The Bristol Health Partners' HIT Model – How does it work? Sabi Redwood on behalf of NIHR CLAHRC West #CLAHRC_West clahrc-west.nihr.ac.uk

Precursor to an evaluation Developing a ‘theory of change’ for whole- system working to improve service delivery and health outcomes Understanding how and why something actually work is vital for the purpose of evaluation Clearly linking observed effects to the changes Generalising findings to models of the same type

Logic between activities and expected results Inputs Processes Outputs Outcomes Impacts

Study aims 1.Retrospectively to assemble the ‘theory of change’ underlying the HIT model 2.To provide fine-grained description of mechanisms by which any intended outcomes are thought to be achieved 3.To inform the development of a formal evaluation strategy for the HITs

Methods Documentary analysis of anonymised Bristol Health Partners’ documents related to HITs and their development (approx. 140) – Data collection period June August 2014 Interviews with key informants involved in developing the HIT model (11) – Data collection December 2014 – February 2015

Analysis Constant Comparative Method involving initial coding, the forming and refining of categories, searching for negative evidence, and comparison across each stage of the analytic development of explanatory concepts Data management, coding and categorisation supported by QRS NVivo software

Overarching themes ‘Whole system’ engagement – WHO? Process/Inputs Collaboration – HOW? Process/Outputs Integration – WHAT? Outcome/Impact Innovation – WHAT? Outcome/ Impact

‘Whole system’ engagement (1) Refers to the process of actively seeking to engage all organisations and people who play a part in the health and social care economy related to LTCs or PH of the HIT being formed – Provider organisations – Commissioning organisations – Professionals/ staff in these organisations – Public(s) and service users/carers – Other public sector organisations (e.g. LAs, H&WBs) – Non-NHS/social care organisations (e.g. TSOs, industry)

‘Whole system’ engagement (2) Facilitated through the process of becoming a HIT – Structured application process focused thinking on who should be involved in tackling the issue (LTCs/ PH) – Iterative assessment process in which applicants may be asked to modify their proposals after initial assessment – Feedback to applicants included suggestions for widening the circle of engagement, often the less obvious Joint strategic PPI across several stakeholders

‘Whole system’ engagement (3) ‘I would hear commissioners saying “this is brilliant”, you know “I’m able to have conversations with people that I could never access before and we can get like-minded people in the room together and we all want the same thing … and I used to sit there thinking “this is what it’s all about, this is actually what we were trying to create”. (Participant 9, clinical academic)

Collaboration (1) Refers to the development of methods that enable partnership working and co-production, involving – Establishing structures and processes that facilitate collaboration – Co-creating scientific questions that people in positions to enact change want answers to – Responsiveness to information/ knowledge needs, and knowledge mobilisation for decision making – Having visibility – being the ‘place to go’ for evidence – Leadership and negotiation skills

Collaboration (2) Breakdown of professional, organisational and sectorial boundaries and silos Mechanism for addressing translational/ implementation gap HIT sponsorship at senior level as key component of organisational commitment to provide resources and proactively facilitating collaboration

Collaboration (3) ‘… without sounding somewhat simple about it, you know, relationships are the most important thing in order to move anything together in a partnership. So the aspect of one area that has been successful was that the relationship with the commissioners was strong in the sense of having a common ideology. And mutual respect of each other’s tensions to deliver this, so when you understand that, you can actually find a common goal that would achieve.’ (Participant 5, HIT director, clinical academic)

Integration (1) Refers to a range of activities which are brought together to maximise benefit, involving – Existing collaborations – Service delivery and research – Biomedical and population based/ community research – Data linkage and data intelligence – (Integration of health and social care services)

Integration (2) Developing / piloting integrated assessment clinics and one-stop-shops Providing integrated information support and advice to GPs to facilitate implementation of pathways Bringing together and addressing gaps in data sets – JSNA, research, clinical – to inform service design and delivery (HIT documents)

Integration (3) So - moving on beyond the language of collaboration and (…) towards a position where organisations are operating in a framework which will encourage them to make decisions on the basis of system benefit and not organisational benefit: that’s a journey we’re still on, but I think that the fact that we’ve begun it and we’ve made that change in terms of language and people’s collective collaboration is a very strong legacy of [the HIT development work] and the HITs are important in that regard because they are a material demonstration of how that will work in practice. You can say to people “This is what it means. Look at the work that they’re doing. This is what it can mean in practice.” (Participant 8, senior manager)

Innovation (1) Refers to novel ways of delivering services or interventions through the introduction or application of new approaches, usually to improve quality and decrease costs – Biotechnology products and IT solutions – Collaboration with industry – New roles and/or organisational models – New insights through data linkage and data intelligence

Innovation (2) The development of novel ‘near patient testing’ technology: expanded links with industrial partners and working with them to develop novel near patient testing. This will facilitate rapid diagnostics in those individuals in which a swift diagnosis can assist in deciding the treatment option Use of technology to increase access to services Piloting of new interventions and services Data linkage and data sharing agreements (HIT documents)

Innovation (3) ‘The hope is that [the HIT work] will potentially open up new ways to think about the sorts of interventions that will have real impact. So spotting an unknown correlation might unlock a whole different sort of area of policy interventions that we just don’t focus on at the moment.’ (Participant 8, senior manager)

What HITs do HITs harness the benefits of collective enquiry through the inclusion of all stakeholders, including patients and the public HITs provide a legitimate ground for negotiation, finding practical solutions and compromise HITs facilitate collaborative work to define, refine, generate and implement evidence

HITs in relation to PH and service delivery (1) Provide focus for key health challenges Unique model of collaboration and knowledge mobilisation Provide pathway from evidence or research to implementation in practice

HITs in relation to PH and service delivery (2) Provide mechanism through which lessons from research can be used quickly, effectively and systematically to improve services Facilitate relationships with WEAHSN to roll out innovation and exploit potential for wealth creation Cross-HIT collaboration and learning

HITs in relation to research (1) Close fit with local and regional strengths HITs provide opportunities for multi- stakeholder research to engage a wide range of perspectives Generate scope for wider genre of research beyond biomedical paradigm Facilitate inclusive research culture Increase research capability and capacity

HITs in relation to research (2) Need for negotiation and brokering across multiple agendas and perspectives Existing collaborative relationships provide ‘competitive edge’ in research funding applications Cross-HIT collaboration and learning

Simple logic model for HITs Inputs: - Application process - Central resources - Organisa tional resources Processes: - Whole system engagement - Collaboration Outputs: What HITs do - Pathways - Coordination & liaison - Work streams - Research - Service evaluation Outcomes: System-level - Integration - Innovation Impacts: - Populations and patients benefit equitably from new approaches to prevention, diagnosis & treatment Subject to summative evaluation