NHS 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.

The 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

The COVID-19 response required rapid change and innovation across health and care. As part of a wider package of evaluation support, from April to June, the Strategy Unit led some qualitative work (training and supporting CCG staff to conduct interviews) across an STP to capture learning from primary care (primarily PCN clinical leads) and community nursing leads about their experiences. The interviews explored the rapid move to total triage, video and online team communications, changes to day-to-day practices, working with care homes and their views on the backlog and unmet need. We held weekly reflective learning workshops with the CCG to both share learning and provide practical support with the delivery of the interviews. We also provided weekly rapid-cycle reporting of headline findings from an initial analysis of interview notes and recordings. Here we share the three rapid-cycle reports that were provided to the STP during the crisis period.

Within months of the COVID-19 pandemic, international evidence on the disproportionate impact of COVID by race and ethnicity began to emerge in countries that collect ethnicity data (the UK, USA, Canada, Norway and Brazil. Each provided more evidence that people living in a country where they were classified as minority ethnic, had a higher risk of contracting COVID-19 infection with more severe outcomes when infected. As a response to this emerging data, the Strategy Unit undertook a small exploratory qualitative study between June and August 2020. We publish these stories, two years into the pandemic as a historical reflection. We recruited via our own personal and professional networks to reach people who are often considered ‘hard to reach’. We conducted 11 in-depth, semi-structured interviews with people who self-identified as minority ethnic and who had experienced symptomatic COVID-19 illness. The purpose of this study was to record individual experiences of: becoming infected with COVID-19; the impact on their households; and, the management of symptoms including how they accessed and used health and care services. Thematic analysis of the qualitative interview data identified five key themes as shown in the figure above. We previously presented these findings at the Strategy Unit’s 2020 Insight festival. We are now publishing a summary of each of these interviews as narrative stories, that is first person accounts under the headings of: My life before COVID My experience of COVID My life after (first infection with) COVID Why my COVID experience matters Whilst acknowledging the many overlapping experiences, we have grouped these 11 stories[1] according to three main categories. We have also provided a summary of each of the three categories. The interpretations are situated in the lived experiences of the qualitative team who undertook this piece of work. We were motivated to challenge the overly simplified narrative of linking the poorer pandemic experiences of minority ethnic people with low socioeconomic status, cultural practices and front-line roles. The accounts collected in these interviews reveal both the counter-arguments and the nuances within these narratives.

During the COVID-19 pandemic we have seen rapid changes in ways of working. We have seen an increase in collaboration, particularly through digital platforms, the sharing of data, and people describing ‘true system working’. So how do we capture innovations and changes in practice? How do we learn from them? How to we identify what should be continued and what should not? How do we sort promising, effective changes from those that are ineffective – or even potentially harmful? If we don’t think about how to do this systematically there is a risk that learning will be lost as pressures to ‘return to normal’ increase. This guide has been developed to help health and social care teams and their leaders learn from service changes put in place or accelerated during the COVID-19 response. The guide is not exhaustive. It offers an overview and practical, helpful suggestions of how learning can be captured and acted upon. It signposts to more detailed resources. The Strategy Unit is currently involved in a wide range of other initiatives to support the COVID-19 response and recovery including through our collaboration with leading think tanks. Please get in touch if you would like to know more.