COMISIÓN DE AUDITORÍA Y CONTROL COMPOSICIÓN Y FUNCIONAMIENTO
ACTIVIDADES DE LA COMISIÓN DE AUDITORÍA Y CONTROL: SESIONES CELEBRADAS, ASUNTOS
This study clearly shows that the experiences of women who have had severe morbidity in pregnancy can usefully be used as the basis for an ELC approach for maternity services. Although mothers frequently
found the process therapeutic, some of the participants found listening to women’s experiences traumatic,
emphasising the importance of good facilitation that not only anticipated but was able to manage strong
TABLE 37 Breakdown of costs for intervention group activities undertaken by the ELC team
Activity Cost estimate (£)a
Programme development and prototyping
Desk work on programme development 7500 ELC programme prototyping
Codesign one (current experience mapping) 3750 Codesign two (desired experience mapping) 3750
Codesign three (PATH) 4500
Codesign four (improvement contract co-design) 4500 Discovery interviews front-line caregivers, people, families (n= 10) 3750 Transcription of interviews (600 minutes) 1500 Analysis of interviews to identify commissioning improvement challenges 8500 Triangulation and aggregation of all data to produce for CCG:
l Health needs assessment (ELC qualitative data set)
l Draft ELC improvement challenges
l Draft ELC strategy
l Draft ELC Management Action Plan
l 360-degree appraisal and review of key commissioning process learning (for internal CCG use)
l Draft contract framework with outcome measures
11,250
Handover coaching for CCG implementation lead to ensure strategy moves swiftly into implementation (gratuity)
0
Project management/contribution overhead 10% 4500 Expenses (17 facilitator days at £200 each– includes travel and overnight) 3400
Total cost 56,900
PATH, Planning Alternative Tomorrows with Hope. a These figures exclude value-added tax.
ethnically diverse, and the balance of the film had to be adjusted during the ELC process. Regardless, the film provided an important way to represent the experiences of women who had severe complications and facilitated patient-focused discussions.
Participant views of the ELC process were largely positive, with the caveat that the CCG that was originally randomised to the ELC process subsequently declined to take part, which may infer less-positive views, and there was a clear perception that ELC led to greater engagement from both health professionals as well as users and a bridging of understanding between the two groups. The participants felt that the ELC process did lead to differences in the outcomes of the commissioning process compared with a standard commissioning approach and the documentary analysis supported this finding. The language of the commissioning strategy produced by the intervention group was more humanistic and less technical than that from the comparison group, and ELC recommendations were clearly linked back to patient experiences. The commissioning strategy from the comparison group tended to be more general, whereas that from the intervention group focused on a smaller number of specific areas in detail. However, there were also numerous similarities in the recommendations, targets and outcomes both CCGs included in their resulting strategies. Both strategies highlighted continuity of care, support for vulnerable groups, training for staff and improving multiagency working.
The costs of the ELC process were significantly greater than the costs of the standard process. At this stage, we cannot assess how these additional costs translate to change in services. Although there are differences in the resultant commissioning strategy for maternity services, implementation is still ongoing and, thus, further evaluation will be needed to determine whether the ELC process has resulted in a different maternity service and, in particular, whether or not the service developed is more responsive to the needs of women with severe morbidities and whether there are additional implementation costs or potential cost savings. It is also important to note that the costs of the process may decrease for other CCGs using this ELC model to commission maternity services, as many of the resources and processes have been developed and, therefore, the amount of staff time needed will be reduced. These factors will impact
on the cost–benefit assessment, and thus this economic evaluation must be considered incomplete and
interim at this stage. Further work is essential to assess the long-term outcomes of the commissioning strategy and the associated implementation costs, and how these compare with standard commissioning. The findings from this evaluation support the following recommendations for future commissioning work in the NHS using ELC.
Developing a commissioning strategy using ELC:
l Additional work is required in acknowledging and helping CCGs allocate the time/resources needed to
align organisations to converting to a new way of commissioning from the outset.
l Ensure the CCG is familiar with, and confident to deliver, the ELC process and plan of activities/event
early on, so that it is clear to CCGs what needs to be done and when.
l Ensure key providers feel fully engaged in the process and explore with them early on what the process
means for them; help them relate the work to other strategic priorities.
l Explore allowing CCGs to adapt some parts of the ELC process (e.g. working with ELC insights to
develop a commissioning strategy), in order to meet the needs of different CCGs/populations more effectively.
l Be aware that although ethnic minorities are included in the trigger films, local areas may have ethnic
diversity that is not possible to include at a national level in trigger films.
l Maintain balance of positive and negative experiences shown in trigger films, in consideration of the
effect that negative experiences may have on patients and consequent group interactions in ELC.
l Be aware that discussing negative emotional experiences for patients can be cathartic and empowering
Commissioning using ELC:
l Commissioners could consider using ELC if they:
¢ need a structure through which to engage with patients in a meaningful way
¢ would like to give patients more influence over commissioning strategy content and development
¢ want to build relationships and improve communication between key stakeholders within a health
economy (e.g. CCG and providers, voluntary sector, patients)
¢ require a transparent approach to commissioning decisions.
Further research/evaluation:
l Link costs of developing the ELC strategy with outcomes (e.g. changes in practice, patient experience).
l Future research could also investigate ELC outcomes numerically, looking more deeply into costs and
other outcomes and over longer periods of time to allow the study of implementation. In particular, it is important to understand the longer-term impacts for implementation of the ELC strategy.
l Develop a set of‘benchmark’ costs for commissioning – for both new strategies and annual strategy
refreshers– so that those seeking to innovate and test new methodologies can compare cost and
benefits of different commissioning management methods.
l The inclusion of a comparison group was useful to shed light on the commissioning processes,
strategies and implementation to establish what ELC might offer maternity services. However, the
inevitable differences between large organisations within the NHS mean that more‘controlled’
comparisons would be difficult in this setting.
l Undertake further work in order to explore ways of making ELC more understandable to those
Chapter 11 Discussion and conclusions
M
any severe maternal morbidities are classified as adverse events and may be the subject of litigationclaims.196They can have a life-long impact on surviving women and their families. Therefore, research
is crucial both to improving safety within the NHS11as well as outcomes for women and babies. The three
aims of this programme were to implement a national programme of study of near-miss maternal morbidity to complement confidential enquiries into maternal deaths, to use mixed methodologies to improve the evidence base for disease prevention and treatment, and inform commissioning of maternity services, and to use the data to develop recommendations for best practice to prevent and manage near-miss maternal morbidities. Our User Advisory Group provided input at all stages of the component projects, including design, monitoring, analysis and dissemination. The series of studies clearly demonstrate the added value of research into maternal morbidity alongside research into maternal death: for each individual maternal death from one of these severe morbidities there were between 4 and 100 women
who had severe illness but survived. In an average-sized maternity unit, this represents 0–4 affected
women with each specific morbidity per year, emphasising the importance of collaborative research at a
national or multinational level11,219to inform management. This also provides a clear illustration of the
difficulty of obtaining RCT evidence to guide treatment for these women. A study randomising only 100 women to two arms of a trial would require the participation of at least 100 units for 1 year or 33 units for 3 years. In this programme, we focused on using robust observational studies as a basis for addressing our key research questions.