Strategic Health Authority Research Articles

Government must act to ease strain on GPs, say Nuffield Trust and King’s Fund

NHS England must take action to ease the “significant strain” on UK general practitioners to encourage primary care to focus more on population health, a report has concluded.1 The report, by health think tanks the Nuffield Trust and the King’s Fund, said that NHS England should work with clinical commissioning groups to give GPs “support, incentives, and permission” to test out new approaches to delivering and organising primary care. The review, commissioned by the former NHS Midlands and East Strategic Health Authority, assessed 21 different models of primary care organisation on their capacity to offer an extended range of services, including rapid and local access to generalist and specialist advice, effective population health strategies, and new forms of care …

Development of maternity dashboards across a UK health region; current practice, continuing problems

ObjectiveTo assess the development of local clinical dashboards in line with UK national guidance and to identify ongoing issues being faced by maternity units, across an entire health region, in developing quality assurance systems. Study designA mixed-methods study involving all consultant-led maternity units in the South West of England Strategic Health Authority region (SWSHA). An electronic survey, followed by semi-structured interviews with the lead obstetrician and risk management midwife (or equivalent) of each maternity unit, to investigate methods employed to monitor outcomes locally, particularly the development of tools including maternity dashboards. Interviews were audio recorded, transcribed and thematically analysed to identify conceptual categories and themes. Results12/15 eligible consultant-led maternity units participated in the study and 10/12 (83%) of these used a dashboard. There was an excessive number of non-standard indicators used by the maternity units, with 352 different quality indicators (QIs), covering 37 different indicator categories, with up to 39 different definitions for one particular QI. Issues identified were: an excess of indicators, disproportionate time taken to produce the dashboard, uncertainty surrounding thresholds for alert within the dashboards and a desire for more guidance and standardisation of indicators, and their use. ConclusionsFollowing recommendation by the Royal College of Obstetricians and Gynaecologists, maternity dashboards have been widely adopted by maternity units across the SWSHA to provide a local quality assurance system. There is, however, wide variation in both the quality indicators monitored and their definition. There is an urgent requirement for a national and international core set of maternity QIs. Further guidance is also required to inform alert thresholds for adverse outcomes. These perinatal data are collected electronically, and automating the production of a standardised dashboard is both possible and desirable.

Regulation and oversight of NHS trusts after the Francis report

The report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, led by Robert Francis QC and published on 6 February 2013 (Francis, 2013), contains a damning account of the failure of the NHS regulatory regime to pick up on the conditions of appalling care that existed in the Mid Staffordshire NHS Foundation Trust between 2005 and 2009. In the foreword to the Government’s initial response to the Francis report (DH, 2013a), the Secretary of State for Health, Jeremy Hunt MP, does not mince his words: “The report of the Mid Staffordshire NHS Foundation Trust Public Inquiry makes horrifying reading. At every level, individuals and organisations let down the patients and families that they were there to care for and protect. A toxic culture was allowed to develop unchecked, which fostered the normalisation of cruelty and the victimisation of those brave enough to speak up. For far too long, warning signs were not seen, or ignored or dismissed. Regulators, commissioners, the Strategic Health Authority, the professional bodies and the Department of Health did not identify problems early enough, or, when they were clear, take swift action to tackle poor care. They failed to act together in the interests of patients. This was a systemic failure of the most shocking kind, and a betrayal of the core values of the health service as set out in the NHS Constitution. We must never allow this to happen again.” The joint policy statement of the DH, CQC, NHS England, Monitor and the TDA (DH, 2013b) (the policy statement) accompanies the Care Bill introduced to Parliament on 9 May 2013. It contains measures that are designed to ensure that the horrific failings identified in the Francis report never happen again. The policy statement sets out a number of significant changes that will be made to the regulation and oversight of NHS hospitals, setting out the new NHS Trust regulatory landscape after Francis.

"Better libraries, better health, better healthcare" - the development of a strategic framework for London Health Libraries

The London Health Libraries network was established in April 2003, following the last re-organisation of the NHS in the capital, which saw the creation of five Workforce Development Confederations (WDCs) and Strategic Health Authorities (SHAs) and the end of the London Region. Building on the work and achievements of the London Library and Information Development Unit (LLIDU), the network includes libraries who are providing services to health and social care staff and students, whether they be managed by the NHS, a higher education institution or an independent or voluntary organisation. In total, this brings together some 125 library services, of which over 85 in the NHS and higher education sectors are receiving NHS funding.

PWE-119 Hospital Admission and In-Hospital Deaths from Alcoholic Liver Disease in England: Analysis of Hospital Episode Statistics Data

IntroductionAlcohol consumption is the third greatest risk factor for global disease, attributing to almost 4% of all deaths worldwide. Alcoholic liver disease (ALD) is one of the major causes of...

Glucose and electrolyte bags: how accurately are they prepared on the neonatal unit?

IntroductionGlucose and electrolyte bags are prepared in many neonatal units to provide maintenance fluid, calories, sodium and potassium in the first few days of life. As part of a safer...

The cost of consumables in intensive care

Cost-effective nursing practice is essential today as resources allocated to healthcare are declining. It is imperative that frontline staff and clinicians be permitted to participate in decision-making processes affecting their work. An honest, open exchange of ideas aimed at achieving cost-effective practices should be encouraged. Intensive care unit (ICU) staff should know the price of consumables they are using. It helps them to decide on cost-effective treatment and involves them in decision-making with the physicians, achieving savings at the unit level. While strategic health authorities and the Department of Health are re-structuring the NHS to make it more viable, in any particular unit, staff members can make their input by controlling costs at a micro level and this will contribute to savings in running costs. Staff should be involved in making their unit cost-effective and this will in turn help to make their trust a cost-effective organisation.

Co-operation and conflict under hard and soft contracting regimes: case studies from England and Wales

BackgroundThis paper examines NHS secondary care contracting in England and Wales in a period which saw increasing policy divergence between the two systems. At face value, England was making greater use of market levers and utilising harder-edged service contracts incorporating financial penalties and incentives, while Wales was retreating from the 1990s internal market and emphasising cooperation and flexibility in the contracting process. But there were also cross-border spill-overs involving common contracting technologies and management cultures that meant that differences in on-the-ground contracting practices might be smaller than headline policy differences suggested.MethodsThe nature of real-world contracting behaviour was investigated by undertaking two qualitative case studies in England and two in Wales, each based on a local purchaser/provider network. The case studies involved ethnographic observations and interviews with staff in primary care trusts (PCTs) or local health boards (LHBs), NHS or Foundation trusts, and the overseeing Strategic Health Authority or NHS Wales regional office, as well as scrutiny of relevant documents.ResultsWider policy differences between the two NHS systems were reflected in differing contracting frameworks, involving regional commissioning in Wales and commissioning by either a PCT, or co-operating pair of PCTs in our English case studies, and also in different oversight arrangements by higher tiers of the service. However, long-term relationships and trust between purchasers and providers had an important role in both systems when the financial viability of organisations was at risk. In England, the study found examples where both PCTs and trusts relaxed contractual requirements to assist partners faced with deficits. In Wales, news of plans to end the purchaser/provider split meant a return to less precisely-specified block contracts and a renewed concern to build cooperation between LHB and trust staff.ConclusionsThe interdependency of local purchasers and providers fostered long-term relationships and co-operation that shaped contracting behaviour, just as much as the design of contracts and the presence or absence of contractual penalties and incentives. Although conflict and tensions between contracting partners sometimes surfaced in both the English and Welsh case studies, cooperative behaviour became crucial in times of trouble.

The novel use of commonly captured data to assess a district's diabetes service that encompasses both primary and secondary care

To identify commonly captured data in the UK to look at the performance of a district's diabetes care that encompasses both primary and secondary care. Primary care quality outcomes framework (QOF) measures for diabetes, referral rates for first appointment for specialist secondary care and emergency admission rates for diabetes (Dr Foster/HES) were used to produce a performance index scoring system. Illustrative measures from QOF were total diabetes points, DM23 attainment of HbA1c <7% (53 mmol/mol) and its exemption rate (number of patients excluded from analysis). The performance index was used to study the effectiveness of the Medway district diabetes service and this was compared to another district (Guildford) within the same Strategic Health Authority and nationally. Medway has the highest prevalence of Diabetes (6.1%) of the 8 Primary Care Trusts examined, the lowest achievement of diabetes QOF points (96.1%) and the lowest achievement of an HbA1c level <7% (53 mmol/mol) (54.3%). Exemption reporting was the 3rd highest. SAR for first diabetes out-patient appointment to the hospital was low at 281 (predicted 576) 48% of expected. The emergency admission rate was high at 225 (predicted 168) 133% of expected. Thus primary care diabetes needs to raise performance and implement a lower threshold for OPD referral to prevent emergency admissions. It is possible to produce an assessment of diabetes care that transcends primary/secondary care that gives a true reflection of a district's performance which will be useful to plan future health service provision.

Duncan Selbie: the new face of public health in England

Duncan Selbie: the new face of public health in England

Northern Engagement: Behind the Scenes Process for Strategic Health Authority Action

s / Can J Diabetes 37 (2013) S217eS289 S266 Community Engagement (SCOPE) is a community-based childhood obesity prevention program. The objective of this study was to develop an evidence-based social media strategy and evaluation protocol for implementation in SCOPE communities. A comprehensive search was conducted using PubMed, Embase, PsycInfo, Web of Science, Cochrane, and GoogleScholar with the search terms “social media AND health.” Case studies, best-practice documents, and peer-reviewed literature were identified and indicated 3 key social media platforms (Facebook, Twitter, YouTube) for integration into the tool. A Facebook strategy would incorporate initial outreach, regular content posting, and interactive contests, with accompanying metrics (i.e. number of likes, comments, demographic analyses). A Twitter strategy would follow and align with similar Twitter groups, engage interactions, and disseminate information, with evaluation measures such as number of followers, clicks, ‘retweets’/replies. YouTube videos and video sharing documenting community involvement would be measured by number of views, subscribers, and comments. Evaluation of social media platforms would include surveys and web analytics, including a Klout score. A social media strategy will add to the growing knowledge on the use of social media in health promotion. In addition to being implemented in SCOPE communities, it can be adopted, adapted, implemented, and evaluated in other communities that support childhood obesity prevention.

Workforce skill mix: modelling the potential for dental therapists in state-funded primary dental care

South Central Strategic Health Authority [SHA], with a population of four million, is one of 10 regions of England with responsibility for workforce planning. To explore future scenarios for the use of the skill mix within the dental team to inform the commissioning of dental therapy training. Data on population demography, oral health needs and demands, dental workforce, activity and dental utilisation were used to create demand (needs-informed) and supply models. Population trends and changing oral health needs and dental service uptake were included in the demand model. Linear programming was used to obtain the optimal make-up of the dental team. Based on the optimal scenario, workforce volumes and costs were examined across a range of scenarios up to 2013. Baseline levels of dental therapists were low and estimated as only achieving 10-20% of the current potential job competency. The optimal exploratory scenario in terms of costs and volume of staff was based on dental therapists working full time and providing 70% of routine care that is within their current job competency; this scenario required 483 therapists by 2013, a figure that appeared achievable. Increasing the level of job competency provided by therapists revealed potentially higher benefits in terms of reduced cost and requiring fewer dentists. The findings suggest that dental therapists can play a more significant role in the provision of primary dental care, both currently and in future; they also highlight the need for health services to routinely collect data that can inform workforce analysis and planning.

Prospects for progress on health inequalities in England in the post-primary care trust era: professional views on challenges, risks and opportunities

BackgroundAddressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario.MethodsSemi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations.ResultsIn general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs’ clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards.ConclusionsThere is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.

Knowledge, attitudes and beliefs of health care workers towards influenza vaccination

Influenza vaccination is routinely offered to health care workers in the U.K. to prevent nosocomial spread to patients and illness among health care workers. Despite its importance uptake has been low in the U.K. To describe the knowledge, attitudes and behaviour of health care workers towards influenza vaccination offered as part of occupational health and to understand their relative importance in promoting uptake of influenza vaccine. We also sought to make comparisons with other vaccines more readily accepted as part of occupational health. An online survey was distributed by e-mail to health care workers in the South Central Strategic Health Authority. The questionnaire included the following: demographic characteristics; vaccination status; and knowledge, attitudes and behaviour towards influenza, MMR and hepatitis B vaccination. We used logistic regression to identify the independent predictors of receipt of influenza vaccine. The survey was completed by 998 health care workers representing just over 1% of health care workers in the region. Of those, 69% thought that overall benefits of influenza vaccination were greater than the risks and inconvenience (versus 92% for hepatitis B and 86% for MMR). The following predicted receipt of influenza vaccine: belief that influenza poses a risk to one's own health (OR 3.74; 95% CI 2.45-5.71); belief that influenza vaccine is harmful (OR 0.25; 95% CI 0.16-0.37); and belief that influenza vaccine will protect patients (OR 2.96; 95% CI 1.89-4.62). Staff knowledge, attitudes and beliefs concerning influenza and its vaccine are an important predictor of uptake and should be a target for campaigns to promote uptake.

Patient perspectives of their leg ulcer journey

To understand the personal impact of venous leg ulceration from the patients' perspective. Face-to-face, unstructured interviews were conducted with nine patient participants with venous leg ulcers. The interviews were digitally recorded, transcribed verbatim and, using thematic analysis, the themes and subthemes which impacted on quality of life were identified. Four core themes were identified: the ulcer, symptoms, wound management and effects on daily life, with 16 subthemes that negatively impacted on quality of life (QoL) also identified. This qualitative study offers a valuable insight into the complex issues that impact on daily living for this patient group. The implications of the findings are far reaching and suggest that proactive symptom management and the fostering of a patient focus to consultations may improve QoL and encourage the patient to engage as an active partner in his/her management plan; both of which are explored in the subsequent phases of the larger study. This study was funded by West Midlands Strategic Health Authority. The authors have no conflicts of interest to declare.

Finding the missing millions - the impact of a locally enhanced service for COPD on current and projected rates of diagnosis: a population-based prevalence study using interrupted time series analysis.

Background:Many patients with chronic obstructive pulmonary disease (COPD) are not identified until their condition is relatively advanced and there is a considerable gap between the modelled and diagnosed prevalence of the disease. We have previously shown that, in the first year after the introduction of a locally enhanced service (LES) for COPD in 2008, there was a significant step-up in the diagnosed prevalence.Aims:To investigate whether this initial increase in prevalence was sustained, and the impact of this increase on future projected rates of COPD diagnosis.Methods:Using data from 2005–2011, we compared the prevalence of diagnosed COPD in the LES Primary Care Trust (LES-PCT) before and after it was introduced. Data were compared with a neighbouring PCT, the London Strategic Health Authority, and England. The true prevalence of COPD was estimated based on data from the Health Survey for England. Trends were extrapolated to estimate the proportion of patients that would be diagnosed in 2017.Results:The introduction of the LES was associated with a significant acceleration in the annual increase in diagnosed COPD (p<0.0001). By 2011 the prevalence was 1.17% in the LES-PCT compared with a predicted value of 0.91% (95% CI 0.86% to 0.95%) based on the pre-LES trend. There was no change in the rate of increase in COPD prevalence for the neighbouring PCT or for London as a whole. The LES-PCT would be expected to diagnose 55.6% of COPD patients by 2017 compared with only 27.3% without the LES, and only 33.3% would be diagnosed in the neighbouring PCT.Conclusions:These data suggest that, with appropriate incentives, it is possible to achieve a sustained improvement in COPD case-finding in primary care and that such policies need to be implemented systematically.

The uptake of health checks for adults with learning disabilities in England: 2008/9‐2011/12

PurposeThe purpose of this paper is to report on trends in the provision of health checks for adults with learning disabilities over the period 2008/9‐2011/12.Design/methodology/approachAnalysis of data collected by the Information Centre for Health and Social Care from Primary Care Trusts in England.FindingsOver the four years the percentage of eligible adults receiving a health check has consistently increased and now stands at 53 percent. There remain marked variations across both Strategic Health Authority areas and Primary Care Trusts.Research limitations/implicationsThere remains considerable distance to travel before minimum standards of satisfactory performance in the provision of health checks are achieved nationally. It is important to consider possible obstacles to provision and how these can be addressed to improve uptake further.Originality/valueThe paper examines consistency of good and poor performance by local areas over time. It is clear that significant improvements are required in a number of strategic health authority and primary care trust areas if minimum standards are to be met.

Husband and wife team to lead innovations in wound care

Nurses will be heavily involved in a Department of Health investigation into alleged abuse of patients by the late broadcaster Jimmy Savile. Several investigations begin this month and will cover hospitals that Savile visited frequently as a volunteer, fundraiser or both. The teams will look at events from the 1960s to 2011, when Savile died. The investigation team at Leeds Infirmary includes NHS North of England deputy chief nurse David Thompson, who has worked in the NHS for 37 years, and former nurse Maggie Boyle, chief executive of Leeds Teaching Hospitals NHS Trust. It will be led by Sue Proctor, former chief nurse at Yorkshire and Humber Strategic Health Authority. Another investigation will begin later this month into abuse at Broadmoor. More than 100 former staff employed at the high-security A wound care unit set up by a husband and wife team 20 years ago will become a national centre for wound management prevention and treatment. The Bradford Royal Infirmary-based service, which was set up by nurse consultant Kath Vowden and surgeon husband Peter Vowden, will be responsible for finding out from patients how wound care products can be improved. The ideas will then be researched and developed by experts within the wound care industry. Starting this month, it will become one of eight Healthcare Technology Cooperatives and will receive £800,000 to develop new care products. ‘At the moment, a new idea takes a long time to get to patients because of the amount of research that is required,’ said Ms Vowden. ‘Becoming the centre for innovation will help us develop new products more quickly.’ Husband and wife team to lead innovations in wound care

The geographic relationship between sexual health deprivation and the Index of Multiple Deprivation 2010: a comparison of two indices

To construct an Index of Sexual Health Deprivation (ISHD), examine its sensitivity, investigate the association between the ISHD and the Index of Multiple Deprivation 2010 (IMD2010), and interpret the observed geographic variation. The modified IMD method was informed by the IMD2010. Thirteen profiles relating to sexual health were selected and grouped into four domains. The observed profile values for each primary care trust (PCT) were smoothed and converted to a normal distribution before principal component analysis. Loadings were used to calculate profile weights. Domain scores were calculated by combining weighted profiles, which were combined to create the ISHD. A Bayesian approach acted as a comparator for the ISHD. Substantial variation in sexual health deprivation was seen across strategic health authorities (SHA). The London SHA had the highest proportion of PCTs (61%) among the most deprived quartile, followed by North-West SHA (29%). More than half of PCTs in East of England (71%), South Central (56%) and South-West (50%) SHAs fell into the least deprived quartile. No PCTs within the East of England, South Central and South-West SHAs were in the most deprived quartile. Only 57% of PCTs were attributed to the same quartile of the ISHD as the IMD2010. The modified IMD method and the Bayesian approach produced consistent results. The ISHD provides a robust picture of the geography of sexual health and shows a weak association with the IMD2010. It can be used to guide public health action to reduce the geographical gradient in sexual health inequality.

Challenges and facilitators for patient and public involvement in England; focus groups with senior nurses

The concepts of patient and public involvement (PPI) have been recognized and linked with quality in health services internationally and in Europe. In England, for more than a decade, NHS policies have increasingly quoted patient-centred services. Limited evidence exists about the implementation of PPI policies and strategies within organisations; three studies only have explored health professionals’ perceptions of PPI. Although nurses’ positive support for patient and public involvement has been noted, comparatively little is known about senior nurses’ experiences of embedding PPI. A national consultation utilising three focus groups aimed to explore senior nurses’ perceptions of challenges and facilitators for PPI implementation. 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. Nurses’ perceptions on patient and public involvement, challenges and facilitators for its implementation were discussed. Focus groups were digitally recorded and transcribed verbatim; anonymised transcripts were validated by participants and analysed with thematic analysis. Limited resources, patient representation and recruitment, complexities of implementing PPI and national policy changes were challenging. Commissioning limitations, lack of feedback on patient experience, limited staff awareness, negative attitudes, management of patients and public expectations constituted further challenges. Nursing role characteristics and informal involvement activities, PPI policy and cultural change, commissioning PPI competencies, related service frameworks, providing feedback on patient experiences to staff and recognition of involvement benefits were recognised as facilitators. Findings provided new insights into senior nurses’ experiences and evidence that progress towards meaningful, effective PPI remains slow. However, recognition of existing nursing role characteristics and potential delivery problems created by expanded nursing roles, informal PPI practice and internal organisational sharing of patient feedback may bring an “emerging productive partnership” with nurses enabling and contributing to effective PPI.