Reducing the length of postnatal hospital stay: implications for cost and quality of care

Background  UK health services are under pressure to make cost savings while maintaining quality of care. Typically reducing the length of time patients stay in hospital and increasing bed occupancy are advocated to achieve service efficiency. Around 800,000 women give birth in the UK each year making maternity care a high volume, high cost service. Although average length of stay on the postnatal ward has fallen substantially over the years there is pressure to make still further reductions. This paper explores and discusses the possible cost savings of further reductions in length of stay, the consequences for postnatal services in the community, and the impact on quality of care.  Method  We draw on a range of pre-existing data sources including, national level routinely collected data, workforce planning data and data from national surveys of women’s experience. Simulation and a financial model were used to estimate excess demand, work intensity and bed occupancy to explore the quantitative, organisational consequences of reducing the length of stay. These data are discussed in relation to findings of national surveys to draw inferences about potential impacts on cost and quality of care.  Discursive analysis  Reducing the length of time women spend in hospital after birth implies that staff and bed numbers can be reduced. However, the cost savings may be reduced if quality and access to services are maintained. Admission and discharge procedures are relatively fixed and involve high cost, trained staff time. Furthermore, it is important to retain a sufficient bed contingency capacity to ensure a reasonable level of service. If quality of care is maintained, staffing and bed capacity cannot be simply reduced proportionately: reducing average length of stay on a typical postnatal ward by six hours or 17% would reduce costs by just 8%. This might still be a significant saving over a high volume service however, earlier discharge results in more women and babies with significant care needs at home. Quality and safety of care would also require corresponding increases in community based postnatal care. Simply reducing staffing in proportion to the length of stay increases the workload for each staff member resulting in poorer quality of care and increased staff stress.  Conclusions  Many policy debates, such as that about the length of postnatal hospital-stay, demand consideration of multiple dimensions. This paper demonstrates how diverse data sources and techniques can be integrated to provide a more holistic analysis. Our study suggests that while earlier discharge from the postnatal ward may achievable, it may not generate all of the anticipated cost savings. Some useful savings may be realised but if staff and bed capacity are simply reduced in proportion to the length of stay, care quality may be compromised

The Development of Professional Responsibility in Counselor Training

Responsibility in the field of counseling is a complex, multi-faceted concept which includes responsibility to the client, responsibility to the profession, and responsibility to the self. These responsibilities encompass the profession’s global role, the call to establish consistent professional requirements, the American Counseling Association’s Code of Ethics, the developmental process of student skill acquisition and professional identity development, and the curriculum and training requirements of counselor education programs. Following a general exploration of responsibility in counselor education, this article focuses on when and how counselors-in-training (CITs), as they grow in counseling skills and professional identity through coursework and mentoring and supervision, develop a sense of professional responsibility. The survey research method was employed in this study. Results indicated that students felt the construct of responsibility most when preparing for and enrolled in field experience courses. Recommendations are then given to promote the continued development of professional responsibility in CITs over the educational continuum

The Irie Classroom Toolbox: Mixed method assessment to inform future implementation and scale up of an early childhood, teacher-training, violence prevention programme

INTRODUCTION: Violence against children (VAC) is a violation of child rights, has high prevalence in low- and middle-income countries, is associated with long-term negative effects on child functioning, and with high economic and social costs. Ending VAC at home and at school is thus a global public health priority. METHODS: In Jamaica, we evaluated an early childhood, teacher-training, violence-prevention programme, (the Irie Classroom Toolbox), in a cluster-randomised trial in 76 preschools. The programme led to large reductions to teachers' use of VAC, although the majority of teachers continued to use VAC at times. In this paper, we describe a mixed-method evaluation of the Irie Classroom Toolbox in the 38 Jamaican preschools that were assigned to the wait-list control group of the trial. In a quantitative evaluation, 108 preschool teachers in 38 preschools were evaluated at pre-test and 91 teachers from 37 preschools were evaluated at post-test. One preschool teacher from each of these 37 preschools were randomly selected to participate in an in-depth interview as part of the qualitative evaluation. RESULTS: Preschool teachers were observed to use 83% fewer instances of VAC across one school day after participating in the programme, although 68% were observed to use VAC at least once across two days. The qualitative evaluation confirmed these findings with all teachers reporting reduced use of violence, but 70% reporting continued use of VAC at times. Teachers reported that the behaviour change techniques used to deliver the intervention increased their motivation, knowledge and skills which in turn led to improved child behaviour, improved relationships and improved professional well-being. Direct pathways to reduced use of VAC by teachers were through improved child behaviour and teacher well-being. The main reasons for continued use of VAC were due to barriers teachers faced using positive discipline techniques, teachers' negative affect, and child behaviours that teachers perceived to be severe. DISCUSSION: We describe how we used the results from the mixed-method evaluation to inform revisions to the programme to further reduce teachers' use of VAC and to inform the processes of training, supervision and ongoing monitoring as the programme is scaled-up through government services

Continuity of care in community midwifery

Continuity of care is often critical in delivering high quality health care. However, it is difficult to achieve in community health care where shift patterns and a need to minimise travelling time can reduce the scope for allocating staff to patients. Community midwifery is one example of such a challenge in the National Health Service where postnatal care typically involves a series of home visits. Ideally mothers would receive all of their antenatal and postnatal care from the same midwife. Minimising the number of staff-handovers helps ensure a better relationship between mothers and midwives, and provides more opportunity for staff to identify emerging problems over a series of home visits. This study examines the allocation and routing of midwives in the community using a variant of a multiple travelling salesmen problem algorithm incorporating staff preferences to explore trade-offs between travel time and continuity of care. This algorithm was integrated in a simulation to assess the additional effect of staff availability due to shift patterns and part-time working. The results indicate that continuity of care can be achieved with relatively small increases in travel time. However, shift patterns are problematic: perfect continuity of care is impractical but if there is a degree of flexibility in the visit schedule, reasonable continuity is feasible

Evaluation of a Violence-Prevention Programme with Jamaican Primary School Teachers: A Cluster Randomised Trial

This study investigated the effect of a school-based violence prevention programme implemented in Grade 1 classrooms in Jamaican primary schools. Fourteen primary schools were randomly assigned to receive training in classroom behaviour management (n = 7 schools, 27 teachers/classrooms) or to a control group (n = 7 schools, 28 teachers/classrooms). Four children from each class were randomly selected to participate in the evaluation (n = 220 children). Teachers were trained through a combination of workshop and in-class support sessions, and received a mean of 11.5 h of training (range = 3–20) over 8 months. The primary outcomes were observations of (1) teachers’ use of violence against children and (2) class-wide child aggression. Teachers in intervention schools used significantly less violence against children (effect size (ES) = −0.73); benefits to class-wide child aggression were not significant (ES = −0.20). Intervention teachers also provided a more emotionally supportive classroom environment (ES = 1.22). No benefits were found to class-wide prosocial behaviour, teacher wellbeing, or child mental health. The intervention benefited children’s early learning skills, especially oral language and self-regulation skills (ES = 0.25), although no benefits were found to achievement in maths calculation, reading and spelling. A relatively brief teacher-training programme reduced violence against children by teachers and increased the quality of the classroom environment

The Irie Classroom Toolbox: Mixed method assessment to inform future implementation and scale-up of an early childhood, teacher-training, violence-prevention programme

IntroductionViolence against children (VAC) is a violation of child rights, has high prevalence in low- and middle-income countries, is associated with long-term negative effects on child functioning, and with high economic and social costs. Ending VAC at home and at school is thus a global public health priority.MethodsIn Jamaica, we evaluated an early childhood, teacher-training, violence-prevention programme, (the Irie Classroom Toolbox), in a cluster-randomised trial in 76 preschools. The programme led to large reductions to teachers' use of VAC, although the majority of teachers continued to use VAC at times. In this paper, we describe a mixed-method evaluation of the Irie Classroom Toolbox in the 38 Jamaican preschools that were assigned to the wait-list control group of the trial. In a quantitative evaluation, 108 preschool teachers in 38 preschools were evaluated at pre-test and 91 teachers from 37 preschools were evaluated at post-test. One preschool teacher from each of these 37 preschools were randomly selected to participate in an in-depth interview as part of the qualitative evaluation.ResultsPreschool teachers were observed to use 83% fewer instances of VAC across one school day after participating in the programme, although 68% were observed to use VAC at least once across two days. The qualitative evaluation confirmed these findings with all teachers reporting reduced use of violence, but 70% reporting continued use of VAC at times. Teachers reported that the behaviour change techniques used to deliver the intervention increased their motivation, knowledge and skills which in turn led to improved child behaviour, improved relationships and improved professional well-being. Direct pathways to reduced use of VAC by teachers were through improved child behaviour and teacher well-being. The main reasons for continued use of VAC were due to barriers teachers faced using positive discipline techniques, teachers' negative affect, and child behaviours that teachers perceived to be severe.DiscussionWe describe how we used the results from the mixed-method evaluation to inform revisions to the programme to further reduce teachers' use of VAC and to inform the processes of training, supervision and ongoing monitoring as the programme is scaled-up through government services

A multicriteria resource allocation model for the redesign of services following birth

Background Many healthcare services are under considerable pressure to reduce costs while improving quality. This is particularly true in the United Kingdom’s National Health Service where postnatal care is sometimes viewed as having a low priority. There is much debate about the service’s redesign and the reallocation of resources, both along care pathways and between groups of mothers and babies with different needs. The aim of this study was to develop a decision support tool that would encourage a systemic approach to service redesign and that could assess the various quality and financial implications of service change options making the consequent trade-offs explicit. The paper describes the development process and an initial implementation as a preliminary exploration of the possible merits of this approach. Methods Other studies have suggested that combining multicriteria decision analysis with programme budgeting and marginal analysis might offer a suitable basis for resource allocation decisions in healthcare systems. The Postnatal care Resource Allocation Model incorporated this approach in a decision support tool to analyse the consequences of varying design parameters, notably staff contacts and time, on the various quality domains and costs. The initial phase of the study focussed on mapping postnatal care, involving interviews and workshops with a variety of stakeholders. This was supplemented with a literature review and the resultant knowledge base was encoded in the decision support tool. The model was then tested with various stakeholders before being used in an NHS Trust in England. Results The model provides practical support, helping staff explore options and articulate their proposals for the redesign of postnatal care. The integration of cost and quality domains facilitates trade-offs, allowing staff to explore the benefits of reallocating resources between hospital and community-based care, and different patient-categories. Conclusions The main benefits of the model include its structure for assembling the key data, sharing evidence amongst multi-professional teams and encouraging constructive, systemic debate. Although the model was developed in the context of the routine maternity services for mothers and babies in the days following birth it could be adapted for use in other health care services

The Friendship Bench programme: a cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe.

BACKGROUND: Common mental disorders (CMD) are a leading cause of disability globally. Emerging evidence indicates that in low and middle income countries the treatment gap for CMD can be addressed through the use of trained and supervised lay health workers (LHWs). Few clinical trials have evaluated the use of such task-shifting approaches in sub-Saharan Africa. In Zimbabwe, we have successfully piloted a task-shifting intervention delivered by LHWs. This protocol describes a cluster randomised controlled trial to assess the effectiveness of this intervention. METHODS: Each of 24 randomly selected clinics from a pool of 42 in Harare will recruit 24 participants (N = 576). The clinics are randomised in a 1:1 ratio to receive either the intervention package [a problem solving therapy package delivered over a 4-6 week period by LHWs (N = 24) followed by a 6-week group support programme which focuses mainly on teaching a craft skill] or enhanced usual care, which includes usual care and psycho-education. Primary care attenders aged 18 years and above who score positive on a locally validated CMD screening questionnaire (Shona Symptom Questionnaire, SSQ-14) will be eligible for recruitment and asked for informed consent to participate in the trial. The primary measure is the SSQ score at 6 months. CONCLUSION: This effectiveness trial using LHWs to address the treatment gap for CMD will contribute to the body of knowledge on the feasibility and ability for scale-up of interventions for CMD. TRIAL REGISTRATION: PACTR201410000876178

Re-thinking dementia care: Day Care vs. Recreation

Supporting disabled people into paid work is a policy priority for local authorities, and commissioners need evidence on which to base investment decisions. The NIHR School for Social Care Research (SSCR) commissioned the National Development Team for Inclusion (NDTi) to carry out a scoping review to see what economic evidence is currently available within published literature. The review particularly focuses on two client groups: people with learning disability and those with mental health problems