London Health Authority Research Articles

A Model for Mental Health Needs and Resourcing in Small Geographic Areas: A Multivariate Spatial Perspective

This paper considers how small area variations in a set of psychiatric referral outcomes in a London health authority of 750,000 people may inform health need assessment and health resourcing for mental illness based on true need. As well as adopting a multivariate perspective, the spatial interdependence of the outcomes is included in the modelling approach outlined. By contrast, existing studies on mental health need tend to focus on single outcomes, and may not include spatial dependence. The analysis relates to three hospital referral outcomes for psychiatric conditions, and to total community mental health referrals across sixty-seven electoral wards in East London.

GPs' views of discussions of prognosis in severe COPD.

Modern palliative care promotes open communication between doctor and patient, which includes access to information about prognosis. GPs play a major role in managing chronic obstructive pulmonary disease (COPD) patients in the final stages of illness. Their views of discussions of prognosis are therefore important if the principles of palliative care are to be extended to COPD. Our aim was to investigate the role that discussions of prognosis play in GPs' management of patients with severe COPD and the factors that influence those discussions. We conducted a questionnaire survey of all GP principals of one inner London Health Authority (n = 389) in April 1999. Questionnaire development involved a literature review to identify issues of importance to GPs in the discussion of prognosis in COPD, and in-depth interviews with five GPs. Of the 214 respondents (55% response), 72.5% thought that discussions of prognosis were often necessary or essential in severe COPD. The majority (82%) felt that GPs have an important role in these discussions. However, only a minority (41%) of GPs reported often or always discussing prognosis. Half the GPs were undecided as to whether most patients with COPD wanted to know about their prognosis. Among the GPs who reported rarely or never discussing prognosis (n = 33), a majority felt ill-prepared to discuss the subject (60% reported that there was insufficient information in the primary care notes to be able to discuss prognosis, and 64% found it hard to start discussions with patients). Although the majority of GPs acknowledged a need to discuss prognosis in severe COPD, this was not reflected in their reported behaviour. It appears that the palliative care approach of open communication, whilst seen to be relevant to severe COPD, is not applied routinely in managing the disease in primary care. Uncertainty among GPs as to how patients view the discussion of prognosis and inadequate preparation may pose potential barriers.

The integrated nursing team in primary care: views and experience of participants exploring ownership, objectives and a team orientation

The development of integrated nursing teams consisting of district nurses, health visitors and practice nurses based in general practice is a widespread recent change in primary care. This development has been justified by promising to meet the need for a more cost-effective service, through a reduction of duplication in nursing work, improvements in the consistency of advice to patients and the provision of accessible and responsive patient care. This paper reports on topic-led qualitative interview data which were collected as part of a multimethod evaluation of various models of evolving integrated nursing teams. The overall aim of the evaluation was to explore progress towards integration by assessing nurse workload, team effectiveness and staff perception of change. The assessment of workload and team effectiveness is reported elsewhere. Staff perception of change was measured by analysis of interview data collected from 12 teams, 9 months after the implementation of nurse integration in two London health authorities in 1998. A total of 33 interviews explored nurses' interpretation of integrated nursing, their expectations relating to their changing roles and activities and their perceptions of key activities and outcomes relating to the implementation of integrated working. Although achievements were identified, including some changes in clinical practice, in general participants reported a partial and variable understanding of the concept of integrated teamwork, and there was uncertainty reported over changes in professional boundaries. A lack of ownership of the process of change and a dearth of team objectives were reported. Developments towards teambuilding were more common than strategic planning to reorganize the workload of the team collectively according to a local population-based agenda. To implement an integrated approach to primary care nursing, we suggest that there is a need for increased ownership and support for teambuilding strategies and skill development. If integrated nursing is to contribute to health improvements, it is necessary that participants agree on patient-focused objectives that orient towards a collective and locally targeted delivery of care.

Accounts of carers' satisfaction with health care at the end of life: a comparison of first generation black Caribbeans and white patients with advanced disease.

While much research has described experiences at the end of life, no studies have explored the black Caribbean perspective. This paper compares the final year of life of first generation black Caribbeans and white patients with advanced disease in an inner London health authority, focusing on their satisfaction with service provision in both primary care and acute settings using face-to face interviews with carers of deceased patients. Of the 106 black Caribbean patients and 110 white deceased patients identified as dying during the study period 50 interviews per ethnic group were conducted with family members or close friends, a response rate of 47% and 45%. Even though examples of excellent and good care were cited, a larger proportion of negative satisfaction ratings of health care was recorded among respondents representing black Caribbean patients. This was true for all health care settings, particularly primary care, but less so for specialist palliative care nurses. However, few black Caribbean patients accessed specialist palliative care nurses or hospices. Qualitative data provided a deeper insight into the black Caribbean experience care at the end of life. We recommend that where examples of best practice in palliative care and culturally sensitive provision are evident they be extended to more health care professionals through education and training. Access to specialist palliative care services needs to be improved.

General practice survey of the management of chickenpox: appropriate targeting of antiviral therapy.

A working party of specialists and GPs recently published their consensus on recommended treatments for chickenpox. These are the closest to recommended guidelines available in the UK. They offer a rational basis for targeting those groups most at risk of complications with antiviral treatment. The aim of the present study was to compare current practice by GPs in the management of chickenpox, particularly in targeting of antiviral therapy, with the working party recommendations. A questionnaire survey was conducted of all GP principals within a single London Health Authority Responses to nine chickenpox clinical scenarios were compared with the working party recommendations. The response rate was (69.2%) 227/328. In five of the nine scenarios, fewer than 70% of GPs selected the correct response according to the recommendations. There was both underuse and overuse of antivirals according to the recommendations, with only 42% (96/227) advising oral antivirals or referral for an asthmatic treated with oral steroids 1 month previously, and 24% (53/221) advising oral antivirals 3 days after the chickenpox rash appeared. The results suggest some high risk groups may be being undertreated with oral antivirals and there may be considerable use of oral antivirals in situations where they are of no proven benefit.

Health status and healthy life measures for population health need assessment: modelling variability and uncertainty

It is increasingly recognised that population health need assessments based on the comparison of clinical or demographic end points (e.g. area mortality rates) neglect population variation in broader aspects of health status and health-related quality of life. Similarly, outcome measures which neglect impacts on health-related quality of life may be an inadequate basis for assessing the effectiveness of health interventions. This paper reviews issues in assessing needs and outcomes at population level based on health status valuations. It considers especially the modelling of sources of uncertainty in measures of health status by using Bayesian sampling estimation methods which produce a distribution of summary outcome measures. The modelling issues are illustrated in models for individual level health status from survey responses and their incorporation in area life tables to derive total and healthy life expectancies. In particular, a health status index derived from Short Form 36 profile responses in a health and lifestyle survey in a London health authority provides a case study of community health needs assessment.

Utilization of out-of-hours services by patients with mental health problems.

This study was designed to provide information about how out-of-hours services are used by those with mental health problems. Data were collected from agencies that patients with a mental health problem could directly access out of hours in an inner London health authority area. Data on all contacts were collected for a period of 4 weeks using various methods, including routinely collected data and specially designed data collection sheets. There were a total of 556 contacts across all of the services with 45 per cent of contacts presenting to an accident and emergency department. The type of service accessed was influenced by the sex of the patient, and the presenting complaint, so that females were more likely to contact their general practitioner and those with deliberate self-harm were more likely to attend an accident and emergency department. Females were more likely to present with deliberate self-harm, whereas men were more likely to present with suicidal feelings and depression. The study highlights some clear patterns in how out-of-hours services are used for mental health problems. The data may be useful in helping providers to plan their services more appropriately. The study also highlighted some of the problems in collecting routine data of this nature.

Small Area Variation in Hospital Admission Rates: Bayesian Adjustment for Primary Care and Hospital Factors

SUMMARY Hospital admission rates are often used as a proxy to reflect patterns of morbidity or health need in population subgroups or across geographic areas. This paper considers the estimation of small area variations in relative health need, as measured by routinely collected hospital admissions data, after allowing for variation in general practice (primary care) and hospital (supply) effects. A fully Bayesian hierarchical modelling framework is adopted, using combinations of electoral ward populations and general practice patients’ lists to define catchment groups for analysis. Hospitals create a further stratum, with flows of patients between catchment groups and hospitals being represented by a gravity model. Variations in health outcomes are modelled by using a range of random-effects structures for each cross-classification of strata, together with a consideration of ward, practice, hospital and crossed level covariates. The approach is applied to case-studies of child respiratory and total emergency hospital admissions for residents in a London health authority.

Ethnicity and prescription of analgesia in an accident and emergency department: cross sectional study

Ethnicity can be a risk factor for inadequate administration of analgesia in accident and emergency departments.1 In an emergency department in Los Angeles, United States, Hispanic patients were twice as...

‘All the services were excellent. It is when the human element comes in that things go wrong’: dissatisfaction with hospital care in the last year of life

Patient satisfaction surveys are seen as an important way of obtaining 'user views' of health service provision. However, there is a growing body of research and theoretical literature that questions the validity of the concept of 'patient satisfaction' and hence the use of this type of survey. A postbereavement survey of people who registered a random sample of cancer deaths in an inner London health authority was undertaken in 1996/7. The survey questionnaire (VOICES) included 14 open-ended questions which asked respondents to add any comments they felt were relevant about the care of the deceased. This paper uses these data to examine the causes of dissatisfaction with hospital-based care. Of the 229 informants responding to the questionnaire, 138 included some written comment about care in hospital. At least one negative comment was made by 59% (82) of those making any comment. Of these, 55% (44) rated the care given by doctors as 'excellent' or 'good' and 63% (50) rated that given by nurses as 'excellent' or 'good'. Qualitative analysis of responses to open questions suggest that expressions of dissatisfaction arise from a sense of being 'devalued', 'dehumanized' or 'disempowered' and from situations in which the 'rules' governing the expected health professional-patient relationships were broken. As such, the causes of dissatisfaction for this particular group of patients are similar to the causes of dissatisfaction with health care in general reported elsewhere. The palliative care approach emphasizes patient- and family-centred care and aims to promote physical and psychosocial well-being. The study findings suggest that adoption of the palliative care approach could reduce the experience of dissatisfaction for many service users, not only those whose deaths are anticipated.

What Constitutes High-Quality HIV/AIDS Palliative Care?

The study assessed the components of high-quality HIV palliative care using the multidimensional model of quality assessment developed by Maxwell (4). Data collection consisted of interviews with individual subjects and focus groups. The interviews took place in three London health authorities. Seven service users and 74 providers of health care and voluntary services were interviewed. Maxwell's model identifies the components of high-quality HIV palliative care as: competent, skilled practitioners (effectiveness); confidential, non-discriminatory, and culturally sensitive care (acceptability); collaborative and coordinated care (efficiency); flexible and responsive care (access and relevance to need); and fair access for all clients (equity). Our results show that the six dimensions of quality appear to be inextricably linked from the client's point of view. Thus, service commissioners and providers need to examine all six of the dimensions when assessing the quality of HIV services. These findings may serve as a model for other palliative care services.

Mental health training needs of primary health care nurses.

The primary health care team (PHCT) has a critical role to play in the care of people with mental health problems. However, little attention has been paid to the mental health training and preparation required by primary health care nurses. This paper reports on a training needs assessment undertaken in one London health authority area. The findings indicate that primary health care nurses are undertaking a wide range and increasing volume of mental health work with little preparation and training. Specific training needs include time and space to identify training gaps; basic training in mental health, safe working practices and management of role boundaries; and multidisciplinary training. In addition, NHS trusts, primary care groups and health authorities need to clarify which aspects of nurses' mental health workloads are appropriate to their role and develop policies, procedures and training to support them in undertaking that role.

Care in the last year of life: satisfaction with health services among the black Caribbean population in an inner London health authority

Care in the last year of life: satisfaction with health services among the black Caribbean population in an inner London health authority

An impact evaluation study of a community mobilisation and HIV prevention programme among gay men

Gay and bisexual men continue to be the group most affected by HIV and AIDS in the UK. In 1996, as part of an effort to address this situation, a consortium of London health authorities commissioned a gay men's HIV prevention project based on principles of community mobilisation which the research literature suggests offers considerable scope for achieving effective HIV prevention. This impact evaluation study, analysing responses to a self- completion nuestionnaire administered to a community-based sample of 674 men in London, found highest reported levels of contact with the awareness- raising interventions in the project. Much lower levels of engagement with more participative and involving activities were identified. In relation to the reported outcomes of the project, awareness-raising was achieved to a greater extent than behavioural outcomes for prevention. Future gay men's HIV prevention based on commmity mobilisation should be oriented to focus more specifically on the achievement of these more complex outcomes.

Purchasing Neurorehabilitation in the UK National Health Service

Neurorehabilitation usually has two objectives: Managing the initial phase of patient improvement and ensuring long-term support for continuing disability. The UK National Health Service (NHS) provides acute neurorehabilitation within general hospital wards and specialist units, but arrangements for long-term placement are less satisfactory. NHS health authorities, administrative agencies responsible for the health of defined local populations of about half a million, hold resources for purchasing both acute and long-term medical and nursing services; long-term care usually also requires financial support from municipal social services departments. The patient's health status may be used in assessing the need for services, but little information on clinical outcome is available for purchasers. This paper describes purchasing for neurorehabilitation in a London health authority, and suggests how the arrangements could be improved.

The influence of health needs assessment on health care decision-making in London health authorities.

Health needs assessment gained prominence under the model of health care purchasing developed to support the 1991 reforms of the UK National Health Service (NHS). The objectives of this paper are to determine how needs assessment has been used in the NHS, to assess the influence it has had on decision-making, and to relate the observed uses of needs assessment to competing theoretical models of health care policy-making. A survey of needs assessment activity in 14 London health authorities identified 217 needs assessments conducted between 1993 and 1996. Semi-structured interviews were conducted with public health and commissioning staff in each authority. The survey indicated that needs assessment directly supported decision-making and action in two-thirds of the studies identified, but up to 20% of needs assessments had no impact on service provision. Four key functions of health needs assessment were observed: identifying a problem; planning detailed changes to services; providing post hoc justification for earlier decisions; and using participation in needs assessment to build 'ownership' of subsequent decisions. The survey suggests that needs assessment is, in practice, consistent with a 'mixed scanning' model of decision-making. Needs assessment is used to help select issues for detailed investigation and to direct analytical and decision-making resources. However, certain key areas are not amenable to technical analysis and solution, and are resolved through bargaining.

Dimensions of class in the integration of health and social care

The paper draws upon a research based consultancy to recommend an appropriate form of integration of health and social care for the elderly population of an outer London Health Authority, which included a general practice Total Purchasing project. It makes a critical analysis of current practice, and argues that prevailing managerial models of intetprofessional care reflect traditional class assumptions about the organisation of work processes in this field. The report developed an argrument for integration which built upon informal and formal joint working among frontline staff provinding home based care. This perspective privileges and legitimates users' perspectives, informal networks, joint working and home care and identifies them as key elements for effective integration. The final policy recommendation of the report that Home care should become the link service between health care and social services reflected this perspective.

A randomised controlled trial of postal versus interviewer administration of a questionnaire measuring satisfaction with, and use of, services received in the year before death.

STUDY OBJECTIVES: To develop a short form of an interview schedule used successfully in previous national surveys of care for the dying, and to investigate the effect of administering it...

Assessing Psychiatric Morbidity from Community Registers: Methods for Bayesian Adjustment

This paper considers Bayesian approaches to adjusting small area prevalence estimates derived from a community register of the seriously mentally ill, by taking account of underlying variability in latent prevalence between areas. Adjustment of individual prevalence rates to take account of the entire spatial distribution has implications both for epidemiological inference and resource rankings for localities. The more commonly adopted empirical Bayes approaches are here compared with fully Bayes approaches. Fully Bayes methods allow for uncertainty in the prevalence parameters and also permit the inclusion of information from other sources (for example, hospital admissions for mental illness) or from previous studies. The impact of socioeconomic indices on morbidity and its relevance for adjusted prevalence estimates is also considered. A case study is applied to an East London Health Authority, Barking and Havering.

Health authority commissioning for quality in contraception services.

OBJECTIVE: To compare the commissioning of contraception services by London health authorities with accepted models of good practice. DESIGN: Combined interview and postal surveys of all health authorities and National...