NHS Priorities Research Articles

The shortage of nurses: a reversing trend?

With fewer people becoming nurses, projections of the past years indicated a declining in the size of nursing workforce and forecast a shortage of up to 1 million of nurses. This trend seems revolving as in the US, due to a series of public and private initiatives, the number of applicants for nursing courses more than doubled since 1985. While the number of nurses is increasing, in some European countries, hospitals are facing a severe shortage of nurses, for costs constraints due to the economic crisis and a mismatch between health and NHS priorities and policies.

Understanding Social Preferences Regarding the Prioritisation of Treatments Addressing Unmet Need and Severity

Background: The UK Government is proposing to include “burden of illness” in its proposed scheme for the value‐based pricing (VBP) of branded medicines. The VBP consultation document suggests that medicines that tackle diseases associated with high levels of burden of illness will be rewarded more highly than those that do not. It includes a definition of burden of illness that incorporates consideration of severity (in terms of either length or quality of life) and unmet need (the degree to which treatments exist). However, there is a dearth of empirical evidence on societal preferences regarding this particular definition of unmet need.Objective: The aim of this exploratory study is to design and pilot an approach to eliciting public preferences regarding the prioritisation of health care resources according to unmet need and severity.Methodology: In face‐to‐face interviews, respondents answered 11 questions. Some of these involved the consideration of hypothetical priority setting scenarios; others involved consideration of pairs of statement about NHS priorities and required choosing the statement with which they most agreed. The various questions were designed to examine the extent to which respondents were willing to make trade‐offs between health gains, treating the severely ill, and addressing areas of unmet need.Results: Sixty members of the general public in southeast England were interviewed in May 2012. We find that maximising health gain is considered by most respondents to be more important than the competing objectives of giving priority to the severely ill and giving priority to treating conditions for which no alternative treatments exist. According to the interviewers, most of the respondents showed a good understanding of the survey tasks.Discussion and Conclusions: Some of our findings run counter to those of empirical studies elsewhere in the literature that examine social preferences regarding unmet need and severity. However, framing effects clearly are at play, since the level of support for an implied policy of giving priority according to unmet need varies greatly from question to question. A key finding is that people’s responses to stated preference questions appear to be influenced heavily by the ways in which the questions are framed.

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in “early adopter” hospitals

Objectives To evaluate the implementation and adoption of the NHS detailed care records service in “early adopter” hospitals in England.Design Theoretically informed, longitudinal qualitative evaluation based on case studies.Setting 12...

A career in stroke medicine

Stroke has become a major NHS priority. Daniel Davies and colleagues look at a career in the area

UK Stroke Forum 2009: main message from the pre-conference

Stroke remains one of the top three causes of death and the largest cause of disability in the UK (National Audit Office, 2010). Publication of stroke strategies have focused attention on stroke as an NHS priority (Department of Health, 2007; Scottish Government, 2009). This has provided leverage for increased funding to improve the quality of stroke care.

Cinderella service to health service priority: infection control in the UK

Reducing the morbidity, mortality and economic burden of healthcare-associated infection has become an NHS priority. However, this has not always been the case. The problems associated with hospital infection have been well known for some considerable time but historically the topic has been afforded scant resources, and relegated to 'Cinderella' status. This began to change when seminal epidemiological studies of the 1970s and 1980s identified the scale of the problem, and accelerated when adjustments to the management of the NHS throughout the 1990s encouraged Trusts to reposition infection control among their priorities. Since the turn of the century, infection control has become increasingly politicized and regulated. There are some suggestions that standards are improving and rates of meticillin-resistant Staphylococcus aureus and Clostridium difficile are falling. Whether or not Trusts are capable of bringing about change through a process of self-regulation, or whether meaningful change will inevitably require regulation and enforcement from outside agencies is an interesting point.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national...

The UK Model for System Redesign and Chronic Kidney Disease Services

The British National Health Service is a closed managed care system. This single health care system for the United Kingdom is funded by the government and paid for by general taxation. All UK citizens are registered with primary care physicians who control access to secondary care services. As a managed care system it should be able to offer integrated care across the whole patient pathway. In reality there are professional, organizational, and institutional barriers to coordination and delivery of care in the NHS. Historically, the United Kingdom has been among the lowest health care spenders of organizations for economic cooperation in developed countries, in absolute terms as well as proportion of the gross domestic product. However, since a Government pledge to place quality at the heart of the NHS and a commitment in 2000 to increase spending on the NHS, the NHS budget has more than doubled-an unprecedented rate of growth, roughly by 7.5% annually in real terms. A quality and outcomes framework has been introduced into primary care to systematically incentivize process measures such as computerization and chronic disease management by establishing practice-based disease registers. The strategic planning for kidney services in England has been developed in this national environment complemented by local research findings and the wider international consensus that has emerged since the publication of the classification of chronic kidney disease in 2002. This program of work has resulted in a paradigm shift from kidney disease being viewed as a secondary care condition to being a primary care priority as part of vascular disease control and management. In the first 2 years of the initiative more than 40% of the expected chronic kidney disease stage 3 to 5 population have been registered in primary care. Kidney disease now is recognized as a public health problem in the United Kingdom, preventative strategies are being integrated into comprehensive vascular risk assessment and management programs, and kidney disease has become an NHS priority area.

Palliative and end of life care of dementia at home is feasible and rewarding

Even though palliative care of dementia and care at home are key NHS priorities, services that set out specifically to support palliative care of dementia at home are virtually non-existent. We studied a novel service that has supported many people with advanced dementia at home through till death. Key factors for success include the right equipment, expertise around relevant medication, food, and social care needs, as well as understanding and support for funding care commissioning and informal care. The study revealed blockages to accessing support as a result of poor understanding of the needs of advanced dementia care as well as organizational prejudice. We demonstrate that good, home based palliative care of dementia can be achieved with very positive outcomes. Bereavement may be helped by the process of caring at home till death. Given that the Audit Commission has cited home care of advanced dementia as good value for money, it is of grave concern that services to support people with advanced dementia at home are not available.

NHS and charitable funding for children and young people with cancer in England and Wales

In 2005 the National Institute for Health and Clinical Excellence Guidance on Cancer Services: Improving Outcomes in Children and Young People with Cancer, identified the need to quantify the substantial contribution made by charities to NHS provision to this group of patients. This article quantifies the contribution in England and Wales. It identifies 51 charities established specifically to assist this patient group, estimates that 340 charities made some financial contribution and 28 organizations administered charitable funds for hospices. The financial contribution to services by charities was estimated to be between pound25 million and pound38 million in 2003, representing between one-third and a half of the total resources directed to the treatment and support of children and young people with cancer in specialist centres across England and Wales. Reliance on the substantial charitable funding of health care in England and Wales raises concerns over government responsibility, and the potential misalignment between NHS priorities and those of the charities.

The effect of the new GMS contract on GP appointment provision in Wales: postal questionnaire survey of practice managers.

BackgroundAccess to health professionals is a key UK NHS priority, and meeting access targets is rewarded through the new General Medical Services (GMS) contract in the UK. We sought to determine the current state of appointment provision in Wales and any changes resulting from the need to meet indicators in the new GMS contract. We undertook a postal questionnaire study of practice managers in all general practices in Wales.FindingsValid responses were received from 396/505 (78.4%) practice managers. 361 (93.1%) practices reported that they had achieved the target for 2004/05. 104 (26%) practices reported that they were 100% open access/advanced access. The most frequent changes reported in response to the new GMS contract were offering more open or advanced access slots (237, 60%), more GP phone consultations (167, 42%), introducing a telephone triage system (100, 25%), introducing a minor illness clinic (76, 19%), and employing or training a nurse practitioner (59, 15%). 83% practice managers believed that patients were able to get an appointment at the time they need it either 'all of the time' or 'most of the time', and 70% that patients were able to get an appointment with the GP of choice either 'all of the time' or 'most of the time'.ConclusionThis survey has demonstrated the current extent of appointment provision in Wales, and how changes have been driven by incentives. Whether these changes are in the best interests of either patients or doctors, or both, remains to be seen.

Surgical training - can we learn from aviation?

The following two articles identify similarities between professional air crew and surgeons, both being leaders of multidisciplinary teams and holding ultimate legal responsibility. In the first article, British Airways training captain Guy Hirst illustrates the non-adversarial teamwork inherent in effective crew resource management with confidential reporting of adverse incidents and the care with which flight instructors are selected and nurtured. Denis Wilkins, a senior surgeon, demonstrates in the second article that nobody takes responsibility for the 'signing off' of trainees for any particular surgical procedure. There are, of course, differences in the training environments of the professions. Advance flying training requires a student pilot to put an aircraft into critical situations and to demonstrate the ability to recover. Mostly, this can be performed repetitively either at sufficient altitude or in the safety of a simulator. In surgery, one cannot purposely put a patient 'at risk' to enable trainees to demonstrate their skills at 'recovery' and surgical simulators are in their infancy and do not achieve priority in a cash-strapped NHS. The authors recognise the need for properly selected trainers who are remunerated accordingly. Having been both a flying instructor and a surgical trainer, I can testify that both professions require patience, rapid reactions and the ability to remain calm. These papers are fascinating and timely in the era of introduction of new surgical curricula. Surgical training requires considerable funding at grass-roots level to catch up with the standards of aviation.

OUTCOME EVALUATION OF A BRIEF SHARED LEARNING PROGRAMME IN COGNITIVE BEHAVIOURAL THERAPY

The purpose of this study was to evaluate a new brief training programme in Cognitive Behavioural Therapy (CBT) within a waiting list control group design. A consecutive sample of 90 mental health professionals were allocated routinely by their managers to be trained in CBT. Over 12 week training periods, these 90 professionals received a total of 48 hours of shared learning, covering core CBT theory and techniques for depression and anxiety. An experiential workshop format was utilized throughout and a comprehensive outcome evaluation was conducted, using multiple measures and methods. The findings indicated that the training was effective in terms of the favourable reactions of the participants, the knowledge and skills they gained, and the generalization of this learning to their work environment. It is concluded that brief shared training in CBT can be successful, in line with current NHS priorities.

Developing integrated CAM services in Primary Care Organisations

Objectives: To explore policy development and the provision of integrated NHS CAM therapy services following the reorganisation of UK primary care services in 1999. Design: Structured survey interviews with Chairpersons in a stratified random sample of 72 Primary Care Organisations (PCOs) in England in 1999 and 2000; semi-structured telephone interviews with purposive samples of (i) providers of primary care CAM services (mostly General Practitioners), and (ii) Commissioners of primary care services in two purposive sub-samples of PCOs involved in positive policy formation in relation to CAM. Results: By the end of 2000, it is estimated that 85% of PCOs in England (95% CI 78–91%) had discussed CAM at board level, and 37% (95% CI 26–48%) had at least one CAM policy in place. The dominant strategy that emerged was a policy of ‘provide and review’, particularly in practices that had managed their own budgets under the previous fundholding system. We found that a small number of PCOs were developing area-wide services. Positive influences or ‘drivers’ for CAM policy formation were identified as: existing services, local enthusiasm and expertise, patient demand, a willingness to consider the wider evidence-base for CAM, and a perception that complementary therapies could help the PCOs to meet national NHS targets. Negative influences included: the cost of ensuring equitable access to services, a perception that CAM lacks the credibility required for public funding, the need to prioritise services and the need to direct funding towards meeting national and local health objectives. Conclusions: Opportunities for development of integrated NHS services are most likely to occur where CAM provision is seen as a potential solution to an NHS problem. Locality-based, integrated CAM services that are responsive to NHS priorities may offer a model for the future development of CAMs in primary care.

Rationing treatment on the NHS--still a political issue

Rationing treatment on the NHS--still a political issue

Valuing Health for All: PCTs and the Health of People with Learning Disabilities

Findings and good practice are reported from a project promoting engagement of PCTs with the health experiences of people with learning disabilities. Project work was most successful where it linked into mainstream NHS priorities, using good information and specialists' expertise to support mainstream practitioners.

The Health of People with Learning Disabilities in the UK: Evidence and Implications for the NHS

The paper presents a comprehensive review of the UK research literature on the health needs of people with learning disabilities, and the response of mainstream health services to those health needs. Evidence from the review, although limited in some areas, clearly demonstrates that people with learning disabilities in the UK have significantly poorer health than the UK population generally in a number of priority areas for the NHS. Furthermore, people with learning disabilities have particularly poor health in a number of additional areas involving significant mainstream NHS resources. Despite these considerably greater health needs, people with learning disabilities receive poorer support from mainstream health services, across primary care, hospital services and screening programmes.The findings of the review indicate that mainstream NHS services should not only include people with learning disabilities, but also prioritise them as a particularly vulnerable group requiring urgent attention if general NHS priorities for health inequalities and service standards are to be met.

A Time-limited model of art therapy in general practice

This article describes an innovative project which was inspired by a successful pilot study of art therapy in a rural GP setting (see Sowton, 1997). The present project was designed to provide art therapy as a complementary treatment for mental health problems in a Scottish urban primary care setting, and to implement an NHS priority by developing an innovative treatment for mental health problems. The project involved an independent formal audit using quantitative and qualitative measures. The article gives an overview of the prevailing conditions at the GP surgery, the contact between the therapist and the doctors, the types of referrals made, and the patients responses. The author shows how a flexible time-limited model was developed, which allowed the patient a short introductory period to overcome their fear of therapy and was followed by a longer period in which the patient could explore new options and build up strengths. Neither budgetary constraints nor the advocacy of alternatives to drug therapy are seen as the prime determinants of such therapy. Reference is made to counselling models developed in similar settings and it is concluded that art therapy can take its place alongside counselling as a suitable treatment for mental health problems in general practice.

Consortium management of triple therapy cost pressures for HIV/AIDS in the North East of England

Reviews NHS policy for the introduction of new technology and drug developments into the NHS with reference to HIV therapy. Also reviews current policy issues related to NHS rationing and priority setting with reference to commissioning services for HIV infection and AIDS. Confirms the destabilisation of HIV contracts in the North East of England caused by the introduction of double therapy in 1996 and triple therapy in 1997 in relation to the above policy areas. Also reviews purchaser and provider contracting following the introduction of triple therapy for HIV infection. Finally, concludes by reviewing local policy and management arrangements and recommendations for change.

Opinions of patients and the public regarding NHS priorities.

The purpose of this study was to ascertain the views of patients and the public on NHS priorities. Data were gathered by interview questionnaire throughout Edinburgh city centre, and within various departments of one large teaching hospital. Of the 1502 responses, 462 were from within the hospital and 1040 were from city centre locations. 1497 (99.7%) were in favour of treating emergencies, and 1467 (97.7%) life threatening conditions as a priority. 1315 (88%) agreed that treatable conditions that seriously affect quality of life should also be considered a priority and 1127 (75%) were in favour of treating patients with incurable terminal disease regardless of cost. In order to provide these services 584 (39%) considered it acceptable to make patients with less serious conditions wait longer. Of the 918 (61%) who considered it not acceptable to wait longer 812 (88%) would be prepared to pay more in tax to provide this. The General Public do support the treatment of emergency and life threatening conditions as an absolute priority. The majority also support the prioritization of conditions which are treatable and seriously affect quality of life. If in establishing these priorities waiting times for other conditions are likely to rise, the public would generally accept increased taxation or some form of fee for service.