Navigating the system/s - full abstract

“District nurses” in Germany - A model of coordinated, managed and cross-sectoral care for multimorbid patients 

Simone Richter(1), Maya Nocon(1), Ibrahim Demirer(1), Holger Pfaff(1), Kyung-Eun Choi(1), Ute Karbach(2)
(1)Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, (2)TU Dortmund University

Background: With the demographic change, the number of chronic diseases and multimorbidity is increasing, and so is the demand for health services. This represents a further challenge for the highly segmented health care system in Germany, which includes neither a gatekeeper system nor a profession such as a district nurse in standard care [1, 2]. Therefore, a new model of coordinated, managed and cross-sectoral care for multimorbid patients - the "MamBo" care model - has been implemented in a region of North Rhine-Westphalia, Germany. As part of the model, a care management system, including trained nurses, has been established within a participating network of physicians. These nurses, known as monitoring and coordination assistants (MoniKas), are working on a practice-overarching basis and perform patient-oriented and coordinative tasks in the context of house calls that can be delegated by physicians.

The aim is to present the structure of the care management and to share the experiences made by the MoniKas according to the process development and challenges.

Methods: In summer 2019, a focus group with all MoniKas (n=3) was conducted following a semi-structured guideline. The focus group was recorded and transcribed verbatim and pseudonymised. The data were analysed using qualitative content analysis according to Mayring [3]. Process data (e.g. numbers of patients and house calls), documented by the care management, were used to pose the implementation status.

Results: The care management consists not only of the MoniKas, but also of coordinating units, which currently manage approx. 2400 patients of 40 physicians. Around 30 percent receive support from a MoniKa at home. The MoniKas operate from a neutral position; they work neither for insurance companies nor for care providers nor for individual physicians. In this way, they are not influenced by external interests and can advise patients comprehensively and not selectively. In a continuous process, the operational stakeholders developed the team with their respective tasks and instruments. This resulted in a standardized assessment tool, disease-specific monitoring according to the needs of patients and a strong network of local health care providers. Challenges for the MoniKas were identified at a) individual level, due to the condition and characteristics of the patients, b) project level, such as gaps in information exchange between physicians and MoniKas, and c) policy level, e.g. that the identified patients needs such as for daycare or home support cannot always be met due to lack of caregivers.

Implications:

A complimentary care model has been implemented in Germany with which the various stakeholders in the care landscape are networked with the MoniKas in the centre and coordinating force. Nevertheless, we face a number of challenges at different levels, in particular at the political level, which is difficult to address. It is therefore important to take structural preconditions into account when developing new care models.

References 

1. Tetzlaff J, Muschik D, Epping J et al. (2017) Expansion or compression of multimorbidity? 10-year development of life years spent in multimorbidity based on health insurance claims data of Lower Saxony, Germany. Int J Public Health 62(6): 679–686.

2. Simon M (2017) The healthcare system in Germany: An introduction to its structure and functioning, 6. edition. Hogrefe, Bern

3. Mayring P (2014) Qualitative content analysis: theoretical foundation, basic procedures and software solution, Klagenfurt

Interrupted time series and synthetic control study to evaluate mental health decision units in acute care pathways: design and protocol

Lucy Goldsmith
St George's, University of London

Background: Acute crisis care is a difficult area in which to run a randomised controlled trial. There is interest in alternative research methods. The setting of this research project is Mental Health Decision Units (MDHUs). They provide dedicated 24-hour facilities for enhanced mental health assessment, offering short-term support targeting people for whom inpatient admission is being considered with the aim of putting alternative treatment in place. These have been developed in response to the pressure on acute mental health care internationally.

Methods: A mixed methods study. We will present the research methods: i) interrupted time series (ITS) design, using routinely collected healthcare data, to explore change in acute and psychiatric hospital activity after the introduction of MHDUs at four partner sites. ii) ITS study with a synthetic control iii) cohort study comparing usage of mental health services preceding and following a patient’s first stay on an MDHU, iv) qualitative study; v) economic analysis plan using typical ‘stories’ of service use constructed from the qualitative study.

Results: We present a methodologically sophisticated approach to research, applied to an area in randomised controlled trials are difficult to run. This will be the first formal evaluation of MHDU services in England and the only project to date that includes comparison of different MHDUs, enabling us to identify and model optimum configuration and scale up of MDHUs.

Implications: The methodological design enables rigorous, comprehensive assessment of MDHUs using non-trial methods to provide an evidence base for their effectiveness, value for money and optimum configuration.

Social Care in Prison

Sue Tucker(1), Claire Hargreaves(2), Amy Roberts(2), Jennifer Shaw(2), Katrina Forsyth(2), Catherine Robinson(2)
(1)Social Care and Society, University of Manchester, (2)University of Manchester

Background: In light of longstanding concern about the lack of social care in prison, the introduction of the Care Act (2014) made local authorities in England responsible for identifying, assessing and meeting prisoners’ social care needs. However, service planning has been difficult, for little is known about the range of their needs or how best to meet them.  Against this background, Social Care and Society (formerly PSSRU) and the Offender Health Management Unit at the University of Manchester have been funded by the NIHR School for Social Care Research to explore the social care needs of this client group. 

Method: The presentation will draw on five strands of research:

• Face-to-face interviews were undertaken with 482 male prisoners in five prisons in North-West England to profile the nature and extent of their health and social care needs;

• Care-planning workshops with 35 prison social workers, managers and commissioners from nine local authorities across England explored which of 13 commonly found prisoner subgroups met the national eligibility criteria for the provision of social care based on a series of short vignettes;

• A survey of local authorities in England collected information on the arrangements in place to identify, assess and meet the social care needs of people in prison;

• A scoping review of the literature is identifying what is known about the social care needs of people on release from prison; and

• Three new surveys of local authorities, prison governors and prison healthcare staff in England are exploring how people with social care needs are identified pre-release, prepared for release and supported post-release. 

Results: More than a tenth of the prisoners interviewed had problems maintaining personal hygiene, dressing and/or getting around safely; a significant minority lacked meaningful occupation; and approaching a sixth acknowledged problems forming/maintaining relationships. Older prisoners were significantly more likely than younger prisoners to need help with personal hygiene, dressing and mobilising and to identify problems with their physical health and memory.  

There appeared to be considerable variation in the way national eligibility criteria were interpreted. Local authorities expressed consistent views about just five of the case studies.

 Although the majority of authorities had processes in place to identify people with social care needs on entry to custody, systematic attempts to identify existing prisoners with social care needs were lacking.  The number of specialist social care staff working in prisons was small, with the general consensus being that this resource was best employed in assessing prisoners’ needs and coordinating their support.  Many prisoners’ social care needs were met by the prison regime and/or other prisoners.  Where commissioned care and support packages were required, these were typically provided by the prison healthcare provider, which had advantages and disadvantages.  

Arrangements for the support of people with social care needs on release from prison are less well developed and remarkably little attention has been given to this population in the research literature.  The ongoing surveys should add considerably to our knowledge.

Implications: The findings highlight the substantial number of prisoners who could potentially benefit from some form of social care and support if they are to maintain their safety and dignity and make best use of their time in prison and suggest there is considerable variation in the way the national eligibility criteria for the provision of social care and support are being interpreted.  It would appear there is a need for more active case finding and a different service response for older prisoners.   

Further research is needed on the relative strengths and weaknesses of different service models for meeting prisoners’ needs both in custody and on release, and their impact on prisoners’ outcomes. 

Mapping the discharge process in the breast cancer centers in Germany for time optimization

Kerstin Dittmer(1), Kira Hower(1), Marina Beckmann(1), Holger Pfaff(1), Ute Karbach(2)
(1)University of Cologne, (2)TU Dortmund University

Background: For patients after breast cancer surgery, the transition to outpatient follow-up treatment is a particular challenge, as further treatment, e.g. chemotherapy, is usually followed. In order to prepare this transition well and due to the short inpatient stay, a coordinated discharge process is necessary. Multidisciplinary cooperation is absolutely necessary to design a discharge process for breast cancer patients. However, the discharge process is rated less well by the respondents to the patient survey in the North Rhine-Westphalia breast cancer centers (Ansmann, Alich, Schmidt & Pfaff, 2015). One possibility to improve work processes in hospitals is the application of process optimization methods from other economic sectors. The Value Stream Mapping method, originally from the automotive industry (Womack, Jones, & Roos, 1990), has already been applied internationally in the hospital context (Nowak, Pfaff, & Karbach, 2016) and is used in the present intervention study in four breast cancer centers (BCC) in NRW. 

Research question: Can the discharge process in breast cancer centers in NRW be measurably optimized with the help of Value Stream Mapping?

Method: The following steps were taken in each BCC:

1. Visualization of the discharge process in the inter-professional team

2. First time measurement of the discharge process (t0)

3. Identification of waste in the process flow

4. Development of appropriate actions by the inter-professional team

5. Second time measurements after six weeks (t1)

6. Third time measurement after six months (t2)

7. Evaluation of the time measurements at t0, t1 and t2 and evaluation of the change

For each time measurement, the process steps worked out in the visualization and, if possible, waiting times were measured in minutes.

Results: 266 patients could be included in the time measurement. The results show that by visualizing the discharge process in each of the four breast centers, waste could be detected by the inter-professional team. Mostly, the team was able to develop solution-oriented actions for the identified waste. Only about half of the action could be evaluated by time measurement (see Fig. 1). It was not possible to check all actions by time, e.g. the giving of prescriptions on discharge. The evaluation of the time measurement to check the measurable actions showed positive changes, e.g. that the waiting time for the final consultation in two BCC could be reduced (from an average of 87 to 21 minutes and from 25 to eight minutes respectively). In another BCC, the duration of sentinel lymph node diagnostics was reduced from an average of 158 minutes to 107 minutes. For some actions, such as the goal of having patients receive the compression chest bandage on the pre-inpatient day, no change could be measured. Negative changes were also observed, such as a decrease in the amount of advice given to patients by the social services (see Fig. 1).

Implications: Value Stream Mapping is an easy-to-use method. With the help of the facilitators, the project teams can develop actions for the identified waste. The results suggest that Value Stream Mapping provides a good framework for inter-professional cooperation. Thus, inter-professional problems can be solved easily. In order to achieve large and long-term changes through VSM, leadership must be involved.

The challenges of integrating ‘signposting’ into general practice: perceptions of staff involved in care navigation and social prescribing roles

Lisa Brunton, Abigail Tazzyman, Damian Hodgson, Jane Ferguson, Pauline Nelson
The University of Manchester

Background:  Care navigation and social prescribing link worker roles have been introduced into general practice as part of a wider effort to address  GP shortages and the increasing challenge of providing care to an ageing and ailing population.  Care navigation roles, usually undertaken by receptionists, aim to provide first point of contact to signpost patients to the most appropriate source of help which may free up GP time.  National investment of £45 million was made available via clinical commissioning groups to train reception staff to incorporate care navigation into their existing roles.  Social prescribing link worker roles aim to provide holistic, community-based support to patients through shared decision-making, care and support planning, utilising community and voluntary sector services. As a new role, it is as yet unregulated/unregistered and  there is no clear role definition, with different models of social prescribing existing.  The NHS long term plan commits to providing 1000 new social prescribing link workers in general practice by 2020/21 and 100% funding for the role is available to primary care networks via the Additional Roles Reimbursement Scheme from 2019.  We explored the planning and integration of these new roles in one region of the UK to identify the operational issues faced in implementing these new roles to understand how issues were being addressed. 

Methods: We report on interviews conducted with individuals involved in care navigation and social prescribing roles - respondents included service leads/role holders and host GP practice staff.  Thirty three respondents (n=23 care navigation; n=10 social prescribing) took part in 18 semi-structured interviews (n=10 care navigation; n=8 social prescribing) and one focus group (n=13 care navigation) between April and July 2019.   These data form part of a wider study exploring the integration of new roles into general practice. We analysed data using a thematic approach and employed inductive and deductive coding techniques.    

Results:  The theme linking the two roles is the challenge of ‘signposting’, with distinct and overlapping challenges faced by both roles in their integration into general practice.  For care navigation, ‘signposting’ was problematic in three ways:  1. Patient and staff perception of the role led to challenging interactions with patients who resisted attempts to signpost away from GP appointments.  2. Receptionists’ perceived lack of preparedness for the role was highlighted as well as some feeling it to be an unsuitable role for non-clinicians.  3. A lack of planning and coordination across services impaired success; for example, some reported signposting patients to overloaded services that refused patients and this led to a lack of patient trust.  For social prescribing, challenges experienced were threefold: 1. A perceived lack of role clarity in general practice led to them receiving inappropriate referrals.  2. Lack of preparedness/training was also a challenge. Given the relative newness of the role, social prescribing link workers came from different professional backgrounds; this led to concerns about providing consistency of offer across areas and led some leads to develop competency frameworks. 3. The sustainability of existing social prescribing schemes was questioned, following the introduction of the PCN employed link workers. This raised concerns that if the social prescribing link worker role became more primary care-based it may become more clinical in focus and less ‘holistic’ or person-centred. Concern was also expressed that the strong links built up with the community and voluntary sector over-time by existing social prescribing schemes could be lost. 

Implications: Our study provides learning opportunities for implementation of new roles into general practice.  We will discuss the need for communication and engagement between stakeholders, including clarity around role definition, specific training for role holders and robust measuring of impact of new roles. 

Defining and identifying components of coordinated care for chronic conditions: A scoping review of reviews with stakeholder feedback

Holly Walton(1), Emma Hudson(2), Amy Simpson(3), Angus I.G. Ramsay(1), Joe Kai(4), Stephen Morris(2), Alastair G. Sutcliffe(5), Naomi J. Fulop(1)
(1)University College London, (2)University of Cambridge, (3)Genetic Alliance UK; University College London, (4)University of Nottingham, (5)University College London; Great Ormond Street Institute of Child Health

Background: The impact of living with a chronic condition may be worsened by the lack of care coordination, particularly for people who have varied or complex health and social care needs. People with rare conditions often have significant treatment burden, due to requirements to attend many different appointments on different days, in different places with different healthcare providers. UK-based policy documents have recently emphasised the need for new models of care, and the need to coordinate care for patients with rare conditions. To coordinate care effectively we need to understand what coordinated care means and what it involves. This will help to inform the development and evaluation of interventions to improve care coordination for people living with rare conditions. This review aimed to: (i) define coordinated care, (ii) identify and categorise components of care coordination for chronic conditions and (iii) explore whether findings apply to rare conditions.

Method: A systematic scoping review of reviews (published after 2006) was conducted. Reviews were included if they: i) defined coordinated care, and ii) outlined components of coordinated care for chronic conditions. Thematic analysis was used to develop a definition and identify components. Components were grouped into four categories: 1) components that may need to be coordinated; 2) components that inform how to coordinate care; 3) multi-purpose components; or 4) components that contextualise coordination. To explore the relevance of review findings for rare conditions, three focus groups were held with patients, carers and healthcare professionals with experience of rare conditions.

Results: We included 154 reviews (n=139 common chronic conditions, n=3 rare conditions, n=12 both common/rare conditions). Our definition indicated that coordinated care requires those involved in a person’s care to work together across multiple coordination components and processes of care to ensure everyone involved achieves shared outcomes across a person’s lifetime throughout different parts of the health and care system. Focus group findings were grouped into five themes: 1) Care pathway, 2) Approaches, 3) Support, 4) Features and 5) Wider environment. These findings were used to situate the relevance of components identified from the scoping review in the context of rare diseases.

Findings from the scoping review and focus groups indicated that many aspects of the patients’ care pathways may need to be delivered and coordinated in practice, including: components relating to support, administration, assessment, planning, review, feedback and technology. There are many ways to coordinate care, including: having someone to take responsibility, coordination through specialist centres, technology, communication, support and other coordination methods (e.g. planning). Components that contextualise coordination for rare and common chronic conditions include: individual differences (e.g. individualised care), evidence-based practice (e.g. the use of guideline-based treatment or evidence-based treatment protocols), the wider healthcare environment (e.g. distance from treatment facilities) and access to care (e.g. access to test results, fighting for access to care or availability of healthcare professionals with expertise). These findings suggest that many of the key components and issues for coordinated care apply to both rare and common chronic conditions, but that there are certain components and context-specific issues that are also relevant in the context of rare conditions (e.g. genetic screening).

Implications: The findings from this review can help to develop and eventually test different ways of coordinating care for people with rare and common chronic conditions. The contextual factors identified also need to be considered when developing models of care coordination for different groups.

Social networks and avoidable emergency department attendances

Catherine Pope(1), Gemma McKenna(2), Anne Rogers(3), Sandra Walker(4)
(1)Nuffield Department of Primary Care Health Sciences, University of Oxford, (2)HSMC University of Birmingham, (3)University of Southampton, (4)N Bristol NHS Trust

Background: There has been a reported 16% rise in emergency admissions over the past five years. Use of emergency department (ED) care seems to be increasing at a faster rate than population growth (Baker 2017).  It is suggested that between 11% to 40% of ED attendances are non-urgent ‘inappropriate’ and the fact that 40% of patients are discharged from the ED without treatment is cited as evidence that these patients did not require this expensive care. The solution to ‘inappropriate’ service use has traditionally been seen as a knowledge problem, requiring, for example, improved sign-posting and information to enable people to self-manage or more appropriately. However research about help-seeking behaviour suggests that the problem may not be an informational one. Rather it is suggested that help seeking is a social process, and that decisions about seeking formal health care are made, shaped and informed by and within social networks. 

Methods: We undertook an interview-based study to look at, problematize and understand ‘inappropriate attendance’ taking a social network approach. We used network analysis methods to map and characterise the personal communities of people seeking help from ED for minor ailments.  We used semi-structured interviews with 40 people attending a single ED and associated GP hub providing equivalent care. Interviews were built around an ego network mapping activity and a topic guide structured to explore attender’s narratives about why they had visited the ED. This ego network activity uses a diagram consisting of three concentric circles  (Fiori et al 2007), representing closest social network members (in the centre) and those at further distance.  Participants were initially presented with one of these diagrams and asked to write names of people or resources that had played a role in their attendance and the interviewer probed the interviewee to discuss the actions, input and value of the people and services that supported the visit to the ED.

Results: We analysed number and type of network connections and undertook a thematic analysis to identify how imagined and actual network members and influences were implicated in ED attendance. The network maps created during the interviews were examined and a typology of networks was developed and used to distinguish different types of networks. The development of the typology was informed by our reading of the data, but also by deductive use of Vassilev’s (2018) Network Typology Scoring Tool, a measure frequency of contact and relationship type in networks. Our study suggests that faced with acute minor illness or injury people’s networks narrow: they do not (and perhaps cannot) mobilise their imagined care network because the resources or connections may not be there or are difficult to engage. In addition we identified important system drivers of behaviour, notably that these patients are often directed to the ED by ‘professional influencers’ including health services staff. 

Implications: Our analysis highlights deficits in existing social network resources and the role of more hidden agents in decisions to attend the ED.    This social network analysis offers an opportunity to avoid the trap of victim blaming, moving away from individualised responsibility and binary representations of ‘good’ and ‘bad’ ED use (Green & Dale 1992; Hudgins & Rising 2016)

References: 

Fiori KL, et al. (2007) Social network types among older adults: a multidimensional approach. J Gerontol B Psychol Sci Soc Sci. 62(6):222–30.

Green J, Dale J. (1992) Primary care in accident and emergency and general practice: a comparison. Soc Sci Med 35:987–95.

Hudgins A. Rising K (2016) Fear, vulnerability and sacrifice: Drivers of emergency department use and implications for policy. Soc Sci Med. 2016;169:50-57

Vassilev I. (2018). Network Typology Scoring Tool. CLAHRC Wessex

Multi-disciplinary teams for integrating health and social care: same names, different purposes?

Lavanya Thana, Gerald Wistow, Nick Douglas, Mustafa Al-Haboubi, Bob Erens, Tommaso Manacorda, Nicholas Mays, Mary Alison Durand
London School of Hygiene and Tropical Medicine

Background: Multidisciplinary teams (MDTs) and teamworking are seen as core mechanisms of care coordination for individuals with a wide range of needs in England (e.g. Stokes et al., 2016a). They were central components of the new care model Vanguards (NHS England 2014) as well as of local plans to allocate the Better Care Fund (BCF) (Forder et al., 2018). Our early evaluation (Erens et al., 2016), of the Integrated Care and Support Pioneers, which were selected to drive health and social care integration ‘at scale and pace, from which the rest of the country can benefit’ (Department of Health, 2013), found that community-based MDTs were the most commonly reported intervention in the 25 sites. However, it was not clear that there was any consistent basis for defining team membership, roles, responsibilities and resources. The contribution of social services, especially social work, seemed under-researched (Bailey et al., 2017). Moreover, the evidence that MDTs necessarily improve care integration was thin (Stokes et al., 2016b). 

Consequently, we chose community-based MDTs involving health and social services staff supporting older people with long term conditions living in their own homes as a focus for more detailed study within the wider Pioneer evaluation. 

The aim of this analysis is to analyse the views and experiences of staff working in local health and care systems with different MDT configurations and contexts so as to improve understanding of their current and potential contributions to care coordination for older people with multiple long-term conditions. In doing so, we seek to understand differences in staff perspectives, and to clarify dimensions along which such teams are intended to vary as well as the nature of such differences in practice. 

Method: Semi-structured face-to-face interviews are being undertaken with health and social services front-line staff involved directly in MDTs, and operational and strategic local system managers. Participants have been purposively selected in relation to 11 MDTs, formally based on four different models, in two Pioneer sites covering a wide range of socio-economic, geographic and organisational contexts. Interviews cover variations in MDT objectives, resources, composition, roles and responsibilities, together with respondents’ experiences of working with such differences. 

Interviews are audio recorded, transcribed verbatim, and managed in Nvivo. Data will be iteratively interrogated using thematic analysis (Braun & Clarke, 2006) for key issues and concepts. We will explore the relationships between themes and concepts generated from the two staff groups using matrices (Miles & Huberman, 1984; Miles et al., 2014), elucidating potential areas of complementarity, inconsistency, and divergence (Farmer et al., 2006).

Results: To date, 22 Interviews have been conducted with MDT staff and 17 interviews with system leaders across the two sites. We will undertake some 20 further interviews by May 2020 and incorporate these data in the analysis

Implications: Our findings will enable us to contribute to the limited evidence base on MDTs. They will illustrate the range of functions that MDTs perform at the interfaces between community and hospital services, on the one hand, and primary and social care, on the other. They will also enable reflections on the implications for improving care integration of the variations in MDT roles, responsibilities and priorities as well as the experiences of staff in different MDT settings and contexts. In turn, the findings will contribute to the team’s further aim of developing a typology of MDTs across all 25 Pioneers sites, including their relationship to the wider care systems in which they are located.

The impact of Outcomes-Based Commissioning on the third sector

Javed Miah
Health Foundation

Background: Outcomes based commissioning (OBC) has the ability to transform the delivery of adult social care (ASC). By focusing on achieving outcomes, rather than standard outputs seen in traditional contracting, commissioners are in a stronger position to meet the long-term needs of users and local communities, thus reducing the pressure on services in the long term.

OBC encourages local authorities to work more collaboratively with local partners, including services providers who have experience and expertise of; providing services, meeting user needs and co-production, the local community and environment in order to focus on outcomes and improving the quality of life for patients by engaging with them to personalise services to their individual and communal need. It offers commissioners a way to encourage providers to be more innovative in delivering improved outcomes for service users and potentially doing so in more cost-effective manner by reflecting the real cost of services.

Third sector organisations (TSOs) are key providers of ASC services, such as residential care and rehabilitation services. They have a set of distinct characteristics, including their; ethos, independence, governance structure and innovative use of co-production. Many are embedded in their local communities, which makes the third sector primed to be able to capitalise from OBC.

The relationship between TSOs and local authorities in ASC has changed significantly since the 1990s. A contract culture emerged that increased pressure on TSOs to adapt, leading to; isomorphism, formalisation and financial pressures that have ultimately undermined many of their distinct characteristics. TSOs want to be able to work more collaboratively with local authorities and other partners, be more innovative in their services, help their users and local communities and work in a system that supports this, but this need has not yet been met.

Despite its potential in solving this challenge, there has been limited research on OBC and the experience of providers, with the majority focusing on the experience of commissioners. The aim of this study was to fill this gap to provide greater understanding of the impact of OBC on the third sector in adult social care. 

Method: This exploratory study utilised a qualitative approach through semi-structured, telephone interviews with senior stakeholders (n=4) from TSOs providing ASC services across England with experience of OBC  to explore the impact of this novel approach.  Interviews were audio-recorded and transcribed, proceeded by qualitative thematic content analysis to identify and group themes which emerged from participants’ discourse. 

Results: Participant recorded advantages of OBC compared to traditional contracting; greater input in the design and delivery of services, greater independence to deliver services as well as new methods to intra-sectoral working. However, barriers and challenges remained, including; disparities between how local authorities engage with providers, gaining ‘buy-in’ from individual commissioners as well as in appropriate funding for providing services.

A new area of interest is the impact of OBC across different services (i.e. rehabilitation services for substance abuse, residential care, housing) and the impact of the collaboration model between TSOs and the local authority as a result of OBC. Alliance models, featuring multiple providers collaborating under one contract with the local authority had the most positive regard from participants.

Implications: Changes need to be made in policy and practice to capitalise on the distinct advantages the third sector bring to service provision, particularly through OBC. The barriers and challenges to its successful uptake have been previously identified and further confirmed here. There is a need for local authorities to change their commissioning practices and the way they engage with providers to maximise the quality of services for users and improve their outcomes.