Thefindings from our research have several implications for policy and practice.
Understanding and assessing outcomes
Although working towards closer alignment, current NOFs remain separate, with one each for the NHS,54
adult social care55and public health.56In identifying indicators that can measure improvement in services
and reflect closer working, there have been efforts to move away from process measures. For example, the NHS and Adult Social Care NOFs have complementary indicators relating to quality of life for people with long-term conditions. However, the current NOFs are still seen as representing a hybrid of different levels of outcomes, some of which‘are not outcomes themselves but rather outputs on the pathway to desired outcomes’.67This continued focus on improving the processes of care that are considered to be linked to
health outcomes has been argued to undermine the professed aim,‘to recalibrate the whole of the NHS system so it focuses on what really matters to patients and carers . . . the delivery of better health outcomes’.106Furthermore, the different types and levels of outcomes that constitute the NOFs make
delineating cause-and-effect relationships between intervention/service and achieving outcomes, difficult.67
Types of outcomes and relationships between services and outcomes need to be clear. Beginning with an understanding of what outcomes service users and carers want, underpins the task of designing and evaluating services around service user-driven outcomes.
Ways of gauging people’s experiences in relation to integrated care are widely recognised as problematic and underdeveloped. The NHS Future Forum report on integration recommended that new patient experience measures must be developed to evaluate patients’experiences across whole journeys of care.48
However, it was acknowledged in recent guidance that it would take time to produce a robust, long-term approach to measurement.68
This research contributes to the development of that approach. Before commissioners and policy-makers can begin to assess service quality in relation to service users’experiences of integrated care, there needs to be a clear understanding of the sorts of outcomes that people want and the types of service that are most effective in delivering those outcomes. In this project, we aimed to identify what people with LTNCs want and to see if those outcomes could be assessed in practice. Our research was set in a particular model of service delivery. In terms of contributing to unravelling cause-and-effect relationships, we were able to define outcomes derived from service user perspectives and definitions. It was also possible to draw conclusions around the feasibility of assessing outcomes of integrated care within these services, but
inferences about how different models of integrated health and social care can affect outcomes are more speculative.
From both the current research and our earlier work on integrated services for people with LTNCs,1we
know that integrated NRTs frequently feel that they have difficulty in formally demonstrating to
commissioners the‘added value’that their particular ways of working engender. Conventional outcome measures only partially reflect what such teams strive to achieve, tending to overlook broader social issues and the sorts of concerns, such as a sense of empowerment or self-worth, which are important to service users. Where teams work in an integrated way, identifying the outcomes that service users want and defining and formalising them into a checklist could help to reflect better what integrated teams do and offers the opportunity to develop an outcome tool for assessment.
Thefindings from this research suggested that:
l Many of the outcomes that are important to service users with LTNCs are not addressed in validated
‘outcome measures’.
l This has implications not only for service users’experiences of the type and quality of care delivered, but also for those commissioning care in identifying priorities for investment.
Outcomes assessment in practice
All services endeavour to achieve equity in practice, but this may be compromised or interpreted in different ways. For example, we identified divergent approaches to exploring clients’needs, and views differed about whose responsibility it was to identify clients’needs beyond the strictly‘clinical’. For some staff, identification of needs depended on clients assuming some responsibility for raising needs during assessment; they felt that staff should raise broad topic areas and then be led by the client. Other staff preferred to raise specific issues and directly ask clients if these were a particular concern for them. Reluctance on the part of staff to raise particular issues was linked, in part, to concern about raising clients’expectations when corresponding service support was absent. Staff across all case sites noted how services were contracting or disappearing and some saw discussions around, for example, exercise classes, skills training or relationship therapy as potentially raising service user expectations when there were no services available locally to offer support.
People with LTNCs also described these different approaches to raising concerns or problems in assessments; that staff sometimes raised issues directly and sometimes left it to clients to raise them. Although some service users were reluctant to discuss particular issues or saw some issues as being outside the team’s remit, there was, nonetheless, a consensus that staff should raise all outcomes on the checklist during assessment. This would help to limit the chance of outcomes being missed due to poor memory or service users’lack of awareness of how the team might be able to help. Even if not every outcome was a priority for service users at the time of assessment, people with LTNCs suggested that raising every outcome opened a door to discussions that might be needed in the future.
We know that the outcomes on the checklist are important to service users because these were the key issues arising from our stage 1 interviews with people with LTNCs and are built on research undertaken by Qureshi2and Harriset al.3with different groups of adults. It is important, therefore, that these outcomes
are raised at assessment by staff so that clients’needs are not missed and that clients receive an equitable assessment.
In the context of long-term conditions, support to maintain a level of functioning or participation is important. NRTs frequently worked with service users to maintain, rather than being able to improve, activities. Conventional outcome measurement tends to focus on pathways to recovery and rarely accounts for the potential deterioration associated with long-term conditions. Moreover, taking time to explore the range of meanings service users attribute to outcomes, rather than relying on service definitions and staff
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perceptions, is important. For example, although‘safety and security’might feature in NRTs’assessments, in existing paperwork it has tended to be addressed in terms of limiting risk, falls assessment and
providing aids and adaptations. The parameters of the service user-defined outcome were more wide-ranging and included feelings of vulnerability, as well as a need to balance safety and security against a desire for independence.
Our research indicated the following:
l Equity of assessment can be compromised if practitioners do not raise each outcome.
l Service availability may affect whether or not outcomes are assessed.
l In the context of long-term conditions, assessment of service user outcomes must account for potential
fluctuation and/or deterioration over time.
l Understanding of and meanings attributed to individual outcomes by service users may differ from conventional staff or service-derived outcomes.
Innovation and integration
Services in health and social care have been required to respond to policy imperatives around innovation and integration promoted by successive governments. Evidence suggests that, most recently, commitment to such initiatives tends to have been overtaken by the demands of major structural reorganisation. Organisational change can lead to a loss of, or hiatus in, established professional roles and relationships that can affect attitudes to innovation and undermine the ability of front-line services to embrace change. This can have an impact on capacity to consider new ways of working within the immediate, and across the wider, service context.
Thefindings from our research suggested that:
l Restructuring of health and social care services fractures existing integration arrangements.
l Instability resulting from restructuring affects services’scopes to innovate around integration.