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Policy Research Programme - (36-01-09) National Evaluation of the Complete Community Care Programme - Population Health Approaches To Tackling Health Inequalities

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Published: 30 May 2023

Version: 1.0 - May 2023

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Timetable and Budget

Description

Deadline/Limit

Deadline for Stage 1 Applications

11 July 2023, 1 PM

Notification of outcome of Stage 1 Application

October 2023

Deadline for Stage 2 application

28 November 2023, 1 PM

Notification of outcome of Stage 2 Application

April-May 2024

Project Start

Summer 2023

Budget

Up to a maximum of £800,000

Introduction 

The National Institute for Health and Care Research (NIHR) Policy Research Programme invites proposals for a national evaluation of the Complete Care Community Programme (CCCP). 

This is a significant opportunity to inform national policy and local service delivery across important areas of health and care systems in England. The primary objective of this research is to carry out a process / formative evaluation of the CCCP, providing a nationally robust assessment of how the CCCP is being implemented. An early assessment of possible benefits, impacts and outcomes is also required. 

Background 

The CCCP was launched in April 2021. Funded by NHS England and its Regional Offices, the CCCP is a national programme designed to help address health inequalities in England. The Programme has adopted a population health management approach to health and care delivery, utilising demonstrator sites that are focused on addressing both the existing health and care needs in their local areas and the wider determinants of health (see Annex B).

Each site is made up of host Primary Care Networks (PCNs) and local system partners (including statutory and non-statutory bodies), that aim to work together collaboratively to target local health priorities through locally agreed interventions. This includes the development of new provider teams of combined health and care professionals, along with other community-based services.   

The CCCP is currently composed of a total of 63 demonstrator sites, with an aggregate population coverage of around 3 million people. The CCCP has been delivered using a phased approach across the last three years (see Annex B). 

Demonstrator sites within the CCCP address a wide range of population health and complex care issues: they target different sections of their local community, in locally tailored ways, and focus on long-term improvements in health outcomes. The CCCP sites are led by different partners within each local health economy and work in different ways to meet local need and harness local innovation. 

However, across all sites, a broadly consistent approach to service integration, cross-sectoral collaboration and multidisciplinary team working is being adopted. Taken as a whole, demonstrator sites cover a suite of interventions and approaches to delivering personalised care and services to individuals, groups, and the wider population. 

The Need for Research

The proposed research should provide a national formative / process assessment of the CCCP. We are particularly keen for the study to explore the effectiveness of the range of local models that have been put in place, to identify the key enablers and barriers or obstacles encountered, and to understand how they are being tackled. It is important that this study generates a robust understanding of how cross-sectoral partnerships can support place-based care, with particular regard to recent system reforms - including the role of Integrated Care Systems (ICS) and Integrated Care Boards (ICB), and potentially the place-based boards or partnerships that support and advise them.

The study should also provide an early assessment of benefits, impacts and outcomes. This might include, for example, consideration of issues related to the experience of local people and the workforce, access to services and care, health inequalities and disparities, and value for money. These topics are illustrative only; we welcome other suggestions from applicants.  

A key interest for national policy makers is for the research findings to provide a robust evidence base to support future policy decisions. The research will, for example:  

  • Help Ministers and policy officials judge the overall success (or otherwise) of the CCCP 
  • Assess the extent to which different models of integrated care and cross-sectoral working across local systems within the CCCP demonstrator sites are effective
  • Build understanding of what role ICPs and ICBs are playing in supporting PCN-level population health initiatives 
  • Contribute to the developing evidence base on the success factors that contribute towards effective partnership working and the reduction of health disparities for a specific population
  • Identify factors which may support or hinder the long-term sustainability of sites
  • Help spread learning on what works, and support national and local policy development and service delivery.  

The evaluation is expected to be designed and delivered in a way that provides structured opportunities for dynamic evaluative feedback to NHS England, the Department of Health & Social Care (DHSC), and their partners. This will inform national policy development but will also identify possible dissemination opportunities that will support participating demonstrator sites.  Applicants should set out suggestions for how to maximise these opportunities.

Inequalities

Addressing health and care inequalities and improving approaches to population health management are longstanding priorities for the health system, its partners, and successive governments. It is also a central component of the CCCP, which provides a consistent framework for measuring and addressing health inequalities whilst also allowing for local flexibility and innovation. This framework is aligned to the ‘Quadruple Aim’ for highly performing healthcare systems. 

There is national and local policy interest in understanding how to maximise the effectiveness of existing policies to improve the health of the poorest fastest, as well as understand why some local areas do well, and some less well, on health inequality measures.  This includes, for example:

  • Enhancing peoples’ experience of care
  • Improving population health
  • Reducing costs by increasing value for money and efficiency 
  • Improving staff experience at work
  • Developing a framework for tackling and measuring health inequalities  
  • Identifying and reducing unwarranted variation in quality of care

Research priorities

We recognise the complexity of the CCCP, and how this may constrain the range of viable approaches that may be possible for such a national evaluation. Subject to feasibility, we would like the study to assess the effectiveness of the CCCP demonstrator sites against key process and outcome criteria and measures. We welcome suggestions from the applicants on whether and how this may be possible.   

The proposed study should build up a robust and detailed national view of how the new architecture of the NHS is working – specifically with regard to the effectiveness of CCCP demonstrator sites at set-up, implementation and delivery. We are especially interested in understanding the different models of collaborative partnerships that are in place, and to what extent they are effective. The study should aim to identify learning that will directly inform national policy and local delivery, including identifying potential success factors.

Related to this, the study should also aim to make an early assessment of the benefits and  impacts (positive and negative, desired, and unintended) of the CCCP. This should include explicit consideration of issues relating to health inequity and disparity.

We have identified an initial list of themes and challenges that are of interest to national policy makers. These are set out in Annex A. The list is neither definitive nor exhaustive; it is intended only to illustrate potential areas of interest. We welcome comments from applicants on these themes, including suggestions of gaps or other potential issues that the study could address.  Applicants should consider how best to address these questions within a coherent study and may also include additional related issues where they are thought to be required. 

Methods/Approach

This research should capture the diversity of local arrangements in demonstrator sites, enabling (where possible) comparisons across sites. Given the complexity of the CCCP and the requested evaluation, we anticipate this study as requiring a multi-year and mixed methods approach composed of different work packages. Applicants are requested to set out their methodological suggestions for each qualitative and quantitative work package. They should also identify appropriate primary and secondary data sources.

We are conscious of the design and delivery challenges involved in such a multi-faceted and multi-phased project. For this reason, the first phase of the research project should be to carry out an initial baseline and feasibility study before proceeding to the main stage phase. For illustrative purposes, our planning assumptions are that the study will consist of two distinct phases:

  • Phase 1: initial baseline / feasibility – consisting of an initial formative assessment of demonstrator sites, and a robust assessment of the research plan (testing scope and feasibility and costs)
  • Phase 2: main stage evaluation.

We invite outline proposals for the topic areas set out in this document using the NIHR PRP Stage 1 form specific to this call. At this stage, applicants are required to submit their plans and costs for the development phase component (initial assessment and feasibility testing), and their initially proposed main stage evaluation. Applicants are required to specify the duration of each phase, along with the costs.  

Within this phased approach, a review of phase 1 outputs and phase 2 plans will be carried out before the main stage commences. On completion of the initial phase, applicants will be required to set out their key findings in a report and produce a separate output that reviews their main stage plans and costs. This will provide the appointed evaluation team with the opportunity to refine their plans and adjust / reprofile the budget before a decision can be made on how the main stage of the study may commence.

Programme Support

The CCCP PMO will work closely with the successful applicants to support them throughout the course of this evaluation. This includes, for example

  • Providing administrative support in connecting with the sites, including making arrangements for any meetings
  • Providing detailed background information to individual demonstrator sites and their up-to-date operational development
  • Support from the facilitators in the PMO currently working with sites on their individual project development

The initial baseline / feasibility phase feasibility study should build on any existing evaluation, data collection and analysis of current processes across the sites, in addition to carrying out additional primary research. 

To assess the initial set-up of this programme, the CCCP PMO commissioned a preliminary study of formative research to help understand the design phase of each site, from the University of Central Lancashire (See Annex B). A second study is in progress focussing on some of the early experience of population groups in the demonstrator sites. This will be made available when completed. 

Areas Out of Scope

The focus of this call is on evaluating existing interventions and approaches that are part of the CCCP. Other initiatives that may be in place outside of the programme are out of scope. 

Within the CCCP demonstrator sites, addressing health inequalities requires action across  the wider determinants of health, and partnerships to address them locally may include a variety of services and sectors. The specific focus of this evaluation is only on initiatives that are actionable by the health and social care system (including those that may be led by Local Authorities). Actions led by or dependent on decisions outside the health and care system are out of scope for this call.

Outputs

Applicants are asked to consider the timing and nature of deliverables in their proposals, including interim outputs. Policymakers will need research evidence to meet key policy decisions and timescales, so the resource needs to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.

For current planning purposes, we assume that a report will be available on completion of phase 1 – which will consist of key findings, as well as an updated, revised plan for the main stage. On completion of phase 2, a final detailed study report should be made available.  

New Guidance on Health Inequalities data collection within NIHR PRP Research

Inequities and inequalities in the provision, access to and experience of health and care services is a high priority area within the Department of Health and Social Care and the NIHR and is present in the majority of funded projects. We are now assessing all NIHR research proposals in relation to health and care inequalities. NIHR asks researchers to explore issues of inequality and inequity in the research being proposed. 

Our goal is also to facilitate more widespread and consistent reporting of data on health and care inequalities relating to the primary outcomes of NIHR funded research. Applicants should, if feasible, collect or analyse data related to health and/or care inequalities, we request that this stated in the proposal. This is a new request from the NIHR PRP and we will be continuing to monitor queries and make any necessary clarifications, as needed.

We understand that research projects may employ different methodologies, and focus on different populations. We ask that you please clearly identify in the research plan section of the application whether your application has a health and care inequalities component. If the project uses quantitative methods, please include detail of the core set of data that will be collected or analysed. Submission of the data collection will be a condition of final reporting that will need to be submitted to NIHR PRP when the grant has finished. If a health and/or care inequalities component is not included, please explain clearly why this does not fit within your research.

Specifically for this project, it may be useful to consider whether any particular groups are particularly impacted by discharge delays, and whether interventions have any differential impact for different groups. This may include consideration of local / regional variation, deprivation or characteristics covered by the Equality Act.

A recording of the Health Inequalities in NIHR PRP Research Q&A Event which was held on 19 September 2022 is available online, this may be useful to refer to as it provides additional information.

Further details about this new request can be found in Annex D

Management Arrangements

A research advisory group including, but not limited to, representatives of the Department of Health & Social Care (DHSC), NHS England, and other partners, and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

  • Provide regular feedback on progress
  • Produce timely reports to the advisory group
  • Produce a final report for sign off

Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR Central Commissioning Facility. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

Budget and Duration

Reflecting the requirements set out in this document, and our planning assumptions on study phasing, the funding available for this research is up to a maximum of £800,000. This is the available budget for all phases of the study, and applicants are required to provide costs for each.   

On completion of the first phase study, applicants will be required to set out their key findings in a report and produce a separate output that reviews their main stage plans and costs. This will provide the appointed evaluation team with the opportunity to refine their plans and adjust / reprofile the budget before a decision can be made on how the main stage of the study may commence.

Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.

References and key documents

Annex A 

We have identified an initial list of themes / challenges that are of interest to national policy makers – see below. The list is neither definitive nor exhaustive; they are intended only to illustrate potential areas of interest. We welcome comments from applicants on these themes, including suggestions of gaps and/or other potential issues that the study could address.  Applicants should consider how best to address these questions within a coherent study and may also include additional related issues where they are thought to be required. 

Creating the right environment, locally and nationally to enable sustainability

Overarching questions

  • To what extent and how are primary care and system partners in CCCP demonstrator sites working together to meet the complex care needs of people in their local areas with a focus on reducing disparities?
  • Is larger scale spread and adoption being achieved? If so, how?

 Example supporting questions

  • What are the key barriers and enablers at neighbourhood level, particularly for Primary Care Networks, to bring partners together to improve population health and reduce health disparities?
  • Are sites demonstrating changes that can be scaled to reach a larger group of people and be adopted to help other population groups?

People

Overarching questions

  • To what extent is the CCCP supporting the primary care workforce to be recognised, supported, and developed as part of ‘one workforce’? 
  • How, and in what ways, are staff working in more integrated models or teams helping to improve population health, and address health inequalities?

Example supporting questions

Establishing a flexible, multidisciplinary team

  • What are the key challenges sites are facing in bringing together workforce from across different organisations in a neighbourhood to form a multi-disciplinary team and/or enable Integrated Neighbourhood working?
  • What are the key enablers in breaking down silos between organisations and enabling new ways of working? 

Participation and engagement

  • How are sites measuring the impact of the CCCP on staff engagement, retention, and job satisfaction, particularly in relation to their roles and career developing within the PCN?

Workforce planning and supervision

  • How are sites deciding what skills or roles are required, and how significant is the Additional Roles Reimbursement Scheme (ARRS) or other dedicated staff funding in this decision?
  • How does clinical supervision and accountability for the service pathway work?

Community and patient impact

Overarching questions

  • To what extent is the CCCP facilitating improved access to local health and care services for the defined populations that the demonstrator sites are serving?
  • Is the CCCP approach strengthening the relationship between primary care, the communities, and people it serves, and the wider health and social care system? In what ways?

Example supporting questions

Public and patient experience of the initiative

  • What benefits or impact, if any, has the CCCP had on reducing disparities and improving access, experience and outcomes for patients been measured at site level?

Emerging similarities

  • Is it possible to compare the change to date and impact of different interventions between sites where they have used similar approaches and/or focused on similar segments of the population?

Data and information

Overarching question

  • How are the demonstrator sites using data to better understand the needs of population groups and individuals being served to develop services where they are needed most? 
  • How are demonstrator sites measuring outcomes for their target population?”

Example supporting questions

Data-informed decisions and monitoring

  • How are sites deciding which segments of the population to focus on?
  • To what extent is the CCCP approach taken by demonstrator sites based on evidence-based theories or principles drawn from available data?

Support and capability

  • What support, if any, is needed to help demonstrator sites make data-informed decisions?

Measurable proxies for impact

  • Are demonstrator sites dealing with the appropriate population to tackle the problems that have been identified, and how do they know?
  • Are CCCP interventions improving resource utilisation, efficient delivery, or increased productivity across the demonstrator sites?

Annex B: List of CCCP demonstrator sites

The CCCP is currently composed of a total of 63 demonstrator sites, with an aggregate population coverage of around 3 million people. The CCP has been delivered using a phased approach across the last three years:

  • Phase 1 (April 2021): composed of 26 sites in 2 NHS England Regions (all of which are still active)
  • Phase 2 (April 2022): a further 20 phase 2 sites were included, so providing national coverage in England (sites active across all 7 NHS England Regions)
  • Phase 3 (April 2023): an additional 17 sites were established recently.  Information about these sites will be available shortly no later than the end of May 2023

Site information is available - Complete Care Community - Demonstrator sites project prospectus 

Annex C: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research 

Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk. 

Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.  

For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group. 

For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.

We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used. 

We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section. 

* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.

** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.

*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.

Example data table for submission at the end of the funded research project

(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.

VariableOutcome (an appropriate average for this subgroup, usually the mean)Number of observationsAdditional information about variation if appropriate, e.g. range, standard deviation
Age 0  0 Additional information
Sex 0  0  Additional information 
Gender 0  0  Additional information 
Disability 0  0  Additional information 
Ethnic Group 0  0  Additional information
IMD Group 0  0  Additional information 
Region  0 0  Additional information