Better Care Together TNS BMRB research programme

Better Care TogetherTNS BMRB research programme

Overview of better care together engagement March 2013 to date

4 July 2014

What is better care together?

Better care, together is a review of local health services which is being carried out by local NHS organisations, led by:

– Lancashire North Clinical Commissioning Group– Cumbria Clinical Commissioning Group– University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the

hospitals in Lancaster, Barrow and Kendal.

The review is an opportunity to make sure the best possible health services are provided across North Lancashire and South Cumbria, which meet the needs of residents, now and well into the future.

Health professionals in the area, including GPs, hospital doctors, voluntary organisations and other NHS and social care colleagues are considering how the different parts of the health service can work together more effectively to ensure individual patients get the most appropriate care.

IntroductionBetter care together is conducting a large-scale programme of public engagement to inform the new clinical strategy. The work to date has been a combination of engagement carried out by better care together and work commissioned externally. The purpose of the engagement to date is to act as a pre-consultation stage of engagement to inform plans to reconfigure health services across Morecambe Bay.

3

Collecting public and stakeholder opinion on health services provided in the Morecambe Bay area and gathering information on their specific experiences and priorities for future service delivery.

Engagement in Spring and Summer 2013 focused on opinion re: four work stream areas: maternity, paediatrics (children and young peoples services), planned and unplanned acute services.

Engagement from Autumn 2013 to date focused on opinion on out of hospital services in terms of current provision and future provision following feedback from patient, public and stakeholders that better integration was needed between in and out of hospital services, and enthusiasm to discuss how out of hospital services could be improved

Research is being undertaken in North Lancashire, South Lakeland and Barrow-in-Furness to reflect the spread of the population across the region served by NHS Cumbria Clinical Commissioning Group, Lancashire North Clinical Commissioning Group and the University Hospitals of Morecambe Bay NHS Foundation Trust.

This presentation summarises the findings from the engagement research to date

Approach

Summary of better care together engagement to date:

Patient and public Elected members Staff Partners Clinicians

Bus roadshow City, Borough, District and Town Councils presentations and feedback

Email bulletins Third sector organisationsSpecific interest partners e.g. Maternity, Children's Health, Learning Disabilities, Complex care, Older Adults, LGBT, Healthwatch etc

GP engagement events

Town centre events Lancashire OSC presentations and feedback

Articles in the UHMBFT Staff Newsletter

Weightings workshops Workshops

Listening events Cumbria OSC presentations and feedback

Information in the “Friday Message” from Chief Exec to UHMBFT staff

Meetings Clinical workstream meetings

Focus groups Joint Lancashire & Cumbria OSC presentations and feedback

Staff drop in events and invitation to public drop in events

World café events Care Design Groups

Discussion groups Lancashire County Council briefings

Team briefings and briefings Listening events Clinical Summit

Workshops Cumbria County Council briefings

CCG Membership Council meetings

Discussion groups CCG Membership meetings

Paper surveys and on-line surveys

Health & Wellbeing Boards, Partnerships and Forums presentations and feedback

Surveys Focus groups Clinical Reference Group

Patient, Public, Neighbourhood, Action, Partnership & Parish groups

MP briefings Consultant meetings Surveys Briefings

Public Reference Group meetings

UHMBFT Governors & Trust Board

Information stands Workshops Staff events

Promoting the engagement opportunities

The engagement opportunities to date were promoted via a number of channels including:• Street recruitment for TNS BMRB focus groups and discussion events• Press releases to local media re: activities • Newspaper advertorials re: bus roadshow• Radio interview re: bus roadshow• Website• Posters promoting the paper survey• A4 4 page leaflets distribution at the bus roadshow and at the public field events• Stakeholder briefings • Paper survey placed in public locations e.g. GP surgeries, pharmacies, libraries

etc.• NHS staff communications• Word of mouth• Direct contact e.g. invitations, email and telephone• Newspaper advertising e.g. re: Spring 2013 and 2014 events• Ad-bike

Externally commissioned engagement

Results of the TNS BMRB 2013 Engagement Programme:

Participant feedback

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Quantitative phase: surveys to access the opinions of a much larger number of respondents, to help identify on a larger scale which emerging issues had greatest significance. Public postal survey (targeted): Questionnaire posted to 10,000 randomly selected households Public open access survey: Questionnaires distributed (c.10,000) to locations such as GPs and pharmacies, questionnaires could

also be requested by members of the general public Staff/ stakeholders: Web survey (invited) Approx. 3700 responses

• Deliberative phase: interactive workshop sessions with service users, to explore future service delivery options in depth 6 deliberative workshops with 20 service users in each

MethodologyIn Spring 2013 better care together commissioned TNS BMRB (an independent specialist in research) to carry out a research programme for Better Care Together. The programme involved four phases of engagement followed by analysis and reporting.

Scoping phase: listening to internal stakeholders (with a geographical spread) to hear, first-hand, their views of the current state of play and ideas on what service changes might look like

16 interviews with senior or specialist staff/stakeholders 4 small groups of staff/stakeholders

Listen

Include

Create

Qualitative exploratory phase: focus groups and one-to-one discussions exploring experiences of services, concerns, preferences and priorities for future service delivery 24 90-minute groups with service users and relatives 30 60-minute interviews with people with negative experiences of health services 20 60-minute in-depth with a range of stakeholders Online community with 30 young people ‘Street interviewing’ with 33 members of the public

Explore

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Geographical areas: summary of people, outlooks and attitudes (TNS BMRB 2013)

Barrow in Furness

SouthLakes

Geographically isolated – a ‘cul-de-sac’ (respondents’ phrase) in terms of location and outlook. Relatively deprived. Many long-term residents; many seldom travel beyond the local area. Easy access to, and ‘pride of ownership’ of, a DGH is a strong influence on views.

Hard to access rather than isolated. Mixed population in terms of income, options and residency – some much more able to deal with access, and much more outward looking, than others. Accustomed to travelling to access healthcare services.

NorthLancs.

Relatively well connected to other places by M6. Divided population – Morecambe, Carnforth etc feels separate from Lancaster. Generally look south to Lancashire rather than north to Cumbria. Expectation of access to ‘big city services’ in Lancaster (not always realised).

4. Unscheduled Care

Better care together initially concentrated their efforts on four workstream areas: this is a summary of key views and priorities (TNS BMRB 2013)

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1. Maternity 2. Paediatrics 3. Planned Care

Proximity the most important factor. Most content with, and see benefits of, the services they have accessed. Most see downsides to alternative service options.

Parents prepared to travel further for expert care for their children than in other service areas, but less willing to travel for routine care. More sensitive to delays and quality of staff approach.

Widespread contentment with medical care received locally (assumption that it will be at least adequate). Willing to travel for specialist care. Most issues regard communication and administration.

Proximity and speed of first assessment is key. Alternatives to A&E are welcomed (where they exist, and as an idea) if they aid this, particularly for minor injuries.

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Maternity services(TNS BMRB 2013)

48 12 31 36

12% 67%

Neither well nor poorly Very poorly Poorly Neither well nor poorly Well

Maternity services were rated positively on the whole(TNS BMRB 2013)The most important factors influencing a positive or negative experience

were the availability and attitude of staff

Good/hard working staff

Helpful/friendly/caring

staff

Good/safe services/care

16

18

24

Those who had a comment about their experience said...

Slow service/long waiting time

Need more caring staff

Better/safer services/care

Staff are unhelpful / unfriendly / bad attitude

Need more staff / availability

10

12

13

18

21

SOURCE : General public survey

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84% of targeted respondents (who were pregnant/had a pregnant partner) said it is important that they are able to decide in which hospital or location the child is delivered

The Explore phase of research demonstrated this has little to do with the ‘identity’ of the child being born in a particular area, and much more to do with proximity to home and safety

At home with a community

midwife

In a hospital by a consultant or doc-

tor

In a midwife-led unit

Don't know

4

42

20

34

8

53

2317

All

Women only

The importance of choice of place of birth (TNS BMRB 2013)

%

70% of the people who answered ‘Don’t know’ were men

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General views on future changes to services (TNS BMRB 2013)Views of options around antenatal care and delivery were very strongly informed by experience

of and access to current services, and beliefs about what is needed

Drivers: Services; Experience; Expectations

Overall: Experience is less prominent than the other drivers: people reluctant to change what had worked in the past, tend to see benefits of the care they received and disadvantages of other options, even if their experience was less than ideal.

Barrow and N Lancs: Expect and draw comfort from presence of consultants, despite negative experiences; see only risks to MLU, not potential benefits

S Lakes: All three drivers align to create strong preferences for MLU; some reluctance to use CLU even if advised to do so

Preference for CLU, MLU or home birth

Drivers: Services; Relationships; Horizons; Expectations

Overall: Proximity to home and perceptions of safety are key considerations: being close to family; minimising need to travel prior to delivery and risk of transfer during labour

Barrow and N Lancs: hard to imagine going anywhere except FGH or RLI – close to home and expected to be able to handle complications

S Lakes: preferred to deliver at Helme Chase, but accept assessments that identify risks and advise going elsewhere

Choice of place of birth and when this would change

Preference: co-location of MLUs and CLUs in Barrow and Lancaster, keep MLU in Kendal

Items for further consideration:

• For Kendal, a concern that a co-located MLU in Lancaster would encourage more risk-averse Kendal mothers to go there, eventually leading to Helme-Chase closure

• Kendal would prefer ‘MLU-plus’ at WGH, where midwives are trained to use forceps etc to avoid transfer for ‘minor interventions’

• Barrow wondered about benefits of locating free-standing MLUs to ‘fill in the gaps’ between CLUs and service a greater breadth of areas. Ultimately ruled out due to practical issues (cost, new inexperienced services) and in favour of locating in areas of highest birth rate

Why would co-locate CLUs and MLUs?

• Satisfies a fear of transfer felt in Barrow and Lancaster

• CLUs can be reserved for complex cases

• Provides ‘risk-free’ choice of MLU and CLU; may encourage more people to try MLU

• Additional free-standing MLUs not seen as practical (cost); unclear where the MLUs would go

Why CLUs in Lancaster and Barrow?

• No-one loses existing services

• Highest birth rates

• Kendal do not want a co-located CLU (concern that it would ruin the MLU experience)

• Barrow think Lancaster too far to travel/transfer – bad road, traffic, unsafe

• Lancaster very resistant to travelling to Preston

Reactions to potential service configurations of co-located Consultant Led Units (CLU) and Midwife Led Units (MLU)

vs stand-alone MLU (TNS BMRB 2013)

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Paediatrics

(TNS BMRB 2013)

94 7 39 35


74%13%%

Better communication/follow up

Need better/safer services/care

Need better/more knowledgeable/competent staff


10

10

16

30

Helpful / friendly / caring staff

Good / hard working staff

Good / safe services / care

11

17

19

Paediatric services generally rated positively (TNS BMRB 2013)Only a minority (one in ten) rated the services as poor or very poor, with poor experiences most often being attributed to long waiting times



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General views on future changes to services (TNS BMRB 2013)Acceptability of alternatives to A&E and personal contact with health professionals depends on

existing access to and confidence in these services

Drivers: Services; Relationships; Capabilities; Experience

Overall: Difficulties in getting appointments and lack of perceived ‘value’ from GPs were barriers in all areas. Mitigated for some who knew how to use the system. Ease of access to A&E was also a factor.

Barrow: Scepticism about ability to get urgent appointments at GP and proximity of FGH made many feel it is ‘acceptable’ to bypass primary care and go straight to A&E. Positive experiences at FGH amplified this.

S Lakes: Depends on short-notice availability of GPs, but also since Westmorland is limited and RLI A&E is distant many reluctant to waste time if need to go to RLI in the end (despite some negative experiences at A&E).

N Lancs: Parents want to make their own assessment of whether A&E is necessary, and likely to err towards it given access to GPs. 111 service helps with this. Mixed experience of being referred to A&E has a strong influence.

Using the GP rather than A&E for urgent care

Drivers: Services; Relationships; Experience

Overall: Ensuring the child gets to know relevant professionals was a key consideration; provided this is covered, remote contact is appreciated. 111 service shows some that it can work. Most appropriate for primary and follow-up care. Least popular in Barrow and Lancaster, due to proximity of DGHs.

Specialist care and other services via video links etc

Items for further consideration:• Parents uncomfortable with taking responsibility for

diagnosis decisions, therefore transportation for “in distress” or at-home care may provide reassurance:

• Enhanced Primary Care services could help meet a diagnosis need and may make SSPAU more appealing to service users

• Clarity that parents would not be responsible for transportation in case of transfer

• Provide reassurance of sufficient numbers of paediatric nurses & in-hospital training

• Families are eager to avoid A&E and its long-waiting times:

• SSPAU would be more appealing if it clearly helped avoid A&E (i.e. more direct access)

• A phoneline into the SSPAU also welcomed for advice

Why keep inpatient service?

• Parents are loss and risk averse: strong emotional desire to retain access to inpatient paediatric care for all but the most serious cases nearby

• Concern about risks to child & parental responsibility during transfer

• SSPAU a positive addition but benefits not sufficiently clear to warrant loss of inpatient

• Community nursing support insufficient

Why keep in Lancaster and Barrow?

• No-one loses existing services

• Both areas extremely opposed to loss of inpatient services; Kendal supports a case for service in Barrow in particular given isolation

Reactions to potential service configurations of Enhanced Community Nursing (ECN) and Short Stay Paediatric Assessment Units

(SSPAU) vs retaining current inpatient services (TNS BMRB 2013)

Preference: Co-location of SSPAUs alongside inpatient wards in Barrow and Lancaster, with enhanced 24h paediatric service in Kendal. Maintain status quo if this is not an option; closure of any inpatient service is strongly rejected.

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Planned care(TNS BMRB 2013)

96 12 34 37


Those with a recent experience rated planned care more positively.Most important factors were waiting times, quality of care and communication

(TNS BMRB 2013)15% 71%

%

Difficult to get appointment

Better/safer services/care

Need more caring staff/don't give enough time to patients

Better communication / follow up


8

8

9

12

23

Helpful / friendly / caring staff


Good/safe service/care

5

5

20


22

General views on future changes to services (TNS BMRB 2013)All prioritised efficient referrals to specialists, with explanations for decisions. Acceptability of

local solutions for episodic care depends on the post-treatment care pathway. Local service delivery for chronic conditions is widely supported

Overall: Speedier access to assessments and diagnoses (GP referrals). Consultants and GPs being more prepared to give explanations of all decisions. Continuity of staff, and making patients aware if continuity can be requested. N Lancs: residents called for better/ speedier access through GPs and management of dischargeBarrow: residents wanted staff to show more ‘care’, to be clear on decisions and outcomesS Lakes: residents asked for more patient transport for appointments and better communication between GPs, Westmorland and other hospitals

Desired improvements

Episodic care: Acceptability of elective day surgery with earlier discharge depended on the condition and advice from specialists, and on improvements to care post-discharge, with a stronger link between specialist and local care (GP/ district nurse). There was interest in ‘intensive’ treatments to reduce total number of appointments – many prepared to travel further if this was possible. On-going care / chronic conditions: Interest in local solutions: mobile specialist clinics, strong support for ‘district nurse’ role (return to older models), greater use of pharmacies – already believed to be in place in some cases. Continuity of care prioritised in all three areas. Stakeholders: More can be done with planned care through teleconference in rural areas. N. Cumbria has had success with a stroke teleconference between 16 hospitals and consultants in north-west.

Solutions

Items for further consideration:

• Some debate about whether ACCs should be:

– numerous and based in the community because they will serve older populations on an ongoing basis

– fewer in number, and centrally located to serve a larger population density and become centres for excellence

• Lancaster would want to retain some emergency and inpatient paediatrics function even if they were losing complex inpatient services for adults

• Support contingent on provision of good access routes for ambulance and public transport

• All changes need to be backed up by increased care in the community

Why reduce inpatients?

• Preference for streamlined day surgery that suits the majority of planned cases and more specialised care locally for long-term conditions

• Recognise need to save space for more serious cases; prefer not to be admitted if unnecessary

Why inpatients in Barrow?

• All agree: Barrow most isolated and in need

• Lancaster happy to travel to Preston

• Kendal used to travelling and would gain services with this arrangement

Why DCS in Kendal?• Most central, becomes ‘planned’ centre

Reactions to potential service configurations: Ambulatory Care Centres (ACCs) and Day Case Surgery (DCS) vs retaining inpatient

services (TNS BMRB 2013)

Preference: Reduce inpatient function across the region as a whole, with complex inpatients remaining in Barrow, DCS in Kendal and ACCs in each location

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Unscheduled care(TNS BMRB 2013)

98 12 34 32


Experience of unscheduled care generally positive though one in five rated it as poor or very poor Waiting time the most significant cause of negative experience (TNS BMRB 2013)


66%17%%

Better diagnosis/triage

More staff/availability

Better/safer services

Better/more knowledgeable/competent staff

Better communication / follow up

Staff are unhelpful/unfriendly/ bad attitude

Slow service / long waiting time

6

7

7

8

8

9

46

Quick/fast service


Good/safe service/care

6

7

15

%%


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General views on future changes to services (TNS BMRB 2013)

Local clinics strongly supported for minor conditions; proximity of A&E a vital consideration if there is an urgent need for unscheduled care

Overall: Nurses normally thought appropriate, given a strong preference for dealing with minor issues as locally as possible, across areas. Strong interest across areas in up-skilling local primary care staff, including pharmacists, and services to deal with more minor complaints. N Lancs and Barrow: Positive experiences of community health units strengthens confidence in this in S Lakes: Minor injury units with longer opening hours suggested as a replacement for Westmorland

Feeling unwell or minor accident

Overall: A&E or specialist GP required for mid-level cases. All areas agree this would require much more responsive GPs to work successfully. Quick access to fully functioning A&E seen as vital in major cases. N Lancs and Barrow: reluctant to consider alternatives to local A&E, but desire to reduce ‘bottlenecks’ by diverting minor injuries elsewhereS Lakes: Interest in more effective immediate diagnostic screening locally, where appropriate, followed by travel if necessary

Seriously unwell or major trauma

N Lancs and Barrow: Specialist nurses already thought to play an effective role closer to home (e.g. diabetic specialist or ME specialist) – build on this. Desire for more ‘walk-in’ health centre facilities to support regular check-ups without requiring GP appointment. S Lakes: Success in preventative, community-based care would depend on strengthened relationships with GPs and greater availability/ travel from other healthcare staff.Stakeholders: Patients (especially elderly) need to be treated as whole person

At risk or chronically ill (ongoing)

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Why could it be in Kendal?

• Barrow would prefer any single A&E for the region to be based in Kendal: central location and more palatable as a transfer destination than Lancaster

Items for further consideration: • Preference would be to maintain existing services with new

services as additions if financially feasible

• Reducing further than 1 A&E and 2 ASTs is not acceptable to most; minor injuries units not seen to be sufficient to provide coverage for region if A&E reduced

Why would it be acceptable to have one A&E?

• Combination of EPC with AST gives confidence that AST will be sufficient for areas without A&E

• Recognition of need to change and that a centralised A&E service might improve quality

• Pre-existing acceptance that you can’t get everything locally – e.g. cardiac in Blackpool

Why could it be in Lancaster?

• Regional hub and largest population – Lancaster averse to losing A&E, and others see argument for it being here

• Barrow able to recognise that they are least accessible for the region

• Kendal already go to and rely on Lancaster

• Uses existing service – avoids new building

Reactions to potential service configurations: Enhanced Primary Care (EPC) and Assess, Stabilise & Transfer (AST) vs

retaining existing A&E function (TNS BMRB 2013)

Preference: First preference is to maintain status quo, with addition of EPC, VW and AST to relieve pressure on A&Es. If necessary, most will accept an AST with transfer to full A&E in Lancaster or Kendal.

Conclusions: Attitudes to travel and transferAttitudes to

travel and transfer

(TNS BMRB 2013)

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Over an hr

Between 31 mins and an hr

30 minutes or under

8

30

59

3

20

71

2

21

74

Maternity

Paediatrics

Planned care


Typical amount of time spent travelling to use the services by workstream

People are currently travelling furthest for planned care, and travelling the least for maternity services (TNS BMRB 2013)

% Most people’s journeys

are 30 minutes or under

People whose closest hospital is Westmorland General Hospital typically travelled for longer (57% spent between 31 minutes and an hour)

30

Willing to travel further Unwilling to travel further

27

68

42 4754

33

Maternity Paediatrics Planned care

Quantitative results support these findings (TNS BMRB 2013)Respondents are least willing to travel further for maternity, and most willing to travel for

planned care

%

Around two thirds said they wouldn’t be willing to travel further for maternity services - this is compared to only a third of people who said they wouldn’t be willing to spend more time travelling for planned care services.

Respondents were willing to spend the most time travelling for planned care – around a fifth said they would travel over 45 minutes to see a specialist.

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Mode of transport used...

82% 3% 2% -5%

Around one in six (15-18%) are not using cars to access services (TNS BMRB 2013)

82% 3% 2% 4% -

75% 4% 6% 6% 1%


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This varied acceptance of travel is also reflected in the results of the criteria weighting exercise (TNS BMRB 2013)

• Geographic access clearly thought less important than staffing levels and patient experience and health outcomes, and similar to other criteria. Has the least resonance amongst Lancaster residents, and most among Barrow residents

Weighting exercise results: mean across all three areas. Base: 106 respondents

Staffing l

evels

Patien

t exp

erien

ce & hea

lth outco

mes

Geogra

phical a

ccess

Efficie

ncy

Appropria

te car

e setti

ng

Servi

ces ar

e susta

inable

Caterin

g for t

he future

Ease

& spee

d of chan

ge0%

5%

10%

15%

20%

25%

Weighting exercise results: mean for each area. Base: c.40 per area

Lancaster Kendal Barrow0%

2%

4%

6%

8%

10%

12%

14%

Note: the ‘geographical access’ criterion did not specifically ask people about their willingness to travel, although this is likely to have factored in to their understanding of this theme.

Barrow-in-Furness

South Lakeland

North Lancashire

Views on acceptability of travel and service requirements can be summarised through an overview of results of the trade-off exercises, showing a minimum

acceptable service levels in each area (TNS BMRB 2013)

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COMPLEX Maternity

SIMPLEPlanned

Care

SIMPLE Paeds

COMPLEX Maternity

SIMPLE Planned

Care

SIMPLE Paeds

• Maternity: all areas feel they need their current provision

• Paediatrics: Barrow and N Lancs accept SIMPLE inpatient paediatrics; Kendal will travel

• Unscheduled: all areas feel they need Enhanced Primary Care; Barrow will accept AST if A&E nearby; N Lancs insist on local A&E; Kendal accept current provision

• Planned: all areas need SIMPLE planned care; prepared to travel for COMPLEX (so undecided about location)

INTENSIVE Unscheduled

Care

SIMPLE & COMPLEX

Unscheduled Care

Preston, Manchester etc

SIMPLE: perceived as routine, non-specialist careCOMPLEX: perceived as more serious or requiring specialist careINTENSIVE: perceived as a ‘full service’ A&E

SIMPLEUnscheduled

Care

SIMPLEMaternity

SIMPLEPlanned

Care

COMPLEX Planned Care

(location undecided)

Integrated care

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Stakeholders stressed the need for a more joined up approach (TNS BMRB 2013)

GPs

HospitalsCommunity Care (incl. third sector)

Change GPs’ and hospitals’ defensive ‘ours’ and ‘yours’ approach to patients, and work cohesively to serve the whole health economy

Break down barriers between primary and secondary care – e.g. opening a GP surgery at Westmorland General; share patient records

Hospitals need to support discharge into the community or home, particularly elderly

Hospitals need to understand out-of-hours services; not use them as a decanter for A&E: important that people are routed to the appropriate service

Community and third sector services need to be mapped

GPs need to know about other support services and refer patients there – integrating health, social care and third sector, focusing on preventative care and early intervention

Need immediate alternatives to hospital admission

“Everybody understands about general practice, and everybody understands something about hospitals. But all that panoply of services that covers the gap are ill-understood”

“People get passed from pillar to post in the system, because there aren’t really the incentives for anyone to take control of them”

“You need to build in that whole range of voluntary support into those pathways, we’re not integral we’re an add on for those who remember”

Weighting Criteria Exercise

Quant and qual approaches to the weighting criteria(TNS BMRB 2013)

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The criteria used in the quantitative survey used the same titles and short descriptions as were used amongst clinicians – no additional information was provided

Respondents were asked to rank the 8 criteria in order of importance

In the Create workshops, edited descriptions were used to make the weighting criteria simpler and were discussed to check understanding

Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign

The weightings given were then discussed as a group to allow respondents to explain their choices

100

Although the methodology of the weighting exercises differed in Include and Create, the results supported each other

The eight factors presented in the quantitative survey – INCLUDE (to be ranked in order of importance) Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign (TNS BMRB 2013)

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Safety of clinical services providedBased on having the right numbers of staff with the right skills in place to deliver the service to the nationally and locally required standards of care

Accessibility of servicesIn terms of how close the service is delivered to patients homes or places of work/study, and waiting time to receive the treatment patients need

Improved quality of the service deliveredBoth in terms of the overall experience for a patient and outcome of the treatment patients receive

Provision of services that can be sustained over a long period of time within the funding available to them

More efficient and effective ways of working for health service staffFor example, less time spent by clinicians travelling as part of their work, using technology to undertake routine tasks more quickly, etc.

Providing care in the most appropriate place for the type of careFor example in the patients home, in the GP surgery, in a community centre, at a hospital etc.

The speed at which changes in healthcare delivery are implemented

Changing health services so they are more able to deal with future changes in the local populations needs for example, increases in diabetes and obesity.

How criteria were presented in qualitative workshopsWhich things are most important to consider when deciding on future services? You have 100 points

to distribute between the 8 themes below – give more points to the areas you think are most important, and fewer to those you think are less important. Make sure the total adds up to 100!

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Evaluation Theme Description Points

1 Staffing levels(Will always meet minimum standards)

Safety of clinical services provided based on having the right numbers of staff with the right skills in place to deliver the service, and the effectiveness of links between hospitals and other services (e.g. GPs)

2 Geographical access Accessibility of services - in terms of how close the service is delivered to patients homes or places of work/study, and waiting time to receive the treatment patients need

3 Patient experience and health outcomes

Improved quality of the service delivered - both in terms of the overall experience for a patient (clean, friendly, safe) and outcome of the treatment patients receive

4 Services are sustainable Provision of services that can be sustained over a long period of time within the funding available to them e.g. whether enough cases in an area to keep services safe and sustainable

5 Efficiency More efficient and effective ways of working for health service staff - for example, less time spent by clinicians travelling as part of their work, using technology to undertake routine tasks more quickly, etc.

6 Appropriate care setting Providing care in the most appropriate place for the type of care - for example in the patients home, in the GP surgery, in a community centre, at a hospital etc.

7 Ease and speed of change The speed at which changes in healthcare delivery are implemented e.g. how much change to existing arrangements will be required to move to different model

8 Catering for the future Changing health services so they are more able to deal with future changes in the local populations needs for example, increases in diabetes and obesity, growing elderly population

How participants engaged with the themesThe following four criteria were closest to the patient

experience, and most salient (TNS BMRB 2013)

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Staffing levels(Will always meet minimum standards)

• Understood as the right number of staff at the appropriate level of expertise; less reliance on junior staff

• Closely linked to ‘front line’ staff and having adequate nursing capacity

• Understaffing had affected almost everyone’s experience

Patient experience and health outcomes

• Focus was on patient experience more than outcomes; the two did not sit together easily. Good outcomes was taken as a given by most

• Linked to spontaneous areas of importance – attitude, communication, cleanliness, food etc

Geographical access

• Related to location of services, how easy or difficult it is to travel there (esp for rural population), and travel infrastructure (roads and public transport)

• Also about the speed of access from start to finish, and not having long waiting times

Efficiency

• Felt to feed into everything – improving this benefits whole system

• An ‘internal’ criterion which affects experiences• Understood as technology improving the continuity of

care: new IT systems; record-sharing; quick diagnostic services; not duplicating work

How participants engaged with the themes These four criteria were seen as more distant; decisions would be

“out of our hands” (TNS BMRB 2013)

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Appropriate care setting•Related to accessing care in the place best for ‘me’, esp. important for older people to be near or in home, or for palliative care•Felt important to have a choice in this

Ease and speed of change

•Seen as being about getting it right the first time, but few had ideas about timescales and most felt this is in the hands of managers•Desire for it to be slow enough for staff and users to learn about new services•Linked to using existing buildings/resources over building new ones

Catering for the future

•Linked to sustainability; the bigger picture and planning for future trends•Variation in level of engagement with future trends; scepticism that obesity affects the area. A view that it was opposed to sorting out current problems

Services are sustainable•Most struggled to relate to this: didn’t engage with the concept of number of cases required to keep an area sustainable; felt had little control over it•Sense that nothing can be sustainable – NHS services change all the time

Criteria which relate most closely to patient experiences scored highest overall in the workshops (TNS BMRB 2013)

42

Ease & speed of change


Services are sustainable

Appropriate care setting

Efficiency

Geographical access

Patient experience & health outcomes

Staffing levels

7%

9%

10%

11%

12%

13%

18%

21%

SOURCE: Weighting exercise results: mean across all three areas. Base: 106 respondents

Proportion of points attributed to each theme

Differences between areas to some extent reflect current concerns with local services (TNS BMRB 2013)

43

Staffing levels - “having the right numbers of staff with the right skills in place to deliver the service”. Kendal rated this is most important, linked to perception that staff at WGH inexperienced

Patient experience and health outcomes - “overall experience for a patient”. Better experiences reported in RLI in terms of patient care, nursing, and feeling looked after, compared to Barrow and Kendal

Geographic access – “location of services, ease of travel to them, transport infrastructure”. Lancaster has best access, and places less weight on this criterion than Kendal or Barrow

Weighting exercise results: Base: 106 respondents

Ease & speed of change


Services are sustainable

Appropriate care setting

Efficiency

Geographical access

Patient experience & health outcomes

Staffing levels

Barrow

Lancaster

Kendal

Age UK South Lakeland engagement listening event May 2013: key themes

• Communication skills: an area for improvement e.g. staff communication skills, “you should not be grilled for an appointment” and NHS-NHS organisations

• Communications systems were also seen as an area for improvement such as IT e.g. “Booking system – a four-page letter, which included a password, to change an appointment either by phone or computer”

• Travel: people are used to travelling for highly specialised care, there is still a need for some services to be local e.g. “…now takes three buses to get to Westmorland General Hospital; from Grange”

• Patient experience: examples of positive experience e.g. “Furness General Hospital nursing team – nurses very understanding, talk to us in language we understand and share information”, and examples of poor experiences including poor care, “Delay led to collapse and emergency admission”

• Staffing levels are an area of concern i.e. are there enough staff in primary and secondary care?• Potential change is acceptable, people are familiar with change in the NHS but would like to see

positive change sooner rather than later so people can benefit from change: older people need good care today, not at some point in the future

• Care pathways are an area for improvement, with particular regard to transport, discharge and integration arrangements e.g. “Health/Social Care – passing between the two don’t work well together”. Good care pathways are important to ensure independence of older people

(Commissioned by better care together, carried out by Age UK South Lakeland with support from better care together)

Key themes to emerge from the Cumbria Youth Alliance engagement activities April - May2013 were:

1. A good awareness of the availability of health services2. Access of health services could be a problematic issue for young

people e.g. making appointments, delayed appointments, waiting times e.g. “Waiting times too long”

3. Young people understand they have a responsibility for looking after their own health

4. Patient experience with GPs is of a higher standard than experiences with A&E e.g. “They fixed me, good service, helpful”

5. Willingness to travel is affected by ability to travel e.g. reliance on public transport

6. Different communication skills are needed to work with young people

(Commissioned by better care together, carried out by Cumbria Youth Alliance via focus groups, discussion groups and surveys)

better care together engagement

March 2013 to date

• There was a range of engagement activities which were arranged and facilitated by better care together.

• In addition better care together were invited to attend several events, meetings and discussion groups to discuss and engage on its programme

• The following section provides a summary of this engagement

Non-externally commissioned engagement

Key themes to emerge from the Information Bus Roadshow engagement activities in March – April 2013 were:

• Travel: Whilst not keen on travelling for the sake of it, most who commented on this issue were willing to travel if that meant that they would receive the best care. Travel was particularly an issue for those who didn’t have their own transport.

• Staffing: Staff on wards seen as not having the capacity to give a level of care that’s needed. Suggestions made re: more vocational training and hands on approach from junior staff, plus the need to “bring back matrons”.

• Access: comments were made re: out of hours GP access, the amount of time that some people had to wait to see their GP of choice and a sometimes lack of empathy from GP reception staff. Feedback was given re: the need to keep some services local

• Care pathways and lack of integration was an issue referred to e.g. “Have been to Royal Lancaster Infirmary, nurses good, but consultants change so start all over again. Went to Westmorland General Hospital, they didn’t give me the results. GP couldn’t give me the results so need to go back to Westmorland General Hospital.”

• Clinical risk concerns: fear that loosing services could put lives at risk

The main themes to emerge from the Public Field Events held in May 2013 were:

1. Access: this can be problematic e.g. accessing appointments with preferred GPs and accessing appointments with GPs evenings and weekends. There was also confusion re: role of PCAS in Kendal

2. Communication: an area for improvement e.g. staff communication skills and NHS-NHS organisations. NHS internal systems were also areas for improvements e.g. patient notes transfer and appointments

3. Care pathways: these can cause confusion and see a lack of integration e.g. between NHS organisations and NHS partners such as social services

4. Willingness to/travel: people are used to travelling for highly specialised care, there is still a need for some services to be local

5. Clinical risk concerns: there are perceived risk areas e.g. travel when poorly, worries of hospital infections and cleanliness standards

6. Staffing levels are an area of concern i.e. are there enough staff in primary and secondary care and were staff roles hampered by paperwork? There were also queries re: numbers of back office staff and numbers of managers

The main themes from the focus group with persons with life limiting conditions May 2013 were:

1. Patient experience of primary care, secondary care and community care all include positive and negative examples:

a. Access to GP appointments can be a struggle, LTC team very helpful, out of hours service can be a long wait and engenders feelings of isolation

b. Secondary care experiences are poor on the ward, medication delays and too many patients

c. Community staff are seen as “come to do” but concerns of “lots of different people” and poor documentation systems

2. Staffing comments range from “nurses are excellent” to lack of continuity in handover and a need for more frontline staff and mental health teams

3. Willingness to/travel: people are used to travelling for highly specialised care, there is still a need for some services to be local. Volunteer drivers can be popular compared to ambulance drivers

The main themes to emerge for the Manna House (Kendal) discussion group May 2013 were:

1. Customer care skills were seen as an area for improvement in dealing with vulnerable people e.g. poor attitude from some staff , “feeling that I`m not worth bothering about”

2. Out of hours services were seen as insufficient i.e. evenings and weekends where people were often signposted or taken to Barrow or Lancaster

3. A lack of integration between NHS Acute and Mental Health e.g. “…told me “I will call your social worker tomorrow” so I called my GP who called the crisis team. The crisis team worker said to me “Why are you ringing the GP?” The police riot team arrived and sat there, I was taken to Barrow to be told there was nothing they could do for me and was taxi`d back to Kendal”

Out of hospital care engagement – Autumn 2013

• Much of the feedback from the Spring 2013 engagement received from patient, public, stakeholders and clinicians referred to primary care and planned care

• Out of hospital care services can be an effective alternative to hospital treatment for some patient groups e.g. elderly and patients with long-term conditions such as COPD

• Some patients report high satisfaction with community-based minor surgery due to ease of access, shorter travelling times and reduced waiting times

• Some people prefer an early discharge from hospital into community-based care settings

• People want health care to be more integrated (joined up) with other health and social care partners

• People wanted to give further feedback on out of hospital services• Therefore engagement from Autumn 2013 onwards included out of hospital

care in addition to in-hospital care

The main themes to emerge from the Patient and Public Reference and Discussion Groups throughout 2013 and 2014 were:

1. Care pathways: stressed the importance of a good discharge and follow up into the community. Suggestion that this could be improved with improved IT.

2. Access to health and social care: concerns that it will this be adversely affected by the reduction in council care funding e.g. “…don’t transfer NHS budget to social care budget”

3. Staffing: the need to publicise meaningful staff-to-patient ratios and the need to invest in community nurse training to deal with current and future demand

4. Clinical risk: concerns re: the impact of the changes in vascular services on the local population, specialist shortages and weekend mortality statistics

5. Transparency needed re: changes and terminology under the Health & Social Care Act: concerns re: conflicts of interests, quotas and additional layers needed under the Health & Social Care Act

6. Access: difficulty accessing appointments with named/preferred GPs. Suggestion that this could be improved with improved IT. The role of PCAS in Westmorland General Hospital can cause confusion in terms of what it does and doesn’t provide

7. Integration of care pathways: difficulty understanding the boundaries between health and social care e.g. what to access from where. NHS needs to work with planning personnel re: suitable housing for the elderly in the area. Also lack of clarity re: follow up when you leave hospital after surgery.

8. Patient experience: good experiences with primary care staff e.g. nurse practioners and the importance of treating the patient not just the condition

9. Travel: Tendency to travel to nearest place: this may be Lancaster or Kendal. 10. Staffing: concerns re: over reliance on bank nurses with accompanying lack of continuity11. Culture: is it reasonable to expect the NHS to pay for certain procedures? Do not like but understand the

rationale for centralisation. A sense of pride in the NHS

The main themes to emerge from the South Lakeland District Council Local Area Partnership meetings in Autumn 2013 were:

1. Access: comments re: priority of access to A&E services and difficulties in seeing a named/preferred GP. Comments were also made re: lack of access to out of hours services e.g. weekend and evening treatment. Concerns were raised re: NWAS response times in the South Lakes area. There was interest in the October 2013 publicity re: 7 day a week GP access pilot schemes.

2. Rurality: concerns re: loss of GP services in low-populated rural areas and a knock-on effect as patients transfer/visit other GP practices which can increase access issues. These rural areas often see high tourist numbers at certain times of the year which can exacerbate this issue. The importance of care closer to home was understood but systems needed to be there to allow for this e.g. in some rural areas it is difficult to recruit home care staff.

3. Communication: the possibility of remote healthcare was discussed as both an opportunity and as a “first-step” only. Better communication of the different services available e.g. via the third sector could be better publicised. Poor communication comments included the subjects of appointment bookings, late or no discharge letters, poor record reconciliation and late issue of take home medicines

4. Clinical risk: there were concerns re: NWAS response times in the South Lakes area5. Care pathways: comments re: it being complicated and time-intense to deal with the NHS as is it doesn’t feel joined up e.g. hospital

to hospital administration. In addition to this there ere comments re: lack of integration with Local Authority Services6. Staffing: feedback re the need to be mindful of staff morale and the impact of covering for staff sickness7. Future change: the need for transparency when discussing recent and possible future changes in the NHS and any options in a

consultation.8. Willingness to/travel: feedback discussed an understanding of the need to travel to centres of excellence coupled with a desire for

some services to remain local as travelling for services can be difficult and travel can also be challenging due to changes in the voluntary driver system. Travel can also be adversely affected by poor roads in some South Lakes locations.

9. Preventative healthcare: important e.g. for example young people’s health, working with public health at Cumbria county Council, and issues such as obesity etc.

10. Culture: the culture of what is expected from the NHS from the NHS has changed over the years with expectations increasing11. Facilities: a number of GP practices were considered to have poor facilities and urban solutions e.g. large health clinics may not be

suitable for rural locations.

Spring 2014 Engagement: An introduction

During March, better care together organised multiple engagement events to capture the views and opinions of staff; members of the public and partners including 3rd sector organisations on out of hospital services

Better care together organised 5 drop in events for staff at each of our three hospital sites, and at Ryelands House and Moor Lane Mills for our community based staff to give them an update and let them know about our forthcoming engagement activity.

We held 12 public ‘drop-in’ style events across different localities within Morecambe Bay which were advertised via full page newspaper adverts, our networks and via the use of an “ad-bike”. Attendees were invited to complete a number of activities to give us feedback, however this was completely voluntary. Some people simply wanted more information and the opportunity to speak with clinicians. There were also opportunities to complete comment cards; to take the activities away and complete at home; to complete the activities online; and to participate in a Q&A session. Numbers of attendees were modest, but the events were well represented by clinicians, better care together team members and external support team members.

We also held three stakeholder workshops in Lancaster, Barrow and Kendal which were facilitated by TNS BMRB- the same independent market research organisation that had conducted the in – hospital work. Personalised invitations were sent out to a range of organisations within the three localities. All participants were asked for their views on the different scenarios/elements of the emerging out of hospital model and the design principles which had emerged from each of the Clinical Commissioning Group out of hospital workstreams.

There were over 250 attendees across all the events and these included Council and OSC representatives ; local media; 3 rd sector representatives; members of public; and a broad spectrum of colleagues.

A Clinical Summit was held for 180 clinicians, this number also includes representatives from third sector organisations and members of the public

Feedback is still being received and we will ensure this gets factored into our final reports, but overleaf we have provided the results of our engagement as of 1 May.

This is part of our on-going programme of engagement and further events will be arranged to ensure we share the outputs with the public and partners.

Results of the TNS BMRB Spring 2014 Engagement Programme:

Participant feedback

Response to principles

Feedback re: Out of Hospital Scenarios for future provision conducted by TNS BMRB

Spring 2014

Five scenarios for future out of hospital care were presented and discussed as follows

Examples used

Joined up service scenario no. 1

Service 1

Do you agree with this model of care?

1 2 3 4 5 6

How could this work for Mary?Mary is struggling at home and needs support to stay independent. Mary would be assessed by one person in the integrated core team, (Mary can contact the team via her GP surgery) who would work with other colleagues e.g. a voluntary organisation and social care worker to put together a package of care for Mary. This means Mary no longer has to ring different people in different health and care organisations: it is done for her.

Integrated (joined up) Core TeamThis service could see a team working together in an out of hospital setting. This could be a multi skilled team e.g. GPs, social care, district and mental health nurses working together. Their role is to try and identify vulnerable people to give them a care plan. This way if you are vulnerable they can work to keep you well and prevent urgent care where possible.

Strongly agree Strongly

disagree

Vision for future joined up “out of hospital” services

60

Joined up service scenario no. 1:Concept has unanimous, strong appeal; difficult to disagree with this scenario

in principle

Benefits

Proactive approach to ensure holistic care for vulnerable people

Appropriate response to shortcomings of the current complicated system

Patient-centric approach welcome; potential benefits to users readily acknowledged

Drawbacks

Few conceptual drawbacks

Concerns at lack of explicit mention of 3rd sector in the core concept

Similar concerns regarding social care and housing

Does not address non-vulnerable audiences

Who would it work for?

Could work for all vulnerable people if executed effectively

Especially strong for those with multiple requirements

Important to focus on the very vulnerable (e.g. those with dementia, mental health issues) and those with very specific needs –physical disabilities, hearing impaired / deaf, blind

61

Joined up service scenario no. 1:Concerns around practicalities and delivery tend to overshadow conceptual appeal

(TNS BMRB 2013)

Team considerations

Notable absence of 3rd sector in core concept – how and when (in the patient journey) will this come about

What will determine who leads the team for each patient – having a named lead often felt important to success

How will collaboration across organisations / team members work in practice – starting points vary greatly

Communication and coordination: little info on how this would work in reality – co-located/virtual?

Resourcing

Assumed to require an increase in staff: how feasible given current state-of-play?

Concerns around changing roles and additional burdens on already stretched staff

Need for re-training; scepticism around whether or not this would be available

Difficult to see cost savings in this approach generally

Audience and involvement

Who is responsible for defining ‘vulnerable’; what criteria are used

Sensitivity required around blanket use of ‘vulnerable’: some might be unhappy about being labelled as such, or might not identify with this term

How will those who do not currently engage with the system be reached – role for 3rd sector here

Care plan and team composition should take patient’s views on board (text currently hints at a generic approach)


Service 2

1 2 3 4 5 6

How could this work for Mary?Mary sometimes struggles to know who to call when she feels ill and today she feels very poorly. Now she just has one number to call and the centre will make an urgent appointment for her with a GP in her local area. Mary can now call a single number rather than several numbers and where possible avoid going to A&E.

Urgent Care Co-ordination Centre This service could see a change in the way you access NHS services and the way health professionals contact each other. This service could see a team, under one telephone number, as a main point of contact who will make the right appointment for you, with the right health professional e.g. a GP or District Nurse. This team will help triage (assess) you, just like a triage at an A&E or GP surgery. This will help prevent you going to A&E if you don’t need to: you will still call 999 if it is an emergency. It will also put health professionals in contact with other colleagues across health, social and voluntary care.

Strongly agree

Strongly disagree


Joined up service scenario no. 2: Concept is confusing and has negative associations

with call-centre services: valued only when seen as a gateway to an integrated care team (TNS BMRB 2013)

63

Benefits

Once understood, a single access point potentially of value

Especially useful if functions as an out-of-hours service

Drawbacks

Potentially unnecessary ‘extra layer’ between patient and services

Relies on patient to have knowledge/understanding of their own difficulties and ability to communicate these


Single number to call could be useful for the elderly

But elderly would also have concerns about call-centre triage process

Strong concerns about accessibility for deaf people – need for a text service or similar

Could be useful for those who are not sufficiently ill for A&E but can’t get to GP or want to check if GP appointment necessary

Joined up service scenario no. 2: Concerns with the concept are reinforced by experience and uncertainty about what it

would offer (TNS BMRB 2013)

64

Ineffective ‘triage process’

Negative experiences and perceptions of NHS Direct (especially given its closure) suggest triage and advice will be inefficient / ineffective

Call centres seen to be manned by unskilled staff, working through questionnaires to diagnose

Lengthy triage process would be off-putting, and a barrier to engagement especially for the elderly and those with dementia or learning difficulties

Insufficiently ‘local’

Project assumed to be aimed at a national or regional level, and thus unable to give tailored, local advice

Perceived value increases if understood as a local service, with access to a team with comprehensive local expertise

But an ambitious approach such as this would require much set-up and piloting

Not responsive enough

Unclear whether this is intended for vulnerable audiences specifically, or everyone?

How will the service distinguish between ‘urgent’ and ‘emergency’ calls?

Concerns that this would not provide an attractive enough alternative to presenting at A&E, where this is in-grained (e.g. Barrow)


Service 3

1 2 3 4 5 6

How could this work for Mary?Mary has had a fall at home and has been taken to A&E. Rather than spending longer than necessary in hospital she will be seen by this specialist team who work jointly across health and social care. They can arrange for Mary to have personal care at home, such as helping to arrange transport home, meals delivered, physiotherapy and support from a falls prevention .co-ordinator.

Integrated (joined up) Rapid Response TeamThis service could see you being treated by a specialist multi disciplinary team of skilled health and social care professionals whose role is to get you home safely. In many instances this team will help you to get home as soon as possible, with the right support, often within 48 hours. This sees a team of health professionals putting together the right package of care for you.

Strongly agree

Strongly disagree


66

Joined up service scenario no. 3Concept of re-establishing people in their home is accepted, but only if support system

genuinely works (TNS BMRB 2013)

Benefits

Belief that care at home can aid the recovery process

Could free up hospital beds for those who really need them

Multi-discipline team to ensure that many illnesses will be covered

Drawbacks

Concerns that scenario would be driven by a desire to ‘clear beds’ and meet hospital targets, not patient needs

Lack of explicit role for 3rd sector and local authorities (esp re social care and housing)


Works best for the able-bodied/minded keen to return home

Also those with unofficial carers (e.g. family members) for whom hospital visits are difficult

Less appropriate for those who might struggle emotionally at home, including those who are living alone (especially the elderly and those with dementia)

67

Joined up service scenario no. 3Concerns around delivery centre on communication, resourcing and the impact of

‘time targets’ (TNS BMRB 2013)

Team considerations

Again, absence of 3rd sector in core concept – how and when (in the patient journey) will this come about

Success / failure will depend on efficient co-ordination of numerous services – who takes responsibility for this?

Co-ordination of services will require alignment of opening/working hours – how will those currently inactive at weekends and evenings adapt to 24/7?

Resourcing

Assumed to be costly alongside existing programs – how will this be funded?

Easier to imagine possible savings when linked explicitly to financial benefits of ‘freeing up beds’

But overemphasis on ‘clearing beds’ risks being seen as a cost-cutting measure at expense of patients

Timescale concerns

Description fuelled some concerns around ‘fast bed clearing’ being core to the concept

Others concerned that “the right support, often within 48 hours” suggested a 48 hour wait at home before support received.

Concerns that the scenario reduces the role for patient choice: what if a patient wants to stay in hospital?

Who judges when a patient is ready to return home?


Service 4

Do you agree with this model of care?

1 2 3 4 5 6

How could this work for Mary?Mary has diabetes: a long term condition. This means she regularly has to go to hospital to see different people for six monthly checks. Mary now has a care plan so knows how to manage her condition if she feels ill in-between checks and a community based person to call if she feels her condition is getting worse. This means as well as out-patient appointments she has the benefit of specialist community services to prevent her diabetes escalating.

Potential community specialist services This service could see the movement of some specialist services e.g. diabetes, respiratory care and pain management into an out of hospital setting e.g. a weekly clinic held in a health clinic or GP surgery, where you would be seen by specialist health professionals. This would expand on the community services already available.

Strongly agree

Strongly disagree


69

Joined up service scenario no. 4:Appeal of this concept varied between locations, depending on current access to local

hospitals (TNS BMRB 2013)

Benefits

Most appreciated attempt to ‘bring services to people’ / facilitate access

Particularly relevant in Kendal, more rural parts of Lancashire, and Barrow

Drawbacks

Concept would involve a significant cultural shift for HPs and the public – important that this is not underestimated

Potential stress / challenges for HPs travelling into communities (especially where there are local geographic challenges)

Some anticipate challenges in convincing HPs with in-grained working patterns to change


Best for those in rural areas

Also helpful for the elderly, those with mobility problems and those on lower incomes who might struggle with travel costs

However, risk of groups with specialist needs (e.g. deaf patients requiring interpreters) being shut out

Also risk of people being reluctant to accept new services without sufficient guarantees of quality

70

Joined up service scenario no. 4:Numerous queries about efficiency and quality challenge confidence in the

scenario’s overall viability

Cost/time effectiveness

How many people would have to attend each local clinic to render specialist visits financially viable?

How often would these services run to remain cost effective? Weekly? Less frequently?

Does travel time mean specialists might end up seeing fewer patients overall?

Guarantee of quality service

Need for reassurance that service will not be ‘second-best’ if services are run by practice nurses rather than consultants

Specialists who do travel into the community might not be those best placed to treat patients – just those most willing to travel


Service 5

1 2 3 4 5 6

How could this work for Mary?Mary has had knee pain for some time but doesn’t want to go through the current process of seeing her GP, then seeing a consultant and then seeing a physiotherapist. Now, under the new referral system, using established referral protocols which determine the best health professional, Mary is referred by her GP straight to the physiotherapist. In this instance it takes one step out of the patient journey meaning she has less travel, and can be seen quicker.

Accessing services: Referral Support ServiceThis service could see a new referral system from one health professional to another health professional. This means you would benefit from an agreed referral system across your area so that you receive consistent advice, guidance, and referrals whoever you see when being treated out of hospital. This system helps staff to help improve your patient journey through NHS services.

Yes No


72

Joined up service scenario no. 5Concept was widely misunderstood – and those who did understand it failed to see

relevance to public (TNS BMRB 2013)

Benefits

Potentially could generate cost savings (but this does not appeal if seen as simply ‘cost-cutting’)

Streamlining might prove beneficial for patients (but no strong complaints about the current system)

Drawbacks

Concerns about placing too much onus on GPs to diagnose correctly

Worries about ‘one-size-fits-all’ referrals following loss of consultant expertise


Issue of inconsistent referral rarely recognised, and not seen as a problem for the public

Assumption that this would be more of a benefit for management than patients

73

Joined up service scenario no. 5:Poor or limited understanding about how the system would work in practice raised

further concerns (TNS BMRB 2013)

Pressure on GPs

GPs might lack sufficient knowledge to make referrals and feel pressured

If GP diagnosis is incorrect, this could result in delay in treatment for patient

Questions about process

Some unsure who makes the referral – e.g. could the physio recommend a consultant?

Unsure about the current referrals process and how this differs

Concerns (once proposal understood) that it would encourage generic form-filling rather than a tailored patient assessment.

©TNS 2014

TNS BMRB

74

Overall response to most of the out of hospital scenarios and principles was ‘good words, but can we deliver this?’ (TNS BMRB 2013)

Most principles and concepts behind some scenarios are appealing and hard to argue against in principle

But general scepticism and some strong concerns around delivery, given views of what might be required and how this matches up to the current situation and previous experience

Many tangible factors were felt to be problematic or unaccounted for in the scenario/principle descriptions:

Funding

Fail to see cost savings

Assume additional funding, training, resources etc. will be needed

Where will the additional money come from?

Collaboration

Experience suggests organisations working together will be difficult

Absence of 3rd sector suggests approach will not be holistic or collaborative

Two CCGs often felt to operate independently

Information Technology

Scepticism around ability of ‘sophisticated’ systems as tools for effective collaboration, etc.

Compatibility

Clinical vs financial sustainability

Desire to attract / retain staff vs proposed changes in working practices

©TNS 2014

TNS BMRB

75

Some concerns were also raised by the way in which scenarios and principles were presented (TNS BMRB 2013)

In addition to strategic-level considerations, the description of many scenarios / principles (wording, level of detail etc) often led to queries or negative reactions:

Apparent absence of 3rd sector disappointed many: often first point of entry for vulnerable, but seen as ‘mopping up’ patients that would otherwise be missed; reassurance needed that they will be crucial part of team, identifying vulnerable people and being involved in their care plan

Important to bear these points in mind when thinking about how to communicate more widely about these scenarios and principles

Linkage

Important to make link between scenario 1 and the others clear – absence of this link risks devaluing other scenarios

Target audience

Switching between explicit mention of ‘vulnerable’ for some principles/ scenarios and broader audiences for others is confusing

Example

Using the same character (‘Mary’) in all scenarios was confusing when the focus of each scenario differed

Lip service

Easy references to benefits such as ‘equal access’ seen as vacuous given cultural, geographic and demographic challenges


Results of the Patient and Public Spring 2014 Engagement Programme conducted by better care together: Participant feedback

Examples used

Results of Scenarios Survey

Core Integ

rated

Team

Urgent C

are Co-ord

ination Se

rvice

Integrat

ed Rap

id Response

Team

Potential

Community Sp

eciali

st Se

rvices

Referra

l Support

Servi

ce0

50

100

150

200

250

300

85110

95 90108

Joined Up Scenarios feedback (50 Participants)

Joined Up Scenarios feedback (50 Participants)

*Please note the lower the score, the better the approval rating (range 50-300)

*

• Overall the model was well received in principle• Themes emerging from each element / scenario are included overleaf

Themes: Core Integrated Team - Scenario one

• Queried who is accountable / responsible for co-ordination• Comment regarding centralising the team in one medical practice.• Generally seen positively as long as it was well funded.• Seen as a good idea, in particularly to vulnerable people.• Concern about how ‘vulnerable’ criteria are assessed. Some patients would not want to be

labelled as such.• Concern that this is a ‘one size fits all’ approach, need reassurance that this is flexible and

patient centred.

“I strongly agree but who pays for voluntary organisation, as they need funding too.”

“Someone needed to co-ordinate (specialist co-ordinator) with medical knowledge.”

“Good idea - so long as well resourced”

Themes: Urgent Care Co-ordination Centre- Scenario two

• The responder needs to be competent to make decision, single number needs to be prominent.

• Seen as a call centre (compared to 111) and concerned over waiting times on calls.• Compared to NHS Direct. • Would require extensive local knowledge of services available.• No deaf provision.• Seen as aimed at the ‘non-vulnerable’, an alternative to the core team.

“A very good idea. Just 1 phone number to call & people wouldn’t be going to A+E, when they didn't need to.”

“Too many potentials for break in communication”

“But they would have to be trained and have a great understanding of mental health and third sector providers.”

Themes: Integrated Rapid Response Team - Scenario three

• As long as the support is accessible and deliverable• Comment that this already happens in some areas.• Good idea as long as team is well established and works together.• Comments about including social care within the term health professional.• Some concern this could be seen as ‘bed clearing’ • 48 hour response can also be seen as a target to get patients out of hospital before they are

ready. Do patients have a choice?

“Good idea. you can get the help you need & also be in your own home.”

“As long as the support is deliverable”

“Again a good sensible idea. But experience shows that adequate funding is critical, to avoid vulnerable people being simply forced out of hospital and left at “

Themes: Potential Community Specialist services - Scenario four

• As long as the venue is accessible to the public (geographically)• Concern about inconsistencies in available services in varied geographical area.• Seen to encourage self care and prevention.• Concern regarding the cost effectiveness of specialists travelling to communities, how often

would ‘clinics’ be held to be cost effective and still provide a good service?• Patients may need reassurance that they are receiving the best care if they are switched from

seeing a consultant in hospital to another health professional in the community• Will specialists want to travel? Need to change working patterns.

“Good idea most GP surgeries are closer to where people live & good to know you can call somewhere if you need any help”

“As long as treatment venue is easily accessible to public”

“Clinics are a great model to fix overstaffing of hospitals, if you have the budget to see that the clinics are properly staffed!”

Themes Referral Support Service – Scenario five

• Concern over whether GPs will know in every case whether to refer to consultant or specialist.

• Seen as a ‘back-office’ change and not really necessary for the public to know.• Commonly seen as more efficient• Need to have built in follow-up process• Would require co-operation between service providers

“Great idea. Much more efficient and helpful procedure for patient.” “Saves alot of time. This

would take a lot of consistent organisation but yes.”

“Would a GP have sufficient specialist knowledge to properly assess the clinical options?”


Results of the Patient and Public Spring 2014 Engagement Programme conducted by better care together: Participant feedback

Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign

Engagement Activity: “My Priorities”

Participants at public events were asked to prioritise the following aspects of future service provision using the form below:

My Priorities - Overall

Safe

Servi

ces

Continuity of C

are

Trave

lling f

or speci

alist

care t

hat is n

ot ava

ilable

locally

Patien

t Exp

erien

ce

Patien

t hea

lth outco

mes

Appropria

te car

e setti

ng

Servi

ces ar

e afford

able

and su

stainab

le

Planning s

ervice

s for t

he future

0200400600800

100012001400160018002000

1789

945

659760

1058

679584 626

My Priorities Survey 2014 - Morecambe Bay Wide

My Priorities Survey - Morecambe Bay Wide

A total of 71 participants took part

POINTS

Trends from My Priorities• The single highest scored priority with over 25% of total ‘points’ allocated

is Safe Services – this is consistent throughout 5 out of the 6 individual localities*

• Patient Health Outcomes appeared as a 2nd priority in 4 of the 6 localities • Continuity of care ranked 3rd overall. This varied significantly depending on

the locality: In Lancaster and Morecambe this was consistent; In Ulverston and Barrow this was ranked 1st and 2nd respectively; In Millom this was ranked 5th; and in Kendal this was ranked 8th.

• Travelling for Specialist Care generally ranked low, this was particularly evident in Lancaster and Morecambe, whilst being more welcome in Millom and Kendal

(*Ulverston attendees scored Continuity of care marginally higher; Safe Services took 2nd place)


Feedback re: draft CCG vision statements conducted by TNS BMRB

Draft clinical CCG commissioning statements

• TNS BMRB worked with stakeholders to discuss a draft vision statement re: commissioning from:– Cumbria CCG with stakeholder groups in Furness

and the South Lakes – Lancashire north CCG with a stakeholder group in

North Lancashire

Statement and principles were generally well received, but with numerous questions about detail and delivery (TNS BMRB 2013)

90

Taken at face value, the S Cumbria Vision Statement and principles for S Cumbria and N Lancs described what most would like to see

As such, many found much of what was proposed hard to argue against in principle

In the context of this general positivity, discussion generally revolved around queries and concerns focussing on:

Delivery

What level of commitment is there to delivering these reforms?

To what extent will these reforms take the views/wishes of patients into account?

Management

Who is responsible for defining, measuring, assessing leading, deciding etc?

Which organisations are involved (absence of 3rd sector noted)?

Can orgs with differing cultures etc coordinate and collaborate?

Challenges

Availability of additional funding to ‘pump prime’ the reforms and/or run new services alongside existing ones

Geographic, demographic and cultural issues

Agenda

Is this really about cost reduction, patient outcomes, a combination of the two?

How are key terms (e.g. ‘equal access’) defined?

Views around detail and delivery were influenced by a number of different factors (TNS BMRB 2013)

91

Views of each Statement bullet or Principle varied most obviously by:

Queries and confusions often regarded fairly fundamental aspects of Principles – e.g. whether clinical and financial sustainability are compatible goals

Reveals a lack of detailed understanding of the points involved (and in some cases cynicism about driving agendas, hence fixation on cost-cutting)

Presentation

The wording of the S. Cumbria Statement was generally more effective than the N Lancs principles – either ‘softer’ or with less distracting detail – leading to fewer queries and concerns.

Knowledge

Participants with greater knowledge of how health services work were able to read more into the descriptions, make more assumptions and so had fewer queries or points of confusion.

Remit

Those representing specific populations (elderly, disabled etc) or services outside core health services (e.g. local authorities) were quicker to note the need to include them explicitly.

Location

Those in Barrow tended to be more conscious of challenges to delivering out of hospital services, in terms of shifting public attitudes and what HPs are prepared to do.

Reactions to Statements/Principles 1-4 (TNS BMRB 2013)

92

“Our services are of good quality that delivers safety, equity and continuous improvement in outcomes”

Feedback: In theory, this principle was difficult to argue against and universally appealing. In practice, an overly ambitious statement lacking real substance.

“Our system is sustainable both financially and clinically and is flexible to meet future demands”

Feedback: Financial concerns were understood to be important in decision making, but the principle raised concerns about cost-cutting and a feeling that low cost may come at the expense of service quality.

“Our design will build on what is already working well and recognises that some of what we are currently doing has to change”

Feedback: This principle raised debate about the type of change that is appropriate – radical innovation vs building on current system. The inclusion of ‘has to change’ in N Lancs implied that decisions have already been made.

“We encourage our patients to take more responsibility for themselves and we take account of their views in our service design”

Feedback: Most controversial principle: proactive, preventative angle is appreciated by some; but strong concern from others that many will not have the ability to self-manage. Also criticised for ignoring contextual barriers.

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2

3

4

Reactions to Statements/Principles 5-8 (TNS BMRB 2013)

93

“All design options will be realistic and based on evidence based best practice”

Feedback: This was not a priority principle overall – in general seen to be more important for management than for public or stakeholders. Queries over whether evidence-based practice is always the most appropriate approach in all circumstances.

“Care will be provided in the right place and at the right time. There will be more care delivered out of hospital and some small volume speciality work may not be viable to provide locally”

Feedback: There was general acceptance that specialist services can and might need to be delivered out-of-hospital, but reassurance about coordination with local care and patient choices is needed.

“Services will be provided in an integrated way with shared records, fewer handoffs and easy navigation. We will manage patients proactively and patients will know who is responsible for their care”

Feedback: Sophisticated streamlining of IT systems to allow for information sharing seen as crucial to success. However, strong doubts over capacity, and some concerns about financial and security challenges.

“Morecambe Bay is an attractive place to work and our workforce will be developed and encouraged to deliver services which are in the best interests of patient”

There was general agreement that staff recruitment is an important principle; but the language of this statement needed reworking to avoid a ‘patronising’ tone.

5

6

7

8

Westmorland Gazette May 2014 (non BCT facilitated)

• The Westmorland Gazette arranged a petition, ‘Hands off our Hospital’ regarding services at Westmorland General Hospital.

• The coupons from the petition were handed to Aaron Cummins, Deputy Chief Executive of the University Hospitals of Morecambe Bay NHS Trust

• This was recorded in the UHMBFT Trust Board Minutes as follows:

“Petition from the Westmorland GazetteAaron Cummins confirmed that he had received a petition from the Westmorland Gazette regarding the Westmorland General Hospital and the services it provides. The petition had been noted.”

Save our Hospital – Furness (non BCT facilitated)

• On Friday 13 June MP John Woodcock and his wife, Councillor Mandy Telford, presented “Save our Hospital” leaflets to Dr Geoff Joliffe, local GP and Lynn Dack, Matron for Surgery at UHMBFT, with community supporters. Councillor Mandy Telford was also there.

• The photo call was organised by the MP office.• John explained that it was to say thank you to

supporters for saving maternity and to say they hoped services would remain.

24 June 2014 – Notice from Tim Farron MP re: Hospital Petition (non BCT facilitated)

The office of Tim Farron MP issued a calling notice stating that Thursday 26th June he would be running from Levens to Westmorland General Hospital and then hand over his petition calling for Westmorland General Hospital to be protected.

The interim Chair for University Hospitals of Morecambe Bay Foundation Trust, John Hutton received the petition.

21 June 2014 Morecambe Bay Wide Patient, Public & Stakeholder engagement event: Kendal - 1

The objectives of this event were for attendees to:– Understand in broad terms why change is needed and how an

options development and evaluation process works for health services reconfiguration

– Find out why certain healthcare options may be unviable– See the feedback from our engagement to date and how this has

influenced the thinking of clinicians – Look at the possible scenarios for future healthcare in and out of

hospitals– Find out more about health service reconfiguration and provide a

patient and public a “sense check” on our work to date– Ask questions to the clinicians who have been developing

proposals

21 June 2014 Morecambe Bay Wide Patient, Public & Stakeholder engagement event: Kendal - 2

The agenda event:• Introductions• Case for change presentation • Facilitated group discussion around perceptions on case for change• Engagement and Evaluation Criteria presentation• Group discussion in regard to evaluation criteria• Current options presentation• Facilitated group discussion to feed into the options development• Q&A session • Thanks and Close

21 June 2014 – event feedback from participants

Case for Change1. Travel concerns i.e. access to public transport and how people without access to a car would be able to travel2. Preference for information sharing across NHS organisations e.g. care records3. Need to clarify health role and social role and where the boundaries overlap in the new world of integration4. Are we sure we are making best use of what we’ve got, making savings where possible?


Evaluation criteria1. Consider the link with mental health and physical for changes to work

effectively2. How will you measure clinical quality and outcomes e.g.

benchmarking v other organisations?3. Working together will improve patient flow4. Can finance be moved across NHS organisations?5. Transition issues will affect success e.g. how to effect changes when

there is a shortage of GPs, ensuring services are kept going while they are being moved. Would well performing services have to move?

6. Ensure people can make informed decisions by ensuring information is accessible in clear language and communications

7. Good integration means integration with social care and the third sector


The Current Options1. Preference to go for day case on all sites, because support afterwards needs to be local2. Feeling that more information is needed to make an informed choice e.g. costs, what back up support would be available, what types of elective surgery and day case could be moved3. People will need to work differently and have the desire to e.g. staff travelling outside of their immediate area and the impact on recruitment issues4. The options may be affected by hospital reputation issues 5. All options need finance and IT to work together and not prove a barrier6. Does patient CHOICE have an impact on this?7. With the options, also consider services being provided outside

Morecambe Bay

Summer 2014: Patient and Public Engagement

Summer 2014 saw a number of different engagement events:

• A meeting with service users of “One Voice”, which is an organisation that works to improve the lives of disabled people in the Lancaster and Morecambe District . We listened to feedback re: how people felt about making complaints and giving feedback, navigating around Royal Lancaster Infirmary, improving booking in systems and facilities, suggestions for staff training and how best to use feedback on services.

• Better Care Together also attended the Westmorland County Show and listened to patient experiences of NHS services inside and outside of hospitals, which included many stories of great care

• Exhibiting at the Lancashire North CCG and Cumbria Partnership Trust Annual General Meetings: many attendees were aware of Better Care Together, for people who weren't it was a great opportunity to introduce the programme and explain how it fits with other NHS programmes in the area.

Summer 2014: The UHMB Annual Members Meeting

• The University Hospitals of Morecambe Bay Annual Members Meeting is an opportunity to find out what has been going on across the hospitals and to hear about future plans

• General Practitioner leads (Dr Alex Gaw and Dr Geoff Jolliffe) from Better Care Together gave a presentation about the work to date, proposals for the future, and took questions from the audience

• There was also a small exhibition stand so people could ask questions, visit the Better Care Together website and meet staff involved in the programme

• Feedback suggested that attendees welcomed the opportunity to hear about out of hospital initiatives from local GPs and to spend time with them after the formal presentation.

Summer 2014: Political Engagement

• In August Better Care Together was invited to attend a follow up meeting with Kendal Town Councillors. The meeting involved a presentation, with case studies of how potential new out of hospital services could work. Dr Hugh Reeve listened to feedback and answered queries including questions re: Westmorland General Hospital services, joint working with social care colleagues, recruitment issues and core services.

• In September Better Care Together also attended a follow up meeting with Lancaster City Overview and Scrutiny. Subjects raised by councillors included, GP access e.g. for emergency appointments, preventative healthcare, the input of mental health services staff, recruitment and funding.

Next steps

Better care together will continue to engage with patients, public and stakeholders as the clinical strategy continues

Information and involvement opportunities can be viewed on the better care together website or accessed by our regular stakeholder briefings. To be added to the stakeholder briefing mailing list please contact [email protected]

mailto:[email protected]

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Thank you for reading this report

For further information please contact [email protected]

Better Care Together TNS BMRB research programme

Documents

Transcript of Better Care Together TNS BMRB research programme