Background: Changes to the general practice (GP) contract in England (April 2019) introduced a new quality improvement (QI) domain. The clinical microsystems programme is an approach to QI with limited evidence in primary care. Aim: To explore experiences of GP staff participating in a clinical microsystems programme. Design and setting: GPs within one clinical commissioning group (CCG) in South East England. Normalisation process theory informed qualitative approach. Method: Review of all CCG clinical microsystems projects using pre-existing data. The Diffusion of Innovation Cycle was used to inform the sampling frame and GPs were invited to participate in interviews or focus groups. Ten practices participated; 11 coaches and 16 staff were interviewed. Results: The majority of projects were process-driven activities related to dministrative systems. Projects directly related to health outputs were fewer and related to externally imposed targets. Four key elements facilitated practices to engage: feeling in control; receiving enhanced service payment; having a senior staff member championing the approach; and good practice–coach relationship. There appeared to be three key benefits in addition to project-specific ones: improved working relationships between CCG and practice; more cohesive practice team; and time to reflect. Conclusion: Small projects with clear parameters were more successful than larger ones or those spanning organisations. However, there was little evidence suggesting the key benefits were unique attributes of the microsystems approach and sustainability was problematic. Future research should focus on cross-organisational approaches to QI and identify what, if any, added value the approach provides.

Purpose: The purpose of this study is to examine the implementation, care processes and sustainability of an integrated, intermediate Acute Response Team (ART) service. The primary aims of the service are to enhance the level of health and social care integration across a range of organisations, to ensure a timelier and appropriate service for people in the community at risk of admission to hospital. Design/methodology/approach: A qualitative methodology was employed in order to gain a deep understanding of the experiences of staff members within the ART service and external stakeholders. Twenty-one professionals took part in a focus group or one-to-one interviews. Data were analysed thematically. Findings: The key to successful implementation was that the service was co-created from the "ground-up" with support from local provider organisations. The inclusion of general practitioners (GPs) as part of the team was instrumental in setting up and maintaining the service and seems to be unique in intermediate care settings. Referrals into the ART service were dependent on awareness of the service at the interface with mainstream services. Transitions out were sometimes delayed due lack of availability of social care packages. To ensure sustainability of the ART and other integrated intermediate care services, continued resources, especially skilled staff members, are necessary. Originality/value: This study adds to the intermediate care and acute response service literature by offering insights into "what works" from a professional perspective in terms of service implementation, care processes and sustainability, in an integrated care system.

Background: In the United Kingdom, pregnant women are offered foetal anomaly screening to assess the chance of their baby being born with eleven different conditions. How health care professionals (HCPs) deliver news about a child having a congenital anomaly affects how it is received and processed by parents. We refer to this news as different news. Methods: We conducted a mixed methods evaluation of a training intervention to improve how HCPs deliver different news. Twenty‐six HCPs self‐completed pretraining and posttraining questionnaires on skills, knowledge, and attitudes related to delivering different news. Qualitative interviews were conducted with eight HCPs. Quantitative data were analysed using descriptive statistics, the paired t test to compare the pre and post scores and estimate the difference between pre and post scores, and the 95% confidence interval. Qualitative data were analysed using framework analysis guided by the Theoretical Domains Framework (TDF). Results: The training intervention was both feasible and acceptable. HCPs indicated that it enhanced or consolidated their knowledge and skills, covered topics relevant to their practice, and that they would recommend it to colleagues. Participants particularly valued integration of the voice of parents with lived experience in the training. Significant increase in mean scores were observed in confidence to deliver different news (2.81, 95% CI [2.43, 3.19] to 4.28, 95% CI [4.09, 4.47]; p < .001) and skills to deliver different news (3.00, 95% CI [2.64, 3.36] to 4.36, 95% CI [4.13, 4.59]; p < .001). HCPs reported feeling more confident in their ability to provide sensitive, responsive, balanced care to families. Conclusions: The significant improvements in confidence and skills reported by HCPs suggest that the training may be effective in equipping HCPs to minimize the distress, anxiety, and depression associated with receiving different news. This represents a key aspect of the prevention of mental ill health across the life course.

We report on two evaluability assessments (EAs) of social prescribing (SP) services in South East England conducted in 2016/7. We aimed to demonstrate how EA can be used to assess whether a programme is ready to be evaluated for outcomes, what changes would be needed to do so and whether the evaluation would contribute to improved programme performance. We also aimed to draw out the lessons learned through the EA process and consider how these can inform the design and evaluation of SP schemes. EAs followed the steps described by Wholey (1987) and Leviton et al. (2010), including collaboration with stakeholders, elaboration, testing and refinement of an agreed programme theory, understanding the programme reality, identification and review of existing data sources and assessment against key criteria. As a result, evaluation of the services was not recommended. Necessary changes to allow for future evaluation included gaining access to electronic patient records, establishing procedures for collection of baseline and outcome data and linking to data on use of other healthcare services. Lessons learned included ensuring that: (i) SP schemes are developed with involvement (and buy in) of relevant stakeholders; (ii) information governance and data sharing agreements are in place from the start; (iii) staffing levels are sufficient to cover the range of activities involved in service delivery, data monitoring, reporting, evaluation and communication with stakeholders; (iv) SP schemes are co-located with primary care services and (v) referral pathways and linkage to health service data systems are established as part of the programme design. We conclude that EA provides a valuable tool for informing the design and evaluation of SP schemes. EA can help commissioners to make best use of limited evaluation resources and prioritise which programmes need to be evaluated, as well as how, why and when.

Health literacy, 'the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health', is key to improving peoples' control over modifiable social determinants of health (SDH). This study listened to adult learners to understand their perspectives on gathering, understanding and using information for health. This qualitative project recruited participants from community skills courses to identify relevant 'health information' factors. Subsequently different learners put these together to develop a model of their 'Journey to health'. Twenty-seven participants were recruited; twenty from community health literacy courses and seven from an adult basic literacy and numeracy course. Participants described health as a 'journey' starting from an individual's family, ethnicity and culture. Basic (functional) health literacy skills were needed to gather and understand information. More complex interactive health literacy skills were needed to evaluate the importance and relevance of information in context, and make health decisions. Critical health literacy skills could be used to adapt negative external factors that might inhibit health-promotion. Our model is an iterative linear one moving from ethnicity, community and culture, through lifestyle, to health, with learning revisited in the context of different sources of support. It builds on existing models by highlighting the importance of SDH in the translation of new health knowledge into healthy behaviours, and the importance of health literacy in enabling people to overcome barriers to health.

This report details the findings of a service evaluation of the Vanguard Encompass MCP (MultiSpecialty Community Provider) in East Kent. Encompass was awarded Vanguard status in 2015, through the first wave of Vanguards prompted by NHS England's 'Five Year Forward View' strategy. The evaluation was conducted from March 2017 to April 2018 by the Centre for Health Service Studies in partnership with Encompass, who provided and analysed the metric data. The operational model developed and implemented by Encompass is Community Hub Operating Centres (CHOCs). CHOCs are holistic community based models of integrated service delivery aiming to improve user experience of co-ordinated care and self-management at home; contribute to a reduction in A&E demand and onward admission in the short term; and reduce pressure on acute services and long term care home placements in the longer term. Five CHOCs were initiated after an initial pilot period in 2016, which consist of clusters of GP practices serving a total practice population of 180,784 patients. The evaluation focused on the CHOCs, and the evaluation questions were informed by the NHSE local evaluation document (NHS 2015): ? What impact are the CHOCs having on user outcomes and experience? ? What are the components of the care model delivery (or 'active/successful ingredients') that are really making a difference? ? What are the influencing contextual factors and how have they affected implementation and outcomes? ? What changes to the use of resources and activity in the local health system have taken place and to what costs? ? What could be improved, replicated and sustained?

Background: We report on a project commissioned by the UK Government's executive agency Public Health England (PHE) to develop and pilot a set of curriculum resources on health and work that were available to six medical schools in England. This project is underpinned by the 2018 Outcomes for Graduates developed by the UK's General Medical Council (or GMC), which sets the standards for medical schools in the UK. It includes an expectation that newly qualified doctors will be able describe the principles of holding a fitness for work conversation with patients…and how to make referrals to colleagues and other agencies. The aim of this project was to improve the health and work dialogue between doctors of the future and patients. The background to this work lies within the UK Government's national vision to reduce health-related worklessness and help individuals achieve their work and health potential, which it set out in its command paper Improving Lives: the Future of Work, Health and Disability. The purpose of the pilot was to answer the question, "Is it feasible to implement the teaching of health and work topics into the medical school curriculum?" Objectives The overarching aim of the project was to design and pilot an integrated curriculum for future doctors that addresses how to communicate with service users/patients about staying in and returning to work. Methods Qualitative and quantitative methods were employed involving telephone interviews with course tutors prior to and following the teaching pilot, student surveys and focus groups in each of the six medical schools who took part in the pilot. Results The results indicated: where aspects of the curriculum improved understanding of broaching health and work conversations; helped to recognise what factors facilitated further learning; what support and advice the tutors required to teach the materials, and where additional resources were needed to help deliver the teaching resources. Lastly, the results highlighted what some of the limitation were with introducing the health and work curriculum. Conclusions This pilot study showed it was possible to introduce a set of curriculum resources on health and work in English medical schools, with course tutors welcoming the opportunity of using a range of teaching materials aimed at undergraduate medical education.

Aims/Objectives/Background: We will present on a project commissioned by Public Health England (PHE) to develop a set of online curriculum resources on health and work that will be universally available to all UK medical schools. The aim of the project is to improve the health and work dialogue between doctors of the future and patients. Content of Presentation: The presentation will outline the process of co-producing curriculum resources via partnership between healthcare professionals, patient and public involvement representatives, academics and national government organisations. We will then set out the planned approach for piloting the new resources at medical schools in England to take place in autumn 2019. Relevance/Impact: The resources will help new doctors use the fit note as a practical advice system as well as a process for sickness certification. The background to this work lies within the Government's national vision to reduce health-related worklessness and help individuals achieve their work and health potential, which it set out in its command paper Improving Lives: the Future of Work, Health and Disability. Outcomes: The set of learning resources and teaching aids is intended to provide knowledge, tools and techniques to improve future doctors' confidence to start conversations with patients around health and work and the 'fit note'. Discussion: The presentation will focus on the contribution both patients and medical undergraduates representatives have provided, which has increased both the quality and rigour of the resources. The barriers and enablers encountered in piloting the resources in medical schools will also be discussed.

Purpose: This is part of a larger study looking at improving the health and work (HW) dialogue between future doctors and patients by designing an integrated curriculum addressing communication with service users about staying in/returning to work. Before developing resources on HW, it is important to understand existing undergraduate programmes. It was through this mapping exercise of medical schools that gaps in medical education were noted. Theory: A six-step approach to curriculum development developed by physician educators helped support the theoretical framework employed. Methods: A scoping review was undertaken to identify where HW could be integrated within core teaching topics in undergraduate medical education. This information was compiled into a database, which consisted of collating online information on the 41 UK medical schools' curriculum. Findings: This exercise illustrated how teaching topics, resources and models of delivery varied across medical schools. The review identified three types of curriculum styles, with schools having a biopsychosocial, biomedical or an intermediary approach to medical education. Discussion: The disparate nature of such curriculum demonstrates how the introduction of new training/education within this realm must complement the existing design.

To design an integrated curriculum for future doctors that addresses how to communicate with service users/patients about staying and returning to work.

Background: In the UK all eligible pregnant women are offered antenatal screening. Screening is useful for making informed decisions about further tests, delivery and treatment options if available. More congenital disorders are now identified during pregnancy due to increased sensitivity of tests. Parents may experience distress, fear, grief, depression, anxiety and chronic stress which can impact on their parenting and the development of the child (Aein & Delaram, 2014; Luz et al., 2017; RCN, 2013). Disclosing this news requires expert verbal and non-verbal communication skills (RCN, 2013). The aims: -To develop a training programme to improve the process of delivering different news to mothers-to-be and their families. -To conduct an evaluation of the training intervention to assess acceptability, feasibility, and optimal design for future roll out of the intervention. Preliminary Findings: An absence of standardized training -Training in DDN varied from mandatory communication courses to having no formal training. -A lack of standardization and/or formal training has resulted in different news being delivered in multitude of ways. -Association between the level of training and role of HCP (i.e. a consultant was likely to have undertaken mandatory relevant training). However, this had no bearing on ability to effectively DDN.

Background: The landscape of healthcare is in a constant state of flux universally. In the United Kingdom (UK) for instance, 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 was published and it was noted amongst other things that a "one size fits all" model of care was simply, no longer practical. As part of delivering this remit, new models of care have been designed to not only deliver more integrated care, but to create partnerships at the community level . One such model is the Encompass multispecialty community provider (MCP), which is one of 14 'vanguards' established across the UK in response to improving the integration of health and social care whilst also looking towards non-clinical resolutions when appropriate. This necessity to pursue a more inclusive and sustainable approach to health has allowed concepts such as social prescribing to rise to prominence. The social prescribing service associated with this scheme; Red Zebra Community Solutions has been tailored to the needs of this MCP by referring and/or signposting patients to non-medical services (i.e. befriending services to combat social isolation) within the community. Based on the needs of the locality, this social prescribing service aims to: •Provide a referral database that will allow residents within the Encompass MCP catchment area to access local activities and services •Provide a social, rather than medical solution when suitable •Reduce the number of unnecessary appointments and hospital admission(s) Method: An evaluability assessment was undertaken of this local social prescribing service to determine if at present there was enough evidence to carry out a full evaluation of Red Zebra in relation to the MCP. It was agreed that the key criteria to consider were: •The quality of the project purpose •The quality of expected outputs •The availability of baseline and monitoring data •The feasibility of attribution Data Collection: To address the key criteria the research team collated and analysed information related to the Encompass MCP developed logic model for social prescribing and Red Zebra's own narrative. This included 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. In-person interviews were also undertaken with social prescribing managers and case officers as well as commissioners engaged with the Encompass MCP process. Conclusion: There is evidence of engagement with voluntary and community support services particularly amongst the older patient population for social isolation. Additionally, there is evidence that GPs are referring patients for social prescribing support although, it is not possible to determine whether Red Zebra itself has increased awareness of community support services among GPs or patients. Whilst promising, in future, the outcome data collected by Red Zebra will need to expand to include a formal assessment of client perceived benefits and anticipated outcomes of the service itself (i.e. measures of psychosocial wellbeing) to permit an evaluation.

In collaboration with local providers, South Kent Coast (SKC) CCG have been developing programmes focusing on supporting integrated health and social care initiatives. A research team at CHSS introduced a light touch" evaluations to address the following aims and objectives: 1. Help SKC CCG and local providers to develop in-house evaluation skills 2. Enable the continuous improvement of initiatives by producing timely evidence identifying strengths and weaknesses 3. Create transferable information through this evidence and the associated evidence scans to key stakeholders in SKC