NHS Care Research Articles

A crisis point for mental health care.

John Tingle, Associate Professor (Teaching and Scholarship), Nottingham Trent University, discusses failings in NHS care for highly vulnerable mental health patients.

068 Survey of the NHS care experience of people living with rare autoimmune rheumatic diseases

068 Survey of the NHS care experience of people living with rare autoimmune rheumatic diseases

Lamotrigine for people with borderline personality disorder: a RCT

No drug treatments are currently licensed for the treatment of borderline personality disorder (BPD). Despite this, people with this condition are frequently prescribed psychotropic medications and often with considerable polypharmacy. Preliminary studies have indicated that mood stabilisers may be of benefit to people with BPD. To examine the clinical effectiveness and cost-effectiveness of lamotrigine for people with BPD. A two-arm, double-blind, placebo-controlled individually randomised trial of lamotrigine versus placebo. Participants were randomised via an independent and remote web-based service using permuted blocks and stratified by study centre, the severity of personality disorder and the extent of hypomanic symptoms. Secondary care NHS mental health services in six centres in England. Potential participants had to be aged ≥ 18 years, meet diagnostic criteria for BPD and provide written informed consent. We excluded people with coexisting psychosis or bipolar affective disorder, those already taking a mood stabiliser, those who spoke insufficient English to complete the baseline assessment and women who were pregnant or contemplating becoming pregnant. Up to 200 mg of lamotrigine per day or an inert placebo. Women taking combined oral contraceptives were prescribed up to 400 mg of trial medication per day. Outcomes were assessed at 12, 24 and 52 weeks after randomisation. The primary outcome was the total score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. The secondary outcomes were depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment and adverse events. Higher scores on all measures indicate poorer outcomes. Between July 2013 and October 2015 we randomised 276 participants, of whom 195 (70.6%) were followed up 52 weeks later. At 52 weeks, 49 (36%) of those participants prescribed lamotrigine and 58 (42%) of those prescribed placebo were taking it. At 52 weeks, the mean total ZAN-BPD score was 11.3 [standard deviation (SD) 6.6] among those participants randomised to lamotrigine and 11.5 (SD 7.7) among those participants randomised to placebo (adjusted mean difference 0.1, 95% CI -1.8 to 2.0; p = 0.91). No statistically significant differences in secondary outcomes were seen at any time. Adjusted costs of direct care for those prescribed lamotrigine were similar to those prescribed placebo. Levels of adherence in this pragmatic trial were low, but greater adherence was not associated with better mental health. The addition of lamotrigine to the usual care of people with BPD was not found to be clinically effective or provide a cost-effective use of resources. Future research into the treatment of BPD should focus on improving the evidence base for the clinical effectiveness and cost-effectiveness of non-pharmacological treatments to help policy-makers make better decisions about investing in specialist treatment services. Current Controlled Trials ISRCTN90916365. Funding for this trial was provided by the Health Technology Assessment programme of the National Institute for Health Research (NIHR) and will be published in full in Health Technology Assessment; Vol. 22, No. 17. See the NIHR Journals Library website for further project information. The Imperial Biomedical Research Centre Facility, which is funded by NIHR, also provided support that has contributed to the research results reported within this paper. Part of Richard Morriss' salary during the project was paid by NIHR Collaboration for Leadership in Applied Health Research and Care East Midlands.

Why the history of public consultation matters for contemporary health policy

Contemporary policy debates construct public involvement in England's National Health Service as "new," or as a practice dating back only as far as the 1990s. This article argues that the longer historical contexts of such consultative practice matter, and it explores various and shifting manifestations of "consultation" in the NHS from the foundation of the Service in 1948. In doing so, it first demonstrates that consultation has always been a part of the theory and practice of postwar health policy. Thinking about consultation as "new" presents such practice as unnecessary or transient, and may function as part of a damaging political vision of public affection for the NHS as a barrier to reform. Second, the article asserts that public interest in shaping NHS practice and policy has never been fully satisfied by official consultative mechanisms. "The public" is not a homogeneous group, but rather composed of various groups, communities, and individuals with rich perspectives and histories to share, having experienced the NHS as patients, friends, supporters, staff, and volunteers. Policy-makers should approach diverse publics as partners, and should meaningfully listen to protests around NHS reform, which often reflect public investment in the NHS, as well as valid concerns about how particular communities will be able to access health care. While the political will for such engagement has varied over time, individual politicians and local-level health agencies can make a difference by supporting, engaging with, and funding organizations which represent and empower a diverse range of communities: such groups have always, and will continue to play, a significant role in shaping NHS debate and care.

Demand rises on emergency NHS care: where do long-term neurological conditions fit?

Demand rises on emergency NHS care: where do long-term neurological conditions fit?

Palliative care in acute hospitals – a new vision

This article explores new and innovative ways of delivering palliative and end-of-life care (EoLC) within the acute hospital setting. Severe financial pressures in the NHS and social care, combined with the increasing clinical complexity of patients, have raised concerns about the quality of EoLC in hospitals. The creation of hospital palliative care units (PCUs) and other improvement initiatives will be described across two large acute hospital trusts which resulted in a rating of 'Outstanding' by the Care Quality Commission (CQC) for their delivery of end-of-life services.

A collaborative approach to developing student placements in care homes.

If high-quality, person-centred care is to be provided for older people with complex needs, it is essential that nurse education should aim to extend students' knowledge and skills in longterm care, and integrated health and social care. Northumbria University, local care homes and NHS organisations have collaborated to develop integrated, cross-sector practice placements that support this learning for nursing students. While there have been challenges in developing these placements, initial feedback is positive, suggesting the placements promote improved interorganisational working and learning for staff as well as students.

RPS Scotland gives evidence to Scottish Labour's NHS and Social Care Workforce Commission

RPS Scotland gives evidence to Scottish Labour's NHS and Social Care Workforce Commission

The perceptions regarding social workers from within an integrated trust in an age of austerity

PurposeThe purpose of this paper is to explore community professionals’: opinions concerning social worker’s roles and statutory functions; understanding of collaborative and cooperative work; experiences of professional support; opinions on the aspects of anti-oppressive practices in social work; views on social work identity within multi-disciplinary team structures; exploring perceptions regarding the challenges of cultural; and contextual drivers of social work practice.Design/methodology/approachDesign: thematic analysis of free-text data from a survey. Setting and participants: social workers, occupational therapists and nurses working within an integrated Health and Social Care NHS Trust. Main outcome measures: free-text coded and categorised by theme. Overarching themes are identified incorporating comment categories. Methods: 41 respondents (of n=600 survey respondents) provided free-text comments. Data were coded using a multistage approach: coding of comments into general categories (e.g. resources, budgets); coding of subcategories within main categories (e.g. s75 agreement, staffing levels); cross-sectional analysis to identify themes cutting across categories; and mapping of categories/subcategories to corresponding comparable research for comparison.FindingsMost free-text respondents (51 per cent) were from social workers, with 32 per cent from occupational therapists and 17 per cent from nurses. These respondents provided comments that the authors developed into four overarching themes: first, culture – cultural biases and clashes of culture within an integrated care organisation which result in a negative experience for professionals and confusion for service users and/or carers. A lack of shared socialisation and the development of a shared culture. Second, austerity: the impact of economic austerity. Third, organisation: conceptual confusion in respect of defining/organising/structuring integrated care within a health organisation. Fourth, political: the political drivers of integration.Originality/valueThis study presents specific areas of concern for social workers and for integrated social care and health as a whole, revealing a number of themes present across the integration journey. While the majority of comments were negative, analysis reveals concerns shared by significant numbers of respondents: conceptual confusion in respect of organising integrated care within a health organisation, a lack of shared socialisation and the development of a shared culture within the integrated organisation, and the impact of economic austerity on integration.

Readers’ panel - Do we need a public debate about the limits of NHS care?

Readers’ panel - Do we need a public debate about the limits of NHS care?

The reality of care in the NHS

The reality of care in the NHS

Working in Partnership to Build Placement Capacity in a Competitive World

A number of higher education institutions (HEIs) report continual issues with placement cancellations due to a lack of commitment at practitioner level. Whilst there is a professional requirement to contribute to student education, it has been difficult to enforce accountability on autonomous practitioners. The culture of sourcing and allocating placements is problematic. As occupational therapists who supported student education in the NHS and Social Care, we have now become responsible for organising placement education opportunities for a HEI. This has provided a privileged insight into the differing cultures, expectations, and issues inherent to this collaboration. Tasked with making placement provision an attractive and quality experience through collaborative working in a competitive world, a new way of working was found to be required. In this reflective paper, we consider an allocation model as a method of building placement capacity whilst challenging cultural norms. The model has been successfully implemented, and is now in its third year of implementation. This new placement capacity model has reduced the time spent sourcing and allocating placements. Additionally, the number of cancellations has become negligible whilst the choice of placements for the HEI has increased.

Hip precautions after primary total hip arthroplasty: ‘It's what we’ve always done’

Purpose: Hip precautions are often advised following primary total hip arthroplasty (THA) for osteoarthritis (OA). Six centres delivering NHS care in the UK have removed standard hip precautions for these patients. The aim of this study was to explore the rationale behind both the continuation and discontinuation of hip precautions following primary THA for OA.

A 100 patient clinical evaluation of an alternating pressure replacement mattress in a home-based setting.

alternating pressure air mattresses (APAMs) support the prevention and management of pressure ulcers. A health and care NHS trust was seeking an APAM that would improve clinical outcomes in relation to pressure ulcers while considering financial cost. An APAM existed that could meet the trust's needs but there was a lack of evidence over its use in a community/home setting. This study examined the effect of using the Dual Professional (IQ Medical) APAM for patients at a high risk of pressure ulceration. It also determined patient and family satisfaction, and the views of clinicians in relation to clinical outcomes. Additionally, infection prevention and control, servicing, maintenance and electrical biomechanical engineer input were considered. a prospective observational study was undertaken of 100 patients in their own homes following a pilot study of 10 patients. The period of the evaluation was from one day up to 295 days, with a mean average of 83 days, and a total of 5809 bed days. with a regimen of regular repositioning of patients and a good diet, the APAM was effective in preventing pressure ulceration in the 100 patients who were at a high or very high risk of skin breakdown and pressure ulceration. selection of pressure redistributing surfaces should be based on holistic patient assessment, including risk assessment, mobility levels, grade of pressure damage and clinical judgment.

Leading support for those with mental health issues and learning disabilities

Alistair Quaile provides the highlights of the NHS Health and Care Innovation Expo 2017 session entitled Leading support for those with mental health issues and learning disabilities. It was a panel discussion with Professor Jane Cummings, Chief Nursing Officer, NHS England; Claire Murdoch, National Director for Mental Health, NHS England, and Chief Executive Officer, Central and North West London NHS; Vicky Stobbart, Executive Director of Nursing and Quality, Guildford and Waverley Clinical Commissioning Group; Julia Hunt, Director of Nursing at James Paget University Hospitals NHS Foundation Trust; Sue Hartley, Executive Director of Nursing, Birmingham and Solihull Mental Health Foundation Trust; Carl Shaw, Learning Disability Advisor; and Katy Chachou, peer support worker.

Putting Person Centred Pathways into Practice

The Advancing Quality Alliance (AQuA) is an NHS membership organisation based in the North West of England. AQuA has extensive experience of supporting and enabling change on a system wide basis over the past six years. In addition, AQuA has supported members to put patients and their families at the heart of the services they commission and provide, by ensuring their views are heard and they are involved in the review, design and improvement of services. In 2016, supported by a grant from the Health Foundation, AQuA undertook a 90-day rapid review into Whole System Flow across care systems. This created a huge amount of energy and interest from our members and so a 12 month discovery programme was developed. As part of this work, we piloted a programme with two localities to test the hypothesis ‘co-designing and commissioning services which are person centred will improve whole system flow, quality and cost’. We developed improvement plan outlines with each locality that were both cognisant of local context and also challenged the teams to consider a strategic ambition for testing coproduction and person centred approaches and improving whole system flow . The presentation will describe the programme of work and the key learning emerging from the pilot sites. We will describe how enabling a person centred approach to service design can deliver improved safety; productivity and experience of care. We will also share the operational, engagement and leadership challenges faced and describe the potential for increased coproduction within health and care services. The presentation will suggest how this approach can be replicated by commissioners, particularly where health and social care systems and their communities are coming together to jointly commission services for a defined population. Targeted population and stakeholders: The presentation will be of interest to NHS and Social Care Leaders and clinicians working in Primary Care, Commissioning, Acute hospitals, Mental Health, Community and Specialist services, patient leaders and involvement groups.

Progress in Building Integration: Lessons from Great Britain, Northern Ireland and the Basque Country

The integration of health and social care has been a constant policy goal of successive UK governments for over 40 years and is a contemporary priority now supported in Great Britain by legislation. It has been noted that the ‘imperative to integrate and transform has never been greater’ (NHS Confederation/Local Government Association, 2016). The main rationales for the importance of integration have also been largely accepted relating to; a holistic approach; facilitating a more person centred approach; producing a better experience and outcomes for users; reducing the complexity of organisational divisions, responding to more complex conditions and delivering more effective and efficient use of resources. Integration is also accepted as an appropriate response to increasing demands on both health and social care services. The challenges to transforming delivery are a consequence of well-established factors. Demographic change, with larger numbers of older people, changes in life expectancy, the needs of people with multiple health problems and complex conditions and large increases in the numbers of older people without a child to care for them if needed. The importance of integration has also been enhanced by the broader direction of change relating to health provision and the desirability of making a shift from acute hospital provision and institutional care to more community based provision covering community health services and social care. Integration is thus part of the envisaged transformation in care in health related areas. Other challenges have come from the impact of economic recession and austerity policy with reductions in the funding resources and increasing costs of services. The task of producing effective integrated care involves in Great Britain bringing together two separate institutional configurations, the NHS and local authority social services and also developing the delivery of integrated services and integrated practice. Numerous policy and delivery initiatives have been developed but generally progress has been piecemeal and limited. The Commission on the Future of Social Care (2014) noted the compelling case for bringing health and social care together, enabling better alignment of the two systems and leading to transformational change. In 2015 much closer integration of health and social care was identified as one of the three major challenges faced by the NHS (Ham, 2015). The Nuffield Trust (2015) has identified five factors to pursue in improving UK health care, each of which relates to integrated approaches, the NHS and social care reform; the quality of care; the workforce; new models of care delivery and older people and complex care. The existing, research on integrated care concludes that there is no one size fits all for achieving this ambition for integration, although factors such as leadership, financial incentives, clinical pathways and aligned IT systems have emerged as significant factors. This paper draws on the authors’ experiences of health and social care in Northern Ireland and the Basque country to suggest the key factors that drive transformation in healthcare systems and ensure that they achieve their full potential.

Initial learning from system wide feedback about an integrated physical and mental health, in-reach, service for care homes

Introduction: There are 35 million people with dementia worldwide, many of whom live in care homes. For example, in the UK one third of people with dementia live in care home facilites, and a large proportion of these individuals have moderate or severe dementia and have highly complex care needs. An Integrated Care Home Support Service adopted a stepped care model to deliver care and treatment of both physical and mental health problems with the aim of early identification of need. A qualitative study formed part of the overall evaluation of the project and presents an opportunity to enhance understanding of factors which are important to implementing integrated health care initiatives and to determine their impact and sustainability in a routine NHS setting. Methods: Eight focus groups were conducted with a range of stakeholders including Care Home Support Service staff, care homes staff, community physical and mental health teams in the NHS as well as a public and patient involvement group. A total of 39 stakeholders participated in the focus groups to explore their experience of the service, their perception of its impact as well as areas of further development. Results: Thematic analysis identified three key themes. The first theme highlighted the challenges of, and factors to consider when, implementing new models in the care home setting. The second theme reflected the importance of relationship building with stakeholders both outside of the NHS as well as within the organisation. The final theme highlighted the continuing needs of stakeholders including the importance of providing them with training and sharing knowledge. Discussion: There was consistency between the groups regarding the challenges of working into care homes. Whilst CHSS staff, care home staff and NHS teams all recognised the importance of relationship building when implementing services, views of these relationships as well as areas for development differed and needs to form part of project planning. The feasibility of creating more holistic care services was confirmed and the need for on-going review and training to respond to evolving cultural changes was highlighted. Conclusion: This qualitative evaluation with a broad range of stakeholders highlights a number of areas to consider when implementing a model of integrated care in care home settings. Lessons learned: The findings highlight the importance of attending to outward facing and specific team relationships, and the importance of reflective and reflexive practice in response to service change and feedback. Limitations: The research is relates to NHS and care home services within the UK and the findings may be context dependent. Suggestions for future research: Future research may benefit from considering the experiences of the stakeholders of services which have become more established to highlight key areas pertaining to sustainability.

Integrated care in practice

Introduction: System integration to achieve sustainable systemic change is not a new concept and something that has been around in International practice for a number of years. Experiential, comparative exploration of system models in Alzira, Boston and Washington DC (via an AQuA fellowship) highlight significant similarities with that of the Oldham economy, at the same time as identifying the stark difference in progress to develop and deploy sustainable system models in the UK. Oldham has taken learning from International best practice and used the intelligence and information to better shape the system in Oldham, aligned to the greater Manchester Devolution mandate. By deploying the same strategic approach as International models to the urgent care system in Oldham (via a multi agency alliance partnership) we are able to demonstrate sustained quality improvements for people and system flow via a number of innovative, transformational approaches that have sustained positive impact on a reduction in unplanned admissions in excess of the National expected average (3.5%). This achievement has received National recognition (NHS England) and also shortlist for two HSJ awards (integration and quality improvement). Description of practice change implemented: Oldham Urgent Care Alliance’s (a partnership of 8+ multi agency organisations) aim is to improve the urgent care system across the Oldham locality. It had a number of objectives: to reduce unplanned admissions to hospital by 3.5%, deliver a number of integration projects and take a performance management approach to the use of resilience funding. Via this approach a number of practice changes are evident, Development of a frail elderly unit which has reduced length of stay by 70-50% Development of a multi agency discharge to assess service, impacting upon admissions to residential and acute provision and improving quality of life Development of a multi agency Primary Care practice before the front doors of AE Pennine Acute Hospitals NHS Trust; Pennine Care NHS Foundation Trust; GotoDoc (a social enterprise providing an out of hours GP service) MIO Care, (a limited company owned by the council to provide homecare and re-ablement services), Voluntary Action Oldham; First Choice Homes; GP representation and Oldham CCG. Timeline: 12 months Highlights: (innovation, impact and outcomes) Sustained improvement in quality of care and life chances are evident as a result of deploying this systematic approach. A sustained reduction of 5.8% in unplanned hospital admissions achieved, despite an annual 6% increase in A&E attendances over the same period Total estimated system saving of £2.79m. Paediatric admissions Triage system introduced to assess conditions prior to admission. Almost 600 fewer paediatric admissions in 2015 compared with 2014 Alternative to transfer (minor injuries) A physiotherapy and occupational therapy service established enabling initial assessment of patients quickly to divert the patient from admission. Over 250 deflections from hospital achieved in 2015. Long term conditions Pro-active and self-management within the community. Almost 500 hospital deflections achieved in 2015, compared with the previous year. Early supported discharge for stroke rehabilitation 15 hospital deflections for stroke patients achieved in 2015. End of life care An overall reduction of the number of deaths in hospital per 1,000 population of 2% Intermediate care, A&E – therapy in-reach Over 250 additional hospital deflections in 2015. SPRINT (Senior persons resilience independence team) Reduced length of stay for over 85yrs by 70% Reduced length of stay for 65-85 yrs by 50% Comments on sustainability: Analysis of performance metrics continue to demonstrate sustained system impact despite growing demand. Review of quality impacts continue to yield positive impacts upon quality. Comments on transferability: The model can be replicated in any system/ care setting. Conclusions: The development of a systematic system leadership and governance approach via integrated working across a number of public, private and voluntary sector organisations has yielded a sustained impact upon quality and performance improvements within the urgent care system. The introduction of the Programme Management Office to co-ordinate and manage multiple projects across multiple partners was critical to the success of the transformation programme and the demonstration of sustained outcomes delivered. Discussions: This theory of change continues to be deployed within the Oldham urgent care economy and there are a number of other innovations that have been deployed as a result. This theory and concept has been driven forward by a sustained fastidious leadership approach across the system with interrogation of quality and performance data to evidence outcomes. Lessons learned: Sustained system leadership is critical to success Interagation of International systems has demonstrated the similarities between UK systems, which has been deployed further than theory and concept and implemented to make real and sustained system change Relationships across organisations are key to success Integrated working is a critical success factor Despite perverse financial incentives front line staff working in an integrated way can make real and sustained impact upon quality The deployment of quality improvement methodology enables and embeds rapid improvement

Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

BackgroundCare homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.ObjectivesTo understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.MethodsUsing realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.FindingsPhase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.LimitationsFindings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.ConclusionsNHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.