How strong is your anchor?
UCLPartners launch a measurement toolkit for health anchors
UCL Partners guest blog
Today at UCLPartners, we are launching a new resource to help Anchor Institutions to measure their activity and impact. ‘How Strong is your Anchor? A Measurement Toolkit for Health Anchors’, has been produced for NHS trusts and partners, and funded by The Health Foundation.
While anchor activity has increased significantly in recent years, particularly in the health sector, systematic and coherent approaches to measurement have not been universally adopted. In many ways, this is not surprising – measurement is hard, and measurement of anchor activity and impact has three core challenges.
Firstly, anchor measurement is different to the types of measurement that health organisations are used to. ‘Healthcare’ measures – for example, numbers of appointments, DNAs, or outcomes of treatment - are not appropriate when the aim of activity is to act at a population level to improve community health and reduce health inequities in the long term. However, ‘population health’ measures – for example, the local unemployment rate, or disability free life expectancy – are not appropriate when we want to hold an institution or partnership accountable for change. An anchor should be aware of these population health measures, but if they worsen over time, it would be unreasonable to hold them (alone) responsible, just as it would be unfair to credit them (alone) for improvement.
Secondly, anchor activity varies significantly. It is locally shaped, based on local population need, assets and preferences; institution size, type and focus; and pre-existing anchor work, partnerships and strategic priorities. This variation is a strength rather than a weakness of anchor – it is a good sign that anchor activity is responsive to local people and place. However, it does make it harder to propose universal indicators to capture impact.
And thirdly, we don’t yet know (exactly) what good looks like. There is significant evidence on the social determinants of health (SDOH) and how improving these conditions can have a positive impact on health and reduce health inequities. However, we don’t know which particular healthcare anchor interventions are the best, in particular contexts, for particular populations, in order to successfully impact on the SDOH. Some of this evidence will emerge in time, and some will always be locally dependent.
This Toolkit needed to respond to these three challenges, and still produce something that had practical use for health anchors. It was clear from our stakeholder engagement that what was needed was something specific yet flexible. Nobody wanted a general reflection on the importance of measurement, but equally, there was a strong preference to not produce a performance management system that mandated all anchors to collect the same information in the same way.
There are three features of the final toolkit that we hope help to meet these challenges:
Starting with the logic
We spent a significant amount of time at the start of the project producing a health anchors logic model. The intended purpose of this was to help us to select indicators (and it has been invaluable for that purpose), but it also helped us to collaboratively shape a common understanding of what anchor activity looks like, and the specific ways in which this connects with outcomes – providing a ‘golden thread’ from what we’re doing, to why we do it.
In a stakeholder workshop at the start of the project, we started mapping out the logic model together in the room. The conversations in that session were essential for the rest of the work – we spoke about not only what anchor activity is, but also what it is not; and we spent a long time focussing on the ‘missing middle’ – bringing clarity on specific anchor outputs and outcomes.
In the final toolkit, the logic model has been broken into 11 parts, each one focussed on a particular strand of anchor activity:
The full logic model is available, but is a little hard to digest. When we ‘zoomed in’ on the strands, however, we were able to map indicators against specific parts of the logic model (shown with an ‘i’ in the image below), providing a visual representation of what we can measure, and how our indicators are spread across the logical chain.
2. Providing a menu
The final Toolkit includes 56 indicators in total. Our initial intention was to suggest a ‘core set’ of 10 or so, that we thought all health anchor institutions should be collecting. However, it increasingly became apparent that this wasn’t possible, or advisable, for our particular purposes.
We wanted to provide options for anchors and partners to select from, based on their own priorities and also their capacity to build new measurement systems for their anchor work. We categorised each indicator by how difficult it would be to measure (easy, medium or hard), and whether it was suitable for regular measurement. There are also a smaller group of the indicators (13 of the 56) that are already gathered and reported nationally.
As with all parts of the Toolkit, we hope local anchors are able to use these indicators as a starting point – to select those that work for them (for example, starting with those that are easy to measure and/or reported nationally, as well as those that are key institutional priorities). We encourage anchors to supplement these with existing local measures that may not be in the Toolkit, and set their own targets and measurement processes (and have provided an editable workbook for this purpose).
3. Sharing examples of measurement in action
Throughout this work, the input of local stakeholders has been essential. We have met regularly with a core expert group who have guided and stewarded the work throughout. Over 65 institutional, system and regional anchor leads attended our stakeholder events, we attended over 40 other meetings and events, and over 190 NHS staff and local residents responded to an online survey.
As well as shaping the structure, focus and content of the logic model and indicators, this stakeholder engagement allowed us to hear about some of the amazing work already taking place to measure anchor activity and impact at institutional, system, regional and national levels.
The final toolkit includes four longer case studies and 16 shorter ‘examples of measurement in action’ – some of which are shown above. We hope these inspire and guide other anchors to consider whether similar approaches and measures could work for them.
Conclusion
Now that the Toolkit is publicly available, we hope that it provides a helpful ‘starting point’ rather than a ‘final word’ on anchor measurement.
One of my personal hopes for this work is that it helps to motivate and guide conversations within and between anchor institutions and their partners on what their anchor work is; the impacts they hope it has; for who, how, and why; and how they’ll know if they’ve been successful.
These conversations, perhaps more so than a list of numbers and figures over time, are likely to be a vital ingredient in ensuring that anchor institution work lives up to its ambitions to improve health, reduce health inequities, and build economic and social development within and in partnership with local communities.
Matilda Allen
Public Health Specialty Registrar
LSHTM and UCLPartners