Professor Rod Sheaff 012, 9 Portland Villas University of Plymouth Drake Circus, Plymouth

1. Professor Rod Sheaff 012, 9 Portland Villas University of Plymouth Drake Circus, Plymouth Devon PL4 8AA, UK phone +44-( 0)1752-586652 e-mail R.Sheaff@plymouth.ac.uk What mechanisms underpin how organisations should work together to create an integrated system? Headline results of recent realist review of multi-specialty community providers

2. Review – but what evidence? Summer 2016 – still no published studies of MCPs. Work-around: 1. Define what policy-makers intend MCPs to do: Horizontal coordination mainly general practice + CHS with any of: therapies, social care, mental health, urgent care, third sector, hospital 2. Find international and historical equivalents 216 studies since 2013 OECD countries (mostly US and UK) 3. Review evidence of mechanisms, their outcomes and contexts Not data-free ‘conceptual models’, wish-lists, think-tank advertorials etc.

3. How to evidence-base a service model? Realist method, three steps 1. Elicit NHS policy assumptions about MCPs 13 key components (network management; multidisciplinary teams … cost reduction, improved patient experience) 28 key causal linkages between them 2 main outcomes: improved patient experience of care + reduced NHS costs 2. Systematically review evidence about the linkages 216 studies since 2013 OECD countries (mostly US and UK) 3. Compare policy assumptions with evidence

4. Policy assumptions about linkages

5. Policy assumptions with supporting evidence (1) • Inter-organisational (e.g. MCP) coordinating bodies • promote development of : • multidisciplinary teams (MDT) • use of health IT for care coordination • planned referral networks (between providers) • Planned referral networks promote diverting patients • from 2º to 1º care

6. Policy assumptions with supporting evidence (2) Changed organisational cultures promote development of: multidisciplinary teams* preventive care* planned referral networks improved patient experience of care Care plans for individual patients promote: preventive care diverting patients from 2º to 1º care* improved patient experience of care * substantial supporting evidence (SR + other primary studies)

7. Unsupported assumptions No evidence that demand management arises from: changed organisation culture voluntary sector involvement planned referral networks demand management systems promote care planning for individual patients preventive care helps divert patients from 2º to 1º care

8. Conflicting evidence about whether ... Planned referral networks promote individual care planning IT for care coordination promotes planned referral networks MDT development demand management care planning for individual patients diverting patients from 2º to 1º care preventive care cost savings Demand management systems promote preventive care diverting patients from 2º to 1º care Diverting patients from 2º to 1º care reduces costs of care Conflicting evidence → local context affects whether this mechanism works

9. We also found … • Multidisciplinary teams promote development of • changed organisational culture (reciprocally) • voluntary involvement in care • informational continuity of care • demand management systems • care planning for individual patients • patients diverted from in-patient to primary care • better experience of care for patients • Care coordination through IT • promotes MDT working • supports demand management activities • promotes preventive care • save costs

10. Relationships found (original policy minus unsupported plus additional mechanisms)

11. Three headline results 1. Multi-Disciplinary Teams a central MCP coordination mechanism: care group level and individual patient level what matters is the content of MDT work making clinical work easier, more continuity of care ‘boundary-spanning’ working practices, roles and objects (pathways, shared EHR & care plans, ‘care compacts’ etc.) not just meetings 2. IT design is critical: can help or obstruct care coordination shared EHR (read/write), generate care plans, notifications 3. Short-term, MCPs more likely to improve care experience than reduce costs.

12. Questions? Comments? Suggestions? Independent research commissioned by the National Institute for Health Research (NIHR) for England through its HSDR programme: HSDR 15/77/34 From Programme Theory to Logic Models for Multi-specialty Community Providers: A Realist Evidence Synthesis. The views expressed in this presentation are not necessarily those of the NHS, the NIHR or the Department of Health for England.