Overarching study of service innovations for people with multiple long-term conditions: what works for whom, how and why?

Background

The Birmingham, RAND and Cambridge (BRACE) rapid evaluation centre is funded by the National Institute for Health Research (NIHR) to conduct rapid evaluations of promising new services and innovations in health and social care. As part of its portfolio of work, BRACE will undertake an overarching, longer-term study as a thematically-linked series of rapid evaluation projects.

The theme underpinning and guiding this longer-term study is service innovations for people of all ages living with multiple long-term conditions, particularly focusing on services provided in primary care and community settings.

The prevalence of multimorbidity is uncertain but large, with estimates ranging from 15-30% of the total population. Although prevalence increases with age, there are large numbers of people in all age groups living with two or more long-term conditions. Patients with multiple morbidities are not only higher users of NHS and social care services and likely to have poorer life expectancy and lower quality of life than other members of the population, they also face particular difficulties and may struggle to cope.

Multimorbidity is now a high-profile issue for consideration in NHS policy and practice. It is a major theme in the NHS Long-Term Plan and the Academic Health Science Network, NIHR and NHS England report on priorities for innovation and research. Hitherto, much of the published work on multimorbidity has focused on those at the highest risk of adverse events (hospitalisations in particular) and/or older patients.

Widening the scope to evaluate services for people of all ages with multimorbidity and looking at services’ impact on diverse sub-populations, are important and explicit aspects of our BRACE overarching study.

There are various frameworks for conceptualising services for people requiring health care when living with more than one long-term condition. This study draws on two frameworks considered by the BRACE team to be particularly helpful: the SELFIE (Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE) framework, and the ‘House of Care Model’.

The patient and their environment are at the core of the SELFIE framework with concepts of integrated care for people with multimorbidity described at the micro, meso and macro levels respectively. Furthermore, the SELFIE framework is based on six WHO components; service delivery, leadership and governance, workforce, financing, technologies and medical products, and information and research.

The House of Care Model is a simpler framework than SELFIE and assumes an active role for patients in determining their own care and support needs. It comprises four main elements within which personalised care planning can be achieved: health care professionals committed to partnership working; engaged informed patients (to which might be added ‘carers’, whether informal or formal); organisational processes; and responsive commissioning of health services.

Objectives

This study will use the combined SELFIE and House of Care thematic framework of multimorbidity to guide an in-depth synthesis of evaluation findings across the BRACE portfolio of research, based on research questions that interrogate critical issues faced by people of all ages who live with multimorbidity. Specific aims of the study are:

1) To build a coherent and in-depth body of evidence and learning about service innovations in primary and community settings for people of all ages with multiple long-term conditions, focused on those questions that matter most to those living with multimorbidity and their families/carers.

2) To develop methodological insights about how rapid evaluation approaches can be used to inform the scoping, testing and implementation of service innovations in health and social care.

By connecting a series of evaluations within a single overarching theme – multimorbidity – we will be able to distil insights and understanding for policy and practice beyond what is possible with discrete rapid evaluation studies. Two levels of research questions are relevant: • Those applying across the whole BRACE long-term project series.

• Those specific to an individual BRACE evaluation project (or subset of projects) within our portfolio. The overarching study’s overall research questions (ORQs) are:

ORQ1: Do people living with multimorbidity and their carers have specific health and care requirements, including for service coordination that people with single morbidities, and their carers, either have to a lesser degree or not at all?

ORQ2: To what extent and how are these requirements met by commissioning and provision of health and care services? Who takes overall responsibility for the totality of care and support? ORQ3: How effectively and cost-effectively are these requirements being met?

ORQ4: To what extent are people living with multimorbidity being supported to design, coordinate and manage their own care?

ORQ5: How do services aimed at people with multiple long-term conditions affect inequalities in access to care and disparities in health; and how is the impact of these services affected by inequalities (of all kinds)?

ORQ6: What can we learn from rapid evaluation studies about the health service delivery and organisational outcome measures that are important to people living with multimorbidity and their carers?

These overall research questions all include consideration of the extent to which the answers are affected by the changes to health and care services brought about by the COVID-19 pandemic. Methods We will include two types of rapid evaluations within the longer-term series, as follows:

• Type 1 evaluations are those in which multimorbidity is not the main focus of the initial evaluation of a service innovation but is one of the lenses through which it is appropriate to view and assess the innovation. For example, BRACE has undertaken an initial rapid evaluation of acute hospitals managing general practice services. Although, the initial evaluation did not focus on multimorbidity, better care coordination, pathway redesign and sharing of patient data are all opportunities that have been linked with vertical integration that are relevant for people with multimorbidity.

• Type 2 evaluations are individual BRACE studies that are focused from the outset on multimorbidity. Examples of such evaluations that have been commissioned from BRACE are a qualitative evaluation of digital first primary care for people with multimorbidity, and a quantitative evaluation of the experience of people with multimorbidity, compared to other service users, of ‘telephone first’ in primary care.

The study team will undertake three sets of analysis and synthesis activities. Specifically, the longer-term overarching framework will be used to:

1) Undertake synthesis of emerging findings and lessons in relation to what works and how, within each of the BRACE evaluations of service innovations for people living with multimorbidity; and prepare and publish a range of outputs aimed at decision-makers. The work will be undertaken within the set of overall research questions, described earlier, for the BRACE longer-term study.

The House of Care and SELFIE frameworks will be used throughout the overarching study to provide a comparable structure to the constituent evaluations.

2) Develop and publish cross-cutting analytical work about common issues that emerge across the portfolio of BRACE projects. This analytical work will be grounded in the overall research questions developed as a result of reviewing theories and frameworks of multimorbidity. It is also being shaped by a programme of engagement and challenge work undertaken with service user and public engagement partners, and the BRACE Health and Care Panel, informed by James Lind Alliance principles.

3) Compare and synthesise the findings from BRACE work in an end of grant report. Topics within this report may include: experience of using the James Lind Alliance partnership approach in setting and refreshing BRACE priorities; reflections on the methods that work most effectively within a rapid evaluation approach and what these mean for health and social care services researcher skills development; the role and experience of professional and service user partners in a rapid evaluation approach; and how rapid service evaluations might be commissioned in such a way that they are truly rapid, responsive and rigorous.

Expected outputs and dissemination

The team will, as part of this overarching study, develop papers and other outputs that explore in more depth the implications of individual and collated BRACE studies for people living with multimorbidity and their carers. These outputs will range from research signals via social media; through concise summaries in podcasts, blogs and pieces for the media; to more detailed briefings for practice, policy and academic audiences.

The team will produce project-specific outputs focused on relevant findings within single evaluations, and outputs reporting on cross-cutting analysis that synthesise findings across evaluation studies. Outputs will be targeted at a range of stakeholders including health and social care professionals and the general public.