Out-of-Hospital Cardiac Arrest (OHCA) strategy: case study

4. Findings

This section discusses the extent to which the development and delivery of the OHCA Strategy illustrates the Scottish Approach in practice. The findings are reported to align with the project’s specific objectives. Section 4.1 begins by outlining the partners’ understanding of the Scottish Approach, and what it means to them. Section 4.2 gives evidence of the Scottish Approach being applied in practice. This focusses on the four elements that were commonly reported during the interview process: (1) focus on shared outcomes (2) cross-sectoral working (3) co-production (4) asset-based approach. The next section discusses the strengths and challenges of the OHCA Strategy (Section 4.3). The final section outlines the broader lessons that are potentially transferrable to future policy implementation (Section 4.4).

4.1 Partners’ understanding of the Scottish Approach

Although the interviewees did not explicitly cite their practices as being aligned to – or driven by – the ‘Scottish Approach’, the majority of partners have heard of the Scottish Approach to some degree and understood it as a way of different organisations working together with a shared focus. Most referenced their understanding in terms of the work they are currently doing through the OHCA Strategy:

‘I see it [the Scottish Approach] as the Government trying to use all partners, whether it be police, fire or ambulance and the wider NHS services and third sector organisations to tackle this nationwide challenge’ Participant 0001

‘What it means to me is using both existing and new partners and colleagues – collaborations – to solve enduring issues that affect Scottish society’

‘So the Scottish approach for me is building on these really solid partnerships and really making new connections’. Participant 0005

‘I think a really good way to describe it would be to describe what it isn’t. Previously we had groups like SFRS saying they were going to do one thing, Trossachs saying they were going to do something else, BHF something else. And everyone was doing the best they could and they were doing the right thing. But nobody knew what everybody else was doing. You know it’s that thing – all those individuals’ parts coming together is better than the sum of the whole. It’s about everybody working together with that joint aim for Scotland’ Participant 0015

This suggests that whilst partners were not overtly aware of abiding by the principles of the Scottish Approach, reflecting on the Strategy’s design and delivery it embodies this model nevertheless. Furthermore, as can be seen from the context provided by the interviewees, the majority of partners outwith the SG conceptualise the Scottish Approach through the lens of OHCA, rather than a set of principles drawn from general policy. This is an expected finding given that the SG partners have been exposed to the Scottish Approach as a concept that crosses different policy sectors. One partner encapsulated this idea by stating:

‘From my experience I hadn’t heard it before. I am very conscious and aware of it now… Scottish Government and NHS partners have, kind of, cited this as saying this is the Scottish Approach, so that would be my level of awareness of that idea as a concept’ Participant 0010

Whilst the majority were aware of the Scottish Approach as a concept, several partners stated they had not heard of this approach:

‘So I had no knowledge of the Scottish Approach as a thing, before our conversation as part of the introduction for this’ Participant 0008

4.1.1 Scepticism towards the Scottish Approach

Several partners expressed scepticism about the reality of a Scottish approach in practice. One partner questioned:

‘whether it is stories we tell ourselves to comfort ourselves that we are doing something special, something good. And I don’t know whether we are’ Participant 0012

Another partner likened the connotations of the Scottish Approach to the notion of civic Scotland which brought its own specific challenges:

‘I think there is a broader problem right across policy in public sector Scotland with this notion of civic Scotland – that if you are asking professional people and “experts” and getting their opinions then that is enough. That is an incredibly narrow way of thinking. We don’t know everything. There’s an assumption that this group is the repository of all wisdom. And my view is that it’s not. It’s hard for governments to want to let go of control. But I think they need to broaden out the debate and welcome ideas from outside the usual suspects. There is definitely a kind of professional class in Scotland which is quite conservative (small c).’ Participant 0014

4.2 Evidence of the Scottish Approach in practice

As highlighted in Section 3.3, there are 9 identifiable elements (approximately) that are regularly cited as features of the Scottish Approach, and these operate at different levels of governance and public service (Figure 3a).

Analysis of the interview data suggests that four elements of the Scottish Approach are strongly evidenced in the OHCA Strategy. Three are moderately supported, whilst the remaining two have limited evidence. A visual aide below describes the extent to which the recognised features of this approach are identifiable in the OHCA Strategy (Figure 3b).

Figure 3b: The extent of the Scottish approach utilised in the OHCA Strategy

The following sections will focus on the four features of the Scottish approach that are strongly evidenced in the OHCA Strategy (outcome based > cross-sectoral working > co-production > asset-based). An outline of the elements with moderate and limited support will also be given.

4.2.1 A focus on outcomes

One of the main features of the Scottish Approach that is readily identifiable in the OHCA Strategy is that it is outcomes-based. As mentioned in the Introduction, the headline outcome is to “increase survival rates after OHCA by 10% across the country within 5 years”. This will be achieved, in part, by equipping “an additional 500,000 people with CPR skills by 2020” which “can increase the likelihood of survival after OHCA by 2 or 3 times” (Scottish Government 2015a, p 4). Partners expressed that having this focus on explicit outcomes allowed them to gather organisational support:

‘Speaking from an organisational point of view, the published and declared strategic commitment and support is what’s made a difference. Often we can be involved in something and there isn’t a reference – you wouldn’t have a strategy to look at…As a manager and implementer and project delivery person then knowing that, you then know why you’re doing it. Participant 0010

There’s not a part of society that the mission doesn’t touch I would suggest. Everybody in the room is affected by it…everyone will have someone in their work or in their family that will be positively affected by this work’ Participant 0005

Partners suggested that the clear commitment to the outcome of lives saved means that there was a compelling argument for delivering the Strategy and getting buy-in from staff:

‘It’s a great story to tell. I mean who doesn’t want to save lives…it was a winnable target if people were willing to get stuck in’ Participant 0012

One partner voiced that ‘It’s about the difference between getting Christmas cards or getting wreaths. That is what it’s about’ Participant 0015. Another expressed a similar sentiment, saying ‘There are people today walking around alive today in Scotland because of the work of the cardiac arrest strategy’ Participant 0001.

Several specific examples recalled by partners gave the sense that the OHCA Strategy is viewed as having an immediate, tangible impact on people’s lives. One interviewee explained a scenario in which the Police, SFRS and SAS were deployed to an unresponsive person in a car as part of a co-response model implemented as a result of the OHCA Strategy (Figure 4). The Police and SFRS successfully resuscitated the patient using their on-board defibrillator. The interviewee reflected on this:

‘There is a tangible result for that investment and training and kit and that co-responding pilot…it’s very real and very tangible and it’s a very personal story for that family as well’ Participant 0005

Another participant described how a patient had survived through SFRS co-responding with the SAS:

‘The reality is that chap probably would have died had the fire service not been co-responding to cardiac arrest’ Participant 0001

Figure 4: SFRS and Police Scotland role in the Chain of Survival. This highlights how the features of the Strategy’s approach work together; focussing on patient outcomes is complemented by cross-sectoral working and co-production

Although the interviewees did not explicitly cite this as an ‘outcomes-based’ Strategy, it is clear from their reflections that having a clear outcome – particularly one that affects patients and their families – allowed the Strategy to gain support from these individuals, which then influenced how the message of the Strategy was received by their organisations. As one partner stated: ‘I’ve sat around previous policy tables and there’s been a sense that if it doesn’t work then we can go on our merry way. Whereas here there is a sense that if this doesn’t work then we’ve only got ourselves to blame’ Participant 0002. The outcomes, therefore, were instrumental in the success of this Strategy, as well as influencing how the partners came together to work across their respective sectors.

4.2.2 Working across sectors

The extent to which there was partnership working and how this supports the Strategy commitments was also explored in the interviews. The particularly positive and inclusive nature of the collaboration between the organisations involved was identified as a feature of the OHCA Strategy partnership.

‘So this strategy, if I had to sum it up in one word it would be ‘inclusive’’ Participant 0015

‘I have to say that the inclusiveness from the outset from the Government to ourselves as a blue light partner has been very welcoming and refreshing’ Participant 0006

The existing work on OHCA was harnessed and enhanced by the partners and has improved effectiveness and added value. One interviewee reported it provided the basis for a coherent response and is true cross-sectoral working that is achieving more than the sum of the parts in practice:

‘There were so many groups trying to do things, and what the strategy did was that thing about all those metaphors – get everybody on the same page, signing from the same hymn sheet, that sort of thing. And people were doing fantastic work. They had been doing this for many years. But this strategy gave the cohesion. So the Scottish Government were the conductor and the fantastic musicians were the individual groups’ Participant 0015

There is a decades long tradition of the public and third sector working together, however this was a step change in partnership working, as an emergency service interviewee put it when comparing previous initiatives:

‘Not as collaborative, I don’t see that at all. I think you could look through the previous 100 to 150 years of the [organisation] and there will be markers of big changes…All of these have been landmarks, but they are still not collaborations. They are changes in funding and response. Whereas if we continue to expand what we are doing from OHCA then that is a seismic shift’ Participant 0010

The way this supported improved working and impact on delivery was highlighted. A third sector interviewee set out how it broadened understanding and effective delivery:

‘This has been distinct because there are so many different sector workers all coming together – the more we connect, the more we can get that broader perspective and think beyond who is going to deliver what and what your outcomes are, the better it is.’ Participant 0011

Interestingly this appeared to have generated improved inter-organisation working at all levels of the agencies involved; from senior leaders to frontline staff. This was not a common achievement:

‘What is often missing is, at senior level in organisations, you definitely see people in my rank and role speaking to partner organisations at a senior level. I’m not entirely sure – and often for good reasons – that that is replicated in the front end delivery of the service…I think there is a visual representation here where you can physically see the front end delivery of training and awareness and impact done in a very collaborative way’ Participant 0005

The distinction between the idea of collaboration in name, and cross-sectoral working as a meaningful, productive process was made and the OHCA Strategy was an excellent example of the latter, but not straightforward to achieve. One respondent spoke of previous experience and the effect on delivery: ‘Sometimes when you force collaboration and you force partnership through legislation you don’t always get the outcomes that you would hope for’ Participant 0005.

4.2.3 Co-producing the OHCA Strategy

As outlined in the Overview of the Scottish Approach ( Section 3.3), the gold standard definition of co-production is ‘a relationship between service provider and service user that draws on the knowledge, ability and resources of both’ (Scottish Co-production Network 2017). With this definition in mind, the consensus from the partners was that this Strategy does not align with the traditional principle of service and user co-production. As one interviewee voiced:

‘If it was me, I’d think how can we go beyond this group and get into difficult to reach communities. I’d like to hear it straight from the horse’s mouth’ Participant 0014

Instead, partners appeared to view co-production through an organisational lens; the Strategy was co-produced by partners advocating for the patient and representing the patient’s voice. One interviewee stated:

‘I think this was co-produced with organisations and suppose, you might argue that some partners there represent the patient voice. I think more so with organisations, yeah.’ Participant 0002

One third sector partner shared this viewpoint, suggesting that ‘People have a great deal of faith in third sector, they see us as advocates, as a vehicle for people to voice their concerns’ Participant 0011. The majority of interviewees pointed towards the work being done by Chest Heart & Stroke Scotland as the main strand of work involving patients. Chest Heart & Stroke Scotland were commissioned to hold a focus group around the theme of cardiac arrest survivorship, lending support to the notion that the patient’s view informed the Strategy.

At first glance, then, the Strategy was not traditionally co-produced. Yet there is good evidence that the broader conceptualisation of co-production expressed by the interviewees is gaining support in the literature. A large review of co-production in Scotland was published in 2013 (Loeffler et al.) and highlighted how the typical definition of co-production has evolved in recent years to reflect a more holistic, multi-layered approach. Co-production can mean co-commissioning of services (including co-planning, co-prioritisation and co-financing), co-design of services, co-delivery (including co-managing and co-performing), and finally co-assessment (including co-monitoring and co-evaluation).

Although it is beyond the scope of this report to state whether the historical or revised form of co-production is the ‘correct’ one, a reasonable conclusion is that the design and delivery of the Strategy fits with the broader model of co-production.

4.2.4 Using assets in the OHCA Strategy

This section on using assets, in many ways, mirrors the section above on co-production. An ‘assets-based approach’, as outlined in the Overview of the Scottish Approach ( Section 3.3), has traditionally meant to “view people as active agents in their own and their families’ lives, recognising opportunities and what people can do to achieve the outcomes they want” (Findlay 2016, p 17). However the OHCA Strategy has extended this individual-centric view to include community and organisational assets. The document itself recognises that “central to the success of our aim to change the system and improve outcomes of OHCA will be the commitment and drive of the national and local groups and organisations” (p 40). Again, this broader conceptualisation is supported by extensive review work (Morgan et al 2010).

One interviewee described how assets can be ‘money, people, kit, equipment and expertise’ Participant 0004. Another partner from one of the emergency services echoed this, stating that:

‘We are trying to utilise – and I say we, the NHS Scotland, the wider NHS…and the other strategic partners – to utilise an assets based approach…whether they be physical assets or team or personal skills…assets of individuals who are capable of doing CPR’ Participant 0001

When asked to clarify whether they meant individual, community or organisational assets, they stated:

‘I think it’s a combination of them all. It’s definitely the guys on the ground in terms of their operational side of things, but to drive that forward we need that team [organisational] approach’

The OHCA Strategy is harnessing the resources of individuals by equipping them with CPR skills and setting up structures that allow these individuals to connect within and across their communities. This is contributing to the success of the Strategy by gradually shifting the ownership of CPR training away from centralised organisations and into the communities and responder groups across Scotland.

At an organisational level, an example from an emergency service interviewee highlighted how they were able to seamlessly pull in personnel assets from another partner and optimise their training:

‘A key part of this also was that the training wasn’t just delivered by somebody who looks like me. I pulled in people around me so that someone was delivering training who was dressed in green [Scottish Ambulance Service Paramedic]. We were taking it beyond what would normally be required to show that level of commitment’ Participant 0010

Being able to draw on the assets of other partners – whether they be people, equipment or expertise – has meant that the staff involved in the delivery of the Strategy have been able to evidence a coherent, unified Scotland-wide approach. This has allowed a clear message to filter down from the strategic Reference and Delivery Groups into the organisations themselves. One interviewee commented that: ‘The OHCA is a good example of strategy working on effectively 2 levels, which is the people who do the job and the people who manage and lead the job and I definitely see it at both levels’ Participant 0005.

This also illustrates how the elements of the Scottish Approach applied in the Strategy, although presented in different sections here for clarity, work together rather than in isolation. In the example described above, the use of organisational assets served as a signal of cross-sectoral working, and was built on the work that had been co-produced up until that point. This encapsulates the multi-layered principles of the Scottish Approach that have been evident in the OHCA Strategy.

4.2.5 Other features of the Scottish Approach

The four elements described above are strongly evidenced in the OHCA Strategy. A further three features are moderately supported, whilst two have limited evidence The three features that are moderately evident are (1) Integrated public service organisations (2) System-wide interventions (3) Community ownership.

(1) Integrated public service organisations – This is defined as the ‘coordination of working arrangements where multiple departments or public sector organisations are involved in providing a service or programme’ (National Audit Office 2013, p 5). The Strategy has seen the emergency services co-responding to OHCAs as part of a trial which has been well received by the ‘blue light’ partners. One emergency service interviewee stated how ‘if you bring people in here, and give them a little bit extra training – we’re already doing all that – what it allows us to do a take a little bit of pressure off the Scottish Ambulance Service’s total volume of calls’ Participant 0010. Although this is not occurring nationally as part of a formal integrated public service delivery model, the work undertaken through the Strategy nevertheless reflects productive integration between public services.

(2) System-wide interventions – Meeting the Strategy’s headline aims of increasing OHCA survival by 10% and equipping an additional 500,000 people with CPR skills requires that the ‘system’ of OHCA is targeted. This means several things, such as developing the right infrastructure, creating a sense of community readiness across Scotland and changing societal norms about CPR. Equipping individuals with CPR skills also needs to happen across the spectrum of society, encompassing different ages, different hinterlands and those from different socio-economic backgrounds.

Currently half way through the lifecycle of the Strategy, many – but not all – of the processes are in place to allow this to happen. Interviewees acknowledged the efforts that have gone in to reaching all parts of society; ‘It was about a whole-systems approach’ Participant 0006. In light of the recent document Initial Results of the Scottish OHCA Data Linkage Project (Clegg et al, 2017), the scale of addressing all parts of the OHCA system is clear and partners express awareness of the need to target all groups, particularly those where outcomes are unfavourable.

(3) Community ownership – As the name suggests, this refers to communities owning – designing, coordinating and delivering – CPR events. All partners recognised that embedding CPR skills within communities is important. A consistent message from the interviewees was that if this work is to be sustainable, then the idea of ‘ CPR is something you do’ Participant 0012 means ‘embedding change within structures that make this normal practice…If we go back to the term ‘Scottish Approach’ and working with communities, you have to embed that very early on because it takes time’ Participant 0011. Although the majority of skills sessions and CPR events are still co-ordinated and lead by the partners, communities across Scotland are gradually being equipped with the skills to deliver CPR.

The two features with limited evidence are (4) National and Local government working closely together (5) Preventative.

(4) National and Local government working closely together – As mentioned in Section 3.2, in 2008 a Concordat between central and local government was negotiated which continues to be the primary mechanism through which central and local government operate. The OHCA Strategy, rather than leverage its work through Scotland’s 32 local authorities, partnered directly with the charities and public service bodies which can deliver the aims of the Strategy.

(5) Preventative – Preventing an OHCA is a broader health issue that is outwith the scope of the OHCA strategy. Although there is mention of highlighting preventable risk factors associated with OHCA, this is part of a much larger health promotion drive in Scotland lead nationally by NHS Health Scotland.

4.3 Strengths and challenges of the OHCA Strategy

The main strengths of this Strategy have been discussed above – a priority on outcomes, thorough cross-sectoral working, a commitment to co-produce and using available assets – however partners raised other salient strengths. These ranged from the rudimentary idea that ‘One strength is that it simply exists at all’ Participant 0014, to more detailed responses such as the way in which the strategy has acted as a catalyst for the emergency services to discuss models of co-responding nationally.

One prominent strength relates to the idea of the ‘people’ involved, and staff from the SG, emergency services and third sector all voiced this sentiment:

‘I think the personalities are quite important…so it was fairly open and there wasn’t any sort of big ‘I am’ – sort of trying to grab the credit, I felt’ Participant 0012

‘There are no egos. Nobody is trying to do something better than what somebody else is trying to do. Yeah we’ve all got our own organisations and our own corporate images, corporate responsibility etc.…but at the end of the day this is all about doing the right thing for the people of Scotland’ Participant 0001

‘These types of collaborations are built on personalities. I think this is a key component part. It’s about people working together and having a mutual understanding. Mutually working together and benefitting from each other’s professional experiences and conduct…I think that’s a really important part in all of this’ Participant 0005

Acknowledging this as a strength is important as it gives time to reflect on the effort and continuing commitment from the partners, which may go unsaid otherwise. During the initial stages of developing the Strategy partners stated that ‘the engagement from [name of civil servant] and [their] team was outstanding’ Participant 0002. This led to the perception that there have been ‘no barriers or hurdles. It’s been a very open and inclusive approach to business’ Participant 0006.

A key message to take away from this finding is that this was likely influenced by the number and profile of partners who have contributed to the design and delivery of Strategy. The document has covered the interests of all sectors whilst at the same time maintaining a manageable Reference and Delivery Group. One interviewee observed, the Strategy has been able to consistently action a representative group of individuals and organisations which consolidates strong working partnerships.

One third sector interviewee voiced that ‘This also affects other areas, like the continuity of sending people who are vested in this’ Participant 0002. Another emergency service partner agreed, stating ‘They help seal the relationships’ Participant 0005. This suggests that the theme of people developing and maintaining strong working relationships across professions is an important part of this Strategy’s on-going delivery and future success.

4.3.1 Challenges of the strategy

Despite the numerous strengths of this strategy, approximately half of all interviewees identified salient challenges that could have been – and still could be – addressed. The main challenge relates to the measurement of performance; how are partners delivering on their strategy commitments? One emergency service partner summed this up as:

‘I think the weakness in the strategy is the measurements of performance. We’ve set these nice aspirational goals of half a million people, a thousand lives, but if it was to be really practical and delivered, I think we would have put some kind of performance measurements for the organisations, about what they would do…that links back to what I was saying earlier about going to each partner and saying ‘how are you doing that’, you know….if we had set out a year by year basis of what people should achieve, then it would have been much easier to say ‘are we on track?’ Participant 0010

This view was shared by a third sector interviewee who stated:

‘I am also not sure if the focus on delivery is strong enough at the moment. They’ve set an ambitious target, but there maybe wasn’t that clear understanding of how it was going to be achieved…I would go back and look to see who is delivering on this. And we are of course not the only ones, but really see who is delivering this and then say that we can work with them to drive this forward’ Participant 0014

4.4 Informing future policy-making

As highlighted in Section 3.1, one of the aims of the project is to offer some ‘lessons learned’ – conclusions that can potentially be transferred to future policy delivery. The central theme that interviewees identified was that this strategy, unlike other policies they have been exposed to, gave clear and measurable targets which were underpinned by a simple message:

‘…getting people aligned behind a single objective. This is far harder than you think, because everyone has a different objective and everyone has different pressures on them. If you can line everyone up, and everyone recognises that reducing the number of people dying from an OHCA is a good thing, and everybody brings their contribution to the party, then you get something that is bigger than the sum of the whole. This is one of the best examples I have seen of that’ Participant 0004

‘If you take OHCA, everyone buys in I think – in fact I know everyone does. They buy into the mission for want of a better phrase. They understand the mission.’ Participant 0005

A different but related theme was that partners felt improving OHCA outcomes was a manageable problem that was anchored in data relevant for the Scottish population.

One partner voiced that:

‘I think the fact that it was predominantly based in Scottish figures – Scottish data. Making that comparison from a Scotland point of view brought that home, you know what I mean. This meant this was a Scottish problem’ Participant 0013

In terms of OHCA being a manageable issue, a third sector partner suggested:

‘It’s a very specific strategy for a very specific thing. Of course it’s a major strategy, but when you look at the numbers it is quite small and manageable. We’ve identified a manageable problem that we can tackle. Sometimes in health policy we publish these massive transformational change strategies, and everyone thinks where can they play a part. With the OHCA strategy everyone knows what they are doing – everyone can absolutely say ‘here’s where I play a role’. This gave it a different feel around the room’ Participant 0002

Future health policies, where possible, can take note of these perceived benefits and develop policy with more discrete targets and outcomes so that the organisations and partners who are tasked with meeting these can focus attention and resources.