Strategic Health Authority Research Articles

A survey of the practice and experience of clinical educators in UK secondary care.

BackgroundExperiences and attitudes of clinical trainers of undergraduate medical students and postgraduate medical trainees in secondary care have received limited attention. Anecdotally, clinical teaching is becoming increasingly restricted by clinical service pressures, thereby presenting a risk to the quality of training provision.MethodsTo explore the commitment, experience and attitudes of clinical teachers and trainers of undergraduate medical students and postgraduate trainees, respectively, amongst secondary care providers across a UK Healthcare Workforce Deanery, an invitation to complete a study-specific, on-line survey, comprising predominantly yes/no response and 5-point Likert scale statements with some open questions, was sent to all registered secondary care trainers/supervisors working in the East Midlands Strategic Health Authority. The survey was open between February and June 2012, with two reminders to complete. Responses were anonymised and the frequency of responses to questions was analysed. Data were analysed for the whole study population and for the relationship between frequency of responses and gender.ResultsThe majority of teachers/trainers considered that they were well prepared and fulfilled their clinical teaching responsibilities. Many reported having restricted time for preparation and delivery and that teaching activities were often completed in their own time. Despite reported poor support and low incentives, many respondents felt valued for their clinical teaching by their Medical Schools and the Deanery, but less so by hospital Trusts.ConclusionsRespondents indicated that some faculty like and enjoy clinical teaching despite lack of allocated time, resources and recognition. The majority indicated that they feel confident and competent in their clinical teaching roles. Insufficient dedicated time due to competing clinical service pressures was reported as the major barrier to clinical teaching provision.

‘Publicity v Privacy: finding the balance’ When and how to publish reports of mental health homicide independent investigations

<p>In 1994 the Department of Health published its guidance on the discharge of mentally disordered people and their continuing care in the community (HSG (94) 27) which established, for the first time, that when a mental health service user kills someone <em>“it will always be necessary to hold an Inquiry which is independent of the providers involved”</em>. The independent investigation (as these inquiries are now called) would take place after the completion of any legal proceedings and its purpose was stated to be: <em>“To learn lessons for the future”</em>. The independent investigation would be commissioned by the responsible strategic health authority, which would also decide on whether to publish it and, if so, in what form.</p>

The NHS: A service under threat.

‘No more top-down re-organisation of the Health Service’. So said David Cameron in his pre-election statements. Then, as soon as the Tory Party was in office, along came Andrew Lansley with the biggest upheaval in the Service since Ken Clarke introduced the purchaser/provider split 20 years before. Quite apart from proposals in the 2012 Health and Social Care Act, unwelcome though they have been, it was always going to be problematic to introduce radical change at the same time as stringent financial constraints were being enforced. The ‘Nicholson Challenge’ of 2010 to make 4% ‘efficiency’ savings each year for 4 years, amounting to a total reduction of £20 billion, was never going to be straightforward. Couple that with the loss of Strategic Health Authorities and the introduction of new untried General Practitioner (GP)-led Clinical Commissioning Group (CCG.s), left the service behaving like a headless chicken as strategic oversight was lost regionally. The disappearance of managers made redundant by obsolete authorities and the re-employment of some in the new bodies led to a loss of continuity and collective memory. Now only a third of Chief Executives have been in post for more than a year and a half for over 2 years.1 Not a good way to introduce the changes that were needed to save money and improve the care of patients at the same time. I reflect elsewhere on the difficulty that new Secretaries of State for Health have in resisting the temptation to introduce a new Health Bill whenever they get into office.2 Politicians rarely recognize that reform does not always require legislation. We have had no less than 11 new Health Acts during the 14 years I have been in the Lords. The resulting re and re-re-organization (what Ray Tallis describes as re-disorganization) …

Perspectives on clinical leadership: a qualitative study exploring the views of senior healthcare leaders in the UK.

Clinicians are being asked to play a major role leading the NHS. While much is written on about clinical leadership, little research in the medical literature has examined perceptions of the term or mapped the perceived attributes required for success. To capture the views of senior UK healthcare leaders regarding their perception of the term `clinical leadership' and the cultural backdrop in which it is being espoused. UK Healthcare sector PARTICIPANTS: Senior UK Healthcare leaders METHODS: Twenty senior healthcare leaders including a former Health Minister, NHS Executives, NHS Strategic Health Authority, PCT and Acute Trust chief executives and medical directors, Medical Deans and other key actors in the UK medical leadership arena were interviewed between 2010 and 2011 using a semi-structured interview technique. Using grounded theory, themes were identified and subsequently analysed in an attempt to answer the broad questions posed. Not applicable for a qualitative research project RESULTS: A number of themes emerged from this qualitative study. First, there was evidence of changing attitudes among doctors, particularly trainees, towards becoming involved in clinical leadership. However, there was unease over the ambiguity of the term 'clinical leadership' and the implications for the future. There was, however, broad agreement as to the perceived attributes and skills required for success in healthcare leadership. Clinical leadership is often perceived to be doctor centric and 'Healthcare Leadership' may be a more inclusive term. An understanding of the historical medico-political context of the leadership debate is required by all healthcare leaders to fully understand the challenges of changing healthcare culture. Whilst the broad attributes deemed essential for success as a healthcare leaders are not new, significant effort and investment, including a physical Healthcare Academy, are required to best utilise and harmonise the breadth of leadership talent in the NHS.

Barriers to accessing HIV services for Black African communities in Cambridgeshire, the United Kingdom.

The majority of new HIV diagnoses in the United Kingdom (UK) occur in people with heterosexually acquired HIV infection, the majority of whom are African communities. Current research shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This study therefore explored barriers to equal access to HIV services by African migrants in the UK. Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, vol 3. University of California Press, Berkeley, 1980) model of health care systems was applied in this research as a theoretical framework and lens through which the reported findings are viewed as it places health within the broader context of culture. In this research a qualitative approach with focus groups was used. A total of thirty participants were recruited from African migrant community organisations in Cambridgeshire in the East of England strategic health authority in order to study the experiences of African migrants when accessing sexual health services. It was found that barriers to equal access to HIV services exist for African communities in Cambridgeshire. These included language barriers and others bordering on the use of traditional medicine by African migrants, understanding of cultural diversity, awareness of how and where to access HIV services, and getting information about HIV. Findings highlighted the importance of taking the sectors of Kleinman's [1] model into consideration when planning HIV services for African communities.

Association between Clostridium difficile infection and antimicrobial usage in a large group of English hospitals.

This study aimed to determine the association between the reduction in the number of Clostridium difficile infection (CDI) cases reported by the English National Health Service (NHS) hospitals and concurrent antimicrobial use. A retrospective ecological study for January 2005 to December 2008 was conducted using data from 26 of the 29 NHS trusts (i.e. a trust manages one or more hospitals) located in the North West Strategic Health Authority of England. Antimicrobial use data, for patients of all ages, were provided by IMS Health, and CDI case data for patients aged ≥65 years were provided by the Health Protection Agency. Antimicrobial use was converted into defined daily doses (DDDs). The overall association between antimicrobial use and CDI for the trusts was investigated using multilevel models. Our study shows a positive significant association between the CDI cases and the use of the following antimicrobials: ‘third-generation cephalosporins’ [11.62 CDI cases per 1000 DDDs; 95% confidence interval (CI), 5.92–17.31]; ‘fluoroquinolones’ (4.79 CDI cases per 1000 DDDs; 95% CI, 2.83–6.74); and ‘second-generation cephalosporins’ (4.25 CDI cases per 1000 DDDs; 95% CI, 1.66–6.83). The strength of this association was not significantly different (95% CI) among the antimicrobial groups. This study shows that the reduction in the number of CDI cases reported by the English NHS hospitals is associated with concurrent reductions in antimicrobial use. This means that the number of CDI cases over time decreased in a similar fashion to the usage of various antimicrobials.

The accuracy of existing prehospital triage tools for injured children in England: an analysis using emergency department data

ObjectiveTo investigate the performance characteristics in children with moderate and minor injuries of prehospital paediatric triage tools currently in use in England for identifying seriously injured children.MethodsEight prehospital paediatric triage...

“Risky Business”: a critical analysis of the role of crisis resolution and home treatment teams

Background: In 2000, the Department of Health for England recommended the creation of crisis resolution and home treatment teams (CRHTs) in order to reduce the number and length of psychiatric hospital admissions. Central to this was the role of gate-keeping all potential admissions.Aim: To examine the interface between crisis resolution and home treatment and other mental health services.Methods: Semi-structured interviews with mental health professionals (n = 25) at eight sites within one Strategic Health Authority region.Results: Despite wide variation in approach and provision, all teams were confronting common issues related to tensions at both ends of the service user trajectory – on initial assessment and on discharge.Conclusion: The CRHT model is likely to be most effective when there is low staff turnover, flexibility in inter-team working arrangements and senior practitioners have both acute and community experience. Rather than being seen primarily as gatekeeper to the acute service, it would be better to take a system approach and view the CRHT as a resource for clients awaiting discharge or seeking to avoid hospital admission that is equally available to both acute and community services.

Summary of: An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study

Contemporary evidence for the effectiveness of water fluoridation schemes in the U.K. is sparse. The utility of routinely collected data in providing evidence warrants further research. To examine inpatient hospital episodes statistics for dental extractions as an alternative population marker for the effectiveness of water fluoridation by comparing hospital admissions between two major strategic health authority (SHA) areas, the West Midlands SHA--largely fluoridated--and the North West SHA--largely unfluoridated. Hospital episodes statistics (HES) were interrogated to provide data on admissions for simple and surgical dental extractions, which had a primary diagnostic code of either dental caries or diseases of pulp and periapical tissues for financial years 2006/7, 2007/8 and 2008/9. Data were aggregated by SHA area and quinary age group. Directly standardised rates (DSR) of admissions purchased for each primary care trust (PCT) were calculated and ranked by index of multiple deprivation (IMD). A significant difference in DSRs of admission between PCTs in the West Midlands and North West was observed (Mann-Whitney U test [p <0.0001]) irrespective of IMD ranking. The difference in rates between the two most deprived PCTs was 27-fold. After ranking by IMD, DSRs of hospital admissions for the extraction of decayed or pulpally/periapically involved teeth is lower in areas with a fluoridated water supply. The analysis of routinely collected HES data may help identify the impact of water fluoridation schemes.

An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study

Contemporary evidence for the effectiveness of water fluoridation schemes in the U.K. is sparse. The utility of routinely collected data in providing evidence warrants further research. To examine inpatient hospital episodes statistics for dental extractions as an alternative population marker for the effectiveness of water fluoridation by comparing hospital admissions between two major strategic health authority (SHA) areas, the West Midlands SHA-largely fluoridated--and the North West SHA--largely unfluoridated. Hospital episodes statistics (HES) were interrogated to provide data on admissions for simple and surgical dental extractions, which had a primary diagnostic code of either dental caries or diseases of pulp and periapical tissues for financial years 2006/7, 2007/8 and 2008/9. Data was aggregated by SHA area and quinary age group. Directly standardised rates (DSR) of admissions purchased for each primary care trust (PCT) were calculated and ranked by index of multiple deprivation (IMD). A significant difference in DSRs of admission between PCTs in the West Midlands and North West was observed (Mann-Whitney U test [p <0.0001]) irrespective of IMD ranking. The difference in rates between the two most deprived PCTs was 27-fold. After ranking by IMD, DSRs of hospital admissions for the extraction of decayed or pulpally/periapically involved teeth is lower in areas with a fluoridated water supply. The analysis of routinely collected HES data may help identify the impact of water fluoridation schemes.

AN INNOVATIVE DEVELOPMENT APPROACH FOR ACUTE HOSPITAL SENIOR CLINICIANS TO IMPLEMENT THE NATIONAL EOLC STRATEGY 2008

BackgroundApproximately half the annual 600,000 deaths in England occur in acute hospitals although research indicates that most would choose to die elsewhere. The National End of Life Care Strategy encourages...

An exploration of how nurse prescribing is being used for patients with respiratory conditions across the east of England.

BackgroundThere is a need to reduce symptoms, exacerbations and improve quality of life for patients with respiratory diseases. Across the world, increasing numbers of nurses are adopting the prescribing role and can potentially enhance service provision. Evidence suggests improved quality of care and efficiencies occur when nurses adopt the prescribing role. No evidence is available on the views of nurse prescribers who care for respiratory patients. The aim was to explore how nurse prescribing is being used for patients with respiratory conditions in different care settings across one strategic health authority, and whether this has benefited patients, healthcare professionals and the National Health Service.MethodsA qualitative study involving semi-structured interviews with a purposive sample of 40 nurses who prescribed for respiratory patients across the six counties in the East of England Strategic Health Authority. Data were collected in 2011 and subject to thematic analysis.ResultsDisease management, including treatment and prevention of exacerbations, emergency episodes and minor illness, optimising and co-ordinating care were key aspects of care provided. Findings are reported under three themes: access, adherence and risk management and impact on nurses. Prescribing enabled nurses overcome existing problems in service provision to improve access, efficiency and patient convenience, reducing hospital admissions and length of stay. It also enabled patient centered consultations, which encouraged self-management, improved adherence, helped manage expectations, and reduced inappropriate service use. While participants experienced increased job satisfaction, knowledge and confidence, concerns were raised about increased responsibility, support, governance and future commissioning of services in line with planned major changes to the National Health Service.ConclusionsThis study provides new knowledge about how nurse prescribers provide care to patients with respiratory diseases. Despite a lack of consensus over the most effective model of respiratory care, prescribing was reported to have improved and extended points of access to treatment, and supported management of complex patients, particularly vulnerable groups. Given the high burden of chronic respiratory disease to patients and families this has important implications that need to be considered by those responsible for commissioning services in the United Kingdom and other countries.

Sport, physical activity and the establishment of Health and Wellbeing Boards in Nottingham and Nottinghamshire

This paper examines the emergence of Health and Wellbeing Boards in Nottinghamshire and the City of Nottingham and explores the implications for sport and physical activity. At the time of writing the transfer of responsibilities for public health and the establishment of Health and Wellbeing Boards in both the City of Nottingham and within Nottinghamshire County Council are considered to be relatively advanced by the Strategic Health Authorities, the respective local authorities and by the boards of the two Primary Care Trusts. “Shadow” Health and Wellbeing Boards have been established in both authorities and they have been meeting regularly for several months. Public health and commissioning staff have also been successfully relocated and new strategies and priorities are starting to emerge. Nottingham and Nottinghamshire have traditionally acknowledged the role of sport and physical activity to the wider determinants of public health and given a relatively high priority to the contribution that sport and physical activity can make to their preventative health and early intervention agendas. This paper looks at the transition to Health and Wellbeing Boards to assess how the role of sport and physical activity may be changing and to identify opportunities for its contribution to policy and practice in the future.It examines both the theory and practice behind the emerging governance arrangements, the strategic objectives and priorities, and the developing evidential base for future policy and delivery within the two areas.

Diversity and Scope of Senior Nurses’ Informal and Formal Experiences of Patient and Public Involvement in England

Patient and public involvement (PPI) has been recognized internationally. In England, NHS policies have increasingly emphasized the importance of patient-centered services, but limited evidence exists about the implementation of PPI policies and strategies within organizations. Few studies have explored health professionals’ perceptions of PPI and comparatively little is known about the experience of senior nurses. A national consultation utilising three focus groups aimed to explore senior nurses’ PPI experience. Four Strategic Health Authorities (SHAs) and eleven Primary Care Trusts (PCTs) in England, with fifteen senior nurses with leadership roles and direct PPI experience, participated. Focus groups were digitally recorded and transcribed verbatim; anonymised transcripts were validated by participants and analysed with thematic analysis. Sixteen categories emerged within five sub-themes of PPI experience: provision of information and raising awareness (1 category), informal generic PPI-activities not perceived as PPI (3 categories), formal generic PPI (3 categories), involvement of specific groups (5 categories) and PPI in commissioning and strategy (4 categories). Findings provided new insights into senior nurses’ experiences and evidence that progress towards meaningful, effective PPI remains slow. Nurses performed PPI in a pragmatic sense, by virtue of the nature of nursing, but they did not recognise or label these activities as such. However, a plethora and variety of innovative activities formally recognised as patient and public involvement were undertaken, together with specific networks and groups’ involvement, and involvement linked to commissioning and strategy. Enhancing awareness of nurses through education, together with monitoring and feedback mechanisms could support the PPI implementation and effectiveness at organisations.

Qualitative evaluation of general practices developing training for a range of health disciplines

This study adopted an interpretative approach, using focus groups and face-to-face interviews to evaluate the development of a five-year pilot project within general practice. The aim of the project is for these practices to offer training to a range of health disciplines from varying academic levels, develop capacity and provide interprofessional education as part of the learning ethos. Eight consortia are involved in the project, which is funded by the workforce and education directorate and the Deanery of the Yorkshire and Humber Strategic Health Authority. The evaluation was undertaken 18 months into the project, to understand the views and experiences of primary care practitioners and university educationalists, in order to identify achievements and barriers to the project's development. The study revealed positive attitudes towards the project, and that steps are being taken to engage in dialogue with universities to increase student numbers, but progress is slow. Early experiences of student nurses taking up placements in the practices reveal incompatible learning outcomes between what is expected for curriculum and learning opportunities within primary care. A common concern is the impact increased students may pose on existing support structures, and that this may compromise student learning. Concern is evident over self-belief and competencies to teach across professions, and the ambiguity over the learning outcomes for IPE and the training required to support this. It is recommended that a systems theory be adopted to provide strategic planning across clinical and education organisations to ensure that structures of communication, leadership and training adequately meet the aims of the project. The paper will be of interest to practitioners in primary care who may be considering expanding services and training, and to educationalists seeking to allocate students to placements in primary care.

Orbital Decompression for Thyroid-Associated Orbitopathy in England: Trends over Time and Geographical Variation

Aims: The aims of this study were to examine trends over time and geographical variation in the annual incidence of surgical orbital decompression for thyroid-associated ophthalmopathy (TAO) in England.Methods: Data on hospital admissions for orbital decompression surgery in patients with thyroid disease were analysed using English national Hospital Episode Statistics for admissions from 1991–2011.Results: Annual rates of orbital decompression surgery performed for patients with thyroid disease increased from 0.06 (95% confidence interval, 0.04--0.09) per 100,000 population in 1991, to 0.62 (0.54--0.67) in 2008, and then fell to 0.56 (0.48--0.60) in 2011. The surgical rate was highest in women aged 45--64 years. Geographical analysis showed significant variation across strategic health authority areas in surgical rates, from 0.22 (0.14–0.35) to 1.04 (0.79–1.34) people per 100,000 population per year in 2007–2011.Conclusion: The incidence of orbital decompression surgery performed annually in England has increased substantially over the past two decades, but peaked in 2008 and decreased since then. Significant geographical variation exists in surgical rates. Potential reasons for the decline include improved management of thyroid disease itself, but altered threshold in medical versus surgical management of TAO may also have played a role. The Amsterdam Declaration and EUGOGO treatment guidelines may also have influenced decisions about whether to operate on these patients.

The snakes and ladders of National Health Service management in England

This article explores managerial careers in the National Health Service (NHS) through the lens of talent management, particularly focusing on how managers view barriers (snakes) and facilitators (ladders) to career progression. There is a significant literature on enablers and barriers to career progression, but much of this focuses on specific groups such as black and minority ethnic and female workers, and there is relatively little material on the general workforce of the NHS. The research design is a mixed method quantitative (questionnaire) and qualitative (interview and focus group) approach consisting of a quasi-probability element that focuses on a maximum variety sample and a purposive element that seeks policy views at central and strategic health authority level, and examines talent management in high-performing NHS organisations. Ladders are identified as follows: volunteering, secondment, networking, mentoring, academic qualifications, development, good role models/managers and appraisal/personal development plan. Snakes are identified as managing expectations; identity and cognitive diversity; location; sector; NHS toxic and favouritism culture; poor talent spotting; credentialism; exclusive approach to talent; and sustainability. It concludes that while previous conceptual and empirical work is fairly clear on any ladders, it is less clear on snakes.

010 Inspiring compassionate care in an acute hospital setting – the power of QELCA

Transforming the traditional delivery of specialist end-of-life care education and training for nursing staff in acute hospital settings through the Quality End of Life Care for All (QELCA) education and...

Nurse–patient consultations in primary care: do patients disclose their concerns?

To quantify the extent to which patients disclose their concerns to community nurses during wound care consultations. Using an 'observation checklist' based on themes and subthemes that were identified in a previous study of the same patients, 20 wound care consultations were observed. The non-participant observer completed the checklist and made field notes regarding the context and nature of interactions. Patient participants had 160 opportunities to raise concerns regarding previously-identified pain, exudate and odour, yet they did not do so on 64 (40%) occasions. They had 28, 32 and 84 opportunities to raise emotional, wound care and daily living issues, respectively, and they did not on 16 (56%), 3 (9%) and 32 (38%) occasions. Overall, patients did not raise 38% of their concerns. Of the concerns that were raised, 8% were either not acknowledged or were disregarded by their community nurse. If these data are representative, this has profound implications for person-centred care and shared decision-making models of care, which are predicated on patients articulating their needs. They also have implications for the development of practitioners' communication and consulting skills.

A pilot study on the potential of remote support to enhance wound care for nursing-home patients

To evaluate the effectiveness of a telehealth system, using digital pen-and-paper technology and a modified smartphone, to remotely monitor and support the effectiveness of wound management in nursing home residents. A randomised controlled pilot study was conducted in selected nursing homes in Bradford, which were randomised to either the control or evaluation group. All patients with a wound of any aetiology or severity, resident in the selected nursing homes were considered eligible to participate in the study. Residents in the control homes who had, or developed, a wound during the study period, continued to receive unsupported care directed by the nursing home staff (defined as 'standard care'), while those in the evaluation homes received standard care supported by input from the remote experts. Thirty-nine patients with a wound were identified in the 16 participating Bradford nursing homes. Analysis of individual patient management pathways suggested that the system provided improved patient outcomes and that it may offer cost savings by improving dressing product selection, decreasing inappropriate onward referral and speeding healing. Despite initial anxiety related to the technology most nursing-home staff found the system of value and many were keen to see the trial continue to form part of routine patient management. The current study supports the potential value of telemedicine in wound care and indicates the value that such a system may have to nursing-home staff and patients. This study was funded by a Regional Innovation Fund grant from the Yorkshire and Humberside Strategic Health Authority. The authors have no conflict of interest to declare with respect to the article or its contents.