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Inter-professional working at the frontline; lessons learned from integrated care teams in Tower Hamlets

LorraineMcDonagh10 August 2018

In this post, Mirza Lalani discusses his experience as an embedded researcher in Tower Hamlets

 ‘The process whereby members of different professions and/or agencies work together to provide integrated health and/or social care for the benefit of service users’ (Pollard et al, 2005)

Why inter-professional working? The World Health Organisation (WHO) has stated that inter-professional collaboration is an essential component in satisfactory service delivery.

Health and social care systems in the UK are facing unprecedented pressures to manage rising demand from an ageing population, which is compounded by an increasingly demotivated and constrained workforce and the requirement to operate within tight financial parameters. Integrated care is often presented as part of the solution, as strengthening coordination between health and social care systems and among different care settings to provide joined up care that can help meet the needs of the growing number of patients with complex health and social care problems.

In 2015, the NHS England Five Year Forward View put a lot emphasis on new models of care based on the idea that care should be person-centred. One of these new models of care, a Multi-specialty Community Provider (MCP) partnership of health, social and voluntary care providers and commissioners in Tower Hamlets, was awarded Vanguard status in 2015. A key aspect of the Vanguard programme is inter-professional working, especially between frontline health and social care professionals with the goal of providing holistic care.

For the last 12 months, I have been working as an embedded researcher in Tower Hamlets spending a lot of time with frontline multi-professional teams to understand how they work. These teams include community nurses, physiotherapists, occupational therapists, care navigators and social workers working together to meet patients’ needs in their locality. The co-location of these staff is an important step towards integration, but its impact is often overstated and in reality professional culture, identity and boundaries make it difficult for senior management to realise their vision of a fully integrated, coherent and joined up health and social care service. For instance, having different management lines (for social workers on the one hand and health professionals on the other) can be a barrier to people feeling like they belong to one team.

There are some reasons to be optimistic. I have witnessed a cultural shift among health professionals, in particular GPs, who are more inclined to refer patients to other professionals when they feel there is a need for social intervention. Indeed, this shift away from a biomedical to a more psychosocial approach has seen the development of new roles within Tower Hamlets including social prescribers and care navigators. With 1 in 5 patients visiting their GP with non-medical problems such as employment, immigration, housing and welfare issues, these new roles have a significant part to play in the care landscape and should be at the centre of future system and service development. In Tower Hamlets, GPs have remarked on the crucial role that care navigators and social workers can play as there is growing recognition of issues associated with the wider social determinants of health.

The evidence for the effectiveness of improving patient and health service outcomes for integrated care has been mixed at best. Initially most integrated care programmes were based on case management, which means identifying the top 2-3% of the population (the most complex adults) most at risks of hospital admission. However, now there is increasingly a move towards looking at whole population health needs, with a stronger focus on prevention and management rather than treatment. Whether there is the capacity on the ground to do so, I’m not entirely sure. In fact, based on my emerging findings we are no closer (if not further away) from Andrew Lansley’s somewhat utopian vision of several local fully integrated health and social care systems – it could be argued that care services have actually become more fragmented due to dwindling resources, workforce shortages and low levels of morale among our frontline professionals.

In Tower Hamlets, however, there is growing effort in generating connections and strengthening relationships among different professionals and across different health and social care organisations.   Multi-professional teams are an important way of addressing siloed and disjointed working and hence, addressing the differences in professional culture will be integral to enabling partnership working to be effective. This is an important lesson for those embarking on integration programmes – one person’s integration is another person’s fragmentation (Leutz et al, 1999), thus, harmonising the health and social care workforce will be a key facilitator in fostering positive population health outcomes. A bottom-up approach with empowered multi-professional teams focussed on meeting the specific needs of the local population might finally help us deliver what until now has been mainly rhetoric: patient-centred care.

The NHS and the cult of change: evaluating integrated care in East London

NathanDavies5 October 2017

In this post Sonia Bussu describes the work of Improvement Science London on integrated care in East London. SBussu_UCL

We trained hard—but it seemed that every time we were beginning to form up into teams we were reorganised. I was to learn later in life that we tend to meet any new situation by reorganising, and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency, and demoralisation.” (Petronius Arbiter 27-66 AD)

As a member of the Improvement Science team (ISL) for the past few months I’ve been evaluating the delivery of integrated care in East London. Integrated care refers to care that is person-centred and co-ordinated across health and social care, so providers, commissioners and local authorities need to work together to deliver the different elements of care that a person needs. In 2013 WEL (Waltham Forest and East London) was launched as one of the 14 Pioneer Programmes of Integrated Care bringing together commissioners, providers and local authorities covering the area served by Barts Health NHS Trust.

When I started this job last May, the ISL team had already carried out a two-year evaluation of WEL, which highlighted a disconnect between strategic thinking and service design on the one hand, and the delivery of integrated care on the other hand. This is hardly surprising. We know as many as 70 percent of change programmes do not achieve their intended outcomes. A lack of commitment (patience?) to see a programme through to the end and high turnover of management might be part of the problem.

Executive is heavy with change, Andrew Grossman

Executive is heavy with change, Andrew Grossman

Very soon I realised that WEL no longer enjoyed much attention. There were new programmes, new acronyms, new objectives, and with them different pressures, different actors, and different priorities: TST (Transforming Services Together), STP (Sustainability and Transformation Partnerships), ACS (Accountability care Systems)… Petronius Arbiter’s quote came to mind, “it seemed that every time we were beginning to form up into teams we were reorganised…” (The fact that this quote might have been misattributed doesn’t make it less painfully relevant).

Where do we look to see organisation change?

Within a very crowded policy context, I faced a dilemma: how could I build on the findings of the previous phase of the WEL evaluation if WEL was no longer a priority? It felt important to look at the impact that all this change at the strategic level is actually having on frontline work, to unpick the gap that my predecessor identified between strategic thinking and operational delivery.  It is at the frontline level, after all, that change is meaningful, when it happens. But how does it happen?

The literature on organisational management is quite clear on the matter: change is often evolutionary rather than the result of radical restructuring (Hodgson, G, 2008). Organisation-level change is hardly ever linear and often has an emergent element (Dawson 1996).  It tends to happen by ‘drift’ rather than by design. By looking at organisational routines we might then have a chance at unpacking the grammar of organisation change, so to speak. Routines are recurrent, collective, and interactive behaviour patterns, which help coordinate work (Becker 2004). This new phase of the WEL evaluation will then focus on frontline professionals’ routines in the three WEL boroughs and look at how health and social services staff work together to deliver more coordinated care. The aim is to shed some light on patterns of resistance to change and sustainability of change towards integrated care and understand the impact of organisational development on the ground.

I am a researcher-in-residence, which in practical terms means that I’m embedded in the organisations I’m evaluating. I work closely with stakeholders across three boroughs with the aim to coproduce learning that is relevant and timely, and so increase the chances that evidence might inform programme developments. This role raises a number of challenges, including maintaining objectivity, but it also gives me regular access to management and frontline professionals, as well as key operational meetings. This gives me a vantage point to understand better their organisational routines, how these professionals work with colleagues across different organisations, and what challenges they face on a day-to-day basis.

Based on my initial scoping work, it is clear that the rhetoric on integrated care is powerful, but so are the blockers on the ground, namely a lack of staff and resources (particularly within social services) and an increased fragmentation of services, after the separation of commissioner and provider functions.

For all the rhetoric, is care really more integrated or actually more fragmented? I hope that my work in the next few months can contribute to finding some answers.

References                                                                                 

Becker MC (2004) Organizational routines: a review of the literature. Industrial and Corporate Change 13:643-77.

Dawson, S. J. N. D. (1996) Analysing Organisations. Hampshire: Macmillan

Hodgson, Geoffrey M. (2008). ‘An Institutional and Evolutionary Perspective on Health Economics’, Cambridge Journal of Economics, 32(2): 235-56.

The Researcher-in-Residence evaluation of the Waltham Forest and East London Collaborative (WELC) integrated care pioneer programme

NathanDavies6 January 2016

In this post we hear from Laura Eyre who talks about her unique role of Researcher-in-Residence for an integrated care programme. 

I am a soLaura_Eyrecial scientist with expertise in linguistics and interpretive policy analysis.  I started working as a Research Associate at UCL and as the Researcher-in-Residence with the Waltham Forest and East London Collaborative (WELC) integrated care programme in September 2014. In my role as Researcher-in-Residence I am responsible for the qualitative evaluation of the development and delivery of integrated care in East London. I work closely with managers, clinicians and front line staff responsible for the delivery of one of the largest and highest profile integrated care ‘pioneer’ programmes in the UK. The overall aim of the evaluation is to use both established evidence and evidence generated by the research to optimise delivery of the programme objectives. I present strategic and operational teams with nationally and internationally relevant research evidence and help them to interpret it for the programme. In addition, I am carrying out a process-oriented and formative evaluation using ethnographic methods of data generation and a critical discourse analysis methodology. The protocol for the evaluation was recently published in BMJ Open.

Integrated care

The integration of health and social care has been central to the thinking of policymakers in the UK since the 1960s. Today, integration is widely accepted as ‘a demand-driven response to what generally ails modern day healthcare: access concerns, fragmented services, disjointed care, less than optimal quality, system inefficiencies, and difficult to control costs’ (Kodner, 2009). In the quests to both enhance efficiency and reduce fragmentation within, and across, health and social care services, integration is seen as ‘a principle driver of reform’ (ibid). In May 2013, localities were invited by NHS England along with national partners to express their interest in becoming integrated care ‘pioneers’. Fourteen localities were successful in their applications to become pioneers for integrated care; they were tasked with leading the development and thinking on the successful integration of health and social care ‘at scale and pace’ to inform national policy development.

Existing literature has had a limited impact on integrated care policy and practice and many questions about integrated care remain, particularly in relation to the processes by which integration can be most effectively achieved. Understanding the processes by which integration is (or is not) achieved across a system must require as much attention as the outcomes of integration if integrated care is to ‘become the norm in the next five years’. There is a need to explore not only what works in the integration of health and social care, but also how integrated care can most successfully be implemented and delivered. Embedding research expertise in an integrated care programme using the Researcher-in-Residence model can add value to the currently available evidence and to practitioners working to develop and implement integrated care programmes in applied settings.

The Researcher-in-Residence model

The Researcher-in-Residence model (Marshall et al. 2014, Eyre et al. 2015), designed by researchers and practitioners from across the UK, is based on the principles of participatory research. The model has three defining characteristics: (1) the researcher is embedded within and an integral part of the programme or team that is the object of the research; (2) the researcher is explicit about the expertise that they bring to the programme, for instance in understanding established evidence and theory, evaluating the impact of interventions and using complex data; and (3) the researcher is willing and able to negotiate their expert knowledge with practitioners in order to increase its impact on practice.

Emerging findings

We are gaining new insights into the complex realities of the development and implementation of integrated care programmes at a specifically local level. Whilst staff throughout the programme are unified in their belief that integrated care is ‘the right thing to do’, a significant disconnect has been identified between the strategic intent of the programme and the operational delivery of integrated care. Furthermore the programme is often rationalised as a technical intervention, an approach which has placed insufficient emphasis on the critical change management components vital to a large scale transformation programme: leadership, relationships, trust, behaviours and culture change. Findings and recommendations from the evaluation are beginning to influence the design and delivery of the programme as it continues to develop.

Laura Eyre

Research Associate, UCL / Researcher in Residence, WELC integrated care programme

l.eyre@ucl.ac.uk

 

Evaluating the regulatory impact of medical revalidation

NathanDavies8 September 2015

In this months edition of the blog Mirza Lalani a Research Assistant for Improvement Science London discusses an evaluation of medical revalidation which they have been commissioned to conduct by the GMC.

After years of deliberation and procrastination mandatory medical revalidation finally became a reality in 2012.

Mirza image

So what exactly is medical revalidation? A paraphrased General Medical Council (GMC) definition refers to it as ‘demonstrating a doctor is up to date and fit to practice’ and ‘to provide extra confidence to patients that their doctor is regularly checked.’ Terms such as ‘patient safety’ and ‘care’ also feature in the GMC revalidation guidance.

Why are doctors being revalidated? Widely publicised tragic medical scandals, ensuing pressure from politicians and damning high profile reports on the state of medical regulation may provide the answer. It is also fair to ask why doctors should not be revalidated, exempt from regular monitoring or dare I say control? After all, the Royal College of General Practitioners recently described healthcare as a ‘safety critical industry’ not unlike aviation.  Or perhaps it is a reflection of the demands of modernity. Another element of a social contract in which accountability and transparency are reasonably expected of a profession that draws on the public purse and that has traditionally been regarded as privileged, autonomous and opaque.

Therefore, unsurprisingly, the notion of public trust underpins the basis for revalidation. Doctors recently topped the list of most trusted professions in the UK according to an IPSOS Mori survey. The narrative of a good and caring doctor is frequently told in homes and schools across the country. So will revalidation further harness public trust in doctors?

How does a doctor revalidate? Through 5 annual appraisals with a fellow doctor (the appraiser), at which they present a myriad of documentary evidence in the form of continuing professional development, feedback from colleagues and patients, clinical audits etc. Ultimately a Responsible Officer (RO) (also a doctor) makes a recommendation (based on the appraisal feedback) to the GMC (the regulator) as to whether the doctor should be revalidated. A simple paragraph to describe revalidation does it an unintended disservice. The appraisal process has been described by some as cumbersome and time-consuming, with an added frustration of having to work with archaic IT recording systems. Collectively these challenges may inadvertently increase pressure on an already teetering workforce.

An evaluation of the first cycle of medical revalidation in the UK has been commissioned by the GMC and aims to gather information about revalidation mechanisms at all levels of the process. To do this, we are using a mixed methods approach. We will use Cultural Historical Activity Theory (CHAT) to frame and systematically manage the extensive research study; conceptualising revalidation as an activity being undertaken within the wider complexity of healthcare delivery. CHAT will enable us to ask: how will revalidation’s regulatory objectives actually be achieved within healthcare delivery systems; how does revalidation, as a series of activity systems focusing on supporting information, appraisal and RO judgement making, impact on healthcare systems? Conversely how might healthcare systems impact on the implementation of revalidation?

The research will be delivered via seven work packages:

  1. Literature reviews
  2. Secondary analysis of existing GMC, Medical Appraisal and Revalidation System (MARS) and Scottish Online Appraisal Resource (SOAR) datasets for England, Wales and Scotland respectively
  3. National and strategic surveys
  4. Appraisal capture
  5. Interviews with stakeholders (appraisees, appraisers, ROs and GMC Employer Liaison Advisors)
  6. Documentary analysis
  7. Root cause analysis of documentation when fitness to practice referral has happened

The overall evaluation is led by the Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA) based at the Peninsula Schools of Medicine and Dentistry, Plymouth University. At UCL we will be working on work packages 1, 4 and 5. The appraisal capture (work package 4) will help us to understand what really happens in appraisal as opposed to what is purported to happen.

Subsequently, semi-structured interviews (work package 5) will be held with the same appraisees, each of their appraisers and a smaller sample of ROs and GMC Employer Liaison Advisors. These interviews will inform and add depth to our understanding of what is happening across the activity of revalidation. It is hoped the findings from the overall study will contribute significantly to shaping the future of medical revalidation.

 

For more information on the evaluation of the first cycle of medical revalidation in the UK visit http://www.umbrella-revalidation.org.uk and for more information about this work contact Mirza m.lalani@ucl.ac.uk.

 

This study is funded by the General Medical Council. The views expressed are those of the author and not necessarily those of the GMC.