Strategic Health Authority Research Articles

Health Care Commissioning: The UK Health Policy Reforms

In 2013/14, the first year of the UK’s reformed health service, area health authorities known as Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) who were largely responsible for the determination of local health challenges and priorities and for the design and delivery of strategies to tackle these challenges, will be abolished from April 2013, and service improvements will be driven by a clinically-led local commissioning system. In this new system, groups of geographically aligned primary care practitioners will come together to create new statutory organisations known as Clinical Commissioning Groups (CCGs) who will take on the responsibility for the direct commissioning of the majority of NHS services with oversight from an umbrella body at the national level, the NHS Commissioning Board (NHSCB) responsible for the effective and economical running of the NHS [7]. The public health function will be transferred from the PCTs to the local governments under the auspicious of Health and Wellbeing Boards (HWBs). The new structure builds on the centrality of practicebased commissioning, taking it a great deal further in primary care with a greater local control of decision-making to improve patient care and outcomes. One school of thought was that the new structure in place would bring ‘patient empowerment, local professional judgement and greater provider dynamisms’ [6].

Confused about the shape of the NHS in England?

This week in England, the sun rose over a sparkling new NHS. Or, at least, the NHS structure that was set out in the much-contested Health and Social Care Act 2012 is now in place. Ten strategic health authorities and 152 primary care trusts are no more, and a host of new organisations have formally […]

Influence of public health is under threat as senior posts remain unfilled

Unfilled senior staff vacancies in public health in local authorities have led to fears that the strategic grip and influence of the specialty will be undermined when local government assumes responsibility for public health from next April.1 Shortages were particularly acute in London, a stocktake by the Local Government Association of staff transfers out of the NHS has shown. The stocktake indicates that, although 95% of local authorities expected to fulfil public health functions effectively from next April, key leadership posts remained a concern “through the transition and beyond.” As of October 2012, 19 of the expected 133 posts of director of public health in England’s 152 councils remained unfilled. The Midlands and East of England, the North, and the South clusters of strategic health authorities each have …

P14 Pneumonia: 30 Months of Advancing Quality in North West England

As part of an initiative to improve the quality of care within the North West Strategic Health Authority, five ‘quality markers’ (QMs) were measured in all adult admissions with pneumonia...

Up to 2000 doctors may not have had correct authority to section patients

The Department of Health has been forced into taking retrospective legal action to correct an irregularity in the approvals process for doctors working under the Mental Health Act. The move was prompted by the discovery that four Strategic Health Authorities had not fully complied with section 12 of the Act. …

PHP21 How Will the New NHS Decentralised Reforms Impact on Access to Medicines in England?

With the formation of Clinical Commissioning Groups (CCGs) GP Practices will come together to commission services for their local populations. However, freedoms to be delegated from the Clinical Commissioning board may mean that considerable ‘command and control' will still be exerted from the centre. Secondary and primary research was undertaken to gain insight into how devolved locality based commissioning is likely to impact on access to medicines. We reviewed 35 first wave CCGs in terms of population coverage, financial stability and current Primary care Trust (PCT) activities in relation to Practice based commissioning. We then interviewed 5 NHS Experts to assess whether these CCGs would be allowed the aspirational freedoms referred to in the 2012 Health and Social Care Act- in particular prescribing freedoms formerly under the guidance of PCTs. Various information sources were used Care Quality Commission, Audit Commission, and Health Select Committee reports to support the interpretation of the findings. The selected CCGs represented an homogeneous group of practices in that they had previously demonstrated financial stewardship and collaborative working with their ‘host' PCTs. Many CCGs had been devolved the Commissioning budget by their PCTs and were routinely involved in setting up medicines management protocols with their provider hospitals. Almost half of the CCGs had coterminous medicines management contracts shared with their PCTs. NHS experts raised issues around corporate and clinical governance and how practices would fundamentally want to take on the devolved financial responsibilities. The NHS reforms mean that £60 Billion of the total health care budget will be under the control of CCGs. PCTs and Strategic Health Authorities will be abolished and with a watered down role for NICE postcode variation may be rife; access to medicines will continue to be fraught with many layers of decision making and further delays.

Monitoring access to nationally commissioned services in England

BackgroundFor over 20 years, the National Health Service in England has run a system of national planning for highly specialised healthcare services. The aim is to ensure that very rare diseases are treated, and very complex procedures performed, in only a few centres, each of which maintains a volume high enough to maintain excellent outcomes. The commissioning strategy for the provision of these national services in England is strongly centralising. Centralising does however create a duty to ensure that patients distant from the treatment centres are not thereby disadvantaged. The commissioning process ensures sufficient capacity to treat the entire national caseload of clinically eligible patients. The aim of this paper is to apply the Systematic Component of Variation (SCV) to study access to services commissioned by the National Specialised Commissioning Team (NSCT) in England. The discussion focuses on the potential explanations for a high level of systematic variation between areas and on the use of the SCV to support the monitoring and development of these nationally commissioned services.MethodData from nationally commissioned services for the year ending 2011 were received from treating hospital. Mid year age and sex appropriate population estimates were then obtained to provide denominator data. Data were analysed at the geographic level of strategic health authority.Results30 services met all requirements for analysis. There is no apparent relationship between SCV and number of locations from which the service is provided. On inspection high SCV is more common among recently commissioned services.DiscussionThe importance of the SCV lies in its ability to support the development of highly specialised services. Once the random variation has been accounted for, the reasons for a systematic component can be explored. While no absolute cut- off exists, the SCV can be used to gauge and explore services that are potentially not covering the national caseload. The reason for a high SCV may not be immediately apparent; thus the SCV can aid those responsible for commissioning the service to seek potential explanations and identify improvements.ConclusionWe have reviewed spatial variation in access to a set of highly specialised services in England. On inspecting our results, we believe that they suggest that equity of access can usually be achieved at about five years after establishing a service, and this is not dependent, within the geography of England, on the number of centres designated.

Providing support for newly qualified practitioners in Scotland

This article describes the development, implementation and outcomes of Flying Start NHS ® , a web-based learning programme developed by NHS Education for Scotland (NES) for newly qualified nurses, midwives and allied health professionals. Flying Start NHS ® aims to address the issues faced by newly qualified staff in the transition from student to capable, confident, registered practitioner. The programme is delivered through a dedicated website that promotes work-based learning. Since 2006, the Flying Start website has registered more than 20,000 newly qualified practitioners taking their first post in NHS Scotland. NES has worked with NHS West Midlands Strategic Health Authority to customise the Flying Start NHS ® programme, which is now being introduced throughout England.

Providing support for newly qualified practitioners in Scotland

This article describes the development, implementation and outcomes of Flying Start NHS, a web-based learning programme developed by NHS Education for Scotland (NES) for newly qualified nurses, midwives and allied health professionals. Flying Start NHS aims to address the issues faced by newly qualified staff in the transition from student to capable, confident, registered practitioner. The programme is delivered through a dedicated website that promotes work-based learning. Since 2006, the Flying Start website has registered more than 20,000 newly qualified practitioners taking their first post in NHS Scotland. NES has worked with NHS West Midlands Strategic Health Authority to customise the Flying Start NHS programme, which is now being introduced throughout England.

Association of Water Softness and Heavy Alcohol Consumption with Higher Hospital Admission Rates for Alcoholic Liver Disease

To test the hypothesis that regional variations in the prevalence of alcoholic liver disease are contributed to by regional variations in 'softness' of drinking water, i.e. its mineral content. Annual hospital admission rates for alcoholic liver disease per 100,000 population in the 28 Strategic Health Authorities (SHAs) existing in England over the period 2003-2006 were compared with regional measures of water hardness, alcohol consumption and social deprivation. As corroborative evidence, the same relations were examined for hospital admission rates for osteoporosis, a disorder with an already established link with calcium deficiency in drinking water (as well as with heavy drinking). Hospital admissions rates for alcoholic liver disease were higher in predominant-soft-water SHAs than with hard water SHAs. These areas, with one exception, were also associated with high alcohol consumption, but not with greater social deprivation. Hospital admission rates for osteoporosis were found to vary in a way similar to that for alcoholic liver disease, with significant correlations with soft water and alcohol consumption. Given experimental evidence that magnesium deficiency can aggravate liver damage from alcohol, soft water with its low magnesium concentration may be a factor additional to alcohol consumption in the development of liver damage. The parallel findings with osteoporosis admissions, explainable by low calcium and magnesium levels present in soft water, along with the known effect of heavy drinking on bone metabolism, provide corollary support for the hypothesis linking soft water with the pathogenesis of these two diseases.

Achieving a key purpose

We often read comments in the literature about being fit for purpose. Consider this key question: are we fit for purpose? Many of you will be aware that the Council for Healthcare Regulatory Excellence (CHRE) has provided its final report on the strategic review of the NMC (CHRE, 2012). The NMC was criticised for its failure to improve and the leaders have been censured for the repeated failure of achieving their key purpose, i.e. regulatory control. Failures in leadership, strategy, decision-making, finance and culture were also identified. We have a responsibility in tissue viability, both as leaders and providers of care, to demonstrate leadership, use clear, supported strategies, make appropriate decisions, maintain finance, maintain a positive culture and achieve a key purpose. The provision of tissue viability is diverse and care is challenging, owing to an increasingly elderly population and the need for complex care. The current population of people over 100 years old is increasing annually with a predicted 110 000 by 2035 (Office for National Statistics, 2012). An important consideration is whether, like the NMC, we are able to achieve our key purposes, i.e. wound prevention. Managing preventable diseases is costly, and so resources become increasingly scare for unavoidable tissue viability needs. Is one of our key purposes to prevent pressure ulceration? I think it is and, if through leadership, decisionmaking, strategic planning and delivery of fundamental care, we can achieve a significant reduction in pressure ulceration, we will be more strongly placed to fund other aspects of care. The Midlands and East Strategic Health Authority has implemented the ‘Ambition 1’ agenda to prevent all avoidable pressure ulcers by December 2012. In the last 6 months, it has become apparent that using the SKIN (Surface, Keep moving, Incontinence, Nutrition) bundle and completing the fundamental elements of pressure ulcer prevention really does make a difference. To be fit for purpose, tissue viability services must not receive censure for repeated failure but focus on the key purpose of preventing avoidable wounds. Achieving zero tolerance of avoidable pressure ulcers is a UK initiative that has the potential to influence care all over the world...and then we can truly say we are fit for purpose! BJCN

A curriculum to ensure nursing staff competency

Nurses and healthcare assistants (HCAs) involved in tissue viability are expected to be competent, but there is little agreement over how to define competence or the expertise required by people filling different roles. Most training in England is provided in house by tissue viability nurses or interested non-specialists; England is lagging behind Scotland and Wales in terms of learning materials and other resources. Staff members at a strategic health authority were surveyed so a consensus could be reached over a basic curriculum for tissue viability and the competence expected of nurses and HCAs at different levels of seniority. Respondents agreed that five topics should be covered by both nurses and HCAs: wound healing; leg ulceration; pressure ulceration; diabetic foot; and skin care. Levels of expertise and competence would depend on seniority. The curriculum provides a checklist that local tissue viability nurses can use as a basis for training colleagues. Trusts and educational providers should set a curriculum for tissue viability and standards of competence.

A workforce review in diagnostic ultrasound

Current ultrasound education for sonographers is at post-graduate level and it is a service expectation that sonographers are equipped with advanced skills on qualification. The aim of the working party review was to assess the current roles and responsibilities of the sonographers, with a view to determining whether there was an opportunity to introduce a lower band practitioner role within the local hospital ultrasound department as well as the wider ultrasound community. Qualitative data, for the review, were obtained from two sources: (i) a local working party consisting of two ultrasound managers, two sonographers, one consultant radiologist, one line manager and one lecturer in diagnostic imaging and (ii) radiologists of the local department, ultrasound colleagues within the Yorkshire and Humber Strategic Health Authority (SHA), local and national Higher Education Institute and Consortium for the Accreditation of Sonographic Education colleagues. The career structure of sonographers was reviewed with options to introduce a band 6 ultrasound practitioner post in the local radiology department. The level of work expected of sonographers within the local Trust demands advanced skills, currently recognized as Agenda for Change band 7, are utilized on a daily basis. Little opportunity for practitioners to work at a lower grade which would require only technical reports, with no diagnostic opinion, was identified. In conclusion, there is currently no scope for a band 6 ultrasound practitioner within the local radiology department. The review suggests there is a need for an ultrasound practitioner career structure, which is comparable with other professional groups. Such developments will require input and support from clinicians, radiologists, the professional body and the higher education institutions. The review recognizes the need for an ultrasound governance team within individual Trusts to oversee ultrasound provision, reporting and clinical developments.

Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? a qualitative study

BackgroundThe treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3–6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors’ decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice.MethodsThink aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.Participants: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.Setting: Two Strategic Health Authority regions, one in the north of England and one in Wales.ResultsThe following key issues arose from the data synthesis: the importance of patient prognosis; the concept of “appropriateness”; “benefits and burdens” of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area.ConclusionsThe above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.

Addressing incontinence for people with dementia living at home: a documentary analysis of local English community nursing service continence policies and clinical guidance

To establish whether the problems and issues experienced by people with dementia living at home and their carers were addressed in the clinical guidance for continence management for community nursing services in England. Internationally, the numbers of people with dementia are rising. Managing incontinence is a significant issue as the presence of incontinence is one of the triggers for people with dementia to move their residence to a care home. People with dementia living at home and their family carers report difficulties in accessing knowledgeable professionals and acceptable continence products. A review by documentary analysis of clinical policies and guidance from a sample of community nursing services in all Strategic Health Authority regions of England. A sample of clinical policy and guidance documents for continence assessment and management from up to four community nursing services in each of the ten Strategic Health Authority regions in England was sought. Documentary analysis was undertaken on the relevance of the documents identified for people with dementia living at home. Ninety-eight documents from 38 local community nursing services spread across ten Strategic Health Authority areas were obtained and analysed. Only in the documents of three services were nurses offered detailed guidance about the management of incontinence for people with dementia at home. In the documentation of only one service were people with dementia identified as a special case which warranted the provision of additional continence products. Clinical guidance on continence assessment and management for community nurses in many parts of England does not address the specific needs of people with dementia living at home or their carers. Nurses working in community settings and those providing clinical leadership in continence care should review their clinical guidance and policies to ensure relevance for people with dementia living at home and their family carers.

Roles of the non-medical prescribing leads within organisations across a Strategic Health Authority: perceived functions and factors supporting the role

Extending the roles of nurses, pharmacists and allied health professionals to include prescribing has been identified as one way of improving service provision. In the UK, over 50 000 non-medical healthcare professionals are now qualified to prescribe. Implementation of non-medical prescribing ( NMP) is crucial to realise the potential return on investment. The UK Department of Health recommends a NMP lead to be responsible for the implementation of NMP within organisations. The aim of this study was to explore the role of NMP leads in organisations across one Strategic Health Authority (SHA) and to inform future planning with regards to the criteria for those adopting this role, the scope of the role and factors enabling the successful execution of the role. Thirty-nine NMP leads across one SHA were approached. Semi-structured telephone interviews were conducted. Issues explored included the perceived role of the NMP lead, safety and clinical governance procedures and facilitators to the role. Transcribed audiotapes were coded and analysed using thematic analytical techniques. In total, 27/39 (69.2%) NMP leads were interviewed. The findings highlight the key role that the NMP lead plays with regards to the support and development of NMP within National Health Service trusts. Processes used to appoint NMP leads lacked clarity and varied between trusts. Only two NMP leads had designated or protected time for their role. Strategic influence, operational management and clinical governance were identified as key functions. Factors that supported the role included organisational support, level of influence and dedicated time. The NMP lead plays a significant role in the development and implementation of NMP. Clear national guidance is needed with regards to the functions of this role, the necessary attributes for individuals recruited into this post and the time that should be designated to it. This is important as prescribing is extended to include other groups of non-medical healthcare professionals.

GP commissioning: will it save money and raise standards of care?

The controversial Health and Social Care Act, passed a few weeks ago, will trigger the most radical re-organisation of the NHS that we have ever experienced. With the abolition of primary care trusts and strategic health authorities, and the creation of new bodies and governance arrangements, the responsibility for a budget of between ￡60-80 billion will pass to GP-led clinical commissioning groups, (CCGs) who will have the unenviable task of tackling variations in standards of care and reducing health inequalities while attempting to save as much as ￡20 billion over the next 5 years. We asked a number of experts and health service leaders to look into their crystal balls and say whether they think that these challenging aspirations can be achieved. # THE CHALLENGE FACING THE NHS AND PRIMARY CARE {#article-title-2} Sir David Nicholson The NHS needs to transform the way services are provided to patients and local people — both to meet the increasing healthcare needs and expectations of those it serves and to ensure it continues to drive real improvement in health outcomes in more constrained financial circumstances. Meeting the scale of these challenges will require all parts of the NHS to take bold measures to secure long-term, sustainable change. Giving frontline clinicians greater freedom and a strong leadership role is an essential element in meeting those challenges. CCGs can use their knowledge of patients' needs and of local services, as well as their standing in local communities, to change clinical practice in ways that improve the quality of care and make more effective use of resources. CCGs will be able to build on their excellent relationships with the public as well as their emerging partnerships with local authorities to lead a collective case for change, focused around the improvement of patient outcomes. Having a GP-led system of clinical commissioning will build on the strengths of general …

Safety Express: a strategic health authority's approach

The Safety Express programme is a national workstream within the Quality, Innovation, Productivity and Prevention (QIPP) programme that is designed to improve health outcomes and quality care, as well as reduce costs associated with the following four patient harms: pressure ulcers, falls, urinary tract infections in patients with catheters and venous thromboembolism (VTE). NHS London developed a pilot project to implement Safety Express across London. This paper presents case studies of the outcomes of the Safety Express pilot in three locations in London. Findings from the pilot showed that the proportion of patients who were harm-free from pressure ulcers, falls, urinary infections (in patients with a catheter) and new VTE compares favourably with the national average, with an overall decrease in all four.

An overiew of non medical prescribing across one strategic health authority: a questionnaire survey.

BackgroundOver 50,000 non-medical healthcare professionals across the United Kingdom now have prescribing capabilities. However, there is no evidence available with regards to the extent to which non-medical prescribing (NMP) has been implemented within organisations across a strategic health authority (SHA). The aim of the study was to provide an overview of NMP across one SHA.MethodsNMP leads across one SHA were asked to supply the email addresses of NMPs within their organisation. One thousand five hundred and eighty five NMPs were contacted and invited to complete an on-line descriptive questionnaire survey, 883 (55.7%) participants responded. Data was collected between November 2010 and February 2011.ResultsThe majority of NMPs were based in primary care and worked in a team of 2 or more. Nurse independent supplementary prescribers were the largest group (590 or 68.6%) compared to community practitioner prescribers (198 or 22.4%), pharmacist independent supplementary prescribers (35 or 4%), and allied health professionals and optometrist independent and/or supplementary prescribers (8 or 0.9%). Nearly all (over 90%) of nurse independent supplementary prescribers prescribed medicines. Approximately a third of pharmacist independent supplementary prescribers, allied health professionals, and community practitioner prescribers did not prescribe. Clinical governance procedures were largely in place, although fewer procedures were reported by community practitioner prescribers. General practice nurses prescribed the most items. Factors affecting prescribing practice were: employer, the level of experience prior to becoming a non-medical prescriber, existence of governance procedures and support for the prescribing role (p < 0.001).ConclusionNMP in this strategic health authority reflects national development of this relatively new role in that the majority of non-medical prescribers were nurses based in primary care, with fewer pharmacist and allied health professional prescribers. This workforce is contributing to medicines management activities in a range of care settings. If non-medical prescibers are to maximise their contribution, robust governance and support from healthcare organisations is essential. The continued use of supplementary prescribing is questionable if maximum efficiency is sought. These are important points that need to be considered by those responsible for developing non-medical prescribing in the United Kingdom and other countries around the world.

The perceived impact of advanced practice nurses (APNs) on promoting evidence-based practice amongst frontline nurses: findings from a collective case study

The aim of this study was to explore the perceived impact of advanced practice nurses in promoting evidence-based practice amongst frontline nurses. A collective instrumental case study was undertaken involving five extended case studies and eighteen short case studies in a range of hospital and primary care settings across seven Strategic Health Authorities in England. The study participants were a purposive sample of 23 advanced practice nurses selected to represent a range of settings, clinical specialities, organisational responsibilities and ways of working. In-depth interviews were undertaken with the advanced practice nurse and up to 10 interviews with health care professionals with whom they worked. For the extended case studies, non-participant observation and follow-up interviews were also undertaken. Data analysis drew on the principles of the Framework approach. From the perspectives of the participants, these advanced practice nurses enhanced the ability of frontline nurses to provide evidence-based care. They improved the competence, knowledge and skills of frontline nurses and empowered them to deliver care which they considered to be safer, holistic, more timely and of a higher standard. This is likely to have a positive effect on patient outcomes and on patient experience. However, this impact is inherently hard to capture.