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Background The mental health of children/young people is a growing concern internationally. Numerous reports and reviews have consistently described United Kingdom children’s mental health services as fragmented, variable, inaccessible and lacking an evidence base. Little is known about the effectiveness of, and implementation complexities associated with, service models for children/young people experiencing ‘common’ mental health problems like anxiety, depression, attention deficit hyperactivity disorder and self-harm. Aim To develop a model for high-quality service design for children/young people experiencing common mental health problems by identifying available services, barriers and enablers to access, and the effectiveness, cost effectiveness and acceptability of such services. Design Evidence syntheses with primary research, using a sequential, mixed-methods design. Inter-related scoping and integrative reviews were conducted alongside a map of relevant services across England and Wales, followed by a collective case study of English and Welsh services. Setting Global (systematic reviews); England and Wales (service map; case study). Data sources Literature reviews: relevant bibliographic databases and grey literature. Service map: online survey and offline desk research. Case study: 108 participants (41 children/young people, 26 parents, 41 staff) across nine case study sites. Methods A single literature search informed both reviews. The service map was obtained from an online survey and internet searches. Case study sites were sampled from the service map; because of coronavirus disease 2019, case study data were collected remotely. ‘Young co-researchers’ assisted with case study data collection. The integrative review and case study data were synthesised using the ‘weaving’ approach of ‘integration through narrative’. Results A service model typology was derived from the scoping review. The integrative review found effectiveness evidence for collaborative care, outreach approaches, brief intervention services and the ‘availability, responsiveness and continuity’ framework. There was cost-effectiveness evidence only for collaborative care. No service model appeared to be more acceptable than others. The service map identified 154 English and Welsh services. Three themes emerged from the case study data: ‘pathways to support’; ‘service engagement’; and ‘learning and understanding’. The integrative review and case study data were synthesised into a coproduced model of high-quality service provision for children/young people experiencing common mental health problems. Limitations Defining ‘service model’ was a challenge. Some service initiatives were too new to have filtered through into the literature or service map. Coronavirus disease 2019 brought about a surge in remote/digital services which were under-represented in the literature. A dearth of relevant studies meant few cost-effectiveness conclusions could be drawn. Conclusions There was no strong evidence to suggest any existing service model was better than another. Instead, we developed a coproduced, evidence-based model that incorporates the fundamental components necessary for high-quality children’s mental health services and which has utility for policy, practice and research. Future work Future work should focus on: the potential of our model to assist in designing, delivering and auditing children’s mental health services; reasons for non-engagement in services; the cost effectiveness of different approaches in children’s mental health; the advantages/disadvantages of digital/remote platforms in delivering services; understanding how and what the statutory sector might learn from the non-statutory sector regarding choice, personalisation and flexibility. Study registration This study is registered as PROSPERO CRD42018106219. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information. Plain language summary In this research study, we explored services for children and young people with ‘common’ mental health problems like depression, anxiety and self-harm. We aimed to find out what services exist, how children/young people and families find out about and access these services, what the services actually do, whether they are helpful and whether they offer value for money. We looked at the international literature (reports and research papers) to identify different approaches to providing support, and to find out whether certain approaches worked better than others and whether children/young people and families preferred some approaches over others. The literature provided very little information about the value for money of services. We also carried out a survey and used the internet to identify 154 relevant services in England and Wales. To explore services in more detail, and hear directly from those using them, we planned to visit 9 of the 154 services to interview children/young people, parents and staff. Unfortunately, coronavirus disease 2019 stopped us directly visiting the nine services and so we conducted phone and video interviews instead. We still managed to speak to, and hear the experiences of, more than 100 people (including children/young people and parents). We combined information from the literature with information from the interviews to create an evidence-based ‘model’ of what services should look like. This model considers some basic things like how quickly children/young people could access a service, what information was available, the importance of confidentiality and whether staff make the service fit with the child/young person’s needs and interests. It also considers whether the service helps children/young people learn skills to manage their mental health and whether staff at a service work well together. We hope our model will help existing and new services improve what they offer to children/young people and families. Scientific summary Background This study is a response to a National Institute for Health and Care Research (NIHR) commissioning call on research to improve services for children and young people (CYP) with common mental health problems (CMHPs). The mental health of CYP has been a growing public health concern both nationally and internationally. Estimates from 2021, covering the height of the coronavirus disease 2019 (COVID-19) pandemic, suggest that around one in six CYP in England may be experiencing significant mental health difficulties, including the likes of anxiety, depression, self-harm and behavioural difficulties. The tiers model has dominated UK service provision for at least two decades. However, it has become increasingly clear that this model has not met the needs of most CYP experiencing mental health problems. Numerous reports and reviews have consistently described UK children’s mental health services as fragmented, unco-ordinated, variable, inaccessible and lacking an evidence base. While there have been recent attempts to transform services using initiatives such as Choice and Partnership Approach (CAPA), Children and Young People-Improving Access to Psychological Therapies (CYP-IAPT) (a CYP’s version of adult IAPT) and THRIVE, little is known about the effectiveness of these initiatives nor the effectiveness of children’s mental health service models in general. Moreover, the disparate factors associated with accessing and navigating services for CYP experiencing CMHPs have not been synthesised into a coherent model of effective and acceptable service provision. Aims and objectives The study’s overarching aim was to develop a model of high-quality service design for CYP experiencing CMHPs by identifying available services, the barriers and enablers to access, and the effectiveness (including cost effectiveness) and acceptability of, those services. Six objectives were derived from this aim: Systematically search, appraise and synthesise the international literature on services for this population group in order to (1) build evidence of the effectiveness and acceptability of current service provision and (2) assist with objective 2. Develop a descriptive typology of services for this population group using the literature referred to in objective 1 and a survey of service provision in England and Wales. Through primary research, explore the barriers and enablers that CYP and their families experience in accessing and navigating services. Identify the key factors influencing effectiveness and acceptability in order to build an evidence-based model of high-quality service provision for this population group. Estimate provider and user costs/benefits associated with different service models. Make evidence-based recommendations to the NHS about future service provision. Methods The study coupled evidence syntheses with primary research, using a sequential, mixed-methods design. There were four work streams: (1) conducting a scoping review and an integrative review of the international literature; (2) mapping service provision across England and Wales; (3) conducting a collective case study of several services in England and Wales; and (4) building a model for high-quality service design for CYP experiencing CMHPs. Patient and public involvement We involved young people and parents/carers, as well as those who commission and provide mental health services throughout the study. Young people and parents/carers were members of the study’s advisory group and the director of a young people’s ‘lived experience’ consultancy was a coinvestigator. We also collaborated with a mental health charity to employ six young adults with lived experience of mental health issues as ‘young co-researchers’. Work Stream 1 (literature reviews) Data sources Relevant bibliographic databases and resources (including grey literature resources) were searched in May 2019. Study selection (inclusion criteria) Population Children and young people was defined as those aged under 18 (service users up to 25 years could be included if a service’s core provision was for under 18s). Common mental health problems were defined as anxiety and related disorders, depression, self-harm, post-traumatic stress disorder (PTSD), ‘emerging personality disorder’, adjustment disorder, attention deficit hyperactivity disorder (ADHD)/attention deficit disorder, conduct disorder, oppositional defiant disorder, substance misuse disorders and ‘at risk of psychosis’. The commissioning brief excluded psychosis, eating disorders and autism spectrum disorder. Interventions Any service provided for CYP experiencing CMHPs. Comparators Not applicable for the scoping review or the acceptability data in the integrative review. For the effectiveness and cost-effectiveness data in the integrative review, comparators were other service models, standard care/treatment as usual or inpatient/residential care. Outcomes Not applicable for the scoping review. Outcomes for the effectiveness data in the integrative review were relevant measures of CYP’s mental health, family functioning, educational attainment or quality of life; for the cost-effectiveness data, the incremental cost effectiveness of service model versus comparator; for the acceptability data, qualitative and quantitative data capturing stakeholder views. Study (document) types For the scoping review, any document containing a sufficiently detailed description of a service for CYP experiencing CMHPs. Effectiveness studies in the integrative review were peer-reviewed quantitative studies with at least one pre/post outcome measure; cost-effectiveness studies were peer-reviewed studies reporting costs, health outcomes and incremental cost-effectiveness analyses; acceptability studies were peer-reviewed qualitative or quantitative studies in which either participants’ views were expressed or in which participation data were available. Data extraction and quality assessment For both reviews, two independent assessors extracted data. Disputes were referred to a third reviewer. Quality assessment was conducted for the integrative review only, using the Mixed-Methods Appraisal Tool (MMAT). Data synthesis In the scoping review, descriptions of services for CYP experiencing CMHPs were mapped into a typology of service models. Synthesis in the integrative review was based on Evidence for Policy and Practice Information and Co-ordinating (EPPI)-Centre methods: the different data sources (effectiveness, cost effectiveness and acceptability) were analysed separately prior to being compared and contrasted. Work Stream 2 (service mapping) Data sources Services across England and Wales were identified via an online survey created in SelectSurvey and internet (desk-based) searches. English or Welsh services identified through the literature search and still in operation were also included. Service selection (inclusion criteria) The same population and intervention definitions as Work Stream 1 were used. Additional inclusion criteria were the service had to operate in England or Wales and be operational during the data collection period. Data analysis On closing the online survey, data were downloaded from SelectSurvey in Microsoft Excel format. Additional data (e-mail submissions and desk-derived information) were inputted into the same Excel spreadsheet by hand. A final Excel spreadsheet containing both survey and desk-derived data was imported into IBM SPSS Statistics for descriptive analysis of service characteristics. Work Stream 3 (case study) Design A collective case study involving nine services sampled from the service map. Services were purposively sampled to capture the spread of models in the typology and to reflect characteristics such as service sector, locality/setting, target age group and mode of delivery. Participants Ninety-six interviews involving 108 participants (41 CYP, 26 parents, 41 staff) from 9 case study sites. Research ethics Ethical and other approvals were granted by the NHS Health Research Authority (reference: 20/SC/0174) and by the organisations operating the services at the case study sites. Four substantial and two minor amendments, all relating to the COVID-19 pandemic, were subsequently approved. Data collection Original data collection plans included individual interviews, focus groups, documentary review and observation of relevant activities at sites. Coronavirus disease 2019 restrictions, however, prevented site visits and observation. Consequently, the primary data (apart from one interview) were collected remotely, either through individual semistructured telephone or video interviews or an online group interview. Twenty-two of the 96 interviews were jointly conducted with 1 of our 6 young co-researchers. Economic data were requested from sites regarding annual service delivery budgets, funding source, key areas of spending and resource use. Data analysis Data analysis was informed by framework, a matrix-based analytic method widely used in qualitative health service research. To familiarise themselves with the data, the research team read and discussed the interview transcripts in depth. The transcripts were then coded deductively in NVivo using a thematic framework based on the study’s aims and objectives, after which the data were ‘charted’ so that deductive codes for each theme could be examined within each case study site and comparatively across sites. The data were then analysed inductively and iteratively to identify cross-cutting themes. Cost data were descriptively summarised into a table. Work Stream 4 (model building) Data synthesis process The integrative review and case study findings were synthesised using the ‘weaving’ approach to integration through narrative. The two sets of findings were analysed, interpreted and reported together on a theme-by-theme or concept-by-concept basis using a set of mixed-methods matrices. Results Work Stream 1 (literature reviews) Overall, 310 documents met the inclusion criteria for the scoping or integrative review. Two hundred and ninety-six documents were included in the scoping review, 98 in the integrative review. To simplify the complexities associated with fragmented, variable and often unco-ordinated services, the 342 service descriptions in the 296 scoping review documents were mapped to produce a descriptive service model typology containing seven broad service model groupings. Across the international literature, the service models most described in the scoping review documents were outreach models, followed by community-embedded specialist CAMHS models. Service transformation frameworks were also relatively common. The integrative review found effectiveness evidence only for collaborative care, outreach approaches, brief intervention services and ‘availability, responsiveness and continuity (ARC)’, a service transformation framework from the USA. The strongest effectiveness evidence was for collaborative care. Cost-effectiveness evidence was very limited (just three papers met the inclusion criteria), with the only robust evidence also being for collaborative care. Since most of the collaborative care evidence was from the USA, its applicability to UK health systems is questionable. No service model appeared to be more acceptable than others. Integrative review findings suggest that effective and acceptable services tend to be underpinned by few barriers to access, interagency working, the use of consultation-liaison and consideration of the service’s culture. Brief intervention approaches may be helpful in managing waiting lists; their brief nature may also facilitate the acquisition of self-management skills. Work Stream 2 (service mapping) One hundred and fifty-four services across England and Wales, provided by 123 different providers, were included in the service map. Service provision across England and Wales is diverse, with providers from the statutory, private and third sectors operating in a range of settings, supporting CYP with a wide range of CMHPs. No single model from the typology was particularly dominant. Most services were provided in community, non-health settings, most focused on secondary school aged children and most offered support for the ‘most common’ of the CMHPs, namely general anxiety issues, depression and self-harm. Open access via self- or parent referral was relatively widespread, particularly in the third and private sectors. Work Stream 3 (case study) Three themes emerged from the case study data: pathways to support (relates to service access and exit); service engagement and learning and understanding. Regarding the enablers of and barriers to service access, self-referral, the timeliness and availability of support, physical accessibility and planning for support following discharge are important determinants of whether a service is seen as accessible by CYP and families. A single point of access (SPoA) to services may be beneficial if it does not result in multiple assessments or multiple waiting lists. The service engagement and learning and understanding themes highlighted the importance of personalised, holistic and flexible services that involve CYP and families, respect confidentiality, ensure continuity in therapeutic relationships, focus on strengths and engage CYP in creative ways. Staff expertise and professional competence are important but so are empathy and compassion. An organisational learning culture appears fundamental to service acceptability and effectiveness: it was important for staff to work in environments that emphasised staff learning and development, supported reflective practice and which valued service improvement especially when CYP and families were able to co-design services. Service effectiveness was also linked to opportunities for CYP to develop knowledge and skills that enabled them to both understand and manage their own mental health. Work Stream 4 (model building) With feedback from relevant stakeholders (including CYP, parents, service providers and academics from a range of relevant disciplines), the three narratives around pathways to support, service engagement and learning and understanding were integrated to create an alternative model of effective and acceptable services for CYP experiencing CMHPs. This evidence-based model outlines the fundamental components necessary for high-quality services for this population group. These fundamental components include information, confidentiality, aftercare, personalised approaches, engagement and organisational culture. Conclusions In a robust and transparent way, we have developed a comprehensible, evidence-based model of high-quality service design for CYP experiencing CMHPs that is transferable across services, sectors and geography. Our model has utility for policy, practice and research. Not only does it support previous research and reports about children’s mental health services, but it also adds significant depth to core issues surrounding mental health service provision for CYP. In terms of implications for policy, practice and education, our research suggests that: Using our model components to support the design and delivery of services – rather than the ‘top–down’ imposition of specific local or national models – could improve the consistency of services for CYP experiencing CMHPs. Our model still allows for tailoring to the local context. We also note that: Aftercare arrangements are often neglected (especially for those aged 16–17 years), not just in terms of transitions to adult services but also in terms of exiting and re-entering a service, longer-term ad hoc support and continuity of care. A learning culture strongly implies services need more than mere staff training. Workforce development requires strategies that incorporate reflexive learning opportunities, clinical supervision, reflective practice, freedom to innovate in practice and leadership. CYP and families need to be the arbiters of what compassion and competence in staff mean. Lived experience in service provision is valuable, but it may work better when delivered alongside professional support. More information about what services are available locally, how services might be accessed, what support is offered and what happens once the CYP leaves the service should be provided. CYP and their families want to be able to choose, ideally from a range of services, those best tailored to their needs. In terms of future research, there should be: research focusing on how to implement into practice the components in our model research determining whether using our model to design, deliver or audit services impacts on outcomes research exploring the advantages and disadvantages of digital/remote platforms in delivering services research around what the statutory sector could learn from the non-statutory sector regarding choice, personalisation and flexibility research with those who refuse and/or disengage from services and others whose voices are seldom heard further research on the cost effectiveness of different approaches in CYP’s mental health research to establish one or more standardised measures of health benefit in children’s mental health services. Study registration This study is registered as PROSPERO CRD42018106219. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information.

Background: In Aotearoa/New Zealand (NZ) general practices diagnose and manage pre-diabetes. This work is important as it has the potential to delay or prevent the onset of Type 2 Diabetes (T2DM), reduce NZ's health inequities, and the burden that T2DM places on health care services. However, no study has previously examined how this work routinely occurs in NZ. Methods: Two case studies of practices serving ethnically and socio-economically diverse populations, followed by cross-case analysis. Results: The NZ health care context including funding mechanisms, reporting targets, and the disease centred focus of care, acted together to dis-incentivise and de-prioritise pre-diabetes care in general practices. The social determinants of health differentially influenced patients' ability to engage with and respond to pre-diabetes care, significantly impacting this work. Differing perspectives about the significance of pre-diabetes and gaps in systematic screening practices were identified. Interventions used were inconsistent and lacked comprehensive ongoing support. Conclusions: Complex multi-layered factors impact on pre-diabetes care, and many of the barriers cannot be addressed at the general practice level. The practice serving the most disadvantaged population who concurrently have higher rates of pre-diabetes/T2DM were more adversely affected by the barriers identified. [ABSTRACT FROM AUTHOR]

Abstract Background A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service. Methods This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed. Results Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low. Conclusion Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting.

Background: Organisational case study proposals can be poorly articulated and methodologically weak, raising the possible need for publication standards in this area. Objectives: To develop reporting standards for organisational case study research, with particular application to the UK National Health Service. Design: Rapid evidence synthesis and Delphi consensus process. Data sources: Relevant case studies and methods texts were identified through searches of library catalogues, key text and author searches, focused searching of health and social science databases and some targeted website searching. Review methods: The reporting standards were developed in three stages: (1) a rapid review of the existing literature to identify items; (2) a modified Delphi consensus process to develop and refine content and structure; and (3) application of the high-consensus Delphi items to two samples of organisational case studies to assess their feasibility as reporting standards. Items for the Delphi consultation were identified from published organisational case studies and related methodological texts. Identified items were sent to a Delphi expert panel for rating over two rounds. Participants were also asked whether or not the provisional framework in which items were presented was appropriate, and were given the opportunity to adapt this alongside the content. In both rounds, the high-consensus threshold was set at 70% agreement among respondents for each item. High-consensus items from the Delphi consultation were then applied to previously identified case study publications to determine their relevance to the reporting of real-world organisational case studies and to better understand how the results of the Delphi consultation might best be implemented as a reporting standard. Results: One hundred and three unique reporting items were identified from 25 methodological texts; eight example case studies and 12 exemplar case studies did not provide any additional unique items. Thirteen items were ultimately rated as ‘Should be reported for all organisational case studies’ by at least 70% of respondents, with the degree of consensus ranging from 73% to 100%. As a whole, exemplar case studies [which had been provided by the National Institute for Health Research (NIHR)’s Health Services and Delivery Research (HSDR) programme as examples of methodologically strong projects] more consistently reported the high-consensus Delphi items than did case studies drawn from the literature more broadly. Limitations: Time and resource constraints prevented an initial ‘item-generation’ round in the Delphi consensus process. Items are therefore likely to have been influenced by the content, wording and assumptions of available literature. Conclusions: The high-consensus items were translated into a set of 13 reporting standards that aim to improve the consistency, rigour and reporting of organisational case study research, thereby making it more accessible and useful to different audiences. The reporting standards themselves are intended primarily as a tool for authors of organisational case studies. They briefly outline broad requirements for rigorous and consistent reporting without constraining methodological freedom. Future work: These reporting standards should be included as part of the submission requirements for all organisational case studies seeking funding. Though these reporting standards do not mandate specific methods, if a reporting item is not reported for legitimate methodological reasons, the onus is on the author to outline their rationale for the reader. Funding: The NIHR HSDR programme.

Background: The use of case studies in health services research has proven to be an excellent methodology for gaining in-depth understanding of the organisation and delivery of health care. This is particularly relevant when looking at the complexity of integrated healthcare programmes, where multifaceted interactions occur at the different levels of care and often without a clear link between the interventions (new and/or existing) and their impact on outcomes (in terms of patients health, both patient and professional satisfaction and cost-effectiveness). Still, integrated care is seen as a core strategy in the sustainability of health and care provision in most societies in Europe and beyond. More specifically, at present, there is neither clear evidence on transferable factors of integrated care success nor a method for determining how to establish these specific success factors. The drawback of case methodology in this case, however, is that the in-depth results or lessons generated are usually highly context-specific and thus brings the challenge of transferability of findings to other settings, as different health care systems and different indications are often not comparable. Project INTEGRATE, a European Commission-funded project, has been designed to overcome these problems; it looks into four chronic conditions in different European settings, under a common methodology framework (taking a mixed-methods approach) to try to overcome the issue of context specificity and limited transferability. The common methodological framework described in this paper seeks to bring together the different case study findings in a way that key lessons may be derived and transferred between countries, contexts and patient-groups, where integrated care is delivered in order to provide insight into generalisability and build on existing evidence in this field.Methodology: To compare the different integrated care experiences, a mixed-methods approach has been adopted with the creation of a common methodological framework (including data collection tools and case study template report) to be used by the case studies for their analyses.Methods of analysis: The four case studies attempt to compare health care services before and after the ‘integration’ of care, while triangulating the findings using quantitative and qualitative data, and provide an in-depth description of the organisation and delivery of care, and the impact on outcomes. The common framework aims to allow for the extraction of key transferable learning from the cases, taking into account context-dependency.Conclusion: The application and evaluation of the common methodological approach aim to distill and identify important elements for successful integrated care, in order to strengthen the evidence base for integrated care (by facilitating cross-context comparisons), increase the transferability of findings from highly context-specific to other settings and lead to concrete and practical policy and operational recommendations.

AimTo evaluate the long-term utilisation of strategic communication as a factor of importance when changing work practices among primary care staff.BackgroundIn many health care organisations, there is a gap between theory and practice. This gap hinders the provision of optimal evidence-based practice and, in the long term, is unfavourable for patient care. One way of overcoming this barrier is systematically structured communication between the scientific theoretical platform and clinical practice.MethodsThis longitudinal evaluative study was conducted among a primary care staff cohort. Strategic communication was considered to be the intervention platform and included a network of ambassadors who acted as a component of the implementation. Measurements occurred 7 and 12 years after formation of the cohort. A questionnaire was used to obtain information from participants. In total, 846 employees (70%) agreed to take part in the study. After 12 years, the 352 individuals (60%) who had remained in the organisation were identified and followed up. Descriptive statistics and multivariate analysis were used to analyse the data.FindingsContinuous information contributed to significant improvements over time with respect to new ideas and the intention to change work practices. There was a statistically significant synergistic effect on the new way of thinking, that is, willingness to change work practices. During the final two years, the network of ambassadors had created a distinctive image for itself in the sense that primary care staff members were aware of it and its activities. This awareness was associated with a positive change with regard to new ways of thinking. More years of practice was inversely associated with willingness to change work practices. Strategic communication may lead to a scientific platform that promotes high-quality patient care by means of new methods and research findings. [ABSTRACT FROM PUBLISHER]

Abstract: Aim: To improve the efficiency of a hospital-based chemotherapy day unit (CDU). Methods: The CDU was benchmarked with two other CDUs to identify their attainable performance levels for efficiency, and causes for differences. Furthermore, an in-depth analysis using a business approach, called lean thinking, was performed. An integrated set of interventions was implemented, among them a new planning system. The results were evaluated using pre- and post-measurements. Results: We observed 24% growth of treatments and bed utilisation, a 12% increase of staff member productivity and an 81% reduction of overtime. Conclusions: The used method improved process design and led to increased efficiency and a more timely delivery of care. Thus, the business approaches, which were adapted for healthcare, were successfully applied. The method may serve as an example for other oncology settings with problems concerning waiting times, patient flow or lack of beds. [Copyright &y& Elsevier]

Background: A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service.Methods: This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed.Results: Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low.Conclusion: Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting. [ABSTRACT FROM AUTHOR]

Objectives: State governments often face capped budgets that can restrict expenditure on health technologies and their evaluation, yet many technologies are introduced to practice through state-funded institutions such as hospitals, rather than through national evaluation mechanisms. This research aimed to identify the criteria, evidence, and standards used by South Australian committee members to recommend funding for high-cost health technologies., Methods: We undertook 8 semi-structured interviews and 2 meeting observations with members of state-wide committees that have a mandate to consider the safety, effectiveness, and cost-effectiveness of high-cost health technologies., Results: Safety and effectiveness were fundamental criteria for decision makers, who were also concerned with increasing consistency in care and equitable access to technologies. Committee members often consider evidence that is limited in quantity and quality; however, they perceive evaluations to be rigorous and sufficient for decision making. Precise standards for safety, effective, and cost-effectiveness could not be identified., Conclusions: Consideration of new technologies at the state level is grounded in the desire to improve health outcomes and equity of access for patients. High quality evidence is often limited. The impact funding decisions have on population health is unclear due to limited use of cost-effectiveness analysis and unclear cost-effectiveness standards., (Copyright © 2018 John Wiley & Sons, Ltd.)