mPower mid-term evaluation report

1. Executive Summary
1.1 Introduction
This report presents the interim findings from the on-going evaluation of the mPower Programme. The Programme aims to deliver social prescribing and eHealth interventions within deployment sites in Scotland, Northern Ireland and Ireland.
Social prescribing is any activity in which a non-pharmaceutical intervention is recommended or provided to people with a non-clinical need such as loneliness, social isolation or low-level depression. eHealth interventions are any use of digital technology to promote health, wellbeing, self-management or efficient and appropriate use of statutory or private healthcare services.
This report examines the outcomes from the mPower programme as evidenced through qualitative work, as well as the differences and similarities between mPower deployment sites. Our evidence mainly consists of interview data gathered from a range of stakeholders including beneficiaries, local staff, mPower Project Board members, primary care representatives and third sector representatives.
1.2 Social Prescribing and eHealth – the Policy Context
The health, care and wider ageing and community policy contexts within each of the mPower partner areas appear to be conducive to supporting both eHealth and social prescribing implementation. Scottish health policy indicates digital technology will play an important part in achieving the Government’s person-centred ‘2020’ vision. Social prescribing is also central to the Government’s strategy on self-management of long-term conditions. In the face of an ageing population and limited funding, Northern Ireland is seeking to maximise the potential of technology to develop and modernise its health and care system to make it more responsive and better focused on the people it serves. According to the eHealth Strategy for Ireland, eHealth is a critical enabler of best-practice health systems and optimum healthcare delivery.
1.3 Existing Evidence on Social Prescribing and eHealth
Common positive outcomes from social prescribing identified in the existing evidence base include increases in self-esteem and confidence; improvements in mental wellbeing; reductions in anxiety and depression; and reductions in social isolation. However, there is a lack of evidence on whether social prescribing decreases non-clinical primary care usage.
Several eHealth interventions are more numerous within the mPower deployment sites: home alarms (pendants and wristbands); Florence (text-based medication reminders) and video conferencing (VC) through the NHS Attend Anywhere system. Home alarms have been shown in the existing evidence base to contribute to enabling older people to live at home, and as independently a possible, for as long as possible. As a text-based reminder system, Florence has been shown to have a positive impact on self-management. Video conferencing has also shown positive outcomes when it is used in clinically appropriate situations. In addition, communications technology has been shown to reduce social isolation of older people.
1.4 Methodology
Our evaluation of the mPower programme takes a realist approach (Pawson and Tilley, 1997). Its key principle is that the context in which an intervention takes place determines whether the intended outcomes are achieved. Realist evaluation aims to identify the underlying generative mechanisms that explain ‘how’ the outcomes were caused and the influence of context.
Multiple data sources have been used in our evaluation, including eHealth readiness questionnaires; baseline deployment site data; qualitative interviews; and observational notes. Interviews have been undertaken with mPower programme beneficiaries (16); Community Navigators (9); Implementation Leads (9); primary care staff (4); third sector staff (4); mPower Business Leads (1); and mPower Project Board members (7). Participant observation has also been carried out at three deployment sites. Interview transcripts and observational fieldnotes were analysed within the NVivo software package, using thematic analysis.
We are limited in what we can say about the generation of outcomes due to a lack of quantitative beneficiary questionnaire data. As data collection took place between the period of October 2018 to September 2019, some issues brought up may no longer be directly relevant to the current context of the deployment sites or programme overall. As interview participants were recruited through local mPower teams, the sampling may not provide a holistic picture of the range of beneficiaries and other stakeholders involved in the mPower programme.
1.5 Overall Programme Targets
mPower has achieved 32% (1,425/4,500) of its target number of digital health interventions and 24% (605/2,500) of its target number of wellbeing plans. The vast majority (98.3%) of all digital health interventions have taken place within the Scottish deployment sites; followed by 1.6% in the Irish sites and 0.1% in Northern Ireland. The vast majority (70.1%) of all wellbeing plans have been carried out within the Scottish deployment sites. The Irish sites have seen completion of 13.4% of wellbeing plans, with the Northern Ireland sites responsible for the remaining 16.5%.
Our evaluation has shown that context and approach to service delivery are central to understanding the generation of outcomes within each deployment site and for the mPower programme as a whole. The Scottish sites, for example, have benefited from having mPower staff in post quicker and employing staff already familiar with the landscape of their local areas. Their work has been aided by embeddedness within multi-disciplinary teams (MDTs). In addition, their eHealth readiness assessments generally show environments more conducive to the use of (innovative) technology.
The highest overall numbers of both eHealth beneficiaries (866) and wellbeing plans (238) are seen within NHS Ayrshire and Arran. The figures for NHS Dumfries and Galloway are the second highest within the programme and they have the greatest reach of any of the deployment sites – equating to reaching 8% of their over 65s population. Much lower levels of wellbeing plan beneficiaries are seen in HSE CHO8 (17) and WHSCT (39). Particularly low numbers of eHealth beneficiaries are seen in the Northern Ireland sites (2). Numbers of eHealth beneficiaries are a bit higher than this in the Irish Sites (8 and 15) but still lower than within any of the Scottish sites.
The numbers achieved so far suggest that the Scottish deployment sites may be able to achieve 2019-21 targets through a focus on the legacy and embedding of mPower. Support should be given to the Irish and Northern Irish sites to help realise numbers of eHealth beneficiaries in particular.
1.6 Local Identity
Areas in which higher numbers of wellbeing plans have been completed, tend to have fairly well-developed identities as ‘specialist’ social prescribing providers for older people. Areas in which staff reported feeling unsure about mPower’s role in eHealth service provision tended to have lower numbers of eHealth beneficiaries.
1.7 Connections to Primary Care and the Third Sector
Evidence shows that Community Navigators and Implementation Leads have personally put a lot of time and effort into establishing connections to primary care and local third sector organisations. The amount of effort was sometimes greater for those staff who had not previously worked or lived within their deployment site. We have seen evidence that effective social prescribing requires good links to both primary care and the local third sector. It is a difficult task for Community Navigators to both build these linkages and to carry out the required number of wellbeing plans/interactions with beneficiaries. Community Navigators and Implementation Leads being physically based within the same space as multidisciplinary teams/primary care, and being embedded within the broader health service, were seen as facilitators of success.
1.8 The Relationship between Community Navigator and Beneficiary
Across all deployment sites, the relationship between Community Navigator and beneficiary was central to the generation of outcomes. Beneficiaries highlighted, for example, that they were able to engage with the programme and achieve health and wellbeing outcomes because Community Navigators visited them in their own home, spent an adequate amount of time with them on each visit, and demonstrated genuine engagement and caring in interactions with them. Community Navigators were shown to be flexible, adaptable and in possession of a considerable skill set.
The Community Navigators have the power to act on the social determinants of health. The importance of the human contact that they provide for older people, who may be experiencing loneliness and isolation, is hard to overemphasize. It is the relationship between Community Navigator and beneficiary that is the foundation of much of the generation of positive outcomes within the mPower programme. However, this role carries with it a not inconsiderable burden in emotional terms. Evidence suggests that Community Navigators could be further supported through more formal debriefing processes and peer support.
1.9 A Broad Approach to eHealth
Numbers of eHealth beneficiaries are higher in the Scottish sites that report the adoption of a broad conceptualisation of eHealth. For example, the use of Attend Anywhere for social interaction (rather than just interaction with a healthcare professional) supports older people’s self-esteem and wellbeing. Supporting the use of technology for increased social connection has the potential to increase self-esteem, reduce depression and alleviate anxiety. Using Attend Anywhere, and other solutions such as Skype and text messaging, to connect people socially and to local activities remotely could, therefore, be an option to increase eHealth beneficiary numbers in those deployment sites that have struggled to implement more formal eHealth solutions due to procurement and other barriers.
1.10 Increasing Beneficiaries’ Confidence and Empowerment
There is evidence that engagement with the mPower programme increases beneficiaries’ confidence and sense of empowerment – this is largely through their interactions with Community Navigators and the completion of wellbeing plans. We have seen how the process of a guided conversation and goal setting with a Community Navigator is particularly important in generating confidence and empowerment for the beneficiaries.
1.11 Reducing Loneliness and Social Isolation
There is evidence that interaction with mPower leads to reductions in loneliness and social isolation. In fact, a reduction in feelings of loneliness and social isolation was the outcome most frequently discussed by beneficiaries, staff, third sector representatives and interviewees working in primary care. Group activities, in particular, contribute to the realisation of this outcome.
1.12 Enhancing Mental Wellbeing
Evidence suggests that interaction with mPower can contribute to maintaining or enhancing older peoples’ mental wellbeing. Our analysis suggests that it is social prescribing, and in particular, the nature of the contact with the Community Navigator, that generates a positive impact on mental wellbeing. However, there are also examples of eHealth and technology solutions contributing to the enhancement of mental wellbeing.
1.13 Facilitating Self-Management
There is some evidence from the analysis of our qualitative material that mPower encourages older people to engage with self-management behaviours. This was most often seen as a result of an interaction with a Community Navigator.
1.14 Safety of the mPower Approach
Generally, mPower stakeholders felt that social prescribing and eHealth are both acceptable and appropriate ways to facilitate self-management and to improve physical and mental health, and that safety issues do not outweigh the positive outcomes that can be achieved.
1.15 Impacts on Primary Care
Interviews with beneficiaries do not suggest that interaction with mPower affects their level of primary care attendance. This may indicate that ‘frequent flyers’ are not always targeted for referrals.
1.16 Benefits of the mPower Programme-Level Approach
Many of the local staff cited a key benefit of the mPower programme-level approach being that it gave them the ability to ‘pick up the phone’ and speak to local staff in other sites if they had a problem or concern they wanted to discuss. The presence of the central operational service spanning the deployment sites took some of the pressure off project leads, once this central team had been established.
1.17 Challenges with the mPower Programme-Level Approach
The main challenges discussed by interviewees surrounded the non-realisation of their expectations of mPower prior to starting in their project posts. Commonly, they had the expectation that there were joining a team to implement a specific service and eHealth solutions, that would be centrally provided by mPower. Participants expresses disappointment that these expectations were not realised.
1.18 Cross-Border Knowledge Exchange
Participants struggled to describe ways in which effective shared learning had taken place so far. Even when opportunities for shared learning were available, the cross-border aspect of the programme meant that learning was not always easy to transfer across areas. However, the recent introduction of case studies to project assemblies was broadly welcomed by local staff as it provided a good platform to communicate about challenges and approaches to service delivery across deployment sites.
1.19 Programme Legacy
A concern often raised by local mPower teams and Project Board members alike was whether mPower would have a meaningful legacy. In particular, they raised concerns about the ability to embed Community Navigator posts within their local systems.
1.20 Recommendations
• The focus for the Scottish partners may now most usefully be on embedding and mainstreaming mPower within local health and social care structures.
• Highlight and disseminate the good work of the Community Navigators, as without them outcomes would not have been achieved.
• Consider moving the physical location (base) of Community Navigators and Implementation Leads who are not currently sitting within the same space as MDTs and/or primary care staff.
• Where possible, find ways to work together with other social prescribing service providers but position each local mPower service as the ‘specialist’ social prescribing referral route for older people.
• Consider how the tasks of local project promotion and relationship brokering could be shifted from Community Navigators.
• Consider ways to mitigate the reliance on Community Navigators as individual sources of knowledge on local assets and towards a role as someone who knows where to look for knowledge.
• Recognise and promote ‘low level’ and ‘off the shelf’ technological solutions at a programme level, as these have been shown to be beneficial.
• Consider broadening the scope of eHealth interventions in the Irish and Northern Irish sites in particular to include some of the more ‘low level’ and ‘off the shelf’ solutions and technologies that have been used in the Scottish deployment sites.
• Encourage and support Community Navigators to identify appropriate eHealth and technological solutions to beneficiary needs during guided conversations.
• Consider use of the ECHO format for Community Navigators to share learning and engender peer support/safe debriefing opportunities.
• Focus on identifying and targeting frequent flyers if there is a desire to act on primary care attendance within the remainder of the programme.
• Consider creating a resource, or toolkit, that defines the essence of the ‘mPower approach’ and gives general guidance on how to go about implementing mPower in a locally appropriate way.
• Ensure that the mPower Project Board are tasked with decision-making and actioning around the legacy of the programme.