Dudley 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

The 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.

The 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.

The 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.

When the national COVID-19 vaccination programme began in December 2020, it was understood that everyone should have equal access to the vaccine, as appropriate to their need, and as prioritised by the Joint Committee on Vaccination and Immunisation. Within a few weeks however, there were early indications that there were differences in uptake amongst different population groups and in different parts of the country (The OpenSAFELY Collaborative 2021). As a result of these differences, many local examples of initiatives to increase vaccine uptake began to emerge. The Health Inequalities Improvement Team in partnership with the Vaccine Equalities Team at NHS England and Improvement commissioned the Strategy Unit to collect and collate some of these examples in a structured way. What we did: using social media channels and professional networks we identified and requested a half hour conversation with people involved in initiatives to increase local vaccine uptake. We spoke to people in March-April 2021, involved in 50 different initiatives across England and wrote up each of these individual accounts in a structured way. The examples we collected focused on four target groups: place of residence, ethnicity, faith communities and health status and could be grouped as two main types of intervention: information and outreach. Representative examples of each of these are included as case studies on the NHS England website, all 50 examples can be viewed below. A blog outlining the three key lessons for working with communities beyond the vaccination programme is hosted on the NHS Confederation website.

Nottinghamshire has been an early mover in the transition from Sustainability and Transformation Partnerships (STP) to Integrated Care Systems (ICS) within the NHS in England. As part of that transition, it made a conscious commitment to prioritise the transformation of mental health and wellbeing across the system, through a process involving the whole range of system partners – NHS organisations, Local Authorities, voluntary and community sector organisations and, above all, people with lived experience of mental ill health. We were delighted to be selected to support the STP in developing an integrated, all-age mental health strategy. It gave us a wonderful opportunity to build on the innovative analysis we had undertaken for all 44 STPs, making the case for integrating physical and mental health services. The STP told us that our bid "very much stood out in the crowd" because of its system focus and our breadth of understanding of mental health issues. In conducting the project, we provided some key inputs – baseline data packs, a summary of the relevant evidence-base and a report on stakeholder views – and facilitated a series of design workshops with up to 100 people contributing. Our work, in partnership with local stakeholders, provided the STP with a set of key strategic pillars that are designed to support the STP’s journey towards a transformed future for the mental health and wellbeing of the Nottinghamshire population.

Good mental health during early years and childhood has a great bearing on health throughout life. By contrast, poor mental health can cast a long shadow. Consequences may include depression, self-harm, and poor physical health. Services recognise this. They aim to provide access to support in a timely and suitable way. A national target has been set, namely that 35% of children and young people with diagnosable needs should be able to access the necessary services. But there is some way to go. There has been an increasing focus on young people’s mental health, which appears to be poor relative to comparable nations and the recent past. So, to gain a clearer sense of need, and patterns of access to services, the Strategy Unit has undertaken specific analysis for the 11 Integrated Care Systems (ICSs) in the Midlands. This is another significant analytical project for the Midlands Decision Support Network. The ICS have further evidence to understand and address the problems in their area. Our findings 1. Services are struggling to keep pace with existing demand In the Midlands there are an estimated 350,000 children and young people with a range of mental health needs. At present, only 43,000 of these are receiving some kind of specialist support. Identifying the children and young people who most need support is difficult, with health and care professionals finding it increasingly challenging to reach those concerned. When they do, there is simply not enough support available. For example, our research found that only 2% of the estimated 160,000 children and young people in the Midlands with eating disorders are finding their way to specialist support. 2. There is wide variation in access to services in the region Even the better-performing areas are only able to provide the necessary support to 30% of those who need it. Children and young people who are Black / socially deprived / aged 18 to 24 / have learning disabilities or autism, tend to struggle more with accessing appropriate support. Health and care professionals suspect that services are not being provided equitably, but current data doesn’t provide clear enough evidence of this. 3. Access targets are a necessary focus, but there needs to be more meaningful analysis on who is, and who should be, using existing services ICSs need to measure what they are proposing to change. Without the correct data and subsequent analysis, this will prove almost impossible. 4. Routes into and through services need to be clearer Those that need support often don’t know how to access it. Health and care professionals acknowledge that those better able to navigate the complex services, for example through parental advocacy, tend to have an advantage in accessing support. 5. Children and young people should be involved in improving services There is limited involvement of young people in improving services. Mental health and care professionals also want this to happen more. Conclusions There is no single or quick fix to the problems highlighted in the research. Evidence suggests that the pandemic will have placed an even greater strain on already stretched services. Children and young people, as well as professionals, deserve these services to be given far greater priority, as well as improved resources. Especially at a time of stretched resources, ‘fixes’ on this scale are not straightforward. This is a long-term, cross-societal challenge: how much do we value young people’s mental health? This question is well outside the scope of our work. So we have focused our recommendations on more achievable improvements that are within current services’ control. They are to: Collect better data and use it Services could improve data collection around aspects of inequity and access. Greater precision is needed. Datasets in primary care, education, social care, criminal justice, and specialist services could all be linked. All data should be disaggregated by gender and ethnicity. Services could consider an investment in analysis and learning from the data, as well as needs assessments. Measure, monitor and maintain All new initiatives and interventions should be robustly evaluated, for equity as well as efficacy. It is essential that we all learn what works in what circumstances and that it is shared systematically. Establishing a serious learning system will inform the development and adaptation of promising service improvements; it will also provide evidence to stop any services that are not working and allow resources to be redirected. Co-design and co-produce Children and young people deserve to be meaningfully involved in their services, and their voices should be heard. A rollout of targeted engagement programmes would provide a way of reaching them. The detail: The full report is here. The evidence map is here. A webinar exploring findings can be viewed here. ICS level data on unmet needs and pathway inequalities are listed below:

There is a clear moral case for supporting unpaid carers. They play an essential role in the lives of the people they care for; they often do so at a cost to their own wellbeing. But what is the economic case for supporting carers? And to what extent does the evidence base support this case? Where there are gaps in the evidence, how might they be filled? Carers play a vital role in the lives of the people they support. There has been a steady increase in the number of unpaid carers in the UK over recent years, from around 8.2 million in 2011 to 9 million in 2014. Given the pressures of an ageing population, the demand for carers is likely to continue increasing. It is also well known that carers often neglect their own health and wellbeing: they are twice as likely to have poorer physical and mental health compared to non-carers. These factors alone make a compelling moral case for supporting carers. But what about the economic case? From an economic perspective, what are the main arguments for supporting carers? To what extent are these arguments supported by current evidence? Where the evidence is weak, what should be done to fill analytical gaps? NHS England’s Patient Experience Team commissioned the Strategy Unit and ICF to provide a scoping review to examine these questions. The report and a one page summary are below. We are especially interested in hearing from people who are keen to advance the analytical agenda set out in the report.

As health and care economies start to plan how they will deliver against the commitments in the NHS Long Term Plan for England, it's a good time to reflect on how the thinking and learning from the Five Year Forward View might be taken forward. Notably, the New Care Models programme, which set out a series of different models of care. We've blogged previously about the evidence review we were commissioned to deliver by the National Institute for Health Research's Health Services and Delivery Research programme. Ours was one of five reviews funded - we looked specifically at the Multispecialty Community Provider model, which focused on an enhanced role for primary care. Since completing our report, we've been working closely with the project leads of the other four evidence reviews funded to collate and share our findings. We've prepared a high level summary of the five reviews, available to download here, to provide a quick view of the headline messages.

Mental illness is common during pregnancy and first postnatal year (perinatal period), and up to 20% of women experience a wide range of mental health conditions. Barriers to accessing mental health care during pregnancy and the first postnatal year (perinatal period) seem to be greater for ethnic minority women. As a consequence of these barriers, mental illness during the peri-natal period frequently remains untreated. This can have a significant negative impact on the health of the mother and the health of their children, on her partner and the wider family and on the society as a whole. The Strategy Unit was commissioned to collaborate with Birmingham and Solihull Mental Health Trust and East London Foundation Trust on an NIHR funded research project “Accessibility and acceptability of perinatal mental health services for women from Ethnic Minority groups”. Our role was to provide analytical support to phase 1 of the study which aimed to explore access rates to secondary mental health services and patterns of engagement with these services for women from ethnic minority groups in the perinatal period in England. The analysis used national patient level linked inpatient and mental health datasets. Large and statistically significant differences were found in access to both community mental health services and psychiatric inpatient care. In particular Black African and Asian women (all sub-groups) had much lower rates of access to community mental health services. The study also found that higher proportions of admissions for Black African and Asian women were involuntary. The study concluded that access to community mental health services should be facilitated for these groups which may help to reduce the level of involuntary admissions. The results of this work have been published in the peer reviewed journal BMC Medicine.