Happy, Healthy, at Home Symposium 2: collected event slides

Happy, Healthy, at Home
Evaluation Symposium 2
Welcome
Due to restrictions associated with purdah ahead of the
General Election, all attendees are requested not to use
Twitter or other social media during the event to
communicate about the Symposium. Thank you for your
co-operation.

17th May 2017
Evaluation Symposium
Roshan Patel, Chief Finance Officer, NEH&F CCG

Our context
 220,000 people in North East
Hampshire and Farnham
 Strong primary care, Frimley
Health is the main acute care
provider
 Frimley STP population of
750,000 people – populations
of North East Hampshire &
Farnham and four other CCGs
in Surrey & Berkshire
 Also integral part of the
Hampshire & Isle of Wight STP
 Partnership of four CCGs in
Hampshire with single Chief
Executive formed on 1 April –
brings strength and influence

Serving our population of 220,000 people
Our Vision is that local
people are supported
to improve their own
health and wellbeing
and that when people
are ill or need help,
they receive the best
possible joined up
care
Local third sector partners
(23 Member Practices)
The people of North East
Hampshire and Farnham

Why do we need to change?
❶ Demand for health & social care
is rising at an unsustainable
rate.
❷ Local people have given a
strong mandate to change.
❸ Lifestyle factors remain the
most significant risk factors for
chronic ill health in our area
Despite strong
organisations and
historical
performance, a
series of challenges
threaten the
sustainability of high
quality services.
❹ Recruiting and retaining
sufficient numbers of skilled
and motivated staff continues
to be challenging.
❺ The cost of delivering services
in the current model is rising
more quickly than the
available resources.

What we are aiming to achieve
❶ Local people
being happier,
healthier and
receiving more of
the care they need
at home or in the
community.
Aiming to halt the
growth in A&E
attendances and
emergency
admissions
❷ Better value for
money for
taxpayers,
contributing
£23M to closing
the £73M gap
between the
available
resources and the
costs of delivering
care
The changes we are making are designed to have
the following impacts:
❸ Improved staff
satisfaction
ability of health
and care
providers to
recruit and retain
sufficient
numbers of
skilled staff to
meet the needs
of local people

The new care model to achieve these ambitions
We are taking targeted action to prevent ill health and
promote self care:
Social Prescribing
Recovery College Courses
Crisis Café
Support to carers and staff
We are strengthening local primary and community care:
Practices working together
Separation of on-the-day
urgent primary care from
planned primary care
Integrated Care Teams
Proactively managing the
health and social care needs of
the population
Expanding the capacity of
community and social care
response services, and
extending their working hours
to 8am-9pm
Redesigning the interface
between hospital care and
primary care – e.g. hospital
consultants supporting locality
hubs, GPs working in hospital
We are improving services for patients in a crisis and those
who need specialist care:
Improved
support to
stay well
Joined up,
accessible
local care
Specialist
care when
needed

Update on evaluation programme
Philippa Darnton, Evaluation Programme Lead, Wessex AHSN

Aims of the Local Evaluation
2. To work with the Vanguard to use the evaluation
findings in further development of the programme
1. To understand the patient, staff and system
outcomes of the new models of care and how they
were implemented
3. To share the learning from the evaluations to
enable spread and adoption to other health care
systems

What did we do in 2016-2017?
Commenced a further two deep dives in the second
locality (Yateley)
One small scale pilot evaluation (MISSION)
Five deep dives: mixed methods, intensive
evaluations of the prevention workstream and of
three new care models in one locality (Farnham)
Commenced qualitative evaluations of new roles in
primary care (Yateley locality) and in the acute
workstream
Completed interim evaluation of Safe Haven

1. Understanding the impact
Improved
personal
wellbeing
Farnham ICT & Pre-diabetes education: R-
Outcomes health confidence improvement
MISSION Clinic: All confident of self
management following clinic attendance
Increased
confidence of
people to take
responsibility of
their own health
Recovery College: Students characterised
experiences as “others like me” and
opportunities for self-progression
Improved
experience of
care
Safe Haven (interim): 87% reported the café
prevented them from being in crisis.
20% said it had helped them “stay alive”
Improved
mental and
physical health
outcomes
Making Connections &Farnham ICT: Increased
sense of wellbeing

More care
delivered at
home or in the
community
Farnham ICT: impact on use of emergency
services
15-20% fewer
emergency
admissions and
fewer hospital and
care home bed days
/ head
Farnham ICT: Potential cost avoidance through
reductions in emergency care
Reduced
annual costs
per head of
population
Recovery College: High job satisfaction,
confidence and motivation amongst staff, and a
strong sense of providing a good service
Improved staff
satisfaction,
confidence and
recommendation
Farnham RMS: Re-directing GP referrals
Farnham ICT: Providing care and rehabilitation at
home
1. Understanding the impact (2)

The experience of service users
554 responses about the ICT and Making connections
services in 4 key areas
N = 371 on referral, 183 post referral

The experience of staff
212 responses have been provided since spring 2016, in
3 key areas

2. Using the Evidence
How has
evidence
been
used?
Informing
business
planning
Informing
who to
target
Organisational
development
Benchmarking
against other
services
Workforce
develop-
ment
Service re-
design and
continuous
improvement
Other
recommen-
dations to
CCGs

Challenges
Key challenges to be overcome and learn from:
• Legislative and policy changes in Information Governance arrangements
• Timelines for Ethics Approval processes
• Delays in service launch dates
• Identifying service users and staff for interview and case study collection
• Variable use of R-Outcomes patient reported measures

Making Connections - Update
Andrew Liles, Wessex AHSN Evaluation Team

AGENDA
Provide update on:
1. Referrals
2. R-Outcomes
3. Activity and economic evaluation

1. Referrals
0
5
10
15
20
25
30
35
40
Aug
2015
Sep Oct Nov Dec Jan
2016
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
2017
Feb Mar
AxisTitlenum
1 coordinator for Farnham 5 coordinators for all localities

N = 140 on referral, 80
on follow up
2. R-Outcomes - Demographics
Age deciles Number of medications taken
Gender

N = 140 on referral, 80 on follow up
2. R-Outcomes - Health Status

2. R-Outcomes - Health Confidence

2. R-Outcomes – Personal Wellbeing

3. Impact on A&E and emergency admissions
165 patient records analysed to look at emergency hospital
activity 120 days before referral to Making Connections
compared with 120 days after
– 120 days Activity + 120
days
Difference
A&E
attendances
98 84 -14%
Emergency
admissions
77 58 -25%

4. Economic evaluation of less A&E + emergency admissions
• Uses tariff charges to identify commissioning value of activity
change – not the same as reduced cost
• Assumes that reduced activity is not permanent - +30% in Q3
and +60% in Q4
• Assume 348 referrals per annum (current average):
Cost before Cost after Value
A&E
attendances
£83,000 £75,000 £8,000
Emergency
admissions
£1.1 million £917,000 £177,000
Total £185,000

4. Economic evaluation of less A&E + emergency admissions
• 81 of the 165 patients supported by Making Connections are
also being supported by their local Integrated Care Team
• The commissioning value for reduced A&E and emergency
admissions is £68,000
• A net savings figure for Making Connections is therefore
somewhere between £117,000 and £151,000
• Vanguard funding for service £165,000 (for 9 months)

R-Outcomes Live!
Andrew Liles, Wessex AHSN

R-Outcomes Live
R-Outcomes - a family of validated, short, generic patient reported
outcome measures
We use as part of our evaluations to
collect patient and staff feedback
Through our evaluations, we now have a
reference dataset of:
- 1,975 participants
- Comprising 9 social prescribing or
integrated community services
across Hampshire and the IoW

Your involvement
You have a survey on your
chair
Please complete it
(participation is optional)
 Circle one face, on
each line

Results
We will present the results later in the day….

Farnham Locality - An Introduction
Dr. David Brown – Clinical Lead, Farnham Locality

Happy, Healthy, at Home Symposium 2: collected event slides

OUT-OF-HOSPITAL CARE ↓
INTEGRATED
CARE
Reablement Adult Social Care
(Waverley and
FPH)
↖ ↗
Farnham
Integrated Care
Team
↙ ↘
Community
Nurses
Care Home
Matron and
MHP
FPH “Sector”
Consultants
D2A
DATC In-Reach Team
and rapid
Response
Consultant in
Primary Care
Salaried GPs Alternative
Healthcare
Practitioners (eg
Physicians’
Associates) URGENT CARE
←
Specialist
community
nurses
Community
Mental Health
Teams
MHPs
Alternative
Healthcare
Practitioners (eg
Paramedic
Practitioners)
GP Registrars
and Foundation
Doctors
Physicians’
Associates in
Training
Primary Care
Pharmacist
SECAmb
Farnham Making
Connections DOMICILIARY CARE ↑ PREVENTION &
SELF-CARE
→
SMUK
PPGs
FPH A&E
Community
Pharmacists
Voluntary Sector
GP Surgeries

Farnham Integrated Care Team
Dr David Brown, GP Clinical Lead, Farnham Locality
Mandy Gundry, Community Matron & ICT Team Leader,
Farnham Locality

AGENDA
1. What we have evaluated
2. The Farnham ICT Model explained
3. Evaluation findings
4. Active Ingredients
5. Plans for 2018/ 19
6. Questions

1. Farnham ICT Logic Model
Improved personal
wellbeing; confidence to
take responsibility for
their own health; and
experience of care
Improved levels of trust
and greater levels of
teamwork
Closer level of working
with partner agencies
and improved
communication and
understanding between
providers
Reduce A&E attendances
and emergency
admissions to hospital –
driving financial savings

2. Farnham ICT Model explained
Timeline.
• April 2015 – first discussions with Vanguard
• July 2015 – first team discussions of patients
• October 2015 – ICT Coordinator in post
0
5
10
15
20
25
30
35
40
45
50
May Jun Jul Aug Sept Oct Nov Dec
Caseload
0
5
10
15
20
25
30
Nov-15
Feb-16
M
ar
Apr
M
ay
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan-17
Feb
M
ar
Referrals to ICT

Core team:
• GP Clinical Lead
• Community Matron
• ICT Coordinator
• Two Adult Social Care Assistants
• Two Mental Health Practitioners
• Making Connections Coordinator
• Dementia Link Practitioner
• Rapid Response Matron
• Proactive Caseload Coordinator
• Primary Care Pharmacist
• Enhanced Recovery at Home Practitioner

Extended team brings into play a wide range of other roles
to provide input to team discussion and action plan.
Core team:
• GP Clinical Lead
• Community Matron
• ICT Coordinator
• 2 Adult Social Care Assistants
• 2 Mental Health Practitioners
• Making Connections Coordinator
• Dementia Link Practitioner
• Rapid Response Matron
• Proactive Caseload Coordinator
• Primary Care Pharmacist
• ER@H Practitioner
Extended team:
• FDMP/FICS Ltd
• VCL
• VCL
• SCC
• SABP
• Age UK
• SABP
• VCL
• FICS Ltd
• Salus Ltd
• FHFT

Patients supported by ICT:
• Reactive caseload initially
• Proactive caseload added in phases
Process:
• Weekly team meeting – Wednesday 1pm to 3pm
• Core team attend in person
• Extended team can attend, dial in or video call
• 20-30 patients discussed at each meeting
• ICT Coordinator completes Action Plan and a Tracker to
monitor completion
• “Discharge” decisions based on professional consensus

3. Evaluation Findings
A. Improved health, wellbeing, confidence and
experience
B. Improved levels of trust and teamwork
C. Closer working between partner organisations
D. Reduced A&E attendances and emergency
admissions driving economic benefits

3A. R-Outcomes –
Demographics
Dec 15 to Dec 16 – 53
on referral 22 post
referral
Age – by decile
Gender
Number of medicines
taken

3A. R-Outcomes –
Health Status
Dec 15 to Dec 16 – 53 on referral 22 post referral

3A. R-Outcomes –
Health Confidence

3A. R-Outcomes –
Personal Wellbeing

3A. R-Outcomes –
Patient Experience

3A. R-Outcomes –
Comparison with GP patients

3A. Case studies
Thematic review of eight case studies identified the following
themes:
• A quick response: home visit by most appropriate team
member/action planning
• A joined up response: around the needs of the individual
e.g. through Making Connections and care plans on IBIS
• Problem solving: using collective experience, initiative
and connections
• Patient Impact: examples of admission avoidance,
perceived improvements in wellbeing and confidence

3B. Teamwork and trust
Team evaluation
• Observed ICT Away Day of 4th October – by Royal Holloway,
University of London
• Two focus groups
• Surveys from 9 core team members
Normalisation Process Theory
• Validated instrument for evaluating quality improvement
interventions in health care.
• An Action Theory – understanding what people ‘do’
• Four themes:
 Coherence
 Cognitive participation
 Collective action
 Reflexive monitoring

Team members understand its purpose, implications and potential value
Coherence – how team members conceptualise the ICT
Coherence
(1 = completely agree and 10 = completely disagree)
Av
score
1. The intervention is distinct from previous ways of working but can easily be
integrated into existing work
2.78
2. Team members have shared understanding of the purpose of the intervention
and of specific responsibilities required
2.22
3. Team members understand how the intervention affects the nature of their work
2.44
4. Team members can see potential value of the intervention for their work
2.22

Members highly value their participation in the team. They
take shared ownership to find solutions. High team spirit
Cognitive participation – how team members actively participate
Cognitive participation
Av
score
5. Key individuals drive the intervention forward and get others involved 1.89
6. Team members are open and willing to work in new ways 1.89
7. Team members believe that contributing to the intervention is a legitimate
part of their work
2.11
8. Team members continue to support the intervention 2.44

Mixed results. Positive scores for trust and work allocation.
Less positive for training and resources
Collective action – how the ICT is organised
Collective action
Av
score
10. The intervention does not disrupt working relationships 2.78
11. Team members trust the intervention and trust each other 1.67
12. Work is seen as appropriately allocated to staff who have the required skills 2.11
13. Sufficient training is provided to staff 3
14. Sufficient resources are available to support the intervention 4.22
15. PM team adequately support intervention 2.56

Awareness of the effectiveness of the team varies across team
members
Reflexive monitoring – how the team appraises its effectiveness
Reflexive monitoring
Av
score
16. Team members are aware of the effects of the intervention 3.22
17. Team members agree that intervention is worthwhile 1.33
18. Team members value the effect of the intervention on their work 1.89
19. Feedback about the intervention can be used to improve it in future 1.33
20. Team members can modify how they work with the intervention 2.11

• Team formation
• Team development
• Team ethos
• Team identity

3C. Partner organisations
The lowest rated scores from the core team survey
External relationships
Av score
21. Communications between providers need to be improved 4.44
22. Those external to ICT have a good understanding of ICT programme 6.89
23. Those external to ICT value work of ICT 5
Team survey extended to include three questions about external
relationships

• North East Hampshire & Farnham
Clinical Commissioning Group
• Frimley Health Foundation Trust
• Farnham Integrated Care Services
Ltd
• Surrey County Council
• Virgin Care Ltd
• Surrey Heath Clinical Commissioning
Group
• Surrey & Borders Partnership
Foundation Trust
• Sollis Partnership Ltd
• South, Central & West
Commissioning Support Unit
3C. Partner organisations

3D. Impact on A&E and
emergency admissions
95 patient records analysed to look at emergency hospital
activity 120 days before referral to ICT compared with 120 days
after
– 120 days Activity + 120
days
Difference
A&E attendances 181 76 -58%
Emergency
admissions
114 55 -59%

3D. Economic evaluation of
reduced A&E and emergency admissions
• Uses tariff charges to identify commissioning value of activity
change – not the same as reduced cost
• Assumes that reduced activity is not permanent - +30% in Q3
and +60% in Q4
• For 109 patients referred in 2016/17:
A&E
attendances
£83,380 £51,700 £31,680
Emergency
admissions
£881,640 £582,860 £298,780
Total £330,460
• The incremental costs of providing the Farnham ICT
are £137,000

How potential commissioning value could scale:
250 patients £2,213,340 £1,455,440 £757,900
400 patients £3,541,340 £2,328,700 £1,212,640
3D. Economic evaluation of
reduced A&E and emergency admissions
Project underway with Health Foundation and NHS
England Improvement Analytics Unit to analyse
economic impact of ICTs against a matched control
group

4. Active Ingredients
The team identified:
• A ‘can-do’ attitude
• Deliberate non-hierarchical leadership style in teams
• Respect for each other skills and contribution
• Willingness to learn and try new things
We also identified
 Good history of cooperation and joint working between the five
practices in Farnham and the other community based services
in the area. They have built upon and developed this further
 The leadership is good. The style, ideas and reputation of the
clinical lead has played a large part in getting to where they are
 Farnham Hospital is a good physical base from which
the service can develop

5. Plans for 2017/18
• Team co-location
• Greater use of IT & Communications solutions for MDT
meetings
• Enhanced proactive case-finding and case management
• Working with NEHF CCG and partners on development of
risk stratification and case management IT tools
• Integrated urgent care working between the Farnham GP
Surgeries and Community Nursing Team
• Overcoming IG barriers relating to access to patient
information at Frimley Health

Refreshments (45 minutes)
Networking
Evaluation Stations
•4 stations to visit
•You all have a dot on your badge
•Please move when you hear the
bell

Holding slides for R-Outcomes
Results

Farnham Referral Management
Service
Dr. David Brown, Clinical Lead, Farnham Locality

AGENDA
1. What we have evaluated
2. Overview of Referral Management Service
3. Impact on hospital referrals
4. Economic evaluation
5. GP Survey
6. Active ingredients
8. Questions

1. Farnham locality logic model
Reduce avoidable use of
secondary planned care
services.
Direct referrals to the
right place, first time
Feedback and education
for referrers
Identify and develop local
services that can further
reduce the need to refer
to secondary care.

2. Overview of Referral
Management Service
• A collaborative project across the 5 practices – their
initiative – launched in 2016
• Three GPs, supported by an administrator meet for
two hours each week to review all non-urgent
referrals – 4 outcomes:
a. Proceed
b. Re-direct to alternative service
c. Proceed, but explore alternative
d. Return to referring GP with advice
• Outcomes fed back to practices. GP’s responsible for
actioning re-referrals
• Practices do not have a direct financial interest or gain
from savings

2. Non-urgent referral activity
• 4,123 referrals reviewed over 41 weeks (av. 101 per week)
• Outcomes:
– 87.7% (n=3,594) Proceed
– 12.6% (n=520) Re-directed
• 51% re-directed to community
services

2. Referral activity (2)
• Comparisons of:
• percentage of referrals re-directed (blue bars)
• number of referrals (red bars)

If 520 referrals were redirected in 41 weeks
• Then assume 660 in a full year
26% of these are still
directed to the acute
sector (e.g. another
speciality)
= No saving
23% don’t proceed (e.g.
rejected or advice only)
= Saves £27,000
51% are redirected to tier 2/
community services, assume a
50% saving on the £175
average acute outpatient tariff
= Saves £29,000
• Potential savings of redirected
referrals £56,000
= Return in Investment 97%
(Service cost £28,400 for 2017/18)
4. Economic evaluation (1)
• Method 1: The value of the redirected referrals
• Cost of service £28,400

This method predicts that RMS could have avoided a
cost of £131,000 in new outpatients in its first year
• Method 2: Comparing Farnham with the rest of the CCG

• Method 3: Predicting what would have happened
without RMS
This method predicts that the RMS could have avoided
a cost of £236,000 in new outpatients in the 9 months
since launch

5. GP Survey
Understanding the views of local GPs and their relationship with the RMS
43 GPs surveyed; 17 responses (range for individual questions from 7 to 14)
How many times have your referrals
been redirected?
If you have had referrals re-directed,
did you always agree with the decision?
“I am satisfied with the way in which
decisions of the referral management
service are fed back to me”
Have you identified any areas of new
learning or new knowledge as a
consequence of feedback received?
From Matheson-Monnet C.B (2017) Independent evaluation of NEHF Vanguard: Referral Management
Scheme [RMS]: survey of GPs. Southampton. Deposited in UoS e-prints

6. Active ingredients
• History of cooperation and joint working across GP’s
practice managers and secretaries
• Good clinical leadership – local GPs willing to lead and
deliver this
• Experienced administrator supporting
• Resources to hand that support decision making (e.g.
care pathways, lists of services)
• Learning by doing – ongoing incremental changes and
improvements
• Needs a good feedback mechanism with referring
GP’s (2-way)

• Updates to GPs on available services and how to access them, LPPs, local
guidelines & pathways, and attending RMS meetings
• Commencement of a locality primary care-based dermatology service
(NHSE Elective Care Development Collaborative)
a. Electronic referral & triage process including clinical photography
b. Provided by Specialty Doctor (FHFT) and GP (FICS), with support
from FHFT Consultant and MDT
c. Direct access primary care minor surgery and to secondary care
interventions (eg phototherapy)
d. Developing a sustainable workforce
e. Explore potential for telemedicine and managing cancer referrals
f. Model for future collaboration with providers
• Locality-based ESP MSK Service
• Monitoring of specific areas of activity (eg hernias, varicose veins)
• Development of primary care educational programme aimed at
improving capability & skills

Group Reflection – What have
we learnt today?

Thank you for attending
Please leave your comment cards
at the desk as you leave
Presentation materials will be
made available online via the
Wessex AHSN website

Happy, Healthy, at Home Symposium 2: collected event slides

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