Griffin, AE; McKeown, A; Page, M; (2017) Evaluating the Programme for Integrated Child Health. UCL Medical School

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Abstract

1.1 Background, aims and research questions Improving child health depends on a rounded understanding of what constitutes good child health. Improving child health is not simply a matter of responding to clinical needs, but must involve the psychosocial dimension of care, and the ability to ensure not only that ill-health is treated, but that good health is maintained which includes attention to prevention. Delivering this holistic care depends on effective collaborative practices between hospital-based and community-based settings which have person-centred care as the driving force behind service design. Integration of child health services should offer an efficient approach which is better designed to improve child health, and a crucial aspect of this is effective communication between general practitioners and paediatricians. The Programme for Integrated Child Health (PICH) has been developed in anticipation of a continuing move towards integrating high quality holistic paediatric care and with the aim of preparing paediatric and general practice trainees for new ways of working in the delivery of child health in the community. The aim of this evaluation was firstly to provide a synthesis of current research and perspectives about integrated care through a rapid review of the literature review. Then, subsequently to evaluate participants’ and mentors’ experiences of being involved in the PICH programme, to explore the following research questions: 1. How do course participants evaluate the PICH programme, in particular? a) What are the participants’ views about the structure of the programme? b) What did the participants learn from the programme? 2. What are participants’ views about integrated care and its impact on healthcare, in particular? a) How do participants understand the concept of integrated care, its aims, and its importance? b) What do participants say are the structural issues relevant to delivering integrated care? 3. How does the intraprofessional nature of the programme influence the participants? 1.2 Methodology A rapid review of the literature was followed by a mixed methods empirical study in which 1:1 interviews and ethnographic observations were used to explore the experiences and perceptions of mentors, GPs and paediatric trainees involved in the programme. 1.2.1 Participant sampling framework and recruitment The study population comprised trainees and mentors from Cohorts 1 and 2 of the PICH programme, which corresponded to the first and second years that the programme had run. All participants volunteered to take part in the study. The induction session from Cohort 3 was observed further research with that cohort was outside of the scope of this evaluation. 1.2.2 Data gathering Three PICH programme sessions were observed and 23 one-to-one participant interviews took place. A semi-structured interview schedule guided all interviews and they were audio-recorded and subsequently transcribed verbatim by a professional stenographer. 1.2.3 Data analysis Observation data and interview transcripts were subjected to thematic analysis. QSR NVivo 11© software was used to assist in the analysis and ensure inter-coder reliability. Data was analysed inductively from themes arising from the data but also deductively in response to the research questions. 1.2.4 Ethics Ethical approval was granted by UCL Research ethics committee (Ref: 8949/001). Participants gave their consent verbally at the start of the interviews. 1.3 Results 1.3.1 Participants Four teaching sessions were observed, three from cohort 2 and the induction session from cohort 3. One-to-one interviews were conducted with 23 participants. 1.3.2 Main findings 1.3.2.1 Programme evaluation The PICH programme was perceived to be well run, worthwhile, and provided the desired benefits in terms of education and learning about how integrated care can be delivered. The observations and interviews both revealed the enthusiasm of participants, mentors and programme leads and this undoubtedly contributed to the supportive yet ‘buzzing’ atmosphere described by many of the course participants. The induction session, the project website, the mentoring scheme, and the monthly seminars were all largely evaluated positively. There were some complications, for example, it was difficult for all trainees to attend all seminars due to busy work schedules. The induction was felt to be rather long and presentations, whilst of immense high quality, were perceived to be ‘too good’ and somewhat intimidating. Mentorship and support was appreciated by many of the trainees, both peers and mentors provided sources of influential advice. Some trainees felt that the mentoring was too open-ended and those who were unable to finalise their projects at the end of the year missed out on guidance. One critical component of the programme was the project. It caused both frustration and pleasure. Where barriers and delays were encountered, which derailed participants from submitting in a timely fashion, they often felt disappointment. However, many reflected later on the generic learning and the importance of the process. The projects gave participants a deep understanding of how using real data could influence traditional systems: an authentic problem-based approach. It also provided a sense of autonomy, enabling them to craft something of personal and professional relevance, to innovate and shape their own clinical environment. There was a widespread and positive perception of the style of learning delivered by the PICH programme. The aims of the project were clearly and spontaneously articulated in the interviews, demonstrating the success in delivering the PICH programme. Whilst participants did talk about learning clinical knowledge and skills in a speciality to which they would not necessarily have exposure, the vast majority of their talk was directed towards their own personal development: gaining confidence, independence, forming networks, tools for individual reflection and application. An important finding from the interviews, with both trainees and mentors, was that the course appeared to be successful in delivering tools for leadership too. Participants acquired skills to take forward integrated care initiatives; ready to enact change as ‘leaders’ of integrated care for the future. 1.3.2.2 Integrated care Trainees and mentors on the PICH programme were all integrated care enthusiasts, having been involved in other educational initiatives, in particular the ‘Learning Together’ clinics or having prior interest in the area. The rationale for integrating care was well understood and articulated by participants. All participants perceived a drive towards integration as rational, since they specified the patient must always be at the centre of care and it is in the patient’s interest that care is seamless, which integrated care enables. Moreover, there was a widespread feeling that integrated care is an idea whose time has come, not only because of the growing prominence of ‘patient-centred care’ as an ideal, but also given the need to increase efficiency in view of increasing economic pressures on healthcare. Participants were hopeful that integrated care was a driver for positive health systems change and believed that more integration was inevitable. However, they were mindful of significant barriers to implementation, including financial and territorial issues. Integrated care was reported to impact on patient care positively. Specific examples of overcoming current voids in the system were smoother referral processes and getting timely specialist advice. Integrated care was also felt to improve efficiency by preventing work from being duplicated. Integration was seen as an important concept centralizing the patient in systems-based re-organisation of health care which was likely to have tangible positive impacts for children and their families. 1.3.2.3 Integrated professions One of the most influential aspects of the programme was the creation of a shared spare for participants to talk about providing care by sharing stories. These narratives became fuller and more nuanced as the diversity of the participants increased. There were frequent stories about how responsibilities are shared within child health care and this provided the impetus for them to start thinking critically about how professional boundaries interlock and / or cross over between paediatrics and general practice. They talked about the vital role of effective communication in both the intra as well as interprofessional context, although the vast majority of the dialogue related to the latter. Communication was seen as a means of establishing effective relationships and reciprocally, building relationships resulted in improved communication and improved sharing of information. During the PICH programme participants’ learnt about seeing the other side of things, others working environment, the burden of paediatric clinical work, service pressures and affiliated health care networks which supported or undermined clinical practice. It was clear that their close perceived professional alignment – paediatricians and GP – was a natural one. However, alignment was not reported as universal. Certain specialities were not seen to align as similarly, which may be problematic for implementing future integrated care pathways. Participants gained a deeper understanding of the differences and similarities in each other’s clinical roles and how, crucially, they would now alter their own professional practice to take these into account. They became a more ‘blended professional’; one who adapts their own practice mindful of the others. This emergence of a blended professional raises the concept of professional identity, how they thought about themselves in their clinical capacity and how stepping out of traditional identities and thus roles aided the development of them as integrated professionals. 1.4 Conclusions The PICH programme was highly evaluated by participants and mentors. The overall feeling was that of a generally well-run course, which was populated by enthusiastic mentors and trainees, and which led to significant learning for everyone involved. Fundamental to its success were two key ingredients. Firstly, the learning environment established at the seminars provided both support and challenge from peers and senior colleagues and secondly, the project which allowed participants to engage with data, work with authentic problems and innovate. Whilst there were logistic issues with attendance and some frustration about project completion participant’s reported developing clinical, professional and transferable skills including leadership. Participants were all enthusiastic adopters of the concept of integrated care. However, they were aware of the practical realities of implementation, often significant structural barriers, but considered integrated care to be an effective patient-centred model for health service development. Alongside organisational systems participants learnt, through the PICH programme, the importance of the interpersonal. They articulated the value of understanding and adapting roles and identities to change professional behaviours and how to work as ‘integrated professionals’.

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