Best use of social care or health research: Manchester City Council
Evaluation of Manchester’s Community Assessment Support Service (CASS)
The research evidenced how designing services to fit how people use them instead of within traditional organisation structures can deliver additional benefits for both the people who use them, and to the systems within which they operate (i.e. in terms of reducing demand and creating sustainable funding models).
CASS is an integrated service delivery model that aims to avoid hospital and social care admissions, reduce length of stay, and improve citizen’s/carer’s experiences through better access to the right intervention, at the right time, delivered by the right health or social care worker. The service was trialled in the Manchester’s North Locality (one of three localities in the city), with over 2,500 people using CASS during its first year of operation. (http://www.pat.nhs.uk/our-services/cass.htm) The complex evaluation of CASS provided a robust methodological and evidence base to demonstrate the effectiveness of an integrated approach to H&SC services. The findings have led to significant investment to expand the service across the whole of the city. The methodological approach provides a proof of concept that now forms a foundation for on-going evaluation of new delivery models in Manchester. The evaluation used evidence from a number of sources and applied qualitative and quantitative methods to assess impact. The work demonstrated the power of combining data from multiple sources/organisations. Primary evidence was gathered from service managers, staff, service users; along with secondary quantitative data from performance management tools and an integrated data warehouse containing patient level health and social care activity and costs data.
The evaluation of CASS operating in the north of the city provided an opportunity to develop evaluation methods to understand and test the assumptions and theories that underpin the CASS model. The methods involved a mixed-method approach applying a realist approach to understand what works for whom, in what context and how. A theory of change was used to formulate the theories of how the activities in the service would lead to short and medium term outputs.
The purpose of the evaluation was to evidence whether or not a new delivery model provided value for money, could demonstrate changes in behaviour amongst patients and staff and support the theory that people who had used the service would have a lower demand for acute care in the future.
Staff have embraced the new way of working shown through delivery of a successful service. The evaluation drew evidence from the performance management dashboard developed by Manchester City Council’s performance team, patient monitoring data from Manchester CCG business intelligence team, social care and hospital services data on patient/staff experiences, financial data from hospital and social care finance teams, and the integrated H&SC data warehouse containing primary, secondary and social care activity data on Manchester residents.
An important test for the service was satisfaction. This was evidenced using qualitative analysis that included gathering staff experience of working in an integrated service, and patient experience using “I statements” to gain insight into experience and the friends and families test. Results showed sustained good patient satisfaction with the service from all those who responded. Analysis of performance indicators showed upward trends for numbers of patients avoiding emergency admission to hospital, being readmitted to hospital within 30 days and a reduction in residential care admissions. The trends seen in the performance indicators were tested and validated by analysing patient level hospital activity and social care activity for the cohort of 2,500 patients by matching them within the health and social care data warehouse.
By applying cluster analysis to patient characteristics, previous hospital activity and risk of future admission score a comparison group of similar patients from other parts of the city was identified. Applying statistical models using linear and generalised linear regression techniques the difference between expected activity from the comparison group and the actual activity of the CASS cohort evidenced a reduction in hospital activity for patients who had used CASS.
A cost – benefit analysis used the quantitative demand reduction data matched to cost data from finance teams to show that by investing in this integrated service a fiscal saving of £1.69 was achieved for every £1 spent. The outcome from the evaluation provided strong evidence for integrated working. The evidence was used in a successful bid for £10.7million of new investment over the next 3 years to scale up and add to this service up to operate city wide. The methodological approach developed for this evaluation now forms the basis of future evaluation of all new models of care being implemented across Manchester.
What should LARIA members learn from your project?
Understanding the complexities of evaluations involving service users and integrated services is an important step in designing evaluations and the methods to use within them. As health and social care services become integrated it is crucial that systems and data can be joined too in order to understand the changes happening in the system and provide insight into its performance. Ensuring good quality evaluation evidence feeds in to service design and implementation is an important aspect of how the services are shaped in the future. It is important to take into account the context within which the service or intervention that is being evaluated operates and will operate if it is scaled up or rolled out in other areas as the model might need adjusting to fit or work in other areas. This is the advantage of the realist approach in understanding how and who a service or intervention works for. If this understanding feeds into service or intervention design as it is moved into other geographical areas there is a greater chance of success. Including service users in service evaluation is important to ensure all views are captured.
More information on CASS: http://www.pat.nhs.uk/our-services/cass.htm