Investigating the use of Hospital Episode Statistics data to measure variation in Performance and Quality in Colorectal Surgery

This thesis provides a comprehensive overview of general and subspecialist colorectal surgery in England. It examines variation in provision and outcome of colorectal surgery in structure, process and outcome factors at the patient, consultant team and NHS Trust levels. Finally, this thesis examines the potential role of increasing surgical caseload to reduce any demonstrable variation and improve outcome. To address these questions, current issues in surgical quality as well as the coding accuracy reported in the published literature have been reviewed. Colorectal resection and the more specialised procedure of restorative proctocolectomy were examined from the Hospital Episode Statistics dataset. Novel outcome measures were derived using longitudinal analysis. Regression analysis was used to understand the predictors of process factors and outcome measures. I have defined new outcome measures and demonstrated considerable variation in these new measures and in more traditional accepted measures in both general and subspecialist colorectal surgery from routinely collected datasets. Routinely collected data offer an exciting potential data source for measuring performance and quality. If data accuracy can be assured, measures such as reoperation may be used alongside established measures of quality in a meaningful way to benchmarking performance of surgical providers. The methods described in this thesis can be applied to a broad range of surgical specialties. Though volume may have a role in determining outcome and reducing variation in subspecialist colorectal surgery, it is by no means the panacea to improve quality across all providers in general colorectal care. The impact of volume on outcome in more general colorectal surgery is less clear. Though centralisation is likely to have benefits, further evidence of the optimum way to implement such changes is needed rather than indiscriminately increasing volume across all providers for general colorectal surgical care

Breastfeeding support at an Australian Breastfeeding Association drop-in service : a descriptive survey

Background: In Australia, during the early establishment phase of breastfeeding, women can access telephone peer support counselling provided by the Australian Breastfeeding Association (ABA) however options for face-to-face peer support are limited. The known factors which improve ongoing and exclusive breastfeeding include face-to-face support, peer and/or professional support, and trained personnel. This study aimed to examine women’s experiences of accessing one breastfeeding drop-in peer support service provided by trained peer support volunteer counsellors from the ABA. Methods: Women who accessed the service were invited, in 2014, to participate in an anonymous online survey which collected both quantitative and qualitative data. Participants were asked about their experiences of breastfeeding support, as well as their experiences of the drop-in service. In total, 53 women completed the online survey, and subsequent analysis generated descriptive statistics and qualitative themes. Results: Responses to the survey revealed that women attended the drop-in service with infants ranging in age from less than 1 week through to 12 months of age. Most women reported attending with infants aged 0–8 weeks of age (72%). The predominant presenting problems identified were sore/damaged nipples, difficulties with infant latching to the breast, or concerns about using nipple shields. Analysis of the open text qualitative responses revealed one overarching theme ‘Support to continue breastfeeding’ and four subthemes: ‘feeling listened to and not judged’; ‘emotional support and confidence building’; ‘the importance of face-to-face, practical support’; and ‘the need for ongoing, free access’. Discussion: In this study many women were seeking support for ongoing breastfeeding difficulties. Health professionals who had limited breastfeeding knowledge and skills were identified as most unhelpful in providing support with ongoing breastfeeding difficulties. Women valued having access to trained peer counsellors, who had the capacity to provide non-judgemental, face-to-face support; who could sit through a feed; in a space that was ‘safe’; and who could enhance a woman’s confidence with breastfeeding over the course of her full breastfeeding journey. Conclusions: Reactive peer support, provided in response to need, at an Australian Breastfeeding Association drop-in service, was described by participants as pivotal to enabling their ongoing breastfeeding

"Meeting the Mum Where She is at": Recommended Best Practice to Support Vulnerable New Mothers

Becoming a new mother can be a complicated life transition with physical, emotional, and psychological changes. Women with additional vulnerabilities are at greatest risk from physical and mental ill-health due to adversities faced when becoming a new mother. The impetus for the current White Paper arose from the desire to develop a deeper understanding of the needs of vulnerable new mothers, the perceived impact of the Early Years Support Service, and the best practice guidelines for how to support new mothers with additional vulnerabilities. This White Paper is based on the first empirical study of the Early Years Support Service, involving 47 stakeholders with direct experience including: 22 mothers who had or currently use the Early Years Support Service, 15 volunteers, 6 staff, 4 significant others. The Early Years Support Service is available to primary carers irrespective of gender. All of the service users who participated in this study identified as mothers and thus this White Paper discusses the experiences of mothers

From coercion to respectful care : women’s interactions with health care providers when planning a VBAC

Background: In many countries caesarean section rates are increasing and this impacts on choices made around mode of birth in subsequent pregnancies. Having a vaginal birth after caesarean (VBAC) can be a safe and empowering experience for women, yet most women have repeat caesareans. High caesarean section rates increase maternal and neonatal morbidity, health costs and burden on hospitals. Women can experience varied support from health care providers when planning a VBAC. The aim of this paper is to explore the nature and impact of the interactions between women planning a VBAC and health care providers from the women’s perspective. Methods: A national Australian VBAC survey was undertaken in 2019. In total 559 women participated and provided 721 open-ended responses to six questions. Content analysis was used to categorise respondents’ answers to the open-ended questions. Results: Two main categories were found capturing the positive and negative interactions women had with health care providers. The first main category, ‘Someone in my corner’, included the sub-categories ‘belief in women birthing’, ‘supported my decisions’ and ‘respectful maternity care’. The negative main category ‘Fighting for my birthing rights’ included the sub-categories ‘the odds were against me’, ‘lack of belief in women giving birth’ and ‘coercion’. Negative interactions included the use of coercive comments such as threats and demeaning language. Positive interactions included showing support for VBAC and demonstrating respectful maternity care. Conclusions: In this study women who planned a VBAC experienced a variety of positive and negative interactions. Individualised care and continuity of care are strategies that support the provision of positive respectful maternity care

Child participation advocacy tool

This tool is a quick reference guide for practitioners working in child protection in Ireland seeking to use international law in advocating for children’s rights in domestic courts. More specifically, it provides an overview of children’s rights sources which can be drawn upon to argue for the participation of children in care in court proceedings. Utilising these sources of law can also bolster submissions in court, thereby improving decisions for children

Doctors attitudes towards medication errors at 2002 & 2015

This paper explores the attitudes and beliefs of doctors towards medication error reporting following fifteen years of anational patient safety agenda. Method: This is a qualitative descriptive study utilising semi structured interviews. A group of ten doctors of different disciplines shared their attitudes and beliefs about medication error reporting. Using thematic content analysis, findings were reflected upon to those collected by the same author of a similar study 13 years before (2002). Findings: Five key themes were identified: lack of incident feedback, non- user friendly incident reporting systems, supportive cultures, electronic prescribing and time pressures. Despite more positive responses to the benefits of medication error reporting in 2015 compared to 2002, doctors at both times expressed a reluctance to use the hospital’s incident reporting system, labelling it time consuming and non-user friendly. A more supportive environment however where error had been made was thought to exist compared to 2002.The role of the pharmacist was highlighted as critical in reducing medication error with the introduction of electronic prescribing being pivotal in 2015. Value: To our knowledge, this is the first study to compare doctors’ attitudes on medication errors following a period of time of increased patient safety awareness. The results suggest that error reporting today is largely more positive and organisations more supportive than 2002. Despite a change from paper to electronic methods, there is a continuing need to improve theefficacy of incident reporting systems and ensure an open, supportive environment for clinicians

Contact with children in care: case law of the European Court of Human Rights

This document provides summaries of judgments delivered by the European Court of Human Rights concerning the right to contact with children in care. It aims to assist child protection practitioners to utilise this case law in advocating for this right in domestic courts. The judgments focus on Article 8 of the European Convention on Human Rights

Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics

Objective To describe national reoperation rates after elective and emergency colorectal resection and to assess the feasibility of using reoperation as a quality indicator derived from routinely collected data in England

Street-level practice, personalisation and co-production in employability: Insights from local services with lone parents

Policymakers in the UK have promised to deliver personalised employability services for vulnerable jobseekers. However, unemployed people often describe their engagement with state-funded services as defined by: the offer of low cost, standardised job search services; and pressure to accept any job, irrespective of quality or appropriateness. This article argues that more progressive, co-produced alternatives are possible. We draw on an evaluation of local, third sector-led services targeting lone parents (LPs) in five local government areas in Scotland. Our research involved more than 100 in-depth interviews with both service providers and LPs. We find that partnership-oriented co-governance mechanisms facilitated collaborative approaches to the management of services and processes of co-production. LPs expressed positive views of the personalised services that were co-produced. We conclude that a commitment to collaboration and co-production may be more effective in promoting personalised services that are responsive to the needs of vulnerable groups