Michelle Farr

Co-production and value co-creation in outcome-based contracting in Public Services

Abstract This paper contributes to theorizing and analysing different processes of co-production and value co-creation within outcome-based contracting (OBC). It investigates how different OBC mechanisms are implemented in practice, and with what implications for public service users’ experiences and outcomes. Using realist synthesis techniques, the paper analyses existing evaluations that focus on users’ experiences of OBC in welfare-to-work services and a homelessness project. It highlights how OBC can affect equality, effectiveness and innovation within public services. The paper also exemplifies the importance of analysing how the political and policy context of public services affects both service pathways and their outcomes.

Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England

Objectives Evaluation of a pilot study of an online consultation system in primary care. We describe who used the system, when and why, and the National Health Service costs associated with its use. Design 15-month observational study. Setting Primary care practices in South West England. Results 36 General practices covering 396 828 patients took part in the pilot. The online consultation website was viewed 35 981 times over the pilot period (mean 9.11 visits per 1000 patients per month). 7472 patients went on to complete an ‘e-consultation’ (mean 2.00 online consultations per 1000 patients per month). E-consultations were mainly performed on weekdays and during normal working hours. Patient records (n=485) were abstracted for eight practices and showed that women were more likely to use e-consultations than men (64.7% vs 35.3%) and users had a median age of 39 years (IQR 30–50). The most common reason for an e-consultation was an administrative request (eg, test results, letters and repeat prescriptions (22.5%)) followed by infections/immunological issues (14.4%). The majority of patients (65.2%) received a response within 2 days. The most common outcome was a face-to-face (38%) or telephone consultation (32%). The former were more often needed for patients consulting about new conditions (OR 1.56, 95% CI 1.05 to 2.27, p=0.049). The average cost of a practice’s response to an e-consultation was £36.28, primarily triage time and resulting face-to-face/telephone consultations needed. Conclusions Use of e-consultations is very low, particularly at weekends. Unless this can be improved, any impact on staff workload and patient waiting times is likely to be negligible. It is possible that use of e-consultations increases primary care workload and costs. Online consultation systems could be developed to improve efficiency both for staff and patients. These findings have implications for software developers as well as primary care services and policy-makers who are considering investing in online consultation systems.

Understanding staff perspectives of quality in practice in healthcare.

BackgroundExtensive work has been focussed on developing and analysing different performance and quality measures in health services. However less has been published on how practitioners understand and assess performance and the quality of care in routine practice. This paper explores how health service staff understand and assess their own performance and quality of their day to day work. Asking staff how they knew they were doing a good job, it explored the values, motivations and behaviours of staff in relation to healthcare performance. The paper illustrates how staff perceptions of quality and performance are often based on different logics to the dominant notions of performance and quality embedded in current policy.MethodsUsing grounded theory and qualitative, in-depth interviews this research studied how primary care staff understood and assessed their own performance and quality in everyday practice. 21 people were interviewed, comprising of health visitors, occupational therapists, managers, human resources staff and administrators. Analytic themes were developed using open and axial coding.ResultsDiverse aspects of quality and performance in healthcare are rooted in differing organisational logics. Staff values and personal and professional standards are an essential element in understanding how quality is co-produced in everyday service interactions. Tensions can exist between patient centred, relational care and the pressures of efficiency and rationalisation.ConclusionsUnderstanding the perspectives of staff in relation to how quality in practice develops helps us to reflect on different mechanisms to manage quality. Quality in everyday practice relies upon staff values, motivations and behaviours and how staff interact with patients, putting both explicit and tacit knowledge into specific action. However organisational systems that manage quality often operate on the basis of rational measurement. These do not always incorporate the intangible, relational and tacit dimensions of care. Management models need to account for these relational and experiential aspects of care quality to support the prioritisation of patients’ needs. Services management, knowledge management and ethics of care literature can provide stronger theoretical building blocks to understand how to manage quality in practice.

Use of an electronic consultation system in primary care: a qualitative interview study

Background The level of demand on primary care continues to increase. Electronic or e-consultations enable patients to consult their GP online and have been promoted as having potential to improve access and efficiency. Aim To evaluate whether an e-consultation system improves the ability of practice staff to manage workload and access. Design and setting A qualitative interview study in general practices in the West of England that piloted an e-consultation system for 15 months during 2015 and 2016. Method Practices were purposefully sampled by location and level of e-consultation use. Clinical, administrative, and management staff were recruited at each practice. Interviews were transcribed and analysed thematically. Results Twenty-three interviews were carried out across six general practices. Routine e-consultations offered benefits for the practice because they could be completed without direct contact between GP and patient. However, most e-consultations resulted in GPs needing to follow up with a telephone or face-to-face appointment because the e-consultation did not contain sufficient information to inform clinical decision making. This was perceived as adding to the workload and providing some patients with an alternative route into the appointment system. Although this was seen as offering some patient benefit, there appeared to be fewer benefits for the practices. Conclusion The experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system. The study also highlights the challenges of remote consultations, which lack the facility for real time interactions.

Can Staff Be Supported to Deliver Compassionate Care Through Implementing Schwartz Rounds in Community and Mental Health Services

Schwartz Rounds are evidence-based interdisciplinary discussions where health care staff can share experiences of the emotional and social aspects of care, to support improvements in patient care. Developed in acute services, they are now being implemented in various settings including U.K. community and mental health services where their implementation has not been researched. Realist evaluation was used to analyze three community and mental health case studies of Round implementation, involving Round observations (n = 5), staff interviews (n = 22), and post-Round evaluation sheets (n = 206). Where Schwartz Rounds were successfully implemented and facilitated, the discussions enabled emotional resonance across interdisciplinary colleagues about caring experiences, enabling the recognition of a common humanity. Participants appreciated attending Rounds and saw they improved communications, trust, and openness with colleagues and enabled more compassionate care with patients. The wide geographical dispersal of staff and work pressures were challenges in attending Rounds, and strong leadership is needed to support their implementation.

The social impact of advice during disability welfare reform: from social return on investment to evidencing public value through realism and complexity

ABSTRACT This article illustrates how advice services create diverse public values within welfare reform. It develops a social impact framework using public value, realism, and complexity literature. Starting from a social return on investment study of advice, qualitative interviews are analysed with twenty-two clients, who sought advice for welfare benefits, and had disabilities, or physical or mental health conditions. Integrating these clients’ experiences with wider evidence illustrates how advice services advocated for people’s needs within a complicated (and controversial) welfare system. However, advice services face funding cuts, benefit assessment costs have risen, and welfare reforms have yet to meet their aims.

Power dynamics and collaborative mechanisms in co-production and co-design processes:

Co-production and co-design practices are increasingly being promoted to develop user-centred public services. Analysing these practices with literature on power, participation and realist social theory this article explores the power dynamics, mechanisms and impacts within co-production and co-design processes. Two case studies were evaluated using qualitative longitudinal methods: an experience-based co-design project within hospital-based breast cancer services was followed from initiation to completion, alongside a local government innovation team that used co-production and co-design techniques to enable person-centred policies and services. The two cases illustrate how co-production and co-design techniques involve facilitating, managing and co-ordinating a complex set of psychological, social, cultural and institutional interactions. Whilst existing power relations can be challenged in different ways, constant critical reflective practice and dialogue is essential to facilitate more equal relational processes within these techniques, and to institute changes at individual, local community and organisational levels.

Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production

Objectives To examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved. Design Mixed-method evaluation of a primary care e-consultation system. Setting Primary care practices in South West England. Methods Qualitative interviews with 23 practice staff in six practices. Patient survey data for 756 e-consultations from 36 practices, with free-text survey comments from 512 patients, were analysed thematically. Anonymised patients’ records were abstracted for 485 e-consultations from eight practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and the usage of the e-consultation system were informed by: (1) normalisation process theory, (2) a framework that illustrates how e-consultations were co-produced and (3) patients’ and staff touchpoints. Results We found different expectations between patients and staff on how to use e-consultations ‘appropriately’. While some patients used the system to try and save time for themselves and their general practitioners (GPs), some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation. Conclusions Where both patients and staff interact with technology, it is in effect ‘co-implemented’. How patients used e-consultations impacted on practice staff’s experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.

Knowledge brokers or relationship brokers? The role of an embedded knowledge mobilisation team

Aim: Policymaking decisions are often uninformed by research and research is rarely influenced by policymakers. To bridge this ‘know-do’ gap, a boundary-spanning knowledge mobilisation (KM) team was created by embedding researchers-in-residence and local policymakers into each other’s organisations. Through increasing the two-way flow of knowledge via social contact, KM team members fostered collaborations and the sharing of ‘mindlines’, aiming to generate more relevant research bids and research-informed decision-making. This paper describes the activities of the KM team, types of knowledge and how that knowledge was exchanged to influence mindlines. Discussion: KM team activities were classified into: relational, dissemination, transferable skills, evaluation, research and awareness raising. Knowledge available included: profession specific (for example, research methods, healthcare landscape), insider (for example, relational, organisation and experiential) and KM theory and practice. KM team members brokered relationships through conversations interweaving different types of knowledge, particularly organisational and relational. Academics were interested in policymakers’ knowledge of healthcare policy and the commissioning landscape. More than research results, policymakers valued researchers’ methodological knowledge. Both groups appreciated each other as ‘critical friends’. Conclusion: To increase research impact, ‘expertise into practice’ could be leveraged, specifically researchers’ critical thinking and research methodology skills. As policymakers’ expertise into practice also bridges the know-do gap, future impact models could focus less on evidence into practice and more on fostering this mutual flow of expertise. Embedded knowledge brokers from the two communities working in teams can influence the mindlines of both. These ambassadors can create improvements in ‘inter-cultural competence’ to draw academia and policymaking closer.