New Models of Care

This work-package is how all the other work-packages translate into the real world. Drawing on the initial findings of all the research work-packages, we will co-create new models of care which are grounded in detailed understanding of individual need, which use existing data and predictive tools to support categorisation of individuals' risk levels. This categorisation will flexibly incorporate proven new technologies as they become available, integrated within existing health and social care services. 

New Models of Care is a collaboration with colleagues from Newcastle University’s Institute for Ageing, which hosts the National Innovation Centre for Ageing. Our collaboration with this world-leading research Institute and centre at Newcastle University greatly strengthens the networking opportunities for the ACRC and thus future funding opportunities for both Universities. 

What are our intentions?

The overall aim of this work-package is to work with health and social care providers to support and evaluate the development of new models of integrated care. To do this we need to understand existing and evolving models of care, and to develop, optimise and test innovative new models of care in Scotland and England. Specifically, we are interested in identifying variation both early in the trajectory of care when interventions are less intensive and more directed to self-management at home, and later when more intensive interventions and residential care are more common. Given that health and social care policies have commonalities but also significant divergence between the two countries, our objectives are: 

Objective 1: to study the international changes in health and social care systems in response to the global challenges of ageing populations, multimorbidity, and frailty, and to relate these findings to the evolving health and social care integration and reorganisation of primary care in Scotland and England, and the intended and actual impact on those with complex care needs 

Objective 2: in the context of objective 1, to explore multidisciplinary team care for people in later life with a spectrum of care needs in South East Scotland and North East England, identifying examples of innovative practice in community and primary care, and barriers and facilitators to change in areas where care has not significantly evolved. Selected examples will then be examined in-depth.

Objective 3: to synthesise findings in collaboration with health and social care stakeholders and public/patient partners to design new models of care for implementation and evaluation at scale. 

Objective 4: To submit a series of major grant proposals to rigorously test these new models of care in terms of effectiveness, safety, and cost-effectiveness.   

We will focus on four areas that influence key care pathways in this work-package.  

1. Community and third-sector support for people in later life living in the community 

2. Integration of statutory health and social care services for people in later life living in the community 

3. Transitions into care homes  

4. Improving the care of those already living in care homes 

Why is this important?

Health and social care in the UK is in a state of rapid change with major initiatives in health and social care integration, primary care reform and new general practice contracts, supporting self-management, and better targeting of new kinds of statutory and third sector care. There are also considerable opportunities for collaborative working to shape and evaluate new models of care as they emerge in service innovation and/or are developed as part of research. 

Two key developments in many areas of the UK relate to the use of asset-based approaches to care, and developing more multidisciplinary comprehensive assessment and intervention for people with the highest care needs. Implementing a new service model brings many challenges, and new tools for sharing information about services have the potential to help break down some of the traditional barriers to self-care and autonomous decision making in this context. Such democratisation of knowledge, that promotes individuals themselves as experts in knowing what will work for them in their lives, is critical.  

How will we achieve this?

These objectives will be carried out by researchers at the Universities of Edinburgh and Newcastle:

1. This work-stream will involve reviewing the international literature, and English and Scottish policy documents. Interviews will also be conducted with key stakeholders. The aim of this work-stream is to gain comprehensive and up-to-date knowledge of the international and UK landscape regarding new models of care in community and primary care settings across our 4 areas of focus. This work-stream will be completed in the first 12 months of the project.

2. This work-stream will involve gathering local information on established or evolving innovative approaches for target groups of patients in South East Scotland and North East England, in order to identify and document in-depth examples of new models of care across our four areas of focus. We will combine qualitative interviews with quantitative approaches. The time-line for this will be months 6-18.  

3. This work-stream will integrate and synthesise the findings from the previous work-streams and will also incorporate emergent developments from the other work-packages. We will use a co-design approach to develop and optimise new models of care for evaluation and implementation at scale. The aim of this work-stream is to have a range of rigorously developed interventions across our four areas of focus ready for testing at scale. The time scale for this will be months 18 – 30. 

4. To submit a series of major grant proposals to test these new models across our four areas of focus of care at scale in terms of effectiveness, safety, and cost-effective. Time-scale for grant submission is 30-36 months. 

Meet the Team: New Models of Care

Workpackage Lead - Professor Stewart Mercer

Stewart Mercer is a General Practitioner, Professor of Primary Care and Multimorbidity and Deputy Director of the ACRC. His research focuses on understanding and responding to the needs of people with multiple complex conditions.

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Academic Lead - Professor Eileen Kaner

Eileen Kaner is Professor of Public Health and Primary Care Research and an applied behavioural scientist with expertise in intervention-based research; she is also Director of the NIHR Applied Research Collaboration for the North East and North Cumbria region of England.

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Academic Lead - Professor Barbara Hanratty

Barbara Hanratty is a GP, Professor of Primary Care and Public Health and deputy director of the NIHR Policy Research Unit for Older People and Frailty. Her research concerns older people, with a focus on the health and social care interface, end of life and long term care.

 Find out more about Barbara Hanratty on their profile page

Academic Lead - Professor Susan Shenkin 

Susan Shenkin is Professor of Healthcare for Older People, University of Edinburgh Consultant, in Medicine of the Elderly, NHS Lothian. She co-chair of ENRICH (Enabling Research in Care Homes), and Deputy Director of the ACRC Academy. Her interdisciplinary research focusses on the causes and impacts of ageing, particularly for people with dementia or delirium, and those who live in care homes.

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Director - Professor Bruce Guthrie

Bruce Guthrie is Professor of General Practice at the Usher Institute, in the Edinburgh Medical School.

Bruce is a mixed methods health services researcher with an interest in the quality and safety of health and social care, particularly in relation to multimorbidity and polypharmacy. As well as research, he works clinically as a GP and works closely with the NHS and government to improve healthcare quality and safety.

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Academic Lead - Professor Amy O'Donnell

Amy O’Donnell is Professor of Applied Health and Social Care Research at the Population Health Sciences Institute. Newcastle University. Her work focusses on using complex systems approaches and digital technology to improve outcomes for patients with multiple complex needs over the life course.

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Research Associate - Dr. Helen Frost 

Helen Frost has been involved in a wide range of clinical and public health research for over 25 years. Early in her career, Helen worked in the NHS in England as a physiotherapist, developing and evaluating complex interventions alongside clinical practice. Prior to completing a PhD in Public Health at the University of Warwick in 2007, she was the Director of Physiotherapy Research at the Nuffield Orthopaedic Centre, Oxford. In this role she was awarded funding from the MRC and other charities to lead several complex randomised trials of physiotherapy and surgical interventions.

In Scotland, Helen joined the ‘Scottish Collaboration for Public Health Research and Policy (SCPRHP)’ and led the ‘Later Life Working Group’ where she developed skills in reviewing and evidence synthesis. In 2014, she joined the NMAHP Research Unit at the University of Stirling, where she gained further experience in Implementation Science, working with the Scottish Improvement Science Collaborating Centre (SISCC). More recently, Helen has worked as a lecturer and researcher in Health and Social Care at the University of Stirling and Edinburgh Napier University.

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Research Associate - Tricia Tooman

Tricia Tooman is a health services researcher with expertise using a knowledge systems lens to understand healthcare improvement. Her background as a social scientist includes medical education research and learning and change management. Tricia has been involved in a wide range of research projects including the Scottish Doctors' Wellbeing Study, Transitions of Healthcare Graduates and the Impact of Covid-19 and Embedded Models of Knowledge Co-Production. She completed her PhD at the University of St Andrews in 2019 and studied the interconnection of research, policy and practice for improving sepsis care in Scotland.

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Research Associate - Bruce Mason

Bruce is a mixed methods social researcher specialising in qualitative and ethnographic research methods. He has worked on a variety of research projects over the last 25 since completing his PhD in Folklore studies at Memorial University of Newfoundland. Since joining the Usher Institute in 2008, he has worked on projects in palliative care focusing on health services research into the issues around providing primary palliative care in the community and the use of screening for future care planning using AnticiPal and SPICT(tm). He is the first member of staff working with the Green Social Prescribing Project.

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Academic Lead - Dr. Atul Anand

Atul Anand is a Senior Clinical Research Fellow. He is interested in the use of routine health and social care data to improve outcomes for older people. This is in line with his clinical work as a consultant geriatrician at the Royal Infirmary of Edinburgh. Atul is the clinical data lead for the DataLoch programme – a data repository of health and social care data in South East Scotland – that is improving access to research-ready datasets for the region. He is interested in understanding the impact of multimorbidity in our population, and refining the way we establish the presence of chronic health conditions from electronic health records. He is a co-investigator on the AIM-CISC Programme in which we are better defining multiple long-term conditions using datasets from across the UK. He is also interested in the use of routine electronic health records in hospital to identify frailty and rehabilitation needs. He is a passionate advocate for these methodologies to improve representation and inclusion of older people in clinical trials.  

Find out more about Atul on their profile page.