Scale and spread of innovation in health and social care: Insights from the evaluation of the New Care Model/Vanguard programme in England.

OBJECTIVE: Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up. METHODS: We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation. RESULTS: A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models. CONCLUSIONS: This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England.

PURPOSE: The article aims to argue that the concept of "distributed leadership" lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the "Strategic Action Field Framework" (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar. DESIGN/METHODOLOGY/APPROACH: Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019. FINDINGS: While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting. ORIGINALITY/VALUE: The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of "social skills" required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

A Cross-European Study of Informal Carers' Needs in the Context of Caring for Older People, and their Experiences with Professionals Working in Integrated Care Settings.

INTRODUCTION: Informal carers are increasingly relied on for support by older people and the health and social care systems that serve them. It is therefore important that health and social care professionals are knowledgeable about and responsive to informal carers' needs. This study explores informal carers' own needs within the context of caregiving; and examines, from the informal carers' perspective, the extent to which professionals assess, understand and are responsive to informal carers' needs. METHODS: We interviewed (2016-2018) 47 informal carers of older people being served by 12 integrated care initiatives across seven countries in Europe. The interviews were thematically coded inductively and analysed. RESULTS: Informal carers reported that professionals treated them with respect and made efforts to assess and respond to their needs. However, even though professionals encouraged informal carers to look after themselves, informal carers' needs (e.g., for respite, healthcare) were insufficiently addressed, and informal carers tended to prioritize older people's needs over their own. DISCUSSION AND CONCLUSION: Informal carers need better support in caring for their own health. Health professionals should have regular contact with informal carers and proactively engage them in ongoing needs assessment, setting action plans for addressing their needs, and identifying/accessing appropriate support services. This will be important if informal carers are to continue their caregiving role without adverse effects to themselves.

Investigating the nature and quality of locally commissioned evaluations of the NHS Vanguard programme: an evidence synthesis.

BACKGROUND: With innovation in service delivery increasingly viewed as crucial to the long-term sustainability of health systems, NHS England launched an ambitious new model of care (Vanguard) programme in 2015. Supported by a £350 million transformation fund, 50 Vanguard sites were to act as pilots for innovation in service delivery, to move quickly to change the way that services were delivered, breaking down barriers between sectors and improving the coordination and delivery of care. METHODS: As part of a national evaluation of the Vanguard programme, we conducted an evidence synthesis to assess the nature and quality of locally commissioned evaluations. With access to a secure, online hub used by the Vanguard and other integrated care initiatives, two researchers retrieved any documents from a locally commissioned evaluation for inclusion. All identified documents were downloaded and logged, and details of the evaluators, questions, methodological approaches and limitations in design and/or reporting were extracted. As included evaluations varied in nature and type, a narrative synthesis was undertaken. RESULTS: We identified a total of 115 separate reports relating to the locally commissioned evaluations. Five prominent issues relating to evaluation conduct were identified across included reports: use of logic models, number and type of evaluation questions posed, data sharing and information governance, methodological challenges and evaluation reporting in general. A combination of resource, data and time constraints means that evaluations often attempted to but did not fully address the wide range of questions posed by individual Vanguards. CONCLUSIONS: Significant investment was made in independent local evaluations of the Vanguard programme by NHS England. This synthesis represents the only comprehensive attempt to capture methodological learning and may serve as a key resource for researchers and policy-makers seeking to understand investigating large-scale system change, both within the NHS and internationally. PROSPERO (Registration number: CRD42017069282).

Exploring the Team Climate of Health and Social Care Professionals Implementing Integrated Care for Older People in Europe.

BACKGROUND AND PROBLEM STATEMENT: Team climate describes shared perceptions of organisational policies, practices and procedures. A positive team climate has been linked to better interprofessional collaboration and quality of care. Most studies examine team climate within health or social care organisations. This study uniquely explores the team climate of integrated health and social care teams implementing integrated care initiatives for older people in thirteen sites across seven European countries, and examines the factors which contribute to the development of team climate. THEORY AND METHODS: In a multiple case study design, data collected as part of the European SUSTAIN (Sustainable Tailored Integrated Care for Older People in Europe) project were analysed. The short-form Team Climate Inventory (TCI-14) was administered before and after implementation of the integrated care initiatives. Qualitative data was used to explain the changes in TCI-14 scores over time. RESULTS AND DISCUSSION: Overall, team climate was found to be high and increased over time in eight of the thirteen sites. The development of a shared vision was associated with a strong belief in the value and feasibility of the initiative, clear roles and responsibilities, and a reflective approach. Strong inter-personal relationships, shared decision-making, and high levels of commitment and motivation contributed to the development of participative safety. Support for innovation increased when staff had the 'space' and time to work together. CONCLUSION: This mixed methods study offers significant insights into the development and maintenance of team climate in complex, integrated care systems in Europe.

The Over 75 Service: Continuity of Integrated Care for Older People in a United Kingdom Primary Care Setting.

Continuity of care is concerned with quality of care over a period of time. It describes a process by which service users and their families are co-operatively involved with health and social care professionals in managing their care needs. Continuity of care can be divided into informational, managerial and relational and has been associated with improved user- and service-related outcomes. To date, there have been few studies which examine how continuity of care is developed and maintained in integrated primary care systems. This paper explores continuity of care in an integrated Over 75 Service for people living at home with complex health and social care needs. Using a case study approach, qualitative data was collected from multiple sources including interviews with managers and professionals, users and carers, care plans, steering group minutes and field notes. Data was analysed thematically. A number of factors are identified which characterise continuity of care, namely: information sharing through direct communication between providers and the development of trusted relationships within the team; identified care co-ordinators who acted as a conduit for information and communication; the development of ongoing relationships with users and carers requiring dedicated time and accessible and flexible services delivered in the users' own home.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe.

INTRODUCTION: Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers' and service users' perspectives. METHODS: A multiple embedded case study design was conducted that included thirteen integrated care sites for older people living at home. RESULTS: Service providers were positive about the activities that aimed to promote person-centred care and thought that most activities (e.g. comprehensive needs assessment) positively influenced person-centredness. Experiences of service users were mixed. For some activities (e.g. enablement services), discrepancies were identified between the views of service providers and those of service users. DISCUSSION AND CONCLUSION: Evaluating activities aimed at promoting person-centredness from both the service providers' and service users' perspectives showed that not all efforts were successful or had the intended consequences for older people. Involvement of older people in designing improvement activities could ensure that care and support reflect their needs and preferences, and build positive experiences of care and support.

Care navigators decision-making in prescribing Telecare for older people.

This aim of this study was to explore the decision-making process of Care Navigators in prescribing Telecare for older people living at home. The study took place in the South of England. A structured model of decision-making was used as the theoretical framework and a qualitative approach was employed. Care Navigators (n = 7), acting on behalf of the Local Authority as 'external trusted assessors' were interviewed according to a semi-structured interview schedule. Documentary evidence of decision-making (Telecare Reasoning Forms) (n = 10), were also analysed and added to the interview data. The main themes identified were the process of decision-making, training needs, and the support of Care Navigators and partnership working. Care Navigators adopted a complex decision-making process involving information gathering, information synthesis, consideration of alternatives to Telecare and implementation. Decision-making has a strong ethical dimension, especially around funding. Training focused on the functioning and technical aspects of equipment. However, other training needs were identified in order to support decision-making, for example, assessing mental capacity. Peer support networks were valuable to Care Navigators and they developed good relationships with social care and Telecare provider staff. However, professionals making referrals to the Care Navigators for Telecare often did not understand their role or funding eligibility. In conclusion, Care Navigators are well-placed to prescribe Telecare in terms of knowledge and decision-making skills. Comprehensive training is necessary in order to support decision-making. Peer support and education of professionals referring for Telecare is also advocated.

A review of integrated heart failure care.

AIM: The aim of this integrative review is to determine the effectiveness of integrated heart failure (HF) care in terms of patient-, service- and resource-related outcomes, and to determine what model or characteristics of integrated care work best, for whom and in what contexts. BACKGROUND: Integration of health and social care services is a significant driver in the development of better and more cost-effective health and social care systems in Europe and developed countries. As high users of health and social care services, considerable attention has been paid to the care of people with long-term conditions. HF is a progressive, prevalent and disabling condition, requiring complex management involving multiple health and social care agencies. METHODS: An integrative review was conducted according to a framework by Whittemore and Knafl (2005). A literature search was undertaken using the databases: Medline, CINAHL, Embase, PsychINFO and the Cochrane Library, using key words of 'heart failure' OR 'cardiac failure' AND 'integrated' OR 'multidisciplinary' OR 'interdisciplinary' OR 'multiprofessional' OR 'interprofessional' OR 'collaborative care'. Application of the inclusion and exclusion criteria resulted in 17 articles being included in the review. Articles were screened and coded for methodological quality according to a two-point criteria. Data were extracted using a template and analysed thematically. FINDINGS: Integrated HF care results in enhanced quality of life (QoL), and improved symptom control and self-management. Reduced admission rates, reduced length of hospital stay, improved prescribing practices and better care co-ordination are also reported. There is more limited evidence for improved efficiency although overall costs may be reduced. Although findings are highly context dependent, key features of integrated HF models are: liaison between primary and secondary care services to facilitate planned discharge, early and medium term follow-up, multidisciplinary patient education and team working including shared professional education, and the development and implementation of comprehensive care pathways.

An exploration of illness representations and treatment beliefs in heart failure.

AIMS AND OBJECTIVES: To explore the beliefs patients with heart failure hold about their illness and its treatment using the common-sense model of illness cognitions and behaviour as the theoretical framework. BACKGROUND: Heart failure is a disabling condition, which has a significant impact on individuals, their families and healthcare provision. The common-sense model provides a framework within which lay beliefs about illness and its treatment can be examined. Previous studies have reported a number of misconceptions in relation to the nature of and treatment for heart failure. Inaccurate beliefs are related to limited self-care and nonadherence to medication. DESIGN: A qualitative research design was used in which thematic analysis was used to interpret interview data. METHODS: Semi-structured interviews were carried out with twelve patients with chronic heart failure in a community setting in South East England. An interview schedule based on the dimensions of the common-sense model guided data collection. Data were analysed thematically using the framework method. RESULTS: A cluster of beliefs around a chronic illness with serious consequences was found. However, patients were unable to distinguish between symptoms of heart failure, effects of medication and emotional responses to the illness. The illness was attributed to external factors, especially stressful life events. There was a strong belief in the necessity of medication coupled with the belief that the illness and its symptoms could be controlled by medication. Concerns about drug interactions and side effects were prevalent. CONCLUSIONS: This study highlights the need for nurses to explore illness representations and treatment beliefs in heart failure. Misconceptions should be corrected to influence behaviour change. RELEVANCE TO CLINICAL PRACTICE: An understanding of illness representations and treatment beliefs should enable structured interventions to be developed, which improve clinical outcomes in this population.

Relationships between illness representations, treatment beliefs and the performance of self-care in heart failure: a cross-sectional survey.

BACKGROUND: Self-care is a key principle in the management of chronic heart failure (HF). The common sense model (CSM) of illness cognitions and behaviour provides a theoretical framework within which relationships between beliefs and behaviour can be examined. AIM: The aim of this study was to determine relationships between illness representations, treatment beliefs and the performance of self-care in community HF patients. METHODS: A cross-sectional survey was carried out in 169 patients with HF in South East England. Illness representations, treatment beliefs and self-care were measured using an adapted Revised Illness Perception Questionnaire (IPQ-R); the Beliefs about Medicines Questionnaire (BMQ) and the Looking After Yourself with Heart Failure Questionnaire (LAYHFQ), according to the CSM. Relationships between these specific concepts were determined using Pearson's correlation co-efficients (r) and stepwise multiple regression. RESULTS: Perceived medication knowledge (r = 0.51, p ≤ 0.01), beliefs about the necessity of medication (r = 0.45, p ≤ 0.01) and illness coherence (r = 0.39, p ≤ 0.01) were moderately correlated with self-care. Multiple regression analysis revealed that 46% of the variance in self-care could be explained by illness representations and treatment beliefs (adjusted R(2) = 0.46, F = 9.93, p = 0.00). Three factors were significant predictors of self-care - medication knowledge (ß=0.319, p=0.003), a belief in the illness having serious consequences (ß = 0.258, p=0.008) and the impact of medication use on lifestyle (ß = -0.231, p = 0.03). CONCLUSION: Illness representations and treatment beliefs should be explored in patients with HF in order to inform the development of targeted interventions designed to correct misconceptions and enhance self-care. This has the potential to improve clinical outcomes in this population.

Cardiac patient assessment: putting the patient first.

Nursing roles are expanding and there is a growing expectation that nurses, with appropriate education and experience, are able to perform assessments that were traditionally conducted by doctors. This article discusses patient history, vital signs and physical examination related to the cardiac patient. This will enable practitioners to enhance their knowledge and understanding of this valuable assessment influencing patient care.

The illness perceptions of women following symptoms of acute myocardial infarction: a self-regulatory approach.

BACKGROUND: Coronary Heart Disease (CHD) has been socially constructed as a gender-specific disease with women not seen to be at risk. Women tend to delay seeking help following the onset of symptoms of acute myocardial infarction (MI). An illness perceptions approach has been used to explain treatment-seeking behaviour. AIMS: The aim of this study was to explore the illness perceptions of a sample of women following acute MI using the self-regulatory model of illness behaviour as the theoretical framework. METHODS: Ten women, with a range of ages, took part in semi-structured interviews, 3 months following an acute infarct. Data were analysed thematically according to the theoretical framework. RESULTS: The development of a serious model of the illness and the decision to seek help was influenced by the experience of severe, unusual symptoms especially if of sudden onset; the absence of co-morbidities and similarities to the known experience of others. Perceived lack of susceptibility to the disease and a belief that symptoms were benign may have resulted in a delay in seeking help. Coping strategies were initially aimed at relieving symptoms before seeking help from families and friends. This resulted in a call for professional help. CONCLUSION: Health promotion strategies need to emphasis the uniqueness of the individual's experience. Interventions designed to alter illness perceptions may influence treatment-seeking behaviour.