Showing papers in "Health Services and Delivery Research in 2018"

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Abstract: Background: There is much enthusiasm from clinicians, industry and government to utilise digital technologies and introduce alternatives to face-to-face consultations. Objective(s): To define good practice and inform its implementation in relation to remote consultations via SkypeTM and similar technologies. Design: Multi-level mixed-method study of remote video consultations (micro-level) embedded in an organisational case study (meso-level), taking account of national context and wider influences (macro-level). Setting: Three contrasting clinical settings (diabetes, antenatal diabetes, cancer) in a National Health Service (NHS) acute trust. Data collection and analysis: Macro-level—interviews with 12 national-level stakeholders combined with document analysis. Meso-level—longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro-level— 30 video-recorded remote consultations; 17 matched audio-recorded face-toface consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter Interactional Analysis System (RIAS), producing descriptive statistics on different kinds of talk and interaction. Results: Policymakers viewed remote video consulting as a way of delivering healthcare efficiently in the context of rising rates of chronic illness and growing demand for services. But the reality of establishing such services in a busy and financially stretched NHS acute trust proved far more complex and expensive than anticipated. Embedding new models of care took much time and resources and required multiple ‘workarounds’. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2 and 20 percent of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter; patients did slightly more talking; and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when clinician and patient knew and trusted each other. Some clinicians used Skype™ adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all. Conclusions: Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) is likely to require considerable support. Limitations: The focus on a single NHS organization raises questions about the transferability of findings, especially quantitative data on likely uptake rates. Future research: Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned. Funding: NIHR Health Services and Delivery Research programme (13/59/26)

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Abstract: Background Schwartz Center Rounds® (Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care. Objectives How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care. Design (1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation). Setting (1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey). Participants (1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings. Results (1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work. Limitations Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds. Conclusion Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Abstract: Background Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism. Objectives This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship. Design Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors. Setting and participants A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015. Main outcomes Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations. Data sources Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations. Results Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays. Limitations This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life. Conclusions Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety. Future work More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration. Trial registration This study is registered as ISRCTN17930973. Funding This 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. 6, No. 38. See the NIHR Journals Library website for further project information.

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Abstract: Background: There is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice. Objectives: Our objectives were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation. Design: Mixed-methods case study. Setting: General practices in England and Scotland with varied experience of implementing alternatives to face-to-face consultations. Participants: Patients and practice staff. Interventions: Alternatives to face-to-face consultations include telephone consultations, e-mail, e-consultations and internet video. Main outcome measures: How context influenced the implementation and impact of alternatives to the face-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms of consultation by different patient groups; and the intended benefits/outcomes. Review methods: The conceptual review used an approach informed by realist review, a method for synthesising research evidence regarding complex interventions. Results: Alternatives to the face-to-face consultation are not in mainstream use in general practice, with low uptake in our case study practices. We identified the underlying rationales for the use of these alternatives and have shown that different stakeholders have different perspectives on what they hope to achieve through the use of alternatives to the face-to-face consultation. Through the observation of real-life use of different forms of alternative, we have a clearer understanding of how, under what circumstances and for which patients alternatives might have a range of intended benefits and potential unintended adverse consequences. We have also developed a framework for future evaluation. Limitations: The low uptake of alternatives to the face-to-face consultation means that our research participants might be deemed to be early adopters. The case study approach provides an in-depth examination of a small number of sites, each using alternatives in different ways. The findings are therefore hypothesis-generating, rather than hypothesis-testing. Conclusions: The current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting. Future work: We have synthesised our findings to develop a framework and recommendations about future evaluation of the use of alternatives to face-to-face consultations. Funding details: The National Institute for Health Research Health Services and Delivery Research programme. ABSTRACT NIHR

Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Abstract: © Queen’s Printer and Controller of HMSO 2018. This work was produced by O’Cathain et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews

Abstract: Background There is compelling evidence to suggest that some (or even many) NHS staff feel unable to speak up, and that even when they do, their organisation may respond inappropriately Objectives The specific project objectives were (1) to explore the academic and grey literature on whistleblowing and related concepts, identifying the key theoretical frameworks that can inform an understanding of whistleblowing; (2) to synthesise the empirical evidence about the processes that facilitate or impede employees raising concerns; (3) to examine the legal framework(s) underpinning whistleblowing; (4) to distil the lessons for whistleblowing policies from the findings of Inquiries into failings of NHS care; (5) to ascertain the views of stakeholders about the development of whistleblowing policies; and (6) to develop practical guidance for future policy-making in this area Methods The study comprised four distinct but interlocking strands: (1) a series of narrative literature reviews, (2) an analysis of the legal issues related to whistleblowing, (3) a review of formal Inquiries related to previous failings of NHS care and (4) interviews with key informants Results Policy prescriptions often conceive the issue of raising concerns as a simple choice between deciding to ‘blow the whistle’ and remaining silent Yet research suggests that health-care professionals may raise concerns internally within the organisation in more informal ways before utilising whistleblowing processes Potential areas for development here include the oversight of whistleblowing from an independent agency; early-stage protection for whistleblowers; an examination of the role of incentives in encouraging whistleblowing; and improvements to criminal law to protect whistleblowers Perhaps surprisingly, there is little discussion of, or recommendations concerning, whistleblowing across the previous NHS Inquiry reports Limitations Although every effort was made to capture all relevant papers and documents in the various reviews using comprehensive search strategies, some may have been missed as indexing in this area is challenging We interviewed only a small number of people in the key informant interviews, and our findings may have been different if we had included a larger sample or informants with different roles and responsibilities Conclusions Current policy prescriptions that seek to develop better whistleblowing policies and nurture open reporting cultures are in need of more evidence Although we set out a wide range of issues, it is beyond our remit to convert these concerns into specific recommendations: that is a process that needs to be led from elsewhere, and in partnership with the service There is also still much to learn regarding this important area of health policy, and we have highlighted a number of important gaps in knowledge that are in need of more sustained research Future work A key area for future research is to explore whistleblowing as an unfolding, situated and interactional process and not just a one-off act by an identifiable whistleblower In particular, we need more evidence and insights into the tendency for senior managers not to hear, accept or act on concerns about care raised by employees Funding The National Institute for Health Research Health Services and Delivery Research programme

Understanding new models of integrated care in developed countries: a systematic review

Abstract: Background The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care. Objectives The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes. Design The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings. Setting Any setting. Participants Patients receiving a health-care service and/or staff delivering services. Interventions Changes to service delivery that increase integration and co-ordination of health and health-related services. Main outcome measures Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff. Study design Empirical work of a quantitative or qualitative design. Data sources We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review. Review methods The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence. Results We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs. Limitations Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness. Conclusions There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models. Future work Links between elements of new models and outcomes require further study, together with research in a wider variety of populations. Study registration This study is registered as PROSPERO CRD37725. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Abstract: Background Interventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success. Objectives This study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted. Design The review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies. Setting Primary and secondary care. Participants Not applicable. Interventions Studies related to antimicrobial prescribing for doctors in training. Main outcome measures Not applicable. Data sources EMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations. Review methods Clearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives. Results A total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training. Limitations Most articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments. Conclusions This review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings. Future work More work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics. Study registration This study is registered as PROSPERO CRD42015017802. Funding The National Institute for Health Research Health Services and Delivery Research programme.

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Abstract: Background Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address. Objectives To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes. Design A systematic mapping review. Setting Evidence from developed countries on interventions delivered in the ED. Participants Frail and high-risk older people and general populations of older people (aged > 65 years). Interventions Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED. Main outcome measures Patient outcomes (direct and indirect) and health service outcomes. Data sources Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016. Review methods A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made. Results Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes. Limitations This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review. Conclusions A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped. Future work Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients. Study registration This study is registered as PROSPERO CRD42016043260. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Abstract: BACKGROUND: Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable. OBJECTIVES: To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care. DESIGN: Pilot cluster randomised trial (CRT) and associated process and economic evaluations. SETTING: Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2). PARTICIPANTS: Patients (n = 639), staff (n = 211) and visitors (n = 188). INTERVENTION: CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity. MAIN OUTCOME MEASURES: Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy). DATA SOURCES: Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities. RESULTS: The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study. LIMITATIONS: Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention. CONCLUSIONS: Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16789770. FUNDING: This 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. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported in Chapter 2 was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Orebro and the Karolinska Institutet.

Identifying perinatal depression with case-finding instruments: a mixed methods study (BaBY PaNDA - Born and Bred in Yorkshire PeriNatal Depression Diagnostic Accuracy)

Abstract: Background Perinatal depression is well recognised as a mental health condition but < 50% of cases are identified in routine practice. A case-finding strategy using the Whooley questions is currently recommended by the National Institute for Health and Care Excellence. Objectives To determine the diagnostic accuracy, acceptability and cost-effectiveness of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to identify perinatal depression. Design A prospective diagnostic accuracy cohort study, with concurrent qualitative and economic evaluations. Setting Maternity services in England. Participants A total of 391 pregnant women. Main outcome measures Women completed the Whooley questions, EPDS and a diagnostic reference standard (Clinical Interview Schedule – Revised) during pregnancy (20 weeks) and postnatally (3–4 months). Qualitative interviews were conducted with health professionals (HPs) and a subsample of women. Results Diagnostic accuracy results: depression prevalence rates were 10.3% during pregnancy and 10.5% postnatally. The Whooley questions and EPDS (cut-off point of ≥ 10) performed reasonably well, with comparable sensitivity [pregnancy: Whooley questions 85.0%, 95% confidence interval (CI) 70.2% to 94.3%; EPDS 82.5%, 95% CI 67.2% to 92.7%; postnatally: Whooley questions 85.7%, 95% CI 69.7% to 95.2%; EPDS 82.9%, 95% CI 66.4% to 93.4%] and specificity (pregnancy: Whooley questions 83.7%, 95% CI 79.4% to 87.4%; EPDS 86.6%, 95% CI 82.5% to 90.0%; postnatally: Whooley questions 80.6%, 95% CI 75.7% to 84.9%; EPDS 87.6%, 95% CI 83.3% to 91.1%). Diagnostic accuracy of the EPDS (cut-off point of ≥ 13) was poor at both time points (pregnancy: sensitivity 45%, 95% CI 29.3% to 61.5%, and specificity 95.7%, 95% CI 93.0% to 97.6%; postnatally: sensitivity 62.9%, 95% CI 44.9% to 78.5%, and specificity 95.7%, 95% CI 92.7% to 97.7%). Qualitative evaluation: women and HPs were supportive of screening/case-finding for perinatal depression. The EPDS was preferred to the Whooley questions by women and HPs, mainly because of its ‘softer’ wording. Whooley question 1 was thought to be less acceptable, largely because of the terms ‘depressed’ and ‘hopeless’, leading to women not revealing their depressive symptoms. HPs identified a ‘patient-centred’ environment that focused on the mother and baby to promote discussion about mental health. Cost-effectiveness results: screening/case-finding using the Whooley questions or the EPDS alone was not the most cost-effective strategy. A two-stage strategy, ‘Whooley questions followed by the Patient Health Questionnaire’ (a measure assessing depression symptomatology), was the most cost-effective strategy in the range between £20,000 and £30,000 per quality-adjusted life-year in both the prenatal and postnatal decision models. Limitations Perinatal depression diagnosis was not cross-referenced with women’s medical records so the proportion of new cases identified is unknown. The clinical effectiveness and cost-effectiveness of screening/case-finding strategies was not assessed as part of a randomised controlled trial. Conclusions The Whooley questions and EPDS had acceptable sensitivity and specificity, but their use in practice might be limited by low predictive value and variation in their acceptability. A two-stage strategy was more cost-effective than single-stage strategies. Neither case-finding instrument met National Screening Committee criteria. Future work The yield of screening/case-finding should be established with reference to health-care records. The clinical effectiveness and cost-effectiveness of screening/case-finding for perinatal depression needs to be tested in a randomised controlled trial. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Economic analysis of service and delivery interventions in health care

Abstract: There are well-developed guidelines for economic evaluation of clearly defined clinical interventions, but no such guidelines for economic analysis of service interventions. Distinctive challenges for analysis of service interventions include diffuse effects, wider system impacts, and variability in implementation, costs and effects. Cost-effectiveness evidence is as important for service interventions as for clinical interventions. There is also an important role for wider forms of economic analysis to increase our general understanding of context, processes and behaviours in the care system. Methods exist to estimate the cost-effectiveness of service interventions before and after introduction, to measure patient and professional preferences, to reflect the value of resources used by service interventions, and to capture wider system effects, but these are not widely applied. Future priorities for economic analysis should be to produce cost-effectiveness evidence and to increase our understanding of how service interventions affect, and are affected by, the care system.

The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study

Abstract: Background: Improving the care of people with dementia on acute hospital wards is a policy priority. Person-centred care is a marker of care quality; delivering such care is a goal of service improvement. Objectives: The Person, Interactions and Environment (PIE) Programme comprises an observation tool and a systematic approach to implement and embed a person-centred approach in routine care for hospitalised patients with dementia. The study aims were to evaluate PIE as a method to improve the care of older people with dementia on acute hospital wards, and develop insight into what person-centred care might look like in practice in this setting. Methods: We performed a longitudinal comparative case study design in 10 purposively selected wards in five trusts in three English regions, alongside an embedded process evaluation. Data were collected from multiple sources: staff, patients, relatives, organisational aggregate information and documents. Mixed methods were employed: ethnographic observation; interviews and questionnaires; patient case studies (patient observation and conversations ‘in the moment’, interviews with relatives and case records); and patient and ward aggregate data. Data were synthesised to create individual case studies of PIE implementation and outcomes in context of ward structure, organisation, patient profile and process of care delivery. A cross-case comparison facilitated a descriptive and explanatory account of PIE implementation in context, the pattern of variation, what shaped it and the consequences flowing from it. Quantitative data were analysed using simple descriptive statistics. A qualitative data analysis employed grounded theory methods. Results: The study furthered the understanding of the dimensions of care quality for older people with dementia on acute hospital wards and the environmental, organisational and cultural factors that shaped delivery. Only two wards fully implemented PIE, sustaining and embedding change over 18 months. The remaining wards either did not install PIE (‘non implementers’) or were ‘partial implementers’. The interaction between micro-level contextual factors [aspects of leadership (drivers, facilitators, team, networks), fit with strategic initiatives and salience with valued goals] and meso- and macro-level organisational factors were the main barriers to PIE adoption. Evidence suggests that the programme, where implemented, directly affected improvements in ward practice, with a positive impact on the experiences of patients and caregivers, although the heterogeneity of need and severity of impairment meant that some of the more visible changes did not affect everyone equally. Limitations: Although PIE has the potential to improve the care of people with dementia when implemented, findings are indicative only: data on clinical outcomes were not systematically collected, and PIE was not adopted on most study wards. Research implications: Further research is required to identify more precisely the skill mix and resources necessary to provide person-focused care to hospitalised people with dementia, across the spectrum of need, including those with moderate and severe impairment. Implementing innovations to change practices in complex organisations requires a more in-depth understanding of the contextual factors that have an impact on the capacity of organisations to absorb and embed new practices. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study

Abstract: Background 25% of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Healthcare professionals report lack of communication skills training. Objectives To identify teachable effective strategies for communication between healthcare professionals and people living with dementia, and to develop and evaluate a communication skills training course. Design We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using co-production and multiple pedagogic approaches. We ran a pilot, followed by six courses for healthcare professionals. We measured knowledge, confidence and communication behaviours before, immediately-and one month-after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations. Setting General hospital acute geriatric medical wards; clinical skills centre. Participants We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six healthcare professionals took part in a pilot course and 45 took part in the training. Results Literature review identified 27 studies, describing ten communication strategies, with modest evidence of effectiveness. Healthcare professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask), and with lowered contingencies (made to sound less difficult, by minimising the extent or duration of the task, as king patients ‘to try’, offering help, or proposing collaborative action). Closings were more successful if the healthcare professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised two days, one month apart, using experiential learning, including lectures, video-workshops, small group discussion, simulation (with specially-trained actors) and reflection. We emphasised incorporation of previous expertise, and commitment to person-centred care. 44 participants returned for the second training day; 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was highly-rated in interviews, especially the use of simulation, real-life video clips, and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them a month after the course finished. Limitations Data were from people with moderate to severe dementia, in an acute hospital, during healthcare professional initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias. Future work Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of healthcare communication. Conclusions Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Abstract: Background The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations. Objectives The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables. Design There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components. Main outcome measures The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience. Data sources Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence. Review methods A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities. Results Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models. Strengths and limitations The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change. Conclusions Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working. Future work A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

A randomised controlled trial to evaluate the impact of a human rights based approach to dementia care in inpatient ward and care home settings

Abstract: Background Although it is widely recognised that adopting a person-centred approach is beneficial in the care of people living with dementia, a gap remains between the rhetoric and the reality of quality care. Some widely adopted care practices can result in the personhood of this group being threatened and their human rights being undermined. Objectives To evaluate the impact of applying a human rights based approach in dementia inpatient wards and care homes on the quality of care delivered and the well-being of the person living with dementia. Design A cluster randomised design was employed to compare the impact of implementing a human rights based approach intervention (i.e. training, applying the ‘Getting It Right’ assessment tool and receiving booster sessions) at 10 intervention sites with 10 control sites. Setting Eight NHS dementia inpatient wards and 12 care homes in the north-west of England. Participants People living with dementia who were residing on dementia inpatient wards or in care homes, and staff working at these sites. The aim was to recruit 280 people living with dementia. Interventions A sample of staff (an average of 8.9 per site) at each of the sites was trained in a human rights based approach to care, including the application of the ‘Getting It Right’ assessment tool. The tool was then introduced at the site and monthly booster sessions were delivered. Main outcome measures The primary outcome measure used in the research was the Quality of Life in Alzheimer’s Disease scale to assess the subjective well-being of the person with dementia. Secondary outcome measures included measures of the quality of care provided (dementia care mapping) and direct measures of the effectiveness of the training in increasing knowledge of and attitudes towards human rights. The study also included an economic evaluation utilising the EuroQol-5 Dimensions, three-level version, and the Adult Social Care Outcomes Toolkit measure. Results The study recruited 439 people living with dementia: 213 to the intervention arm and 226 to the control arm. Primary outcome data were analysed using a linear mixed model. There were no significant differences found in the reported quality of life of residents between the control and intervention groups after the intervention [ F (1,16.51) = 3.63; p = 0.074]. The mean difference between the groups was 1.48 (95% confidence interval –7.86 to 10.82). Conclusions Despite the fact that the training increased staff knowledge of and positive attitudes towards human rights, and although there were some changes in staff decision-making strategies in clinical situations, there was no change in the quality of care provided or in the reported well-being of people living with dementia in these settings. This led to questions about the efficacy of training in bringing about cultural change and improving care practices. Limitations There was limited uptake of the training and booster sessions that were integral to the intervention. Future work Future work could usefully focus on understanding the difficulty in translating change in attitude and knowledge into behaviour. Trial registration Current Controlled Trials ISRCTN94553028. Funding This 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. 6, No. 13. See the NIHR Journals Library website for further project information.

Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study

Abstract: Background Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete. Objectives To model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions. Design Observational study. Setting English NHS. Participants All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD. Interventions None. Main outcome measures One-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD. Data sources Patient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information. Results One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor; p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase; p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP; p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98; p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator. Limitations Data lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated. Conclusions Following an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators. Future work Hospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability.

Abstract: Background African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically. Aims (1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’. Design A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference. Setting Two mental health trusts in north-west England. Participants We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs. Interventions An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family. Main outcome measures Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement. Results Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals. Limitations The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population. Conclusions It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups. Future work A fully powered, multicentre trial, comparing CaFI with usual care, is planned. Trial registration Current Controlled Trials ISRCTN94393315. Funding This 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. 6, No. 32. See the NIHR Journals Library website for further project information.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Abstract: Background Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely. Objectives To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation. Design Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups. Setting Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions. Participants One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists. Interventions Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol. Main outcome measures Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility. Data sources Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications. Results Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health. Limitations Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available. Conclusions Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people. Future work Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes. Study registration Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792. Funding The National Institute for Health Research Health Services and Delivery Research programme.

From Programme Theory to Logic Models for Multispecialty Community Providers: A Realist Evidence Synthesis

Abstract: Background: The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets. Objectives: To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly. Design: Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way. Data sources: Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions. Results: The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs. Limitations: The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed. Conclusions: Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Experiences of the ‘Nearest Relative’ provisions in the compulsory detention of people under the Mental Health Act: a rapid systematic review

Abstract: Background Service users detained for assessment and/or treatment under the Mental Health Act 1983 (MHA 1983) are allocated a ‘Nearest Relative’ (NR). The NR has access to confidential information about the service user and can make decisions about their care and treatment. Tensions exist regarding the identification, displacement and powers of the NR. Objectives To examine the experiences of service users, carers and relevant professionals of the NR provisions of the MHA 1983, and the equivalent Named Person (NP) provisions in Scotland. Five research objectives were defined: understanding the experiences of and issues associated with (1) the identification of the NR, (2) the displacement of the NR, (3) confidentiality and information-sharing, (4) access to support from carers and (5) making decisions about treatment or care. Data sources Seven bibliographic databases were searched: MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Social Policy and Practice (via Ovid), Health Management Information Consortium (via Ovid), Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost) and Applied Social Sciences Index and Abstracts (via ProQuest). Citation searching, author contact and grey literature searches were conducted. Review methods A rapid systematic review was conducted in 6 weeks. Evidence published after 1998 from the UK pertaining to the experiences of those involved in compulsory detention under the MHA 1983 (or UK variants), including service users, carers, family members, NRs, NPs, mental health professionals, policy-makers and lawyers, was sought. Study selection, data extraction and critical appraisal were completed independently by two reviewers. We looked for data about experiences, which were obtained through qualitative means or surveys. Included studies containing several paragraphs of participant quotations and/or author interpretations were entered into a framework synthesis; the rest were summarised descriptively. The framework synthesis was based on the five research objectives and refined using the findings of key studies from England and Scotland and an inductive thematic analysis. Results Twenty studies were included with 12 prioritised for framework synthesis. Four themes emerged: (1) issues regarding the identification of the NR/NP, (2) confidentiality and information-sharing, (3) enabling the use of the NR/NP role and (4) the importance of maintaining relationships. The involvement of service users in choosing their representative and the role of services in supporting the NR/NP was identified as important. Limitations There is little recent evidence to inform this important and complex discussion. The review was rigorously conducted despite the short time scale; however, a more in-depth, iterative thematic analysis of all the included studies may have provided additional insights into the mechanisms underpinning the issues. Conclusions The NR provisions of the MHA 1983 are complex and of significant importance to individuals detained under the Mental Health Act and their carers. This rapid review provides specific examples of issues that individuals may experience. More research is needed to aid understanding of this complex topic. Future work Primary research specifically focused on the perceived and actual use and impact of the NR provisions in England and Scotland. Study registration This study is registered as PROSPERO CRD42018088237. Funding The National Institute for Health Research Health Services and Delivery Research programme.

NHS managers' use of nursing workforce planning and deployment technologies: a realist synthesis

Abstract: Background Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings. Objectives The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’. Design A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing. Participants NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory. Results Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose. Limitations The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public. Conclusions and recommendations The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory. Study registration This study is registered as PROSPERO CRD42016038132. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT

Abstract: Background The Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness. Objectives To explore the process of implementation of the SICP and the impact on patient outcomes and costs. Design Qualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies. Setting Salford in the north-west of England. Participants Older people aged ≥ 65 years, carers, and health and social care professionals. Interventions A large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’). Main outcome measures Patient self-management, care experience and quality of life, and health-care utilisation and costs. Data sources Professional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation. Results The SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776). Limitations The Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were Conclusions The SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes. Future work Further research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use. Trial registration Current Controlled Trials ISRCTN12286422. Funding This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC)

Abstract: Background With a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe. Study aim To evaluate the introduction of predictive risk stratification in primary care. Objectives To (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM. Design Randomised stepped-wedge trial with economic and qualitative components. Setting Abertawe Bro Morgannwg University Health Board, south Wales. Participants Patients registered with 32 participating general practices. Intervention PRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support. Main outcome measures Primary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs. Data sources Routine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews. Results Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets. Limitations In Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative. Conclusions Introduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients. Future research (1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners. Trial and study registration Current Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874. Funding The National Institute for Health Research Health Services Delivery and Research programme.

Variation in outcome of hospitalised patients with out-of-hospital cardiac arrest from acute coronary syndrome : a cohort study

Abstract: Background Each year, approximately 30,000 people have an out-of-hospital cardiac arrest (OHCA) that is treated by UK ambulance services. Across all cases of OHCA, survival to hospital discharge is less than 10%. Acute coronary syndrome (ACS) is a common cause of OHCA. Objectives To explore factors that influence survival in patients who initially survive an OHCA attributable to ACS. Data source Data collected by the Myocardial Ischaemia National Audit Project (MINAP) between 2003 and 2015. Participants Adult patients who had a first OHCA attributable to ACS and who were successfully resuscitated and admitted to hospital. Main outcome measures Hospital mortality, neurological outcome at hospital discharge, and time to all-cause mortality. Methods We undertook a cohort study using data from the MINAP registry. MINAP is a national audit that collects data on patients admitted to English, Welsh and Northern Irish hospitals with myocardial ischaemia. From the data set, we identified patients who had an OHCA. We used imputation to address data missingness across the data set. We analysed data using multilevel logistic regression to identify modifiable and non-modifiable factors that affect outcome. Results Between 2003 and 2015, 1,127,140 patient cases were included in the MINAP data set. Of these, 17,604 OHCA cases met the study inclusion criteria. Overall hospital survival was 71.3%. Across hospitals with at least 60 cases, hospital survival ranged from 34% to 89% (median 71.4%, interquartile range 60.7–76.9%). Modelling, which adjusted for patient and treatment characteristics, could account for only 36.1% of this variability. For the primary outcome, the key modifiable factors associated with reduced mortality were reperfusion treatment [primary percutaneous coronary intervention (pPCI) or thrombolysis] and admission under a cardiologist. Admission to a high-volume cardiac arrest hospital did not influence survival. Sensitivity analyses showed that reperfusion was associated with reduced mortality among patients with a ST elevation myocardial infarction (STEMI), but there was no evidence of a reduction in mortality in patients who did not present with a STEMI. Limitations This was an observational study, such that unmeasured confounders may have influenced study findings. Differences in case identification processes at hospitals may contribute to an ascertainment bias. Conclusions In OHCA patients who have had a cardiac arrest attributable to ACS, there is evidence of variability in survival between hospitals, which cannot be fully explained by variables captured in the MINAP data set. Our findings provide some support for the current practice of transferring resuscitated patients with a STEMI to a hospital that can deliver pPCI. In contrast, it may be reasonable to transfer patients without a STEMI to the nearest appropriate hospital. Future work There is a need for clinical trials to examine the clinical effectiveness and cost-effectiveness of invasive reperfusion strategies in resuscitated OHCA patients of cardiac cause who have not had a STEMI. Funding The National Institute for Health Research Health Services and Delivery Research programme.

The provision of services in the UK for UK armed forces veterans with PTSD: a rapid evidence synthesis

Abstract: Background Our research arises from anticipated increases in demand for psychological trauma services in the UK, with particular reference to armed forces veterans with post-traumatic stress disorder (PTSD). Commissioning and service provider activity to improve veterans’ health is evolving. Objectives To explore what UK services exist and establish potentially effective models of care and effective treatments for armed forces veterans with PTSD. Design A four-stage rapid evidence synthesis comprising information gathering on UK service provision; an evidence review on models of care; a metareview on treatment effectiveness; and a synthesis highlighting research priorities. Setting For the evidence reviews, any setting that was relevant to the UK health and social care system. Participants UK armed forces veterans with PTSD following repeated exposure to traumatic events. Interventions Any model of care or treatment. Main outcome measures Any relevant outcome. Data sources Information about current UK practice. Searches of databases [including MEDLINE, PsycINFO and PILOTS (Published International Literature on Traumatic Stress)], guidelines and relevant websites, up to November 2016. Review methods We screened titles and abstracts using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, UK) and EndNote X7 [Clarivate Analytics (formerly Thomson Reuters), Philadelphia, PA, USA]. Decisions to include papers were made by two reviewers independently. We conducted a narrative synthesis of research literature on models of care and on treatments, guided by information from UK practice. In our evidence reviews, we assessed (when appropriate) the quality of included studies using established criteria. To help interpret our findings, we consulted recently published public and patient involvement data, a veteran service user and experts with academic, military and commissioning backgrounds. Results We gathered information about current UK practice. Sixty-one studies were included in the rapid evidence review on models of care and seven systematic reviews in the rapid metareview of treatments. The quality of evidence in both evidence reviews was limited. Promising models of care from more robust studies (three randomised controlled trials and one qualitative study) were collaborative arrangements and community outreach for improving intervention access and uptake; integrated mental health services and behavioural intervention on increased smoking abstinence; and peer support as an acceptable complement to PTSD treatment. A poor fit was noted between the research literature and UK service provision. Promising treatments were psychosocial interventions (eye movement desensitisation and reprocessing, cognitive processing therapy, trauma-focused and exposure-based intervention) and pharmacotherapy (selective serotonin reuptake inhibitors, antidepressants, anticonvulsants, antipsychotics) for improving PTSD and mental health symptoms. Limitations The literature pool was larger than anticipated. Evidence for potentially effective models of care and potentially effective treatments is limited in quality and quantity. Although we aimed for a comprehensive evidence synthesis, pragmatic decisions in searching, screening and inclusion of studies may mean that relevant studies were overlooked. Conclusions There is tentative support for the effectiveness of some models of care and certain treatments currently delivered in UK practice. Our findings are timely for commissioners and service providers when developing present activity in veterans’ health care. Future work We report potential implications for future health-care practice, including early intervention for veterans transitioning from military life, improving general practitioners’ knowledge about services, implementing needs-based service design and tackling wider-system challenges. Regarding potential areas of future research, we have identified the need for more-robust (and longer) evaluative studies in the UK setting. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study

Abstract: Background We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another. Objectives To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making. Design A mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision. Setting and participants The primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated. Results Distribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed. Limitations A main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation. Conclusions Patient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making. Future research To advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence). Funding The National Institute for Health Research Health Services and Delivery Research programme.

An Evaluation of a Near Real-Time Survey for Improving Patients’ Experiences of the Relational Aspects of Care.

Abstract: Background The Francis Report (2013) provided many recommendations to improve compassionate care in NHS organisations, including more wide-spread use of real-time feedback (RTF) to collect patient experience data. This research directly addressed these recommendations and aimed to provide an evidence-based toolkit to support NHS quality improvements. Objectives To develop and validate a survey of compassionate care for use in near-real time on elderly care wards and AE departments. This research also evaluated the effectiveness of the realtime feedback approach for improving relational aspects of care and provides suggestions for how the approach can be used by other hospitals to strengthen compassionate care. Design The research utilised a mixed methods design, using quantitative, qualitative and participatory research approaches to collect patients’ experiences of relational care and the views of NHS staff in an effort to evaluate the processes and impacts of NRTF data collection. Setting The research was carried out across six case study sites across England, in wards that predominately served elderly patients, and in Accident and Emergency (AE) departments Participants The 3928 participants in the patient experience survey were inpatients on elderly care wards, as well as persons who had sought medical care in AE Frontline staff, service leads, senior management and volunteers also took part in surveys (n = 274) and interviews (n = 82) designed to understand the staff perspectives and opinions of collecting patient experience data. Interventions A patient experience survey was implemented using a tablet computer-based methodology facilitated by trained volunteers. Responses were used alongside feedback from staff to evaluate the use of a NRTF approach as a method for improving patient experiences of relational aspects of care. Main Outcome Measures The patient experience survey measured relational aspects of care. Another outcome measure was improvements to care as planned, implemented and reported by staff. Data Sources Data sources included an NRTF patient experience survey, weekly volunteer diaries, staff interviews and surveys, workshops, and meetings with case study sites. Results A small but statistically significant improvement (p=.044) in relational aspects of care over the course of the study was noted overall. Staff implemented a variety of improvements to enhance communication with patients. Limitations Maintaining volunteer and staff engagement throughout the study was difficult. Few surveys were completed per ward or department each week. This made examining trends in patient experiences over time challenging. Conclusions Near real-time feedback (NRTF) offers an effective approach for monitoring and improving relational aspects of care. Future Work Staff frequently expressed a view that volunteers’ interactions with patients whilst administering the survey were themselves beneficial to patients. Future research should examine the impact of volunteer interactions with patients on their experiences of relational aspects of care.

Measuring quality in community nursing: a mixed methods study

Abstract: Background High-quality nursing care is crucial for patients with complex conditions and co-morbidities living at home, but such care is largely invisible to health planners and managers. Nursing care quality in acute settings is typically measured using a range of different quality measures; however, little is known about how service quality is measured in community nursing. Objective To establish which quality indicators are selected for community nursing; how these are selected and applied; and their usefulness to service users (patients and/or carers), commissioners and provider staff. Design A mixed-methods study comprising three phases: 1)A national survey of ‘Commissioning for Quality and Innovation’ indicators applied to community nursing care in 2014/2015. Data were analysed descriptively using SPSS 20.0. 2)In-depth case study in five sites. Qualitative data were collected through observations, interviews, focus groups and documents. Thematic analysis was conducted using QSR NVivo 10. Findings from the first two phases were synthesised using a theoretical framework to examine how local and distal contexts affecting care provision impacted on selection and application of quality indicators for community nursing. 3)Validity testing the findings and associated draft good practice guidance through a series of stakeholder engagement events held in venues across England. Setting The national survey was conducted by telephone and e-mail. Each case study site comprised a Clinical Commissioning Group (CCG) and its associated provider of community nursing services. Participants Survey: 145 (68.7%) CCGs across England. Case study: NHS England national and regional quality leads (n=5); commissioners (n=19); provider managers (n=32); registered community nurses (n=45); adult patients (n=14) receiving care in their own homes and/or carers (n=7). Findings A wide range of indicators was used nationally, with a major focus on organisational processes. Lack of nurse and service user involvement in indicator selection processes impacted negatively on their application and perceived usefulness. Indicator data collection was hampered by problematic IT software and connectivity and inter-organisational system incompatibility. Frontline staff considered indicators designed for acute settings inappropriate for use in community settings. Indicators did not reflect aspects of care such as time spent, kindness and respect, highly valued by frontline staff and service user participants. Workshop delegates (commissioners, provider managers, frontline staff and service users, n=242) endorsed the findings and draft good practice guidance. Limitations On-going service re-organisation during the study period affected access to participants in some sites. Limited available data precluded in-depth documentary analysis. Conclusions Current quality indicators for community nursing are of limited use: Commissioners and provider managers should ensure that service users and frontline staff are involved in identifying and selecting indicators. Difficulties with connectivity and compatibility should be resolved before rolling new IT packages out into practice. Quality measures designed for acute settings should not be applied in community settings without modification. A mix of qualitative and quantitative methods should be used to determine service quality Future work Research investigating appropriate modifications and associated costs of administering quality indicator schemes in integrated care settings. Funding details The study was funded by the NIHR Health Service and Delivery Research programme.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Abstract: Background Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction. Research questions Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services? Design A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation. Setting The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital. Participants Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation. Interventions A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service. Main outcome measures Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described. Results In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern. Conclusions Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively. Study limitations The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals. Future work The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage. Funding The National Institute for Health Research Health Services and Delivery Research programme.