Rural maternity care: Can we learn from Wal-Mart?

In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of other rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community–maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community–midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens

Health Care Insurance Key Political issue in the USA

Letter to news item in the British Medical Journa

Specialist services in the community: a qualitative study of consultants holding novel types of employment contracts in England.

The aim of this study was to understand, from consultants' experiences, the potential benefits and limitations of specialists being employed by a community organisation. We carried out a qualitative study using semi-structured interviews with consultants holding novel contracts across three specialties: geriatric, respiratory and palliative medicine. Consultants in our study reported that community-based roles offered a number of potential benefits. They felt better able to take a population perspective, to treat patients in a holistic sense and to form good working relationships with community-based colleagues. A number of challenges were also evident, including a lack of clarity about their role, professional isolation and, for those in geriatric and respiratory medicine, a lack of training and career development opportunities. Our study suggests that community-based consultant posts are often taken up by highly motivated individuals who report the benefits in terms of being able to provide more appropriate care for patients but that the long-term development of these posts may be constrained by a number of factors. Their idiosyncratic nature, the lack of clarity around the role, challenges to professional identity and lack of training opportunities or professional development suggest that current approaches to their development may not be sustainable.This work was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) programme [ref:12/135/02]. This paper presents independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.This is the author accepted manuscript. The final version is available from the Royal College of Physicians via http://dx.doi.org/10.7861/futurehosp.2-3-17

Advocating mixed-methods approaches in health research

This methods paper provides researchers in Nepal with a broad overview of the practical and philosophical aspects of mixed-methods research. The three authors have a wide-ranging expertise in planning and conducting mixed-methods studies. The paper outlines the different paradigms or philosophies underlying quantitative and qualitative methods and some of the on-going debates about mixed-methods. The paper further highlights a number of practical issues, such as (a) the particular mix and order of quantitative and qualitative methods; (b) the way of integrating methods from different philosophical stance; and (c) how to synthesise mixed-methods findings

Delphi Method and Nominal Group Techniques in Family Planning and Reproductive Health Research

Both the Delphi method and nominal group technique offer structured, transparent and replicable ways of synthesising individual judgements and have been used extensively for priority setting and guideline development in health-related research including reproductive health. Within evidence-based practice they provide a means of collating expert opinion where little evidence exists.They are distinct from many other methods because they incorporate both qualitative and quantitative approaches. Both methods are inherently flexible; this article also discusses other strengths and weaknesses of these methods

Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary-secondary care interface.

Objectives Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians' skills through education or joint consultations with complex patients.This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 12/135/02).This is the final version of the article. It first appeared from SAGE via http://dx.doi.org/10.1177/1355819616648982

The effectiveness of community-based social innovations for healthy ageing in middle- and high-income countries: a systematic review

Objectives: Community-based social innovations (CBSIs) are one type of intervention that may help to address the complex needs of ageing populations globally. The aim of this research was to assess evidence for the effectiveness and cost-effectiveness of CBSIs involving in such contexts. Methods: We conducted a systematic review of CBSIs for healthy ageing in middle- and high-income countries, including any CBSI that aimed to empower people aged 50 and over by motivating them to take initiative for their own health and wellbeing. The protocol was registered with Prospero (CRD 42016051622). A comprehensive search was conducted in 15 academic databases and advanced search in Google. We included published studies from 2000 onwards in any language. Exploratory meta-analysis was conducted for quantitative studies reporting similar outcomes, and qualitative studies were analysed using thematic analysis. Narrative synthesis was conducted. Searches yielded 13,262 unique hits, from which 44 papers met the inclusion criteria. Results: Most studies reported interventions having positive impacts on participants, such as reduced depression, though the majority of studies were classified as being at medium or high risk of bias. There was no evidence on costs or cost-effectiveness and very little reporting of outcomes at an organization or system level. CBSIs have the potential for positive impacts, but with nearly half of studies coming from high-income urban settings (particularly the United Kingdom and the United States of America), there is a lack of generalizability of these findings. Conclusions: Our research highlights the need to improve reporting of CBSIs as complex interventions, and for improved conceptualization of these interventions to inform research and practice

Systematic Review of Sexual Health Interventions with Young People from Black and Minority Ethnic Communities (REO44)

Executive Summary Background There is little data on sexual well-being of young people from BME in Scotland. The purpose of this systematic review of the literature covering sexual health interventions with young people from BME communities was to collate the ‘best evidence of effectiveness’ in the field and make recommendations for further practice. To do this, evidence was sought about such interventions in any industrialised country. Limited research has previously been conducted in this area and a broad definition of both sexual health and ethnic minorities was taken in order to maximise the number of studies that could be included in the review. Methods We searched a wide range of (electronic) data bases for studies aimed at young people from BME communities which included an sexual health-type intervention, an valuation, a control of comparison group, clearly defined outcomes and which were published in the English language. In addition we searched for sexual health studies of (a) parents and carers of young people in the BME communities; (b) professionals working with young BME people; and (c) access to sexual health services for young BME people. Results Our systematic review found 52 relevant papers (from nearly 5,000) reporting interventions in this area, but only one was based in the UK. The majority of studies were based in the US and involved interventions aimed at African Americans or Hispanics. Interventions were divided into nine categories according to targeted outcomes and/or group: (1) general sexual health and behaviour; (2) pregnancy avoidance; (3) Sexually Transmitted Infections (STIs) and HIV; (4) Sex and Relationship Education for young people from BME communities; (5) BME parents and carers; (6) professionals who work with young BME people; (7) access to sexual health services for BME youths; (8) peer education; and (9) BME communities targeted in order to improve sexual health in BME youths. The most common method used in included studies was a Randomised Controlled Trial (RCT), employed in just over half of the interventions. Key messages This review provides an overview of the interventions and identifies some common characteristics of effective interventions. Interventions with clearly defined aims and outcomes were more likely to demonstrate effectiveness. Skills-based programmes were more effective than information-based interventions. Having a theoretical basis seemed to contribute to the intervention’s effectiveness. Interventions aimed at improving sexual health in young people from BME communities have not been studied very well in the UK. There is a pressing need for good quality research to aid the development of intervention programmes to address this. Future research concentrating on demonstrating the effectiveness of different interventions will be vital in developing policies. The studies providing better quality research evidence are all US-based, their findings may or may not be transferable to a Scottish setting. Using the findings from such US-base studies in a Scottish context requires additional research to make the Scottish intervention culturally appropriate. It is important to note that the absence of evidence does not mean that there is evidence of the intervention is not being successful, often in this field it means that the relevant interventions have not been evaluated in an appropriate way that allows the effectiveness to be assessed

Outpatient services and primary care: scoping review, substudies and international comparisons

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience. Funding, The NIHR Health Services and Delivery Research programme.The NIHR Health Services and Delivery Research programme