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  • Dudley MCP Scenario Analysis

    Frith, David (The Strategy Unit, 2018-02)
    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
  • Evaluation of the Dudley New Care Models Programme

    Battye, Fraser; Mulla, Abeda; Begum, Mahmoda (The Strategy Unit, 2018-09)
    The 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:
  • Lessons from the Vanguard: Innovation and Evaluation

    Battye, Fraser; Maubach, Paul (The Strategy Unit, 2018-10)
    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.
  • Integrated Impact Assessment for Major Hospital Reconfiguration

    Frith, David (The Strategy Unit, 2016-11)
    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.
  • Lessons from the Vanguard: Procurement

    Battye, Fraser; Maubach, Paul (The Strategy Unit, 2018-09)
    This 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.
  • The Potential Economic Impact of Virtual Outpatient Appointments in the West Midlands: A scoping study

    de Lacy, James (The Strategy Unit, 2018-11)
    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.
  • A framework for understanding policy change

    Battye, Fraser (The Strategy Unit, 2021-03)
    A new policy, strategic direction or major programme is announced. How do we begin to understand, interpret and explain it? And how can we start the task of analysing and critiquing it? I see three main approaches: 1: Personal views As an individual, we might ask whether we like or agree with the proposed change. Here, we will draw on some combination of personal experience, position and world view. This is a starting point, but results are limited to expressions of individual opinion. 2: ‘Inside-out’, taking the logic of the suggested change We can ‘climb inside’ the proposal to see what we find. Here we would read about the proposal, doing our best to understand it in its own terms. We can then examine the ways its logic might play out in practice. We can test for internal coherence; we can spot likely challenges in implementation; we can also then compare it to analogous efforts. This is more useful than personal views alone. It allows a systematic assessment of any proposal. But maybe this method accepts too much? Maybe it misses something that an outside-in perspective would give. 3: ‘Outside-in’, using a framework of common features We can also view proposed changes from the outside-in. Equipped with a set of typical features, we can ask what the policy looks like from these different standpoints. This could be very useful in supplementing the ‘inside-out’ perspective. But any such set of ‘common features’ would need to be broader than current established and focused approaches to policy analysis (those contained in the Green and Magenta Books, for example). Are there ‘common features’ of policy change that could form a framework? The framework (below) is my attempt to address this question. I was prompted by running an internal Strategy Unit session on NHSE’s ‘Integrating Care’ paper. This forced me to be explicit about the ways of thinking about policy that I have absorbed and used implicitly over the years. I then developed my early drafts by drawing on different commentators’ pieces on the subsequent NHS White Paper. I read: Nigel Edwards discuss the pros and cons of approaches based on competition or collaboration. Judith Smith and Robin Miller think about whether there was continuity or break in policy direction. Hugh Alderwick looking at tensions between political and bureaucratic control - and short Vs longer term decision making. Nicholas Timmins focusing on shifts in power, concentrating on Local Vs National and Democratic Vs Technocratic tensions. The Kings Fund examining similar themes: competition and collaboration; national and local; and the place of NHS reform alongside that of social care and public health. Tony Hockley using the lenses of Prevention Vs Treatment and Equity Vs Efficiency. Donna Hall thinking about organisational and systems perspectives – and treating people as citizens, rather than as consumers. Jennifer Dixon on central ‘command and control’ and the risks of using politics to decide operational priorities. Obviously, I haven’t reflected the range and subtlety of these perspectives in a single framework (!). Instead, I’ve tried to draw out some of the main ways of looking at policy used by these different analyses. Draft framework V0.1 The resulting draft is below. The nature of the task means that there will be no such thing as ‘the finished article’, but I think there is enough to share now for comment. I don’t have a fully refined sense of audience or use, so I'm testing the waters on this too. But I suspect the framework might be useful to: Leaders and managers. It gives them a quick way to understand the main features of policy change, to help them and their teams think critically around it. We will certainly use this as part of the education and development programme in the Midlands Decision Support Centre. Strategists and analysts. The framework suggests ways that different features of a policy will tend towards success and failure. So it can be used to design local strategies and focus analytical attention; and Students interested in policy analysis. It gives them a set of common policy features and ways of thinking that should apply to multiple situations.
  • Making a priority of mental health and wellbeing in Nottinghamshire

    Frith, David (The Strategy Unit, 2018-10)
    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.
  • Scoping study: the economics of caring

    Spilsbury, Peter; Battye, Fraser (The Strategy Unit, 2017-12)
    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.
  • COVID-19: breaking the cycle of deprivation and ill health

    Frith, David (The Strategy Unit, 2020-10)
    The current coronavirus pandemic has prompted a highly-charged debate in which what is good for health and what is good for the economy are unhelpfully and inaccurately set in opposition to one another. In a novel analysis for the Healthier Futures Academy in the Black Country and West Birmingham, we illustrate the effects that a COVID-driven recession could have on population health, and we frame a discussion about how the NHS, with other local organisations, can more effectively address the causes as well as the effects of ill health.
  • Outcomes based commissioning: A framework for local decision making

    de Lacy, James; Frith, David (The Strategy Unit, 2020-04)
    The Strategy Unit has developed a local decision-making framework to empower systems as they look to design new contracting approaches aimed at improving outcomes. It is free to use for all NHS and Third Sector organisations. The NHS Long Term Plan (LTP) calls for a shift to a new service model with patients receiving joined up care, at the right time and in the most optimal care setting. Central to achieving this will be the health and care system working together in alignment and coordinating resources towards these shared goals. The LTP also sets the NHS’s priorities for outcomes and quality improvement for the next 10 years. It is unlikely that any single provider will be able to achieve these outcomes alone. Progress will instead be dependent upon the work of a range of organisations across health, social care, local government, the third sector and beyond. Local systems will need to design approaches to contracting and payment that align with their approaches to quality and outcomes improvement, and that reflect the population covered, the scope of services and the associated provider configuration. Without that alignment, the risk of conflicting incentives and ineffectual interventions is high. In the absence of a nationally-determined approach, each local system should determine how it will proceed. This resource provides a framework, based on relevant national guidance and the international evidence base, to support local decision-makers embarking on a new approach. The framework guides systems in: Confirming system aims and objectives; Determining the scope of populations and services to be included in contracts, and the priority outcomes; Determining the local provider configuration model; Assessing the appropriateness of the mechanisms available for – Allocating resource to providers, and Generating improvement in quality and outcomes; Understanding the drivers of system behaviours likely to operate as a result of, or independent of, those mechanisms.
  • Integrated Impact Assessment for Major Hospital Reconfiguration

    Frith, David (The Strategy Unit, 2016-11)
    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.
  • Future Fit - Acute hospitals options appraisal

    Frith, David (The Strategy Unit, 2016-11)
    The Strategy Unit worked as a strategic partner of the NHS Future Fit Programme in Shropshire and Telford & Wrekin from its initiation and until it was able to move to public consultation. A key output was the comprehensive appraisal of acute hospital options, the recommendations from which were unanimously approved by a Joint Commissioning Committee of two CCGs with their partners.
  • Stage 2 Clinical Assurance Evidence Framework

    Frith, David (The Strategy Unit, 2017-06)
    Service change assurance exists to give confidence to the NHS and public that proposals are well thought through, have taken on board a wide range of views and will deliver real benefits. At the heart of the NHS England assurance process are the ‘five tests for service change’ that are in the government’s mandate to NHS England, as updated in Next Steps on the Five Year Forward View. One of these five mandatory tests is that a clear clinical evidence base underpins service change proposals. Working with Clinical Senates nationally, the West Midlands Clinical Senate commissioned the Strategy Unit to develop this evidence framework in order to help sponsoring organisations ensure that they are building the required evidence from the outset, minimising the risk of any delay.
  • Socio-economic and environmental impact of Herefordshire and Worcestershire STP

    Frith, David (The Strategy Unit, 2020-10)
    Anchor institutions are large, typically non-profit, public sector organisations whose long-term sustainability is tied to the wellbeing of the populations they serve. They also have a significant impact on the health and wellbeing of their local communities. Health and care organisations act as anchor institutions and are often some of the largest local employers and procurers of local services. This puts them in a position where their resources and spending can influence socio-economic outcomes considerably. Wealth, social circumstances and health are inherently linked. Therefore, if health and care’s decisions relating to resource allocation and configuration could also be informed by greater knowledge of this wider socio-economic impact, the benefits derived from each public sector pound could be significantly increased, way beyond simply providing health and care. To explore this for their system, Herefordshire and Worcestershire STP commissioned the Strategy Unit, using funding provided by the West Midlands Academic Health Science Network. We initially conducted a baseline assessment to understand the current impact of the STP on socio-economic and environmental factors. This analysed: Total expenditure in H&W by relevant organisations Gross value added resulting from that expenditure Employment Value of informal care Impact of current outpatient models of care on the environment Economic impact of ill health re: CVD, COPD, and anxiety and depression For the second phase of this work, we analysed two potential initiatives, agreed with the project steering group, that could enhance the STP’s wider socio economic impact. The selected initiatives were: Reducing the adverse impacts of attending face to face hospital outpatient appointments Realising the benefits of providing increased support to informal carers. The results and findings from both phases can be found in the documents below. Following the completion of this work, the STP highlighted: ‘We are really getting some traction around this report. It is getting air time and use, and it has been used heavily to inform our refreshed ICS vision.’
  • Using logic models in evaluation

    Battye, Fraser (The Strategy Unit, 2015-06)
    This briefing was prepared for NHS England, by the Strategy Unit, as part of a programme of training to support national and locally-based evaluation of the Vanguard programme and sites. This paper accompanied a series of national workshops for Vanguard sites and is designed to support stakeholder engagement in the development of logic models, providing a brief summary and signposting further information.
  • Economic impact of NHS spending in the Black Country

    Frith, David (, 2017-07)
    The Strategy Unit is a strategic partner to the Black Country and West Birmingham Sustainability and Transformation Partnership. Our innovative work has built on the local appetite for focusing on transformations that can make a real different to local populations. As well as our national work for NHS England on integrating mental and physical health, initiated by the Black Country and West Birmingham STP, we are also helping to shape work with the West Midlands Combined Authority on the wider determinants of health. A key foundation for this is the economic analysis undertaken with our partners at ICF International to understand the current and potential impact of NHS spending on the wider Black Country economy.
  • Change, complexity, feedback and the role of evaluation

    Battye, Fraser (The Strategy Unit, 2017-11)
    Feedback is a vital component of any complex change programme. Without feedback, it is impossible for policy makers, programme and frontline teams to learn, adapt and improve. The Strategy Unit therefore sees evaluation as a vital part of the mix in making large-scale change. Evaluation is all too often a late – or even an after the event – addition to programmes. Traditionally undertaken as a removed and academic exercise, evaluation has not fulfilled its potential as a tool for change. The Strategy Unit takes a different view. We see a role for evaluation that is highly applied and focused on aiding programme development and implementation. Especially where programmes are large scale and complex, we see evaluative feedback as a fundamental part of the process of change.
  • Logic Models and Complex Programmes

    Battye, Fraser (The Strategy Unit, 2017-11)
    Logic models have become a standard tool for planning and evaluation. This short presentation offers a step-by-step guide to assembling logic models for complex programmes. The Strategy Unit is well known for its use of logic models. We use them to help programmes and organisations – including Vanguard sites and Sustainability and Transformation Partnerships – to set out the thinking behind their work. Logic models clarify thought at the outset. This brings two main benefits: better design and increased ability to evaluate. These slides, which we generally use to accompany training workshops, provide a brief introduction and a step-by-step guide to assembling a logic model.
  • Intelligence-driven health and care: phase two

    de Lacy, James (The Strategy Unit, 2018-09)
    Following on from the Design Summit in May, the Strategy Unit has continued to work on how Intelligence-driven health and care can improve outcomes for patients and local communities. The project, commissioned by MLCSU, aims to explore the emerging intelligence needs of the health and care sector as it moves towards place-based and integrated care systems. As part of the first phase of this work, we developed a set of design principles that are fully informed by evidence, best practice and cutting-edge technology – nationally and internationally. These can be found here: Design Principles The design principles are a means of moving from the evidence that has been gathered to a process for redesigning intelligence systems and strategies. We see the ‘Understanding what really matters’ principle as the most meaningful. This is because the evidence shows that the process should start by finding out what really matters to the population, patients / communities, clinical teams, managers and leaders. It should first establish the questions that they want answering, rather than focusing on ever growing amounts of data without any sense of the questions it is intended to address. In other words, thinking about ‘why?’ and ‘what?’ before getting to ‘how?’. A key input in the formation of the design principles was the set of case studies of US based Accountable Care Organisations (ACOs) – conducted by our partner organisation ICF. The intention of this exercise was to explore US ACOs approaches to the use of data, evidence analysis and business intelligence to identify what learning could be potentially transferable to health and care systems in England. The full report, which includes the case studies of the five selected US ACOs and the discussion and conclusions for the health and care sector, is available here: US based Accountable Care Organisations Case Studies Going forward, phase two of the project will be split into two elements. We will be working with a number of clients looking to apply the principles at system, integrated care provider, and neighbourhood levels, respectively We will also be looking to continue to build on the collaborative learning and knowledge exchange opportunities that have developed as a result of the work in phase one of the project

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