National Health Service Policy Research Articles

The Health Impact of Waiting for Elective Procedures in the NHS in England: A Modeling Framework Applied to Coronary Artery Bypass Graft and Total Hip Replacement.

The aim of this study is to demonstrate a practical framework that can be applied to estimate the health impact of changes in waiting times across a range of elective procedures in the National Health Service (NHS) in England. We apply this framework by modeling 2 procedures: coronary artery bypass graft (CABG) and total hip replacement (THR). We built a Markov model capturing health pre- and postprocedure, including the possibility of exiting preprocedure to acute NHS care or self-funded private care. We estimate the change in quality-adjusted life-years (QALYs) over a lifetime horizon for 10 subgroups defined by sex and Index of Multiple Deprivation quintile groups and for 7 alternative scenarios. We include 18 wk as a baseline waiting time consistent with current NHS policy. The model was populated with data from routinely collected data sets where possible (Hospital Episode Statistics, Patient-Reported Outcome Measures, and Office for National Statistics Mortality records), supplemented by the academic literature. Compared with 18 wk, increasing the wait time to 36 wk resulted in a mean discounted QALY loss in the range of 0.034 to 0.043 for CABG and 0.193 to 0.291 for THR. The QALY impact of longer NHS waits was greater for those living in more deprived areas, partly as fewer patients switch to private care. The proposed framework was applied to 2 different procedures and patient populations. If applied to an expanded group of procedures, it could provide decision makers with information to inform prioritization of waiting lists. There are a number of limitations in routine data on waiting for elective procedures, primarily the lack of information on people still waiting. We present a modeling framework that allows for an estimation of the health impact (measured in quality-adjusted life-years) of waiting for elective procedures in the NHS in England.We apply our model to waiting for coronary artery bypass graft (CABG) and total hip replacement (THR). Increasing the wait for THR results in a larger health loss than an equivalent increase in wait for CABG.This model could potentially be used to estimate the impact across an expanded group of procedures to inform prioritization of activities to reduce waiting times.

Solving poverty or tackling healthcare inequalities? Qualitative study exploring local interpretations of national policy on health inequalities under new NHS reforms in England

ObjectivesMajor reforms to the organisation of the National Health Service (NHS) in England established 42 integrated care systems (ICSs) to plan and coordinate local services. The changes are based on...

The policy of permeation of Fabian Society into the National Health Service policy of Labour Party in the early 20th century

In pursuit of social reform, Fabian Society, a British Socialist Group, adopted the a policy of permeation of other parties. Under the influence of osmosis, Fabian Society, represented by Mr and Mrs Webb, exerted influence over Labour’s policy on the National Health Service, and in the continuous run-in to the national health service in part of the Labour policy and views with Fabian Society gradually convergence. By drawing on the positive experience of Fabian, combining the establishment of a jointly managed health system, the consolidation of redundant health services, the improvement of the administrative efficiency of government-related services, the development of voluntary hospitals and sanatoriums with the inherent commitment of the Labour Party to free health care for all, and the establishment of a public health sector at the national level, thus for the UK in the field of public health to establish a national medical social system to provide an excellent blueprint. Labour’s policies in the field of national health have profoundly changed the face of British society.

Socio-demographic predictors of obesity among 12,975 adult ever married Egyptian women of reproductive age group: evidence from nationwide survey

AimWe aimed to explore the predictors associated with obesity among adult ever-married Egyptian women aged 20–49 years based on the Egyptian Demographic and Health Survey (EDHS).MethodWe included adult ever married women from the EDHS conducted in 2014 that initially recruited 21,903 women. Univariate and multivariable analysis was conducted to identify socio-demographic predictors of women’s obesity.ResultWe included 12,975 Egyptian women. Among them, 76% of the total respondents were obese where as 24% were with normal body mass index (BMI). In multivariable analysis, the results revealed that increasing age, higher wealth index, listening to radio at least once a week and women with primary and secondary education were at significant odds of developing obesity (p < 0.05). However, we found no association between residence of participants and the frequency of watching television upon the development of obesity (p > 0.05).ConclusionAppropriate and targeted interventions should be implemented among the Egyptian reproductive age women to reduce the obesity as well as non-communicable diseases load associated with obesity. National Health Service policy makers should take multilevel approach targeting high risk sub-groups to raise awareness and to provide prevention against obesity and the subsequent complications.

Shared leadership in integrated care networks: the case of “hub and spoke” networks in oral and maxillofacial surgery (OMFS) in the English NHS

PurposeThe purpose of this paper is to explore leadership in the context of the hub and spoke network in oral and maxillofacial surgery (OMFS) in the English National Health Service (NHS).Design/methodology/approachThis paper is a conceptual paper using literature relating to the antecedents of shared leadership and relevant policy documents pertaining to both NHS policy and the development of OMFS. The paper is informed, theoretically by the conceptual lens of shared leadership.FindingsThe paper identifies the challenges that may be faced by policymakers and those involved in the hub and spoke network in developing shared leadership. It also reveals the implications for policymakers in developing shared leadership.Research limitations/implicationsThe paper is conceptual. It is acknowledged that this is a preliminary study and further work will be required to test the conceptual framework empirically. The paper discusses the policy implications of developing leadership in the hub and spoke network. As networks are of interest internationally this has wider relevance to other countries.Originality/valueThere is limited research on the antecedents of shared leadership. In addition, the conceptual framework is applied to a new policy context.

Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity

"Healthy Living for People with type 2 Diabetes (HeLP-Diabetes)" was a theory-based digital self-management intervention for people with type 2 diabetes mellitus that encouraged behavior change using behavior change techniques (BCTs) and promoted self-management. HeLP-Diabetes was effective in reducing HbA1c levels in a randomized controlled trial (RCT). National Health Service (NHS) England commissioned a national rollout of HeLP-Diabetes in routine care (now called "Healthy Living"). Healthy Living presents a unique opportunity to examine the fidelity of the national rollout of an intervention originally tested in an RCT. This research aimed to describe the Healthy Living BCT and self-management content and features of intervention delivery, compare the fidelity of Healthy Living with the original HeLP-Diabetes intervention, and explain the reasons for any fidelity drift during national rollout through qualitative interviews. Content analysis of Healthy Living was conducted using 3 coding frameworks (objective 1): the BCT Taxonomy v1, a new coding framework for assessing self-management tasks, and the Template for Intervention Description and Replication. The extent to which BCTs and self-management tasks were included in Healthy Living was compared with published descriptions of HeLP-Diabetes (objective 2). Semistructured interviews were conducted with 9 stakeholders involved in the development of HeLP-Diabetes or Healthy Living to understand the reasons for any changes during national rollout (objective 3). Qualitative data were thematically analyzed using a modified framework approach. The content analysis identified 43 BCTs in Healthy Living. Healthy Living included all but one of the self-regulatory BCTs ("commitment") in the original HeLP-Diabetes intervention. Healthy Living was found to address all areas of self-management (medical, emotional, and role) in line with the original HeLP-Diabetes intervention. However, 2 important changes were identified. First, facilitated access by a health care professional was not implemented; interviews revealed this was because general practices had fewer resources in comparison with the RCT. Second, Healthy Living included an additional structured web-based learning curriculum that was developed by the HeLP-Diabetes team but was not included in the original RCT; interviews revealed that this was because of changes in NHS policy that encouraged referral to structured education. Interviewees described how the service provider had to reformat the content of the original HeLP-Diabetes website to make it more usable and accessible to meet the multiple digital standards required for implementation in the NHS. The national rollout of Healthy Living had good fidelity to the BCT and self-management content of HeLP-Diabetes. Important changes were attributable to the challenges of scaling up a digital intervention from an RCT to a nationally implemented intervention, mainly because of fewer resources available in practice and the length of time since the RCT. This study highlights the importance of considering implementation throughout all phases of intervention development.

Qualitative documentary analysis of guidance on information provision and consent for the introduction of innovative invasive procedures including surgeries within NHS organisations’ policies in England and Wales

ObjectiveTo review guidance, included in written local UK National Health Service (NHS) organisation policies, on information provision and consent for the introduction of new invasive procedures- including surgeries, and devices...

“Raising the curtain on the equality theatre”: a study of recruitment to first healthcare job post-qualification in the UK National Health Service

BackgroundUK equality law and National Health Service (NHS) policy requires racial equality in job appointments and career opportunities. However, recent national workforce race equality standard (WRES) data show that nearly all NHS organisations in the UK are failing to appoint ethnically diverse candidates with equivalent training and qualifications as their white counterparts. This is problematic because workforce diversity is associated with improved patient outcomes and other benefits for staff and organisations.AimTo better understand the reasons behind underrepresentation of ethnically diverse candidates in first NHS healthcare jobs post-qualification and to identify any structural or systemic barriers to employment for such groups.MethodsThe study was informed by critical theory and the authors’ interdisciplinary perspectives as educators and researchers in the healthcare professions. Data collected from semi-structured face-to-face interviews with 12 nurse and physiotherapy recruiting managers from two NHS trusts in London were analysed using a healthcare workforce equity and diversity conceptual lens we developed from the literature. Using this lens, we devised questions to examine six dimensions of equity and diversity in the interview data from recruiting managers.ResultsRecruiting managers said they valued the benefits of an ethnically diverse workforce for patients and their unit/organisation. However, their adherence to organisational policies for recruitment and selection, which emphasise objectivity and standardisation, acted as constraints to recognising ethnicity as an important issue in recruitment and workforce diversity. Some recruiting managers sense that there are barriers for ethnically diverse candidates but lacked information about workforce diversity, systems for monitoring recruitment, or ways to engage with staff or candidates to talk about these issues. Without this information there was no apparent problem or reason to try alternative approaches.ConclusionThese accounts from 12 recruiting managers give a ‘backstage’ view into the reasons behind ethnic inequalities in recruitment to first healthcare job in the UK NHS. Adherence to recruitment and selection policies, which aim to support equality through standardisation and anonymisation, appear to be limiting workforce diversity and creating barriers for ethnically diverse candidates to attain the jobs that they are trained and qualified for. The Healthcare Workforce Equity + Diversity Lens we have developed can help to ‘raise the curtain on the equality theatre’ and inform more inclusive approaches to recruitment such as contextualised recruitment or effective allyship between employers and universities.

Personal Health Records an Approach to Answer: What Works for Whom in What Circumstances?

National Health Service (NHS) policy suggests that increasing usage of electronic personal health records (PHR) by patients will result in cost savings and improved public health, especially for people with long-term conditions. PHR design features are inevitably important, since a good PHR design should make the users achieve their health goals effortlessly, which is understandable and usable. Three original theoretical models were developed using realist evaluation, one per long-term condition cohort, describing the interaction between the PHR design features and the patient and disease specific factors, to help determine what works for whom in what circumstances.

Collaboration over competition? Regulatory reform and inter-organisational relations in the NHS amidst the COVID-19 pandemic: a qualitative study

BackgroundIn 2021, during the COVID-19 pandemic, England’s Department of Health and Social Care (DHSC) released a White Paper outlining proposed legislative reform of the National Health Service (NHS). Key to the proposals is the shift from relationships between providers based on competition, to cooperation, as the central driver of improved performance and quality. Against this background we explore potential regulatory barriers and enablers to collaboration identified by key NHS stakeholders and assess whether the proposed policy changes are likely to deliver the desired improvement in collaborative relationships, in the context of challenges experienced during the COVID-19 pandemic.MethodsWe conducted 32 semi-structured interviews with 30 key stakeholders, taking place during the COVID-19 pandemic from Jan 2020 to May 2021. Participants were selected for their expertise regarding collaboration and were recruited purposively. Interviews were conducted online with the use of video conferencing software. The interviews were thematically analysed to identify themes. Proposals contained in the DHSC White Paper helped to structure the thematic analysis, interpretation, and reporting of the results.ResultsRequirements to compete to provide services, regulatory ability to block collaborative arrangements, lack of collaboration between providers and Clinical Commissioning Groups, and current lack of data sharing were found to hamper collaborative efforts. These issues often negatively affected collaborative relations by increasing bureaucracy and prompted leaders to attempt to avoid future collaborations. Other barriers included opaque accountability arrangements, and erosion of trust in regulators. The COVID-19 pandemic was found to foster collaboration between organisations, but some changes mandated by the new legislation may stifle further collaboration.ConclusionsMany of the proposed legislative changes in the White Paper would help to remove existing barriers to service integration and collaboration identified by stakeholders. However, the proposed shift in the concentration of power from NHS England to the DHSC may exacerbate historically low levels of trust between providers and regulators. Many of the proposed changes fail to address endemic NHS policy issues such as chronic understaffing. Further dialogue is needed at all levels of the health and social care system to ensure future legislative changes meet the needs of all stakeholders.

Sexual harassment and organisational silencing in nursing: a cross-sectional study in Greece

ObjectiveThis study investigates the frequency of sexual harassment among female nurses in the Greek health system and the nurses’ reluctance to report their experiences.DesignCross-sectional study.SettingGreece.Participants1264 female nurses of working age...

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients’ reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Missing the human connection: A rapid appraisal of healthcare workers’ perceptions and experiences of providing palliative care during the COVID-19 pandemic

Background: During infectious epidemics, healthcare workers are required to deliver traditional care while facing new pressures. Time and resource restrictions, a focus on saving lives and new safety measures can lead to traditional aspects of care delivery being neglected. Aim: Identify barriers to delivering end-of-life care, describe attempts to deliver care during the COVID-19 pandemic, and understand the impact this had on staff. Design: A rapid appraisal was conducted incorporating a rapid review of policies from the United Kingdom, semi-structured telephone interviews with healthcare workers, and a review of mass print media news stories and social media posts describing healthcare worker’s experiences of delivering care during the pandemic. Data were coded and analysed using framework analysis. Setting/Participants: From a larger ongoing study, 22 interviews which mentioned death or caring for patients at end-of-life, eight government and National Health Service policies affecting end-of-life care delivery, eight international news media stories and 3440 publicly available social media posts were identified. The social media analysis centred around 274 original tweets with the highest reach, engagement and relevance. Incorporating multiple workstreams provided a broad perspective of end-of-life care during the COVID-19 pandemic in the United Kingdom. Results: Three themes were developed: (1) restrictions to traditional care, (2) striving for new forms of care and (3) establishing identity and resilience. Conclusions: The COVID-19 pandemic prohibited the delivery of traditional care as practical barriers restricted human connections. Staff prioritised communication and comfort orientated tasks to re-establish compassion at end-of-life and displayed resilience by adjusting their goals.

A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocol

BackgroundPrevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery.MethodsThe design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13–17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a ‘healthy living’ behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness.DiscussionUK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression.Trial registrationISRCTN, ISRCTN66452702. Registered 9 April 2020.

Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice

ObjectivesDespite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general...

Who is allowed to read and write?

Who is allowed to read and write?

The politics of frailty.

The world population is ageing because of falling fertility and improved life expectancy. Knowing this has not helped governments develop sustainable health and care policies because the underlying causes and impacts of population ageing remain poorly understood. Planning using only population age structure does not account for uneven geographical distribution of older people, their health characteristics, functional needs or lived experiences. English National Health Service (NHS) policy has previously focused on arbitrary age segmentation, failing to capture the origins of cumulative disease and functional burden and missing the opportunity to incorporate wider determinants of health into prevention of poor-quality ageing. This is despite growing international evidence that adults living in places with low per capita income and educational attainment experience a higher burden of age-related disease. Lack of a credible ageing narrative and good quality population health data have contributed to a focus on single disease prevention, rather than life course disease aggregation and its personal impacts. However, a fully explicated health and care narrative incorporating frailty does now give some cause for optimism. In 2017, England became the first country to characterise and systematically identify frailty as a long-term treatable health condition. This was coincident with a UK Government's Industrial Strategy targeting societal ageing. In 2019, the English NHS published a funded long-term plan including a major programme focused on ageing well. Policy makers, health leaders and clinicians must not squander these opportunities but instead pursue frailty prevention and intervention to improve the quality of population ageing.

A Tale of Two Inquiries: Sans Everything and Ely

AbstractThe government acknowledged scandalously poor care of long‐stay patients in National Health Service (NHS) hospitals in 1969. This followed the Ely Hospital inquiry, which emerged in the aftermath of revelations of abuse at seven hospitals described in Barbara Robb's book Sans Everything: A Case to Answer (1967). Allegations in Sans Everything and at Ely were similar. However, the inquiry committees which investigated, ‘disproved’ those in Sans Everything and upheld those at Ely. The Ely inquiry became pivotal to NHS policy reform for long‐stay mental illness and mental handicap hospitals, and for giving patients and their families a greater voice if they had concerns about inadequacies. This paper explains the relationship between Sans Everything and ‘Ely’ and analyses the impact of Robb's work—her high‐profile press campaign, networking, and determination to achieve improvement—which triggered revelations at Ely and elsewhere, and helped shape the course and constructive outcome of the Ely inquiry.

Conflicting Logics of Public Relations in the English NHS: A Qualitative Study of Communications and Engagement

Since the formation of the National Health Service (NHS), all UK citizens have been entitled to access a universal health service, but radical changes to the NHS are now occurring. Although recent NHS policy claims that ‘the NHS belongs to us all’ and ‘the NHS is a social movement’, these collectivist rhetorical claims appear when such communitarian discourse is under threat, as NHS’s Five Year Forward View tries to square the circle of efficiency, quality, and equity. Historically, patients and user-groups have formed support networks and social movements, and collectively campaigned for their voices to be heard by policymakers, clinicians, and managers. In contrast to the discourse of user movements, the field of marketing and public relations generally relies on the idea of the public as consumers rather than citizens. As complex governance arrangements blur the lines between public and private, concerns have been raised about how ‘spin’ associated with public relations might contravene accountability, communicative rationality, and deliberative or participatory democracy. Using qualitative methods, we conducted empirical research in two localities to explore the role of communications and engagement staff as they worked to ‘transform’ the NHS in line with the vision of the Five Year Forward View. We gathered documentary data and interview data from people whose roles required them to ‘do engagement’. These staff came from a range of backgrounds, including professional marketing backgrounds, and many were unaware of emancipatory goals or user-led involvement and activism. Our analysis examines the competing logics of marketing and patient empowerment within a key stakeholder matrix document and that surfaced in participants’ accounts of their engagement practices.

Funding and policy incentives to encourage implementation of point-of-care C-reactive protein testing for lower respiratory tract infection in NHS primary care: a mixed-methods evaluation

ObjectivesUtilisation of point-of-care C-reactive protein testing for lower respiratory tract infection has been limited in UK primary care, with costs and funding suggested as important barriers. We aimed to use...