Healthcare Organisations In England Research Articles

The use of locum doctors in the NHS: understanding and improving the quality and safety of care.

The use of locum doctors in the National Health Service is widely believed to have increased, and there have been widespread and sustained concerns among policy-makers, healthcare providers, professional associations and professional regulators about the quality/safety, cost and effective use of locum doctors. To provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English National Health Service, to support policy and practice. Four interlinked work packages involving surveys of National Health Service trusts and of general practices in England; semistructured interviews and focus groups across 11 healthcare organisations in England; analysis of existing routine data sets on the medical workforce in primary care and in National Health Service trusts in England from National Health Service Digital and National Health Service Improvement; and analysis of data from the Clinical Practice Research Datalink in primary care and of electronic patient record data from two National Health Service hospitals in secondary care. In primary care, about 6% of general practice medical consultations were undertaken by locums in 2010 and this had risen slightly to about 7.1% in 2021. In National Health Service trusts (mostly secondary care and mental health), about 4.4% of medical staff full-time equivalent was provided by locum doctors. But those overall national rates of locum use hide a great deal of variation. In primary care, we found the National Health Service Digital workforce returns showed the rate of locum use by Clinical Commissioning Group varied from 1% to almost 31%. Among National Health Service trusts, the reported rate of locum use varied from < 1% to almost 16%. We found that there was poor awareness of and adherence to national guidance on locum working arrangements produced by National Health Service England. Our research showed that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. Our research was hampered in some respects by the COVID pandemic which both resulted in some delays and other challenges. Our efforts to use electronic patient record data in secondary care to explore locum doctor working were stymied by the problems of data access and quality. Locum doctors are a key component of the medical workforce in the National Health Service, and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found that patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information.

How can healthcare organisations improve the social determinants of health for their local communities? Findings from realist-informed case studies among secondary healthcare organisations in England

ObjectivesIncreasingly, healthcare and public health strategists invite us to look at healthcare organisations as not just care providers but as anchor institutions (ie, large community-rooted organisations with significant impact in...

The Evolution of External Healthcare Regulation in England; From Performance Oversight to Supporting Improvement Comment on "The Special Measures for Quality and Challenged Provider Regimes in the English NHS: A Rapid Evaluation of a National Improvement Initiative for Failing Healthcare Organisations".

The Special Measures and Challenged Provider (SMCP) Regime introduced for struggling healthcare organisations in England represents a subtle shift to the scope of external regulation from performance oversight to include supporting internal service improvement. External regulation alone has a had a mixed impact on the quality of care and Vindrola-Padros and colleagues' study highlights that externally driven improvement initiatives may also struggle to succeed in turning around performance. Principally, this is due to a failure in acknowledgment that poor performance results from a myriad of external and internal factors which coalesce to impede organisational performance. A struggling organisation may be indicative of wider issues in the local health and care system. Whole systems approaches to improvement with collaboration across providers and the effective use of data may support struggling organisations but their role maybe tempered with the increased centralisation of the delivery of improvement regimes such as SMCP.

Uptake of advanced clinical practice roles in the health service in England: Perspectives at the micro level

Health care organisations in many countries are developing advanced clinical practitioner roles to address workforce shortages and growing demand for services. Even in countries where advanced practice roles are more established there are low numbers, clustered in a limited range of professions, mostly nursing specialities. Successful implementation of national policies encouraging increased advanced practice roles and from a broader range of professions, requires attention to all levels of the health system. There is a lack of evidence as to the motivation to take-up these roles at the micro, individual actor level. This study explored the motivations important at the micro level in influencing a range of health professionals to undertake advanced practice roles. The study used an interpretive methodology with thematic analysis and was framed by theories of motivational domains in the work environment. Semi-structured interviews were undertaken with eighteen advanced clinical practitioners working in health care organisations in England. The motivators for role take-up were found to be predominantly intrinsic reflecting participants’ desires for advancement, both personal and for their profession, and improved efficiency of patient care. Participants described experiencing limited organisational support and sometimes discouragement from other professionals. There is potential for health organisations at the meso level of health care systems to support national growth of advanced practice roles by giving attention to the motivations of diverse health professionals. We propose a new theoretical framework of motivators for advanced clinical practice role uptake at the micro level.

Drug company payments to General Practices in England: Cross-sectional and social network analysis.

Although there has been extensive research on pharmaceutical industry payments to healthcare professionals, healthcare organisations with key roles in health systems have received little attention. We seek to contribute to addressing this gap in research by examining drug company payments to General Practices in England in 2015. We combine a publicly available payments database managed by the pharmaceutical industry with datasets covering key practice characteristics. We find that practices were an important target of company payments, receiving £2,726,018, equivalent to 6.5% of the value of payments to all healthcare organisations in England. Payments to practices were highly concentrated and specific companies were also highly dominant. The top 10 donors and the top 10 recipients amassed 87.9% and 13.6% of the value of payments, respectively. Practices with more patients, a greater proportion of elderly patients, and those in more affluent areas received significantly more payments on average. However, the patterns of payments were similar across England's regions. We also found that company networks-established by making payments to the same practices-were largely dominated by a single company, which was also by far the biggest donor. Greater policy attention is required to the risk of financial dependency and conflicts of interests that might arise from payments to practices and to organisational conflicts of interests more broadly. Our research also demonstrates that the comprehensiveness and quality of payment data disclosed via industry self-regulatory arrangements needs improvement. More interconnectivity between payment data and other datasets is needed to capture company marketing strategies systematically.

How widely has ANTT been adopted in NHS hospitals and community care organisations in England and Scotland?

To the detriment of patient safety, the important clinical competency of aseptic technique has been notoriously variable in practice, and described ambiguously in the literature, internationally. From a UK perspective, attempts have been made to improve patient safety by reducing variability and improving education and practice through standardisation. The Welsh Government mandated Aseptic Non Touch Technique (ANTT®) as a specific national standard in 2015. All healthcare organisations in England are required by the Health and Social Care Act 2008 to have a single standard aseptic technique, demonstrable by the clinical governance indicators of education, training, competency assessment and compliance audit. In Scotland, an education-based initiative was launched by NHS Education for Scotland in 2012. To review the impact of these and other initiatives on the current status of aseptic technique, all NHS trusts in England and NHS health boards in Scotland were assessed under the Freedom of Information procedure. 93% of NHS trusts in England use a single standard for aseptic technique. In 88% of these trusts the single standard was stipulated as being ANTT. In Scotland, 62% of NHS acute and community care hospitals within health boards use a single standard. In 56% of these, the single standard was ANTT. When including those that use ANTT in combination with other techniques ANTT usage is 73%. These data demonstrate significant progress in standardising aseptic technique education, assessment and governance, and confirms ANTT as the de facto aseptic technique used in NHS trusts in England and health boards in Scotland.

Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England

BackgroundUntil recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work. ObjectiveTo explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England. DesignThematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England. ResultsRevalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role – to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance. ConclusionRevalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.

A mixed methods analysis of lithium-related patient safety incidents in primary care.

Background:Lithium is a drug with a narrow therapeutic range and has been associated with a number of serious adverse effects. This study aimed to characterise primary care lithium-related patient safety incidents submitted to the National Reporting and Learning System (NRLS) database with respect to incident origin, type, contributory factors and outcome. The intention was to identify ways to minimise risk to future patients by examining incidents with a range of harm outcomes.Methods:A mixed methods analysis of patient safety incident reports related to lithium was conducted. Data from healthcare organisations in England and Wales were extracted from the NRLS database. An exploratory descriptive analysis was undertaken to characterise the most frequent incident types, the associated chain of events and other contributory factors.Results:A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded. Community pharmacies reported 100 incidents (96 dispensing related, two administration, two other), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. A total of 99 dispensing-related incidents were recorded, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging (n = 41), and ‘mistakes’ (n = 22), whereas no information regarding contributory factors was provided in 41 reports.Conclusion:Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly described contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce the risk of incidents and improve patient safety.

Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts.

Background: Healthcare organisations in England rated as inadequate in terms of leadership and one other domain enter the Special Measures for Quality (SMQ) regime to receive increased support and oversight. There is also a ‘watch list’ of challenged National Health Service (NHS) providers at risk of going into SMQ that receive support. There is limited knowledge about whether the interventions used to deliver this support drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. The study will seek to determine how provider organisations respond to these interventions, and whether and how these interventions impact organisations’ capacity to achieve and sustain quality improvements over time. Methods: This is a multi-site, mixed methods study. We will carry out interviews at national level to understand the programme theory underpinning the interventions. We will conduct 8 NHS case studies to explore the impact and implementation of the interventions that form part of the SMQ and challenged providers programme. We will use a conceptual framework based on models of organisational readiness for change and draw on board maturity research for implementing quality improvement. We will also review the use of quantitative metrics and data for tracking the progress of improvements in quality of care and sustainability upon leaving SMQ, as well as the costs and benefits of the interventions through a cost-consequence analysis (CCA). Discussion: High-quality interventions that successfully support struggling healthcare organisations are essential and an issue that is an international concern. Our study will allow a greater understanding of the programme theory, impact, and staff views and experiences of the SMQ and challenged providers regime. Formative feedback will be reported to key stakeholders.

Non-medical practitioner roles in the UK: who, where, and what factors influence their development?

traditional health workforce roles are changing, with existing roles being extended and advanced, while new roles are being created, often undertaking duties previously completed by doctors, sometimes referred to as non-medical practitioners (NMPs). to investigate which NMP roles exist within the UK, mapping distribution, and explore factors influencing their development and recruitment. two descriptive, exploratory, online self-completed semi-structured questionnaires were used. One was sent to all NHS acute healthcare providers (n=156) and private/independent healthcare providers in England (n=90). A separate questionnaire collected data, using convenience and snowballing approaches, from NMPs across the UK. Quantitative data were analysed using descriptive and frequency statistics. Qualitative data derived from open questions and comments were analysed using content and thematic analysis. healthcare organisations in England returned 23/246 useable questionnaires; 115 NMPs returned responses, 19 did not meet the criteria, leaving 96 useable responses. seven NMP roles were identified, throughout the UK, with regional variation. Several factors influence the development and recruitment of NMP roles in England such as service delivery and national policies. Inconsistencies were noted in Agenda for Change pay banding. Many practitioners undertook NMP roles to progress their career clinically.

Antimicrobial Stewardship Programmes in Community Healthcare Organisations in England: A Cross-Sectional Survey to Assess Implementation of Programmes and National Toolkits.

Objective: The aim of this study was to assess antimicrobial stewardship activities in Community Healthcare Organisations (CHOs) with focus on the implementation of the two national antimicrobial stewardship toolkits, TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) and SSTF (Start Smart, then Focus). The study utilised a web-based survey comprising 34 questions concerning antimicrobial policies and awareness and implementation of antimicrobial stewardship toolkits. This was distributed to pharmacy teams in all 26 CHOs in England. Twenty CHOs (77%) responded. An antimicrobial stewardship (AMS) committee was active in 50% of CHOs; 25% employed a substantive pharmacist post and 70% had a local antibiotic policy. Fourteen of the responding CHOs were aware of both AMS toolkits, five organisations were aware of either SSTF or TARGET, and one organisation was not aware of either toolkit. Of the organisations aware of SSTF and TARGET, eight had formally reviewed both toolkits, though three had not reviewed either. Less than half of the respondents had developed local action plans for either toolkit. National guidance in England has focused attention on initiatives to improve AMS implementation in primary and secondary care; more work is required to embed AMS activities and the implementation of national AMS toolkit recommendations within CHOs.

How do NHS organisations plan research capacity development? Strategies, strengths, and opportunities for improvement

Research that is integral into a ‘learning healthcare system’ can promote cost effective services and knowledge creation. As such, research is defined as a ‘core function’ in UK health service organisations, and is often planned through research and development (R&D) strategies that aim to promote research activity and research capacity development (RCD).The discussion focuses around the content of ten R&D strategies for healthcare organisations in England and Scotland, with respect to RCD. These organisations were engaged with a research interest network called ACORN (Addressing Organisational Capacity to do Research Network) that included two Scottish Health Boards, four community and mental health trusts, two provincial district hospitals, and two teaching hospitals.We undertook a thematic documentary analysis of the R&D strategies which identified 11 ‘core activities’ of RCD. The potential for building research capacity in these ‘core activities’ was established by reviewing them through the lens of a RCD framework.Core activities aimed to ‘hard wire’ RCD into health organisations. They demonstrated a complex interplay between developing a strong internal organisational infrastructure, and supporting individual career planning and skills development, in turn enabled by organisational processes. They also included activities to build stronger inter-organisational relationships and networks. Practitioner, manager and patient involvement was a cross cutting theme. The potential to demonstrate progress was included in plans through monitoring activity across all RCD principles. Strategies were primarily aimed at research production rather than research use. Developing ‘actionable dissemination’ was poorly addressed in the strategies, and represents an area for improvement.We describe strengths of RCD planning activities, and opportunities for improvement. We explore how national policy and research funders can influence health systems’ engagement in research.

A whole health economy approach to reducing MRSA bacteraemia incidence in diabetic foot ulcer patients.

Ulceration of the foot is a common problem among diabetic patients. Infection is a major risk in diabetic foot ulcers (DFU) and many of these are caused by Staphylococcus aureus, in particular meticillin-resistant strains (MRSA). The control and management of MRSA remains a significant challenge and all healthcare organisations in England are required to meet Zero Tolerance Objectives for cases of MRSA bacteraemia (MRSAB). This paper describes a collaborative approach across the health economy to investigate factors contributing to the acquisition of MRSA and MRSAB among DFU patients and make improvements to care to reduce the risk of healthcare-associated infections. A collaborative approach between acute and community healthcare providers and commissioners was used to conduct Root Cause Analysis and drive improvement to prevent MRSA transmission in DFU patients. Screening of all DFU patients was initiated after 6 MRSAB were found to be associated with in DFU. In total 15 patients with the same MRSA antibiogram were identified. Following the implementation of actions focused on isolation, wound management, screening and cleaning no further cases were identified. This outbreak has demonstrated the value of cross-sector collaboration in investigating HCAI in patients with DFU, improving patient care and reducing the risk of MRSA transmission in these vulnerable patents.

From Scanning to Keeping Knowledgeable: A Practice Based View of the Information Behavior of CEOs

In this paper, we outline a practice-based understanding of the information behaviour of chief executives running large healthcare organisations in England. Building on an in-depth, longitudinal et...

An evaluation of staff engagement programmes in four National Health Service Acute Trusts

The purpose of this paper is to report the findings from an evaluation project conducted to investigate the impact of two staff engagement programmes introduced to four National Health Service (NHS) hospital Trusts in England. It seeks to examine this development in the context of current policy initiatives aimed at increasing the level of staff involvement in decision-making, and the related literature. A mixed-methods approach incorporating document analysis, interviews, a survey and appreciative inquiry, informed by the principles of impact evaluation design, was used. The main finding to emerge was that leadership was crucial if widespread staff engagement was to be achieved. Indeed, in some of the trusts the staff engagement programmes were seen as mechanisms for developing leadership capability. The programmes had greater impact when they were "championed" by the Chief Executive. Effective communication throughout the organisations was reported to be a prerequisite for staff engagement. Problems were identified at the level of middle management where the lack of confidence in engaging with staff was a barrier to implementation. The nature of the particular organisational context is crucial to the success of efforts to increase levels of staff engagement. The measures that were found to work in the trusts would need to be adapted and applied to best meet the needs of other organisations. Many health care organisations in England will need to harness the efforts of their workforce if they are to meet the significant challenges of dealing with financial restraint and increasing patient demand. This paper provides some insights on how this can be done.

Efficiency and productivity change in the English National Health Service: can data envelopment analysis provide a robust and useful measure?

Several tools are available to health care organisations in England to measure efficiency, but these are widely reported to be unpopular and unusable. Moreover, they do not have a sound conceptual basis. This paper describes the development and evaluation of a user-friendly tool that organisations can use to measure their efficiency, based on the technique of data envelopment analysis (DEA), which has a firm basis in economic theory. Routine data from 57 providers and 14 purchasing organisations in one region of the English National Health Service (NHS) for 1994-1996 were used to create information on efficiency based on DEA. This was presented to them using guides that explained the information and how it was to be used. They were surveyed to elicit their views on current measures of efficiency and on the potential use of the DEA-based information. The DEA measure demonstrated considerable scope for improvements in health service efficiency. There was a very small improvement over time with larger changes in some hospitals than others. Overall, 80% of those surveyed gave high scores for the potential usefulness of the DEA-based measures compared with 9-45% for existing methods. The quality of presentation of the information was also consistently high. There is dissatisfaction with efficiency information currently available to the NHS. DEA produces potentially useful information, which is easy to use and can be easily explained to and understood by potential users. The next step would be the implementation, on a developmental basis, of a routine DEA-based information system.