Integrated policy making in England for adults with long-term neurological conditions (LTNCs): some preliminary findings from a scoping study

Introduction: Long-term neurological conditions are a major cause of disability in the UK and internationally. Their successful management, in order to enhance health and well-being, requires both sophisticated organisation across a number of health, social care and other service boundaries, and the real involvement of people with neurological conditions and members of their support networks. <br><br> Policy development: This paper reports on part of the preliminary scoping phase of a study designed to evaluate the impact of the National Service Framework for long-term neurological conditions on integrated care. It describes current policies in England and reports on discussions with a range of people involved in the planning, provision or use of services, which took place during the scoping exercise. These interviews inform how policy affecting people with long-term neurological conditions has been received and implemented so far. <br><br> Conclusion and discussion: Findings suggest that progress towards integrated service provision is patchy and slow. In the competing priorities within government policy, neurological conditions have tended to be marginalised, within healthcare policy generally and in initiatives to support people with long-term conditions in particular. The reasons for this are explored and will inform the next stages of the research

Can general practitioner commissioning deliver equity and excellence? : Evidence from two studies of service improvement in the English NHS

Objectives: To explore some of the key assumptions underpinning the continued development of general practitioner-led commissioning in health services. Methods: Qualitative data from two studies of service improvement in the English NHS were considered against England's plans for GP-led commissioning. These data were collected through in-depth interviews with a total of 187 professionals and 99 people affected by services in 10 different primary care trust areas across England between 2008 and 2009. Results: Internationally, GPs are seen to have a central position in health systems. In keeping with this, the English policy places emphasis on the 'pivotal role' of general practitioners, considered to be ideally placed to commission in the best interests of their patients. However, our evidence suggests that general practitioners do not always have a pivotal role for all patients. Moreover, it is planned that the new commissioning groups in England will not be subject to top-down performance management and this raises the question of how agreed quality standards will be met under the proposed new system. Conclusions: This paper questions the assumption that GPs are best placed to commission health services in a way that meets quality standards and leads to equitable outcomes. There is little evidence to suggest that GPs will succeed where others have failed and a risk that, without top-down performance management, service improvement will be patchy, leading to greater, not reduced, inequity

The Impact of Digital Health Interventions for the Management of Type 2 Diabetes on Health and Social Care Utilisation and Costs: A Systematic Review

BACKGROUND: Digital health interventions such as smartphone applications (mHealth) or Internet resources (eHealth) are increasingly used to improve the management of chronic conditions, such as type 2 diabetes mellitus. These digital health interventions can augment or replace traditional health services and may be paid for using healthcare budgets. While the impact of digital health interventions for the management of type 2 diabetes on health outcomes has been reviewed extensively, less attention has been paid to their economic impact. OBJECTIVE: This study aims to critically review existing literature on the impact of digital health interventions for the management of type 2 diabetes on health and social care utilisation and costs. METHODS: Studies that assessed the impact on health and social care utilisation of digital health interventions for type 2 diabetes were included in the study. We restricted the digital health interventions to information provision, self-management and behaviour management. Four databases were searched (MEDLINE, EMBASE, PsycINFO and EconLit) for articles published between January 2010 and March 2021. The studies were analysed using a narrative synthesis approach. The risk of bias and reporting quality were appraised using the ROBINS-I checklist. RESULTS: The review included 22 studies. Overall, studies reported mixed evidence on the impact of digital health interventions on health and social care utilisation and costs, and suggested this impact differs according to the healthcare utilisation component. For example, digital health intervention use was associated with lower medication use and fewer outpatient appointments, whereas evidence on general practitioner visits and inpatient admissions was mixed. Most reviewed studies focus on a single component of healthcare utilisation. CONCLUSIONS: The review shows no clear evidence of an impact of digital health interventions on health and social care utilisation or costs. Further work is needed to assess the impact of digital health interventions across a broader range of care utilisation components and settings, including social and mental healthcare services. CLINICAL TRIAL REGISTRATION: The study protocol was registered on PROSPERO before searches began in April 2021 (registration number: CRD42020172621)

What outcomes are important to people with long-term neurological conditions using integrated health and social care?

Measuring the outcomes that are meaningful to people with long-term neurological conditions (LTNCs) using integrated health and social care services may help to assess the effectiveness of integration. Conventional outcomes tend not to be derived from service user experiences, nor are they able to demonstrate the impact of integrated working. This paper reports findings about outcomes identified as being important to people with LTNCs using integrated services. We undertook qualitative work with five community neuro-rehabilitation teams that were integrated in different ways and to different degrees. In-depth, semi-structured interviews were conducted with 35 people with LTNCs using these teams. Data were collected between 2010 and 2011 and analysed using an adapted version of the Framework approach. We identified 20 outcomes across three domains: personal comfort outcomes, social and economic participation outcomes, and autonomy outcomes. Inter-relationships between outcomes, both within and across domains, were evident. The outcomes, and the inter-relationships between them, have implications for how individuals are assessed in practice

'Maze' not pathway: focus group exploration of patients' and public experiences of the UK NHS elective total joint arthroplasty pathway

OBJECTIVE: To explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway. DESIGN: Three qualitative focus groups undertaken March-May 2018, as part of a mixed-methods evaluation of Getting It Right First Time. Transcripts were subject to framework analysis to identify thematic content between October 2018 and October 2021. SETTING: Elective TJA surgery in the English NHS. PARTICIPANTS: Two focus groups including patients who had undergone TJA in the previous 2 years (group 1: n=5; group 2: n=4) and the other individuals who had not but were aged 60+ (group 3: n=5). Participants were recruited via community groups and patient panels. RESULTS: Fourteen individuals took part in the focus groups; all were aged over 60; seven (50%) were female and nine (64%) had undergone TJA surgery. Participants' perspectives were categorised into themes and mapped onto stages of the TJA pathway. Although perioperative care is often the focus of improvement efforts, participants argued that the patient journey begins before individuals present to primary care. Participants had concerns about other aspects of the pathway, such as obtaining a surgical referral, with prereferral interventions aimed at potentially avoiding the need for surgery (ie, physiotherapy) being perceived as a mechanism to restrict access to secondary care. Patient experience was also conceptualised as a 'maze', rather than the logical, sequential process set out in clinical guidelines; exacerbated by a lack of information, knowledge and power imbalances. CONCLUSION: The linear conceptualisation of the TJA pathway is at odds with patient experience. Improvement programmes focused on perioperative care fail to consider patient concerns and priorities. Patients should be directly involved in improvement programmes, to ensure that patient experience is optimised, as well as informing related processes and important outcomes of care

'Maze' not pathway: focus group exploration of patients' and public experiences of the UK NHS elective total joint arthroplasty pathway

Objective: To explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway. / Design: Three qualitative focus groups undertaken March–May 2018, as part of a mixed-methods evaluation of Getting It Right First Time. Transcripts were subject to framework analysis to identify thematic content between October 2018 and October 2021. / Setting: Elective TJA surgery in the English NHS. / Participants: Two focus groups including patients who had undergone TJA in the previous 2 years (group 1: n=5; group 2: n=4) and the other individuals who had not but were aged 60+ (group 3: n=5). Participants were recruited via community groups and patient panels. / Results: Fourteen individuals took part in the focus groups; all were aged over 60; seven (50%) were female and nine (64%) had undergone TJA surgery. Participants’ perspectives were categorised into themes and mapped onto stages of the TJA pathway. Although perioperative care is often the focus of improvement efforts, participants argued that the patient journey begins before individuals present to primary care. Participants had concerns about other aspects of the pathway, such as obtaining a surgical referral, with prereferral interventions aimed at potentially avoiding the need for surgery (ie, physiotherapy) being perceived as a mechanism to restrict access to secondary care. Patient experience was also conceptualised as a ‘maze’, rather than the logical, sequential process set out in clinical guidelines; exacerbated by a lack of information, knowledge and power imbalances. / Conclusion: The linear conceptualisation of the TJA pathway is at odds with patient experience. Improvement programmes focused on perioperative care fail to consider patient concerns and priorities. Patients should be directly involved in improvement programmes, to ensure that patient experience is optimised, as well as informing related processes and important outcomes of care

A Protocol for a Mixed-Methods Process Evaluation of a Local Population Health Management System to Reduce Inequities in COVID-19 Vaccination Uptake

Population health management is an emerging technique to link and analyse patient data across several organisations in order to identify population needs and plan care. It is increasingly used in England and has become more important as health policy has sought to drive greater integration across health and care organisations. This protocol describes a mixed-methods process evaluation of an innovative population health management system in North Central London, England, serving a population of 1.5 million. It focuses on how staff have used a specific tool within North Central London’s population health management system designed to reduce inequities in COVID-19 vaccination. The COVID-19 vaccination Dashboard was first deployed from December 2020 and enables staff in North London to view variations in the uptake of COVID-19 vaccinations by population characteristics in near real-time. The evaluation will combine interviews with clinical and non-clinical staff with staff usage analytics, including the volume and frequency of staff Dashboard views, to describe the tool’s reach and identify possible mechanisms of impact. While seeking to provide timely insights to optimise the design of population health management tools in North Central London, it also seeks to provide longer term transferable learning on methods to evaluate population health management systems

A mixed-methods process evaluation of an integrated care system's population health management system to reduce health inequalities in COVID-19 vaccination uptake

Purpose: Many countries have a renewed focus on health inequalities since COVID-19. In England, integrated care systems (ICSs), formed in 2022 to promote integration, are required to reduce health inequalities. Integration is supported by population health management (PHM) which links data across health and care organisations to inform service delivery. It is not well-understood how PHM can help ICSs reduce health inequalities. This paper describes development of a programme theory to advance this understanding. Design/methodology/approach: This study was conducted as a mixed-methods process evaluation in a local ICS using PHM. The study used Framework to analyse interviews with health and care professionals about a PHM tool, the COVID-19 vaccination uptake Dashboard. Quantitative data on staff Dashboard usage were analysed descriptively. To develop a wider programme theory, local findings were discussed with national PHM stakeholders. Findings: ICS staff used PHM in heterogeneous ways to influence programme delivery and reduce inequalities in vaccine uptake. PHM data was most influential where it highlighted action was needed for “targetable” populations. PHM is more likely to influence decisions on reducing inequalities where data are trusted and valued, data platforms are underpinned by positive inter-organisational relationships and where the health inequality is a shared priority. Originality/value: The COVID-19 pandemic accelerated a shift toward use of digital health platforms and integrated working across ICSs. This paper used an evaluation of integrated data to reduce inequalities in COVID-19 vaccine delivery to propose a novel programme theory for how integrated data can support ICS staff to tackle health inequalities