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

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

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

Australian foster carers' views and concerns regarding maternal drug use and the safety of breastmilk

Parental substance misuse and mental health issues are major factors associated with infant placement into out-of-home care. Such placements may result in disruption and/or cessation of breastfeeding. Provision of breastmilk to infants in out-of-home care (OOHC) is desirable in terms of infant health and development, and also in supporting maternal caregiving. However, little is known about how breastfeeding is supported for infants in out-of-home care. This study used an online survey to explore the facilitation of breastfeeding in the context of OOHC and foster carers’ management of expressed breastmilk (EBM). Foster carers were generally open to the idea of maternal breastfeeding and infants in their care receiving EBM from their mothers. However, the majority of respondents expressed concern regarding the safety of EBM for infant consumption due to the possibility of harmful substances in the milk. Concerns regarding the safety of handling EBM were also prevalent. These concerns caused foster carers to discard EBM. Findings suggest foster carers’ may lack knowledge related to maternal substance use and breastmilk. Better integration between health care and social service systems, where the voices of mothers, foster carers and child protection workers are heard, is necessary to develop solutions enabling infants living in OOHC access to their mother’s breastmilk

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

Background: Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women’s experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women’s experiences when planning a VBAC in Australia. Methods: The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor. Results: In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC. Conclusion: This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC