Multispecialty Community Provider Research Articles

No service is an island: towards an ecosystem approach to mental health service evaluation.

No service is an island: towards an ecosystem approach to mental health service evaluation.

Frailty care in a community based clinic – maximising the potential of integrated care

To develop a pragmatic model for frailty care in one locality, and assess both the benefits and blocks to wider application within one vanguard multispecialty community provider (MCP) in Hampshire. A series of facilitated meetings were funded in 2016 to establish an integrated care approach to reducing inappropriate admissions for frail patients in crisis. A local champion and the appointment of two frailty nurses within Hampshire provided a focus on frailty. The clinic evolved as part of a series of Plan, Do, Study, Act (PDSA) cycles, and was then evaluated …

Information technology in multispecialty community providers: results from a realist evidence synthesis

Introduction: Multispecialty community providers (MCPs) are a proposed model of care by which the NHS can reduce pressures on hospitals and general practices whilst improving the quality and continuity of care for people with complex health problems. MCPs integrate primary, community, mental health, and social care services by linking up services virtually or geographically. This paper presents findings that focus on how heath information technology (HIT) could be used to improve services and patient care in the MCP context using a realist synthesis approach. Methods: We followed the RAMESES guidelines, which outline the following process of conducting a realist synthesis: Develop an initial programme theory for how the intervention is thought to work. To create our programme theory we met held three meetings with policymakers and service users and conducted a search for relevant policy papers in the HMIC database. Conduct a systematic and iterative search of the literature to find evidence to support or refute the initial programme theory. To find evidence, we conducted a search in four databases (MEDLINE, PsycINFO, CINHAL, and ASSIA), and screened, extracted data, and critical appraised articles by five team members with 10% of records error checked by a second person. Revise the theory based on the collated evidence and build a new (evidence-based) logic model based on the findings. Results: Forty-one primary and secondary sources were included in the synthesis. We found some evidence that HIT in MCP-like organisations support multidisciplinary team working, care planning at the population and inter-organisational level, care planning at the patient level, and reduce unplanned hospital admissions. Few studies directly linked HIT with these outcomes, but there was a great deal of conceptually rich evidence about different contexts and mechanisms that can support or hinder projects from being most effective. Discussion: We found a very clear pattern that the most effective HIT projects in new models of care were implemented based on the unique needs of the organisation, customised as needed, and included input from the health professionals that would be using the system. This, in turn, often led to staff buy-in for the projects and supported good team working. Many sources also described the difficulties in using existing healthcare technology within new models of care and provided insight as to how an ideal HIT system might be designed. Such a system would be interoperable, capable of complex data analysis, contain workflow tools, and be flexible enough to support formal and informal communication between healthcare providers. Conclusions: We found some evidence that HIT, when well designed, can support MCP-like organisations. Lessons learned: The presence of HIT does not, by itself, lead to more efficient services or better patient outcomes. HIT must be carefully designed based on organisational needs. Limitations: Studies were limited to OECD countries and published between 2014-2016. Future Research: Further primary research is required to test elements of our revised logic model. Additional review work on aspects of HIT in new models of care such as patient registries and telehealth is needed.

Patient Experiences of Care from Multi-Speciality Community Providers: Findings from a Realist Synthesis of International Evidence

Introduction : Multispecialty Community Providers (MCPS) aim to provide horizontal coordination of care via networks of primary care providers (general practice, community health services, mental health, ambulance, etc.) and non-health services (e.g. voluntary sector, social services etc.). MCPs are also expected to improve the quality, continuity and coordination of care for people with chronic health problems. Our Realist Synthesis identified policy assumptions about how MCPs are thought to achieve outcomes and the extent to which these were supported by evidence. Improvements to patient experiences of care was also an expected outcome of MCP care. We explored the evidence for this outcome. Theory/Methods : Three stage synthesis: 1) Review of policy material to identify the underlying programme theory (PT) for MCPs. This work surfaced policy makers assumptions about how MCPs would achieve their outcomes. These were elicited from policy documents and ‘think-tanks’ with stakeholders. We searched Health Management Information Consortium (HMIC) database, and the King’s Fund database. The elaboration of the policy-makers’ assumptions about MCPs provided search terms for the second stage. 2) A systematic literature review and synthesis of secondary evidence mapped to the initial PT. We searched for evidence of the ‘causal links’ in the initial PT by searching databases: MEDLINE, PsycINFO, CINAHL, and ASSIA. 1319 titles/abstracts reviewed in two rounds, and 116 selected for full-text data extraction. Secondary data were extracted and synthesised into a framework reflecting causal links in the initial PT. We used the Mixed Methods Appraisal (MMAT) and the Assessment of Multiple Systematic Reviews (AMSTAR) tools to assess quality and validity. 3) Comparison (and reformulation) of original PT based on secondary evidence and identification and focus on all studies measuring patient experience as an outcome (e.g. goal setting, care planning at a patient level etc.). Results : We found supporting evidence that if MCPs implement care planning at a patient level then patient experiences of care improve. The evidence was less strong for improvements in patient experience as a consequence of diversion from in-patient care. MDTs and boundary spanning roles helped improve patient experience. There was emerging evidence that MDTs and boundary spanning roles facilitated the delivery of person centred care by improvements in care planning and access to services. Discussion : Individuals with complex needs or those with long term conditions commonly report poor experiences of care (5, 6), particularly care from multiple organisations (7). Our review suggests that MCPs can improve patient experiences of care by providing tailored and accessible coordinated care. Conclusions : Patients’ experiences of care have the potential to improve if care planning at a patient level becomes prevalent and delivered through MDTs and/or professionals with boundary spanning roles. Lessons learned : MDTs and boundary spanning roles are potential mechanisms to improve the experiences of care. Limitations : Due to the large volume of material we only included studies published 2014-2016; reviews covered earlier periods. Suggestions for future research : Changes in organisational culture was a potential mechanism associated with improvements in patient experience. Primary research that explore how this works would help unpack this newly identified mechanism.

Social Prescribing and Integrated Care: An Evaluability Assessment

Background: In the United Kingdom UK there is a desperate need to fund the National Health Service NHS to better reflect the populace at a local level. In response, the NHS Five Year Forward View [1] was published and noted that a “one size fits all” model of care was no longer practical. As part of delivering this remit, new models of care have been designed to deliver more integrated care and create partnerships at the community level.[1] One such model is the Encompass multispecialty community provider MCP; one of 14 ‘vanguards’ established across the UK in response to improving the integration of health and social care [2] whilst also looking towards non-clinical resolutions. This necessity to pursue a more inclusive and sustainable approach to health has allowed concepts such as social prescribing to rise to prominence. Method: An evaluability assessment EA was undertaken to determine if there was enough evidence to carry out a full evaluation of the social prescribing service Red Zebra in relation to the MCP remit. The EA included collaboration with end users, elaboration, testing and refinement of an agreed programme theory, understanding the programme reality, identification and review of existing data sources and making assessments against key criteria.[3], [4] The key criteria considered were: Quality of project purpose Quality of expected outputs Availability of baseline and monitoring data Feasibility of attribution Data Collection: In-person interviews were undertaken with social prescribing managers, case officers and commissioners engaged with the Encompass MCP process. To address the key criteria the research team also collated and analysed information related to Red Zebra’s history, aims, objectives, staff job descriptions, copies of client feedback forms and the social prescribing platform they utilise to undertake their work known as Connect Well CW.The CW database documents online referrals and whether the activity provider has responded to the referral. Self-referrals are recorded independently by the organization. Additionally, as this system is not compliant with NHS information governance NHS patient numbers are not recorded and therefore cannot be linked with other patient activity. Conclusion: Data showed, service users being predominantly older people with long-term conditions requiring support for social isolation. At the time of this assessment, impact of the service was not possible to evaluate as there was not a formal assessment of either patient reported outcomes or change in health service use. While satisfaction with onward referral providers is assessed via feedback forms, these do not include questions on users’ experience of Red Zebra. Whilst promising, the outcome data collected by Red Zebra at this juncture needed to have included a formal assessment of client perceived benefits and anticipated outcomes of the service itself to be considered for a full evaluation.

Future models of general practice

The partnership model has been at the heart of UK general practice since the beginning of the NHS. In recent years new models of care have emerged that both challenge and complement the partnership model. These include: Federations; Super-partnerships; Accountable Care Organisations; and Multispecialty Community Providers. Many are questioning whether the partnership model can survive, and whether small independent practices will become a thing of the past. This article examines what these new models of care are, where they have come from, and looks at the future of the partnership model.

Understanding the impact of alliances in healthcare: The multispecialty community provider model

This empirical study examines whether the multispecialty community provider (MCP) healthcare model has the capacity to deliver improved efficiency and quality in primary healthcare. This model, an ...

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

BackgroundThe NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.ObjectivesTo use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.DesignRealist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.Data sourcesSystematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.ResultsThe IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.LimitationsThe studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.ConclusionsMultidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.Study registrationThis study is registered as PROSPERO CRD42016038900.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

BackgroundThe Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.ObjectivesThe three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.DesignThere were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.Main outcome measuresThe quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.Data sourcesSearches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.Review methodsA realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.ResultsDelivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.Strengths and limitationsThe project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.ConclusionsMultispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.Future workA set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.Study registrationThis study is registered as PROSPERO CRD42016039552.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The impact of out-of-hospital models of care on paediatric emergency department presentations

ObjectiveTo estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP).DesignObservational study.Patients & settingData collected prospectively...

System-level mechanisms and contexts for health and social care coordination through Multi-Specialty Community Providers in England: a Realist evidence synthesis

Introduction: Current National Health Service (NHS) policy towards care coordination in England, involving the introduction of Multi-Specialty Community Providers (MCPs), assumes that repeated unplanned admissions of older people with multiple morbidity make disproportionately heavy use of hospital bed-days, that a substantial number of these admissions are preventable, and that reducing these admissions would substantially reduce cost and access pressures on hospital services. 'Integrated' (better-coordinated) care, delivered by MCPs, is intended to reduce these admissions by partly replacing hospital care with non-hospital care, hence raising the quality and reducing the cost of care. Our study synthesised existing evidence about how to integrate care at the system-level, including management of complexity and whole system patient flow. Theory/Methods: Stage 1. From grey literature, MCPs’ published logic models, and a think tank (policy makers, health-workers, patients/public), we elicited policy-assumptions ('programme theory') about what structures, working practices and services ('mechanisms') the MCPs will contain, and how these mechanisms are expected to produce the outcomes above. Stage 2. Realist review: Evidence from other ‘integrated’ care projects which related to the programme theory identified in stage 1 was synthesised to produce a revised, more strongly evidence-based explanation of how complex, MCP-like ‘integrated’ care systems function in different contexts. 3. 'Critical Analysis': The policy-makers' initial programme theory (from stage 1) was compared with the evidence from stage 2. In that way the policy-makers’ initial programme theory was elaborated, qualified and revised, better to inform the development of health and social care co-ordination in England. Results: We present 1) the initial programme theory, built from NHS England policy-makers' assumptions as to what outcomes the MCP models of care integration will produce in England, and by what means, and 2) some main findingsof how different models of care co-ordination might contribute to achieving these outcomes and under what conditions. Discussions: We discuss 1) how realist review methods were used to elaborate, qualify or challenge policy-makers' assumptions about how care co-ordination by means of MCPs would achieve the desired outcomes, and 2) how these findings can inform better care co-ordination. Conclusions: We describe the main empirical strengths and weaknesses in the assumptions underlying the models of care and care coordination which inform current NHS policy, and indicate where existing evidence is weak or lacking. Lessons learned: We discuss how we met the challenge of focusing the scope of a project that encompasses complex system-level issues across health and social care, and how far the findings and lessons might apply to other, differently-structured health systems. Limitations: Policy-makers assumptions were complex and incompletely articulated, making our findings depend, at points, upon our interpretation of what policy makers specifically intended. The complexity constrained us to focus our review on the policy makers’ most central assumptions. Future research: 1) Understanding how the logic models informed practice by evaluating the usefulness, and any future policy application, of our findings by policy makers in England. 2) Testing our findings empirically through primary research (Realist evaluation) of MCPs in practice.

Building workforce capacity and capability for integrated working

Introduction: Context – The NHS England (NHSE) Five Year Forward View (2015) aims to improve health, the quality of care and the predicted financial gap of 30 billion pounds by 2021. Strategic initiatives include prevention and self-care; enhancing primary care; efficiency measures; technology and innovation; workforce development; ‘local’, ‘joined up' services delivered ‘out of hospital’. In 2015, 29 ‘vanguard’ sites were chosen as part of the NHS New Care Models Programme to develop and test different, innovative, local models of integrated care. These models include ‘multispecialty community provider’, ‘enhanced health in care homes’, ‘acute care collaborations’,’ urgent and emergency care collaborations’ and ‘primary and acute care’ systems. The Sunderland ‘multispecialty community provider’ site is in the northeast of England (high deprivation). Risk stratification shows that 3% of the population account for 50% of the health/social care spend (frail elderly with 2 or more co-morbidities with high risk of hospital admission). Three models have been developed in Sunderland – Enhanced primary care; Community integrated teams (one in each of the 5 areas of the city); a Recovery at home service to facilitate early discharge and prevent re-admission. The problem – Workforce planning ‘across the system’ had not been addressed. Key issues - Historic recruitment challenges, workforce engagement, change management and governance. Practice change implemented: The University of Sunderland was commissioned to carry out action research to support the development of an integrated workforce strategy and planning process Aim and theory of change: Research questions: What are the skills, knowledge and behaviours which staff need to work in integrated care to deliver high quality effective care for patients? How can current workforce development and planning approaches be improved and delivered? Action research includes phases of action and evaluation, with findings fed back into the service developmental process. It is useful when there is little evidence of best practice, where new roles/services are being developed, or there is potential for tension across services. It can also support behavioural change. The research includes documentary analysis, semi-structured interviews and focus groups. Targeted population/stakeholders: System leaders, frontline health/social care staff, patients/carers Timeline: January 2016 - April 2017 (3 phases) Highlights: This final phase is focussing on the patient and carer perspective of the new workforce for integrated care. Early themes about skills required for integrated care are linked to developing 'teamness', managing increasing demand and need, and the challenges of developing holistic care (including psychological support) across the system. Workforce planning to address these challenges is still not evident within the integrated care system. The skills to support workforce planning are in short supply Sustainability: The outputs of the research are being built into the strategic. operational, and workforce planning processes to enable integrated workforce planning and development. Transferability: Research findings are fed back to the national NHS New Care Models workstream to share learning across vanguard sites and to develop the evidence base. Conclusions: Overall themes: The need to develop impact measures for new roles in integrated care to ensure there are no unintended consequences in the ‘system’ Governance and accountability across the system - setup a ‘system wide workforce group’ The need to develop an organisational development strategy to ensure staff engagement and leadership skills A plan for ‘upskilling’ staff The development of a dataset for the ‘system’ workforce To develop a compact to support the development of future workforce planning approaches The workforce group to commence modelling of the future workforce using evidence based tools provided by NHS England A system wide training needs analysis Workshops to be held with locality leads to support future workforce modelling To pilot ‘care co-ordination’ and to agree a local definition Lessons learned: Action research to support integrated workforce development and planning is an approach which can raise awareness of the challenges across a range of sectors

Using action research for workforce development and planning in integrated care

Introduction: Context – The NHS England (NHSE) Five Year Forward View (2015) aims to improve health, the quality of care and the predicted financial gap of 30 billion pounds by 2021. Strategic initiatives include prevention and self-care; enhancing primary care; efficiency measures; technology and innovation; workforce development; ‘local’, ‘joined up' services delivered ‘out of hospital’. In 2015, 29 ‘vanguard’ sites were chosen as part of the NHS New Care Models Programme to develop and test different, innovative, local models of integrated care. These models include ‘multispecialty community provider’, ‘enhanced health in care homes’, ‘acute care collaborations’,’ urgent and emergency care collaborations’ and ‘primary and acute care’ systems. The Sunderland ‘multispecialty community provider’ site is in the northeast of England (high deprivation). Risk stratification shows that 3% of the population account for 50% of the health/social care spend (frail elderly with 2 or more co-morbidities with high risk of hospital admission). Three models have been developed – Enhanced primary care; Community integrated teams (one in each of the 5 areas of the city); a Recovery at home service to facilitate early discharge and prevent re-admission. The problem – Workforce planning ‘across the system’ had not been addressed. Key issues - Historic recruitment challenges, workforce engagement, change management and governance. Practice change implemented: Action research to support the development of the workforce to deliver integrated care. Aim and theory of change: Research questions: What are the skills, knowledge and behaviours which staff need to work in integrated care to deliver high quality effective care for patients? How can current workforce development and planning approaches be improved and delivered? Action research includes phases of action and evaluation, with findings fed back into the service developmental process. It is useful when there is little evidence of best practice, where new roles/services are being developed, or there is potential for tension across services. It can also support behavioural change. The research includes documentary analysis, semi-structured interviews and focus groups. Targeted population/stakeholders: System leaders, frontline health/social care staff, patients/carers Timeline: January 2016 - April 2017 (3 phases) Highlights: Documentary analysis and scoping interviews with ‘system leaders’ in phase 1 elicited themes/challenges which have been translated into actions and are being implemented and evaluated (report Autumn 2016). Sustainability: The process/outputs will be evaluated as part of the final report Transferability: Findings are fed back to participants for validation and the New Care Models workstream to share learning and develop the evidence base. Conclusions: Phase 1 themes/challenges: • Day-to-day management • Team-working • The change process • Technology skills • Mental health skills • Patient/carer engagement and co-production • Clinical pathway development • Care co-ordination • Holistic care skills - prevention and self-care Discussion: Phase 1 results have provided a focus for the development of a workforce strategy for integrated care. Action research appears to support the engagement and development of the workforce – this will be tested further in phase 2/3. Lessons learned: To date: Building trust to share information/learning between partner organisations from the onset

Quality Expeditions for GP Federations

Introduction : The five-year forward view for the English NHS sets out an ambition to integrate care by decisively breaking down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support” (The NHS five-year forward view). One of the proposed model to do this would bring together GPs with nurses and other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care as the Multispecialty Community Provider. Across England many GP practices, presently small independent businesses have started to fall into groups or GP federations with an ambition to develop new care models. At present many of these organisations are emergent, have poorly defined infrastructure including the infrastructure to deliver quality at the scale of their ambition. We see this as an opportunity to embed quality as a core founding principle of these organisations. integrated care, person centred care and population level responsibility are hallmarks of these new models, we wish to help GP Federations develop Quality Strategies based on these aspects. Recognising that there is an is often a disconnection between evidence conducted on single disease populations with participation from a narrow band of the population to patients with multiple diseases and complicated integrating needs both health and social and mindful that research is often conducted within the dominant paradigm that health is an absence of disease; rather than an ability to cope with life challenges, contribute and feel content whilst also living with multiple conditions. We have developed an approach to allow emerging organisations to explore quality and to develop their own quality strategies and frameworks. Target Audience : Those in or supporting the emergence of integrated care models or with an interest in Quality in an integrated care context. Workshop Objectives : To explore with the delegates a participative approach to the development of Quality Strategies and how quality approaches should be developed in integrated care organisations. Much of our methodology of the delivery of the event has been adapted from the Hackathons methodology as it is applied to healthcare. During events teams are led through a series of sprints, each addressing a particular aspect of quality. We make available resources, and subject experts either in person or via IT links he wouldn’t be available to be engaged as the teams see that as part of their quality expedition. The structure provided by the sprints or help guide the teams to consider quality within the context of integrated new models of care, covering Planning – quality control and quality improvement & innovation (after Juran’s trilogy). During a workshop there would be opportunity to experience a sprint as well as discuss the learning points from our experience of applying the methodologies.

MCP, easy as 1, 2, 3

GP practices need to start thinking about how they will work with newly forming multispecialty community providers. Samir Dawlatly outlines their options

An evidence synthesis of the international knowledge base for new care models to inform and mobilise knowledge for multispecialty community providers (MCPs).

BackgroundNHS England’s Five Year Forward View (NHS England, Five Year Forward View, 2014) formally introduced a strategy for new models of care driven by simultaneous pressures to contain costs, improve care and deliver services closer to home through integrated models. This synthesis focuses on a multispecialty community provider (MCP) model. This new model of care seeks to overcome the limitations in current models of care, often based around single condition-focused pathways, in contrast to patient-focused delivery (Royal College of General Practitioners, The 2022 GP: compendium of evidence, 2012) which offers greater continuity of care in recognition of complex needs and multimorbidity.MethodsThe synthesis, an innovative combination of best fit framework synthesis and realist synthesis, will develop a “blueprint” which articulates how and why MCP models work, to inform design of future iterations of the MCP model. A systematic search will be conducted to identify research and practice-derived evidence to achieve a balance that captures the historical legacy of MCP models but focuses on contemporary evidence. Sources will include bibliographic databases including MEDLINE, PreMEDLINE, CINAHL, Embase, HMIC and Cochrane Library; and grey literature sources. The Best Fit synthesis methodology will be combined with a synthesis following realist principles which are particularly suited to exploring what works, when, for whom and in what circumstances.DiscussionThe aim of this synthesis is to provide decision makers in health and social care with a practical evidence base relating to the multispecialty community provider (MCP) model of care.Systematic review registrationPROSPERO CRD42016039552.Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0346-x) contains supplementary material, which is available to authorized users.

Co‐commissioning: the architecture of integration

Co‐commissioning: the architecture of integration

Congenital Abnormalities of Anus and Rectum: Mortality and Function

<h3>Objective</h3> To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP). <h3>Design</h3> Observational study. <h3>Patients &amp; setting</h3> Data collected prospectively on 3020 CYP 0–17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care. <h3>Measures</h3> Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations. <h3>Results</h3> Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education. Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS. <h3>Conclusions</h3> High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.