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Background: The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three 'waves' across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time. Methods: We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time. Results: We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options. Conclusion: This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation. [ABSTRACT FROM AUTHOR]

Background: A lifelong gluten-free diet is the only treatment for coeliac disease. The cost and availability of gluten-free substitute food (GFSF) remain challenging. Some local areas in England have stopped gluten-free prescriptions for coeliac disease. The aim of this paper is to present the quantitative findings of the financial impact of prescription withdrawal on people with coeliac disease. Methods: A cross-sectional survey with adults in England who reported having been diagnosed with coeliac disease by a health professional. The postal survey was distributed by Coeliac UK to their members in 13 prescribing and 13 non-prescribing local areas that were matched for geographical location and level of deprivation. Additionally, an advertisement for the survey was placed on social media. The questionnaire contained items on the availability and use of prescriptions; the weekly amount spent on GFSF; amount of specific GFSF bought; affordability of GFSF; demographics and health-related variables. Data were analysed by descriptive statistics, analysis of variance and regression analysis. Results: Of the 1697 participants, 809 resided in areas that provided prescriptions and 888 in non-prescribing areas. Participants self-report of their prescription did not always match the local area prescription policy. There was no statistically significant difference between prescribing and non-prescribing areas in how easy or difficult participants found it to obtain GFSF (p = 0.644) and its availability in various locations. Participants in non-prescribing areas purchased most types of GFSF items in statistically significantly higher quantities and thereby spent an additional £11.32/month on GFSF items than participants in prescribing areas (p < 0.001). While taking into account the self-reported prescription status, the amount increased to £14.09/month (p < 0.001). Although affordability to buy GFSF did not differ based on local area prescription policy or self-reported prescription status, it was dependent on equivalised annual income. However, affordability did not influence spending on GFSF. Regression analysis indicated that males and households with additional members with coeliac disease spent more on GFSF. Conclusions: The study has highlighted that gluten-free prescription withdrawal can have financial implications for people with coeliac disease. Any future changes to the prescription policy of GFSF should consider the impact on the population, especially lower income households. [ABSTRACT FROM AUTHOR]

Background: Little is known about the effectiveness of, and implementation complexities associated with, service delivery models for children and young people (CYP) experiencing 'common' mental health problems such as anxiety, depression, behavioural difficulties and self-harm. This paper outlines how a model for high-quality service design for this population group was developed by identifying available services, their effectiveness, cost-effectiveness and acceptability, and the barriers and enablers to access. Methods: Sequential, mixed-methods design, combining evidence syntheses (scoping and integrative reviews of the international literature) with primary research (a collective case study in England and Wales). Data from these two elements were collaboratively synthesised in a subsequent model-building phase. Results: The scoping review yielded a service model typology. The integrative review found effectiveness evidence only for four models: collaborative care (the only service model to also have cost-effectiveness evidence), outreach approaches, brief intervention services and an organisational framework called 'Availability, Responsiveness and Continuity'. No service model seemed more acceptable than others. Three case study themes were identified: pathways to support; service engagement; and learning and understanding. The model-building phase identified rapid access, learning self-care skills, individualised support, clear information, compassionate and competent staff and aftercare planning as core characteristics of high-quality services. These characteristics were underpinned by four organisational qualities: values that respect confidentiality; engagement and involvement; collaborative relationships; and a learning culture. Conclusions: A consistent organisational evidence-base for service design and delivery in CYP's mental health spanning many years appears to have had little impact on service provision in England and Wales. Rather than impose – often inflexible and untested – specific local or national models or frameworks, those commissioning, designing and delivering mental health services for CYP should (re)focus on already known, fundamental components necessary for high-quality services. These fundamental components have been integrated into a collaboratively produced general model of service design for CYP with common mental health problems. While this general model is primarily focused on British service provision, it is broad enough to have utility for international audiences. [ABSTRACT FROM AUTHOR]

Background: The MODEM project (A comprehensive approach to MODelling outcome and costs impacts of interventions for DEMentia) explores how changes in arrangements for the future treatment and care of people living with dementia, and support for family and other unpaid carers, could result in better outcomes and more efficient use of resources.Methods: MODEM starts with a systematic mapping of the literature on effective and (potentially) cost-effective interventions in dementia care. Those findings, as well as data from a cohort, will then be used to model the quality of life and cost impacts of making these evidence-based interventions more widely available in England over the period from now to 2040. Modelling will use a suite of models, combining microsimulation and macrosimulation methods, modelling the costs and outcomes of care, both for an individual over the life-course from the point of dementia diagnosis, and for individuals and England as a whole in a particular year. Project outputs will include an online Dementia Evidence Toolkit, making evidence summaries and a literature database available free to anyone, papers in academic journals and other written outputs, and a MODEM Legacy Model, which will enable local commissioners of services to apply the model to their own populations.Discussion: Modelling the effects of evidence-based cost-effective interventions and making this information widely available has the potential to improve the health and quality of life both of people with dementia and their carers, while ensuring that resources are used efficiently. [ABSTRACT FROM AUTHOR]

Background: Children and young people's (CYP) mental health is a major public health concern internationally and the recent Covid-19 pandemic has amplified these concerns. However, only a minority of CYP receive support from mental health services due to the attitudinal and structural barriers they and their families encounter. For over 20 years, report after report has consistently highlighted the shortcomings of mental health services for CYP in the United Kingdom and attempts to improve services have been largely unsuccessful. The findings reported in this paper are from a multi-stage study that aimed to develop a model of effective, high-quality service design for CYP experiencing common mental health problems. The aim of the stage reported here was to identify CYP's, parents' and service providers' perceptions of the effectiveness, acceptability and accessibility of services. Methods: Case studies were conducted of nine different services for CYP with common mental health problems in England and Wales. Data were collected using semi-structured interviews with 41 young people, 26 parents and 41 practitioners and were analysed using the Framework approach. Patient and Public Involvement was integrated throughout the study with a group of young co-researchers participating in data collection and analysis. Results: Four key themes defined participants' perceptions of service effectiveness, acceptability and accessibility. Firstly, open access to support with participants highlighting the importance of self-referral, support at the point of need and service availability to CYP/parents. Secondly, the development of therapeutic relationships to promote service engagement which was based on assessment of practitioner's personal qualities, interpersonal skills and mental health expertise and underpinned by relational continuity. Thirdly, personalisation was viewed as promoting service appropriateness and effectiveness by ensuring support was tailored to the individual. Fourthly, the development of self-care skills and mental health literacy helped CYP/parents manage and improve their/their child's mental health problems. Conclusions: This study contributes to knowledge by identifying four components that are perceived to be central to providing effective, acceptable and accessible mental health services for CYP with common mental health problems irrespective of service model or provider. These components could be used as the foundations for designing and improving services. [ABSTRACT FROM AUTHOR]

Background: In the English NHS, integrated care is seen as an opportunity to deliver joined-up care for children and families. This paper examines the lessons learnt by professional stakeholders in the process of developing different examples of integrated models of care/frameworks for children's services. Methods: Initial desk research was undertaken to identify different examples of integrated care models and systems/frameworks for children's services. This identified forty-three examples in England. Of these, twelve examples were shortlisted after consultation with the senior managers within the Health and Care Partnership that had commissioned the research, and a more detailed online search for published documents was undertaken. Semi-structured qualitative interviews were then conducted with sixteen professional stakeholders in eight of these examples, ranging from one to four interviewees per example. Interviews focused on the lessons learnt from integrating and transforming services. Data were analysed using framework analysis. Results: The eight examples vary in their design but have several broad commonalities. A number of common themes and learning have emerged, of which two were identified within all eight examples: the first is about focusing on children and young people; the second is about focusing on partner engagement and collaboration and the importance of building trust and relationships between partners. A number of other important themes also emerged together with several challenges. Conclusions: A number of common factors were identified that are essential to success in integrating health and care systems. Common across all localities were being child-centric and focusing on child outcomes plus the importance of building trust, engagement and relationships with partners. The findings can help health and care system leaders transform services to ensure efficiency, improvement in services and integration. [ABSTRACT FROM AUTHOR]

Background: Medication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident.Method: This is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents (n = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data.Results: Analysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error.Conclusion: Negative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice. [ABSTRACT FROM AUTHOR]

Background: Community-based multi-disciplinary teams (MDTs) are the most common means to encourage health and social care service integration in England yet are rarely studied or directly observed. This paper reports on two rounds of non-participant observations of community-based multi-disciplinary team (MDT) meetings in two localities, as part of an evaluation of the Integrated Care and Support Pioneers Programme. We sought to understand how MDT meetings coordinate care and identify their 'added value' over bilateral discussions.Methods: Two rounds of structured non-participant observations of 11 MDTs (28 meetings) in an inner city and mixed urban-rural area in England (June 2019-February 2020), using a group analysis approach.Results: Despite diverse settings, attendance and caseloads, MDTs adopted similar processes of case management: presentation; information seeking/sharing; narrative construction; solution seeking; decision-making and task allocation. Patient-centredness was evident but scope to strengthen 'patient-voice' exists. MDTs were hampered by information governance rules and lack of interoperability between patient databases. Meetings were characterised by mutual respect and collegiality with little challenge. Decision-making appeared non-hierarchical, often involving dyads or triads of professionals. 'Added value' lay in: rapid patient information sharing; better understanding of contributing agencies' services; planning strategies for patients that providers had struggled to find the right way to engage satisfactorily; and managing risk and providing mutual support in stressful cases.Conclusions: More attention needs to be given to removing barriers to information sharing, creating scope for constructive challenge between staff and deciding when to remove cases from the caseload. [ABSTRACT FROM AUTHOR]

Introduction: Pharmacogenomics (PGx) testing services have been delivered through community pharmacies across the globe, though not yet in the UK. This paper is reporting a focus group study, the first stage of a participatory co-design process to increase the chance of a successful implementation of a PGx service through community pharmacy in the UK.Aim: To identify the barriers and enablers to implementing a community pharmacy based PGx service in the UK.Method: Three focus groups were conducted with community pharmacists (n = 10), prescribers (n = 8) and patients (n = 8) in England. The focus groups were recorded, transcribed and thematically analysed using the Braun and Clarke six phase reflexive thematic analysis approach.Results: The analysis identified five themes about PGx testing in community pharmacies: (1) In- principle receptiveness, (2) Appreciation of the benefits, (3) Lack of implementation resources (4) Ambiguity about implications for implementation and (5) Interprofessional relationship challenges.Conclusion: The identified enablers for implementation of a PGx service were at a macro health system strategic level; the concerns were more at a granular operational procedural level. Overall receptiveness was noted by all three participant groups, and both prescriber and pharmacist groups appreciated the potential benefits for patients and the healthcare system. Prior to implementation in the UK, there is a need to disambiguate health professional's concerns of the guidance, resources, and knowledge required to set up and deliver the service and to resolve patient concerns about the nature of genomics. [ABSTRACT FROM AUTHOR]

Background: Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.Methods: A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.Results: Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.Conclusions: Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established. [ABSTRACT FROM AUTHOR]

Blackpool is one of the most deprived Local Authority (LA) areas in England; in April 2015 the Blackpool Better Start (BBS) Partnership was allocated £45 million over 10 years from the Big Lottery Fund (BLF) as one of five 'A Better Start' initiative areas in England. The aim of the 'A Better Start' initiative is to improve outcomes for children from conception to 3 years of age. Co-designed by professionals and the community, the Community Connector (CCx) programme employs residents to directly engage caregivers of children, in seven of Blackpool's most socio-economically deprived wards. The CCx follow a socioecological framework which proposes that caregivers will be positively influenced to engage in early years activities because of connections to trained peers. Peer support models are commonly applied within targeted early years health settings (i.e., infant feeding support, literacy) yet their role to improve child outcomes at a universal level has received little attention. This paper focuses on caregiver-level evidence of the strategies employed by CCx - part of an early stage pilot study supported by Frontiers of Innovation, the Harvard Centre on the Developing Child's Research and Development platform.The study collated attendance data from Children's Centres, these are publically funded community centres providing information and activities for families with children 0-5 years of age. The study data included individual interactions between a CCx and caregiver over a 1 year period (1st April 2018 - 31st March 2019). A sampling frame was created from which a total of 22 interviews with caregivers were undertaken in early years community settings. The interview data was thematically analysed; the findings highlighted the mechanisms by which CCx served to mediate service and caregiver communication boundaries, negotiate access to spaces, and encouraged sustained engagement in longer term activities such as volunteering and training. Value was embedded by the CCx in their process of establishing and maintaining connections with caregivers through the 'everyday' conversations, their individualised approach and in demonstrating self-efficacy behaviours. Further research is required to review the impact of the CCx role in caregiver's recall of early years information, nevertheless the study provided important learning for establishing formalised CCx programmes elsewhere, and has implications for community health and early years policy and practice. [ABSTRACT FROM AUTHOR]

Background: National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day services (7DS), from an organisational behaviour perspective.Methods: We conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response.Results: Senior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations.Conclusions: National standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by resources and tailored support for improvement, taking into account local context and organisational culture. [ABSTRACT FROM AUTHOR]

Background: To help promote a flexible and sustainable workforce in dentistry, it is necessary to access accurate and timely data about the structure and nature of the evolving dental team. This paper considers the results and learning from a region-wide dental workforce survey conducted in one area of Health Education England and how the team has changed since the last survey a decade earlier.Methods: A mixed-methods approach comprised two phases. In Phase 1 a customised workforce questionnaire was sent to all dental practices registered with the Care Quality Commission in the North East of England and North Cumbria in March 2016. Findings then informed Phase 2, a regional symposium held in October 2016, where interactive workshops generated qualitative data that elaborated on factors influencing workforce development.Results: Of 431 primary dental care practices identified, 228 questionnaires were returned - a 53% response rate. The largest professional groups were dental nurses (n = 1269, 53% by headcount; 50% of fte) and dentists (34% by headcount; 42% by fte), though there had been increases in numbers of all staff groups over the decade, which was most marked for dental therapists (from 1 per 39 dentists to 1 per 8 dentists). The dental team predominantly fell into 'younger' age groups (< 46 years age), with evidence of a significant increase in the number of dentists reporting part-time working in a practice since the last survey. Around one third of dental practices reported employing dental nurses with additional skills (n = 74, 32.5%) or dental therapists (n = 73, 32%), and nearly half employed a dental hygienist (n = 104, 46%). However, there was considerable variability in whether these staff actually carried out the range of skills within their scope of practice. Factors shaping workforce development were identified as, the national context, loss of expertise, patients' health needs and expectations, surgery premises and financial constraints.Conclusions: The composition and work patterns of the primary care dental workforce have changed markedly over the last decade, though utilisation of skill-mix continues to be constrained. Consideration of factors determining career progression of dentists and dental care professionals is needed to optimise a sustainable future workforce. [ABSTRACT FROM AUTHOR]

Background: Rapid evaluation was at the heart of National Health Service England's evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods.Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard.Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168.Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify "quick wins" and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to explore the impact of the implementation of an electronic prescribing and medication administration system (ePA) on the safety of medication administration in an inpatient hospital setting. Objectives were to compare the prevalence and types of: 1) medication administration errors, and 2) documentation discrepancies, between a paper and an ePA system. Additionally, we wanted to describe any observed changes to medication administration practices.Methods: The study was based on an elderly medicine ward in an English hospital. From December 2014 to June 2015, nurses' medication administration rounds were observed every 5 days before and after ePA implementation using an interrupted time-series approach. Medication administration error and documentation discrepancy rates pre- versus post-ePA were analysed descriptively and chi-squared tests used to test for any difference; segmented regression analysis was used to determine changes in longitudinal trend.Results: Observations were made at 15 pre- and 15 post-ePA implementation time-points. Pre-ePA on paper, there were 18 medication administration errors in 428 opportunities for error (4.2%; 95% confidence interval 2.3-6.1%), and with ePA there were 18 in 528 (3.4%; 95% confidence interval 1.9-5.0%; p = 0.64). Regarding documentation, pre-ePA on paper there were 5 discrepancies in 460 observed documentations (1.1%; 95% confidence interval 0.1-2.0%); with ePA there were 18 in 557 (3.2%; 95% confidence interval 1.8-4.7%; p = 0.04). The most common electronic documentation discrepancy was documentation that a dose had been administered when it had not. Segmented regression analysis was unable to detect any significant longitudinal changes. Changes to working practices post-ePA were observed, such as nurses demonstrating less-consistent self-checking when preparing and administering medications.Conclusions: Findings suggest no change in medication error rate, although ePA encourages certain types of errors and mitigates others. There was a statistically significant increase in documentation discrepancies which is likely to be due to adoption of new working practices with ePA. [ABSTRACT FROM AUTHOR]

Background: In recent years joint commissioning has assumed an important place in the policy and practice of English health and social care. Yet, despite much being claimed for this way of working there is a lack of evidence to demonstrate the outcomes of joint commissioning. This paper examines the types of impacts that have been claimed for joint commissioning within the literature. Method: The paper reviews the extant literature concerning joint commissioning employing an interpretive schema to examine the different meanings afforded to this concept. The paper reviews over 100 documents that discuss joint commissioning, adopting an interpretive approach which sought to identify a series of discourses, each of which view the processes and outcomes of joint commissioning differently. Results: This paper finds that although much has been written about joint commissioning there is little evidence to link it to changes in outcomes. Much of the evidence base focuses on the processes of joint commissioning and few studies have systematically studied the outcomes of this way of working. Further, there does not appear to be one single definition of joint commissioning and it is used in a variety of different ways across health and social care. The paper identifies three dominant discourses of joint commissioning - prevention, empowerment and efficiency. Each of these offers a different way of seeing joint commissioning and suggests that it should achieve different aims. Conclusions: There is a lack of clarity not only in terms of what joint commissioning has been demonstrated to achieve but even in terms of what it should achieve. Joint commissioning is far from a clear concept with a number of different potential meanings. Although this ambiguity can be helpful in some ways in the sense that it can bring together disparate groups, for example, if joint commissioning is to be delivered at a local level then more specificity may be required in terms of what they are being asked to deliver. [ABSTRACT FROM AUTHOR]

Background: The English National Health Service (NHS) has significantly extended the supply of evidence based psychological interventions in primary care for people experiencing common mental health problems. Yet despite the extra resources, the accessibility of services for 'under-served' ethnic and religious minority groups, is considerably short of the levels of access that may be necessary to offset the health inequalities created by their different exposure to services, resulting in negative health outcomes. This paper offers a critical reflection upon an initiative that sought to improve access to an NHS funded primary care mental health service to one 'under-served' population, an Orthodox Jewish community in the North West of England.Methods: A combination of qualitative and quantitative data were drawn upon including naturally occurring data, observational notes, e-mail correspondence, routinely collected demographic data and clinical outcomes measures, as well as written feedback and recorded discussions with 12 key informants.Results: Improvements in access to mental health care for some people from the Orthodox Jewish community were achieved through the collaborative efforts of a distributed leadership team. The members of this leadership team were a self-selecting group of stakeholders which had a combination of local knowledge, cultural understanding, power to negotiate on behalf of their respective constituencies and expertise in mental health care. Through a process of dialogic engagement the team was able to work with the community to develop a bespoke service that accommodated its wish to maintain a distinct sense of cultural otherness.Conclusions: This critical reflection illustrates how dialogic engagement can further the mechanisms of candidacy, concordance and recursivity that are associated with improvements in access to care in under-served sections of the population, whilst simultaneously recognising the limits of constructive dialogue. Dialogue can change the dynamic of community engagement. However, the full alignment of the goals of differing constituencies may not always be possible, due the complex interaction between the multiple positions and understandings of stakeholders that are involved and the need to respect the other'-s' autonomy. [ABSTRACT FROM AUTHOR]

Background: London has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London's TB services' organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently. Methods: Objectives were: 1) To establish how London's TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London's five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2). Results: Findings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals' interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs. Conclusions: This paper has identified key issues relating to London's TB services' organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities. [ABSTRACT FROM AUTHOR]

Background: Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.Methods: A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.Results: Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time.Conclusions: There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital. [ABSTRACT FROM AUTHOR]

Background: There is a political drive in the UK to use assistive technologies such as telehealth and telecare as an innovative and efficient approach to healthcare delivery. However, the success of implementation of such services remains dependent on the ability to engage the wider population to adopt these services. It has been widely acknowledged that low acceptance of technology, forms a key barrier to adoption although findings been mixed. Further, it remains unclear what, if any barriers exist between patients and how these compare to those who have declined or withdrawn from using these technologies. This research aims to address this gap focusing on the UK based Cambridgeshire Community Services Assistive Telehealth and Telecare service, an integrated model of telehealth and telecare.Methods: Qualitative semi-structured interviews were conducted between 1st February 2014 and 1st December 2014, to explore the views and experiences of 'users' and 'non-users' using this service. 'Users' were defined as patients who used the service (N = 28) with 'non-users' defined as either referred patients who had declined the service before allocation (N = 3) or had withdrawn after using the ATT service (N = 9). Data were analysed using the Framework Method.Results: This study revealed that there are a range of barriers and facilitators that impact on the decision to adopt and continue to engage with this type of service. Having a positive attitude and a perceived need that could be met by the ATT equipment were influential factors in the decision to adopt and engage in using the service. Engagement of the service centred on 'usability', 'usefulness of equipment', and 'threat to identity and independence'.Conclusions: The paper described the influential role of referrers in decision-making and the need to engage with such agencies on a strategic level. The findings also revealed that reassurance from the onset was paramount to continued engagement, particularly in older patients who appeared to have more negative feelings towards technology. In addition, there is a clear need for continued product development and innovation to not only increase usability and functionality of equipment but also to motivate other sections of the population who could benefit from such services. Uncovering these factors has important policy implications in how services can improve access and patient support through the application of assistive technology which could in turn reduce unnecessary cost and burden on overstretched health services. [ABSTRACT FROM AUTHOR]

Background: There is very little published work on the visual needs of homeless people. This paper is the first study to investigate the visual needs of homeless people in the UK. Although similar work has been done in other countries, this study is unique because the United Kingdom is the only country with a National Health Service which provides free healthcare at the point of access. This study analysed the refractive status of the sample used, determined the demographics of homeless people seeking eye care and established if there is a need for community eye health with access to free spectacle correction in East London.Methods: This retrospective case study analysed the clinical records of 1,141 homeless people using the Vision Care for Homeless People services at one of their clinics in East London. All eye examinations were carried out by qualified optometrists and, where appropriate, spectacles were dispensed to patients. Data captured included age, gender, ethnicity and refractive error. Results were analysed using two-sample t-tests with Excel and Minitab.Results: Demographics of age, gender and ethnicity are described. Spherical equivalents (SE) were calculated from prescription data available for 841 clinic users. Emmetropia was defined as SE-0.50DS to +1DS, myopia as SE < -0.50DS, and hyperopia as SE > +1DS. The majority of clinic users were male (79.2 %, n = 923). Approximately 80 % (n = 583) of clinic users were white, 10 % (n = 72) were 'black', 4 % (n = 29) 'Asian' and the remaining 5.6 % (n = 40) were of 'mixed ethnicity' and 'other' groups. The mean age of females attending the clinic was significantly lower than that of males (45.9 years, SD = 13.8 vs' 48.4 years, SD = 11.8) when analysed using a two-sample t-test (t (317) = 2.44, p = 0.02). One third of service users were aged between 50-59 years. Myopia and hyperopia prevalence rates were 37.0 % and 21.0 % respectively. A total of 34.8 % of homeless people were found to have uncorrected refractive error, and required spectacle correction.Conclusions: This study has identified a high proportion of uncorrected refractive error in this sample and therefore a need for regular eye examinations and provision of refractive correction for homeless people. [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.Methods: This paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.Results: Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.Conclusions: Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes. [ABSTRACT FROM AUTHOR]

Background: National Health Service (NHS) trusts, which provide the majority of hospital and community health services to the English NHS, are increasingly adopting a 'public firm' model with a board consisting of executive directors who are trust employees and external non-executives chosen for their experience in a range of areas such as finance, health care and management. In this paper we compare the non-executive directors' roles and interests in, and contributions to, NHS trust boards' governance activities with those of executive directors; and examine non-executive directors' approach to their role in board meetings.Methods: Non-participant observations of three successive trust board meetings in eight NHS trusts (primary care trusts, foundation trusts and self-governing (non-foundation) trusts) in England in 2008-9. The observational data were analysed inductively to yield categories of behaviour reflecting the perlocutionary types of intervention which non-executive directors made in trust meetings.Results: The observational data revealed six main perlocutionary types of questioning tactic used by non-executive directors to executive directors: supportive; lesson-seeking; diagnostic; options assessment; strategy seeking; and requesting further work. Non-executive board members' behaviours in holding the executive team to account at board meetings were variable. Non-executive directors were likely to contribute to finance-related discussions which suggests that they did see financial challenge as a key component of their role.Conclusions: The pattern of behaviours was more indicative of an active, strategic approach to governance than of passive monitoring or 'rubber-stamping'. Nevertheless, additional means of maintaining public accountability of NHS trusts may also be required. [ABSTRACT FROM AUTHOR]

Background: Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team.Methods: TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates.Results: The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival.Conclusions: The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system. [ABSTRACT FROM AUTHOR]

Background: Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods: We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results: In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services. In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions: Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions. [ABSTRACT FROM AUTHOR]

Background: In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control ('media of power') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so. Methods: Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources. Results: The comparison exposes and contrasts two basic generic modes of commissioning: 1. Surrogate planning (English NHS), in which a negotiated order involving micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers. 2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power. Conclusions: Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control. [ABSTRACT FROM AUTHOR]

Background: This paper examines NHS secondary care contracting in England and Wales in a period which saw increasing policy divergence between the two systems. At face value, England was making greater use of market levers and utilising harder-edged service contracts incorporating financial penalties and incentives, while Wales was retreating from the 1990s internal market and emphasising cooperation and flexibility in the contracting process. But there were also cross-border spill-overs involving common contracting technologies and management cultures that meant that differences in on-the-ground contracting practices might be smaller than headline policy differences suggested. Methods: The nature of real-world contracting behaviour was investigated by undertaking two qualitative case studies in England and two in Wales, each based on a local purchaser/provider network. The case studies involved ethnographic observations and interviews with staff in primary care trusts (PCTs) or local health boards (LHBs), NHS or Foundation trusts, and the overseeing Strategic Health Authority or NHS Wales regional office, as well as scrutiny of relevant documents. Results: Wider policy differences between the two NHS systems were reflected in differing contracting frameworks, involving regional commissioning in Wales and commissioning by either a PCT, or co-operating pair of PCTs in our English case studies, and also in different oversight arrangements by higher tiers of the service. However, longterm relationships and trust between purchasers and providers had an important role in both systems when the financial viability of organisations was at risk. In England, the study found examples where both PCTs and trusts relaxed contractual requirements to assist partners faced with deficits. In Wales, news of plans to end the purchaser/provider split meant a return to less precisely-specified block contracts and a renewed concern to build cooperation between LHB and trust staff. Conclusions: The interdependency of local purchasers and providers fostered long-term relationships and cooperation that shaped contracting behaviour, just as much as the design of contracts and the presence or absence of contractual penalties and incentives. Although conflict and tensions between contracting partners sometimes surfaced in both the English and Welsh case studies, cooperative behaviour became crucial in times of trouble. [ABSTRACT FROM AUTHOR]

Background: The article explores the implications of personal budgets within English social care services, which position the individual as market actor. Rooting the research in the broader personalization agenda, the study looks at the limitations of the market in relation to individual purchase of private goods (e.g. home care), in the pooling of funds to purchase group services and in the provision of public goods such as building-based services. Method: The article takes a multi-method approach, combining an interpretive focus on the framing of the personal budget-holder by advocates of personalization with national evaluation data, and data from a small survey of day centre workers. Results: The article identifies three framings of the individual budget-holder articulated by advocates of personalization. The first is that personal budget-holders will be empowered market actors, commissioning the services they need. The second is that budget-holders will pool resources with others to purchase group services in order to broaden the range of options available to them. The third is that services which cannot be disaggregated into individual or group budgets - such as day centres - are not valued by service users. The article looks at the evaluation data on these three claims in turn. It identifies four limitations to the capacity of people to purchase care goods on an individual basis: lack of transparency in allocating budgets, complexity in managing a budget, excessive auditing of spending and lack of responsiveness from the provider market. Pooling of budgets to purchase collective services is found to be underdeveloped, and hampered by the complexity which is a broader limitation on personal budgets. Day centres are found to be closing not in response to commissioning decisions by individual budget-holders but because of decommissioning by local authorities, minimising the scope for individuals to express a preference for this type of care. The survey highlights patterns of day centre closure, rising fees for attendance and reduced eligibility, and the underdevelopment of mechanisms to facilitate commissioning of new collective spaces. Conclusions: The paper concludes that the transition to personal budgets - in the context of the accompanying financial crisis in local authorities - has led to inadequate attention to the potential for an undersupply of collective and public goods. The loss of day centre provision will be felt by personal budget holders but also by self-funders and people in residential accommodation who may no longer be eligible for, or able to afford, to access shared spaces. Local authorities are actively taking on the role of decommissioners without sufficient responsiveness to how and what individuals want them to commission. [ABSTRACT FROM AUTHOR]

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the "Livewell project". 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies 'negotiated order', managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system. [ABSTRACT FROM AUTHOR]

Background: Inequalities in uptake of cancer screening by ethnic minority populations are well documented in a number of international studies. However, most studies to date have explored screening uptake for a single cancer only. This paper compares breast and bowel cancer screening uptake for a cohort of South Asian women invited to undertake both, and similarly investigates these women's breast cancer screening behaviour over a period of fifteen years. Methods: Screening data for rounds 1, 2 and 5 (1989-2004) of the NHS breast cancer screening programme and for round 1 of the NHS bowel screening pilot (2000-2002) were obtained for women aged 50-69 resident in the English bowel screening pilot site, Coventry and Warwickshire, who had been invited to undertake breast and bowel cancer screening in the period 2000-2002. Breast and bowel cancer screening uptake levels were calculated and compared using the chi-squared test. Results: 72,566 women were invited to breast and bowel cancer screening after exclusions. Of these, 3,539 were South Asian and 69,027 non-Asian; 18,730 had been invited to mammography over the previous fifteen years (rounds 1 to 5). South Asian women were significantly less likely to undertake both breast and bowel cancer screening; 29.9% (n = 1,057) compared to 59.4% (n = 40,969) for non-Asians (p < 0.001). Women in both groups who consistently chose to undertake breast cancer screening in rounds 1, 2 and 5 were more likely to complete round 1 bowel cancer screening. However, the likelihood of completion of bowel cancer screening was still significantly lower for South Asians; 49.5% vs. 82.3% for non-Asians, p < 0.001. South Asian women who undertook breast cancer screening in only one round were no more likely to complete bowel cancer screening than those who decided against breast cancer screening in all three rounds. In contrast, similar women in the non-Asian population had an increased likelihood of completing the new bowel cancer screening test. The likelihood of continued uptake of mammography after undertaking screening in round 1 differed between South Asian religio-linguistic groups. Noticeably, women in the Muslim population were less likely to continue to participate in mammography than those in other South Asian groups. Conclusions: Culturally appropriate targeted interventions are required to reduce observed disparities in cancer screening uptakes. [ABSTRACT FROM AUTHOR]

Background: Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'. Methods: Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision. Results: The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care. Conclusion: Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply. [ABSTRACT FROM AUTHOR]

Background: Although young people's transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) in England is a significant health issue for service users, commissioners and providers, there is little evidence available to guide service development. The TRACK study aims to identify factors which facilitate or impede effective transition from CAHMS to AMHS. This paper presents findings from a survey of transition protocols in Greater London. Methods: A questionnaire survey (Jan-April 2005) of Greater London CAMHS to identify transition protocols and collect data on team size, structure, transition protocols, population served and referral rates to AMHS. Identified transition protocols were subjected to content analysis. Results: Forty two of the 65 teams contacted (65%) responded to the survey. Teams varied in type (generic/targeted/in-patient), catchment area (locality-based, wider or national) and transition boundaries with AMHS. Estimated annual average number of cases considered suitable for transfer to AMHS, per CAMHS team (mean 12.3, range 0-70, SD 14.5, n = 37) was greater than the annual average number of cases actually accepted by AMHS (mean 8.3, range 0-50, SD 9.5, n = 33). In April 2005, there were 13 active and 2 draft protocols in Greater London. Protocols were largely similar in stated aims and policies, but differed in key procedural details, such as joint working between CAHMS and AMHS and whether protocols were shared at Trust or locality level. While the centrality of service users' involvement in the transition process was identified, no protocol specified how users should be prepared for transition. A major omission from protocols was procedures to ensure continuity of care for patients not accepted by AMHS. Conclusion: At least 13 transition protocols were in operation in Greater London in April 2005. Not all protocols meet all requirements set by government policy. Variation in protocol-sharing organisational units and transition process suggest that practice may vary. There is discontinuity of care provision for some patients who 'graduate' from CAMHS services but are not accepted by adult services. [ABSTRACT FROM AUTHOR]

Background: The 2003 revision of the UK GMS contract rewards general practices for performance against clinical quality indicators. Practices can exempt patients from treatment, and can receive maximum payment for less than full coverage of eligible patients. This paper aims to estimate the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care (the pay-performance gap), and to estimate how much of the gap is attributable respectively to thresholds and to exception reporting. Methods: Analysis of Quality Outcomes Framework data in the National Primary Care Database and exception reporting data from the Information Centre from 8407 practices in England in 2005 -- 6. The main outcome measures were the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care at the practice level, both for individual indicators and a combined composite score. An additional outcome was the percentage of that gap attributable respectively to exception reporting and maximum threshold targets set at less than 100%. Results: The mean pay-performance gap for the 65 aggregated clinical indicators was 13.3% (range 2.9% to 48%). 52% of this gap (6.9% of eligible patients) is attributable to thresholds being set at less than 100%, and 48% to patients being exception reported. The gap was greater than 25% in 9 indicators: beta blockers and cholesterol control in heart disease; cholesterol control in stroke; influenza immunization in asthma; blood pressure, sugar and cholesterol control in diabetes; seizures in epilepsy and treatment of hypertension. Conclusion: Threshold targets and exception reporting introduce an incentive ceiling, which substantially reduces the percentage of eligible patients that UK practices need to treat in order to receive maximum incentive payments for delivering that care. There are good clinical reasons for exception reporting, but after unsuitable patients have been exempted from treatment, there is no reason why all maximum thresholds should not be 100%, whilst retaining the current lower thresholds to provide incentives for lower performing practices. [ABSTRACT FROM AUTHOR]

Background: Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey. Methods: Randomised controlled trial. Setting: North and West Birmingham. 8,645 patients aged 18 or over randomly selected from registers of eight general practices (family physician practices). Intervention: Inclusion of a flyer and letter with a health questionnaire informing patients that returned questionnaires would be entered into a lottery-style draw for £100 of gift vouchers. Control: Health questionnaire accompanied only by standard letter of explanation. Main outcome measures: Response rate and completion rate to questionnaire. Results: 5,209 individuals responded with identical rates in both groups (62.1%). Practice, patient age, sex and Townsend score (a postcode based deprivation measure) were identified as predictive of response, with higher response related to older age, being female and living in an area with a lower Townsend score (less deprived). Conclusion: This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for £100 of High Street vouchers has no effect on response rates to a postal health questionnaire. [ABSTRACT FROM AUTHOR]

Background: PRIMEtime CE is a multistate life table model that can directly compare the cost effectiveness of public health interventions affecting diet and physical activity levels, helping to inform decisions about how to spend finite resources. This paper estimates the costs and health outcomes in England of two scenarios: reformulating salt and expanding subsidised access to leisure centres. The results are used to help validate PRIMEtime CE, following the steps outlined in the Assessment of the Validation Status of Health-Economic decision models (AdViSHE) tool.Methods: The PRIMEtime CE model estimates the difference in quality adjusted life years (QALYs) and difference in NHS and social care costs of modelled interventions compared with doing nothing. The salt reformulation scenario models how salt consumption would change if food producers met the 2017 UK Food Standards Agency salt reformulation targets. The leisure centre scenario models change in physical activity levels if the Birmingham Be Active scheme (where swimming pools and gym access is free to residents during defined periods) was rolled out across England. The AdViSHE tool was developed by health economic modellers and divides model validation into five parts: validation of the conceptual model, input data validation, validation of computerised model, operational validation, and other validation techniques. PRIMEtime CE is discussed in relation to each part.Results: Salt reformulation was dominant compared with doing nothing, and had a 10-year return on investment of £1.44 (£0.50 to £2.94) for every £1 spent. By contrast, over 10 years the Be Active expansion would cost £727,000 (£514,000 to £1,064,000) per QALY. PRIMEtime CE has good face validity of its conceptual model and has robust input data. Cross-validation produces mixed results and shows the impact of model scope, input parameters, and model structure on cost-per-QALY estimates.Conclusions: This paper illustrates how PRIMEtime CE can be used to compare the cost-effectiveness of two different public health measures affecting diet and physical activity levels. The AdViSHE tool helps to validate PRIMEtime CE, identifies some of the key drivers of model estimates, and highlights the challenges of externally validating public health economic models against independent data. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases are the leading cause of death in England, and poor diet and physical inactivity are two of the principle behavioural risk factors. In the context of increasingly constrained financial resources, decision makers in England need to be able to compare the potential costs and health outcomes of different public health policies aimed at improving these risk factors in order to know where to invest so that they can maximise population health. This paper describes PRIMEtime CE, a multistate life table cost-effectiveness model that can directly compare interventions affecting multiple disease outcomes.Methods: The multistate life table model, PRIMEtime Cost Effectiveness (PRIMEtime CE), is developed from the Preventable Risk Integrated ModEl (PRIME) and the PRIMEtime model. PRIMEtime CE uses routinely available data to estimate how changing diet and physical activity in England affects morbidity and mortality from heart disease, stroke, diabetes, liver disease, and cancers either directly or via raised blood pressure, cholesterol, and body weight.Results: Model outcomes are change in quality adjusted life years, and change in English National Health Service and social care costs.Conclusion: This paper describes PRIMEtime CE and highlights its main strengths and limitations. The model can be used to compare any number of public policies affecting diet and physical activity, allowing decision makers to understand how they can maximise population health with limited financial resources. [ABSTRACT FROM AUTHOR]

Background: In the regulation of healthcare, the subject of patient and family involvement figures increasingly prominently on the agenda. However, the literature on involving patients and families in regulation is still in its infancy. A systematic analysis of how patient and family involvement in regulation is accomplished across different health systems is lacking. We provide such an overview by mapping and classifying methods of patient and family involvement in regulatory practice in four countries; Norway, England, the Netherlands, and Australia. We thus provide a knowledge base that enables discussions about possible types of involvement, and advantages and difficulties of involvement encountered in practice.Methods: The research design was a multiple case study of patient and family involvement in regulation in four countries. The authors collected 1) academic literature if available and 2) documents of regulators that describe user involvement. Based on the data collected, the authors from each country completed a pre-agreed template to describe the involvement methods. The following information was extracted and included where available: 1) Method of involvement, 2) Type of regulatory activity, 3) Purpose of involvement, 4) Who is involved and 5) Lessons learnt.Results: Our mapping of involvement strategies showed a range of methods being used in regulation, which we classified into four categories: individual proactive, individual reactive, collective proactive, and collective reactive methods. Reported advantages included: increased quality of regulation, increased legitimacy, perceived justice for those affected, and empowerment. Difficulties were also reported concerning: how to incorporate the input of users in decisions, the fact that not all users want to be involved, time and costs required, organizational procedures standing in the way of involvement, and dealing with emotions.Conclusions: Our mapping of user involvement strategies establishes a broad variety of ways to involve patients and families. The four categories can serve as inspiration to regulators in healthcare. The paper shows that stimulating involvement in regulation is a challenging and complex task. The fact that regulators are experimenting with different methods can be viewed positively in this regard. [ABSTRACT FROM AUTHOR]

Background: There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements.Methods: The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme.Results: One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of 'emotional labour' that staff members need to invest in implementing the programme.Conclusions: Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The 'emotional labour' for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement. [ABSTRACT FROM AUTHOR]

Background: Health systems, globally, are attempting to strengthen primary care to promote a population-health management approach to care provision, incentivising prevention and self-management. This paper evaluates the "Enhanced Primary Care" model implemented in a geographical region in England. Enhanced Primary Care introduces a new non-medical role, health coaches, to the traditional primary care team to provide additional support for patients with chronic conditions. We evaluate effects of health coaching on patient outcomes using a quasi-experiment.Methods: We estimate the programme's effects on health status (EQ-5D-5L, physical functioning, psychological wellbeing, and resilience), health behaviour (smoking habit), experience of care (person-centeredness and continuity of care), and health care (primary care) utilisation using data from 3.5 million respondents to the national GP Patient Surveys between 2013 and 2017. We use a weighted difference-in-differences design to compare changes in outcomes over time between intervention practices and comparable control practices in the rest of England. We conduct our main analysis on multimorbid patients and additional analysis on all patients to assess population-level effects.Results: For multimorbid patients, we find reductions in psychological wellbeing (short and medium term) of -0.0174 (95% confidence interval -0.0283 to -0.0065), relative difference -2% from the pre-intervention mean; and person-centeredness (short term) of -0.0356 (-0.0530 to -0.0183), -4%. We find no significant effects on other outcome measures. For population-level effects, in the short term we find reductions in primary care utilisation of -0.0331 (-0.0448 to -0.0214), -5%. All other outcomes are not consistently statistically significant.Conclusions: Our results show that there is very little effect of health coaching on patient experience and outcomes in the short-to-medium term (up to 14 months). Introduction of Enhanced Primary Care was associated with slightly lower psychological wellbeing and person-centeredness amongst multimorbid patients (it might be initially difficult for patients to adjust to the model). However, it was also associated with a decline in primary care visits at the population-level (potentially freeing up practitioner time for more complex patients). The results raise important questions regarding primary care workforce changes advocated in the NHS Long Term Plan, and the time horizon of any benefits of prevention strategies. [ABSTRACT FROM AUTHOR]

Background: Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention.Methods: Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices.Results: Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability.Conclusions: NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients. [ABSTRACT FROM AUTHOR]