England Healthcare System Research Articles

Integrated care systems in England: the significance of collaborative community assets in promoting and sustaining health and wellbeing.

Until recently the healthcare system in England was based on a commissioning/provider model. However, this has been replaced with an Integrated Care Systems (ICSs) approach, aimed at improving health and wellbeing and reducing inequalities through local collaborative partnerships with public sector organizations, community groups, social enterprise organizations and other local agencies. Part of this new approach is an emphasis on the role of community assets (i.e., local resources), that are considered integral to promoting positive health and wellbeing outcomes. This paper presents research from a series of three research studies on "community assets" conducted in the East of England within a newly established ICS. Based on analysis of qualitative data highlighting the lived experience of community asset members, this paper shows the positive wellbeing impact on vulnerable community members that assets provide. Further insight on the local impact and the collaborative nature of the research is provided suggesting that new asset-based approaches recognize the social determinants of health. This presents a shift away from positivistic linear approaches to population health and wellbeing to a new non-linear collaborative approach to addressing health inequalities and promoting wellbeing. The authors suggest that exploring this through a complexity theory lens could illuminate this further. Finally, the authors warn that while community assets have an important role to play in empowering citizens and providing much needed support to vulnerable and disadvantaged communities, they are not a substitute for functioning funded public sector services that are currently being undermined by ongoing local governments funding cuts. As such, while community assets can help ameliorate some of the negative effects people experience due to economic, structural and health disadvantages, only a more fair and more equal distribution of resources can address growing health inequalities.

What Are the Economic Arguments for Mandating LGBT+ Health Training for Healthcare Providers? An Economic Evaluation of the Impacts of LGBT+ Health Training on Cervical Screening.

Background: Equitable access to healthcare is a priority of many healthcare systems, aiming to ensure access is driven by need and not minority groups such as those defined by sexual orientation. However, there are healthcare areas where inequity in access across sexual orientation groups is found that are not justified based on need. Mandated LGBTQ+-specific training of the healthcare workforce may help address some barriers of access for these groups. The study aims to understand the potential economic implications for mandated LGBTQ+-specific healthcare training on the healthcare system in England, UK to inform commissioning of training provision. Methods: Cervical cancer screening was used as an exemplar case where there appears to be inequity in access for different sexual orientation groups. A decision model was developed and analysed that considered the impacts of greater uptake of screening for lesbian and bisexual women due to LGBTQ+ training. Costs took the perspective of the healthcare system and outcomes modelled were cancer cases averted in a timeframe of 5 years. Results: Based on cervical cancer screening alone, where training costs are fully attributed to this service, training would likely result in fewer cancer cases detected in the lesbian and bisexual populations, though this comes at a modest increase in healthcare sector costs, with this increase largely reflecting a greater volume of screens. Training costs do not appear to be a major component of the cost implications. Conclusions: In resource-constrained systems with increasing pressures for efficiency savings, the opportunity cost of delivering training is a realistic component of the commissioning decision. The findings in this paper provide a signal that mandated LGBTQ+ training in healthcare could lead to potentially greater outcomes and in breaking down barriers of access and could also enable the healthcare system to provide more equitable access to healthcare.

Health systems, health policies, and health issues for people with intellectual disabilities in England

AbstractPeople with intellectual disabilities face health disparities, including in high‐income countries such as the United Kingdom, despite publicly funded healthcare. This paper describes the healthcare system in England (a nation of the United Kingdom) for the general population, and more specifically for people with intellectual disabilities. Key legislation that impacts the lives of people with intellectual disabilities, such as the UK Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15/contents), the Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9/contents), and the UN Convention on the Rights of Persons with Disabilities, and its implementation in the United Kingdom, is discussed. The role of deinstitutionalization and the shift to living in the community for people with intellectual disabilities is also discussed. Programmes that have been implemented to address the health disparities experienced by people with intellectual disabilities are reviewed. Finally, the recent changes to healthcare organization in the UK, the COVID‐19 pandemic, and the implementation of the Valuing People white paper are discussed.

Cerebrospinal fluid metagenomics has greatest added value as a test for Powassan virus among patients in New England with suspected central nervous system infection

Cerebrospinal fluid (CSF) metagenomic next generation sequencing (mNGS) can detect diverse pathogens in patients with central nervous system infection. Due to its high cost and unclear clinical utility, it is typically reserved for patients with unrevealing routine workups. A multi-center retrospective analysis of real-world CSF mNGS was performed involving orders between 2017 and 2022 at a large New England healthcare system. CSF mNGS was performed 64 times with 17 positive results (27 %). In 11/17 positive samples (65 %), the infectious agent had not been previously detected using routine methods. Arboviruses (n = 8) were the most frequently detected agents, particularly Powassan virus (n = 6). Results changed therapy in 3/64 cases (5 %). Positive results were associated with immunodeficiency (p = 0.06), especially anti-B-cell therapy (p = 0.02), and earlier sample collection (p = 0.06). The association with compromised humoral immunity was stronger in the arbovirus and Powassan virus subgroups (p = 0.001), whose constituents were older than the overall cohort and had higher mortality rates.

Understanding suboptimal e-consult requests: lessons from the VA.

Electronic consultations, or e-consults, which are requests for specialist advice without direct patient interaction, are becoming increasingly common across health systems. We sought to identify clinicians' perspectives on the quality of e-consult requests that they send and receive. A qualitative research study at the US Department of Veterans Affairs (VA) New England Healthcare System. We interviewed a total of 73 clinicians, including 38 specialists across 3 specialties (cardiology, neurology, pulmonology) and 35 primary care clinicians (PCCs), between March and June 2019. The interviews were analyzed using thematic analysis. VA specialists and PCCs generally agreed that e-consult requests should be focused and precise, not require lengthy chart review, and include adequate preliminary workup results. At the same time, specialists expressed frustration with what they perceived as suboptimal e-consult requests. Interviewees attributed this gap to 3 factors: limitations of the electronic health record user interface, divergence between PCCs and specialists in the areas of expertise, and organizational pressures on the 2 groups. VA clinicians' perspectives on suboptimal requests contain lessons that are broadly applicable to other health systems that seek to maximize the potential of e-consults to facilitate clinician collaboration and care coordination.

Proactively tailoring implementation: the case of shared decision-making for lung cancer screening across the VA New England Healthcare Network

BackgroundShared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening.MethodsWe conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).ResultsWe tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening.ConclusionsFormative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.

Prerequisites and practice of introducing integrated systems of medical care in England

The introduction of new conceptual approaches to public health protection is a trend of public health reform in Russia and European countries. The success of the implementation of public health policy in Russia depends both on the development of their own ideas and their implementation, on the study and use of the experience of foreign countries. For example, in England in the last decade, as part of the reform of the public health system, the idea of creating integrated medical care systems (ICS) has been actively developing and the experience of its implementation is of practical interest for Russian healthcare. 
 Goal. To study the experience of England in implementing integrated medical care systems and analyze the possibility of using its individual elements in Russia. 
 Materials and methods. The study was conducted on the basis of a comprehensive study of open reporting data of the Department of Health and Social Security of England, the National Health Service and the National Audit Office of England (NAO), as well as scientific reports on integrated public health management systems. 
 Results. The development of integrated public health management systems being a trend in world practice, contributes to the improvement of public health indicators. The study of the experience of implementing ICS in England showed the presence of a number of risks during its implementation.
 Limitations. When conducting research, there were no restrictions that could influence the preparation of the article.
 Conclusions. Dissatisfaction with the level of management and financing of the healthcare system in England served as an impetus for the start of reforms that contribute to improving the management of medical care to the population, and the introduction of integrated medical care systems. The analysis of the NAO auditors revealed the main risks of the success of the ICS implementation. Studying the experience of implementing ICS is useful for use in the implementation of Russian national projects in the field of healthcare and demography.

Long-term healthcare utilization and costs of babies born after assisted reproductive technologies (ART): a record linkage study with 10-years' follow-up in England.

Is the long-term health care utilization of children born after ARTmore costly to the healthcare system in England than children born to mothers with no fertility problems? Children born after ART had significantly more general practitioner (GP) consultations and higher primary care costs up to 10 years after birth, and significantly higher hospital admission costs in the first year after birth, compared to children born to mothers with no fertility problems. There is evidence that children born after ART are at an increased risk of adverse birth outcomes and a small increased risk of rare adverse outcomes in childhood. We conducted a longitudinal study of 368088 mother and baby pairs in England using a bespoke linked dataset. Singleton babies born 1997-2018, and their mothers, who were registered at GP practices in England contributing data to the Clinical Practice Research Datalink (CPRD), were identified through the CPRD GOLD mother-baby dataset; this data was augmented with further linkage to the mothers' Human Fertilisation and Embryology Authority (HFEA) Register data. Four groups of babies were identified through the mothers' records: a 'fertile' comparison group, an 'untreated sub-fertile' group, an 'ovulation induction' group, and an ART group. Babies were followed-up from birth to 28 February 2021, unless censored due to loss to follow-up (e.g. leaving GP practice, emigration) or death. The CPRD collects anonymized coded patient electronic health records from a network of GPs in the UK. We estimated primary care costs and hospital admission costs for babies in the four fertility groups using the CPRD GOLD data and the linked Hospital Episode Statistics (HES) Admitted Patient Care (APC) data. Linear regression was used to compare the care costs in the different groups. Inverse probability weights were generated and applied to adjust for potential bias caused by attrition due to loss to follow-up. Children born to mothers with no fertility problems had significantly fewer consultations and lower primary care costs compared to the other groups throughout the 10-years' follow up. Regarding hospital costs, children born after ART had significantly higher hospital admission costs in the first year after birth compared to those born to mothers with no fertility problems (difference = £307 (95% CI: 153, 477)). The same pattern was observed in children born after untreated subfertility and ovulation induction. HFEA linkage uses non-donor data cycles only, and the introduction of consent for data use reduced the availability of HFEA records after 2009. The fertility groups were derived by augmenting HFEA data with evidence from primary care records; however, there remains some potential misclassification of exposure groups. The cost of neonatal critical care is not captured in the HES APC data, which may cause underestimation of the cost differences between the comparison group and the infertility groups. The findings can help anticipate the financial impact on the healthcare system associated with subfertility and ART, particularly as the demand for these treatments grows. C.C. and this work were funded by a UK Medical Research Council Career Development Award [MR/L019671/1] and a UK MRC Transition Support Award [MR/W029286/1]. X.H. is an Australia National Health and Medical Research Council (NHMRC) Emerging Leadership Fellow [grant number 2009253]. The authors declare no competing interest. N/A.

'Nurses are seen as general cargo, not the smart TVs you ship carefully': the politics of nurse staffing in England, Spain, Sweden, and the Netherlands.

Nurse workforce shortages put healthcare systems under pressure, moving the nursing profession into the core of healthcare policymaking. In this paper, we shift the focus from workforce policy to workforce politics and highlight the political role of nurses in healthcare systems in England, Spain, Sweden, and the Netherlands. Using a comparative discursive institutionalist approach, we study how nurses are organised and represented in these four countries. We show how nurse politics plays out at the levels of representation, working conditions, career building, and by breaking with the public healthcare system. Although there are differences between the countries - with nurses in England and Spain under more pressure than in the Netherlands and Sweden - nurses are often not represented in policy discourses; not just because of institutional ignorance but also because of fragmentation of the profession itself. This institutional ignorance and lack of collective representation, we argue, requires attention to foster the role and position of nurses in contemporary healthcare systems.

Estimating surgery, radiotherapy and systemic anti-cancer therapy treatment costs for cancer patients by stage at diagnosis

BackgroundThe increasing burden of cancer has economic implications for the healthcare system in England. However, there is limited evidence on the cost of cancer treatment. We calculated the costs of initial cancer treatment (resection, radiotherapy, systemic anti-cancer therapy [SACT]) based on stage at diagnosis.MethodsData from England’s National Cancer Registration Dataset were matched to English Hospital, Radiotherapy and SACT data for breast, lung, prostate, colon and rectal cancers diagnosed between 2016 and 2018. Treatment data were matched to National Schedule of Reference Costs data to calculate the cost of each treatment event.ResultsBreast, colon and rectal cancers treated with resection, radiotherapy or SACT had increasing costs with later stage at diagnosis; costs for lung and prostate cancers were lower at stages 1 and 4 compared to stages 2 and 3. In general, surgery and SACT were the most expensive treatments. Radiotherapy and SACT costs showed little change across stages 1–3; radiotherapy costs decreased in stage 4, while SACT costs increased.ConclusionsThis analysis estimates initial treatment costs by stage based on observed data. Future research can build on this to provide more comprehensive costings associated with cancer; this is important for future planning of cancer services.

Referral Patterns for Pediatric Sports-Related Concussion in One New England Health Care System

Referral Patterns for Pediatric Sports-Related Concussion in One New England Health Care System

Factors Associated with the Digital Patient Experience of Virtual Care Across Specialties.

We aimed to characterize patient experience with virtual care across medical specialties using validated survey data. Primary objective: to determine whether experience varied by visit modality (virtual vs. in-person) and whether relationships persisted after adjusting for patient and provider characteristics. Secondarily, among physicians with sufficient data, we compared virtual versus in-person patient experience scores at the physician level and identified characteristics associated with better experience scores for virtual care. This was a retrospective analysis of administrative databases from a large New England health care system, including all ambulatory visits from October 1, 2020 to September 30, 2021 with patient experience scores recorded. We compared experience between virtual and in-person at the visit level (score: 0-10) and the physician level for likelihood of recommending the physician to friends or family. We used a series of cross-classified hierarchical models with visits grouped by patient and by physician to decompose sources of variation. Among physicians with sufficient data, we compared physicians with higher virtual versus higher in-person net promoter score (NPS). Of 378,472 visits performed by 3368 physicians, 86,878 (23%) were conducted virtually. Most scored ≥9 for either modality, with a small preference for virtual versus in-person care (9.6 vs. 9.5, p < 0.001). We found that more variation in scores was explained by patient than by physician (22.9% vs. 3%). Visit modality was of minimal explanatory value. Most physicians' virtual and in-person NPS were similar, and virtual visit volume was not associated. We found robust evidence for the parity of patient experience between virtual and in-person modalities across specialties.

Selection of patient-reported outcomes measures for implementation in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program.

The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) assesses safety after metabolic and bariatric surgery and the impact on weight and obesity-related diseases. However, changes in quality of life are likely what matters most to patients, and these are not currently assessed. The best way to measure health-related quality of life (HRQoL) is to use validated patient-reported outcomes measures (PROMs), which capture patients' perspectives of their quality of life both before and after surgery. Identify the outcomes most important to bariatric surgery patients and identify the most appropriate validated PROMs to implement in a national program for the MBSAQIP. Five hospitals from a single healthcare system in New England. A series of 18 focus groups and/or interviews conducted with patients, patients' family members, and bariatric health providers determined the outcomes most important to bariatric patients and which validated PROMs would accurately measure those outcomes. Immersion crystallization was used to analyze focus group data and identify appropriate PROMs. Focus group participants ranked health as the most important outcome for metabolic and bariatric surgery. Self-confidence, mobility, and everyday activities were the next highest ranked HRQoL domains. The Patient-Reported Outcomes Measurement Information System 10-Item Global Health Survey was selected as the general health measure. The Obesity-Related Problems scale and the Obesity and Weight-Loss Quality of Life Instrument were the disease-specific measures selected for inclusion in the MBSAQIP PROMs program. The addition of PROMs to the MBSAQIP provides a unique opportunity to monitor HRQoL at the national level, which can foster improved shared decision-making before surgery.

Making 1-1 Support Person Centred and an Effective Therapeutic Intervention

The use of 1-1 support in care homes within the healthcare system in England and Wales is a recognised protective safeguard. However, it is not without its controversies and conflicts as it can prove to be both a highly restrictive and expensive intervention. This paper will examine the use of 1-1 support within care homes for people who present with behaviours that challenge. It will record the findings from a review of 1-1 support for 23 service users over a 30-month period. It will also make a number of recommendations to make 1-1 support an effective, therapeutic, person centred and a correctly targeted resource.

A Pandemic Presidency

Having become President of the Royal College of Psychiatrists in July 2020, Dr. Adrian James had a first-hand experience of how the health-care system in England responded to the pandemic. This article explores the College's response to COVID-19's impact on mental health services and how they worked to support psychiatrists and patients alike. It also reflects on how the long-term implications of the pandemic on mental health are just starting to come to light, as well as some of the new challenges facing psychiatry worldwide.

EE222 Evaluating the Budget Impact on the Health Care System in England and Wales of RefluxStop as a Treatment for Refractory Gastroesophageal Reflux Disease (GORD)

EE222 Evaluating the Budget Impact on the Health Care System in England and Wales of RefluxStop as a Treatment for Refractory Gastroesophageal Reflux Disease (GORD)

Ziconotide for the Management of Cancer Pain: A Budget Impact Analysis

ObjectivesRecent recommendations on starting dose, smaller dose increments, and longer intervals between dose increase have the potential to increase the safety of ziconotide administration in addition to improving its value for money. Ziconotide is not routinely commissioned in England, with one of the concerns being whether it represents the best use of resources. The aim of this project is to conduct a budget impact analysis to estimate the costs or savings associated with the changes in ziconotide dosage in addition to its use in combination with morphine for the management of cancer pain. Materials and MethodsAn open, Markov-like cohort decision analytic model was developed to estimate the budget impact of ziconotide in combination with morphine (ziconotide combination therapy) vs morphine monotherapy through intrathecal drug delivery (ITDD) for the management of cancer pain. The perspective adopted was that of the UK National Health Service, with a five-year time horizon. Sensitivity analyses were conducted to evaluate different scenarios. ResultsZiconotide combination therapy was more expensive than treatment with morphine monotherapy. The total costs of ziconotide combination therapy and morphine monotherapy for the first year were £395,748 and £136,628 respectively. The estimated five-year cumulative budget impact of treatment with ziconotide combination therapy for the five-year time horizon was £2,487,539, whereas that of morphine monotherapy was £913,804. The additional costs in any of the first five years are below the resource impact significance level of £1 million for medical technologies in England. ConclusionsThe results of this budget impact analysis suggest that although a combination of intrathecal ziconotide in combination with morphine is associated with higher costs to the health care system in England, the incremental costs are not significant. Routine commissioning of ziconotide alone or in combination with morphine would provide an alternative for a population with limited ITDD treatment options.

ASAD: A Novel Audification Console for Assessment and Communication of Pain and Discomfort

Pain and discomfort are subjective perceptions that are difficult to quantify. Various methods and scales have been developed to find an optimal manner to describe them; however, these are difficult to use with some categories of patients. Audification of pain has been utilized as feedback in rehabilitation settings to enhance motor perception and motor control, but not in assessment and communication settings. We present a novel tool, the Audification-console for Self-Assessment of Discomfort (ASAD), for assessing and communicating pain and discomfort through sound. The console is a sequence of increasing pitch and frequencies triggered at the press of buttons and displayed as a matrix that can be associated with the subjective perception of pain and discomfort. The ASAD has been evaluated in its ability to capture and communicate discomfort, following a fatigue test in the lower limbs with thirty healthy volunteers, and compared to the most common self-reported methods used in the NHS. (The National Health Service (NHS) is the publicly funded healthcare system in England and one of the four National Health Service systems in the United Kingdom.) This was a qualitative, within subjects and across groups experiment study. The console provides a more accurate assessment than other scales and clearly recognizable patterns of sounds, indicating increased discomfort, significantly localized in specific frequency ranges, thus easily recognizable across subjects and in different instances of the same subject. The results suggest a possible use of the ASAD for a more precise and automatic assessment of pain and discomfort in health settings. Future studies might assess if this is easier to use for patients with communication or interpretation difficulties with the traditional tools.

An overview of a successful COVID-19 vaccination campaign at a prominent Connecticut healthcare system.

The coronavirus disease 2019 (COVID-19) pandemic has required healthcare systems to adapt, innovate, and collaborate to protect public health through treatment, testing, and vaccination initiatives related to the virus. As the pandemic evolved, lessons learned early on through testing and treatment were applied to vaccination efforts. Hartford HealthCare (HHC) is one of the largest healthcare systems in New England and took an integral role in vaccinating patients throughout the region, thus providing one of the largest vaccination campaigns in Connecticut. Early planning for equipment and personnel, in addition to effective communication between providers and patients, was critical in accomplishing HHC's goal of rapidly providing access to COVID-19 vaccines. The efficient and effective response to the pandemic at HHC was led by the Office of Emergency Management, which worked to ensure continuity of patient care and physician excellence in the face of disaster. Initially, resources were directed to testing and treatment of the disease; as vaccine clinical trials announced successful outcomes, these efforts shifted to preparing for the storage and distribution of a mass number of vaccines. This manuscript details the factors that enabled success in HHC's vaccination campaign and serves to provide a useful template for similar healthcare systems for future pandemic response.

Optimising acute stroke pathways through flexible use of bed capacity: a computer modelling study

BackgroundOptimising capacity along clinical pathways is essential to avoid severe hospital pressure and help ensure best patient outcomes and financial sustainability. Yet, typical approaches, using only average arrival rate and average lengths of stay, are known to underestimate the number of beds required. This study investigates the extent to which averages-based estimates can be complemented by a robust assessment of additional ‘flex capacity’ requirements, to be used at times of peak demand.MethodsThe setting was a major one million resident healthcare system in England, moving towards a centralised stroke pathway. A computer simulation was developed for modelling patient flow along the proposed stroke pathway, accounting for variability in patient arrivals, lengths of stay, and the time taken for transfer processes. The primary outcome measure was flex capacity utilisation over the simulation period.ResultsFor the hyper-acute, acute, and rehabilitation units respectively, flex capacities of 45%, 45%, and 36% above the averages-based calculation would be required to ensure that only 1% of stroke presentations find the hyper-acute unit full and have to wait. For each unit some amount of flex capacity would be required approximately 30%, 20%, and 18% of the time respectively.ConclusionsThis study demonstrates the importance of appropriately capturing variability within capacity plans, and provides a practical and economical approach which can complement commonly-used averages-based methods. Results of this study have directly informed the healthcare system’s new configuration of stroke services.