Backgrounds and Aims
In 2014/15, NHS Birmingham South Central CCG offered its member practices the opportunity to participate in a pilot Local Improvement Scheme (LIS).
The ‘intervention’ aimed to deliver a model of care that reduced avoidable hospital admissions and improve the experiences of those delivering and receiving over 75s health services. They commissioned the Strategy Unit, to conduct separate quantitative and qualitative evaluations of the scheme.
The quantitative evaluation demonstrated unintended consequences with some increases in acute activity and costs of cases compared to controls. The qualitative findings suggested much variability in the delivery of the health-check at individual practices. This variation was less a result of innovative approaches but more dependent on existing processes and culture at individual practices. The patients interviewed had a positive experience of the health check and their general practice; less positive experiences were described for other health or social services.
Quantitative: A matched cohort study design was used: for each case (a patient enrolled onto the LIS by a participating practice), a matched control was identified. Each case and control pair share a set of characteristics before the intervention which are thought to influence or predict the programme outcomes. Whereas cases received a specific intervention (the Over 75s LIS), controls did not. Three outcomes were assessed: the number of emergency admission and A&E attendances and the commissioner cost of emergency. The outcomes of cases and controls were compared with a view to attributing any differences to the intervention.
Qualitative: 15 semi-structured telephone interviews were conducted with general practice staff (GPs, Nurses, Health Care Assistant and Practice Managers); all from 15 different general practices to assess the perspectives of delivering the LIS. Five patient narrative face-to-face interviews were also conducted to assess the experience of receiving an Over 75s health check. Qualitative data was subjected to thematic analysis using a deductive approach, using McKinsey’s 7-S Framework for organisational effectiveness in internal management or change (Wilson et al 2015). Impact
- Together the findings suggest that unmet need in the over 75s patients was identified; some practices explicitly intended to use the LIS to uncover unmet health and social care needs in order to capitalise on the benefit of reducing emergency activity as a long-term strategy.
- The scheme was popular with practices because it provided equity of service provision to over 75s patients who would not otherwise receive a health check.
- “Best Practice” for delivery could be identified through interviewee accounts. A nurse led service delivery was proposed with clear roles and responsibilities such as delegation for certain tasks to HCA and escalation to GP for patients with complex needs. Training for consistent implementation and to improve skills is warranted. A team based approach is crucial, not just at the level of the practice but for the health and social care economy.
- Roll-out of the pilot scheme was not supported by the quantitative findings
The mixed findings of unintended increase in emergency activity and enhanced patient and staff experiences in the short term posed a dilemma for the CCG. The intention was to monitor the impact of the pilot further to understand its effect on emergency activity over a longer time period whilst considering a more standard approach to delivery of the health checks.