Outcomes that Matter for Community Services in Richmond
In June 2014, Richmond CCG and LBRuT considered a ‘Case for Change’ for community services in
the borough of Richmond. This identified that the current model of commissioning has led to
fragmentation, uneven care and unnecessary levels of bureaucracy preventing integrated working
across health teams.
It is not that the service provided to patients by individual members of staff at Hounslow and
Richmond Community Healthcare is of poor quality, or that they do not work extremely hard on
behalf of patients, it is the system staff are working within that needs a fundamental overhaul.
To achieve this, the commissioning model should be outcomes based, so that community NHS
care is designed around the outcomes that matter most to patients, service users and carers.
In Richmond the outcomes that matter suggest a more holistic/less clinical model of care, and,
in many cases, will require providers to collaborate to achieve them. This will be a different way
of working for the CCG, LBRuT and providers.
The starting point for developing the framework was a review aimed to establish a set of draft
outcome themes. This begun with a review of recent relevant work undertaken locally,
nationally and internationally, that could be then tested in face-to-face engagement sessions
with local patients and public.
Research and engagement to date
Research and engagement took place over Summer 2014 to develop an outcomes framework for
use in a redesigned outcomes based contract for community based care in Richmond. It aimed to
collect information on what mattered most to local people and to make sure the views of patients
and service users, carers and the wider public were central to the development of the outcomes
framework.
The four key population groups were targeted: Children and young people, adults preparing
for/returning from a hospital stay, older people and carers. Six in-depth interviews took place
with a small sample of participants, seven qualitative sessions with target groups and two codesign sessions with a range of stakeholders.
Insufficient meaningful engagement had been possible with children and young people and it was
agreed that outcomes based commissioning of community-based services concentrated instead on
the part of the population where engagement was stronger (i.e. older people). Children and
young people will be further explored over the coming 18 months.
Focused engagement on the framework’s content was undertaken with GPs, practice nurses,
public health and social care leads, and senior representatives of the current provider of
community services (Hounslow and Richmond Community Healthcare NHS Trust)
The outcomes framework for Richmond can be found overleaf.
The Outcomes Framework for Richmond
The final Richmond outcomes framework considers outcomes for two population groups: people with clinical needs (such as long term conditions,
disability, or frailty); and carers. For each group, outcomes relate either to experience of care or the impact of care on the person’s quality of life.
Population-wide Outcomes
I need to trust the
system and services
I want to feel I am a
full partner in my care
• ‘Trust’ was a word that kept being repeated across the co-design workshops and in the interviews and focus
groups. People wanted assurance that both the individuals providing care and the health and social care
‘bureaucracy’ are working first and foremost in the best interests of patients.
• Patients and service users want to be empowered, to have a greater say in what was important to them from their
care, and have the information to make the best choice for their circumstances at that time.
I get the best clinical
outcomes possible
• Clinicians wanted to ensure that clinical outcomes were included in the outcomes framework, recognising that
there are some conditions that are more prevalent in this population and require specialist community care.
I need to trust the
system and services
• ‘Trust’ was a word that kept being repeated across the co-design workshops and in the interviews and focus
groups. People wanted assurance that both the individuals providing care and the health and social care
‘bureaucracy’ are working first and foremost in the best interests of patients.
I want to feel part of a
community
I want to live as
normal a life as
possible
When the time
comes, I have a
peaceful and dignified
end to my life
• Social isolation was a theme that came across as particularly prevalent within Richmond. People recognised the
important link between emotional wellbeing and being able to ‘belong’ to a community, to have social interaction
with other people, but to still be in control of when and how that happened.
• People reflected that ultimately, health and social care input should be helping them live independently and as
they want to for as long as possible. Local participants therefore viewed this outcome domain one of the most
important.
• Improving end of life care has been a priority for local services, with, in the past, relatively high numbers of older
people dying in acute hospital beds. Local participants in the development of this outcomes framework raised the
importance of a good quality death after a good quality life. Where possible, they wanted to be able to plan with
their family, retaining control and dignity to the end.
Carer outcomes
I want to have a good
experience of care and support
• Carers felt that they deserved to be treated with respect and dignity by services, and recognised
as playing an important part in the wellbeing of the person being cared for. As well as wanting
the best for the person they care for, the carer also wants services to help make the process of
caring as smooth as possible.
I need help reducing the stress
of caring
• Carers described how they may not realise how stressed they are becoming and therefore the
importance of having regular reviews of their own health and wellbeing. They also described the
need for readily available information on how to find support and respite that best suits their
needs and those of the person they care for.
I want support to live a normal
life
• During the local engagement, carers described the tensions between wanting to care and
wanting to have their own life independent of the person they care for, including the ability to
work, exercise, and meet other friends. The benefits of this independence to carers’ wellbeing
should result in more sustainable caring arrangements.