Local Health Economies Research Articles

Evaluation of the North West London Diabetes Foot Care Transformation Project: A Mixed-Methods Evaluation.

Introduction:Diabetes foot ulceration (DFU) presents an enormous burden to those living with diabetes and to the local health systems and economies. There is an increasing interest in implementing integrated care models to enhance the quality of care for people living with diabetes and related complications and the value of co-production approaches to achieve sustainable change. This paper aims to describe the evaluation methodology for the North West London (NWL) Diabetes Foot Care Transformation project.Description:A mixed methods design including: i) a quasi-experimental quantitative analysis assessing the impact of the implementation of the local secondary care multi-disciplinary diabetes foot team clinics on service utilisation and clinical outcomes (amputations and number of healed patients); ii) a phenomenological, qualitative study to explore patient and staff experience; and iii) a within-trial cost-effectiveness analysis (pre and post 2017) to evaluate the programme cost-effectiveness.Discussion and Conclusion:Demonstrating the impact of multidisciplinary, integrated care models and the value of co-production approaches is important for health providers and commissioners trying to improve health outcome. Evaluation is also needed to identify strategies to overcome barriers which might have reduced the impact of the programme and key elements for improvement.

Incidence and Death Rates from COVID-19 Are Not Always Coupled: An Analysis of Temporal Data on Local, Federal, and National Levels.

SARS-CoV-2 has caused a deadly pandemic worldwide, placing a burden on local health care systems and economies. Infection rates with SARS-CoV-2 and the related mortality of COVID-19 are not equal among countries or even neighboring regions. Based on data from official German health authorities since the beginning of the pandemic, we developed a case-fatality prediction model that correctly predicts COVID-19-related death rates based on local geographical developments of infection rates in Germany, Bavaria, and a local community district city within Upper Bavaria. Our data point towards the proposal that local individual infection thresholds, when reached, could lead to increasing mortality. Restrictive measures to minimize the spread of the virus could be applied locally based on the risk of reaching the individual threshold. Being able to predict the necessity for increasing hospitalization of COVID-19 patients could help local health care authorities to prepare for increasing patient numbers.

Beyond SARS-CoV-19: Understanding the Implications of National Pandemic Policies on Local Health Care Systems

Overall aim of the paper: use what we have learnt from SARS-CoV-19 pandemic and make policy recommendations that would aid policy decisions during any future pandemics. We have evidence of the various policy interventions and the manifested local healthcare implications (admissions/occupancy/deaths etc.) to suggest that local variation is significant enough to warrant local interventions in future pandemics. We have modelled the implications of national pandemic policy on local health economies and suggest that nationally coordinated approaches do not attain their policy objective of reducing infections. Therefore, we suggest local policy approaches to enable relevant positive progress on containment by protecting the vulnerable and increasing shielding measures which data modelling suggests has the most positive impact on population health and reducing SARS-CoV-19 mortality rates whilst, at the same time, reducing the economic impact of national, often less relevant, pandemic policies.

Reducing infections

A revised infection prevention and control commissioning toolkit has been launched by the RCN and the Infection Prevention Society. The toolkit provides information to support commissioners in developing infection prevention and control strategies that can be delivered by local health economies to reduce infection, and manage the risks associated with antimicrobial resistance. It also includes a series of optional indicators to support performance management and assurance against provider contracts, and an example of a healthcare-associated infection reduction plan that commissioners can adapt for local use. For information go to tinyurl.com/z645bho

Perspectives on the policy ‘black box’: a comparative case study of orthopaedics services in England

There has been much recent debate on the impact of competition on the English National Health Service (NHS). However, studies have tended to view competition in isolation and are controversial. This study examines the impact of programme theories associated with the health system reforms, which sought to move from a dominant target-led 'central control' programme theory, to one based on 'market forces', on orthopaedics across six case-study local health economies. It draws on a realistic evaluation approach to open up the policy 'black box' across different contexts using a mixed methods approach: analysis of 152 interviews with key informants and analysis of waiting times and admissions. We find that the urban health economies were more successful in reaching the access targets than the rural health economies, although the gap in performance closed over time. Most interviewees were aware of the policies to increase choice and competition, but their role appeared comparatively weak. Local commissioners' ability to influence demand appeared limited with providers' incentives dominating service delivery. Looking forward, it is clear that the role of competition in the NHS has to be considered alongside, rather than in isolation from, other policy mechanisms.

Divergence of NHS choice policy in the UK: what difference has patient choice policy in England made?

To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK. Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs). GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists. There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.

Provider Diversity in the English NHS: A Study of Recent Developments in Four Local Health Economies

To assess the impact of provider diversity on quality and innovation in the English NHS by mapping the extent of diverse provider activity and identifying the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organizations within the NHS, and the factors that affect the entry and growth of new providers. Case studies of four local health economies. Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and third sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Involvement of diverse providers in the NHS is limited. Commissioners' local strategies influence degrees of diversity. Barriers to entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS trusts to respond by making improvements. Information sharing diminishes as competition intensifies. There is scope to increase the participation of diverse providers in the NHS but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Managing cultural diversity in healthcare partnerships: the case of LIFT

The National Health Service (NHS) Local Improvement Finance Trust (LIFT) programme was launched in 2001 as an innovative public-private partnership to address the historical under-investment in local primary care facilities in England. The organisations from the public and private sector that comprise a local LIFT partnership each have their own distinctive norms of behaviour and acceptable working practices - ultimately different organisational cultures. The purpose of this article is to assess the role of organisational culture in facilitating (or impeding) LIFT partnerships and to contribute to an understanding of how cultural diversity in public-private partnerships is managed at the local level. The approach taken was qualitative case studies, with data gathering comprising interviews and a review of background documentation in three LIFT companies purposefully sampled to represent a range of background factors. Elite interviews were also conducted with senior policy makers responsible for implementing LIFT policy at the national level. Interpreting the data against a conceptual framework designed to assess approaches to managing strategic alliances, the authors identified a number of key differences in the values, working practices and cultures in public and private organisations that influenced the quality of joint working. On the whole, however, partners in the three LIFT companies appeared to be working well together, with neither side dominating the development of strategy. Differences in culture were being managed and accommodated as partnerships matured. As LIFT develops and becomes the primary source of investment for managing, developing and channelling funding into regenerating the primary care infrastructure, further longitudinal work might examine how ongoing partnerships are working, and how changes in the cultures of public and private partners impact upon wider relationships within local health economies and shape the delivery of patient care. To the authors' knowledge this is the first study of the role of culture in mediating LIFT partnerships and the findings add to the evidence on public-private partnerships in the NHS.

Quality Observatories: using information to create a culture of measurement for improvement

In June 2008 High Quality Care for All was published, a blueprint for the delivery of NHS services in the future with quality of care put firmly at the heart of the principles guiding the NHS. Measurement of quality was identified as a crucial aspect of achieving delivery, enabling clinical teams to focus on where they need to improve most, and monitor the effects of interventions and initiatives. To date, the South East Coast Quality Observatory has developed over 80 benchmarking tools, products and analyses which contribute to the goal of delivery high quality analysis in a way that can be understood and utilized effectively by all levels of staff in a variety of clinical and managerial settings to evidence and drive improvement and innovation across organizations and local health economies. Patient safety, as a fundamental aspect of high quality care, makes up a significant part of this output, focusing on key topic areas that can deliver the best, and safest, results for patients. The following sets out details of a selection of the patient safety areas that the Quality Observatory has focused on and describes the analysis undertaken and, crucially, the key outcomes linked to its publication and usage.

Action learning: a tool for the development of strategic skills for Nurse Consultants?

This paper will discuss the process of action learning and the outcomes of using action learning as a tool to achieve a more strategic function from Nurse Consultant posts. It is documented that one of the most challenging aspect of Nurse Consultant roles, in terms of leadership, is the strategic contribution they make at a senior corporate Trust level, often across organizations and local health economies. A facilitated action learning set was established in Brighton, England, to support the strategic leadership development of eight nurse consultant posts across two NHS Trusts. Benefits to patient care, with regard to patient pathways and cross-organizational working, have been evident outcomes associated with the nurse consultant posts involved in the action learning set. Commitment by organizational nurse leaders is essential to address the challenges facing nurse consultants to implement change at strategic levels. The use of facilitated action learning had been a successful tool in developing the strategic skills of Nurse Consultant posts within this setting. Action learning sets may be successfully applied to a range of senior nursing posts with a strategic remit and may assist post holders in achieving better outcomes pertinent to their roles.

‘A potential fifth column’: conflicts and struggles for control in the context of local NHS privatization

This article uses case study data to discuss how a new procurement policy (Local Improvement Finance Trust, or LIFT) in English primary care may affect general practitioners' control over their work. LIFT, a series of 51 public-private partnerships, will enable over the medium term a shift towards the corporate ownership of surgeries and the creation of polyclinics or 'onestop-shops'. In this article, I explore the struggles over work autonomy and control within these new LIFT structures, as expressed by clinicians and managers in meetings and in research interviews. More generally, I consider how the findings inform debates over the changing position of professionals within increasingly financialized 'local health economies'.

Moving specialist care into the community: An initial evaluation

To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England. The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients' views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction. New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals. Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.

Will Practice-Based Commissioning in the English NHS Resolve the Problems Experienced by GP Fundholding?

Labour's new approach to primary health care, based around the policy of practice-based commissioning, has considerable potential for learning from the general practitioner fundholding reforms put in place by the Conservative governments of the 1990s. However, practice-based commissioning seems to repeat many of the same problems as the earlier policy. Despite the increased scope for GPs to make a significant difference to the shape of local health economies because of the incentives and opportunities offered by payment by results and patient choice reforms, the potential problems of practice-based commissioning threaten the reform's viability and long-term success.

Managing risk and regulation within new local ‘health economies’: The case of NHS LIFT (Local Improvement Finance Trust)

This paper analyses NHS Local Improvement Finance Trust (LIFT), a relatively new policy that shifts UK primary care premises into corporate ownership. LIFT is a more radical version of the Private Finance Initiative (PFI), and may indicate the future direction of neoliberal welfare services. Like PFI, LIFT foregrounds issues of risk and regulation, enabling their reconceptualization. This echoes certain themes present in the sociology of risk, including the idea that the welfare state has created and amplified, rather than managed, risk. Under LIFT, risks are constructed as (a) primarily economic and (b) primarily from the point of view of the large commercial organizations involved. Evidence presented here depicts banks as risk averse, challenging assumptions that private firms display risk-taking behaviour. The prioritization of economic risks is shown to amplify social risks, and to produce threats to social regulation. These threats are amplified by unequal power relationships within these new ‘local health economies.’ It is argued that LIFT is undermining the NHS's social embeddedness in local areas, partly by threatening the position of general practitioners and other small business or community organizations. Ultimately, the model is likely to generate new social and economic risks currently obscured by official discourse around LIFT.

Room for manoeuvre?

Decentralisation has returned as a key theme in English health policy in recent years in policies such as Patient Choice and Foundation Trusts, among many others. The goal of these policies appears to be to stimulate self-sustaining incentives to continuous organisational reform and performance improvement through creating a pluralist model of local provision. However, the ability of local organisations to exercise autonomy and to deliver such performance is highly contingent upon their local context, not least in terms of existing patterns of dependencies. Explaining variation in local outcomes of national policies demands an understanding and explanation of local autonomy and its effect on performance which takes into account the role of the local 'health economy'--the local context within which organizations are embedded. It is this combination of vertical and horizontal autonomy which effectively determines the local room for manoeuvre in decision-making. The aim of the paper is to examine the local dimension of decentralisation policies. It draws from different strands of literature to discuss the room for manoeuvre of local organisations within local health economies in England with specific reference to Primary Care Trusts. It draws conclusions about the nature of decentralisation itself and the impact of such policies.

Implementing NICE guidelines: the difficulties

PurposeThis purpose of this study is to look at the availability of routine antenatal anti‐D prophylaxis (RAADP) in the maternity units within the North‐west Deanery, England five years after the publication of this technology appraisal guideline (no. 41) by the National Institute for Clinical Excellence (NICE).Design/methodology/approachAntenatal clinics of all the major 18 maternity hospitals were contacted about their existing practice on RAADP. Responses were obtained by facsimile and telephone.FindingsA total of 11 of the 18 units had implemented the practice between April 2003 and May 2007. Some had changed their practice from two doses to a single dose on the grounds of logistics. Cost appeared to be the most important reason in non‐user units. The practice is under consideration in two units.Practical implicationsThere may be difficulty in universal implementation of NICE guidelines despite the supporting evidence.Originality/valueThis study demonstrates the issue of difficulty of local health economies in supporting national guidelines.

‘Informal’ learning to support breastfeeding: local problems and opportunities

This study explored 'informal' learning opportunities in three health economies, both for National Health Service (NHS) staff and lay people wishing to promote and support breastfeeding and for new mothers wishing to breastfeed. The word 'informal' indicates local learning opportunities that are not part of recognized academic or professional training courses. Semi-structured telephone interviews were conducted with 31 key informants, including health visitors, midwives, infant feeding advisers, Sure Start personnel, voluntary organization representatives, Strategic Health Authority representatives, senior nurses and trainers. The results were analysed thematically. In each site, there were regular training events for NHS staff to acquire or update knowledge and skills. Training was provided by a small number of enthusiasts. Midwives and health visitors were the groups who attend most frequently, although many find it difficult to make time. Although many training events were multidisciplinary, few doctors appeared to attend. Individual staff also used additional learning opportunities, e.g. other courses, conferences, web-based learning, and training by voluntary organizations. Services offered to lay people by the NHS, Sure Start and voluntary organizations included parentcraft, antenatal and post-natal classes, breastfeeding support groups, 'baby cafés' and telephone counselling. Interviewees' organizations did not have a specific breastfeeding strategy, although action groups were trying to take the agenda forward. Local opportunities were over-dependent on individual champions working in relative isolation, and support is needed from local health economies for the facilitation of coordination and networking.

Lost in Translation: A Multi‐Level Case Study of the Metamorphosis of Meanings and Action in Public Sector Organizational Innovation

This paper explores the early implementation of an organizational innovation in the UK National Health Service (NHS) – Treatment Centres (TCs) – designed to dramatically reduce waiting lists for elective care. The paper draws on case studies of 8 TCs (each at varying stages of their development) and aims to explore how meanings about TCs are created and evolve, and how these meanings impact upon the development of the organizational innovation. Research on organizational meanings needs to take greater account of the fact that modern organizations like the NHS are complex multi‐level phenomena, comprising layers of interlacing networks. To understand the pace, direction and impact of organizational innovation and change we need to study the interconnections between meanings across different organizational levels. The data presented in this paper show how the apparently simple, relatively unformed, concept of a TC framed by central government is translated and transmuted by subsequent layers in the health service administration, and by players in local health economies, and, ultimately, in the TCs themselves, picking up new rationales, meanings and significance as it goes along. The developmental histories of TCs reveal a range of significant re‐workings of macro policy with the result that there is considerable diversity and variation between local TC schemes. The picture is of important disconnections between meanings, that in many ways mirror Weick's (1976) ’loosely coupled systems’. The emergent meanings and the direction of micro‐level development of TCs appear more strongly determined by interactions within the local TC environment, notably between what we identify as groups of ’idealists’, ’pragmatists’, ’opportunists’ and ’sceptics’ than by the framing (Goffman 1974) provided by macro and meso organizational levels. While this illustrates the limitations of top down and policy‐driven attempts at change, and highlights the crucial importance of the front‐line local ’micro‐systems’ (Donaldson and Mohr 2000) in the overall scheme of implementing organizational innovations, the space or headroom provided by frames at the macro and meso levels can enable local change, albeit at variable speed and with uncertain outcomes.

Is a target culture in health care always compatible with efficient use of resources? A cost-effectiveness analysis of an intervention to achieve thrombolysis targets

The UK government has attempted to improve the quality of health care in the National Health Service and minimize geographical variations in quality by imposing targets in certain areas of health care. The measures taken by local health economies to achieve these targets have not before been subjected to cost-effectiveness analysis. We have assessed the cost effectiveness of an intervention designed to achieve thrombolysis time targets. In the setting of a single district general hospital in England, we audited local pain-to-needle (PTN) and door-to-needle (DTN) times, before and after a pounds 208,000 (Euro 310,000, dollar 370,000) annual expenditure to improve performance against government targets. The intervention included the recruitment of additional nursing time in the Accident & Emergency Department and the use of a single bolus thrombolytic agent for all patients with ST elevation myocardial infarction. An economic evaluation was performed, based on the expected number of additional lives saved, extrapolated from a meta-analysis of previous thrombolysis trials. The intervention reduced mean DTN time from 37.6 +/- 5.9 minutes (mean +/- SEM) to 27.6 +/- 3.6 minutes (p = 0.06). The cost per life saved was pounds 3,423 +/- 850 (Euro 5,100,000, dollar 6,100,000), the cost per life year gained was pounds 222,184 (Euro 330,000, dollar 390,000) and the cost per quality-adjusted life year (QALY) gained was pounds 246,871 (Euro 370,000, dollar 440,000). Although moderately successful at improving performance against government targets, this intervention to promote rapid thrombolysis proved to be an inefficient use of health-care resources. Strict government targets in health care may not always lead to efficient targeting of resources.

To Prevent, React, and Rebuild: Health Research and the Prevention of Genocide

To develop an approach to the primary prevention of genocide, based on established public health-based violence prevention methods derived from a variety of high-risk settings. (1) Peer-reviewed literature in the fields of public health, violence/injury prevention, medicine, economics, sociology, psychology, history, and genocide studies, (2) demographic and health data bases made available by governments and international organizations, (3) reports on recent episodes of genocide published by international and nongovernmental organizations, (4) newspaper and journalistic accounts of recent and past genocides, (5) archival testimonies of genocide victims and perpetrators, and (6) court transcripts of international genocide prosecutions. The research was conducted as a medical-historical policy analysis synthesizing data within the following framework: (1) Assessment of current violence and injury prevention models for suitability in the prevention of extreme, population-wide violence, (2) analysis of morbidity and mortality data to quantify the impact of genocide on the health of populations, (3) making an inventory of the known societal risk factors for genocidal violence, (4) identification of the theorized, modifiable attitudinal risk factors for genocidal behavior within a population health model, and (5) assessment of existing projects targeting primary violence and injury prevention in high risk jurisdictions, for future adaptation within a structured, public health approach. Mortality rates due to genocidal violence are far in excess of other public health emergencies including malaria and HIV/AIDS. The immediate and long-range health consequences of genocide include the sequelae of infectious diseases, organ system failure, and psychiatric disorders, conferring an increased burden of disease on affected populations for multiple subsequent generations. The impact of genocide on local health economies is catastrophic, and the opportunity costs of diverting scarce global health dollars toward ameliorating genocide related outcomes are substantial. Structural risk factors for genocide within societies include: totalitarian government, exclusionary ideologies, armed conflict, economic hardship, and inaction of bystander nations. Proposed psychological risk factors for genocidal behavior include: moral exclusion, authority orientation, action in self-interest, desensitization, and compartmentalized thinking. Violence and injury prevention models, incorporating what is currently known about the societal and behavioral risk factors for genocide in high-risk populations, may be modified to address the primary prevention of catastrophic violence on a population-wide scale. A number of existent global peace building initiatives may serve as models for the design of future prevention initiatives in high-risk, pre-genocide jurisdictions. Our analysis suggests that genocide is one of the most pressing threats to the health of populations in the twenty-first century. Recent advances in the public health discipline of violence prevention provide a blueprint for approaches to primary genocide prevention based on epidemiological methods.