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Objectives Community-based social innovations (CBSIs) are one type of intervention that may help to address the complex needs of ageing populations globally. The aim of this research was to assess evidence for the effectiveness and cost-effectiveness of CBSIs involving in such contexts. Methods We conducted a systematic review of CBSIs for healthy ageing in middle- and high-income countries, including any CBSI that aimed to empower people aged 50 and over by motivating them to take initiative for their own health and wellbeing. The protocol was registered with Prospero (CRD 42016051622). A comprehensive search was conducted in 15 academic databases and advanced search in Google. We included published studies from 2000 onwards in any language. Exploratory meta-analysis was conducted for quantitative studies reporting similar outcomes, and qualitative studies were analysed using thematic analysis. Narrative synthesis was conducted. Searches yielded 13,262 unique hits, from which 44 papers met the inclusion criteria. Results Most studies reported interventions having positive impacts on participants, such as reduced depression, though the majority of studies were classified as being at medium or high risk of bias. There was no evidence on costs or cost-effectiveness and very little reporting of outcomes at an organization or system level. CBSIs have the potential for positive impacts, but with nearly half of studies coming from high-income urban settings (particularly the United Kingdom and the United States of America), there is a lack of generalizability of these findings. Conclusions Our research highlights the need to improve reporting of CBSIs as complex interventions, and for improved conceptualization of these interventions to inform research and practice.

Approximately 13% of the total UK workforce is employed in the health and care sector. Despite substantial workforce planning efforts, the effectiveness of this planning has been criticised. Education, training, and workforce plans have typically considered each health-care profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention. Areas of particular concern highlighted in this Health Policy paper include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives. Impending challenges for the UK health and care workforce include growing multimorbidity, an increasing shortfall in the supply of unpaid carers, and the relative decline of the attractiveness of the National Health Service (NHS) as an employer internationally. We argue that to secure a sustainable and fit-for-purpose health and care workforce, integrated workforce approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working. Enhancing career development opportunities, promoting staff wellbeing, and tackling discrimination in the NHS are all needed to improve recruitment, retention, and morale of staff. An urgent priority is to offer sufficient aftercare and support to staff who have been exposed to high-risk situations and traumatic experiences during the COVID-19 pandemic. In response to growing calls to recognise and reward health and care staff, growth in pay must at least keep pace with projected rises in average earnings, which in turn will require linking future NHS funding allocations to rises in pay. Through illustrative projections, we show that, to sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose. [Abstract copyright: Copyright © 2021 Elsevier Ltd. All rights reserved.]

Objectives Antibacterial resistance (ABR) is a major global health security threat, with a disproportionate burden on lower-and middle-income countries (LMICs). It is not understood how ‘One Health’, where human health is co-dependent on animal health and the environment, might impact the burden of ABR in LMICs. Thailand's 2017 “National Strategic Plan on Antimicrobial Resistance” (NSP-AMR) aims to reduce AMR morbidity by 50% through 20% reductions in human and 30% in animal antibacterial use (ABU). There is a need to understand the implications of such a plan within a One Health perspective. Methods A model of ABU, gut colonisation with extended-spectrum beta-lactamase (ESBL)-producing bacteria and transmission was calibrated using estimates of the prevalence of ESBL-producing bacteria in Thailand. This model was used to project the reduction in human ABR over 20 years (2020–2040) for each One Health driver, including individual transmission rates between humans, animals and the environment, and to estimate the long-term impact of the NSP-AMR intervention. Results The model predicts that human ABU was the most important factor in reducing the colonisation of humans with resistant bacteria (maximum 65.7–99.7% reduction). The NSP-AMR is projected to reduce human colonisation by 6.0–18.8%, with more ambitious targets (30% reductions in human ABU) increasing this to 8.5–24.9%. Conclusions Our model provides a simple framework to explain the mechanisms underpinning ABR, suggesting that future interventions targeting the simultaneous reduction of transmission and ABU would help to control ABR more effectively in Thailand., Highlights • We present a novel mathematical model of human, animal and environment ABR transmission and ABU. • Human ABU was identified as the main driver of human ABR. • Resistance within humans was primarily driven by human activity rather than animal or environmental usage or transmission. • One Health interventions which consider human, animal and environmental transmission and usage can yield the highest impact.

Background The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today’s older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function. Aims To undertake feasibility testing of an intervention (‘VOLITION’) aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations. To inform the design of a fully powered trial to assess intervention effectiveness. Methods This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days. Discussion Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care. Trial registration CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18

Objective To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations. Methods Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate. Results 8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome ‘patient involvement in decision-making about their healthcare’. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured. Conclusion The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare. Practice implications There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

Background The increasing difficulty experienced by general practices in meeting patient demand is leading to new approaches being tried, including greater use of telephone consulting. Objectives To evaluate a ‘telephone first’ approach, in which all patients requesting a general practitioner (GP) appointment are asked to speak to a GP on the telephone first. Methods The study used a controlled before-and-after (time-series) approach using national reference data sets; it also incorporated economic and qualitative elements. There was a comparison between 146 practices using the ‘telephone first’ approach and control practices in England with regard to GP Patient Survey scores and secondary care utilisation (Hospital Episode Statistics). A practice manager survey was used in the ‘telephone first’ practices. There was an analysis of practice data and the patient surveys conducted in 20 practices using the ‘telephone first’ approach. Interviews were conducted with 43 patients and 49 primary care staff. The study also included an analysis of costs. Results Following the introduction of the ‘telephone first’ approach, the average number of face-to-face consultations in practices decreased by 38% [95% confidence interval (CI) 29% to 45%; p p p = 0.0883). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload. Comparing ‘telephone first’ practices with control practices in England in terms of scores in the national GP Patient Survey, there was an improvement of 20 percentage points in responses to the survey question on length of time to get to see or speak to a doctor or nurse. Other responses were slightly negative. The introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions; there was no initial change in accident and emergency (A&E) department attendance, but there was a subsequent small (2%) decrease in the rate of increase in A&E attendances. We found no evidence that the ‘telephone first’ approach would produce net reductions in secondary care costs. Patients and staff expressed a wide range of both positive and negative views in interviews. Conclusions The ‘telephone first’ approach shows that many problems in general practice can be dealt with on the telephone. However, the approach does not suit all patients and is not a panacea for meeting demand for care, and it is unlikely to reduce secondary care costs. Future research could include identifying how telephone consulting best meets the needs of different patient groups and practices in varying circumstances and how resources can be tailored to predictable patterns of demand. Limitations We acknowledge a number of limitations to our approach. We did not conduct a systematic review of the literature, data collected from clinical administrative records were not originally designed for research purposes and for one element of the study we had no control data. In the economic analysis, we relied on practice managers’ perceptions of staff changes attributed to the ‘telephone first’ approach. In our qualitative work and patient survey, we have some evidence that the practices that participated in that element of the study had a more positive patient experience than those that did not. Funding The National Institute for Health Research Health Services and Delivery Research programme.

BackgroundTo better manage patient demand, some general practices have implemented a ‘telephone first’ approach in which all patients seeking a face-to-face appointment first have to speak to a GP on the telephone. Previous studies have suggested that there is considerable scope for this new approach, but there remain significant concerns.AimTo understand the views of GPs and practice staff of the telephone first approach, and to identify enablers and barriers to successful adoption of the approach.Design and settingA qualitative study of the telephone first approach in 12 general practices that have adopted it, and two general practices that have tried the approach but reverted to their previous system.MethodA total of 53 qualitative interviews with GPs and practice staff were conducted. Transcriptions of the interviews were systematically analysed.ResultsStaff in the majority of practices reported that the approach was an improvement on their previous system, but all practices experienced challenges; for example, where practices did not have the capacity to meet the increase in demand for telephone consultations. Staff were also aware that the new system suited some patients better than others. Adoption of the telephone first approach could be very stressful, with a negative impact on morale, especially reported in interviews with the two practices that had tried but stopped the approach. Interviewees identified enablers and barriers to the successful adoption of a telephone first approach in primary care. Enablers to successful adoption were: understanding demand, practice staff as pivotal, making modifications to the approach, and educating patients.ConclusionPractices considering adopting or clinical commissioning groups considering funding a telephone first approach should consider carefully a practice’s capacity and capability before launching.

ObjectivesTo estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation.DesignObservational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)’s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values.Setting94 practices in Southwark and Lambeth and 263 control practices from other parts of England.Main outcome measuresHospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay.ResultsBy the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM.ConclusionsThe Older People’s Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Plans for ‘medicities’, announced in the Indian press from 2007 onwards, were to provide large scale ‘one-stop-shops’ of super-speciality medical services supplemented by diagnostics, education, research facilities, and other aspects of healthcare and lifestyle consumption. Placing this phenomenon within the recent domestic and global political economy of health, we then draw on recent research literatures on place and health to offer an analysis of the narration of these new healthcare places given in promotional texts from press media, official documents and marketing materials. We consider the implications of such analytic undertakings for the understanding of the evolving landscapes of contemporary health care in middle-income countries, and end with some reflections on the tensions now appearing in the medicity model.

BackgroundThere are ambitious overseas recruitment targets to alleviate current GP shortages in the UK. GP training in European Economic Area (EEA) countries is recognised by the General Medical Council (GMC) as equivalent UK training; non-EEA GPs must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained GPs. The CEGPR may be a barrier to recruiting GPs from non-EEA countries. It is important to facilitate the most streamlined route into UK general practice while maintaining registration standards and patient safety.AimTo apply a previously published mapping methodology to four non-EEA countries: South Africa, US, Canada, and New Zealand.Design & settingDesk-based research was undertaken. This was supplemented with stakeholder interviews.MethodThe method consisted of: (1) a rapid review of 13 non-EEA countries using a structured mapping framework, and publicly available website content and country-based informant interviews; (2) mapping of five ‘domains’ of comparison between four overseas countries and the UK (healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation). Mapping of the domains involved desk-based research. A red, amber, or green (RAG) rating was applied to indicate the degree of alignment with the UK.ResultsAll four countries were rated ‘green’. Areas of differences that should be considered by regulatory authorities when designing streamlined CEGPR processes for these countries include: healthcare context (South Africa and US), CPD and revalidation (US, Canada, and South Africa), and assessments (New Zealand).ConclusionMapping these four non-EEA countries to the UK provides evidence of utility of the systematic method for comparing GP training between countries, and may support the UK’s ambitions to recruit more GPs to alleviate UK GP workforce pressures.

ObjectiveTo understand patients’ views on a ‘telephone-first’ approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP).DesignQualitative interviews with patients and carers.SettingTwelve general practices in England.Participants43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English.ResultsPatients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the ‘telephone-first’ approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients’ needs better than others and practices varied significantly in how they had implemented the approach.ConclusionsThe ‘telephone-first’ approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the ‘telephone-first’ approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.

The aim of this study is to understand barriers and facilitators to the delivery of injury prevention programmes in English children's centres (CCs). Unintentional injury is a major cause of disability and death in children aged 1–4 years; those living in poverty are at greatest risk. CCs are pivotal in English public health strategies to improve outcomes and reduce inequalities for disadvantaged children through health promotion and family support. This study is part of the National Institute for Health Research funded ‘Keeping Children Safe at home’ programme, which aims to develop a better understanding of how to prevent unintentional injuries in pre-school children. Thirty-three interviews with CC staff from 16 CCs across four study sites, Nottingham, Norwich, Newcastle and Bristol, explored practitioners' experience of factors that impact on their implementation of health promotion and injury prevention interventions. Using Framework Analysis, managed by NVivo, key facilitators and barriers were identified across all levels of CCs' operation. Facilitators included knowledge of policies and strategies in injury prevention, partnership working and effective parent engagement. Barriers included paucity of national and local injury data, difficulties reaching disengaged families and funding constraints. The challenge is to learn from those who work in CCs the best ways to harness facilitators and to address barriers to child injury prevention activities, and to provide support, including practical advice, for further development of their essential work in injury prevention.

BackgroundUnintentional injuries among 0- to 4-year-olds are a major public health problem incurring substantial NHS, individual and societal costs. However, evidence on the effectiveness and cost-effectiveness of preventative interventions is lacking.AimTo increase the evidence base for thermal injury, falls and poisoning prevention for the under-fives.MethodsSix work streams comprising five multicentre case–control studies assessing risk and protective factors, a study measuring quality of life and injury costs, national surveys of children’s centres, interviews with children’s centre staff and parents, a systematic review of barriers to, and facilitators of, prevention and systematic overviews, meta-analyses and decision analyses of home safety interventions. Evidence from these studies informed the design of an injury prevention briefing (IPB) for children’s centres for preventing fire-related injuries and implementation support (training and facilitation). This was evaluated by a three-arm cluster randomised controlled trial comparing IPB and support (IPB+), IPB only (no support) and usual care. The primary outcome was parent-reported possession of a fire escape plan. Evidence from all work streams subsequently informed the design of an IPB for preventing thermal injuries, falls and poisoning.ResultsModifiable risk factors for falls, poisoning and scalds were found. Most injured children and their families incurred small to moderate health-care and non-health-care costs, with a few incurring more substantial costs. Meta-analyses and decision analyses found that home safety interventions increased the use of smoke alarms and stair gates, promoted safe hot tap water temperatures, fire escape planning and storage of medicines and household products, and reduced baby walker use. Generally, more intensive interventions were the most effective, but these were not always the most cost-effective interventions. Children’s centre and parental barriers to, and facilitators of, injury prevention were identified. Children’s centres were interested in preventing injuries, and believed that they could prevent them, but few had an evidence-based strategic approach and they needed support to develop this. The IPB was implemented by children’s centres in both intervention arms, with greater implementation in the IPB+ arm. Compared with usual care, more IPB+ arm families received advice on key safety messages, and more families in each intervention arm attended fire safety sessions. The intervention did not increase the prevalence of fire escape plans [adjusted odds ratio (AOR) IPB only vs. usual care 0.93, 95% confidence interval (CI) 0.58 to 1.49; AOR IPB+ vs. usual care 1.41, 95% CI 0.91 to 2.20] but did increase the proportion of families reporting more fire escape behaviours (AOR IPB only vs. usual care 2.56, 95% CI 1.38 to 4.76; AOR IPB+ vs. usual care 1.78, 95% CI 1.01 to 3.15). IPB-only families were less likely to report match play by children (AOR 0.27, 95% CI 0.08 to 0.94) and reported more bedtime fire safety routines (AOR for a 1-unit increase in the number of routines 1.59, 95% CI 1.09 to 2.31) than usual-care families. The IPB-only intervention was less costly and marginally more effective than usual care. The IPB+ intervention was more costly and marginally more effective than usual care.LimitationsOur case–control studies demonstrate associations between modifiable risk factors and injuries but not causality. Some injury cost estimates are imprecise because of small numbers. Systematic reviews and meta-analyses were limited by the quality of the included studies, the small numbers of studies reporting outcomes and significant heterogeneity, partly explained by differences in interventions. Network meta-analysis (NMA) categorised interventions more finely, but some variation remained. Decision analyses are likely to underestimate cost-effectiveness for a number of reasons. IPB implementation varied between children’s centres. Greater implementation may have resulted in changes in more fire safety behaviours.ConclusionsOur studies provide new evidence about the effectiveness of, as well as economic evaluation of, home safety interventions. Evidence-based resources for preventing thermal injuries, falls and scalds were developed. Providing such resources to children’s centres increases their injury prevention activity and some parental safety behaviours.Future workFurther randomised controlled trials, meta-analyses and NMAs are needed to evaluate the effectiveness and cost-effectiveness of home safety interventions. Further work is required to measure NHS, family and societal costs and utility decrements for childhood home injuries and to evaluate complex multicomponent interventions such as home safety schemes using a single analytical model.Trial registrationCurrent Controlled Trials ISRCTN65067450 and ClinicalTrials.gov NCT01452191.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 14. See the NIHR Journals Library website for further project information.

BackgroundThe notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.ObjectivesThis study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.MethodsA multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.ResultsThe evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.LimitationsThe use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.ConclusionsAt a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background The lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact. Methods We conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents. Results Our data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program’s lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households’ uptake of services. Conclusion This paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2284-2) contains supplementary material, which is available to authorized users.

Background:\ud Limited availability of skilled health providers in developing countries is thought to be an important barrier to achieving maternal and child health-related MDG goals. Little is known, however, about the extent to which scaling-up supply of health providers will lead to improved pregnancy and birth outcomes. We study the effects of the Midwives Service Scheme (MSS), a public sector program in Nigeria that increased the supply of skilled midwives in rural communities on pregnancy and birth outcomes.\ud \ud Methods:\ud We surveyed 7,104 women with a birth within the preceding five years across 12 states in Nigeria and compared changes in birth outcomes in MSS communities to changes in non-MSS communities over the same period.\ud \ud Results:\ud The main measured effect of the scheme was a 7.3-percentage point increase in antenatal care use in program clinics and a 5-percentage point increase in overall use of antenatal care, both within the first year of the program. We found no statistically significant effect of the scheme on skilled birth attendance or on maternal delivery complications.\ud \ud Conclusion:\ud This study highlights the complexity of improving maternal and child health outcomes in developing countries, and shows that scaling up supply of midwives may not be sufficient on its own.

AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.

Background: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. Methods: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. Results: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. Conclusions: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

Background The Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented. Methods A qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach. Results The majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care. Conclusions Our research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1026-5) contains supplementary material, which is available to authorized users.

This paper examines the challenges and opportunities in establishing and sustaining north–south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease. Established in 2006 with seed funding from the British Academy, the partnership aimed to bring together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. We review the partnership’s achievements and challenges, applying established criteria for developing successful partnerships. During the funded period we achieved major success in creating a platform for research dissemination through international meetings and publications. Other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. Chronic disease research partnerships in low-income regions operate within health research, practice, funding and policy environments that prioritise infectious diseases and other pressing public health and developmental challenges. Their long-term sustainability will therefore depend on integrated funding systems that provide a crucial capacity building bridge. Beyond the specific challenges of chronic disease research, we identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.