a strategic partner of the NHS Future Fit Programme in Shropshire and Telford and Wrekin from its initiation and until it was able to move to public consultation. A key output was a comprehensive Integrated Impact Assessment of acute hospital options that enabled commissioners to make a unanimous decision in a very sensitive context. This included an additional focus around women’s and children’s services.
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Lessons from the Vanguard: ProcurementThis short paper sets out learning from Dudley on the above topic. Its fundamental argument is simple: that NHS commissioners should be allowed to award an ‘Integrated Care Provider (ICP) contract’ to an NHS provider without having to undertake a large-scale procurement process. This would enable the system to reap the potential benefits of this contractual form while removing the costs of procurement and related concerns around privatisation. The paper was produced by Dudley Clinical Commissioning Group (CCG) and its partners the Strategy Unit. It draws on Dudley’s experience as a ‘Vanguard’ site under the New Care Models programme.
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The Potential Economic Impact of Virtual Outpatient Appointments in the West Midlands: A scoping studyThe Strategy Unit was recently approached to examine the case for a shift from traditional outpatient services to the use of virtual and remote access technologies for appropriate outpatient appointments. An essential part of this assessment was broadly scoping the potential socio-economic impacts of the shift – something that is arguably not always given enough consideration when thinking about transforming services. This work was commissioned by Andy Williams, Accountable Officer at Sandwell and West Birmingham CCG. The notion for such a shift emerged from discussions between the West Midlands CCG Accountable Officers and the Directors of Adult Social Services in relation to the wider economic impact of the NHS and how it could be improved. The introduction of virtual style appointments provides the opportunity to reduce the negative socio-economic impacts attributable to traditional outpatient services. These are in the form of; effects on productivity for businesses through work absenteeism (time off to attend and travel to/from outpatient appointments); the direct cost incurred by the individual from travel and parking, and the environmental effects of the CO2 emissions from the travel. If implemented effectively, there is the potential to also reap benefits in NHS provider efficiency and cost effectiveness. Virtual and remote access technologies such as Skype are also developing to be increasingly more refined, reliable and sophisticated. They are also becoming more accessible to patients as familiarity with such technologies continues to improve across age ranges. These factors offered the rationale for the scoping study. In addition to analysing the outpatient data, a key component of the study was the review of the evidence base for previous initiatives of where virtual appointments have been tested. It was found that the evidence around relevant interventions largely consisted of small-scale pilots in a variety of acute specialties. Using these findings, the study was able to produce high level estimates for the potential impact of a shift upon: Economic productivity impact (£ GVA), NHS impact (capacity and DNAs), Patient travel and parking costs (£) and Reduced environmental impact (CO2 emissions). The analysis provides an analytical framework for assessing the socio-economic impact of making outpatient services more accessible to patients who are in employment. It does not represent a complete business case for a service change but does estimate that considerable gains could be made – particularly in terms of productivity, which could be of significant benefit to the local economy. To determine whether this can be delivered in practice and reap the possible benefits for the health and care system, as well as the local economy, we are looking for systems who are interested in piloting and evaluating such an approach at a scale not currently available in the evidence base. This latest study built on our economic analysis undertaken with our partners at ICF International, which aimed to understand the current and potential impact of NHS spending on the wider Black Country economy.
