Results of implementation 2

Integrated contact centre

We provide a description of the service, followed by a discussion of:

1. a summary of major issues in implementation and relationships to known drivers of change
2. patient experience.

Description of the integrated contact centre

Although the SICP focused on those aged ≥ 65 years, the ICC was developed around an existing ‘all-adult’ service and was not restricted to older people, although they formed the bulk of the caseload. The ICC initially comprised three strands: SIRP, health coaching and telehealth. Although health coaching was part of the ICC, the results of the health coaching are presented in Chapter 13. Telehealth (based on text messaging) aimed to affect admission rates by providing monitoring equipment and links to the ICC, but the SICP did not renew the licence.

Single integrated referral point

The SIRP aimed to manage referrals into health (excluding general practice) and social care via a single number, to enhance perceptions of integration and ease navigation. During fieldwork, the three teams were receiving calls to their own numbers, which were then rerouted; this later changed to two numbers [adult social care contact team (ASCCT) and intermediate care numbers being combined with district nurses (DNs) retaining their own number]. Having an integrated team triaging and responding to calls meant that needs could be dealt with more appropriately:

The goal that we’re working towards is a model whereby it doesn’t matter which service you ring in for . . . and the response that you will get will be the right response for what you’re ringing in for. So you might ring in for a social worker, but you actually might get an OT [occupational therapist] . . . [my] mum’s had a fall, she needs a social worker, she needs support at home. And actually she might not do, what she might need is some rehab, some enablement.

Most SIRP staff were administrators from three teams working centrally in a single base (Table 28).

Adult social care contact team

Staff had one half-day per week for handling e-mail enquiries and a further half-day for dealing with alerts concerning people coming into hospital or who have a planned discharge with social care implications. This provided a break from the general call-handling work, although staff highlighted call variety compared with their role title:

You don’t know what the call’s going to be about. It could just be transferring the call through to somebody or it could be a referral. It could be an appropriate adult [safeguarding], which takes about an hour to deal with . . . If a carer has been to a client and they’ve not been able to get any answer at their home so we have to then follow up to find out where the person is.

Two advanced practitioners and 11 occupational therapists and community assessment officers worked alongside, allowing staff answering calls to pass referrals on to colleagues and avoiding the need for assessment and support from locality teams. When a request was made for social worker involvement, staff completed a needs assessment by telephone and passed to the locality team if required. The ASCCT has been functioning in this way since 2011.

District nurse team

The SIRP was the main contact point for district nursing. As a result of calls, messages were relayed to nurses in each locality base. Managers saw benefit in the ICC being able to answer calls to the nurse service where callers had previously only been able to leave messages:

. . . from the DN side I would say it’s working for the people [patients] because initially the phone never got answered. You used to phone a district nurse, you kind of accepted you were getting an answering machine. Whereas now the majority of them calls you get to speak to a person, and I can only think that must be a benefit.

Attempts were made to incorporate clinicans from district nursing and intermediate care who would provide clinical input to SIRP staff to manage more calls in-house, which was seen as preferable to telephoning nurses for advice, as they were frequently out on visits. If patients or carers were not happy discussing medical issues with ‘admin’ staff, the DN called patients back.

Intermediate care

Access to intermediate care was via the single entry point (SEP), which had two administrative workers plus a clinician based within the SIRP. In contrast to callers to adult social care and district nursing, callers included health professionals. Intermediate care had around 100 beds based in three units providing rehabilitation and assessment. Although units did not have a permanent medical presence, they were regularly visited by geriatricians and a GP.

Uptake and usage of the integrated contact centre

Calls were tracked to ensure that targets set by the council in terms of response time, satisfaction and call volume were met. Initially the corporate target of answering 70% calls within 30 seconds was used, but the emphasis for SIRP was on the quality of the call. For adult social care staff, call handling was reviewed every 3 months by managers. All SIRP staff had access to data on call numbers and response times. Reports from the date we interviewed SIRP staff showed that 672 calls were received by the three colocated teams (between 07.00 and 18.00).

Issues in implementation and relationships to known drivers of change

We initially used the ‘five simple rules’ (see Chapter 3) as a framework to understand ICC implementation. In terms of the ‘simple rules’, the core issues facing the ICC related to mission and vision (a function of ‘designated and distributed leadership’). The ICC demonstrated the greatest level of change and disagreement between partners as to what should be included, and what might be considered separate. During ICC development, additional projects (care homes HomeSafe and out of hours, all involving telephony) were incorporated into the ICC model along with ‘Ways to Well-being’ for signposting callers. Incorporating these additional projects within the ICC led to a complex business case, prolonging discussions around funding:

The centre of contact [ICC] is a concept more than an actual place for the programme, because the actual workstream has involved that many different things in order to pull everything together to have one contact centre, centre of contact would become completely unworkable.

Although some staff believed the ICC remit was too large, others felt that integrating the workstreams was necessary to achieve its aims:

. . . things have slowed down and stopped because people have started to think ‘actually we need to join these things together’. People are going off and doing wonderful work but because it’s so huge, . . . are automatically going off and working in silos, and I don’t know how we overcome that.

Examples of the success of such linkage were reported:

There’s been five referrals [to the wellbeing project] from here [SIRP] up to now . . . He first met up with [community assets worker] . . . [he was] very closed, hood, hat covering his face, very quiet and reserved. He’s now walking round, enjoying life, wearing a flat cap. He’s just completed a 5-day computer course. They’re looking at him going on and becoming a well-being plan champion.

In terms of ‘presence and use of feedback’, measurement of performance was something that was naturally possible for the ICC, although that focused on measures of call volume and handling efficiency, an important part of a system designed to improve patient experience, but is only a very partial view of the process. Although call quality was assessed as part of staff management, such data were more difficult to capture.

Finally, ‘patient involvement’ was an important issue. A key function of the ICC was patient centred – to make navigation easier and create the perception of a ‘joined up’ service. The ICC involved introducing new ways of working, which could complicate access for those who had already navigated previous systems. We now explore these issues further.

Other barriers to, and facilitators of, effective functioning and outcomes

As well as the analysis of the ‘five simple rules’, we also identified additional factors of relevance to the implementation of the ICC.

Colocation

Staff from all three services were colocated, interspersed within two banks of desks. Physical proximity helped them learn informally about colleagues’ work:

. . . you, kind of, want to listen to what their call is because you know you’re going to be dealing with those calls so you want to pick up and see what they do but most of the time you’re on the phone anyway.

Ultimately, staff felt that the integrated approach would improve responsiveness:

. . . eventually when it’s one number that will be even better because sometimes they do ring through and they’ve got a social care query and they might have a district nurse query as well so we will be able to deal with that all at once . . . I’ll just ask the person next to me rather than giving the number to ring somewhere else you’d just deal with that yourself and ask your colleague or leave a message with them.

Staff felt that colocation was essential to support the SIRP administrative team in call management:

I think it works at the moment for social care staff. I don’t think it’s working as well for the district nurse staff. And if we are integrated they’d have to put more professionals with us, and they’d maybe then need to rotate them, I don’t know. But it would need people here so that you’ve got some back up.

Central integration versus fragmenting existing local teams

Although part of the SICP, administrative staff were employed by different employers (adult social care by the council and DNs by the trust). When located separately, the fact that SIRP staff were employed on different pay scales and bands did not cause issues. Since July 2016, the employer of council staff working for the SICP has been the ICO (see Chapter 10), with human resources undertaken by the trust as ‘lead provider’:

. . . the other problem we’ve got at the moment is we’re persistently talking about three groups of people doing the same job, and them three groups of people are all on different pay grades, and how do we move that forward?

Administrative staff from NHS services contrasted their experiences with those of their social care colleagues who had been in place for 5 years and who had managers within the same open-plan office, providing regular opportunities for team and one-to-one meetings. District nursing and intermediate care managers were based off-site. This meant that staff often sought advice from social care managers:

. . . they’ve got their bosses, they’ve got four bosses on the floor . . . We’ve nobody, and we feel a little bit hurt and deserted really. I know they’re contactable by e-mail but it’s not the same . . .

District nursing and intermediate care reported some loss of sense of being part of a team:

I get a lot of hostility at the moment as well because they’re rushed off their feet . . . they’re not fully aware and understand what we do really. We were taken for granted when we were with them [in the locality bases], we were always there; also part of the team. I don’t feel a part of any team now, I don’t feel . . . I hope I make a difference but I don’t feel . . . I’m just a faceless person looking at a screen now . . .

Centralising the SIRP created difficulties for services elsewhere. Removing DN administrative staff meant that new ‘housekeeper’ posts had to be created at each locality base to replace some of the functions that were too costly for band 5 nurses. Having at least one DN within the SIRP supported administrative decision-making and enabled calls to be dealt with in-house, but was viewed as unsustainable in the long term:

. . . there was a district nurse based here with a very specific role and purpose for triage . . . She’d already stopped about three or four calls going through to the team at like half nine, quarter to ten in the morning, which might not sound a lot, but she’s probably done a lot more by then, and that was really successful . . . I think there was the will, but there wasn’t the staff to dedicate a district nurse from here.

Loss of a sense of ‘team’ was also true of intermediate care staff when community rehabilitation, the SEP administrative team, rapid response and the intermediate care units were in separate locations:

. . . even though we’re based with the Salford council, and integrating with them [at SIRP], . . . from our point . . . we’re merging more with Salford council team, but our own team seem to be separated quite a lot.

Similarly, for intermediate care, relocating the clinician away from SIRP meant that administrative staff could not physically pass on messages. As the clincian spent a large amount of time on the telephone, it was difficult for staff to relay messages. Although other SIRP administrative staff relayed messages via e-mail, the consensus was that it was easier to give out direct numbers and suggest that people contact staff themselves, contrasting with the ethos of SIRP. Staff felt that, over time, this might mean that calls that should be routed through the SIRP would bypass them:

. . . we’ve found it a bit harder taking messages, because she likes phone call messages . . . because she’s on the phone so often, she can’t check her e-mails as often, so it’s not great really, with her not being here, for that reason . . . so I’d rather just give [her] number out to that person . . .

Centralising the contact service aimed to make access easier, but it also created issues when people were referred for multiple assessments: a person might require an occupational therapy and social work assessment and their carer might require a carer’s assessment. This was recorded as three separate referrals. The process was being streamlined to ensure that, to avoid duplication, a single assessment was conducted by the most appropriate person:

I was thinking, ‘hang on a minute, this one person has been contacted three times in 2 days by three different people in the same office.‘. What that person on the end of the phone must have been thinking’s going on here I’ve no idea, because if it was me I’d be like, ‘hello, are you talking to each other?’. So we’ve worked on changing that now and it does work a lot better.

A 3-day test of change was conducted to try to rectify this. It found that colocation of a DN or intermediate care clinician alongside their administrative counterparts from SIRP was helpful in providing clinical advice and led to more calls being dealt with in-house, although this was not sustainable because of staffing shortages. One proposed solution was for clinicians to work on a rotation basis, enabling them to gain experience of SIRP work:

. . . a good mentor is being with nurses . . . I’ve picked up an awful lot of information. I don’t give clinical information out, but I do understand what their procedures are, and what they do now, it’s invaluable that.

Mental health involvement

A lack of representation from mental health within the SIRP created issues. Concerns about mental health were raised with social care via the ICC, either through referrals or through welfare notices from the police or ambulance service:

. . . if something comes through here and it’s mental health we can’t simply say ‘oh, well, we’ll assign that to mental health’ because it doesn’t work, and if we just sent things to them via their generic inbox which may or may not be manned you’ve got no guarantee that’s going to be picked up . . . all we can do here is notify the GP and see if they want to consider referring them to mental health . . . an awful lot of people have said, ‘well, why don’t we just triage mental health here’ . . .

Two main issues seem to have influenced this: (1) the contractual agreements concerning what the mental health trust would provide and (2) the fact that, although the team will assess people, any mental health issues attributable to functional illness are discharged back to GP care without the requirement for the mental health trust to provide any intervention:

I had a meeting with the commissioners and the managers in the old person’s mental health teams and it soon transpired that historical agreements of what GMW were going to provide in terms of social care, with GMW restructuring over the years, agreements no longer were fit for purpose. They no longer fit the service like it is today.

Although the mental health trust was one of the four integrated organisations, its staff were not transferring across to the ICO and it was undergoing its own organisational change.

Complex information technology systems

An issue faced by the SICP in general, but which particularly affects the ICC, is that the NHS and council each invested in different IT systems. Although integration of health and social care services was the primary aim, call handlers were required to work with multiple IT systems.

The trust had developed a system enabling its electronic patient record (EPR), which held hospital data to link with data from primary care via the Salford integrated record interface prior to the SICP. This was then used to develop the shared care record (SCR), which supported the sharing of information at MDG meetings. Although facilitating the MDG meetings, the summary SCR was not available to staff within SIRP. Meetings in spring 2016 showed that links between the SICP on a wider level were being considered, with a suggestion that, if a person known to MDGs telephoned SIRP and consequently had a SCR, their care co-ordinator could be contacted and updated with any relevant details. Subsequent to this, plans were discussed that ICC telephone triage would be used to manage telephone referrals from patients and carers wishing to self-refer to MDGs.

How was the integrated contact centre experienced by patients and carers?

The patients and carers interviewed appreciated the care provided by both district nurses and social care, but reported frustration at having to call the SIRP frequently to get cases reopened:

. . . at the moment me mum’s off social services’ books, but she’ll be back on them by now because of this bed situation [levered provision at home] that has kicked off today . . . So she’s off the books and then she’s back on and then she’s off the books and she’s back on. It just means I’ve got to keep ringing them when . . . I ring them when we need them and they respond. They’re great, you know. And I know it’s a numbers game and it’s about making it look as if they’re managing better than they are . . . They’re very responsive. They are good. When they say they’ll get back to you, they get back to you.

Some people reported difficulties communicating with the DN service. Although the ICC provided a mechanism for calls to be answered (as opposed to previous systems, in which the majority of calls went to an answer machine), patients were frustrated at not being able to get their queries answered:

. . . I had a clash. So I needed to ring . . . it was the clinic number. But it went to a central something. Now, so I tried Thursday and spoke to somebody, and nobody ever came back to me. I tried Friday about three times. Oh, I’ll post it on the board and I’ll send a message, and all this jazz.

Patients and carers hoped to be given an approximate time for visits. During observations at locality bases we identified some patients calling multiple times to ensure that they had not been overlooked. Each time a caller spoke to a member of the administrative staff from the ICC, a message had to be logged, creating issues for patients having to ‘re-tell their story’ (one of the alleged benefits of integrated care). As a result, patients and carers found alternative ways to communicate:

I know that they’ve changed the system at the contact centre . . . and that’s been, in my view, quite disastrous. . . . where, say she’s had a hospital appointment on a Tuesday, I’ve rung and I’ve left a message for the district nurses and said, ‘you know, she’s going to be out so don’t come or come in the morning.’. And in the old system that message got through because you were basically ringing their office. Three times now, that message hasn’t got through and the district nurses have turned up when my mum’s been out. So they’ve had a wasted journey and me mum hasn’t had her dressing changed. So now what I do is I leave a little note for the district nurse, you know. So she comes on a Tuesday, if we’re not going to be in on a Friday afternoon, I leave a note in what we call the nurse’s box, where she keeps all her dressings and that works. So the nurses pass the message on between them . . . once it became clear that that wasn’t working I just thought, well, they always go in the box. And so I leave them notes and they sometimes leave me notes . . . But that shouldn’t have to happen.

The SIRP staff expected that people calling a central number would be happier knowing to whom they were speaking, but even when people asked for a specific member of the contact team by name, calls were not always transferred:

With us just having one number now, rather than one when we were in different places, it’s easier now with just the one number to come through to so they know who they’re ringing . . . There’s certain people who do phone up and ask for particular staff but you just deal with that yourself. You just deal with a call rather than transfer it to your colleague.

Some respondents reported feeling better connected when calling the locality base previously, as it meant that they dealt with a smaller number of people answering their calls and so were able to develop relationships over time.

Multidisciplinary group

We initially provide a description of the MDGs, followed by a discussion of:

• major issues in implementation and relationships to known drivers of change
• patient experience.

Multidisciplinary groups served eight neighbourhoods based on electoral wards (Table 29). A separate MDG existed for patients registered with a ‘care homes practice’ (85% of care home residents).

Description of the service

An operational document set out the MDG vision, model and process of service delivery. Core membership included MDG administrators, a social worker (joint chairperson), a DN (joint chairperson), a GP, a mental health lead, a community psychiatric nurse, a consultant psychiatrist, a practice nurse and a geriatrician. The document also suggested wider MDG membership if direct care or support for the individual was required, including a health improvement officer, mental health practitioners (community occupational therapist, social worker, clinical psychologist), a pharmacist, a rapid response team, a housing officer, intermediate care workers and third-sector staff.

Observations at MDG meetings and analysis of the attendance registers collated by the CCG showed that similar membership and attendance existed across all the neighbourhoods (see Appendix 4, Table 63).

The first three staff roles were funded to varying degrees by SICP. One-hundred per cent of the time of administrative and nursing leads was funded, with social care leads funded 50% for MDG work and retaining caseloads for the other 50% of their funding. This meant that nursing leads had more time available for MDG work. This led to tensions when this was seen to be at the expense of direct work with patients:

They see us on a computer and say, well, that’s not a nursing task. When I input it [SCRs] on the iPad [Apple Inc., Cupertino, CA, USA], I used to sit out in the car park because you can still get Wi-Fi there, but nobody can see you. But it’s almost like a dirty little secret doing admin when you’re a nurse, because you should be attending to patients.

These frustrations led to the team leader for the MDG nurses arranging a single central workspace for all nurses in one locality base.

The pre work for MDGs was a vital part of the process, and the nursing and social care leads were responsible for ensuring that links between health and social care records were added to the SCR. In some MDGs, nursing and social care staff sat together each using their own system, with the nursing chairperson also inputting data into the SCR. In other neighbourhoods, the nursing chairpersons travelled to the locality bases to work collaboratively, combining this with ‘safety huddles’ to reduce travel. If this was not possible, two nurse co-chairpersons tended to prepare the SCR for their patient caseload then e-mail it to their co-chairperson for their input, before forwarding to others.

The nursing co-chairpersons continue to attend ‘safety huddle’ meetings in the locality bases. At these meetings the local district nursing teams discussed patients they were concerned about, and nurses visiting the same patient shared their expertise. ‘Safety huddles’ enabled the nurses to promote the benefit of MDG working, accepting referrals on behalf of patients who might benefit from discussion within MDGs:

We’ve had some difficulties in describing what the [MDG nursing] role is, so we’ve had some . . . not issues, but the question from district nursing is around, well, what exactly is it you’re doing? Now, at this point, we’re just going to a time where you can see that clinical duties will be part of the role, it was almost as if we had to step out of them initially and to try and find out how we would fit.

In contrast, social care leads remained embedded within their locality teams and retained a small yet complex caseload. Similarly, they were keen to promote the benefits of MDGs among colleagues, and one way was getting colleagues to shadow them at meetings:

We have monthly team meetings . . . I update my team about what we’re doing. I like to keep people informed because they might find themselves as care co-ordinator so it is important for me they understand the work of the MDG and also I am trying to get them involved by getting them one by one to attend the MDG with me, so that will give them a better understanding when I’m asking for information or asking them to do things then they will understand why.

Weekly micro-coaching meetings at the nurse base were delivered by a facilitator from the quality improvement team. Social care chairpersons were invited to participate, although only half were present at the session observed.

General practitioners were reimbursed for MDG attendance by Salford CCG, with the CCG eventually agreeing to pay for 7 hours, including pre and post work. Practice nurses attending the MDGs were not reimbursed, although in some cases they deputised for the GPs and often shared the pre and post work, particularly when they had more frequent patient contact:

. . . we tend to split the list between us and we each take the patients that we have more information on and know best. There’s quite a lot of work to do after the meetings too and its especially important when we have discussed patients that our colleagues have referred to MDG that we write up the outcomes from the meetings quickly so they know exactly what the outcomes are.

Project managers and administrators pointed out that single-handed GPs were keen for support from colleagues. Even where differences existed, this did not affect the functioning of the meetings:

. . . they’re really good groups now. They work quite well together. And the key is regular attendance really from the same people, because you can’t build a forum of trust with new faces all the time, can you? . . . we’ve had the same faces over and over, and we can be really open and honest about the conversations that we have with our colleagues, and then we all agree what’s recorded formally and put into the shared care record.

Practice nurse input was highly regarded by the MDG team, with practice nurses often seeing patients over a prolonged period while providing long-term care.

Multidisciplinary groups chose to involve practice managers in different ways. Initially, they provided a critical function in terms of assisting with allocating ‘Sally’ levels to patients. Some accompanied their GP to meetings or deputised. MDG meetings were seen as a clinical arena for discussing patient care, and it was expected that their input would cease once MDGs became established:

. . . in the newer [MDG] meetings I can forgive it, because a lot of it is about the system and the processes, so what’s risk stratification, what’s the next steps, we need to code them, we need to refer them into choose and book . . . [But] we are experiencing more and more practice managers at MDGs at the moment, and I’m not particularly comfortable with it . . . Then it was fed back to me that actually we could do with practice managers being put on there [SCR access list], because if you want information copied from one clinical system into another, who’s going to sit there and do that?

In many neighbourhoods, the geriatricians were appointed later, and only at pilot sites were they involved at an early stage. Even once identified, staff shortages and increasing demand limited their input:

. . . recruiting has been difficult across each of the different services . . . only three geriatricians qualified last year . . . I know that there’s a geriatrician coming to those [two MDG] areas in August, September time . . . because they are hospital-based staff really, they could, and it’s not the same as having them there in the forum for conversation, but they could liaise with us via the shared care record.

The geriatricians’ role within the MDG was viewed as key, with high expectations about the value of their input. GPs saw the geriatricians as a key reason to engage:

I think once the geriatrician is involved, and we establish good links with him, I think it could actually be much more stimulating, and much more rewarding, in terms of educating us, and improving our standards of care. But, obviously, we’ve spent 6, 7 months without anybody . . .

During observations, the geriatricians were able to access hospital patient data, enriching the discussions with information not contained in the SCR. They were involved in many key actions and frequently advised GPs on medication reviews:

. . . earlier we were discussing a case where a lady had a rapid deterioration of a wound and I asked if she might be diabetic. The geriatrician was able to pull up her blood glucose results confirm she hadn’t been tested and sent a message for this to be done. MDG reviews mean more people can contribute to a possible solution that may otherwise have not been considered.

Involvement of mental health professionals could be an issue owing to resource limitations:

I think there’s buy-in from mental health . . . you know what they’re able to deliver is fairly limited and the need is massive . . . mental illness, it goes on over a period of time and, sort of, we’re so far off anticipating what the need might be, because we’re worried about putting more need [support] in there than what’s required.

Process and content of multidisciplinary group meetings

Patients were stratified into four groups of ‘need’ to allow services to be better matched. Patients receiving three or more visits per week from district nursing and/or social care teams (around 3100 patients) were deemed most likely to benefit from MDGs. Practices had voluntarily participated in an exercise to identify the 2% of their population at greatest risk of admission (national ‘enhanced service’). Although existing algorithms existed [e.g. Patients at Risk of Rehospitalisation (PARR), PARR+] to identify patients at risk, dissatisfaction led to new ones being developed to code patients to ‘Sally’ levels (Table 30 and Appendix 4, Figure 15).

Although there were tensions between the amount of work and pre work provided by various parties, there was mutual respect for the different perspectives provided. During interviews, the concept of teams tended to be reserved for each group’s specialty, and team working seemed more limited at the MDG meeting itself. An exception was where the nursing and social care co-chairpersons worked closely together and formed strong dyads.

An electronic SCR was used to enable information to be shared between the relevant statutory agencies, and these were projected during MDG discussions. The majority of SCRs were initially created by the MDG nurses, with input being provided by the social care chairperson and then being sent onto GPs, practice nurses and mental health staff. An agreed shared care plan within the SCR was then developed based on MDG discussion.

Initially, there was an emphasis on the creation of the SCR, and targets to encourage this could have affected the quality of data they contained. A working group was set up to look at content of the SCR, especially when there was an expectation that a summary SCR (in the form of a plan) would be shared with patients:

. . . we’ve, kind of, learned about the shared care record, about the data and how to look through it quickly and how working alongside the social worker with their system open and shared care record, how together, you know, you can get really good quality information, it’s much quicker to do it that way, so more timely.

. . . the patients eventually, they’re going to be getting a copy of this . . . you don’t want to write anything that’s going to upset them. There’s a lot of debate at the moment about what we should be writing, and we’ve had a few little working groups about trying to standardise documentation.

By the end of observations, SCRs were still not being shared with patients. Patients often had not been told they had been assigned a care co-ordinator and did not have their contact details.

Summary of major issues in implementation and relationships to known drivers of change

We used the ‘five simple rules’44 (see Chapter 3) as a framework to understand implementation.

Involvement of general practitioners

In terms of the factors identified by the ‘five simple rules’, one of the core issues facing the MDGs related to GP involvement. Initial participation was not always enthusiastic; not all practices took part, and identifying a GP to be the MDG lead was difficult for some practices. Incentives were required, although over time the involvement of GPs grew (as did that of practice nurses). The SICP delivered a somewhat unique neighbourhood model (compared with a practice-based one), which meant that GPs were exposed to MDG work around patients in other practices, which might be seen as inefficient, although it could have advantages.

Two MDG managers visited practices to explain the MDG concept and worked with practice managers and a GP lead at each site to encourage engagement. As a result, most practices in Salford agreed to participate, although some delayed joining owing to staffing and/or relocation issues:

I don’t remember being made to feel compelled to do it, I could be wrong . . . for me, we had to try it, so I went in thinking, ‘I’ll give you 6 months, at the very most I’ll give you 6 months.’. I went in with a very negative attitude. Fortunately, I didn’t allow my head to rule my heart and I started being a bit more open about it . . .

Practices agreeing to participate met together and underwent three training sessions initially. The first meeting introduced MDGs and how they operated. The second planned to carry out a Belbin assessment of all the team members to identify strengths and weaknesses and to facilitate better project working. At this second meeting the process to refer patients and the SCR were demonstrated. At the third training meeting, practices were each asked to identify one patient as a trial run for MDG discussion. In the MDG meetings that followed, practices were asked to refer other patients into the system (initially two or three patients per practice and then five patients per practice).

There were competing initiatives with these groups of patients, such as those run by the CCG:

[Long-term conditions] creates a lot of work. It’s a local initiative and the CCG want us to review patients twice yearly who have a LTC [long-term condition]. Discussion re[garding] symptoms, medication, health promotion advice and agree an action plan with them. If the individual has a respiratory condition or diabetes they receive an action plan for this and a LTC action plan. This is a lot of duplication and the process is time consuming. Reviews have become a tick-box exercise and the discussion about agreed actions is comprised due to time constraints.

Measurement

The second simple rule related to measurement. Again, the MDGs had ready indices to assess progress and care delivery (such as numbers of SCRs). The initial risk stratification identified 3100 people potentially requiring discussion at MDGs, creating a tension between creating SCRs (to meet targets) and collecting data of sufficient quality to aid care co-ordination and planning.

One of the main ways in which learning was shared across the neighbourhoods was through the ‘MDG joint chairpersons’ meeting. MDG project managers led this meeting, which managed issues and facilitated learning. The number of level 3 patients with SCRs was fed back in terms of their achieving red, amber or green status. This feedback aimed to encourage a sense of competition between the neighbourhoods, but also highlighted difficulties when individual practices had not met the requirement of creating SCRs for 80% of their identified level 3 patients. In addition to this in-depth monitoring, which was updated on a weekly basis, ‘dashboards’ were created, which allowed interrogation of the data by individual practices.

Patient involvement

The NHS National Collaboration for Integrated Care and Support4 adopted a narrative definition of what integrated care should feel like for the patient [e.g. ‘I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me’]. Recent qualitative work has highlighted some of the dimensions of this experience, identifying six themes around person-centeredness (holism, naming, heed, compassion, continuity of care, and agency and empowerment) and exploring the patient experience of being ‘unseen’ by their practitioners.11

In principle, there are two key processes by which MDGs may help deliver patient-centred care. The first is care planning, which involves an assessment of the needs of the individual patient and the development of an individualised care plan reflecting the patient’s personal circumstances and needs. Second is care co-ordination, which is the process of helping patients to navigate services by enhancing communication and providing advocacy. Nevertheless, there are potential tensions between patient-centred care and MDG working. Core features of patient-centred care include detailed knowledge of the patient (and application to decision-making) and an effective ‘therapeutic relationship’, both of which may be more difficult to achieve in the context of team-based care. A patient seeing a variety of health professionals may feel less able to build up a relational continuity.145 Patient involvement can be difficult in the context of MDGs and team-based clinical decision-making.

Multidisciplinary group guidance indicated that patients and carers should be contacted and a discussion had with them ahead of MDG discussions. In reality, the pressure to create a SCR and wider service pressures meant this rarely happened. Virtually all MDG staff interviewed felt that consent should be sought ahead of discussion:

I think the idea is that if they’re open to a particular worker within social services that we would have that discussion with them, if they’ve got district nurses going in regularly that they would or that if they are regular visitors to the GP that they would . . . I guess it’s sort of one of them where ideally the care co-ordinator would be in place and it would be that person that would then go and have that discussion with them and give them the feedback from the meeting and everything.

In December 2015, the CCG launched standards for services across practices, with guidance regarding consulting patients ahead of MDG discussions and feeding back outcomes. However, observations at MDG meetings showed that the discussions were of patients receiving feedback in the future.

We identified three core themes concerning how MDGs delivered patient-centred care:

1. structure of MDGs and person-centred care
2. processes within MDGs supporting person-centred care
3. barriers to the delivery of person-centred care.

The structure of multidisciplinary groups and person-centred care

The SICP used the ‘Sally Ford’ character to highlight the issues faced by older people. The multidisciplinary nature of MDGs provided a platform for a biopsychosocial assessment. By working together, health and social care professionals better appreciated each other’s roles. A second critical structural support was the creation of the SCR, which used data from the existing locally integrated primary, secondary and clinical settings, and into which social care staff could input data. The SCR was displayed during the discussion for each patient and updated with outcomes and actions arising.

Processes within multidisciplinary groups supporting person-centred care

All staff viewed the MDGs as an opportunity to share knowledge and provide a more holistic approach to care provision:

It’s bringing everything together so that we’re truly thinking more holistically about a person and considering not just individual kind of professional service-specific issues but seeing the overview and what might really matter to a person or what might be a priority and then coming up with an action plan that actually meets that.

Although colocated previously, the arrangement whereby MDGs were co-chaired by staff from district nursing and social care provided greater insights into each other’s work and changes to practice:

. . . I’ve seen where there have been suspicions between health and social care, and crucially where people have different priorities . . . the pressure on hospital beds, which means people need to be discharged . . . Now having a better understanding around how the social care, how we do things that will help them to understand that it’s not as straightforward to just discharge somebody. We need to discharge and ensure that they are safe wherever they are going, and I think that wider integration [including psychological, medical and community services] can help address that.

Multidisciplinary group discussions yielded rapid solutions, particularly when local authority-commissioned social care packages required amendments. Small changes, termed ‘tinkering at the edges of care’,146 enabled patients to attend one-off hospital appointments and also regular exercise classes:

. . . we were saying about this fellow going at night to [a hospital] appointment, and I was saying about the care agency going in later, the social workers can arrange that; and she said, ‘but they finish at 8 o’clock’; so everything I was saying was being answered really negatively . . . But then we realised that maybe . . . the evening district nurses could go and put him in bed that night.

Knowledge of patients’ interests helped MDGs find some solutions to frequent hospital attendance:

. . . one time the [MDG] nurse was in the house, [the patient] went in the other room and rang an ambulance, this gentleman. [Then] it’s somebody who just thought . . . ‘such a person’s not rang, what’s going on?’. [Then] . . . somebody realising that whenever, say, the tennis was on or the Olympics, he never went into A&E. He never rang A&E, he never went in. Then the practice nurse must have had a conversation with the son and he might have just said, he really loves sport. His son went out and bought him a Freeview box and it’s got sports channels on. Since that date, he’s never had an admission to A&E.

A second process concerned MDGs sharing knowledge from health and social care perspectives about local services, encouraging a broader approach to meeting patient needs. Although time-consuming, MDG meetings provided a forum for professionals to learn about services available. GPs found it difficult to keep abreast of service changes, especially those delivered by non-statutory organisations:

. . . some of the other GPs . . . they’ve said, ‘oh well, I’ve learnt that there’s this service or that service.’. But they’ve learnt about maybe a handful of services in coming up to a year of . . . a part of the MDG you’ve got to ask is that actually a good educational use? . . . A lot of those services I knew about before . . . [It’s] hard to look at all your e-mails ’cause you get bombarded with so many, it’s easy to miss a service or you read one you think, ‘oh, that sounds fantastic’ and then you forget about it ’cause you won’t refer to it very much.

Multidisciplinary groups could also support person-centred care by involving those best known to the patient. A professional already known to the patient was usually assigned to the role of care co-ordinator, and the details of all those involved in their care were recorded in the SCR, pulling data from many agencies into a single source to aid care co-ordination.

Continuity of care was seen as vital to having effective knowledge of patients and their families, with GPs being seen as key. Despite this in-depth knowledge, the geriatricians were continuing to see patients face to face during assessments, and they questioned whether or not admissions can really be avoided. Geriatricians suggested that more proactive care planning, by GPs in particular, is required to reduce future admission rates and support more appropriate (rather than earlier) discharge for those who are hospitalised:

They [GPs] know them inside out, yet, they’re not necessarily thinking about what might tip them into, you know, non-elective emergency responses . . . but they [GPs] may not see that there’s any other alternative.

Barriers to person-centred care

Although consultations during the development of the SICP had included patients and carers, MDG discussions did not directly include them:

. . . why wouldn’t they want to be involved? What is being discussed there that the person and their families wouldn’t find relevant, appropriate or interesting? . . . and is that right and what is the purpose of those [MDGs] if it’s, if it’s not to engage, you know, . . . [Is this] a process for just professionals to speak short hand about, together, about the integrated care management of a person and the contact with the person takes place elsewhere, possibly?

Observations showed that although GPs fed back the outcome of MDG meetings to their patients, patients did not always agree to the suggestions made. This was especially true when MDGs recommended memory or social care assessments, which caused anxiety.

Aspects of MDGs limited the degree to which patient-centred care could be delivered. Nurses recognised the value of visiting patients at home, building a relationship and getting quality information to inform care planning, but flagged up difficulties with this when workload pressures limited the information supplied by colleagues:

. . . we need to be taking the patients that we’re seeing for MDG, to go and meet them, . . . to actually have a good picture of how they live and what’s going on, and the dynamics of families, and just get an overall picture. Because you can’t [get that] from looking at a screen.

Some questioned the utility of the SCR:

I can’t tell you how annoying I find that . . . It’s not a plan. There is no care plan. It is a record of information about a person . . . There are no directions on that record that give you a prescription for treatment. So it’s not a care plan . . . And as nurses, we pick up on that, they don’t.

Towards the end of our observations, there was a change in MDG discussions, which coincided with the inclusion of a ‘summary of existing risks and issues’ on the SCR, which helped generate a more proactive care planning approach.

How is the work of the multidisciplinary groups experienced by patients and carers?

Patients and carers knew little about the SICP or the MDGs. Of those who did, many had been directly involved in the initiative through the Older People’s Partnership Board or the Citizens Reference Group.

This lack of awareness, combined with shared care plans not being shared with patients, meant that people were unlikely to know that they were part of a MDG. As patients were not routinely consulted ahead of MDG meetings, this limited the number of interviews that we were able to undertake.

Among those who were interviewed, there was limited evidence of active ‘case management’, and any care co-ordination seemed to focus on integrating records from health and social care via the SCR. Most patients could not identify a ‘care co-ordinator’.

Most GPs (during interviews and at MDG meetings) said that they would tell patients about discussions with colleagues if they saw the patient, but would not make a specific telephone call to discuss the MDG. If patients ended up being referred to health improvement services, then the GP would put the referral on hold while they confirmed that the patient was happy for their details to be shared:

The [GP] did mention it to me once I think, something about she’d been talking and she was going to put my name forward, something to do with this kind of thing [MDG], yeah . . . you can only give it a try and if you think it’s going to do you good well you’ll do it, won’t you?

Some patients don’t even know they are being discussed. I will try to contact patients or ask when I see them about discussing them at an MDG, but sometimes if we can’t contact them and there is a pressing issue that needs discussing we will have the meeting and then afterwards I will talk to them about it.

There were examples of patient involvement in MDGs. An 80-year-old woman with a history of frequent A&E visits arising from repeated falls had lost confidence and was no longer going out of her flat, citing fears about using her stairlift. She gave consent to be discussed at MDG by her GP, who was concerned about the changes occurring:

I’ve known her for nearly 20 years, and she lives in a sheltered housing complex. She used to go and visit her mates [in another housing scheme], and get involved in all this social stuff . . . I also know she’d lost her confidence after various falls, and she wasn’t going out . . . she’s scared to leave her front door. I have a very good idea about what the patients I know very well want.

I had about five or six [falls], from last Christmas, in the flat and everywhere, you know, and I’ve lost my confidence . . . I’d left my [care on call] band in the bathroom . . . You know, if I fall I can ring them right away, . . . So sometimes I was sitting here 2 or 3 . . . about 3 hours before anybody came . . .

Prior to the MDG discussion, the GP requested a change of housing. Once relocated to a bungalow in the same complex, she was assessed for, and received, mobility equipment from the rehabilitation team and was able to re-engage with other residents after the health improvement team invited all residents to attend a meeting.

It is possible that limited patient involvement limits the benefits of MDG work and the creation of relevant care plans. The process to refine the shared care plan, however, took far longer than anticipated, and there were many issues around what format the plan should be in so it could be shared with patients:

. . . we were discussing the logistics of how printing off a copy of the shared care plan for the patient and how that’s difficult at the moment. It doesn’t look nice. It’s not very ergonomic. It’s not very user friendly at all. In fact it’s horrible.

. . . the patients eventually, they’re going to be getting a copy of this, . . . you don’t want to write anything that’s going to upset them. There’s a lot of debate at the moment about what we should be writing, and we’ve had a few little working groups about trying to standardise documentation.

Patients and carers were often overwhelmed by the sheer number of services they received. Where carers were aware of the MDGs and knew the appointed care co-ordinator, they were happy to remain involved in making arrangements:

[Mum] had visits from nurses, doctors, hospitals, GPs, physiotherapists, dieticians, intravenous teams, and others . . . care agency, et cetera, so her house is like Waterloo Station. It’s very busy . . . [If you’ve got a hospital visit] I phone [the care agency] usually a couple of days before, and say, my mum’s got a hospital visit on whatever day. Can you leave her in the wheelchair in the morning, and don’t do her lunch. I’ll do her lunch when I bring her back. So . . . and that always works. I don’t want to do that sort of stuff through a [care] co-ordinator. I’m happy to . . . on day-to-day issues like that, that’s fine.

Some carers felt too much was sometimes being done to patients in the NHS, which was unnecessary:

The NHS has a concept of ‘doing things to the older person’ . . . It pathologizes. It treats people as patients ‘cause that’s how they present rather than standing back a bit . . . older people tend to be hypochondriacs and they’re costing the NHS a lot of money. So rather than not constantly respond to them as patients, we might be sensible to stand back and actually talk to them a bit.