Better Care Together TNS BMRB research programme

Better Care TogetherTNS BMRB research programme Overview of better care together engagement – March 2013 to date May 2014

What is better care together? Better care, together is a review of local health services which is being carried out by local NHS organisations, led by: Lancashire North Clinical Commissioning Group Cumbria Clinical Commissioning Group University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the hospitals in Lancaster, Barrow and Kendal. The review is an opportunity to make sure the best possible health services are provided across North Lancashire and South Cumbria, which meet the needs of residents, now and well into the future. Health professionals in the area, including GPs, hospital doctors, voluntary organisations and other NHS and social care colleagues are considering how the different parts of the health service can work together more effectively to ensure individual patients get the most appropriate care.

IntroductionBetter care together is conducting a large-scale programme of public engagement to inform the new clinical strategy. The work to date has been a combination of engagement carried out by better care together and work commissioned externally. The purpose of the engagement to date is to act as a pre-consultation stage of engagement to inform plans to reconfigure health services across Morecambe Bay. Collecting public and stakeholder opinion on health services provided in the Morecambe Bay area and gathering information on their specific experiences and priorities for future service delivery. Engagement in Spring and Summer 2013 focused on opinion re: four work stream areas: maternity, paediatrics (children and young peoples services), planned and unplanned acute services. Engagement from Autumn 2013 to date focused on opinion on out of hospital services in terms of current provision and future provision following feedback from patient, public and stakeholders that better integration was needed between in and out of hospital services, and enthusiasm to discuss how out of hospital services could be improved Research is being undertaken in North Lancashire, South Lakeland and Barrow-in-Furness to reflect the spread of the population across the region served by NHS Cumbria Clinical Commissioning Group, Lancashire North Clinical Commissioning Group and the University Hospitals of Morecambe Bay NHS Foundation Trust. This presentation summarises the findings from the engagement research to date Approach

Better care together engagement to date Includes: TNS BMRB independent research company: four phases including a survey for staff, stakeholders and the public St Johns Hospice focus groups Age UK South Lakeland listening event Road show bus visits Cumbria Youth Alliance focus groups and questionnaires Manna House Centre for the homeless Field events in town centres MP and key stakeholder meetings e.g. OSC, Joint OSC, Health & Wellbeing boards, District Councils etc. UHMBFT Governor meetings and workshop Local Area Partnership Groups, discussion groups, partnership meetings, forums and associations Public Reference Group meetings Events e.g. Westmorland County Show Clinical engagement Staff engagement

Promoting the engagement opportunities The engagement opportunities to date were promoted via a number of channels including: • Street recruitment for TNS BMRB focus groups and discussion events • Press releases to local media re: activities • Newspaper advertorials re: bus roadshow • Radio interview re: bus roadshow • Website • Posters promoting the paper survey • A4 4 page leaflets distribution at the bus roadshow and at the public field events • Stakeholder briefings • Paper survey placed in public locations e.g. GP surgeries, pharmacies, libraries etc. • NHS staff communications • Word of mouth • Direct contact e.g. invitations, email and telephone Newspaper advertising e.g. re: Spring 2013 and 2014 events Ad-bike

Externally commissioned engagement

Results of the TNS BMRB 2013 Engagement Programme: Participant feedback

MethodologyIn Spring 2013 better care together commissioned TNS BMRB (an independent specialist in research) to carry out a research programme for Better Care Together. The programme involved four phases of engagement followed by analysis and reporting. Quantitative phase:surveys to access the opinions of a much larger number of respondents, to help identify on a larger scale which emerging issues had greatest significance. Public postal survey (targeted): Questionnaire posted to 10,000 randomly selected households Public open access survey: Questionnaires distributed (c.10,000) to locations such as GPs and pharmacies, questionnaires could also be requested by members of the general public Staff/ stakeholders: Web survey (invited) Approx. 3700 responses Deliberative phase: interactive workshop sessions with service users, to explore future service delivery options in depth 6 deliberative workshops with 20 service users in each Scoping phase: listening to internal stakeholders (with a geographical spread) to hear, first-hand, their views of the current state of play and ideas on what service changes might look like 16 interviews with senior or specialist staff/stakeholders 4 small groups of staff/stakeholders Create Include Qualitative exploratory phase: focus groups and one-to-one discussions exploring experiences of services, concerns, preferences and priorities for future service delivery 24 90-minute groups with service users and relatives 30 60-minute interviewswith people with negative experiences of health services 20 60-minute in-depth with a range of stakeholders Online community with 30 young people ‘Street interviewing’ with 33 members of the public Explore Listen

Geographical areas: summary of people, outlooks and attitudes (TNS BMRB 2013) Barrow in Furness Relatively well connected to other places by M6. Divided population – Morecambe, Carnforth etc feels separate from Lancaster. Generally look south to Lancashire rather than north to Cumbria. Expectation of access to ‘big city services’ in Lancaster (not always realised). Hard to access rather than isolated. Mixed population in terms of income, options and residency – some much more able to deal with access, and much more outward looking, than others. Accustomed to travelling to access healthcare services. South Lakes Geographically isolated – a ‘cul-de-sac’ (respondents’ phrase) in terms of location and outlook. Relatively deprived. Many long-term residents; many seldom travel beyond the local area. Easy access to, and ‘pride of ownership’ of, a DGH is a strong influence on views. North Lancs.

Better care together initially concentrated their efforts on four workstream areas: this is a summary of key views and priorities (TNS BMRB 2013) 4. Unscheduled Care 1. Maternity 2. Paediatrics 3. Planned Care Proximity the most important factor. Most content with, and see benefits of, the services they have accessed. Most see downsides to alternative service options. Parents prepared to travel further for expert care for their children than in other service areas, but less willing to travel for routine care. More sensitive to delays and quality of staff approach. Widespread contentment with medical care received locally (assumption that it will be at least adequate). Willing to travel for specialist care. Most issues regard communication and administration. Proximity and speed of first assessment is key. Alternatives to A&E are welcomed (where they exist, and as an idea) if they aid this, particularly for minor injuries.

Maternity services (TNS BMRB 2013)

Maternity services were rated positively on the whole(TNS BMRB 2013)The most important factors influencing a positive or negative experiencewere the availability and attitude of staff Those who had a comment about their experience said... SOURCE : General public survey

The importance of choice of place of birth (TNS BMRB 2013) 84%of targeted respondents (who were pregnant/had a pregnant partner) said it is important that they are able to decide in which hospital or location the child is delivered The Explore phase of research demonstrated this has little to do with the ‘identity’ of the child being born in a particular area, and much more to do with proximity to home and safety 70% of the people who answered ‘Don’t know’ were men %

General views on future changes to services (TNS BMRB 2013)Views of options around antenatal care and delivery were very strongly informed by experience of and access to current services, and beliefs about what is needed Preference for CLU, MLU or home birth Drivers: Services; Experience; Expectations Overall: Experience is less prominent than the other drivers: people reluctant to change what had worked in the past, tend to see benefits of the care they received and disadvantages of other options, even if their experience was less than ideal. Barrow and N Lancs: Expect and draw comfort from presence of consultants, despite negative experiences; see only risks to MLU, not potential benefits S Lakes: All three drivers align to create strong preferences for MLU; some reluctance to use CLU even if advised to do so Choice of place of birth and when this would change Drivers: Services; Relationships; Horizons; Expectations Overall: Proximity to home and perceptions of safety are key considerations: being close to family; minimising need to travel prior to delivery and risk of transfer during labour Barrow and N Lancs: hard to imagine going anywhere except FGH or RLI – close to home and expected to be able to handle complications S Lakes: preferred to deliver at Helme Chase, but accept assessments that identify risks and advise going elsewhere

Reactions to potential service configurations of co-located Consultant Led Units (CLU) and Midwife Led Units (MLU) vs stand-alone MLU (TNS BMRB 2013) Items for further consideration: For Kendal, a concern that a co-located MLU in Lancaster would encourage more risk-averse Kendal mothers to go there, eventually leading to Helme-Chase closure Kendal would prefer ‘MLU-plus’ at WGH, where midwives are trained to use forceps etc to avoid transfer for ‘minor interventions’ Barrow wondered about benefits of locating free-standing MLUs to ‘fill in the gaps’ between CLUs and service a greater breadth of areas. Ultimately ruled out due to practical issues (cost, new inexperienced services) and in favour of locating in areas of highest birth rate Why would co-locate CLUs and MLUs? Satisfies a fear of transfer felt in Barrow and Lancaster CLUs can be reserved for complex cases Provides ‘risk-free’ choice of MLU and CLU; may encourage more people to try MLU Additional free-standing MLUs not seen as practical (cost); unclear where the MLUs would go Why CLUs in Lancaster and Barrow? No-one loses existing services Highest birth rates Kendal do not want a co-located CLU (concern that it would ruin the MLU experience) Barrow think Lancaster too far to travel/transfer – bad road, traffic, unsafe Lancaster very resistant to travelling to Preston Preference: co-location of MLUs and CLUs in Barrow and Lancaster, keep MLU in Kendal

Paediatrics (TNS BMRB 2013)

Paediatric services generally rated positively (TNS BMRB 2013)Only a minority (one in ten)rated the services as poor or very poor, with poor experiences most often being attributed to long waiting times 74% 13% % Those who had a comment about their experience said... SOURCE : General public survey

General views on future changes to services (TNS BMRB 2013)Acceptability of alternatives to A&E and personal contact with health professionals depends on existing access to and confidence in these services Using the GP rather than A&E for urgent care Drivers: Services; Relationships; Capabilities; Experience Overall: Difficulties in getting appointments and lack of perceived ‘value’ from GPs were barriers in all areas. Mitigated for some who knew how to use the system. Ease of access to A&E was also a factor. Barrow: Scepticism about ability to get urgent appointments at GP and proximity of FGH made many feel it is ‘acceptable’ to bypass primary care and go straight to A&E. Positive experiences at FGH amplified this. S Lakes: Depends on short-notice availability of GPs, but also since Westmorland is limited and RLI A&E is distant many reluctant to waste time if need to go to RLI in the end (despite some negative experiences at A&E). N Lancs: Parents want to make their own assessment of whether A&E is necessary, and likely to err towards it given access to GPs. 111 service helps with this. Mixed experience of being referred to A&E has a strong influence. Specialist care and other services via video links etc Drivers: Services; Relationships; Experience Overall: Ensuring the child gets to know relevant professionals was a key consideration; provided this is covered, remote contact is appreciated. 111 service shows some that it can work. Most appropriate for primary and follow-up care. Least popular in Barrow and Lancaster, due to proximity of DGHs.

Reactions to potential service configurations of Enhanced Community Nursing (ECN) and Short Stay Paediatric Assessment Units (SSPAU) vs retaining current inpatient services (TNS BMRB 2013) Items for further consideration: Parents uncomfortable with taking responsibility for diagnosis decisions, therefore transportation for “in distress” or at-home care may provide reassurance: Enhanced Primary Care services could help meet a diagnosis need and may make SSPAU more appealing to service users Clarity that parents would not be responsible for transportation in case of transfer Provide reassurance of sufficient numbers of paediatric nurses & in-hospital training Families are eager to avoid A&E and its long-waiting times: SSPAU would be more appealing if it clearly helped avoid A&E (i.e. more direct access) A phoneline into the SSPAU also welcomed for advice Why keep inpatient service? Parents are loss and risk averse: strong emotional desire to retain access to inpatient paediatric care for all but the most serious cases nearby Concern about risks to child & parental responsibility during transfer SSPAU a positive addition but benefitsnot sufficiently clear to warrant loss of inpatient Community nursing support insufficient Why keep in Lancaster and Barrow? No-one loses existing services Both areas extremely opposedto loss of inpatient services; Kendal supports a case for service in Barrow in particular given isolation Preference: Co-location of SSPAUs alongside inpatient wards in Barrow and Lancaster, with enhanced 24h paediatric service in Kendal. Maintain status quo if this is not an option; closure of any inpatient service is strongly rejected.

Planned care (TNS BMRB 2013)

Those with a recent experience rated planned care more positively.Most important factors were waiting times, quality of care and communication (TNS BMRB 2013) 15% 71% % Those who had a comment about their experience said...

General views on future changes to services (TNS BMRB 2013)All prioritised efficient referrals to specialists, with explanations for decisions. Acceptability of local solutions for episodic care depends on the post-treatment care pathway. Local service delivery for chronic conditions is widely supported Desired improvements Overall: Speedier access to assessments and diagnoses (GP referrals). Consultants and GPs being more prepared to give explanations of all decisions. Continuity of staff, and making patients aware if continuity can be requested. N Lancs: residents called for better/ speedier access through GPs and management of discharge Barrow: residents wanted staff to show more ‘care’, to be clear on decisions and outcomes S Lakes: residents asked for more patient transport for appointments and better communication between GPs, Westmorland and other hospitals Solutions Episodic care: Acceptability of elective day surgery with earlier discharge depended on the condition and advice from specialists, and on improvements to care post-discharge, with a stronger link between specialist and local care (GP/ district nurse). There was interest in ‘intensive’ treatments to reduce total number of appointments – many prepared to travel further if this was possible. On-going care / chronic conditions: Interest in local solutions: mobile specialist clinics, strong support for ‘district nurse’ role (return to older models), greater use of pharmacies – already believed to be in place in some cases. Continuity of care prioritised in all three areas. Stakeholders: More can be done with planned care through teleconference in rural areas. N. Cumbria has had success with a stroke teleconference between 16 hospitals and consultants in north-west.

Reactions to potential service configurations: Ambulatory Care Centres (ACCs) and Day Case Surgery (DCS) vs retaining inpatient services (TNS BMRB 2013) Items for further consideration: Some debate about whether ACCs should be: numerous and based in the community because they will serve older populations on an ongoing basis fewer in number, and centrally located to serve a larger population density and become centres for excellence Lancaster would want to retain some emergency and inpatient paediatrics function even if they were losing complex inpatient services for adults Support contingent on provision of good access routes for ambulance and public transport All changes need to be backed up by increased care in the community Why reduce inpatients? Preference for streamlined day surgery that suits the majority of planned cases and more specialised care locally for long-term conditions Recognise need to save space for more serious cases; prefer not to be admitted if unnecessary Why inpatients in Barrow? All agree: Barrow most isolated and in need Lancaster happy to travel to Preston Kendal used to travelling and would gain services with this arrangement Why DCS in Kendal? Most central, becomes ‘planned’ centre Preference: Reduce inpatient function across the region as a whole, with complex inpatients remaining in Barrow, DCS in Kendal and ACCs in each location

Unscheduled care (TNS BMRB 2013)

Experience of unscheduled care generally positive though one in five rated it as poor or very poor Waiting time the most significant cause of negative experience (TNS BMRB 2013) 66% 17% % Those who had a comment about their experience said... % SOURCE : General public survey

General views on future changes to services (TNS BMRB 2013)Local clinics strongly supported for minor conditions; proximity of A&E a vital consideration if there is an urgent need for unscheduled care Overall: Nurses normally thought appropriate, given a strong preference for dealing with minor issues as locally as possible, across areas. Strong interest across areas in up-skilling local primary care staff, including pharmacists, and services to deal with more minor complaints. N LancsandBarrow: Positive experiences of community health units strengthens confidence in this in S Lakes: Minor injury units with longer opening hours suggested as a replacement for Westmorland Feeling unwell or minor accident Seriously unwell or major trauma Overall: A&E or specialist GP required for mid-level cases. All areas agree this would require much more responsive GPs to work successfully. Quick access to fully functioning A&E seen as vital in major cases. N LancsandBarrow: reluctant to consider alternatives to local A&E, but desire to reduce ‘bottlenecks’ by diverting minor injuries elsewhere S Lakes: Interest in more effective immediate diagnostic screening locally, where appropriate, followed by travel if necessary At risk or chronically ill (ongoing) N Lancs and Barrow: Specialist nurses already thought to play an effective role closer to home (e.g. diabetic specialist or ME specialist) – build on this. Desire for more ‘walk-in’ health centre facilities to support regular check-ups without requiring GP appointment. S Lakes: Success in preventative, community-based care would depend on strengthened relationships with GPs and greater availability/ travel from other healthcare staff. Stakeholders: Patients (especially elderly) need to be treated as whole person

Reactions to potential service configurations: Enhanced Primary Care (EPC) and Assess, Stabilise & Transfer (AST) vs retaining existing A&E function (TNS BMRB 2013) Why could it be in Kendal? Barrow would prefer any single A&E for the region to be based in Kendal: central location and more palatable as a transfer destination than Lancaster Items for further consideration: Preference would be to maintain existing services with new services as additions if financially feasible Reducing further than 1 A&E and 2 ASTs is not acceptable to most; minor injuries units not seen to be sufficient to provide coverage for region if A&E reduced Why would it be acceptable to have one A&E? Combination of EPC with AST gives confidence that AST will be sufficient for areas without A&E Recognition of need to change and that a centralised A&E service might improve quality Pre-existing acceptance that you can’t get everything locally – e.g. cardiac in Blackpool Why could it be in Lancaster? Regional hub and largest population – Lancaster averse to losing A&E, and others see argument for it being here Barrow able to recognise that they are least accessible for the region Kendal already go to and rely on Lancaster Uses existing service – avoids new building Preference: First preference is to maintain status quo, with addition of EPC, VW and AST to relieve pressure on A&Es. If necessary, most will accept an AST with transfer to full A&E in Lancaster or Kendal.

Conclusions: Attitudes to travel and transfer Attitudes to travel and transfer (TNS BMRB 2013)

People are currently travelling furthest for planned care, and travelling the least for maternity services (TNS BMRB 2013) Typical amount of time spent travelling to use the services by workstream Most people’s journeys are 30 minutes or under People whose closest hospital is Westmorland General Hospital typically travelled for longer (57% spent between 31 minutes and an hour) % SOURCE : General public survey

Quantitative results support these findings (TNS BMRB 2013)Respondents are least willing to travel further for maternity, and most willing to travel for planned care % Around two thirds said they wouldn’t be willing to travel further for maternity services - this is compared to only a third of people who said they wouldn’t be willing to spend more time travelling for planned care services. Respondents were willing to spend the most time travelling for planned care – around a fifth said they would travel over 45 minutes to see a specialist.

Around one in six (15-18%) are not using cars to access services(TNS BMRB 2013) Mode of transport used... 2% 82% 5% 3% - 82% 2% 4% 3% - 4% 1% 6% 6% 75% SOURCE : General public survey

This varied acceptance of travel is also reflected in the results of the criteria weighting exercise (TNS BMRB 2013) Geographic access clearly thought less important than staffing levels and patient experience and health outcomes, and similar to other criteria. Has the least resonance amongst Lancaster residents, and most among Barrow residents Weighting exercise results: mean for each area. Base: c.40 per area Weighting exercise results: mean across all three areas. Base: 106 respondents Note: the ‘geographical access’ criterion did not specifically ask people about their willingness to travel, although this is likely to have factored in to their understanding of this theme.

Views on acceptability of travel and service requirements can be summarised through an overview of results of the trade-off exercises, showing a minimum acceptable service levels in each area (TNS BMRB 2013) Maternity: all areas feel they need their current provision Paediatrics: Barrow and N Lancs accept SIMPLE inpatient paediatrics; Kendal will travel Unscheduled: all areas feel they need Enhanced Primary Care; Barrow will accept AST if A&E nearby; N Lancs insist on local A&E; Kendal accept current provision Planned: all areas need SIMPLE planned care; prepared to travel for COMPLEX (so undecided about location) SIMPLEPlanned Care SIMPLEUnscheduled Care SIMPLEMaternity COMPLEX Planned Care (location undecided) SIMPLE Paeds SIMPLE Paeds COMPLEX Maternity SIMPLE & COMPLEX Unscheduled Care SIMPLE Planned Care INTENSIVE Unscheduled Care SIMPLE Planned Care COMPLEX Maternity SIMPLE: perceived as routine, non-specialist care COMPLEX: perceived as more serious or requiring specialist care INTENSIVE: perceived as a ‘full service’ A&E Preston, Manchester etc

Integrated care

Stakeholders stressed the need for a more joined up approach (TNS BMRB 2013) “Everybody understands about general practice, and everybody understands something about hospitals. But all that panoply of services that covers the gap are ill-understood” “People get passed from pillar to post in the system, because there aren’t really the incentives for anyone to take control of them” GPs Community and third sector services need to be mapped GPs need to know about other support services and refer patients there – integrating health, social care and third sector, focusing on preventative care and early intervention Need immediate alternatives to hospital admission Change GPs’ and hospitals’ defensive ‘ours’ and ‘yours’ approach to patients, and work cohesively to serve the whole health economy Break down barriers between primary and secondary care – e.g. opening a GP surgery at Westmorland General; share patient records Hospitals need to support discharge into the community or home, particularly elderly Hospitals need to understand out-of-hours services; not use them as a decanter for A&E: important that people are routed to the appropriate service Community Care (incl. third sector) Hospitals “You need to build in that whole range of voluntary support into those pathways, we’re not integral we’re an add on for those who remember”

Weighting Criteria Exercise

Quant and qual approaches to the weighting criteria(TNS BMRB 2013) Although the methodology of the weighting exercises differed in Include and Create, the results supported each other The criteria used in the quantitative survey used the same titles and short descriptions as were used amongst clinicians – no additional information was provided Respondents were asked to rank the 8 criteria in order of importance In the Create workshops, edited descriptions were used to make the weighting criteria simpler and were discussed to check understanding Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign The weightings given were then discussed as a group to allow respondents to explain their choices 100

The eight factors presented in the quantitative survey – INCLUDE (to be ranked in order of importance) Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign (TNS BMRB 2013)

How criteria were presented in qualitative workshopsWhich things are most important to consider when deciding on future services? You have 100 points to distribute between the 8 themes below – give more points to the areas you think are most important, and fewer to those you think are less important. Make sure the total adds up to 100!

How participants engaged with the themesThe following four criteria were closest to the patient experience, and most salient (TNS BMRB 2013)

How participants engaged with the themes These four criteria were seen as more distant; decisions would be “out of our hands” (TNS BMRB 2013)

Criteria which relate most closely to patient experiences scored highest overall in the workshops (TNS BMRB 2013) Proportion of points attributed to each theme SOURCE: Weighting exercise results: mean across all three areas. Base: 106 respondents

Differences between areas to some extent reflect current concerns with local services (TNS BMRB 2013) Staffing levels - “having the right numbers of staff with the right skills in place to deliver the service”. Kendal rated this is most important, linked to perception that staff at WGH inexperienced Patient experience and health outcomes - “overall experience for a patient”. Better experiences reported in RLI in terms of patient care, nursing, and feeling looked after, compared to Barrow and Kendal Geographic access – “location of services, ease of travel to them, transport infrastructure”. Lancaster has best access, and places less weight on this criterion than Kendal or Barrow Weighting exercise results: Base: 106 respondents

Age UK South Lakeland engagement listening event May 2013: key themes Communication skills: an area for improvement e.g. staff communication skills, “you should not be grilled for an appointment” and NHS-NHS organisations Communications systems were also seen as an area for improvement such as IT e.g. “Booking system – a four-page letter, which included a password, to change an appointment either by phone or computer” Travel: people are used to travelling for highly specialised care, there is still a need for some services to be local e.g. “…now takes three buses to get to Westmorland General Hospital; from Grange” Patient experience: examples of positive experience e.g. “Furness General Hospital nursing team – nurses very understanding, talk to us in language we understand and share information”, and examples of poor experiences including poor care, “Delay led to collapse and emergency admission” Staffing levels are an area of concern i.e. are there enough staff in primary and secondary care? Potential change is acceptable, people are familiar with change in the NHS but would like to see positive change sooner rather than later so people can benefit from change: older people need good care today, not at some point in the future Care pathways are an area for improvement, with particular regard to transport, discharge and integration arrangements e.g. “Health/Social Care – passing between the two don’t work well together”. Good care pathways are important to ensure independence of older people (Commissioned by better care together, carried out by Age UK South Lakeland with support from better care together)

Key themes to emerge from the Cumbria Youth Alliance engagement activities April - May2013 were: 1. A good awareness of the availability of health services 2. Access of health services could be a problematic issue for young people e.g. making appointments, delayed appointments, waiting times e.g. “Waiting times too long” 3. Young people understand they have a responsibility for looking after their own health 4. Patient experience with GPs is of a higher standard than experiences with A&E e.g. “They fixed me, good service, helpful” 5. Willingness to travel is affected by ability to travel e.g. reliance on public transport 6. Different communication skills are needed to work with young people (Commissioned by better care together, carried out by Cumbria Youth Alliance via focus groups, discussion groups and surveys)

better care together engagement
March 2013 to date

Non-externally commissioned engagement There was a range of engagement activities which were arranged and facilitated by better care together. In addition better care together were invited to attend several events, meetings and discussion groups to discuss and engage on its programme The following section provides a summary of this engagement

Key themes to emerge from the Information Bus Roadshow engagement activities in March – April 2013 were: Travel: Whilst not keen on travelling for the sake of it, most who commented on this issue were willing to travel if that meant that they would receive the best care. Travel was particularly an issue for those who didn’t have their own transport. Staffing: Staff on wards seen as not having the capacity to give a level of care that’s needed. Suggestions made re: more vocational training and hands on approach from junior staff, plus the need to “bring back matrons”. Access: comments were made re: out of hours GP access, the amount of time that some people had to wait to see their GP of choice and a sometimes lack of empathy from GP reception staff. Feedback was given re: the need to keep some services local Care pathways and lack of integration was an issue referred to e.g. “Have been to Royal Lancaster Infirmary, nurses good, but consultants change so start all over again. Went to Westmorland General Hospital, they didn’t give me the results. GP couldn’t give me the results so need to go back to Westmorland General Hospital.” Clinical risk concerns: fear that loosing services could put lives at risk

The main themes to emerge from the Public Field Events held in May 2013 were: 1. Access: this can be problematic e.g. accessing appointments with preferred GPs and accessing appointments with GPs evenings and weekends. There was also confusion re: role of PCAS in Kendal 2. Communication: an area for improvement e.g. staff communication skills and NHS-NHS organisations. NHS internal systems were also areas for improvements e.g. patient notes transfer and appointments 3. Care pathways: these can cause confusion and see a lack of integration e.g. between NHS organisations and NHS partners such as social services 4. Willingness to/travel: people are used to travelling for highly specialised care, there is still a need for some services to be local 5. Clinical risk concerns: there are perceived risk areas e.g. travel when poorly, worries of hospital infections and cleanliness standards 6. Staffing levels are an area of concern i.e. are there enough staff in primary and secondary care and were staff roles hampered by paperwork? There were also queries re: numbers of back office staff and numbers of managers

The main themes from the focus group with persons with life limiting conditions May 2013 were: Patient experience of primary care, secondary care and community care all include positive and negative examples: Access to GP appointments can be a struggle, LTC team very helpful, out of hours service can be a long wait and engenders feelings of isolation Secondary care experiences are poor on the ward, medication delays and too many patients Community staff are seen as “come to do” but concerns of “lots of different people” and poor documentation systems Staffing comments range from “nurses are excellent” to lack of continuity in handover and a need for more frontline staff and mental health teams Willingness to/travel: people are used to travelling for highly specialised care, there is still a need for some services to be local. Volunteer drivers can be popular compared to ambulance drivers

The main themes to emerge for the Manna House (Kendal) discussion group May 2013 were: 1. Customer care skills were seen as an area for improvement in dealing with vulnerable people e.g. poor attitude from some staff , “feeling that I`m not worth bothering about” Out of hours services were seen as insufficient i.e. evenings and weekends where people were often signposted or taken to Barrow or Lancaster A lack of integration between NHS Acute and Mental Health e.g. “…told me “I will call your social worker tomorrow” so I called my GP who called the crisis team. The crisis team worker said to me “Why are you ringing the GP?” The police riot team arrived and sat there, I was taken to Barrow to be told there was nothing they could do for me and was taxi`d back to Kendal”

Out of hospital care engagement – Autumn 2013 Much of the feedback from the Spring 2013 engagement received from patient, public, stakeholders and clinicians referred to primary care and planned care Out of hospital care services can be an effective alternative to hospital treatment for some patient groups e.g. elderly and patients with long-term conditions such as COPD Some patients report high satisfaction with community-based minor surgery due to ease of access, shorter travelling times and reduced waiting times Some people prefer an early discharge from hospital into community-based care settings People want health care to be more integrated (joined up) with other health and social care partners People wanted to give further feedback on out of hospital services Therefore engagement from Autumn 2013 onwards included out of hospital care in addition to in-hospital care

The main themes to emerge from the Patient and Public Reference and Discussion Groups throughout 2013 and 2014 were: 1. Care pathways: stressed the importance of a good discharge and follow up into the community. Suggestion that this could be improved with improved IT. 2. Access to health and social care: concerns that it will this be adversely affected by the reduction in council care funding e.g. “…don’t transfer NHS budget to social care budget” 3. Staffing: the need to publicise meaningful staff-to-patient ratios and the need to invest in community nurse training to deal with current and future demand 4. Clinical risk: concerns re: the impact of the changes in vascular services on the local population, specialist shortages and weekend mortality statistics Transparency needed re: changes and terminology under the Health & Social Care Act: concerns re: conflicts of interests, quotas and additional layers needed under the Health & Social Care Act Access: difficulty accessing appointments with named/preferred GPs. Suggestion that this could be improved with improved IT. The role of PCAS in Westmorland General Hospital can cause confusion in terms of what it does and doesn’t provide Integration of care pathways: difficulty understanding the boundaries between health and social care e.g. what to access from where. NHS needs to work with planning personnel re: suitable housing for the elderly in the area. Also lack of clarity re: follow up when you leave hospital after surgery. Patient experience: good experiences with primary care staff e.g. nurse practioners and the importance of treating the patient not just the condition Travel: Tendency to travel to nearest place: this may be Lancaster or Kendal. Staffing: concerns re: over reliance on bank nurses with accompanying lack of continuity Culture: is it reasonable to expect the NHS to pay for certain procedures? Do not like but understand the rationale for centralisation. A sense of pride in the NHS

The main themes to emerge from the South Lakeland District Council Local Area Partnership meetings in Autumn 2013 were: Access: comments re: priority of access to A&E services and difficulties in seeing a named/preferred GP. Comments were also made re: lack of access to out of hours services e.g. weekend and evening treatment. Concerns were raised re: NWAS response times in the South Lakes area. There was interest in the October 2013 publicity re: 7 day a week GP access pilot schemes. Rurality: concerns re: loss of GP services in low-populated rural areas and a knock-on effect as patients transfer/visit other GP practices which can increase access issues. These rural areas often see high tourist numbers at certain times of the year which can exacerbate this issue. The importance of care closer to home was understood but systems needed to be there to allow for this e.g. in some rural areas it is difficult to recruit home care staff. Communication: the possibility of remote healthcare was discussed as both an opportunity and as a “first-step” only. Better communication of the different services available e.g. via the third sector could be better publicised. Poor communication comments included the subjects of appointment bookings, late or no discharge letters, poor record reconciliation and late issue of take home medicines 4. Clinical risk: there were concerns re: NWAS response times in the South Lakes area 5. Care pathways: comments re: it being complicated and time-intense to deal with the NHS as is it doesn’t feel joined up e.g. hospital to hospital administration. In addition to this there ere comments re: lack of integration with Local Authority Services 6. Staffing: feedback re the need to be mindful of staff morale and the impact of covering for staff sickness Future change: the need for transparency when discussing recent and possible future changes in the NHS and any options in a consultation. Willingness to/travel: feedback discussed an understanding of the need to travel to centres of excellence coupled with a desire for some services to remain local as travelling for services can be difficult and travel can also be challenging due to changes in the voluntary driver system. Travel can also be adversely affected by poor roads in some South Lakes locations. Preventative healthcare: important e.g. for example young people’s health, working with public health at Cumbria county Council, and issues such as obesity etc. Culture: the culture of what is expected from the NHS from the NHS has changed over the years with expectations increasing Facilities: a number of GP practices were considered to have poor facilities and urban solutions e.g. large health clinics may not be suitable for rural locations.

Spring 2014 Engagement: An introduction During March, better care together organised multiple engagement events to capture the views and opinions of staff; members of the public and partners including 3rd sector organisations on out of hospital services Better care together organised 5 drop in events for staff at each of our three hospital sites, and at Ryelands House and Moor Lane Mills for our community based staff to give them an update and let them know about our forthcoming engagement activity. We held 12 public ‘drop-in’ style events across different localities within Morecambe Bay which were advertised via full page newspaper adverts, our networks and via the use of an “ad-bike”. Attendees were invited to complete a number of activities to give us feedback, however this was completely voluntary. Some people simply wanted more information and the opportunity to speak with clinicians. There were also opportunities to complete comment cards; to take the activities away and complete at home; to complete the activities online; and to participate in a Q&A session. Numbers of attendees were modest, but the events were well represented by clinicians, better care together team members and external support team members. We also held three stakeholder workshops in Lancaster, Barrow and Kendal which were facilitated by TNS BMRB- the same independent market research organisation that had conducted the in – hospital work. Personalised invitations were sent out to a range of organisations within the three localities. All participants were asked for their views on the different scenarios/elements of the emerging out of hospital model and the design principles which had emerged from each of the Clinical Commissioning Group out of hospital workstreams. There were over 250 attendees across all the events and these included Council and OSC representatives ; local media; 3rd sector representatives; members of public; and a broad spectrum of colleagues. A Clinical Summit was held for 180 clinicians, this number also includes representatives from third sector organisations and members of the public Feedback is still being received and we will ensure this gets factored into our final reports, but overleaf we have provided the results of our engagement as of 1 May. This is part of our on-going programme of engagement and further events will be arranged to ensure we share the outputs with the public and partners.

Results of the TNS BMRB Spring 2014 Engagement Programme: Participant feedback

Response to principles Feedback re: Out of Hospital Scenarios for future provision conducted by TNS BMRB Spring 2014 Five scenarios for future out of hospital care were presented and discussed as follows

Examples used

Vision for future joined up “out of hospital” services Joined up service scenario no. 1 Integrated (joined up) Core Team This service could see a team working together in an out of hospital setting. This could be a multi skilled team e.g. GPs, social care, district and mental health nurses working together. Their role is to try and identify vulnerable people to give them a care plan. This way if you are vulnerable they can work to keep you well and prevent urgent care where possible. How could this work for Mary? Mary is struggling at home and needs support to stay independent. Mary would be assessed by one person in the integrated core team, (Mary can contact the team via her GP surgery) who would work with other colleagues e.g. a voluntary organisation and social care worker to put together a package of care for Mary. This means Mary no longer has to ring different people in different health and care organisations: it is done for her. Strongly agree Strongly disagree

Joined up service scenario no. 1:Concept has unanimous, strong appeal; difficult to disagree with this scenario in principle Benefits Proactive approach to ensure holistic care for vulnerable people Appropriate response to shortcomings of the current complicated system Patient-centric approach welcome; potential benefits to users readily acknowledged Drawbacks Few conceptual drawbacks Concerns at lack of explicit mention of 3rd sector in the core concept Similar concerns regarding social care and housing Does not address non-vulnerable audiences Who would it work for? Could work for all vulnerable people if executed effectively Especially strong for those with multiple requirements Important to focus on the very vulnerable (e.g. those with dementia, mental health issues) and those with very specific needs –physical disabilities, hearing impaired / deaf, blind

Joined up service scenario no. 1:Concerns around practicalities and delivery tend to overshadow conceptual appeal (TNS BMRB 2013) Resourcing Assumed to require an increase in staff: how feasible given current state-of-play? Concerns around changing roles and additional burdens on already stretched staff Need for re-training; scepticism around whether or not this would be available Difficult to see cost savings in this approach generally Audience and involvement Who is responsible for defining ‘vulnerable’; what criteria are used Sensitivity required around blanket use of ‘vulnerable’: some might be unhappy about being labelled as such, or might not identify with this term How will those who do not currently engage with the system be reached – role for 3rd sector here Care plan and team composition should take patient’s views on board (text currently hints at a generic approach) Team considerations Notable absence of 3rd sector in core concept – how and when (in the patient journey) will this come about What will determine who leads the team for each patient – having a named lead often felt important to success How will collaboration across organisations / team members work in practice – starting points vary greatly Communication and coordination: little info on how this would work in reality – co-located/virtual?

Vision for future joined up “out of hospital” services Joined up service scenario no. 2 Urgent Care Co-ordination Centre This service could see a change in the way you access NHS services and the way health professionals contact each other. This service could see a team, under one telephone number, as a main point of contact who will make the right appointment for you, with the right health professional e.g. a GP or District Nurse. This team will help triage (assess) you, just like a triage at an A&E or GP surgery. This will help prevent you going to A&E if you don’t need to: you will still call 999 if it is an emergency. It will also put health professionals in contact with other colleagues across health, social and voluntary care. How could this work for Mary? Mary sometimes struggles to know who to call when she feels ill and today she feels very poorly. Now she just has one number to call and the centre will make an urgent appointment for her with a GP in her local area. Mary can now call a single number rather than several numbers and where possible avoid going to A&E. Strongly agree Strongly disagree

Joined up service scenario no. 2: Concept is confusing and has negative associations with call-centre services: valued only when seen as a gateway to an integrated care team (TNS BMRB 2013) Drawbacks Potentially unnecessary ‘extra layer’ between patient and services Relies on patient to have knowledge/understanding of their own difficulties and ability to communicate these Benefits Once understood, a single access point potentially of value Especially useful if functions as an out-of-hours service Who would it work for? Single number to call could be useful for the elderly But elderly would also have concerns about call-centre triage process Strong concerns about accessibility for deaf people – need for a text service or similar Could be useful for those who are not sufficiently ill for A&E but can’t get to GP or want to check if GP appointment necessary

Joined up service scenario no. 2: Concerns with the concept are reinforced by experience and uncertainty about what it would offer (TNS BMRB 2013) Ineffective ‘triage process’ Negative experiences and perceptions of NHS Direct (especially given its closure) suggest triage and advice will be inefficient / ineffective Call centres seen to be manned by unskilled staff, working through questionnaires to diagnose Lengthy triage process would be off-putting, and a barrier to engagement especially for the elderly and those with dementia or learning difficulties Insufficiently ‘local’ Project assumed to be aimed at a national or regional level, and thus unable to give tailored, local advice Perceived value increases if understood as a local service, with access to a team with comprehensive local expertise But an ambitious approach such as this would require much set-up and piloting Not responsive enough Unclear whether this is intended for vulnerable audiences specifically, or everyone? How will the service distinguish between ‘urgent’ and ‘emergency’ calls? Concerns that this would not provide an attractive enough alternative to presenting at A&E, where this is in-grained (e.g. Barrow)

Vision for future joined up “out of hospital” services Joined up service scenario no. 3 Integrated (joined up) Rapid Response Team This service could see you being treated by a specialist multi disciplinary team of skilled health and social care professionals whose role is to get you home safely. In many instances this team will help you to get home as soon as possible, with the right support, often within 48 hours. This sees a team of health professionals putting together the right package of care for you. How could this work for Mary? Mary has had a fall at home and has been taken to A&E. Rather than spending longer than necessary in hospital she will be seen by this specialist team who work jointly across health and social care. They can arrange for Mary to have personal care at home, such as helping to arrange transport home, meals delivered, physiotherapy and support from a falls prevention . co-ordinator. Strongly agree Strongly disagree

Joined up service scenario no. 3Concept of re-establishing people in their home is accepted, but only if support system genuinely works (TNS BMRB 2013) Drawbacks Concerns that scenario would be driven by a desire to ‘clear beds’ and meet hospital targets, not patient needs Lack of explicit role for 3rd sector and local authorities (esp re social care and housing) Benefits Belief that care at home can aid the recovery process Could free up hospital beds for those who really need them Multi-discipline team to ensure that many illnesses will be covered Who would it work for? Works best for the able-bodied/minded keen to return home Also those with unofficial carers (e.g. family members) for whom hospital visits are difficult Less appropriate for those who might struggle emotionally at home, including those who are living alone (especially the elderly and those with dementia)

Joined up service scenario no. 3Concerns around delivery centre on communication, resourcing and the impact of ‘time targets’ (TNS BMRB 2013) Team considerations Again, absence of 3rd sector in core concept – how and when (in the patient journey) will this come about Success / failure will depend on efficient co-ordination of numerous services – who takes responsibility for this? Co-ordination of services will require alignment of opening/working hours – how will those currently inactive at weekends and evenings adapt to 24/7? Resourcing Assumed to be costly alongside existing programs– how will this be funded? Easier to imagine possible savings when linked explicitly to financial benefits of ‘freeing up beds’ But overemphasis on ‘clearing beds’ risks being seen as a cost-cutting measure at expense of patients Timescale concerns Description fuelled some concerns around ‘fast bed clearing’ being core to the concept Others concerned that “the right support, often within 48 hours” suggested a 48 hour wait at home before support received. Concerns that the scenario reduces the role for patient choice: what if a patient wants to stay in hospital? Who judges when a patient is ready to return home?

Vision for future joined up “out of hospital” services Joined up service scenario no. 4 Potential community specialist services This service could see the movement of some specialist services e.g. diabetes, respiratory care and pain management into an out of hospital setting e.g. a weekly clinic held in a health clinic or GP surgery, where you would be seen by specialist health professionals. This would expand on the community services already available. How could this work for Mary? Mary has diabetes: a long term condition. This means she regularly has to go to hospital to see different people for six monthly checks. Mary now has a care plan so knows how to manage her condition if she feels ill in-between checks and a community based person to call if she feels her condition is getting worse. This means as well as out-patient appointments she has the benefit of specialist community services to prevent her diabetes escalating. Strongly agree Strongly disagree

Joined up service scenario no. 4:Appeal of this concept varied between locations, depending on current access to local hospitals (TNS BMRB 2013) Drawbacks Concept would involve a significant cultural shift for HPs and the public – important that this is not underestimated Potential stress / challenges for HPs travelling into communities (especially where there are local geographic challenges) Some anticipate challenges in convincing HPs with in-grained working patterns to change Benefits Most appreciated attempt to ‘bring services to people’ / facilitate access Particularly relevant in Kendal, more rural parts of Lancashire, and Barrow Who would it work for? Best for those in rural areas Also helpful for the elderly, those with mobility problems and those on lower incomes who might struggle with travel costs However, risk of groups with specialist needs (e.g. deaf patients requiring interpreters) being shut out Also risk of people being reluctant to accept new services without sufficient guarantees of quality

Joined up service scenario no. 4:Numerous queries about efficiency and quality challenge confidence in the scenario’s overall viability Cost/time effectiveness How many people would have to attend each local clinic to render specialist visits financially viable? How often would these services run to remain cost effective? Weekly? Less frequently? Does travel time mean specialists might end up seeing fewer patients overall? Guarantee of quality service Need for reassurance that service will not be ‘second-best’ if services are run by practice nurses rather than consultants Specialists who do travel into the community might not be those best placed to treat patients – just those most willing to travel

Vision for future joined up “out of hospital” services Joined up service scenario no. 5 Accessing services: Referral Support Service This service could see a new referral system from one health professional to another health professional. This means you would benefit from an agreed referral system across your area so that you receive consistent advice, guidance, and referrals whoever you see when being treated out of hospital. This system helps staff to help improve your patient journey through NHS services. How could this work for Mary? Mary has had knee pain for some time but doesn’t want to go through the current process of seeing her GP, then seeing a consultant and then seeing a physiotherapist. Now, under the new referral system, using established referral protocols which determine the best health professional, Mary is referred by her GP straight to the physiotherapist. In this instance it takes one step out of the patient journey meaning she has less travel, and can be seen quicker. No Yes

Joined up service scenario no. 5Concept was widely misunderstood – and those who did understand it failed to see relevance to public (TNS BMRB 2013) Drawbacks Concerns about placing too much onus on GPs to diagnose correctly Worries about ‘one-size-fits-all’ referrals following loss of consultant expertise Benefits Potentially could generate cost savings (but this does not appeal if seen as simply ‘cost-cutting’) Streamlining might prove beneficial for patients (but no strong complaints about the current system) Who would it work for? Issue of inconsistent referral rarely recognised, and not seen as a problem for the public Assumption that this would be more of a benefit for management than patients

Joined up service scenario no. 5:Poor or limited understanding about how the system would work in practice raised further concerns (TNS BMRB 2013) Pressure on GPs GPs might lack sufficient knowledge to make referrals and feel pressured If GP diagnosis is incorrect, this could result in delay in treatment for patient Questions about process Some unsure who makes the referral – e.g. could the physio recommend a consultant? Unsure about the current referrals process and how this differs Concerns (once proposal understood) that it would encourage generic form-filling rather than a tailored patient assessment.

Overall response to most of the out of hospital scenarios and principles was ‘good words, but can we deliver this?’ (TNS BMRB 2013) Most principles and concepts behind some scenarios are appealing and hard to argue against in principle But general scepticism and some strong concerns around delivery, given views of what might be required and how this matches up to the current situation and previous experience Many tangible factorswere felt to be problematic or unaccounted for in the scenario/principle descriptions: Funding Fail to see cost savings Assume additional funding, training, resources etc. will be needed Where will the additional money come from? Collaboration Experience suggests organisations working together will be difficult Absence of 3rd sector suggests approach will not be holistic or collaborative Two CCGs often felt to operate independently Compatibility Clinical vs financial sustainability Desire to attract / retain staff vs proposed changes in working practices Information Technology Scepticism around ability of ‘sophisticated’ systems as tools for effective collaboration, etc.

Some concerns were also raised by the way in which scenarios and principles were presented (TNS BMRB 2013) In addition to strategic-level considerations, the description of many scenarios / principles (wording, level of detail etc) often led to queries or negative reactions: Apparent absence of 3rd sector disappointedmany: often first point of entry for vulnerable, but seen as ‘mopping up’ patients that would otherwise be missed; reassurance needed that they will be crucial part of team, identifying vulnerable people and being involved in their care plan Important to bear these points in mind when thinking about how to communicate more widely about these scenarios and principles Linkage Important to make link between scenario 1 and the others clear – absence of this link risks devaluing other scenarios Target audience Switching between explicit mention of ‘vulnerable’ for some principles/ scenarios and broader audiences for others is confusing Example Using the same character (‘Mary’) in all scenarios was confusing when the focus of each scenario differed Lip service Easy references to benefits such as ‘equal access’ seen as vacuous given cultural, geographic and demographic challenges

Response to principles Results of the Patient and Public Spring 2014 Engagement Programme conducted by better care together: Participant feedback

Examples used

Results of Scenarios Survey * *Please note the lower the score, the better the approval rating (range 50-300) Overall the model was well received in principle Themes emerging from each element / scenario are included overleaf

Themes: Core Integrated Team - Scenario one Queried who is accountable / responsible for co-ordination Comment regarding centralising the team in one medical practice. Generally seen positively as long as it was well funded. Seen as a good idea, in particularly to vulnerable people. Concern about how ‘vulnerable’ criteria are assessed. Some patients would not want to be labelled as such. Concern that this is a ‘one size fits all’ approach, need reassurance that this is flexible and patient centred. “I strongly agree but who pays for voluntary organisation, as they need funding too.” “Someone needed to co-ordinate (specialist co-ordinator) with medical knowledge.” “Good idea - so long as well resourced”

Themes: Urgent Care Co-ordination Centre- Scenario one The responder needs to be competent to make decision, single number needs to be prominent. Seen as a call centre (compared to 111) and concerned over waiting times on calls. Compared to NHS Direct. Would require extensive local knowledge of services available. No deaf provision. Seen as aimed at the ‘non-vulnerable’, an alternative to the core team. “A very good idea. Just 1 phone number to call & people wouldn’t be going to A+E, when they didn't need to.” “But they would have to be trained and have a great understanding of mental health and third sector providers.” “Too many potentials for break in communication”

Themes: Integrated Rapid Response Team - Scenario three As long as the support is accessible and deliverable Comment that this already happens in some areas. Good idea as long as team is well established and works together. Comments about including social care within the term health professional. Some concern this could be seen as ‘bed clearing’ 48 hour response can also be seen as a target to get patients out of hospital before they are ready. Do patients have a choice? “Again a good sensible idea. But experience shows that adequate funding is critical, to avoid vulnerable people being simply forced out of hospital and left at “ “Good idea. you can get the help you need & also be in your own home.” “As long as the support is deliverable”

Themes: Potential Community Specialist services - Scenario four As long as the venue is accessible to the public (geographically) Concern about inconsistencies in available services in varied geographical area. Seen to encourage self care and prevention. Concern regarding the cost effectiveness of specialists travelling to communities, how often would ‘clinics’ be held to be cost effective and still provide a good service? Patients may need reassurance that they are receiving the best care if they are switched from seeing a consultant in hospital to another health professional in the community Will specialists want to travel? Need to change working patterns. “Good idea most GP surgeries are closer to where people live & good to know you can call somewhere if you need any help” “Clinics are a great model to fix overstaffing of hospitals, if you have the budget to see that the clinics are properly staffed!” “As long as treatment venue is easily accessible to public”

Themes Referral Support Service – Scenario five Concern over whether GPs will know in every case whether to refer to consultant or specialist. Seen as a ‘back-office’ change and not really necessary for the public to know. Commonly seen as more efficient Need to have built in follow-up process Would require co-operation between service providers “Great idea. Much more efficient and helpful procedure for patient.” “Would a GP have sufficient specialist knowledge to properly assess the clinical options?” “Saves alot of time. This would take a lot of consistent organisation but yes.”

Response to principles Results of the Patient and Public Spring 2014 Engagement Programme conducted by better care together: Participant feedback Respondents were asked to assign each of the 8 criteria points, with a total of 100 to assign

Engagement Activity: “My Priorities” Participants at public events were asked to prioritise the following aspects of future service provision using the form below:

My Priorities - Overall POINTS A total of 71 participants took part

Trends from My Priorities The single highest scored priority with over 25% of total ‘points’ allocated is Safe Services – this is consistent throughout 5 out of the 6 individual localities* Patient Health Outcomes appeared as a 2nd priority in 4 of the 6 localities Continuity of care ranked 3rd overall. This varied significantly depending on the locality: In Lancaster and Morecambe this was consistent; In Ulverston and Barrow this was ranked 1st and 2nd respectively; In Millom this was ranked 5th; and in Kendal this was ranked 8th. Travelling for Specialist Care generally ranked low, this was particularly evident in Lancaster and Morecambe, whilst being more welcome in Millom and Kendal (*Ulverston attendees scored Continuity of care marginally higher; Safe Services took 2nd place)

Response to principles Feedback re: draft CCG vision statements conducted by TNS BMRB

Draft clinical CCG commissioning statements TNS BMRB worked with stakeholders to discuss a draft vision statement re: commissioning from: Cumbria CCG with stakeholder groups in Furness and the South Lakes Lancashire north CCG with a stakeholder group in North Lancashire

Statement and principles were generally well received, but with numerous questions about detail and delivery (TNS BMRB 2013) Taken at face value, the S Cumbria Vision Statement and principles for S Cumbria and N Lancs described what most would like to see As such, many found much of what was proposed hard to argue against in principle In the context of this general positivity, discussion generally revolved around queries and concerns focussing on: Agenda Is this really about cost reduction, patient outcomes, a combination of the two? How are key terms (e.g. ‘equal access’) defined? Delivery What level of commitment is there to delivering these reforms? To what extent will these reforms take the views/wishes of patients into account? Management Who is responsible for defining, measuring, assessing leading, deciding etc? Which organisations are involved (absence of 3rd sector noted)? Can orgs with differing cultures etc coordinate and collaborate? Challenges Availability of additional funding to ‘pump prime’ the reforms and/or run new services alongside existing ones Geographic, demographic and cultural issues

Views around detail and delivery were influenced by a number of different factors (TNS BMRB 2013) Location Those in Barrow tended to be more conscious of challenges to delivering out of hospital services, in terms of shifting public attitudes and what HPs are prepared to do. Presentation The wording of the S. Cumbria Statement was generally more effective than the N Lancs principles – either ‘softer’ or with less distracting detail – leading to fewer queries and concerns. Knowledge Participants with greater knowledge of how health services work were able to read more into the descriptions, make more assumptions and so had fewer queries or points of confusion. Remit Those representing specific populations (elderly, disabled etc) or services outside core health services (e.g. local authorities) were quicker to note the need to include them explicitly. Views of each Statement bullet or Principle varied most obviously by: Queries and confusions often regarded fairly fundamental aspects of Principles – e.g. whether clinical and financial sustainability are compatible goals Reveals a lack of detailed understanding of the points involved (and in some cases cynicism about driving agendas, hence fixation on cost-cutting)

Reactions to Statements/Principles 1-4 (TNS BMRB 2013) “Our services are of good quality that delivers safety, equity and continuous improvement in outcomes” Feedback: In theory, this principle was difficult to argue against and universally appealing. In practice, an overly ambitious statement lacking real substance. 1 “Our system is sustainable both financially and clinically and is flexible to meet future demands” Feedback: Financial concerns were understood to be important in decision making, but the principle raised concerns about cost-cutting and a feeling that low cost may come at the expense of service quality. 2 “Our design will build on what is already working well and recognises that some of what we are currently doing has to change” Feedback: This principle raised debate about the type of change that is appropriate – radical innovation vs building on current system. The inclusion of ‘has to change’ in N Lancs implied that decisions have already been made. 3 “We encourage our patients to take more responsibility for themselves and we take account of their views in our service design” Feedback: Most controversial principle: proactive, preventative angle is appreciated by some; but strong concern from others that many will not have the ability to self-manage. Also criticised for ignoring contextual barriers. 4

Reactions to Statements/Principles 5-8 (TNS BMRB 2013) “All design options will be realistic and based on evidence based best practice” Feedback: This was not a priority principle overall – in general seen to be more important for management than for public or stakeholders. Queries over whether evidence-based practice is always the most appropriate approach in all circumstances. 5 “Care will be provided in the right place and at the right time. There will be more care delivered out of hospital and some small volume speciality work may not be viable to provide locally” Feedback: There was general acceptance that specialist services can and might need to be delivered out-of-hospital, but reassurance about coordination with local care and patient choices is needed. 6 “Services will be provided in an integrated way with shared records, fewer handoffs and easy navigation. We will manage patients proactively and patients will know who is responsible for their care” Feedback: Sophisticated streamlining of IT systems to allow for information sharing seen as crucial to success. However, strong doubts over capacity, and some concerns about financial and security challenges. 7 “Morecambe Bay is an attractive place to work and our workforce will be developed and encouraged to deliver services which are in the best interests of patient” There was general agreement that staff recruitment is an important principle; but the language of this statement needed reworking to avoid a ‘patronising’ tone. 8

Next steps Better care together will continue to engage with patients, public and stakeholders as the clinical strategy continues Information and involvement opportunities can be viewed on the better care together website or accessed by our regular stakeholder briefings. To be added to the stakeholder briefing mailing list please contact ivan.drozdov@mbht.nhs.uk

Thank you for reading this report For further information please contact ivan.drozdov@mbht.nhs.uk

Better Care Together TNS BMRB research programme