Informing NHS policy in 'digital-first primary care': a rapid evidence synthesis

Background In ‘digital-first primary care’ models of health-care delivery, a patient’s first point of contact with a general practitioner or other health professional is through a digital channel, rather than a face-to-face consultation. Patients are able to access advice and treatment remotely from their home or workplace via a number of different technologies. Objectives This rapid responsive evidence synthesis was undertaken to inform NHS England policy in ‘digital-first primary care’. It was conducted in two stages: (1) scoping the published evidence and (2) addressing a refined set of questions produced by NHS England from the evidence retrieved during the scoping stage. Data sources Searches were conducted of five electronic databases (MEDLINE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and PROSPERO were searched in July 2018) and relevant research/policy and government websites, as well as the National Institute for Health Research Health Service and Delivery Research programme database of ongoing and completed projects. No date or geographical limitations were applied. Review methods After examining the initial scoping material, NHS England provided a list of questions relating to the potential effects of digital modes and models of engagement, and the contracting and integration of these models into primary care. Systematic reviews and evidence syntheses, including evidence on the use of digital (online) modes and models of engagement between patients and primary care, were examined more closely, as was ongoing research and any incidentally identified primary studies focused on the use of digital (online) modes and models of engagement. All records were screened by two reviewers, with disagreements resolved by consensus or consulting a third reviewer. Results Evidence suggests that uptake of existing digital modes of engagement is currently low. Patients who use digital alternatives to face-to-face consultations are likely to be younger, female and have higher income and education levels. There is some evidence that online triage tools can divert demand away from primary care, but results vary between interventions and outcome measures. A number of potential barriers exist to using digital alternatives to face-to-face consultations, including inadequate NHS technology and staff concerns about workload and confidentiality. There are currently insufficient empirical data to either substantiate or allay such concerns. Very little evidence exists on outcomes related to quality of care, service delivery, benefits or harms for patients, or on financial costs/cost-effectiveness. No studies examining how to contract and commission alternatives to face-to-face consultations were identified. Limitations The quality of the included reviews was variable. Poor reporting of methodology and a lack of adequate study details were common issues. Much of the evidence focused on exploring stakeholder views rather than on objective measurement of potential impacts. The current evidence synthesis is based on a rapid scoping exercise and cannot provide the breadth or depth of insight that might have been achieved with a full systematic review. Conclusions Rapid scoping of the literature suggests that there is little high-quality evidence relating to ‘digital-first primary care’ as defined by NHS England. The broader evidence on alternatives to face-to-face consultation addresses certain policy-maker concerns, such as the possible impact of new technologies on workload and workforce, inequalities, local implementation and integration with existing services. However, although this evidence gives an insight into the views and experiences of health professionals in relation to such concerns, quantitative empirical data are lacking

Updated meta-review of evidence on support for carers

Objective To update a 2010 meta-review of systematic reviews of effective interventions to support carers of ill, disabled, or older adults. In this article, we report the most promising interventions based on the best available evidence. Methods Rapid meta-review of systematic reviews published from January 2009 to 2016. Results Sixty-one systematic reviews were included (27 high quality, 25 medium quality, and nine low quality). The quality of reviews has improved since the original review, but primary studies remain limited in quality and quantity. Fourteen high quality reviews focused on carers of people with dementia, four on carers of those with cancer, four on carers of people with stroke, three on carers of those at the end of life with various conditions, and two on carers of people with mental health problems. Multicomponent interventions featured prominently, emphasizing psychosocial or psychoeducational content, education and training. Improved outcomes for carers were reported for mental health, burden and stress, and wellbeing or quality of life. Negative effects were reported in reviews of respite care. As with earlier work, we found little robust evidence on the cost-effectiveness of reviewed interventions. Conclusions There is no ‘one size fits all’ intervention to support carers. There is potential for effective support in specific groups of carers, such as shared learning, cognitive reframing, meditation, and computer-delivered psychosocial support for carers of people with dementia. For carers of people with cancer, effective support may include psychosocial interventions, art therapy, and counselling. Carers of people with stroke may also benefit from counselling. More good quality, theory-based, primary research is needed. </jats:sec

A Brief Report on a Facilitated Approach to Connect Cooperative Extension Southern Region State-Level Health Specialists

Improving the nation’s health will require collaboration among many stakeholders and systems, including representatives from Cooperative Extension Services (CES). This paper describes the process of establishing a multistate collaboration and discusses initial outcomes of a third-party facilitated participatory planning meeting. State-level specialists with expertise and responsibilities in “health” promotion participated. Satisfaction with meeting format; feasibility, acceptability, and appropriateness of the proposed approach to public health impact; and general meeting feedback were collected through a survey and cultural artifacts (e.g., notes, worksheets). Preparation and attendance costs were captured. Seventeen of the 20 attendees (85%) responded to the survey and reported the process was satisfactory and the proposed plan for moving forward was feasible, acceptable, and appropriate. The meeting cost was $1,011 per attendee. The process mobilized a multistate Extension collaborative to promote health but revealed potential cost-benefit challenges. Leveraging resources is necessary to plan, implement, and measure collaborative public health efforts. Future data on outcomes will show if the process leads to intended objectives. If successful, this approach can be replicated across CES for stronger impacts

Regulating and inspecting integrated health and social care in the UK : scoping the literature

Background: The integration of care, particularly across the health and social care sectors, has been a long-standing policy objective in the UK. We sought to scope the evidence related to the regulation and inspection of integrated care. Objective(s): To identify and classify published material that could potentially address four key questions: 1. What models of regulation and inspection of integrated care have been proposed? (Including approaches taken in other countries) 2. What evidence is available on the effectiveness of such models? 3. What are the barriers and enablers of effective regulation and inspection of integrated care? 4. Can barriers to effective regulation and inspection be overcome without legislative change? Design: Rapid scoping review. Publication type and focus: Both empirical and non-empirical publications related to the regulation and inspection of integrated care were included. Setting: Publications focused on the integration of health and social care services, or provision delivered across other settings/sectors by different professional groups working together. Outcomes: Empirical studies reporting on any outcome relevant to the regulation and/or inspection of integrated care. Non-empirical publications focusing on any relevant issue including proposed models of regulation or outcome frameworks. Data sources: A targeted search of five databases was undertaken. Additionally, we conducted supplementary searches of the websites of key organisations and searched for other grey literature using the advanced search function of Google. Key contacts were also approached, and a request made for relevant documents. Review methods: The title and abstracts of 5380 records were screened and a total of 166 publications were included. Documents were coded based on key characteristics, and a descriptive summary of the literature produced. No attempt was made to assess the quality or synthesise the findings of the retrieved evidence. Results Out of the 166 included publications, 71 were identified from database searches and 95 were included from supplementary website searches. While there were records that could be classified as relevant to one or more of the research questions identified through the stakeholder consultation, there was a notable absence of evidence relating to (a) effectiveness of regulatory/inspection strategies and (b) professional regulation. Conclusions and future work The evidence base relating to the regulation or inspection of integrated care is relatively small. There may be an opportunity to synthesise some of the existing views and experience data on system regulation and inspection identified in a more formal systematic review. However, before a useful evidence base can be developed, policy makers and researchers need to agree what constitutes ‘effective’ regulation, how this can be measured, and which study designs are most appropriate for evaluation. Related questions about what constitutes ‘successful’ integration of care should also be taken into account when planning such research. While potentially useful reforms have been proposed, empirical evidence in relation to professional regulation appears particularly scarce. Organisations responsible for regulating professionals might therefore consider incorporating some form of evaluation into any planned strategic reforms. Limitations The degree of focus on integration or regulation was a difficult criterion to apply with strict consistency

The provision of services in the UK for UK armed forces veterans with PTSD : a rapid evidence synthesis

Background Our research arises from anticipated increases in demand for psychological trauma services in the UK, with particular reference to armed forces veterans with post-traumatic stress disorder (PTSD). Commissioning and service provider activity to improve veterans’ health is evolving. Objectives To explore what UK services exist and establish potentially effective models of care and effective treatments for armed forces veterans with PTSD. Design A four-stage rapid evidence synthesis comprising information gathering on UK service provision; an evidence review on models of care; a metareview on treatment effectiveness; and a synthesis highlighting research priorities. Setting For the evidence reviews, any setting that was relevant to the UK health and social care system. Participants UK armed forces veterans with PTSD following repeated exposure to traumatic events. Interventions Any model of care or treatment. Main outcome measures Any relevant outcome. Data sources Information about current UK practice. Searches of databases [including MEDLINE, PsycINFO and PILOTS (Published International Literature on Traumatic Stress)], guidelines and relevant websites, up to November 2016. Review methods We screened titles and abstracts using EPPI-Reviewer 4 (EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, UK) and EndNote X7 [Clarivate Analytics (formerly Thomson Reuters), Philadelphia, PA, USA]. Decisions to include papers were made by two reviewers independently. We conducted a narrative synthesis of research literature on models of care and on treatments, guided by information from UK practice. In our evidence reviews, we assessed (when appropriate) the quality of included studies using established criteria. To help interpret our findings, we consulted recently published public and patient involvement data, a veteran service user and experts with academic, military and commissioning backgrounds. Results We gathered information about current UK practice. Sixty-one studies were included in the rapid evidence review on models of care and seven systematic reviews in the rapid metareview of treatments. The quality of evidence in both evidence reviews was limited. Promising models of care from more robust studies (three randomised controlled trials and one qualitative study) were collaborative arrangements and community outreach for improving intervention access and uptake; integrated mental health services and behavioural intervention on increased smoking abstinence; and peer support as an acceptable complement to PTSD treatment. A poor fit was noted between the research literature and UK service provision. Promising treatments were psychosocial interventions (eye movement desensitisation and reprocessing, cognitive processing therapy, trauma-focused and exposure-based intervention) and pharmacotherapy (selective serotonin reuptake inhibitors, antidepressants, anticonvulsants, antipsychotics) for improving PTSD and mental health symptoms. Limitations The literature pool was larger than anticipated. Evidence for potentially effective models of care and potentially effective treatments is limited in quality and quantity. Although we aimed for a comprehensive evidence synthesis, pragmatic decisions in searching, screening and inclusion of studies may mean that relevant studies were overlooked. Conclusions There is tentative support for the effectiveness of some models of care and certain treatments currently delivered in UK practice. Our findings are timely for commissioners and service providers when developing present activity in veterans’ health care. Future work We report potential implications for future health-care practice, including early intervention for veterans transitioning from military life, improving general practitioners’ knowledge about services, implementing needs-based service design and tackling wider-system challenges. Regarding potential areas of future research, we have identified the need for more-robust (and longer) evaluative studies in the UK setting. Funding The National Institute for Health Research Health Services and Delivery Research programme