Section 3: answering study questions

In this section we briefly summarise the evidence relating to our original objectives. The intention here is to bring together the evidence that we have presented in the previous sections in summary form in order to answer our initial research questions, before putting these in context with reference to other research and our analytical framework in theDiscussion.

How do commissioners view the programme, what they expect from it and how it is seen in terms of their objectives?

It was envisaged that the SICP would be seen by the CCG as something they were commissioning, alongside other programmes. In practice, however, CCG leaders were committed to the programme as equal partners. The SICP was seen by the CCG as essential to contain costs and improve quality, and there was a significant commitment to partnership working, whereby the needs of individual organisations were subsumed to the needs of the programme.

However, the development of the ICO and the institution of a‘prime provider’contract led to the

establishment of formal governance arrangements which reintroduced a separation between commissioners and providers. At the time of data collection, the implications of these changes to the governance and the formal ICO arrangements were still unknown. In particular, it will be interesting to see whether or not the reintroduction of a separation between commissioners and providers leads to a different approach to outcomes and performance management.

How is the programme viewed by strategic partners such as the local authority and how is it sustained under financial pressure?

History played a pivotal role in encouraging the main stakeholder organisations to develop the SICP and the Alliance Agreement. Positive experiences of working together in the past enabled them to develop the SICP and recognised that they all had a vested interest in the programme. All stakeholders discussed the potential difficult decisions that would need to be made. However, they believed that the organisations were willing to face organisational challenges without walking away from the programme. The collective success of SICP was deemed to be more important than individual organisational gains.

The financial pressures that were being faced by all organisations provided an incentive to senior leaders to support their organisations to work differently. Although the foundation trust and CCG were perceived to have a strong financial position, there was recognition that all organisations were working together, and, therefore, the shrinking local authority budget was not considered to inhibit partnership working. However, it remains to be seen in the longer term whether or not developing financial pressures affect the work of the ICO.

The role of Greater Manchester West Foundation Trust (GMWFT) in the SICP was different from the other three stakeholder organisations. GMWFT provided services to a wider geographical footprint, and its interaction with the programme was perceived to be more distant at times. For example, GMWFT did not have as many staff working on the SICP or attending high-level meetings. This different relationship was also identifiable in the move towards the ICO. GMWFT did not have a formal role within the organisation, and its services were to be subcontracted by the prime provider.

The local development of SICP was further supported by national policy and an appetite to introduce new models of care (vanguards), which provided Salford with an opportunity to get additional investment into the local health and social care economy. Moreover, the vanguard status also gave Salford organisations the prospect of recognition as exemplars of new approaches to service delivery. The decision to move to a formal ICO was made collectively by all stakeholder organisations. We were unable to find any evidence that this decision was based upon an appraisal of the impacts of the SICP; the focus appeared to be on the prevention of future problems rather than evidence of SICP success.

Overall, the programme involved a strong partnership between all the organisations involved. All stakeholders that we interviewed expressed their commitment. However, the question as to how the SICP figured in the broader strategic plans of the stakeholder organisations was reduced in relevance by the decision to move towards an ICO. It is possible that the early decision to move towards an ICO was prompted, in part, by financial pressures, but this was not clearly articulated by those involved.

How does the programme impact on the work of the two foundation trusts, in particular how the integrated community and acute provider adapt to reductions in inpatient activity?

This question presupposed that acute hospital activity would be reduced. In practice this has not happened (seeChapter 12).

How does the programme impacts on primary care, in particular general practice? We have described and explained how the SICP, overall, struggled to engage with general practices, and we have considered some of the underlying causes of this, as well as identified solutions.

How far are the financial incentives (explicit and implicit) in the local health and social care system aligned with the ambitions of the programme?

The SICP did not put in place any specific incentive schemes, other than direct payments to GPs to take part in MDG work and the implicit incentive that any money saved could be reinvested in services. The initial funding for GPs was not deemed to be adequate to cover their costs and time; therefore, additional funding was required by the CCG to ensure GP commitment. The CCG funded local GPs

(seeChapter 11) that GPs were being funded twiceboth by the local enhanced service and through the SICP–for doing similar work. This demonstrates how the objectives of the CCG mirrored that of the SICP, but also highlights difficulties associated with engaging GPs. Over and above the GP-related work, we did not see any evidence of reliance on specific financial incentives to implement SICP, other than the general incentive that it was argued that the programme would improve the sustainability of the local health economy.

In document Improving care for older people with long-term conditions and social care needs in Salford : the CLASSIC mixed-methods study, including RCT (Page 102-104)