Implementation 2 was designed to address the following research questions.
Multidisciplinary groups:
- What are the characteristics and composition of the groups?
- How do the groups function as teams and in collaboration with other providers?
- How well do the groups achieve fidelity to the original SICP model?
- What are the key barriers to and facilitators of effective functioning and outcomes?
- How is the work of the groups experienced by patients and carers?
Integrated contact centre:
- What services are provided by the centre and which staff provide those services?
- What is uptake and usage of the ICC services?
- What are the key barriers to, and facilitators of, effective functioning and outcomes?
- How are ICC services experienced by patients and carers?
Methods and analysis
As discussed in Chapter 3, we drew on the realist model and the ‘five simple rules of large-scale transformation’ (designated and distributed leadership, presence and use of feedback, attention to historical factors, provider engagement, and PPI)7 as a framework to understand the process of implementation of these two aspects of the SICP. We also drew on NPT and psychological models of self-management and patient centredness to guide analysis.
Study methods: multidisciplinary groups
Multidisciplinary group fieldwork took place from March to December 2015, with fieldwork largely based on non-participatory attendance at neighbourhood MDG meetings. Data collection included 72 hours observing MDG meetings, with sequential fortnightly observations in one neighbourhood MDG for each of the three waves of roll-out (Table 5). Additional observations were undertaken at other meetings supporting the MDG process (including the working group meetings, joint chairpersons’ meetings and administrator meetings) as well as engagement events. Further observations were conducted with MDG nurse and social care co-chairpersons to outline how the work of referring and prioritising patients for discussion and pre-MDG meetings was enacted.
| Data collection method | Number | Further information |
|---|---|---|
| Interviews | 37 | 27 with MDG staff 5 with non-MDG staff 5 patients/carers |
| Observations | 36 (approximately 72 hours) | Observations included:MDG meetings in seven neighbourhoodscare home MDG meetingpre-MDG preparationMDG working groupMDG joint chairpersonsMDG administration team engagement events |
By agreement, field notes made during the MDG meetings did not contain any identifiable patient data. Initials, sex and the general practice were recorded, permitting further questioning around individual cases with the relevant general practitioners (GPs) and to identify potential patients to be invited to participate in qualitative interviews.
Thirty-two face-to-face interviews were carried out with professionals participating in the MDG meetings or those whose work was associated with them. Maximum variation sampling was used to ensure that representatives from all staff groups participating in MDGs were interviewed.
We used routine data (workload and throughput, patient characteristics, links with other services) to contextualise our data. Operational documents were collected from the MDG processes and meetings around them and used to provide information about the implementation.
Study methods: integrated contact centre
Fieldwork took place between October 2015 and July 2016, during which time the single integrated referral point (SIRP) was based within a Salford City Council facility. Colocation with the council corporate team unfortunately meant that permission to carry out observational work within the SIRP was declined. Data collection was therefore based mainly on interviews with 11 ICC staff during which in-depth descriptions of their work were provided in lieu of observations (Table 6).
| Data collection method | Number | Further information |
|---|---|---|
| Interviews | 17 | 11 ICC staff 6 patients/carers |
| Observations | 5 (approximately 11 hours) | Observations included:SIRP baseLocality base workingTelecare/telehealth workshopCare homes meetingEngagement eventsHealth coaching |
We explored the various services provided by the centre through individual interviews with participating staff and managers to assess the development of the service over time, how fidelity to the model was achieved and the potential for unintended consequences. We used routine data reported by respondents (workload, patient characteristics, referrals) to contextualise the data.
We described the characteristics of the centre, its staffing and technology, and how the existence and function of the centre is communicated to patients. At the level of the patient, we described the interaction between the staff and patients, through individual interviews with six patients/carers who had direct experience. Observations included 11 hours of non-participant observations of meetings directly related to the centre, including a short visit to the SIRP, observing the locality base, a care homes meeting and initial engagement events promoting the wider SICP. In addition, documents providing evidence of the implementation process and allowing a comparison with the initial plans for the ICC at the start of the SICP were collated. Health coaching data are presented in Appendix 2.
Qualitative analysis methods
Qualitative data from both the ICC and MDG observations and interview transcripts were organised using NVivo 10. Techniques from grounded theory were used for the thematic analysis.76 Analytical memos were written and discussed to develop a collective understanding of the issues represented in the data. Members of the qualitative team met monthly to discuss emerging themes and to agree subthemes.
Normalisation process theory was used as a starting point to inform the original topic guide used in the qualitative interviews. We considered how data mapped onto the framework, and although there were some connections between concepts, these were limited. We therefore adopted a more responsive approach, using iterative sampling and analysis of data until no new information emerged. This prevented the background framework from constraining the interviews and allowed us to learn from, and develop, the topic guide as the interviews were conducted.
Qualitative data from both the ICC and MDGs observations and interview transcripts were organised using NVivo 10. We conducted a thematic analysis drawing on some techniques from a grounded theory approach, including open coding and the creation of analytical memos as a basis for iterative analysis and sampling as outlined previously. Members of the qualitative team met monthly to discuss emerging themes and subthemes, any unusual cases and to agree the final stage of ‘selective’ coding. These processes of coding and iterative analysis enabled core themes to emerge inductively from the data consistent with a grounded theory approach.76