Key areas of learning

• ▶ Stakeholder engagement

  Ways to Wellness represents a collaboration across sectors – public, private and third (VCSE) sectors. Each sector brings unique insights and approaches to the undertaking, creating an opportunity to collaborate and draw from the strengths of each, while learning from one another in the process. Ways to Wellness’ position in the middle as a ‘special purpose vehicle’ (SPV) provides a shared platform upon which to build the collaboration.

  Ways to Wellness involved key parties and stakeholders from an early stage of its development. The service development included an element of ‘co-design’, bringing together key stakeholders to ask for their insights and input into the service design and intervention approach. This strengthened the delivery model and also increased stakeholder understanding and buy-in. Innovation, by its nature, involves risk and uncertainty; it is human nature to feel more comfortable taking risks with people we trust and building trust is a key aim in our stakeholder engagement.

  Stakeholder engagement and collaborative working continues to be one of the critical success criteria during Ways to Wellness’ delivery phase, due to the innovative nature of the approach and the associated need to respond to new information and adapt the model as the plan unfolds.

• ▶ Social investor engagement

  The social investor is likely to play a significant role in the latter stages of development of a SIB-funded service, if not earlier. The level of investor involvement in the delivery phase of a SIB-funded service varies with different investor approaches. A social investor with previous first-hand experience with SIB funding can offer valuable insights and expertise, particularly with regard to the contracting structure and financial model. Private sector approaches and expertise can strengthen collaborative working, for example, increasing rigour of data analysis. Building effective processes and guidance for decision-making and performance management, including managing differences in opinion or resolving conflicts of interest will be key to successfully navigating the inevitable challenges that arise from unexpected results or situations. Scenario planning for a wide range of possible outcomes might also help prepare all parties for potentially difficult conversations.

• ▶ Simplicity of outcome payments

  Outcome-based contracting and SIB investment appear to work well when the paid outcomes are as straightforward as possible – i.e. the outcomes are few in number, change can be convincingly attributed (or at least clearly linked) to the service intervention and outcomes can be reliably measured either in the course of delivering the service or through accessible data normally generated. Ideally, outcome payments (and other payments) should be designed through a contracting structure that supports the alignment of key parties through shared outcomes and associated incentives, whilst simultaneously aiming for an appropriate balance of power and risk.

• ▶ GP practice engagement

  GP practice staff teams are the primary source of patient referrals in the Ways to Wellness model. Engagement of GP practice teams is therefore critical to achieve beneficiary engagement targets. Furthermore, an ambition of Ways to Wellness is to play a role in expanding GP practices’ offer to their patients, to supplement the medical model of care with a well-delivered social approach to patient care that will lead to reduction in demand for NHS services. Ways to Wellness has increased the awareness and endorsement of social prescribing amongst the great majority of the GP practices in the catchment area, including introducing effective new referral and feedback processes, tailored to each GP practice, to best support their team’s systems and patients.

• ▶ Sharing of risk and alignment of incentives

  The design of Ways to Wellness’ contract structure aims to align contracting arrangements and payment incentives such that risk could be appropriately shared and balanced against potential benefit. For example, service providers are shielded from the risk of variable outcome payments through a contract structure that predominantly pays based on activity (linked to patient engagement). The formation of Ways to Wellness as a special purpose vehicle (see below) is a key structural element enabling the sharing of risk and alignment of incentives.

• ▶ Use of a focused 'special purpose vehicle' (SPV)

  Ways to Wellness formed as a new organisation, termed a ‘special purpose vehicle’ (SPV), prior to signing contracts with the commissioner, investor and service providers. Ways to Wellness has a small central staff team who are fully focused on the successful delivery of this service, alongside a Board of Non-Executive Directors. Creating an SPV the service allowed for careful calibration in the alignment of risk, costs and benefits for each stakeholder through contractual terms and management responsibilities. The SPV also ensures that a dedicated team remains focused on supporting the service and outcome achievements, provides a ‘middle ground’ position to lead the collaboration (and potential negotiations) amongst the key stakeholders and keeps a central repository for evidence base and knowledge building.

• ▶ Multi-provider model

  The scale of Ways to Wellness’ delivery model and contract value has the potential to overwhelm or destabilise smaller VCSE organisations. Creating the Ways to Wellness SPV and subcontracting the work to four different service providers protected the service providers from this potential risk and furthermore spread the investment and expertise building across four VCSE organisations, while allowing different delivery approaches to be tested. Different service providers bring unique organisational expertise, business models and operational approaches. Collaborative working has the potential to strengthen the delivery and increase learning. The multi-provider model is optimised when collaboration is underpinned by shared commitment to the aims of the service, transparency, trust and effective communication. Effective collaborative working requires time and commitment from all parties, particularly when innovative approaches require iterative change cycles. Outcome-based contracting and SIB funding require detailed modelling, monitoring, analysis and forecasting – for this approach to be successful, it needs to be supported by service providers and compatible with their business and operational models.

• ▶ Level of expertise at Board level

  The innovative nature of the SIB investment and outcomes-based contracting model, in addition to the beneficiary focus of the service’s aims and objectives, has attracted experienced and dedicated Non-Executive Director Board members. The SIB investor holds two corporate Board positions. The ten Board members supplement the limited capacity and expand the range of expertise of the small SPV staff team. In navigating uncharted territory, it has been important to build effective governance and processes for decision-making and management of unexpected scenarios.

• ▶ Quality of service provision and patient experience

  Patient wellbeing improvements have been consistently above target across disease category, gender, age and ethnicity. Other measures of service quality are also consistently strong such as, patient surveys, GP practice staff surveys and qualitative research results from Newcastle University. Funding secured from the National Institute of Health Research (NIHR) by Newcastle and Durham Universities will build further qualitative and quantitative evidence and understanding of Ways to Wellness service provision characteristics and impact.

• ▶ Enthusiasm and commitment to innovation and social impact objectives

  The pioneering nature of Ways to Wellness’ approach has required tenacity and perseverance of those involved, in the development and delivery phases. For example, frequent analysis of emerging data and incorporating new learning into delivery improvements and outcome achievement requires flexibility, dedication and collaboration of staff and stakeholders. Key staff and stakeholders have persevered despite setbacks and high demands, overcoming barriers, in large part due to their enthusiasm and commitment to the innovation and the social impact objectives.

• ▶ Delivery approach informed by rigorous data collection and analysis

  Collecting and recording key data that allows for ‘real time’ monitoring and analysis is critical to successful service delivery with SIB investment and outcomes-based contracting. This approach supports the careful monitoring of key performance indicators (KPIs) linked to outcome achievement and service quality, which in turn allows for any areas of concern to be acted upon promptly. It is easy to underestimate the time and energy involved in these processes; adequate time and resources should be allocated to rigorous data collection, monitoring, analysis and response.

• ▶ Bespoke information technology (IT) management system

  Ways to Wellness worked with a sub-contracted IT firm to develop a bespoke management information system to allow remote access by Link Workers as well as central office staff. This facilitates ‘real time’ data monitoring and the prompt identification of any potential issues that may affect outcome achievement. Our system continues to evolve with service delivery. It has been particularly useful to design the system such that it is supports delivery staff in their day-to-day activities with clients, provides reliable service metrics in ‘real time’ and produces useful reports or a ‘dashboard’ of KPIs.

• ▶ Training and workforce development of Link Workers

  The social prescribing approach is gaining momentum in the UK but remains variably understood, likely because it is a highly individualised (person-centred) approach and can be defined and implemented differently depending upon the context and objectives. Ways to Wellness has developed a unique approach to longer-term, ‘at scale’ social prescribing, including a training and workforce development model, which continues to be adapted as the service delivery model matures.

• ▶ Detailed operational and financial model development

  Ways to Wellness developed a detailed financial and operational model to inform the negotiation and agreement of contractual terms. This detailed model supported understanding and transparency for stakeholders to be comfortable with the commitment, innovation and risk. As the service has unfolded, a dynamic financial model has been created that includes actual achievements and can be flexed to model projections at different levels of achievement of variables. Ways to Wellness has furthermore developed operational guidance documents for service delivery.

  Ways to Wellness’ service delivery approach is increasingly well defined and unit costs can be demonstrated. This is a valuable framework for others who wish to understand what is practical and possible for a SIB funded, social prescribing service.

• ▶ Service impact on NHS demand (cost, activity)

  Secondary care costs have been regularly measured for the Ways to Wellness cohort and its comparison cohort, including retrospective data from 2012/13, with increasing frequency and granularity. Data showing service impact on activity and demand reduction in both secondary and primary care is being to emerge. NHS data analysts and Newcastle University researchers agree that further data and more sophisticated statistical analysis techniques are required to fully understand service impact. Funding from the NIHR has been secured to undertake extensive service impact research and evaluation in 2018-2020, including economic evaluation. Further impact data and more sophisticated analysis should also help NHS commissioners to better understand how potential ‘cashable’ savings might be released from the system.

• ▶ Long-term financial viability for all key stakeholders

  With over three years of service delivery experience and metrics, Ways to Wellness has a clear understanding of annual costs, including central and overhead costs and variable service delivery costs. Some uncertainty still exists at this stage regarding the long-term viability of this model of service delivery, including the cost of finance and repayment of the SIB investment and the longer-term consistency of outcome payment achievement. The longer-term impact on other VCSE services to which patients are often signposted is also an area of continued monitoring.

• ▶ Further patient benefits and effects of social prescribing

  Although the wellbeing improvements for patients are, on average, consistently above target for Ways to Wellness, further research is required to better understand the impact of the wellbeing improvements on patients’ health and other areas of their lives, to identify other health and social benefits that might be related to the Ways to Wellness service and to explore any potential differences in impact for stratified patient categories (for example, higher needs related to mental health or chaotic life situations, language barriers, learning disabilities, dementia, etc.). The NIHR-funded research being conducted in 2018 to 2020 by Newcastle and Durham Universities, in collaboration with Ways to Wellness, will make a significant contribution to the evidence and understanding in these areas.