Independent evaluation of the North East Hampshire and Farnham Vanguard. Using the Normalisation Process Theory [NPT] framework to evaluate a new care model [NCM]: the Happy Healthy at Home [HHH] Enhanced Recovery at Home [ER@H]

Abstract

Background: In a context in which greater partnership working and new integrated models of care have been promoted as the way forward (Cameron and Lart, 2003; Banks, 2004; Williams and Sullivan, 2010; Ham and Curry, 2011; Rand Europe and Ernst and Young, 2012; NHS England, 2014; GovUK, 2015), ER@H brings together staff from a wide range of health and social care professions and organisations to provide holistic care and support to patients after they are discharged from hospital. The ER@H team agrees holistic care plan with patients and carers for patients on the ER@H caseload, focussing on rehabilitation after leaving hospital. All patients are visited by an ER@H team member on the day they leave hospital. If the discharge is late in the day, they are visited by the community nurses who provide support to ER@H.

Aims and objectives: The team evaluation sought to understand the experience of the staff involved in developing and delivering the implementation of the ER@H including enablers and barriers to embedding the ER@H in a sustainable way on a long term basis.

Methods: The conceptual framework was mixed methods (Plowright, 2015) informed by Normalisation Process Theory (May and Finch 2009), Force Field Analysis (Lewin, 1949; 1951) and Alexander (1985) team effectiveness as well as the NEHF Vanguard HHH ER@H Logic Model. Data collection was by way of: non-participant observation of a regular multi-disciplinary team meeting [MDT] (n=23); a focus group that took place directly following the MDT (n=23), which included an anonymous survey and brainstorming and a ranking exercise (n=23). Data were analysed using the constant comparative method (Glaser and Strauss, 1967) and thematic analysis (Braun and Clarke, 2006).

Results: The highest overall score (n=23) was for that ER@H is worthwhile [7.7] [with 8.3 for RSWs (n=14) and 6.7 for registered staff (n=9)]. Ranked second overall was team members value the effect of ER@H on their work followed by feedback about ER@H can be used to improve it in future. The top barrier categories were identified as changes x19 (28% of the votes), environment x17 (25% of the votes), communications x14 (20% of the votes), team x 11 (16% of the votes and not feeling valued x5 (7% of the votes). The top driver categories were identified as team x29 (44% of the votes), patient outcomes x17 (26% of the votes), flexibility x11 (16% of the votes) and asset for the NHS x5 (8% of the votes). Overall, team members somewhat disagreed that ER@H had achieved the ER@H team goals which included a cultural shift in organisational integration [4.2] [with 4.1 for RSWs and 4.2 for registered staff] and successful upskilling of staff in generic roles [4.0] [with 3.5 for RSWs and 6.1 for registered staff].

Conclusion: This pragmatic evaluation of a pilot implementation of a NCM in a real life setting undertaken with limited resources found that despite difficulties with sense-making, participation and action and in particular operational barriers, team members had a belief in the worthwhileness of ER@H and its effect on their working practice that has persisted regardless (May et al, 2015). Together the team is working towards delivering its goal of bringing together staff from a wide range of health and social care backgrounds to provide holistic care and support to patients after they are discharged from hospital. The extent to which team members believed that ER@H was worthwhile is very encouraging.

Recommendations: The team should continue to improve sense-making, engagement, collective action and reflexive monitoring i.e. better defined roles, enhancing the capacity and willingness of team members to organise themselves to collectively contribute to the work involved, but most especially to make explicit and clarify operational issues. The team are already planning to put into action a plan to make ER@H more responsive in dealing with arising issues as soon as possible. The ER@H team should be encouraged to access all available information about ER@H and its effects in order to take steps to optimise the effectiveness and worthwhileness of ER@H.

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