Synthesising and mobilising knowledge to inform new care models of community-based integrated care in England

Health service delivery frequently proposes innovative models of care that require timely evaluation and analysis in seeking to identify what works, critical success factors and transferable lessons learnt. Conventional... [ view full abstract ]

Health service delivery frequently proposes innovative models of care that require timely evaluation and analysis in seeking to identify what works, critical success factors and transferable lessons learnt. Conventional systematic review methods with their typical emphasis on average effects and generalised lessons have proved themselves inappropriate for such evaluation. We describe a novel method of review that harnesses the explanatory potential of realist synthesis principles with the inherent efficiency of framework approaches.
The National Institute for Health Research Health Services and Delivery Research Programme has commissioned a rigorous evidence-based evaluation of New Care Models currently being delivered through NHS England's Vanguard Programme. Such models seek to contain costs, improve care and deliver services closer to home. Within the Vanguard programme, the Multispecialty Community Provider (MCP) models aim to provide integrated and coordinated specialist services for patients in a community setting. The evidence base for integrated care is both equivocal and diffuse; no single model or approach can be applied universally as is evident in the diversity of models developed in the 14 MCP sites. Whilst a universal model may not exist, interrogation of the evidence base will provide important lessons regarding what might be considered “active ingredients”.
Our synthesis will develop a conceptual framework which articulates what works, why and in what circumstances, by using an innovative combination of best fit framework synthesis and realist synthesis to yield unique insights. This synthesis will inform design and implementation of future iterations of the MCP model, by:
• articulating underlying programme theories;
• identifying sources of theoretical/empirical/practice evidence to test programme theories;
• appraising, extracting and analysing evidence, reconciling confirmatory and contradictory evidence;
• producing a “blueprint” to explain how mechanisms in different contexts contribute to outcomes/process variables;
• consulting with key stakeholders to validate findings and test applicability in different contexts;
• disseminating findings through practical tools to support knowledge mobilisation.
The synthesis will employ “best fit” framework synthesis, as a rapid tool by which to facilitate the data extraction and analysis process. The methodology (Carroll et al., 2011), a pragmatic variation on framework synthesis, is “especially suitable in addressing urgent policy questions where the need for a more fully developed synthesis is balanced by the need for a quick answer” (Dixon-Woods, 2011). The methodology introduces the deductive step of developing an a priori framework. Best-fit framework synthesis will be combined with realist synthesis principles to maximise the value of the interpretative process, resulting in practicable and feasible recommendations for practice. Recently, methods have been proposed for rapid approaches to realist synthesis (Saul et al., 2013) and the methods proposed in this review offer an alternative systematic route to harnessing the exploratory potential of the realist lens within an accelerated timescale.
We will produce a range of outputs (including visual models and briefings), influenced by Colquhoun et al.’s (2014) key components for knowledge mobilisation:
• strategies/techniques (active ingredients);
• how they function (causal mechanisms);
• how they are delivered/applied (mode of delivery);
• what they aim to change (intended targets).