Health Service Scotland Research Articles

The transition between mental health services in Scotland

PurposeThe purpose of this paper is to describe the barriers and facilitators to an effective transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). It also presents a new entry into considering how the transition can be improved.Design/methodology/approachInsights into the transition from CAMHS to AMHS were gathered through eight semi-structured interviews with mental health professionals. Two methods of data analysis were employed to explore the emerging themes in the data and the observed deficit approach to organisational development.FindingsThe findings identified a vast volume of barriers in comparison to facilitators to the transition. Adolescents who transition from CAMHS to AMHS initially experience difficulty adapting to the differences in the services due to the short duration of the transition period. However, despite the established barriers to the transition, adolescents tend to adapt to the differences between the services. Findings also showed a negative framing towards the transition amongst the mental health professionals which resembles a deficit approach to organisational development.Originality/valueThis paper explores mental health professionals’ perspectives regarding the transition in Dumfries and Galloway, Scotland. The transition is increasingly recognised as an area in health care that requires improvement. This research provides a new way to consider the transition by exploring the perceived deficit approach to organisational development in the services.

Factor validation and Rasch analysis of the individual recovery outcomes counter

Objective: The individual recovery outcomes counter is a 12-item personal recovery self-assessment tool for adults with mental health problems. Although widely used across Scotland, limited research into its psychometric properties has been conducted. We tested its’ measurement properties to ascertain the suitability of the tool for continued use in its’ present form.Materials and methods: Anonymised data from the assessments of 1743 adults using mental health services in Scotland were subject to tests based on principles of Rasch measurement theory, principal components analysis and confirmatory factor analysis.Results: Rasch analysis revealed that the six-point response structure of the individual recovery outcomes counter (I.ROC) was problematic. Re-scoring on a four-point scale revealed well-ordered items that measure a single, recovery-related construct, and has acceptable fit statistics. Confirmatory factor analysis supported this. Scale items covered around 75% of the recovery continuum; those individuals least far along the continuum were least well addressed.Conclusions: A modified tool worked well for many, but not all, service users. The study suggests specific developments are required if the I.ROC is to maximise its’ utility for service users and provide meaningful data for service providers.Implications for RehabilitationAgencies and services working with people with mental health problems aim to help them with their recovery.The individual recovery outcomes counter has been developed and is used widely in Scotland to help service users track their progress to recovery.Using a large sample of routinely collected data we have demonstrated that a number of modifications are needed if the tool is to adequately measure recovery.This will involve consideration of the scoring system, item content and inclusion, and theoretical basis of the tool.

Cancer drug funding decisions in Scotland: impact of new end-of-life, orphan and ultra-orphan processes

BackgroundThe Scottish Medicines Consortium evaluates new drugs for use in the National Health Service in Scotland. Reforms in 2014 to their evaluation process aimed to increase patient access to new drugs for end-of-life or rare conditions; the changes include additional steps in the process to gain further information from patients and clinicians, and for revised commercial agreements. This study examines the extent of any impact of the reforms on funding decisions.MethodData on the Scottish Medicines Consortium’s funding decisions during 24 months post-reform were extracted from published Advice, for descriptive statistics and thematic analysis. Comparison data were extracted for the 24 months pre-reform. Data on decisions for England by the National Institute for Clinical and Health Excellence for the same drugs were extracted from published Technology Appraisals.ResultsThe new process was used by 90% (53/59) of cancer submissions. It is triggered if the initial advice is not to recommend, and this risk-of-rejection level is higher than in the pre-period. Thirty-eight cancer drugs obtained some level of funding through the new process, but there was no significant difference in the distribution of decision types compared to the pre-reform period. Thematic analysis of patient and clinician input showed no clear relationship between issues raised and funding decision. Differences between SMC’s and NICE’s definitions of End-of-Life did not fully explain differences in funding decisions.ConclusionsThe Scottish Medicines Consortium’s reforms have allowed funding of up to 38 cancer drugs that might previously have been rejected. However, the contribution of specific elements of the reforms to the final decision is unclear. The process could be improved by increased transparency in how the non-quantitative inputs influence decisions. Some disparities in funding decisions between England and Scotland are likely to remain despite recent process convergence.

EXPERIENCES IN ADAPTING EUROPEAN NETWORK FOR HEALTH TECHNOLOGY ASSESSMENT RAPID REVIEWS TO INFORM LOCAL DECISION MAKING.

The Scottish Health Technologies Group (SHTG) produces rapid reviews on nonmedicine technologies to inform advice for decision making in the National Health Service in Scotland (NHSScotland). This study describes our experiences and lessons learned in adapting for NHSScotland two rapid Relative Effectiveness Assessments (REAs) produced as part of the European Network for Health Technology Assessment (EUnetHTA) project to test collaborative preparation and then local adaptation. The REAs were examined for their relevance to NHSScotland and the feasibility of their adaptation evaluated using a screening toolkit. Some supplementary literature searches were conducted and additional background information on epidemiology and the specific technologies was sought. To inform decision making within Scotland, it was also necessary to identify and review cost-effective analyses. Robust evidence reviews were delivered for NHSScotland. Time saved was less than anticipated, partly due to the need to add in health economic information, and partly because of attempts to supplement and update the EUnetHTA material. The preparation of an accompanying advice statement for NHSScotland enabled the inclusion of local contextual information. Collaborative production and adaptation of HTAs is feasible and would be aided by the inclusion of cost-effectiveness analyses in the original work. Agencies should develop clear processes for adapting such reviews for their context with the focus on selecting appropriate topics for adaptation, avoiding unnecessary supplementation of the original work, and ensuring local ownership of final advice.

Scottish patients at risk of readmission and admission (Sparra)

Background: The healthcare system in Scotland is facing increased demands as a consequence of the aging population and budgetary constraints. There has also been a shift in government policy towards a more preventative and anticipatory approach to the management of long term conditions. The value of this is maximised when it is targeted at patients who are most likely to benefit. To achieve this, it is essential to have valid and robust techniques, which enable stratification of the population by risk. SPARRA is a stratification tool, developed for the National Health Service in Scotland. Launched in 2006, SPARRA is a predictive tool to evaluate an individual’s risk of being admitted to hospital as an emergency inpatient within the next year. In 2012, it’s cohort was widened to allow risk scores to be derived for more patients and for patients from lower risk strata, who may benefit from early preventative interventions. Risk scores are calculated for approximately 4.2 million patients and details of patients whose score indicates that they may be at increased risk are distributed to a range of health care professionalsDescription: SPARRA requires a patient-level history comprising information about each patient during a pre-prediction period and information on whether or not the patient experienced an emergency admission in the twelve months following this period. In the 2012 SPARRA (Version 3), national patient-level data on hospitalisations, prescribing, emergency department, outpatients and psychiatric admissions were linked and a range of variables were derived from this combined dataset. The SPARRA cohort was then divided into three sub-cohorts: ‘Frail Elderly’, ‘Long Term Conditions’ and ‘Younger Emergency Department’. Following the creation of these three sub-cohorts, logistic regression was used to test the variables’ predictive power in evaluating the risk of emergency admission for each sub-cohort. Performance of the resulting model was then tested by considering some relevant statistical measures, such as sensitivity and positive predicted value.Results: The modelling process identified a number of risk factors which improved the predictive power of the SPARRA algorithm. Some of these variables are relevant to each sub-cohort, some to only one or two. Widening of the cohort has meant that more than 95% of patients experiencing an emergency hospital admission within the year are captured. The remaining 5% that do not appear in the SPARRA cohort are largely unpredictable admissions, for example, trauma and orthopaedics patients. When we compared the performance of SPARRA against the Devon Prediction Model (a combined model based on a systematic review of around 26 models) at thresholds 50%, SPARRA performed better and reported a positive predicted value of 59.8% compared to Devon’s 54.6%.SPARRA also reported a sensitivity of 10.5% while Devon reported 8.4%. SPARRA risk scores can range from 1 to 99%; patients with a score of 40+% are generally regarded to be at increased risk.Highlights: SPARRA plays a key role in the shift to preventative, anticipatory approaches to healthcare, as a case finding tool and as a service planning tool. Details of patients at risk of emergency admission are distributed to the relevant NHS Health Boards, Health & Social Care Partnerships, GP Practices and other health agencies. This allows anticipatory interventions at the individual patient level and, at a higher level, assists in service planning. For example, SPARRA data can define lists of polypharmacy patients that GPs and pharmacists can use to select the individuals most in need of a medicine review.Conclusion: SPARRA has proven very effective both as a case finding tool and as a service planning tool. For SPARRA to fully support health and social care integration, the linked datasets used in SPARRA will be widened to include data from GP systems, out-of-hours, NHS 24, care home and social care.

Considering social enterprise involvement in the commissioning of health services in Shetland

Social enterprises are increasingly becoming involved in the commissioning of health services as the National Health Service in Scotland seeks more efficient and effective ways to care for an ageing population in a period of austerity. This development is of particular importance in rural areas where health services are being disproportionately affected due to funding cuts and health outcomes are suffering as a result. A geographic area of interest in terms of the inclusion of social enterprise in health strategies is Shetland. As a remote island group, different solutions to the provision of health services are required due to often inaccessible, ill-equipped and expensive statutory services. A history of available funding and ample volunteers has created a strong third sector that is able and willing to provide health services and which is increasingly adopting trading practices to ensure sustainability as non-traded income becomes scarcer. This research investigated the role currently played by social enterprises in the co-governance and co-management of health services in Shetland, what factors influence that involvement and how successful the commissioning process is seen to be. The findings shed light on the current role that social enterprises play in designing, delivering and managing health services in Shetland with implications for other rural and remote communities in Scotland.

The mutuality metaphor: understanding healthcare provision in NHS Scotland.

Purpose - Better Health, Better Care Action Plan (Scottish Government, 2007) sets out how the Scottish Government intends to strengthen public ownership of the National Health Service in Scotland. The purpose of this paper is to advance extant knowledge by understanding how a state-led mutual health policy may be interpreted, and importantly, communicated. Design/methodology/approach - The definitional problem of mutuality will be discussed and analysed in terms of how it is (or perhaps should be) communicated? will be offered. Findings - It actually may be more instructive to think of, and communicate, mutuality as a metaphor to aid understanding of the openness and fluidity found in NHS Scotland. Research limitations/implications - The existence of paradox and ambiguity does not, however, negate the usefulness of the term "mutuality". Quite the opposite in fact: it is precisely by examining healthcare and its delivery through the lens of mutuality (rather than rejecting its complexity as a failure) that this amorphousness can be better appreciated. Practical implications - There is a need for more public, professional, and academic debate to explore and clarify its implementation, and how it is to be led. This must be provided whilst recognising the daily imperatives that NHS leaders must face. This would suggest, therefore, that a dual development path may help. Originality/value - Although Better Health, Better Care Action Plan was published in 2007, some eight years on there is still confusion and misunderstanding as to what mutuality in healthcare is, not only in policy and theory, but also in practice. It is hoped that this analysis will help address, in part, some of this confusion and misunderstanding.

Cost Effectiveness of Sucroferric Oxyhydroxide Compared with Sevelamer Carbonate in the Treatment of Hyperphosphataemia in Patients Receiving Dialysis, from the Perspective of the National Health Service in Scotland.

BackgroundHyperphosphataemia is common and harmful in patients receiving dialysis. Treatment options include noncalcium-based phosphate binders such as sevelamer carbonate (SC) and sucroferric oxyhydroxide (PA21).ObjectiveThe aim of this study was to determine the health economic impact of PA21-based strategies compared with SC-based strategies, from the perspective of the Scottish National Health Service (NHS).MethodsA Markov model was constructed based on data from a randomised clinical trial comparing PA21 and SC. Model input parameters were derived from published literature, national statistics and unpublished sources. Costs (price year 2012) and effects were discounted at 3.5 %. Analysis with a lifelong time horizon yielded the incremental cost-effectiveness ratio (ICER), expressed as cost or savings per quality-adjusted life-year (QALY) gained or forgone. Deterministic and probabilistic sensitivity analysis was performed to explore uncertainties around assumptions and model input parameters.ResultsIn the base-case analysis, phosphorus reductions for PA21 and SC were 1.93 and 1.95 mg/dL. Average undiscounted survival was estimated to be 7.61 years per patient in both strategies. PA21 patients accrued less QALYs (2.826) than SC patients (2.835), partially due to differential occurrence of side effects. Total costs were ₤13,119 and ₤14,728 for PA21 and SC, respectively (difference per patient of ₤1609). By using PA21 versus SC, one would save ₤174,999 (or ₤123,463 when including dialysis and transplantation costs) for one QALY forgone. A scenario modelling the nonsignificant reduction in mortality (relative risk 0.714) observed in the trial yielded an ICER for PA21 of ₤22,621 per QALY gained. In probabilistic sensitivity analysis of the base-case, PA21 was dominant in 11 %, and at least cost-effective in 53 %, of iterations, using a threshold of ₤20,000 per QALY gained.ConclusionsThe use of PA21 versus SC in hyperphosphataemic patients being intolerant of calcium-based phosphate binders may be cost saving and yields only very limited disadvantages in terms of quality-adjusted survival. PA21 appears to be cost-effective from the perspective of the Scottish NHS.

Developing clinical skills bundles.

This article describes an innovative method of learning clinical skills. A care bundle is defined as a small set of evidence-based interventions that, when implemented together, results in significantly better patient outcomes than when implemented individually. Care bundles improve the consistency of standards of care delivered, and hence reduce harm. In 2007 The Scottish Clinical Skills Strategy identified the use of simulation-based education to ensure all health care staff can deliver a consistently high standard of clinical skills practice throughout the National Health Service in Scotland (NHS Scotland). Clinical skills bundles were developed to underpin a number of evidence-based care bundles. Grouping the clinical skills together and learning them as a clinical skills bundle may improve the reliability of skills delivery for each care bundle. Three groups were recruited and asked to identify a consensus of the essential technical and non-technical skills for clinical skills bundle for a central venous catheter (CVC) maintenance care bundle. As a pilot, six clinical skills bundle workshops were held for junior doctors, nursing and medical students, and clinical skills educators. The aims of the workshops were to introduce the concepts of clinical skills bundles and to give participants a chance to practice the underpinning clinical skills bundle for a care bundle using simulation. The majority of participants rated the workshop as excellent or good. Self-reported learning included refreshing their clinical skills in a different context. Care bundles improve the consistency of standards of care delivered Learning skills together as a bundle may enhance the reliability of clinical skills performance for care bundles, and may also reinforce the use of care bundles.

A population-based survey of barriers and enablers to physical activity in people using, and working in a mental health service in Scotland

Research into physical activity in people who experience mental disorders has tended to focus on those who have agreed to participate in exercise programmes. For effective health promotion across this population, it is important to understand the barriers and enablers to increasing physical activity in all of those who use mental health services. Qualitative and quantitative data were collected from consecutive service users and all staff in a General Adult Mental Health Service in Scotland. Thematic analysis was undertaken. A total of 127 service users and 186 staff participated. Data saturation was achieved. Staff and service users identified different barriers and enablers towards increasing physical activity rates. Different themes were identified in our population compared with those researched in other studies who had agreed to participate in exercise programmes. Our findings suggest there is a role for education, activity scheduling, motivational interviewing, social skills training and cognitive-b...

Services for children with developmental co-ordination disorder: an evaluation against best practice principles

Purpose: The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD); however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. Methods: A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N = 13 interview participants, N = 24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. Results: Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children’s participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. Conclusion: Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children’s participation.Implications for RehabilitationThere are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD).It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child.Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.

Transition from paediatric to adult health services in Scotland for young people with cerebral palsy.

Transition from paediatric to adult health-care services has been characterized as being poorly planned and coordinated, resulting in a reduction in services and may be distressing for families. This study aimed to establish what provisions are currently available in Scotland for transition of young people with cerebral palsy and what some clinicians believe future provisions should involve. Semi-structured interviews were conducted with 13 community paediatricians (or equivalents in health boards without community paediatricians) from 12 different Scottish health boards. Interviews were audio recorded, transcribed and analysed thematically using framework analysis. Both current transition provision and the areas that the clinicians felt needed improvement varied greatly between health boards. Key areas in need of improvement were coordination and communication within health services and also between health services and educational, social services and adult health services to which young people were transitioning. Transition remains problematic and variable. For transition to be improved, further research is needed to explore the effect this variation is having on young people and their families.

‘I think that Polish doctors are better’: Newly arrived migrant children and their parents׳ experiences and views of health services in Scotland

Understanding users׳ perceptions and expectations of health care provision is key to informing practice, policy and health-related measures. In this paper, we present findings from a qualitative study conducted with recently migrated Eastern European children and their parents, reporting on their experiences of accessing health services post-migration. Unlike the case of adults, the experiences of newly migrated children have rarely been explored in relation to health services. We pay particular attention to three key areas: (1) migrant families׳ views of health service provision; (2) barriers to health service use; and (3) transnational use of health services. By using a social capital approach, we show how concerns about the Scottish health care practices enacted by migrant parents are adopted by children and are likely to impact on families׳ health beliefs and behaviours. The study highlights the important role of migrants׳ active participation as users of health services. We conclude that appropriate health services need to consider more carefully migrants׳ expectations and complex health care activities, in order to be fully inclusive and patient-centred.

A mutual health service in Scotland

Purpose– The purpose of this paper is to explore the leadership implications of a mutual health service in National Health Service (NHS) Scotland.Design/methodology/approach– Analysis of extant government policy and suggestions of leadership considerations for practice.Findings– Moving towards a mutual health system will require new ways of thinking about health care and existing leadership practices in NHS Scotland. The leadership implications at the strategic, operational and tactical levels of delivery in NHS Scotland will need to be thought through. At present, it is not clear how this will be done, either from the available health-related literature or from policy. “Mutuality” will require a complex and multi-layered effort to embed it within the culture of the organisation, which will require inspirational leadership and sustained management from the government, the NHS and the wider public to make the change happen.Research limitations/implications– This paper suggests that more leadership research is still required to understand fully – and implement – a mutual health service in Scotland. A theoretical framework and/or empirical reference points have yet to be developed.Practical implications– This paper highlights the practical implications in operationalising government policy.Originality/value– Little – if any – has been written about the leadership implications of a mutual and public health service.

Independence and oral health: implications of the Scottish referendum.

On 18 September 2014, a referendum will be held on Scotland becoming a nation independent from the rest of the United Kingdom. Since devolution in 1999 child dental health in Scotland has improved significantly, although the National Health Service in Scotland has always been governed through a separate legislative framework from that in England and Wales. Scotland was also first to introduce a ban on smoking in public places and is pursuing minimum alcohol pricing to directly improve public health. This article explores if a vote for an independent Scotland would influence either dental and/or general health.

Fifty years ago: 'The first group occupational health service in Scotland'. 1964.

Fifty years ago: 'The first group occupational health service in Scotland'. 1964.

Perceived need and barriers to continuing professional development among doctors

There is growing need for continuing professional development (CPD) among doctors, especially following the recent introduction of compulsory revalidation for all doctors in the United Kingdom (UK).We use unique datasets from two national surveys of non-training grade doctors working in the National Health Service in Scotland to evaluate doctors’ perceptions of need and barriers to CPD. We test for differences over time and also examine differences between doctor grades and for other characteristics such as gender, age, contract type and specialty.Doctors expressed the greatest need for CPD in clinical training, management, and information technology. In terms of perceived barriers to CPD, lack of time was expressed as a barrier by the largest proportion of doctors, as was insufficient clinical cover, lack of funding, and remoteness from main education centres. The strength of perceived need for particular CPD activities and the perceived barriers to CPD varied significantly by doctors’ job and personal characteristics.An understanding of the perceived needs and barriers to CPD among doctors is an important precursor to developing effective educational and training programmes that cover their professional practice and also in supporting doctors towards successful revalidation.

Victory for volunteerism? Scottish health board elections and participation in the welfare state

This paper presents findings from a multimethod study of pilot elections held to choose members of health boards in the National Health Service in Scotland. We begin by proposing that much current public involvement practice is dominated by a volunteerist model, in which members of the public with time and skills to offer play essentially supportive and non-challenging roles within health care organizations. This model contrasts sharply with the adversarial, political model of electoral democracy. Nonetheless, drawing on a postal survey of voters, non-participant observation of Boards, and semi-structured interviews with candidates, elected Board members and other stakeholders, we demonstrate that the introduction of elections did not overcome the volunteerist slant of current public involvement with health care organizations. Far from offering a ‘quick fix’ for policymakers seeking to ensure accountability of health care organizations, elections may produce remarkably similar outcomes to existing mechanisms of public involvement.

Mixing medication into foodstuffs: Identifying the issues for paediatric nurses

Medication is often mixed into soft foods to aid swallowing in children. However, this can alter the physical/chemical properties of the active drug. This study reports on the prevalence of the modification procedure, the nature of foodstuffs routinely used and factors which influence how the procedure is performed by nurses working in the National Health Service in Scotland. Mixed methods were employed encompassing an online self-administered questionnaire and semi-structured interviews. One hundred and eleven nurses participated, of whom 87% had modified medication prior to administration. Fruit juice (diluted and concentrated) and yoghurts were most commonly used. The interviews (i) identified the limitations of the procedure; (ii) explored the decision-making process; and (iii) confirmed the procedure was a last resort. This study intends to address some of the uncertainty surrounding the medicine modification procedure within the paediatric population.

Question of identity

What does it mean to be a healthcare chaplain? The recent introduction of the chaplaincy guidelines has taken chaplains into the heart of the healthcare system and ensured that the National Health Service in Scotland has to think about and perhaps re-think the role of chaplaincy and its place within the system of healthcare delivery within Scotland. This presents a challenge not only to the National Health Service but also to chaplaincy. Chaplains will be called to account for who they are and what they do in a way that they have not previously had to. The question of the professional identity of the chaplain is thus crucial. This paper reflects critically on the identity of chaplaincy as a healthcare discipline and offers some reflective comments on the pros and cons of what it might mean for chaplains to develop an identity as “healthcare professionals.”