My Plan was a locally developed patient-held and owned plan (in paper form but ultimately envisaged as an app or dedicated digital device) to be used as a tool to support person-centred care. Similar tools had been demonstrated to be successful in improving services to patients elsewhere. The overarching concept was that it was held by the person and it set out what was important to that person. That included what they could do to stay well, what care and support they might need from others, what they were able do to manage their own health or to prevent a health condition worsening, and also, where appropriate, their wishes at the end of life.
The Hertfordshire and West Essex STP Personalisation Steering Group had agreed the content and had committed to rolling it out as part of their drive towards ‘person-centred care’, targeting in particular people (1) living with frailty, (2) with a new diagnosis of End of Life , (3) identified as frequent A&E attenders (4) living with long-term conditions. My Plan was intended to be initiated (but not necessarily completed with) health and social care staff who were to be the ‘key enablers’.
The task of rolling out My Plan to a tightly prescribed timetable in East and North Hertfordshire CCG fell to the Frailty Programme Manager. She was a former CLAHRC research associate and – through the ARC’s Ageing and Multimorbidity Theme – secured the help of the ARC’s Implementation Leads.
Early discussions revealed that on closer review not only was the evidence base for My Plan in fact fairly weak, but that many of the health and social care practitioners had misgivings about the feasibility, efficacy and even the safety of the MyPlan scheme. However, in parts of the service and among some of the patient advocates and senior director level, there was strong support, and there was pressure to go ahead with the rollout which included a cohort in Stevenage; it was a core element of the commitment to person-centred care.
The ARC Implementation Leads established a community of practice (CoP) in Stevenage, consisting between 6 and 9 service managers and senior community clinical and social care staff who were facilitated in the usual way by the ARC Implementation Leads. Using relational techniques, the CoP members were encouraged to explore, in a safe environment, all the diverse views about the innovation within the contexts of the services they worked in, and to agree a plan. Their emergent view was that before My Plan could be rolled-out they wanted to run a pilot scheme to evaluate if, how, and with whom it worked. The views of the CoP were sufficient to persuade the senior directors, who had previously held firm about implementing My Plan as planned, to delay the launch pending the results of the pilot. Over a series of three CoP meetings between July and December 2019, the pilot was designed and executed. Eighty patients in various Stevenage community services were offered the booklet and guidance in filling it in. The results of the pilot demonstrated beyond any doubt that the scheme would not be accepted by patients or staff in its current form: not a single patient had used it in a way that would have been helpful in practice.
Meanwhile the roll out had been commenced as planned in four other services/ sites across the county, including the original community clinic that had strongly advocated it. At a final meeting of 20 managers, practitioners and patients from all the sites that had used My Plan, it emerged that those that had introduced it with no formal evaluation were also running into difficulties, though interestingly one independent care home had adopted it for care planning and found it useful. It was agreed that the scheme as currently designed was unworkable unless certain organisational conditions – not found in the other services where the launch had been tried or planned – were met.
Unlike those running the other rollouts, the Programme Manager was able to use the findings of the evaluation carried out by the CoP to explain to the senior directors how and why it was inappropriate to run the My Plan scheme in their context. She later described this as a “really powerful” way of using an evaluative approach to implementation that “saved wasted effort and disillusionment” as well as the unnecessary costs of a large rollout doomed to failure.