NHS Modernisation Agency Research Articles

One door closes, another opens: Surviving and thriving through organizational restructure by ensuring knowledge continuity

Since the 2001 formation of the NHS Modernisation Agency, service improvement organizations in the NHS have regularly faced organizational restructure. Through successive restructures, there has been a growing awareness of the need to preserve organizational memory. In 2015, faced with the largest upheaval in NHS service improvement history, one knowledge team took steps to enable ‘knowledge continuity’ – the process of capturing organizational memory as one organization closes and transferring it to a successor organization. This article outlines the actions the team took to capture and migrate a wealth of NHS service improvement knowledge content and their actions to reconfigure the content for its new organizational home. The team selected and tagged content that aligned to business priority and enabled user access through the development of a SharePoint-based knowledge hub. With the necessary actions to secure knowledge continuity achieved, the knowledge team redefined its role, building a 5Cs knowledge service of content, curate, collaborate, consultancy and capability. The article concludes by looking positively towards the future and outlining lessons learned. With new knowledge products and an external improvement hub, and working more closely than ever before with their stakeholders, the knowledge team have not only survived organizational restructure but have begun to thrive.

Successful development and testing of a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS)

ObjectivesTo develop a tool for the accurate reporting and aggregation of findings from each of the multiple methods used in a complex evaluation in an unbiased way. Study Design and SettingWe developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) within a gastroenterology study [Evaluating New Innovations in (the delivery and organisation of) Gastrointestinal (GI) endoscopy services by the NHS Modernisation Agency (ENIGMA)]. We subsequently tested it on a different gastroenterology trial [Multi-Institutional Nurse Endoscopy Trial (MINuET)]. We created three layers to define the effects, methods, and findings from ENIGMA. We assigned numbers to each effect in layer 1 and letters to each method in layer 2. We used an alphanumeric code based on layers 1 and 2 to every finding in layer 3 to link the aims, methods, and findings. We illustrated analogous findings by assigning more than one alphanumeric code to a finding. We also showed that more than one effect or method could report the same finding. We presented contradictory findings by listing them in adjacent rows of the MATRICS. ResultsMATRICS was useful for the effective synthesis and presentation of findings of the multiple methods from ENIGMA. We subsequently successfully tested it by applying it to the MINuET trial. ConclusionMATRICS is effective for synthesizing the findings of complex, multiple-method studies.

S85 Initiation of long-term non-invasive ventilation enables successful weaning from prolonged mechanical ventilation

IntroductionProlonged mechanical ventilation is an increasing workload for intensive care units (ICU). Units distinct from ICU can provide step-down care for stable slow-to-wean patients and facilitate weaning by the use...

Framing quality improvement tools and techniques in healthcare

The purpose of this paper is to present a study of how quality improvement tools and techniques are framed within healthcare settings. The paper employs an interpretive approach to understand how quality improvement tools and techniques are mobilised and legitimated. It does so using a case study of the NHS Modernisation Agency Improvement Leaders' Guides in England. Improvement Leaders' Guides were framed within a service improvement approach encouraging the use of quality improvement tools and techniques within healthcare settings. Their use formed part of enacting tools and techniques across different contexts. Whilst this enactment was believed to support the mobilisation of tools and techniques, the experience also illustrated the challenges in distributing such approaches. The paper provides an important contribution in furthering our understanding of framing the "social act" of quality improvement. Given the ongoing emphasis on quality improvement in health systems and the persistent challenges involved, it also provides important information for healthcare leaders globally in seeking to develop, implement or modify similar tools and distribute leadership within health and social care settings.

MATRICS: A Method for Aggregating The Reporting of Interventions in Complex Studies

Background There are few rigorous methods for combining qualitative and quantitative findings from studies with complex interventions using multiple research methods and giving appropriate weight to each without introducing bias to the overall conclusions. We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) for the ENIGMA study (Evaluating Innovations in Gastroenterology by the NHS Modernisation Agency) – a multicentre, mixed-methods study to evaluate the impact of the Modernising Endoscopy Services programme [1], funded by the UK National Institute for Health Research (NIHR SDO ref 08/1304/46).

Ductal carcinoma in situ of the male breast presenting as adolescent unilateral gynaecomastia

A 17 year old male patient was referred to the breast surgery service with a unilateral swelling of the left breast. Subsequent evaluation led to discharge with a diagnosis of adolescent gynaecomastia. Four years later the same patient was referred back to the breast surgery service and the referral was turned down without a consultation as the surgical treatment of gynaecomastia was not funded by the local Primary Care Trust (PCT). Three years following, this now 24 year old gentleman was referred to the Plastic surgery service at the Hospital Trust where he had been initially referred as a 17 year old. He underwent a nipple sparing mastectomy through a peri-areolar incision. The histology amounted to a diagnosis of ductal carcinoma in situ (DCIS). A literature review revealed the rarity of pure DCIS in the adolescent male. The variation in availability of treatments across the National Health Service in England has lead to a "postcode lottery" due to "rationing" decisions being made by individual Primary Care Trusts. "Action on Plastic Surgery", an NHS Modernisation Agency document, was designed as an aid to PCT's making funding decisions on Plastic Surgery patients in 2005. The case described in this report illustrates the difficulty in clinical diagnosis of a male breast lump. This persistent lesion was sampled on 2 separate occasions with fine needle aspiration, neither aspirate raising the possibility of DCIS. In conclusion this case describes a rare pre-malignant condition of the male breast. Complete histology of such a lump is the only conclusive investigation necessary and the limitations put upon the surgeon by the "rationing" of such treatment must be overcome on clinical grounds.

The best job I've had.

MY INTEREST in strategy and service improvement really started developing when I worked at the NHS Modernisation Agency with health professional teams and in the clinical governance support team.

Day case and short stay surgery: 2

Day case and short stay surgery: 2

What is in a name — patients' view of the involvement of ‘care practitioners’ in their operations

There has been a plethora of new job titles emerging in the NHS. While the term 'nurse practitioner' was fairly well received, and offers a pretty clear indication of the background of the person working, other new titles can be misleading. Since 2003, when the NHS Modernisation Agency proposed its 'Changing Workforce Programme', nurses and other allied health professionals were recruited and trained to perform 'simple operations'. The surgical care practitioner is being developed along with other practitioners. To find out whether patients are able to identify healthcare professionals by their title and what do patients think about a non-medically qualified person carrying out their operations. A cross-sectional survey of ENT patients using a questionnaire. Titles similar to those of medically qualified professionals--anaesthetic practitioner, consultant nurse and surgical care practitioners--can lead patients to think that they are doctors. Fifty-three per cent of the respondents agreed that not all hospital visits need to be attended by a doctor, but if an operation is needed, 92% of respondents thought it should be carried out by someone who is medically trained. Ninety-four per cent stated that they should be informed if this is not the case. Seventy-nine per cent of the respondents stated that they would rather wait longer to be operated on by a doctor than being operated on earlier by someone who is not medically qualified but trained to perform the operation only. This result is significant, p<0.001). Patients do find the different titles confusing, with many preferring a more transparent approach in knowing who their surgeon is. The majority would prefer to wait longer for their operation if this means it is carried out by a doctor.

Pharmacology - a systems approach: introduction

Medicines administration is a common but extremely important aspect of care delivery that is performed within many healthcare settings. In a previous article by Dickens (2007) it was discussed that on occasion medicine administration is delegated to healthcare assistants (HCAs) by qualified nurses to improve the timely delivery of medication in the patient’s best interests. In a document titled Medicine Matters, it states that any authorized member of healthcare staff who is suitably trained can administer medicines from a patient specific instruction. (NHS Modernisation Agency and Department of Health, 2005). For example, if Dr. Watson prescribes 1 gram of paracetamol to be administered orally to a patient Mr. Wood, the HCA, provided they have had suitable training and have been authorized by their manager, can administer this medication to Mr. Wood.

Prospective Evaluation of a Novel One-Stop Testicular Clinic

In 2003, the waiting time for routine scrotal assessment approached 6 months in our hospital. The patients' diagnostic pathway was not uniform and involved several delays between general practitioner, radiologist and urologist. If malignancy was suspected, patients were seen and assessed within 2 weeks. However, it was possible for patients with unsuspected malignancy to have their diagnosis delayed. Funding was provided by the NHS Modernisation Agency's Action On Urology project. Men who were referred by their general practitioner (GP) with a testicular or scrotal condition would be reviewed in a one-stop joint sonographer and urology nurse specialist clinic provided entirely within the urology department with rapid open access. Data were prospectively collected for 2 years. Source of referral, suspected diagnosis, findings and outcome were recorded. A total of 1017 patients attended the clinic over this period; of these, 203 (4%) were referred under the '2-week wait' criteria. Of patients attending the clinic, 79% were discharged to GP care, 8% were added to the waiting list for a surgical procedure and 20% were referred with 'testicular lump'. Eleven patients were suspected to have testicular tumour on ultrasound and proceeded to orchidectomy in this period. One patient (0.1%) was found to have an unsuspected seminoma. The waiting time for all scrotal ultrasound examinations has fallen from 22 to 2 weeks. The waiting times for intravenous urography and general ultrasound were also significantly reduced following the introduction of this service (P = 0.005). The majority of patients passing through this clinic are the 'worried-well' with benign scrotal pathology. They can now be seen within 2 weeks regardless of whether their GP suspects testicular tumour. This reduces anxiety in this large group of patients freeing capacity elsewhere in the diagnostic imaging department.

What the journals say

The NHS Cancer Plan (Department of Health, 2000), Improving Outcomes guidance (National Institute for Health and Clinical Excellence, 2001) and the NHS Modernisation Agency′s 10 High Impact Changes (2004) will all ultimately affect the way future cancer care is delivered. They have been developed to ensure quality assurance of services, allowing for growth and development. Acknowledging that the clinical nurse specialist plays a pivotal role within the cancer team, providing expert knowledge to ensure the delivery of high-quality standards of care, the authors take this opportunity to explore specific areas of the cancer pathway.

Cancellations of elective orthopaedic procedures

PurposeThe purpose of this paper is to find the incidence and medical reasons for cancellations of elective orthopaedic cases following admission for an operation in a district general hospital. The paper also aims to determine the deficiencies in the local preoperative assessment protocol.Design/methodology/approachThis is a retrospective study. The elective orthopaedic surgeries cancelled following their admission into the hospital due to medical reasons between January 2003 and December 2004, were identified. These cases were reviewed using the preoperative assessment charts and case notes. The NHS Modernisation Agency's guidelines,National Good Practice Guidance on Preoperative Assessment for Inpatient Surgery, are taken as the benchmark for comparison.FindingsThe paper finds that 44 elective orthopaedic cases were cancelled due to medical reasons. Of these patients, 64 per cent did not have a pre‐operative assessment prior to the admission for the planned surgery; 6 per cent had inadequate documentation of relevant past medical history; and 30 per cent (patients with significant medical problems) were not referred to the anaesthetist for advice although these problems were identified during the pre‐operative assessment.Research limitations/implicationsIt is possible to stimulate good medical practice through audit.Practical implicationsCancellation of an elective operation is not uncommon in hospital practice. This paper aims to highlight the possible avoidable causes for such cancellations. The paper identifies such deficiencies in the local preoperative assessment protocol and suggests remedies to improve the quality of care. These improvements and close adherence to the guidelines are important as preoperative assessment by nurse‐led clinics are being increasingly practised through out the UK.Originality/valueThe paper fulfils its aims of identifying the medical causes for cancellation of an operation and also the existing deficiencies in the preoperative assessment practice. The paper values the importance of adherence to NHS Modernising Agency's guidelines in preoperative assessment. It is useful not only to the Orthopaedic department but also to the department managers.

The hospital at night: a service evaluation of the role of the paediatric night sister

The objective of this evaluation was to review the role of the paediatric night sister in a large regional children’s unit in the south of England in the light of the NHS Modernisation Agency report, The Hospital At Night (Modernisation Agency, 2004). It aimed to compare and contrast the role of the traditional night sister with that of an internal rotational model. A single-site case study service evaluation was undertaken using non-participant observation of the night sister role over two full night shifts, a questionnaire, semi-structured interviews with night duty nursing and medical staff, and analysis of night sister diaries. Two full-time night sisters and 34 night nursing and medical staff took part. The review obtained a description and analysis of night sister roles, the views of staff towards the role of the night sister, an insight into enhanced skills acquisition of night sisters, and makes recommendations for future utilisation of the night sister role. Most respondents were very supportive of the traditional night sister role but were critical of the lack of collaboration between the night medical and nursing teams.

Bilateral breast reduction surgery in England: a postcode lottery

There is good evidence for the benefits of bilateral breast reduction (BBR). However, such surgery is often considered cosmetic and is rationed. The NHS Modernisation Agency and the British Association of Plastic Surgeons (as was) have produced national guidelines, but Primary Care Trusts adapt these for local implementation. We surveyed the funding criteria for BBR of all 303 Trusts in England. 245 (81%) responded. The NHS guidelines were followed accurately by only 11 Trusts. 198 trusts specified a maximum BMI (range 25 to 32; guideline 30). 187 accepted musculoskeletal symptoms as an indication and 117 accepted intertrigo. 31 required a professionally fitted bra. Many Trusts included other restricting criteria that are not in the NHS guidelines. Some Trusts mentioned the American Society of Plastic Surgeons' guidelines, but did not follow them wholly. Even with explicit guidelines, considerable variation in local funding criteria exists with resultant inequalities in provision. The so-called 'postcode lottery' of healthcare in the UK is rife within Plastic Surgery. The recent reconfiguration of English Primary Care Trusts provides an excellent opportunity for the rationalisation of BBR provision and to this end we will distribute our findings and the NHS guidelines to the new Trusts and to the National Institute for Health and Clinical Excellence.

‘Research into Practice’: a model for healthcare management research?

English Traditional modes of researching health service practice and policy have been criticised in terms of timeliness and relevance by potential users, and of poor uptake by researchers themselves. Newer models, based on principles of collaboration and integration, are being used in some healthcare settings, and there is evidence that these approaches help to bridge the gap that exists between ‘research’ and ‘practice’. This article describes the work of a small research team within the former NHS Modernisation Agency, appropriately named Research into Practice, and reflects on its experience of using collaborative and integrative approaches to its work.

The Expert Patients Programme

PurposeTo describe the purpose, establishment, work and achievements of the Expert Patients Programme (EPP) of the NHS Modernisation Agency's Clinical Governance Development Programme.Design/methodology/approachThe Expert Patients Programme (EPP) is one initiative of the Clinical Governance Support Team (CGST) which provides support for health professionals in implementation of the NHS Clinical Governance Programme arising out of the early work of the Patient Experience Team (PET). “Expert patients” are those with experience of self‐management of long‐term conditions and the programme centres on developing a model of peer support for patients with similar conditions. The EPP team has built on work at Stanford University in the USA where patients and their carers provide peer advice and support – an initiative termed “lay‐led self‐management”. The EPP team developed a six‐week course facilitated by trained lay people based on the Stanford “Chronic Disease Self Management Course” (CDSMC). This course was incorporated in a pilot study which ended in 2004 and in which the NHS collaborated with accredited voluntary organisations. A total of 98 per cent of Primary Care Centres in the UK took part. The methodology and benefits of the support programme are outlined.FindingsEvaluation by questionnaire confirms data from other countries on showing improvement in patients' conditions and a decrease in their use of health services. Access to the EPP programme is to be widened and will be available throughout the NHS by 2008.Originality/valueAn account of the formation, activities and outcomes to date of the EPP programme are provided.

Communication interaction in ICU—Patient and staff experiences and perceptions

Patients on intensive care units (ICU) have difficulty with communication [Menzel LK. Factors related to the emotional responses of intubated patients to being unable to speak. Heart Lung 1998; 27(4):245-52]. Feelings of anger and low mood have been reported, which can lead to reduced participation in rehabilitation. For members of the multidisciplinary team breakdown in communication with patients may be frustrating and related to a limited knowledge of strategies and resources to facilitate communication. The NHS Modernisation Agency Critical Care Programme (2002) identified speech and language therapists (SLTs) as having a role in the assessment and management of patients with communication difficulties on ICU. This multi-centre pilot study aimed to investigate staff and patient perceptions and experiences of communication within ICUs. A short questionnaire was devised using semi-structured interviews to collect quantitative and qualitative information. Patterns were identified including insights into SLT service delivery and possible directions for future research and development.

Report on the proceedings of ‘E-learning in health and social care – theory to practice’ North East Wales Institute, Wrexham, Friday, 18th March 2005

The North East Wales Institute for Higher Education (Wrexham) was host to its first ‘E-learning in health and social care – theory to practice’ conference, held on Friday, 18th March 2005. In recent times, a plethora of events addressing various aspects of E-learning have taken place around the UK but with few focussing on its development and application in the field of health and social care, this observation being the impetus for this conference. Delegates were welcomed from organisations throughout the United Kingdom, which included many FE and HE institutions, practice settings, local voluntary organisations, the Royal College of Nursing, Social Care Institute for Excellence, Macmillan National Institute of Education, NHS Modernisation Agency, Health Professions Wales, The Open University in Wales and the JISC Regional Support Centre (Wales). It was envisaged that the conference would provide delegates with the opportunity to celebrate and share good practice and experiences whilst reflecting on their own E-learning endeavours and

Support workers in intermediate care

Despite the proliferation of support worker roles in the UK, little is known about their actual numbers, employment conditions or levels of training. Intermediate care services appear to be an important employer of support workers, but the diversity of intermediate care services makes the task of understanding support worker roles even more complex. This paper presents data from 33 services which were involved in an NHS Modernisation Agency's Changing Workforce Programme project, the Accelerated Development Programme for Support Workers in Intermediate Care in England. Within this project, the main employers of support workers were primary care trusts and/or social services. Participating intermediate care teams were involved in admission avoidance, assisted discharge and reablement, or combinations of these services, and the majority of care was provided in the patient's own home. The 33 services employed 794 support workers and 368 professionally qualified staff. The mean ratio of professionally qualified staff to support workers was 0.95 (range = 0-4.9, SD = 1.05). Support worker roles included multidisciplinary working, meeting rehabilitation needs, providing personal care and enablement. Team leaders included nurses, social workers, physiotherapists, professional managers, home carers and support workers. The most commonly reported sources of support worker training were National Vocational Qualifications and in-house training. In 80% of the services, at least half of the support workers had a qualification. Three models of supervision emerged across the services: the allocation of a mentor; team supervision; and formal and informal line management. These findings illustrate the diversity of employment of support workers in intermediate care. The variations in training, supervision and skill mix have implications for clinical governance and support worker regulation. The employment of support worker staff jointly across health and social care raises cross-boundary issues around employment contracts and pay.