Health Services and Delivery Research最新文献

{"title":"Using patient experience data to support improvements in inpatient mental health care: the EURIPIDES multimethod study","authors":"S. Weich, Sarah-Jane Fenton, S. Staniszewska, A. Canaway, David Crepaz-Keay, M. Larkin, J. Madan, C. Mockford, K. Bhui, Elizabeth Newton, Charlotte Croft, Una Foye, A. Cairns, E. Ormerod, S. Jeffreys, F. Griffiths","doi":"10.3310/hsdr08210","DOIUrl":"https://doi.org/10.3310/hsdr08210","url":null,"abstract":"BackgroundAll NHS providers collect data on patient experience, although there is limited evidence about what to measure or how to collect and use data to improve services. We studied inpatient mental health services, as these are important, costly and often unpopular services within which serious incidents occur.AimsTo identify which approaches to collecting and using patient experience data are most useful for supporting improvements in inpatient mental health care.DesignThe study comprised five work packages: a systematic review to identify evidence-based patient experience themes relevant to inpatient mental health care (work package 1); a survey of patient experience leads in NHS mental health trusts in England to describe current approaches to collecting and using patient experience data in inpatient mental health services, and to populate the sampling frame for work package 3 (work package 2); in-depth case studies at sites selected using the work package 2 findings, analysed using a realist approach (work package 3); a consensus conference to agree on recommendations about best practice (work package 4); and health economic modelling to estimate resource requirements and potential benefits arising from the adoption of best practice (work package 5). Using a realist methodology, we analysed and presented our findings using a framework based on four stages of the patient experience data pathway, for which we coined the term CRAICh (collecting and giving, receiving and listening, analysing, and quality improvement and change). The project was supported by a patient and public involvement team that contributed to work package 1 and the development of programme theories (work package 3). Two employed survivor researchers worked on work packages 2, 3 and 4.SettingThe study was conducted in 57 NHS providers of inpatient mental health care in England.ParticipantsIn work package 2, 47 NHS patient experience leads took part and, in work package 3, 62 service users, 19 carers and 101 NHS staff participated, across six trusts. Forty-four individuals attended the work package 4 consensus conference.ResultsThe patient experience feedback cycle was rarely completed and, even when improvements were implemented, these tended to be environmental rather than cultural. There were few examples of triangulation with patient safety or outcomes data. We identified 18 rules for best practice in collecting and using inpatient mental health experience data, and 154 realist context–mechanism–outcome configurations that underpin and explain these.LimitationsThe study was cross-sectional in design and we relied on examples of historical service improvement. Our health economic models (in work package 5) were therefore limited in the estimation and modelling of prospective benefits associated with the collection and use of patient experience data.ConclusionsPatient experience work is insufficiently embedded in most mental health trusts. More attention to analysis and i","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-338"},"PeriodicalIF":0.0,"publicationDate":"2020-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48967042","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multisystemic therapy compared with management as usual for adolescents at risk of offending: the START II RCT","authors":"P. Fonagy, S. Butler, D. Cottrell, Stephen Scott, S. Pilling, I. Eisler, P. Fuggle, A. Kraam, S. Byford, J. Wason, Jonathan A. Smith, A. Anokhina, Rachel Ellison, E. Simes, Poushali Ganguli, Elizabeth Allison, I. Goodyer","doi":"10.3310/hsdr08230","DOIUrl":"https://doi.org/10.3310/hsdr08230","url":null,"abstract":"Background \u0000The Systemic Therapy for At Risk Teens (START) trial is a randomised controlled trial of multisystemic therapy (MST) compared with management as usual (MAU). The present study reports on long-term follow-up of the trial (to 60 months). \u0000 \u0000Objectives \u0000The primary objective was to compare MST and MAU for the proportion of young people in each group with criminal convictions up to 60 months post baseline. Secondary outcomes included group comparisons of psychological and behavioural factors. An economic analysis was carried out to determine the cost-effectiveness of MST compared with MAU. Two qualitative studies were conducted to better understand the subjective experiences of the participants. \u0000 \u0000Design \u0000Primary outcomes (collected up to 60 months) were collected using a centralised police database. Secondary outcomes were evaluated using self-report questionnaires completed by both young people and parents or carers at the 24-, 36- and 48-month follow-ups. Research assistants were blind to treatment allocation. \u0000 \u0000Setting \u0000Participants were recruited from participating MST sites in nine areas of England. Secondary outcomes were typically collected within the family home. \u0000 \u0000Participants \u0000A total of 684 families were recruited into the START trial and allocated randomly to a treatment group. Of these, 487 remained in the second phase of the trial. Young people were aged, on average, 13.8 years at baseline, with 63% male and 37% female. \u0000 \u0000Interventions \u0000MST is a manualised programme for young people exhibiting antisocial behaviour and their families that uses principles from cognitive–behavioural and family therapy to provide an individualised approach. MAU content was not prespecified, but consisted of the standard care offered to young people who met eligibility for the trial. \u0000 \u0000Main outcome measures \u0000Young people’s offending was evaluated using the Police National Computer. Secondary measures included validated self-report measures completed by both the young person and their parent or carer. The economic evaluation took a broad perspective and outcomes were assessed in terms of quality-adjusted life-years and offending. \u0000 \u0000Results \u0000No significant differences were found in the proportion of offending between the groups (hazard ratio 1.03, 95% confidence interval 0.84 to 1.26; p = 0.78). No differences were found between the groups on secondary outcome measures, with a few exceptions that did not hold up consistently across the follow-up period. The economic analysis did not find evidence to support the cost-effectiveness of MST compared with MAU. Outcomes from the qualitative studies suggest that families mostly felt positive about MST, and that MST was associated with greater maturity in young men. \u0000 \u0000Limitations \u0000Some intended evaluations were not possible to deliver. Selective attrition may have influenced the nature of the sample size. It is also unclear how representative the MAU services were of reality. \u0000 \u0000Future research \u0000Re","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-114"},"PeriodicalIF":0.0,"publicationDate":"2020-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43044788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Undiagnosed dementia in primary care: a record linkage study","authors":"C. Aldus, A. Arthur, Abi Dennington-Price, P. Millac, P. Richmond, T. Dening, C. Fox, F. Matthews, L. Robinson, B. Stephan, C. Brayne, G. Savva","doi":"10.3310/hsdr08200","DOIUrl":"https://doi.org/10.3310/hsdr08200","url":null,"abstract":"Background The number of people living with dementia is greater than the number with a diagnosis of dementia recorded in primary care. This suggests that a significant number are living with dementia that is undiagnosed. Little is known about this group and there is little quantitative evidence regarding the consequences of diagnosis for people with dementia. Objectives The aims of this study were to (1) describe the population meeting the criteria for dementia but without diagnosis, (2) identify predictors of being diagnosed and (3) estimate the effect of diagnosis on mortality, move to residential care, social participation and well-being. Design A record linkage study of a subsample of participants (n = 598) from the Cognitive Function and Ageing Study II (CFAS II) (n = 7796), an existing cohort study of the population of England aged ≥ 65 years, with standardised validated assessment of dementia and consent to access medical records. Data sources Data on dementia diagnoses from each participant’s primary care record and covariate and outcome data from CFAS II. Setting A population-representative cohort of people aged ≥ 65 years from three regions of England between 2008 and 2011. Participants A total of 598 CFAS II participants, which included all those with dementia who consented to medical record linkage (n = 449) and a stratified sample without dementia (n = 149). Main outcome measures The main outcome was presence of a diagnosis of dementia in each participant’s primary care record at the time of their CFAS II assessment(s). Other outcomes were date of death, cognitive performance scores, move to residential care, hospital stays and social participation. Results Among people with dementia, the proportion with a diagnosis in primary care was 34% in 2008–11 and 44% in 2011–13. In both periods, a further 21% had a record of a concern or a referral but no diagnosis. The likelihood of having a recorded diagnosis increased with severity of impairment in memory and orientation, but not with other cognitive impairment. In multivariable analysis, those aged ≥ 90 years and those aged Limitations People with moderate to severe dementia at baseline could not consent to record linkage. The small numbers in some groups limited power to detect effects. Conclusions The lack of relationship between severity of non-memory impairment and diagnosis may reflect low awareness of other symptoms of dementia. There remains little objective evidence for benefits of diagnosis for people with dementia. Future work Potential benefits of diagnosis can be realised only if effective interventions are accessible to patients and carers. Future work should focus on improving support for people living with cognitive impairment. Study registration National Institute for Health Research Clinical Research Network Central Portfolio Management System (CPMS 30655). Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Re","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-108"},"PeriodicalIF":0.0,"publicationDate":"2020-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47843020","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Interventions to minimise doctors’ mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review","authors":"D. Carrieri, M. Pearson, K. Mattick, C. Papoutsi, S. Briscoe, G. Wong, M. Jackson","doi":"10.3310/hsdr08190","DOIUrl":"https://doi.org/10.3310/hsdr08190","url":null,"abstract":"Background The growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem. Objectives Our aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts. Design Realist literature review consistent with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards. Data sources Bibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.\u0000\u0000 Review methods We included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations. Results A total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost informati","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-132"},"PeriodicalIF":0.0,"publicationDate":"2020-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44050285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study","authors":"M. Gittins, D. Lugo-Palacios, A. Vail, A. Bowen, L. Paley, B. Bray, B. Gannon, S. Tyson","doi":"10.3310/HSDR08170","DOIUrl":"https://doi.org/10.3310/HSDR08170","url":null,"abstract":"Background \u0000Therapy is key to effective stroke care, but many patients receive little. \u0000 \u0000Objectives \u0000To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use. \u0000 \u0000Design \u0000Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders. \u0000 \u0000Setting \u0000Stroke services in England, Wales and Northern Ireland. \u0000 \u0000Participants \u0000A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours. \u0000 \u0000Results \u0000Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation. \u0000 \u0000Limitations \u0000Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed. \u0000 \u0000Conclusions \u0000Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use. \u0000 \u0000Funding \u0000This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":"1-114"},"PeriodicalIF":0.0,"publicationDate":"2020-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45207142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Workplace-based interventions to promote healthy lifestyles in the NHS workforce: a rapid scoping and evidence map","authors":"G. Raine, Siân Thomas, M. Rodgers, Kath Wright, A. Eastwood","doi":"10.3310/hsdr08180","DOIUrl":"https://doi.org/10.3310/hsdr08180","url":null,"abstract":"\u0000 \u0000 The health and well-being of staff working in the NHS is a significant issue for UK health care. We sought to identify research relevant to the promotion of healthy lifestyles among NHS staff on behalf of NHS England.\u0000 \u0000 \u0000 \u0000 To map existing reviews on workplace-based interventions to promote health and well-being, and to assess the scope for further evidence synthesis work.\u0000 \u0000 \u0000 \u0000 Rapid and responsive scoping search and evidence map.\u0000 \u0000 \u0000 \u0000 Adult employees in any occupational setting and in any role.\u0000 \u0000 \u0000 \u0000 Any intervention aimed at promoting or maintaining physical or mental health and well-being. Early intervention initiatives and those addressing violence against staff, workplace bullying or harassment were also included.\u0000 \u0000 \u0000 \u0000 Any outcome related to the effectiveness, cost-effectiveness or implementation of interventions.\u0000 \u0000 \u0000 \u0000 A scoping search of nine databases was conducted to identify systematic reviews on health and well-being at work. Searches were limited by publication date (2000 to January/February 2019).\u0000 \u0000 \u0000 \u0000 The titles and abstracts of over 8241 records were screened and a total of 408 potentially relevant publications were identified. Information on key characteristics were extracted from the titles and abstracts of all potentially relevant publications. Descriptive statistics (counts and percentages) for key characteristics were generated and data from reviews and ‘reviews of reviews’ were used to produce the evidence map.\u0000 \u0000 \u0000 \u0000 Evidence related to a broad range of physical and mental health issues was identified across 12 ‘reviews of reviews’ and 312 other reviews, including 16 Cochrane reviews. There also exists National Institute for Health and Care Excellence guidance addressing multiple issues of potential relevance. A large number of reviews focused on mental health, changing lifestyle behaviour, such as physical activity, or on general workplace health/health promotion. Most of the reviews that focused only on health-care staff addressed mental health issues, and stress/burnout in particular.\u0000 \u0000 \u0000 \u0000 The scoping search process was extensive and clearly effective at identifying relevant publications, but the strategy used may not have identified every potentially relevant review. Owing to the large number of potentially relevant reviews identified from the scoping search, it was necessary to produce the evidence map using information from the titles and abstracts of reviews only.\u0000 \u0000 \u0000 \u0000 It is doubtful that further evidence synthesis work at this stage would generate substantial new knowledge, particularly within the context of the NHS Health and Wellbeing Framework[NHS England. Workforce Health and Wellbeing Framework. 2018. URL: www.nhsemployers.org/-/media/Employers/Publications/Health-and-wellbeing/NHS-Workforce-HWB-Framework_updated-July-18.pdf (accessed 10 January 2019)] published in 2018. Additional synthesis work may be useful if it addressed an identifiable need and it was possible to identify one of the foll","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43609151","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study","authors":"P. Griffiths, C. Saville, J. Ball, R. Chable, A. Dimech, Jeremy Jones, Y. Jeffrey, N. Pattison, A. Saucedo, N. Sinden, T. Monks","doi":"10.3310/hsdr08160","DOIUrl":"https://doi.org/10.3310/hsdr08160","url":null,"abstract":"Background The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care. Objectives To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure. Design This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand. Setting Medical/surgical wards in four NHS hospital trusts. Main outcome measures The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved. Data sources The data sources were hospital administrative systems, staff reports and national reference costs. Results In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000. Lim","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":"1-162"},"PeriodicalIF":0.0,"publicationDate":"2020-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48854002","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study","authors":"A. O’Cathain, E. Knowles, Jaqui Long, J. Connell, L. Bishop-Edwards, R. Simpson, J. Coster, L. Abouzeid, S. Bennett, E. Croot, J. Dickson, S. Goodacre, E. Hirst, R. Jacques, M. Phillips, J. Turnbull, J. Turner","doi":"10.3310/hsdr08150","DOIUrl":"https://doi.org/10.3310/hsdr08150","url":null,"abstract":"Background \u0000There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. \u0000 \u0000Objectives \u0000To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. \u0000 \u0000Design \u0000This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. \u0000 \u0000Results \u0000From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. \u0000 \u0000Limitations \u0000Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. \u0000 \u0000Conclusions \u0000Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reason","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-256"},"PeriodicalIF":0.0,"publicationDate":"2020-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44563594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The impacts of GP federations in England on practices and on health and social care interfaces: four case studies","authors":"R. McDonald, L. Riste, Simon Bailey, F. Bradley, J. Hammond, S. Spooner, R. Elvey, K. Checkland","doi":"10.3310/hsdr08110","DOIUrl":"https://doi.org/10.3310/hsdr08110","url":null,"abstract":"The impacts of GP federations in England on practices and on health and social care interfaces: four case studies Ruth McDonaldo ,1,2* Lisa Risteo ,2 Simon Baileyo ,3 Fay Bradleyo ,1 Jonathan Hammondo ,2 Sharon Spoonero ,2 Rebecca Elveyo 2 and Kath Checklando 2 1Alliance Manchester Business School, University of Manchester, Manchester, UK 2Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK 3Centre for Health Services Studies, University of Kent, Canterbury, UK *Corresponding author ruth.mcdonald@manchester.ac.uk Background: General practices have begun working collaboratively in general practitioner federations, which vary in scope, geographical reach and organisational form. Objectives: The aim was to assess how federating affects practice processes, workforce, innovations in practices and the interface with health and social care stakeholders. Design: This was a structured cross-sectional comparison of four case studies, using observation of meetings, interviews and analysis of documents. We combined inductive analysis with literature on ‘meta-organisations’ and networks to provide a theoretically informed analysis. Results: All federations were ‘bottom-up’ voluntary membership organisations but with formal central authority structures. Practice processes were affected substantially in only one site. In this site, practices accepted the rules imposed by federation arrangements in a context of voluntary participation. Federating helped ease workforce pressures in two sites. Progress regarding innovations in practice and working with health and social care stakeholders was slower than federations anticipated. The approach of each federation central authority in terms of the extent to which it (1) sought to exercise control over member practices and (2) was engaged in ‘system proactivity’ (i.e. the degree of proactivity in working across a broader spatial and temporal context) was important in explaining variations in progress towards stated aims.We developed a typology to reflect the different approaches and found that an approach consisting of high levels of both top-down control and system proactivity was effective. One site adopted this ‘authoritative’ approach. In another site, rather than creating expectations of practices, the focus was on supporting them by attempting to solve the immediate problems they faced. This ‘indulgent’ approach was more effective than the approach used in the other two sites. These had a more distant ‘neglectful’ relationship with practices, characterised by low levels of both control over members and system proactivity. Other key factors explaining progress (or lack thereof) were competition between federations (if any), relationship with the Clinical Commissioning Group, money, history, leadership and management issues, size and geography; these interacted in a dynamic way. In the context of a tight deadline and fixed targets, federations were able to respond to the re","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-118"},"PeriodicalIF":0.0,"publicationDate":"2020-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49521151","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study","authors":"D. Walsh, H. Spiby, C. McCourt, Dawn Coleby, Celia Grigg, S. Bishop, M. Scanlon, L. Culley, Jane Wilkinson, Lynne Pacanowski, J. Thornton","doi":"10.3310/hsdr08120","DOIUrl":"https://doi.org/10.3310/hsdr08120","url":null,"abstract":"Background \u0000Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why. \u0000 \u0000Objectives \u0000To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators. \u0000 \u0000Design \u0000Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed. \u0000 \u0000Setting \u0000English NHS maternity services. \u0000 \u0000Participants \u0000All trusts with maternity services. \u0000 \u0000Interventions \u0000Establishing MUs. \u0000 \u0000Main outcome measures \u0000Numbers and types of MUs and utilisation of MUs. \u0000 \u0000Results \u0000Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo. \u0000 \u0000Limitations \u0000When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings. \u0000 \u0000Conclusions \u0000Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted. \u0000 \u0000Future work \u0000Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increa","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-106"},"PeriodicalIF":0.0,"publicationDate":"2020-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46517730","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}