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Sharing the Learning from the Evercare Project
Taking Stock
3 best things about the project
Changing roles
"Development opportunities for nurses" and "Improved nurse education"
"The advocate role, proactive focus and increased confidence of the APN"
"Generalist nurses with expanded assessment skills working in the community"
"Seeing staff understand and apply the model"
"Main project headlines voiced across health economy"
"GPs and Geriatricians sharing learning"
"Catalyst for new thinking by nurses"
"Triumph of prevention over medical model"
"Creation of enthusiasm"
"Increased nursing skills used more fully"
"Catalyst for modernisation of services"
Patient Focus
"Focus on vulnerable people not institutions"
"Care is already improving for some community patients"
"Person centred care"
"A real focus on older people in primary care by primary care"
"Patient choices"
"Improvements to patient journey/experience"
"Patient/family focus challenges the inflexible system"
"Patients with active problems being assessed and treated = functional and quality of life improvement"
Data
"Identified unmet need"
"Identified gaps in provision for a vulnerable group"
"Integration of data sources"
"Improved clarity of data requirements"
"Data driving models of care - and data people being valued"
"Sharing patient information across community and hospital"
"Learning around data inquiry and analysis"
Relationships
"Joint working – primary and secondary care"
"Co-operation – acute trust and social services"
"Relationships medical & nursing"
"Collaboration – consultant, GP and APN"
"Bridging the gap between services"
"Strong Support from some acute trust partners"
"Consolidation of interagency collaborative working"
"More knowledge of the NHS & local trusts issues, challenges, opportunities"
"Closer collaboration with GPs and understanding across health care groups"
"Bridging the gap between nurse and doctor"
"Geriactric/ psychogeriatric collaboration"
"Strengthened relations with social services"
Miscellaneous
"Positive ‘can do’ support is refreshing"
"Being with other individuals with passion, enthusiasm and optimism about what they can do"
"Proactive thinking"
"Review of current use of Clinical Resources"
"A strong focus on one improvement"
"Imposed structure on Management of chronic disease"
"Raised profile of community-based alternatives to hospital"
"Raised the profile of the ‘older person’"
What have been the 3 biggest challenges?
Delegates identified the challenges and categorised as follows:
Funding
"Money"
"Funding for additional staff"
"Lack of pump priming funds"
"Sustainable funding"
"Staff and money to focus on and perform new roles"
"Finding the money to fund the project"
"Shifting our finances around"
APNs
"Role development – working at a higher level"
"Recruitment – finding backfill nurses"
"Managing risk associated with changing expanding roles"
"Mentorship to APNs – including GPs"
"GPs"
"Professional recognition and accreditation"
"Expectations of very skilled practitioners within a very short time"
"Not having full-time APNs"
"Achieving full caseloads"
Data
"Lack of UK evidence base"
"Unclear what data to collect"
"Getting primary care data – multiple sites and systems"
"Implementing model without evidence base"
"Accessing information"
"Getting a solid baseline"
Timescales
"Managing expectations"
"Managing target achievement alongside development"
"Another demand of people’s time – when the role is not solely dedicated to the project"
"Capacity to implement and sustain"
"Pace – meeting it ourselves and dragging others along"
"Time too short for adaptation"
"Caldicott ‘rules’ slowed the process"
"Time to properly integrate the model into the mainstream"
Hearts and Minds
"Cynical GPs – bringing them on board"
"Evercare fatigue"
"Demonstrating outcomes"
"Medical nursing interface"
"Changing clinical culture mindset – reactive specialist to proactive generalist"
"Inertia/tradition", "Resistance to change" and "Fear of the unknown"
"New APN role seen as threat"
"Linking Evercare to other culture changes"
"Implementing across two acute trusts"
"Developing nurse roles and confidence across community"
"Stakeholder engagement e.g. LMC & CHC"
"Communicating the vision"
"Getting acute care to recognise the potential"
"That proper evaluation is taking place"
The group then discussed these areas in more detail.
- What have you done to tackle this problem?
- To what extent have you been successful?
- What resources have you used?
- What is the key learning in this area?
Advanced Primary Nurse (APN)
Local solutions to recruitment problems – these included ensuring backfill for nurses recruited in to the project e.g. negotiating shorter notice periods, selling this project to GPs and nursing teams and seeking support from sources such as the Workforce Development Confederations.
Securing mentorship for the new nursing role has also been approached in a number of ways. Engagement of GPs was very important and was achieved with differing levels of financial incentive. Consultants had also been engaged as part of a bigger picture team approach to providing care.
The speed of development in this project has posed challenges around the educational and training aspects of the APN role. Close involvement with local universities has been important to develop training modules for APNs and this needs to be co-ordinated. Mentorship, the involvement on universities e.g. masters preparation for nurses and a competency base has been crucial for the development of the APN role.
The key messages from this discussion were summarised as
- Take time to plan – consider this not in isolation as an extension of role but within a wider process of system re-design.
- Be creative around mentorship, make full use of the range of mentoring resource – GPs, hospital consultants or other APNs.
Funding
This is an obvious area of risk. It was felt that it was more difficult to invest, and encourage investment, through the movement of funding without robust financial modelling or more certain outcomes and expected results of the project. This posed challenges for the funding of the model beyond the life of the project.
Solutions lay in the bigger picture to identify the full costs of implementation of the model e.g. nurses, infrastructure, leadership, training. Business cases needed to build the case for sustainability based around the costs and benefits for the at-risk population and on real outcomes.
Other sources of funding have been explored by the projects e.g. the SHAs, Modernisation Agency, Social Services Performance Funding, WDCs and secondary care.
Key messages around funding were summarised as
- See funding as a bigger issue than finding the money to implement any one model.
- Work to demonstrate the cost/benefits – in easy to understand terms e.g. cost per patient per year
- Funding solutions can lay in the reengineering of current nursing workforce.
Time constraints of rapid rollout
The speed of Evercare implementation posed its own challenges.
The PCTs highlighted robust plans/targets and the support from Evercare in bring a project management focus to the implementation as important. This was backed up with a workload prioritisation approach and sharing of workloads.
Cultural differences had led to differing expectations around the optimum pace and what differing operational processes would allow.
Adapting roles within the workforce resource and making use of networks had helped PCTs to balance their other projects to deliver Evercare. In particular, use of the CEO networks had helped resolve issues around data protection.
A summary of the key learning around time constraints was
- Not all problems were predictable but it was predictable that there would be problems.
- Different approaches had been used and had been successful
- Cultural differences needed to be accounted for.
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