*2.3.4.5 The lived experiences of two TSOs engaging in the SILC project*

Informed by the QIF, improvement for future applications requires learning from experience [8]. To gauge the experiences of those participating in the project, a brief semi-structured interview was conducted at the end of the year to explore what service managers thought of the initiative, and how they might improve it for future services embarking on a similar journey of collaborative learning. The boxes below contain extracts from these interviews with two self-selected TSOs.

#### **Service A: Interview Extracts**

*I did that like kind of cyclical journey, that it's not linear, we've got new practitioners all the time, we've just got 8 new practitioners in now, and they're going back through that loop. They're doing their first data clean this week where I'm just putting them through all the information, right we need to go through and see, right this is done, this is done, and you keep on embedding it, keeping the data quality up really. Constant, it must be really because when I've dipped out of the service, it went a little bit, my practitioners got a little bit complacent.*

*Our first question was how is it going to work for our clients? Building that value for them, and the practitioners, giving them a value to the work. This is not a measurement, it's not an outcome, it's an aide to the process, something that helps the work with clients. And then, once we all understood that, we could have an open conversation about why we might want something like this. You really need that opportunity to embed it early on though. It completely allowed us to cement and consolidate how we work. I mean the data the project provided, really cemented what we were doing, how we were doing, we were using data in the right way, but it also gave us ways to look at data differently, what we could do, so it was an enhancing experience. That allowed us to feel quite proud of what we do, and have it validated, which for us a charity tucked away from others, that was a nice thing to have it validated on that level.*

*I think one of the biggest things for us, the 4-session thing, spotting that. We actively use that in supervision now, so it's really looking at, from that first session, you can see it quite clearly. So, there's more focus in those first 4 sessions, really looking at what the client needs, with a view to contracting through goals, further through that process. So that we're really meeting those needs, making that environment that's conducive then to achieving good outcomes.*

*We're about sharing good practice, we're about empowerment, we're about creating choice and all those things. Being part of SILC fitted with part of the ethos so it was nice to go and be there in that capacity with other services. There's something about talking to someone who's been through it, we're just through it. It's that kind of picking their brains and have you thought this?*

*For me it's about credentialing the sector, it's about professionalism, it's about best practice, it's about evidence base, not being afraid to strive, to get to those levels, and get good outcomes and be accountable for that. I don't think therapy is any different from if you go to a shop to buy something you expect it to be good quality. I don't see why in therapy, clients shouldn't expect it to be any different.*

#### **Service E: Interview Extracts**

*Having the support from the team that was specific to our service, having experts on hand when you needed them. Keeping on top of the data quality is not as easy without the help of the project team, and our monthly calls and the little tool pointing out the problems… Whereas sitting down and finding the problems myself is another matter. I personally enjoy getting involved in things like this. I find it very stimulating. It ticked a lot of boxes for me, in terms of what we wanted for the service, but also for me personally, it was an interest. You couldn't have designed it better for me… So, I think without that personal interest and enthusiasm it wouldn't have happened. I think I'm very fortunate in that I've got a very good group of people, I think credit needs to go where it's due, they are a group of people who are motivated and supportive and I think all we did was talk about, well this is going to be a benefit to the service, and they're all very committed to the service and they came, I suppose, with open minds. That's been one of the key things for me, has been the experience of being part of the learning collaborative. And I think that is so valuable, personally and also for the service, because you're going through a journey with other services, their journey's different but there are similar issues. It's just that ability to share learning and connect with people who have a similar job, are having similar issues. When you have something, and they say, yeah that's happened to me. And for me, it takes away that sense of being in your own little bubble, in your own little service, which I wouldn't say is isolating but that you're not part of anything else. The learning collaborative made you feel part of something bigger with some connections, and yeah, doing the same thing you're doing, I thought it's fabulous, it's brilliant. It's the practical stuff, we've become a service that does sessional measurement using tablets, that's the way we do things now. We've changed the way we manage DNAs, we have an appreciation of data quality, and that's not just me, the team come along and say why haven't I got 100%? Why is this only saying 90%? Can we have a look where that 10% has gone? So, there is an appreciation now of the importance of good data. In fact, the things that SILC was meant to address, are the things that have changed in our service.*

*It's a no-brainer. Why wouldn't you? I can't see any reason why you wouldn't, unless you haven't got the support to see it through. Know your organisation, know that you've got that support, to be able to put the time into it, those are the two caveats, otherwise, it's a no-brainer.*

#### *2.3.5 Resolution: How things have ended up in this story*

In keeping with the IHI's [10] collaborative learning model framework, the first year of the SILC project culminated in a summative conference. Nearly 100 delegates were in attendance, each representing a range of different sectors within the field of talking therapies. Both the project team and self-selected SILC TSOs held a discussion regarding their experiential learning during the first year of the project. There was a consensus at the event about the operational challenges facing modern-day talking therapy services. While systems were becoming increasingly sophisticated, the training and support necessary to build in-house expertise were reportedly difficult to access due to time and resource constraints, a saturated and uncertain field, and isolated working practices. Providers, particularly in the thirdsector, desired the opportunity to work in partnership with others to share learning and enhance theirs and the sector's organisational and therapeutic models further.

With the first stage complete, the SILC project has amassed a wealth of learning which will be converted into a modular learning programme, providing a resource for future applications of the network [8, 9]. This will replicate the CLN model and invite existing SILC members to act as guest speakers and offer unique support and valuable insights to newly recruited collaborative members. There are three existing SILC TSOs who have declared their interest and commitment to continuing with the project. Due to a turnover in management and decrease in contribution, two members have since withdrawn. The next phase of the initiative will focus on expanding the network, building on the existing knowledge and aggregate data to support ongoing analyses and resource development.

#### **2.4 Themes**

Themes are the essence of a story, the central constructs which reflect the actions, perceptions and experiences of the characters in their situational contexts. They represent the underlying 'big ideas' which transcend the distinctions between

#### *Evaluation of Health Services*

settings and circumstances and help conceptualise elements and links between them. This is important given the lack of guiding conceptual models for the sustainment phase of implementation [11]. Listed below is a discussion on some of the key themes both the participating services and project team uncovered during this stage of the project.

## *2.4.1 The possibilities of CLNs in mental health TSOs*

The unintegrated nature of TSOs in the UK means there can be obstructions to developing and integrating EBP [2–4]. Within the field of talking therapies, determining what constitutes as EBP has been criticised for its reliance on controlled study methodologies which, due to their somewhat artificial nature, are considered detached from the clinical realities of routine practice settings [22, 23]. Certain advocates support a PBE approach to complement and address these limitations [24]. However, PBE relies on the collection of robust, aggregate datasets across multiple organisations sharing a common system or model.

Fragmentation, isolated working practices, and resource constraints can limit TSOs generating the PBE necessary to support their delivery [2–4]. Indeed, the primary interest from prospective members in this project was overcoming these barriers and demonstrating they were treating clients effectively. By pooling experience, resources and expertise around a central, unifying theme, TSOs were able to systematically explore, assess, understand and reflect upon key aspects of service quality development. Through iterative cycles, strategic improvement models and coordinated and collaborative dialogue [10], services were able to generate timely and actionable insights that were relevant to their unique circumstances. Testing practice changes on small scales, using focused inquiry and PDSA cycles, helped achieve small wins which, according to evaluation theories, can be an effective strategy for boosting perceived capabilities [6, 10].

Replicating previous research findings [2, 3], access to a supportive academic project team was deemed invaluable for producing, mentoring and synthesising analyses and learning across the network. However, liaising with several TSOs proved to be a lengthier and more complicated process than first envisaged; an experience which is echoed elsewhere [6]. This identifies an important obstacle for sustaining CLNs, particularly those undertaking continuous analyses. It might be that by offsetting resources to a project team, this creates a more efficient process within individual services as it shares the expertise around a common need. If this were true, then it could prove more efficient and cost-effective for TSOs overall.

Given the central communicative nature of CLNs, it is important these channels are equitable. Within the third-sector, organisations tend to differ in size and can be equally varied in their operational modelling [2, 3]. This inequity in size and visibility could feasibly leverage greater influence over smaller providers to work towards their agenda. To overcome the challenges of distinct delivery models within CLNs, a central governing platform using cooperative representation could therefore be valuable for identifying topics of interests and establishing a dictionary of terms. Similarly, these communication channels ought to use terminology that is consistent and agreed upon, particularly around subjective concepts such as ending types as doing so would ensure greater validity and reliability in data analytics [20].

#### *2.4.2 Management and leadership*

Many implementation frameworks emphasise the planning stages as critical to successfully embedding innovation [8, 11–13]. Because implementation can be a complex process involving integrating existing practices with new, it typically

### *Evaluating the Efficiency of a Collaborative Learning Network in Supporting Third Sector… DOI: http://dx.doi.org/10.5772/intechopen.84294*

requires a well-planned, structured and iterative process, addressing the various philosophical and practical barriers that can occur regularly [9, 15, 21]. It is within these contexts that supportive leadership can be a facilitating factor [2, 11, 15, 21, 25]. Without effective leadership to track, monitor and effectively champion the merging of practices, any expended effort can unravel [9, 15, 25]. Those in leadership positions need to be present and well-respected, retaining a detailed awareness and understanding of delivery and operation [15]. Service quality development through CLNs therefore appears to be reliant on management structures and local leadership.

In considering the scale of change and level of turnover in TSOs, particularly at a managerial level, the reliance on leadership highlights a notable barrier. Given the project team tended to work exclusively through managers brokering knowledge and training, their absence ultimately affected their organisation's participation and operational processes. It could be argued this was a sideeffect of the chosen methodology which may have benefitted from a broader involvement and contribution among the workforce. Advocates across the field recommend ensuring a local champion is permanently in place, advising that those departing a service provide sufficient training to those replacing them [9, 15, 26]. While this recommendation is practical, how it applies to TSOs is perhaps more complicated.

Continually nurturing the operational climate through sustained involvement and being present can help resolve the functional mechanisms of feedback systems [15, 25–28]. A perceived lack of presence in the project among some practitioners served to undermine the initial enthusiasm and positive ethos established at the project's outset. Services which thrived tended to dedicate additional time and resources to sharing information in an open and accessible manner. This actively engaged the workforce in the minutiae of feedback informed treatment (FIT) [28] and encouraged more open dialogue. The literature on FIT teaches the value of routinely soliciting responses from clients about treatment progress, aiding practitioners at a therapeutic level [28–30]. However, there is an additional service-level which could also help inform practitioners and other stakeholders about enhancing client engagement and outcomes. By combining a FIT model with a feedback informed service, practitioners could have timely access to relevant learning. With reference to the QIF [8], supportive feedback mechanisms will be relevant to all stakeholder levels and through aggregate data, the client voice can be made accessible to all, helping sustain innovation.

## *2.4.3 The resource challenge of TSOs*

Based on the learning from this initiative and relevant national and international research [2–4], there appears to be a significant resource challenge facing TSOs. Although many report having an interest in quality improvement [3], the constraints on providers including turnover, financial pressures and limited budgets, appear to greatly impact their ability to generate data and engage in practice development [2–4]. For a sector that relies heavily on volunteers, some of whom are in trainee positions [1], preserving a level of local expertise represents a continual challenge, particularly as systems become more expansive, specialised and costly. Although the CLN was a means to pool and share resources, supporting the implementation phase [11], external pressures had a notable influence on its integration, process and overall output. The level of attrition at the beginning and eventual withdrawal of others highlights the scale of this challenge. Consequently, this further demonstrates the criticality of the QIF phases in thoroughly assessing the fit between the host setting's aspirations and readiness for change [8, 9].

Given the sheer scale of change and advancing pace of new technologies, feedback systems and innovations are becoming increasingly sophisticated while at the same time, access to training and support might not be keeping pace [3, 31]. For many, including attendees at the summative conference and across the wider literature [3], allocating resources to this endeavour might be considered non-feasible as few can afford or justify it economically. This issue is further compounded by the fluctuating and isolated nature of services as well as barriers in accessing the literature due to subscription paywalls [2, 3]. Accordingly, this highlights the need to consider the additional training and support required when adopting new innovations.

Despite its limitations, a CLN could address some of the resource challenges identified, increasing the opportunities for learning. Disseminating feedback throughout a network might help overcome some of the barriers to accessing research and forming partnerships [5, 6, 10]. Shared learning across all levels of the network, could foster a broader culture of openness and training, supporting collaboration across multiple platforms, while also generating an asset for feeding back insights across the sector. Undoubtedly, this would rely on the aggregation of robust datasets and communication platform to support this process [5].
