Using an organisational change tool to monitor and support the implementation of Person Centred Coordinated Care (PCCC) in General Practice in Somerset, UK

Talk Code: 
Inocencio Maramba
Jane Horrell, Richard Byng, Donna Chard, Helen Lloyd
Author institutions: 
NIHR CLAHRC South West Peninsula (PenCLAHRC), Plymouth University Peninsula Schools of Medicine & Dentistry


Person Centred Coordinated Care (PCCC) has the potential to achieve better outcomes for patients and to improve efficiency for health and care economies. As part of the ‘Test and Learn’ programme, three sites with associated general practices across the health and social care system in Somerset, are implementing different innovative models of PCCC to improve outcomes for patients with complex long term conditions (LTCs) likely to benefit from input from several professionals.


The South West Peninsula CLAHRC, in collaboration with South West Academic Health Science Network (SWAHSN) is conducting an evaluation using a three tiered, multi-perspective longitudinal approach including qualitative interviews and observations, structured questionnaire data and quantifiable service use data. To capture the processes of care from an organisational perspective we are using the Person Centred Coordinated Care Organisational Change Tool (P3C - OCT) which is completed by the core staff for each practice. Developed for use across the programme the tool consists of 31 questions, each related to practitioner activities and supporting organisational processes, for which there is evidence to improve PCCC. The tool explores the extent of multi-disciplinary working, liaison, information sharing and practice of care planning amongst other domains. The questions are grouped into five sections: Person and practitioner interaction, Practitioner and practitioner interaction, Organisational Systems and Support, Information systems/ IT tools and a space for Managers and Practitioners to reflect on the use of this tool and assist in its further development.

As part of the evaluation, in January 2015 we invited 50+ practices from the three rural sites in Somerset (South Somerset, Taunton, and Mendip) to complete the P3C-OCT, and to submit the results electronically in a Word Document, or by completing a Web-based survey. SPSS version 22 was used to analyse the responses.



14 practices completed the tool in the first four weeks; reminders and further follow up continues in coordination with the ‘test and learn’ sites. Early findings revealed that all practices had a shared care plan as a written document in place within the team; however only a third responded that the written care plan was shared across all teams. The majority of respondents (70%) stated that the shared written care plan worked well within the team; in contrast, only 30% of the respondents thought that a shared written care plan across teams worked well. Further analysis will be carried out detailing the extent to which key practices and supportive organisational processes operate within and across the three sites.


The P3C-OCT can be used to support organisations and individuals in delivering improved PCCC by benchmarking practice and considering options for change. Next steps include testing feedback to practice and implantation support using benchmarking processes.

Submitted by: 
Inocencio Daniel Maramba
Funding acknowledgement: 
South West Academic Health Science Network (SWAHSN)