Image of a men receiving treatment, representing healthcare in the community

WORKTECC: Workforce Operations that Realise Knowledge-based Transformational Efficiency gains in Community Care

This was a four-year project begun in 2017. It was funded by the Health Foundation and led by CORU (The Clinical Operations Research Unit) at UCL and worked with North East London NHS Foundation Trust (NELFT), the London Boroughs of Redbridge and Barking & Dagenham and the innovation test bed CareCity.

The aim of the project was to identify workforce changes that could improve the efficiency and effectiveness of the delivery of community healthcare to older residents in the two London Boroughs. CORU used their OR expertise to identify eight candidate changes in service delivery that could offer significant benefits and the Institute examined the ‘readiness to change’ in the boroughs to understand the issues that would need to be addressed if these changes were to become embedded as regular practice in the delivery of community healthcare.

In the project we reviewed 16 change programmes that have been undertaken in community healthcare in recent years in order to understand how changes were made and the outcomes that were achieved. There were several examples of major structural changes and of the implementation of significant new technical systems.

All of these changes were successful although each required considerable resources to implement them. There were also many attempts to make role changes and changes to local work practices. These all involved behavioural change and have so far been less successful. The aim of the project was to carry forward the lessons from these change programmes to examine what would need to happen if the OR changes identified were to be successfully implemented.

In the course of the project we developed a toolkit to assist local staff in the identification of the issues to be addressed in making changes. It is particularly useful for the early identification of unanticipated implications of a change programme for the local work system. The toolkit called the Planning for Change Framework (PfCF) can be downloaded from here.

 

Image of a woman pushing an elderly woman in a wheelchair in a field, representing care meeting social needs

Evaluating the West London Primary Care Navigator Scheme

The concept of Social Prescription has grown in importance in recent years as it has been recognised that many people have both medical needs and social needs. Elderly people, may for example, find themselves isolated in flats in tower blocks or may not be sufficiently mobile to attend GP or hospital appointments.

There are services in most communities that can help people with problems of this kind but how is the person in need to connect with such services? In West London the local Clinical Commissioning Group working in association with AgeUK, recruited a team of Primary Care Navigators who each worked with two or three local GP practices to identify the social needs of patients and ‘navigate’ them to an appropriate service.

The Institute undertook a qualitative and quantitative evaluation of the service, assessing whether, for example, patients helped in this way made fewer visits to A&E, undertaking focus groups with the Navigators and interviewing other stakeholders (GPs and their staff, the patients, the service providers and the commissioners).

The patients really valued the service, the GPs valued being able to refer patients to the Navigator and the quantitative evidence demonstrated that the service was decreasing the load on the health service.

There were, however, many issues about the establishment of the role in GP practices: for example, what access was there to patient records, what part should the Navigator plan in multi-disciplinary meetings about patients, what technical system supported the Navigator’s work (none were planned) and in the blurred line between health and social care, what part could and should the Navigator play in health care?

 

The evaluation report is here.

Image of older woman looking at phone, in relation to digital social care

Project Evaluations in the Local Government Association (LGA) Social Care Digital Innovation Programme (SCDIP)

The Local Government Association (LGA) in conjunction with NHS Digital launched two programmes (LIP and SCDIP which funded local councils to implement new technology innovations that addressed issues in the integration of health and social care. The Institute working with Traverse was commissioned to evaluate the progress of the projects funded under these schemes.

Many of the projects funded in LIP made slower progress than planned and one of the main issues identified was that, as the work got underway, it was found that the initial specifications for the projects did not match the needs of potential users. As a result of this learning, in the successor programme (SCDIP), the first part of each project was a ‘discovery phase’ in which the project team engaged with their user community to develop a fuller understanding of user requirements for the technical innovation being planned.

Twelve projects received funding for the discovery phase and the Institute and Traverse undertook formative evaluations with the teams to support their learning from this phase. Nine of the projects were funded to proceed to the implementation of the technology. This study confirmed the Institute approach to projects of this kind: introducing new technology into a complex and changing organisational context, (in this case where new forms of integrated health and social care were emerging), requires an evolutionary approach in which regular summative evaluations of progress serve to progressively shape subsequent phases of the work.

 

The evaluation report of the discovery phase of SCDIP is here.

 

Image of a garden with "NHS" visible in the grass

Evaluating the Adopter Role in the NHS Innovation Accelerator Programme

The NIA (NHS Innovation Accelerator Programme) is a programme of support for innovators who have demonstrated that their products have the potential to provide benefit within the NHS. The Institute was invited to evaluate nine applications of the innovators’ products not from the perspective of the innovators but from the perspective of the NHS organisations that were adopting their products.

The focus was not, for example, on the initial application of a new form of digital technology but on its subsequent delivery in a different part of the NHS. The results showed the work that was required by stakeholders in the NHS organisations to achieve adoption. We adopted a ‘lock and key’ metaphor to describe the need for a match to be obtained between the way the NHS organisation worked (‘the lock’) and the way the innovative product worked (‘the key’).

For adoption to be successful there had to be adaptation in both. For adoption to occur in a complex organisation it was also necessary to have more than one ‘champion’ for the innovation in the adopting organisation: it often needed a concerted and persistent programme of work by a variety of stakeholders to achieve sustained adoption.

 

The report is available at:

https://nhsaccelerator.com/wp-content/uploads/2018/11/NHS-Innovation-Accelerator-Understanding-how-and-why-the-NHS-adopts-innovation.pdf

 

Two of the case studies are discussed in more detail in:

Eason K., Hoare A. and Maton-Howarth W. (2021) ‘Getting the benefits from connecting digital health applications to complex healthcare systems’ In Soares M. Rebelo F & Ahram T. (eds) ‘Handbook of Usability and User -Experience: London, Taylor & Francis Vol1, Chapter 10.

Image of a man using his phone representing the use of the My Health Guide app

The Use of the ‘My Health Guide’ Digital Application to Support People with Learning Disabilities

My Health Guide (now called Hear Me now) is a digital app that enables people with learning disabilities and/or autism to store photos and videos, follow detailed guidance about their daily routines and communicate their needs and desires to others. In a project in the NHS Digital Social Care Pathfinder programme the care provider Hft worked with the technology supplier Maldaba, to roll-out My Health Guide within Hft and in other care providers.

The Institute evaluated the adoption of the app in eleven social care providers and assessed the benefits that were obtained. The results showed that although the app is designed as a tool for an individual to use, its adoption was a sociotechnical change challenge because it depends on changes in the complex health and social care environment that supports people with learning disabilities. In particular, if the app is to be successfully used by people with learning disabilities, the support workers who assist them on a daily basis have to be fully engaged in the adoption process.

In addition to evaluating the adoption process for My Health Guide, the Institute also evaluated the planned benefits and the benefits actually achieved from the use of the app. In addition to the benefits for people with learning disabilities there were potentially significant benefits for other stakeholders including the support workers, families and local healthcare agencies.

As a result of the project we produced a ‘blueprint for the adoption of digital apps in social care’ and a ‘process for establishing and assessing the benefits of digital apps in social care’.

An extended summary of the project is available here together with the blueprint for the adoption of digital apps and the process for assessing the benefits of digital apps: My Health Guide

V-connect device

EVALUATING OF THE USE OF LINCUS AND THE HEALTH EQUALITIES FRAMEWORK (HEF)

Hft is a national charity that supports people with learning difficulties. They have deployed two forms of technology to help them provide improved support for their clients. Lincus provides easy to use tablet interfaces that enable people with limited language capability to communicate their needs and it can also capture a wide range of information about people with learning difficulties which can be used to manage the support they are given. Linus has been deployed with the Health Equalities Framework (HEF) which provides a series of scales enabling an assessment to be made of the degree to which people with learning difficulties are able to access support and services. The institute evaluated progress in the adoption of Lincus with the HEF in two Hft locations. The evaluation demonstrated there was considerable benefit for some people with learning difficulties in using Lincus to communicate their needs and that the use of the HEF highlighted inequalities of provision that led to local remedial action. The broader aim of using Lincus as a major management tool were to some extent hampered by difficulties in capturing all the necessary information.

illustrative image of older person

EVALUATING AN ACTIVITY BASED MONITORING SYSTEM FOR OLDER PEOPLE IN THEIR OWN HOMES (ALLY)

The Institute has begun an evaluation of a system that is able to monitor the extent and form of activity in the home of an older person on a 24-hour basis. The activity monitor can be used to raise an alarm if activity differs radically from the norm and can also provide insights that might lead to changes in support plans.

The system is being deployed in two locations in the north and south of England and the Institute will evaluate the impact of the system upon residents, their families and services providing support.

Together these projects and others conducted in health and social care settings are revealing both the promise of new innovations and the difficulties of establishing them as normal parts of service delivery. Each innovation has consequences for the processes by which service is normally delivered and the issues are therefore not just about technical change but are also about organisational development and service re-design. These projects are enabling the Institute to refine its evaluation and action research techniques in order that it can better provide client-centred support for all the parties involved to enable them to tackle the sociotechnical challenges of embedding new practices in the normal delivery health and social care.

Video conferencing for people with learning disabilities

BETTER OUTCOMES FOR PEOPLE WITH LEARNING DISABILITIES – TRANSFORMING CARE (BOLDTC)

VIDEO-CONFERENCING SERVICES FOR PEOPLE WITH LEARNING DISABILITIES

People with learning disabilities often have problems sustaining contact with their families and accessing health and other services when they need them. This project provided video-conferencing facilities that people with learning disabilities and their carers could use to ease these communication problems. The technology was deployed across five locations in England and the Institute played an action research and evaluation role to support the project in its search for the best way to exploit this technology for the benefit of people with learning disabilities. Early results suggest a major benefit is that the technology can be a significant benefit to families in maintaining contact with people with learning disabilities but that organisational issues in revising service procedures may hamper adoption of the technology within the health services. The project worked in an iterative way to support the learning of all parties about the value of this technology and how to overcome the organisational problems in its adoption.

Fractal image

The Law of Unexpected Consequences –
Download our guide to spotting knock-on effects

Th The law of unexpected consequences

Government actions to combat the coronavirus keep having unexpected consequences: students returning to University spread the virus, an examination algorithm leads to school children from disadvantaged backgrounds having their grades downgraded, and closing bars at 10 pm leads to people not socially distancing in the streets.  

We should not be surprised about these unexpected consequences because it is a well-recognized systems phenomenon. When you make a change in one part of a system it has knock-on effects elsewhere and some of them may be disadvantageous to what you are trying to achieve. And in all the examples we are now seeing, changes are being made that impact wider systems whether it is the existing educational system or the night-time leisure social ‘systems’ of our towns and cities.

Why do we not identify these consequences when we are planning a change? They always seem so obvious after the event. Part of the answer is that when we are planning a change we are usually focused on the change itself and we are probably under time and resource pressure to deliver it. There may not be much time to lift the blinkers and look for wider implications. And it is possible we don’t want to know: we may have enough trouble planning the change without looking for things that may or may not happen.

But this is a shortsighted and potentially disastrous strategy: it might jeopardise the whole venture. Spotting potential problems early means there is an opportunity to find ways of avoiding them.

This is a systems analysis problem and there are ways of spotting potential implications before anything is implemented. In one of our current projects, (the WORKTECC project lead by the CORU, the Clinical Operational Research Unit at University College London), we have developed a framework for the systematic search for implications of a change programme which is based on sociotechnical systems theory. It is designed to search for implications in a work system. The framework is here as a free resource:

Download our guide here

We have often helped project teams work through this process but this framework is designed for people to use for themselves. If you are concerned about the implications of a change you are engaged with, please try it. And please provide us with some feedback so that we can go on refining it.  

Professor Ken Eason

Keeping your concentration when working from home

Weapons of mass distraction

When you travel to work there are things that shape the day and help you focus on getting the job done: the daily timetable (arrive, go home, lunch breaks etc), the enclosed work spaces, the meetings and appointments, the deadlines to meet and so on. When we are working from home many of these ways of organising the day disappear and it is easy to get distracted and lose our concentration. We are thrown back on our own resources to create a discipline that will sustain good working practice.  

 Using psychological theory Will Bedingfield gives some excellent advice on how to sustain concentration when working at home 

https://www.wired.co.uk/article/how-to-concentrate-pomodoro-wfh 

 A major conclusion from psychological research is that we are ‘single channel information processors’. That is, we can only focus on one thing at a time. We may celebrate multitasking but the evidence says we do it by rapid switching of our focus and it is stressful and inefficient. So working well depends on cutting out distractions. At home there can be plenty of them so how can we sustain our work focus? 

  1. Cut yourself off from temptation   Try to create a workspace that is free of all other homely features. Not just the rest of the family but all the other temptations of your home – magazines, food, music, evidence of your hobbies or whatever.  
  2. Use the normal structure of your working life. No doubt there will be deadlines, zoom meetings, telephone appointments etc that will shape parts of the day but make sure there are chunks of time to do the things you have to schedule yourself and don’t leave them until you are tired at the end of the day. Try not to get over committed to video meetings because they need extra concentration. There is growing evidence that people suffering from ‘zoom fatigue’. This seems to be most pronounced when people go straight from one meeting to another throughout the day.   
  3. Limit engagement with on-line ‘distractions’. Your PC or tablet is full of possible distractions – Facebook to check and Google to search etc. Many of the distractions may come from work itself: all those emails most of which you can bin. Many people adopt a policy of only checking emails once an hour for example so that they can keep their focus on the task in hand.  
  4. Give yourself breaks.   Don’t expect too much of yourself. We work best if we take regular breaks whether that is to get some exercise away from the fixed posture in front of the screen or to give our brain a chance to relax.  

All this advice amounts to: give yourself a chance of a decent run at each major task you undertake. 

Professor Ken Eason