3.1 Brief name
WMCP is a novel county-wide approach to scaling the MC intervention across a rural County of England.
3.2 Why: rationale, theory, or/and objectives of the programme
MCs are defined as “a local resource, operating out of ordinary community buildings, that offers on-going…support to people with mild to moderate dementia and their families. At the heart of a MC is a social club where people…get help that focusses on what they need…to cope well in adjusting to living with” dementia (37). It is an evidence-based intervention underpinned theoretically by the Adaptation-Coping Model which was translated to the UK in 2017 as the Adjusting to Change Model (38). The Adjusting to Change Model aims to empower people affected by dementia to accept their situation and engage with social (e.g. maintain social networks), emotional (e.g. positive self-image), and practical (e.g. professional relationships) support. Figure 1 shows the model’s areas of adjustment and support strategies.
The intervention was successfully implemented (39) and evaluated (40–42) in UK, Italy and Poland providing ‘proof of concept’ (i.e. what is it and does it work) and ‘real world implementation’ (i.e. approach to and factors affecting implementation) (1). Since the first two pilot MCs opened in 2015 and 2016 the intervention has been replicated over 60 times in the UK through a dissemination project, Meeting Centres UK [MCUK]. The MCUK project raised awareness and advocated to a range of stakeholders including grass root organisations, national charities, and policymakers (dissemination) for the adoption, implementation, and institutionalisation of MCs (diffusion) (43). MCUK has been a highly effective mechanism for supporting providers to set up and sustain a MC, although their diffusion into real-world practice has been sporadic rather than systematic. One consequence is that MCs are operational in many regions of the UK, yet only available to a small number of people due to limited coverage.
Following the success and sustainability of a pilot MC in Worcestershire since 2015, WMCP was launched in 2019 by Worcestershire County Council [Funder] with a deadline for funding to be deployed by March 2024. The programme provided £540,000 to scale MCs county-wide. This implementation project was led by the Association for Dementia Studies at the University of Worcester [Leader]. Awards of up to £60,000 were available for third sector organisations in three instalments (once per annum) towards the implementation costs. A small contribution was made by the Funder to the Leader for the programme’s management and evaluation. Table 3 demonstrates WMCP core and sub-components. The ability of the programme to replicate the success of the pilot MC (scalability) was not assessed (44, 45).
Table 3
Components of the Worcestershire Meeting Centres Programme
Component | Sub-components | Description |
Develop and distribute resources | Promotion, publicity, and marketing | • Spread awareness so that stakeholders adopt the programme |
| Assessment Panel established to review and allocate funding Awards | • Reach consensus on application decisions |
| | • Award funding to organisations to implement Meeting Centre(s) |
| | • Review funding Awards annually |
| Meeting Centre fidelity, implementation, and evaluation | • Guidebook on the Essential Features of a Meeting Centre |
| | • Guidebook on Setting up and Running a Meeting Centre |
| | • Data collection booklets and ‘how to’ guidance |
| | • Technical support from Leader to address emerging issues |
Report on monitoring and evaluation | Monitoring, evaluating, and reporting objectives of set by Funder | • 6-monthly report completed by Leader against ‘milestones and targets’ |
| | • Final programme evaluation of impact completed by Leader using routine data collected by Meeting Centres |
| | • Assessment Panel meetings held periodically to monitor progress |
| Monitoring, evaluating, and reporting objectives set by Leader | • Providers adherence to the Essential Features of a Meeting Centre assessed and reported annually by Leader and Providers |
| | • Meeting Centre funding forecasts and overall financial viability assessed and reported annually by Providers |
| | • Routine data including attendance, satisfaction, and wellbeing data collected and reported by Providers |
Training and spreading learning | MCUK training course for staff and volunteers | • Online short course focused on ‘Adjusting to Change’ theory and person-centred dementia care |
| Collecting and sharing information with stakeholders (feedback loops) | • Identify emerging issues and evidence to stimulate progress of the programme |
| | • Respond to emerging information to progress the aims of the programme |
| MCUK Community of Learning and Practice [CoLP] | • Opportunities to share and learn from current practice nationally |
| | • Engage providers in adopting principles and practices of Meeting Centres |
3.3 Development of the scaling strategy
The development of WMCP strategy recognises that relevant frameworks and principles should be used to inform the development, implementation, and evaluation of scaling programmes (46, 47). A seed funding approach was used to influence the scaling-out of MCs (impacting greater numbers) (46), on the basis that the organisation delivering a MC (Provider) could secure investment from elsewhere to stimulate growth and sustainability (49). This was driven by a focus on maximal scale, defined loosely by the programme’s primary ‘performance target’, as up to nine MCs within Worcestershire with at least one in each of its six districts. WMCP intended to distribute funding to a range of third sector providers based on the assumption these create ‘added value’ compared with public sector provision through the utilisation of volunteers, and access and responsiveness to local need in neglected areas (50). Other implementation objectives are demonstrated in Table 3 and discussed in the next section.
Modelling by the Funder forecast WMCP could reach ‘600 people based on 60 people attending 10 MCs on a given day’, and deliver a Return on Investment (ROI) of £1,830,114 through avoided cost of residential care (£915,057 for Local Government). ROI included the initial investment as a cost and avoidance of residential care as a benefit, subsequently ignoring many relevant costs and benefits rigorous approaches account for (e.g. Social Cost Benefit Analysis) (51). Furthermore, there is no evidence that preliminary situational analysis to explore internal and external factors affecting WMCP implementation was completed, such as public preference, system readiness, and supply/demand issues (52). Consequently, there was limited evidence to indicate optimal scale based on the specific needs of target populations/areas, nature of the programme, and environmental complexities (10, 46).
At the service delivery level evidence-based resources promoted implementation fidelity through The Essential Features of a Meeting Centre (EFs)(53) and adaptive implementation to local contexts (39). These can enable Providers to understand and balance what features are needed to support fidelity, while modifying to be effective across different contexts (54). Performance targets were set for Providers by the Leader in line with EFs (See Table 3).
The implementation structure of WMCP matters as a strategic feature of the programme (55). The Leader established an Assessment Panel to assess applications and overall monitoring of WMCP. This included the Leader (programme manager, research assistant, and administrator), independent chair, and a representative of Local Government and Public Health. This ‘top down’ approach meant that strategic decision making was completed by the Assessment Panel independent of local level professional and public opinion, experience, and context (‘bottom up’) (56).
3.4 What implementation materials and procedures were used
3.4.1 Programme promotion and application resources
To promote WMCP the Leader published press releases and maintained social media activity. Information sessions were initiated to identify applicants. The Leader followed up prospective applicants via email and phone call which was important to building commitment to transition from registering an interest to applying. All potential applicants were provided with guidance materials for Setting up and Running a Meeting Centre (57), EFs (53), and WMCP application form (online and physical).
3.4.2 Reviewing applications and allocating funding awards
Applications were made in five funding rounds. The staggered approach enabled piloting of the process and management of application while continuing to offer technical support to applicants. It also shortened decision making at Assessment Panel meetings due to the limited number of applications per-round.
Initial screening and scoring of applications based on the EFs were completed by the Leader (research assistant). The Assessment Panel decided the outcome of applications as either; awarded funding, not awarded funding, or awarded funding with amendments to the application.
Successful applicants received an email including a ‘Welcome and Information Pack’ that signposted them to necessary forms to complete. It was made clear that draft copies of publicity materials (e.g., press releases, leaflets) must be sent to the Leader and Funder for approval. ‘Kick off’ meetings were held to introduce Providers to the Lead organisation, discuss roles within WMCP, and answer any questions (e.g. reporting, data protection, securing funding). First payment must have been claimed withing 3 months of the MC opening.
3.4.3 Training Meeting Centre staff and volunteers
MC staff and volunteers were encouraged to complete a free 5-week online course delivered by the Leader (58). This training included the EFs; Adjusting to Change model; practical, social, and emotional effects of movement; and importance of involving/engaging families and professionals. The course ran three times a year throughout WMCP implementation and was delivered via an online teaching platform. Learning modalities included independent study materials (videos, resources, and literature); and a 1-hour live taught session each week by a lecturer (58). Learners were expected to spend approximately 3–4 hours per week engaging independently with the course content. Attendance at four online sessions (at least) was needed to complete the course.
Providers were sent data collection resources including instructions to collect and submit data routinely. Those responsible for collecting and reporting attendance and wellbeing data were expected to attend an online data collection information session provided by the Leader, that included background and purpose of data collection; what data Providers collect already; overview of data collection methods; roles and next steps.
3.4.4 Programme monitoring, evaluation, and reporting
Prior to the release of year 2 and 3 funding the Leader reported to the Assessment Panel to approve/disapprove further payments, based on whether Providers had met contractual obligations demonstrated through three reporting requirements:
(1) Annual Progress Report (adhering to or working towards the EFs)
(2) Annual Statement of Income and Expenditure; and
(3) Final Progress Report in year 3 (overall impact of the award and sustainability planning).
Additionally, the Leader visited MCs at 9, 18, and 27-months to assess their adherence to the EFs (programme fidelity). Where visits were not possible, reviews were carried out online between the Leader and Providers.
The Leader provided a 6-monthly report on the programme’s progress against targets set by the Funder, such as coverage, unplanned changes (underspend/overspend, location changes), financial targets, risks and mitigating actions. Formative programme monitoring was implemented through monthly internal WMCP meetings and quarterly Assessment Panel meetings. Topics included coverage, uptake, and data collection. Additionally, the Leader undertook a programme evaluation using routine data collected by MCs of the impact on individual well-being, and the effectiveness of the county-wide funding model. This included recommendations on the feasibility of the programme. Findings along with emerging results from research carried out by Stephens et al. (31) were fed back to key stakeholders to support continuous learning cycles throughout implementation (feedback loops) (59).
3.5 Who provided the programme
Reported in Table 4 is the variety of stakeholders involved in WMCP and how they were intended/did support scaling processes.
Table 4
Stakeholders, their expertise, and role during WMCP implementation
Stakeholder | Expertise | Description of role in WMCP |
| Worcestershire County Council | • Senior representative of Communities Directorate | • Funder: Provided seed funding for the programme and technical support at a strategic level in the programme’s design and implementation such as time frames, vision of scale, and allocation of resources. Was not involved with the day-to-day delivery of the programme. |
| University of Worcester | • Programme manager • Programme administrator/finance officer • Research assistant • Lecturer | • Leader: Primary organisation responsible for design, implementation, and evaluation of programme. Has oversight on strategic and day-to-day decision making, as well as the development and distribution of programme materials and components such as funding Awards, training, monitoring, and evaluation. • Utilises their independence from health and social care markets and professional reputation to enable interactions within and between services and systems to drive scaling. For example, identifying, communicating, and facilitating opportunities for collaboration and mobilising internal and external resources. |
| Public Health | • Public health practitioner | • Intermediary: Holds no direct accountability for the programme, however, can offer strategic level technical support from a public health perspective. For example, to inform programme design and implementation (e.g. reach, equity of access) by utilising public health data. Uses their authority in relevant professional spaces to share programme information and influence implementation outcomes (e.g. penetration, adoption). |
| Integrated Care System | • Dementia lead | • Intermediary: Holds no direct accountability for the programme, however, can offer strategic level technical support for programme implementation through mobilising resources, championing vision of programme, and enabling channels of communication within and between health and social care services. |
| Services operating as part of the healthcare pathway | • Primary care services (General Practice) • Secondary care services (Memory Assessment Services) • Third sector PDS services | • Intermediary: Holds no direct accountability for the programme, however, can support the implementation of the programme through providing information and advice about Meeting Centres, and signposting and directly referring people living with dementia (i.e. reach, uptake). |
| Meeting Centre Providers | • Meeting Centre manager • Meeting Centre staff • Volunteers | • Provider: Is accountable for contractual obligations, principally, delivering the intervention or integrating the intervention into their existing activities according to the Essential Features of a Meeting Centre. • Funder: Works to secure funding and investment to ensure sustainability of Meeting Centre. |
| People living with dementia and their unpaid carers | • People living with early to moderate stage dementia and their unpaid carers such as family and friends | • Users: Individuals who pay a membership fee to utilise the intervention. Should have some level of ownership and input into the operation of the Meeting Centre(s). |
3.6 How the programme was implemented
When scaling social programmes modes of delivery are multiplied and become increasingly complex due to the number of stakeholders, components, and contexts (60, 61). Therefore, all modes of delivery could not reasonably be described, and instead, this section focuses on how resources were distributed; and monitoring, evaluation, and reporting completed.
Resources were mainly distributed remotely by the Leader through email and online methods. To enable the use of resources video conferencing meetings and phone calls were used to explain how and why resources should be used. At a service delivery level, MC promotion and marketing resources were developed and distributed by Providers remotely (email and online) and in-person (posters and leaflets) to GP practices, PDS services, and relevant community settings. Intermediaries circulated key programme information and resources via email to relevant networks such as the Dementia Action Alliance and Adult Social Care. These materials were developed by Providers to increase uptake (e.g. open days), and the Leader to penetrate key services and systems to increase referrals into MCs from primary and secondary care services (e.g. MC referral form).
Routine data included attendance (reported monthly), satisfaction (every 6-months); and wellbeing measures for Loneliness (62), Quality of Life (63), and Mental Wellbeing (64) (baseline and every 6-months follow-up). Measures were collected by staff and volunteers from people living with dementia and unpaid carers at MCs and sent to the Leader. This time series data was inputted into Microsoft Excel. Descriptive statistical analysis was completed to monitor and report reach and impact of WMCP. Ethical approval was granted to use the data for research purposes that included a data sharing agreement between each Provider and the Leader.
3.7 Where the interventions took place
To demonstrate programme context (‘circumstances WCMP was developed, implemented, and evaluated under’)(15, 65) the WMCP implementation structure was simplistically modelled, see Fig. 2 (66).This included key interactions within and between levels, stakeholders, and WMCP, including the direction of involvement. MC11 was operating prior to WMCP.
At the macro level national dementia policies provide the rationale for reducing the PDS gap (11, 67). Through these, aspirations including service integration and reduced inequality set out in National Health Service reforms (68) and legislation (69) can be progressed. Health and Social Care workforce strategies contributed to understanding the programme’s value through recruitment, training, and retention of staff and volunteers and existing skills gap (70). MCUK Commuity of Learning and Practice [CoLP], facilitated by the Leader, meet online fortnightly and include community-based organisations nationally who are operating/in the process of implementing MCs. The CoLP interfaces with MC staff and volunteers at the micro level to effect everyday operations (e.g., price, support activities), and by extension, outcomes for people affacted by dementia. The CoLP is a vehicle for scaling accountability for the intervention’s principles among Providers (71).
WMCP is positioned at the meso level of the system. This is because the Funder and Leader are the key stakeholders driving WMCP implementation. The former is responsible for drawing on the assets of people and places to create communities that promote health and happiness (‘placemaking’). The latter is a specialist dementia research and education department. Scaling is as much about changing existing services and systems as it is about implementing new ones (47) and this is demonstrated in the number of interactions between WMCP and external stakeholders including NHS, Social Care, Public Health, and the third sector channelled through a select number of key contacts. These intermediaries can support scaling processes through mobilising resources, championing WMCP vision, and bridging communications and understanding (e.g. policies, systems, norms) between WMCP Leader and frontline services (72).
Implementation of WMCP at the micro level involves PDS services and primary and secondary care, who work directly with people affected by dementia providing information, advice, and referrals to MCs. These services act as a key juncture between WMCP county-wide and local level operations. The supply of MCs was dominated by two providers operating under a national charity for older adults, indicating a monopoly power, and thus a concentration of power in WMCP.
3.8 When and how many Meeting Centres were implemented.
As of June 2023, ten new MCs had been established in Worcestershire. It took three to eight months for MCs to open from the point they were awarded funding. Providers planned to increase the number of days they opened per week from 1–2 to 3-days in the final year. Similar year-on-year targets were set for reaching people living with dementia and unpaid carers.
3.9 Tailoring to the programme
Meeting Centres are implemented ‘adaptively’ (39), and so it is important to document what, why, and how individual MCs were tailored. Table 5 demonstrates the alterations that were made in response to challenges (e.g., uptake, need for targeted support, (greed)flation).
What, why and how the intervention was tailored
What | Why | How |
Targeted support for people living with Young Onset Dementia | • This population were not utilising the programme | • Provider set up a Meeting Centre for people with Young Onset Dementia • Branding and publicity specifying support for people with Young Onset dementia (under 65 years) • Increased focus on physical adjustment, including leisure and sports activities |
Free membership | • Cost was identified as barrier to uptake and the cost-of-living crisis meant people had less purchasing power | • Individual membership was subsidised by Providers for approximately 10 months |
Number of days open per week | • Low uptake and inflated venue costs meant it was financially unviable to increase weekly provision | • In year three of the programme one Meeting Centre opened 3-days per week, most opened 2-days, and some opened 1-day |
Providing lunch for members | • Meeting Centres opened during COVID-19 restrictions and lunch could not be provided | • Meeting Centres asked members to bring their own lunch which has continued after restrictions were lifted |
Having a stable staff team | • Because there was a ‘monopoly power’ where ‘economies of scale’ were a focus (consolidate effort to reduce cost) | • A Meeting Centres Manager worked across several sites with no/limited support, as opposed to a manager at each with staff and volunteer support |
Focus on unpaid carers as well as people living with dementia | • Some providers were unaware of Meeting Centres dyadic focus and/or had reduced staff/volunteer capacity to engage unpaid carers meaningfully (e.g. facilitate peer support group) | • Staff and volunteers encouraged unpaid carers to leave the Meeting Centre for care breaks • Limited opportunities for unpaid carers to participate in relevant activities • Most unpaid carers preferred not to attend |
Types of activities/support offered | • Person-centred practice means tailoring support to the interests, abilities, and circumstances of individuals | • Offering a programme activities that reflects individual Meeting Centre membership • Offering ad-hoc support to unpaid carers to address specific needs |
3.10 Modifications to the programme
Modifications to WMCP were initiated by the Leader through a ‘Task and Finish Group’ which intervened to drive improvements. The group met online monthly and included senior representatives of key systems including the Integrated Care Board, Adult Social Care, and third-sector organisations. Modifications are summarised below.
3.10.1 Referrer Workshops to spread awareness of the programme
Workshops were delivered by the Leader to: - (1) educate professionals about WMCP and how to directly refer people to MCs; and (2) connect professionals to strengthen the referral pathway. Workshops enabled professionals to share their experiences and feedback on the programme. Approximately 60 professionals in total including Social Workers, Psychologists, and Occupational Therapists attended the two workshops. Outputs included a MC referral form and contact list of all MCs to be publicly available. This modification was positively reflected upon:
“you've [Leader] organised those meetings, you've got professionals together. I think that will make a huge difference down the line. I think referrals will start coming through more rapidly” (Provider C Chief Executive Officer)
3.10.2 Community Engagement Officer
A Community Engagement Officer [EO] was employed 2.5 days a week for 12 months to: - (1) raise WMCP awareness within statutory and third sector organisations; (2) meet people affected by dementia and facilitate visits to MCs; and (3) monitor the impact of the EO role. Findings included limited professional awareness of WMCP and accessibility issues, including membership costs and unattractive programme of activities. Thus provider workshops and promotional videos were sub-components added to the programme. Furthermore the EO role was found to be ineffective due to the countywide remit not being conducive with the part-time hours and objectives. The role was discontinued after 12-months, and instead, small amounts of funding were made available for each Provider to engage the community locally.
“My role came from the…low numbers of people attending. Originally, the idea was that the EO would…get in touch with people in that kind of diagnosis pathway…and literally accompany people to the Meeting Centre for that first time…But the reality of how my role has panned out is quite different, because I don't think it was particularly well conceived. It was based on experiences from Meeting Centres in other parts of the country where you had…one person who was…part of the local dementia care pathway, who was able to support people coming to one Meeting Centre. Whereas…there are different organisations running the Meeting Centres…that community engagement needs to happen across the 10 Meeting Centres. One person doing 10 Meeting Centres in half a week. It's not feasible.” (Community Engagement Officer)
3.10.3 Provider workshops to enable adoption of the Essential Features
A workshop for Providers was facilitated by the EO. This explored implementation challenges (e.g. uptake, professional engagement) and opportunities to address issues. While the focus was on reinforcing the intervention principles, the opportunity for providers to interact was equally important:
“We're running this workshop next week…to try and support them to reflect on how well they're meeting the Essential Features… And actually, some of these people have never even met each other. And that's almost one of the most important bits of the workshop, is them talking to each other and sharing practice, sharing ideas, sharing what works for them and what doesn't work.” (Community Engagement Officer)
3.10.4 Promotional videos for public and professionals
Two short (under 5 minutes) educational videos were developed by the Leader in collaboration with individual MCs on the basis that these could support positive behaviour change in professionals and public (73, 74). Videos were targeted for professional referrers (https://www.youtube.com/watch?v=DpzwtlduXho) and people affected by dementia (https://www.youtube.com/watch?v=5zQmQW2T3lU) to increase awareness of what a MC is and how it may benefit individuals and services. Importantly, the voices of staff, volunteers, and members were used to create the videos including footage captured at MCs.
3.11 How well was the programme implemented
3.11.1 Development and distribution of resources
The programme implemented 10 MCs with at least one in each of the six districts that covered all of the Primary Care Networks in the county. WMCP had a focus on reducing health inequities through investment of MCs in “areas of greater disadvantage” (Integrated Care Board representative). One MC was implemented in a highly deprived neighbourhood, however it was not sustained, raising concerns to the Funder and Public Health:
…the feedback from that initial work…was that it just wasn't working…whether there was a cost prohibitive element…But it was an area of concern that myself and Public Health colleagues had in terms of the relocation of that centre to a different part of Worcester.” (Local Government representative)
Funding was intended to be distributed to promote a mix of third sector providers. This was not achieved. WMCP replicated existing market power through two Providers operating under a national charity ‘dominating’ the supply chain, and subsequently having the ability to dictate price, support offered, and other outputs, resulting in less choice for people and professionals (75).
“[National charity name] aren't actually interested in what happens in Worcestershire because there's no competition for them…and I think there's also a general feeling amongst both professionals and service users, that [they are] taking over the world” (Community Engagement Officer).
“I've seen it happen elsewhere where the bigger charities can soak up…the money because they've got the infrastructure…to do so. And if you want a quick win, that's often a good way to go. But if you actually want to make change…Then you need to make sure that no one party dominates…in an ideal world we would have had ten different types of organisations delivering…Meeting Centres.” (Assessment Panel Chair)
Evidence suggests all MCs were working towards meeting the EFs, notwithstanding several areas of improvement being identified through other programme monitoring related to ‘Skilled and stable team’ (EF 4); ‘Leadership’ (EF 5); ‘Focus on members and unpaid carers’ (EF 6), ‘Programme of Activities’ (EF 7), and ‘Data Collection’ (EF 11). Consistent fidelity issues were caused by Providers reducing the intervention’s EFs (simplification) which raises fundamental questions about their feasibility. For example, developing economies of scale by sharing staff to bring down service delivery costs, which meant ‘non-essential’ components such as data collection were overlooked.
3.11.2 Training and spreading learning
Providers were expected to enrol staff and volunteers onto the MC training course to ensure they had the knowledge and skills to replicate the EFs. Uptake was good with around 73% of staff and volunteers having completed training. Although for a period, there were some MCs that did not have trained personnel. This impacted programme fidelity and quality of support offered, because most social care professionals, irrelevant of previous care experience, do not have the necessary skills to deliver multicomponent support programmes (70).
The online data collection support session was provided to ensure Providers understood how and why data collection is completed. An initial attempt at retrieving data, however, found that health and wellbeing data was missing, and some sites were not capturing daily attendance. Also, the quality of data (e.g. missing data) was a problem. To address these issues, the Leader supported data collection at certain MCs until other mechanisms could be trialled. For example, university students from allied-health courses were trained and collected data as part of their work experience placements.
3.11.3 Monitoring and evaluating the programme
Monitoring and evaluation procedures were important feedback mechanisms that enabled knowledge to be captured and used by the Leader to reinforce or adapt scaling processes (46). The ‘Task and Finish Group’ fed into key services that engage with people affected by dementia to promote the programme aims. This had variable impact due to existing health and social care pressures. MC effectiveness is highly dependent on the functioning of existing healthcare pathways to ensure people utilise MCs as planned (76). Therefore, services need to be sufficiently resourced and integrated to adopt WMCP activities and work collaboratively across sectors and services. For example, a Provider reported working with eleven Social Prescribers in two years, reducing the consistency at which referrals were made. An explanatory sub-theme for this factor was the impact of the COVID-19 pandemic:
“COVID is the overriding factor here, in that the referral routes that used to be open are now closed…GP practices have been shut…and health professionals have been concentrating on vaccines…we know it's had a huge impact on people being diagnosed, even getting into the system in the first place, and also for people getting information about the services out there.” (Provider C Chief Executive Officer)
The EO role, which was supplemented with funding for individual Providers, are further examples of using evaluative reasoning to modify the programme and demonstrate the complexity of using feedback loops in a meaningful way (59). Even when information was employed efficiently to modify WMCP, it was sometimes counterproductive. For example, if the scale of the issue had been assessed it would have been clear that a part-time EO could not make a meaningful impact on uptake county-wide. Similarly, while small pots of money are better placed to serve local need, the investment undervalues the problem, and duration of investment means that any progress may not be sustained. Anecdotal evidence from Providers suggests this funding is increasing the number of referrals but not actual MC membership. Complex systems approaches may have been beneficial here to address the internal and external complexity of scaling (65).Thus, there is a need to retrieve and respond to programme and external information, as these are not mutually exclusive, and to do so with the understanding that external components may also require scaling:
“It's not as simple as assuming that you just need one thing…We've multiplied the number of Meeting Centres, but actually, there's some of those other sorts of strategic level stuff [that has] not been upscaled.” (Community Engagement Officer).
3.11.4 Role of intermediaries and infrastructure
Intermediaries, mobilising resources and facilitating channels of communication, can support scaling processes, and their support was orchestrated by the Leader. Participants described the Leader’s strategic reach (e.g. Integrated Care System) and “kudos” (political capital) as key enablers to locating and involving intermediaries to drive systems and culture change, or as one participant described; “get groups of people to do things” (Provider C Chief Executive Officer)
“…the really good thing…was the university taking very seriously the referral issue…that ended up being a kind of pincer movement with the university pushing that. Where, in one sense, the weight of the university can go and talk to the that point in the NHS, at a slightly more senior level” (Provider B Senior Management)
MCUK was an important asset. Having the infrastructure to provide training, offer technical implementation support, and facilitate the CoLP provided the foundation for WMCP implementation and evaluation; and in doing so, reduced the workload and implementation costs to develop guidance and evaluation frameworks. Providers could utilise MCUK resources which provide education on fundamental principles and practices, yet participation by Providers in the CoLP was poor, and overall, there is limited evidence that they used resources effectively.
“…the main benefits have been through the wider network. So we've probably learned more from the Scottish and the Welsh [Meeting] Centres. The online meeting…where people from different Meetings Centres across the country share knowledge…one of our trustees always goes…And she always comes back with 'this is really interesting, we should try this'. We're planning to talk to the guys who run one of the Scottish Meeting Centres, because they seem to have nailed the community-based aspect…Because that's what we're aspiring. So those have been hugely valuable.” (Provider B Senior Management)
3.12 Voice
An initial draft of TIDieR was sent for review to WMCP programme manager, research assistant, and financial administrator who made comments that clarified key components and sub-components, how implementation deviated from initial planning, and factors affecting implementation outcomes such as fidelity and reach.