Impact of vertical integration on patients’ use of hospital services in England

Background Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is ‘vertical integration’, where a provider of specialist care, such as a hospital, also runs general practices. Aim To quantify the impact of vertical integration on hospital use in England. Design & setting Analysis of activity data for NHS hospitals in England between April 2013 and March 2020. Method Analysis of NHS England data on hospital activity: Accident and Emergency Department (A&E) attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; length of stay. We compare rates of hospital use by patients of vertically integrated practices and controls, before and after the former were vertically integrated. Results In the two years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio (95% CI) of 0.98 (0.96–0.99), P<0.0001]), outpatient attendances (1% reduction [0.99 (0.99–1.00), P=0.0061]), emergency inpatient admissions (3% reduction [0.97 (0.95–0.99), P=0.0062]) and emergency readmissions within 30 days (5% reduction [0.95 (0.91–1.00), P=0.039]), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. Conclusion Vertical integration is associated with modest reductions in use of some hospital services and no change in others

From COVID-19 research to vaccine application: why might it take 17 months not 17 years and what are the wider lessons?

Abstract: It is often said that it takes 17 years to move medical research from bench to bedside. In a coronavirus disease (COVID-19) world, such time-lags feel intolerable. In these extraordinary circumstances could years be made into months? If so, could those lessons be used to accelerate medical research when the crisis eases? To measure time-lags in health and biomedical research as well as to identify ways of reducing them, we developed and published (in 2015) a matrix consisting of overlapping tracks (or stages/phases) in the translation from discovery research to developed products, policies and practice. The matrix aids analysis by highlighting the time and actions required to develop research (and its translation) both (1) along each track and (2) from one track to another, e.g. from the discovery track to the research-in-humans track. We noted four main approaches to reducing time-lags, namely increasing resources, working in parallel, starting or working at risk, and improving processes. Examining these approaches alongside the matrix helps interpret the enormous global effort to develop a vaccine for the 2019 novel coronavirus SARS-CoV-2, the causative agent of COVID-19. Rapid progress in the discovery/basic and human research tracks is being made through a combination of large-scale funding, work being conducted in parallel (between different teams globally and through working in overlapping tracks), working at greater (but proportionate) risk to safety than usual, and adopting various new processes. The overlapping work of some of the teams involves continuing animal research whilst entering vaccine candidates into Phase I trials alongside planning their Phase II trials. The additional funding available helps to reduce some of the usual financial risks in moving so quickly. Going forward through the increasingly large human trials for safety, dosage and efficacy, it will be vital to overlap work in parallel in the often challenging public policy and clinical tracks. Thus, regulatory and reimbursement bodies are beginning and preparing rapid action to pull vaccines proving to be safe and effective through to extraordinarily rapid application to the general population. Monitoring the development of a COVID-19 vaccine using the matrix (modified as necessary) could help identify which of the approaches speeding development and deployment could be usefully applied more widely in the future

From COVID-19 research to vaccine application: why might it take 17 months not 17 years and what are the wider lessons?

Abstract: It is often said that it takes 17 years to move medical research from bench to bedside. In a coronavirus disease (COVID-19) world, such time-lags feel intolerable. In these extraordinary circumstances could years be made into months? If so, could those lessons be used to accelerate medical research when the crisis eases? To measure time-lags in health and biomedical research as well as to identify ways of reducing them, we developed and published (in 2015) a matrix consisting of overlapping tracks (or stages/phases) in the translation from discovery research to developed products, policies and practice. The matrix aids analysis by highlighting the time and actions required to develop research (and its translation) both (1) along each track and (2) from one track to another, e.g. from the discovery track to the research-in-humans track. We noted four main approaches to reducing time-lags, namely increasing resources, working in parallel, starting or working at risk, and improving processes. Examining these approaches alongside the matrix helps interpret the enormous global effort to develop a vaccine for the 2019 novel coronavirus SARS-CoV-2, the causative agent of COVID-19. Rapid progress in the discovery/basic and human research tracks is being made through a combination of large-scale funding, work being conducted in parallel (between different teams globally and through working in overlapping tracks), working at greater (but proportionate) risk to safety than usual, and adopting various new processes. The overlapping work of some of the teams involves continuing animal research whilst entering vaccine candidates into Phase I trials alongside planning their Phase II trials. The additional funding available helps to reduce some of the usual financial risks in moving so quickly. Going forward through the increasingly large human trials for safety, dosage and efficacy, it will be vital to overlap work in parallel in the often challenging public policy and clinical tracks. Thus, regulatory and reimbursement bodies are beginning and preparing rapid action to pull vaccines proving to be safe and effective through to extraordinarily rapid application to the general population. Monitoring the development of a COVID-19 vaccine using the matrix (modified as necessary) could help identify which of the approaches speeding development and deployment could be usefully applied more widely in the future

Identifying where hospital and community trusts are managing general practices in England: a service mapping study

Background Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of ‘vertical integration’ is happening is lacking, making it difficult to evaluate its impact. Aim To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements. Design and setting Review, collation, synthesis and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021. Method Desk-based collection, including hand-searching, of secondary care organisations’ statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts. Results It was possible to construct a database of all instances of trusts running general practices in England as at end-March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework. Conclusion We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and, whether that is an NHS trust, another public body or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration

Using pulse oximeters in care homes for residents with COVID-19 and other conditions: a rapid mixed-methods evaluation

Background: There are over 15,000 care homes in England, with a total of approximately 450,000 beds. Most residents are older adults, some with dementia, and other residents are people of any age with physical or learning disabilities. Using pulse oximetry in care homes can help the monitoring and care of residents with COVID-19 and other conditions. Objectives: To explore the views of care home staff, and the NHS staff they interact with, with regard to using pulse oximetry with residents, as well as the NHS support provided for using pulse oximetry. Design: We carried out a rapid mixed-methods evaluation of care homes in England, comprising (1) scoping interviews with NHS leaders, care association directors and care home managers, engaging with relevant literature and co-designing the evaluation with a User Involvement Group; (2) an online survey of care homes; (3) interviews with care home managers and staff, and with NHS staff who support care homes, at six purposively selected sites; and (4) synthesis, reporting and dissemination. The study team undertook online meetings and a workshop to thematically synthesise findings, guided by a theoretical framework. Results: We obtained 232 survey responses from 15,362 care homes. Although this was a low (1.5%) response rate, it was expected given exceptional pressures on care home managers and staff at the time of the survey. We conducted 31 interviews at six case study sites. Pulse oximeters were used in many responding care homes before the pandemic and use of pulse oximeters widened during the pandemic. Pulse oximeters are reported by care home managers and staff to provide reassurance to residents and their families, as well as to staff. Using pulse oximeters was usually not challenging for staff and did not add to staff workload or stress levels. Additional support provided through the NHS COVID Oximetry @home programme was welcomed at the care homes receiving it; however, over half of survey respondents were unaware of the programme. In some cases, support from the NHS, including training, was sought but was not always available. Limitations: The survey response rate was low (1.5%) and so findings must be treated with caution. Fewer than the intended number of interviews were completed because of participant unavailability. Throughout the COVID-19 pandemic, care homes may have been asked to complete numerous other surveys etc., which may have contributed to these limitations. Owing to anonymity, the research team was unable to determine the range of survey respondents across location, financial budget or quality of care. Conclusions: Using pulse oximeters in care homes is considered by managers and staff to have been beneficial to care home residents. Ongoing training opportunities for care home staff in use of pulse oximeters would be beneficial. Escalation processes to and responses from NHS services could be more consistent, alongside promoting the NHS COVID Oximetry @home programme to care homes. Future research: Further research should include the experiences of care home residents and their families, as well as finding out more from an NHS perspective about interactions with care home staff. Research to investigate the cost-effectiveness of pulse oximetry in care homes, and of the NHS COVID Oximetry @home programme of support, would be desirable. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 35. See the NIHR Journals Library website for further project information

Identifying options for funding the NHS and social care in the UK: international evidence

We investigate how other high-income countries have thought about and implemented changes to their funding systems for health and social care to better meet the challenges ahead. This paper is part of a broader project funded by the Health Foundation, which aims to identify a range of feasible options for the future funding of health and social care in the four countries of the UK, and assess the relative (un-)attractiveness of different funding approaches to the general public. The research reported here examines trends and innovations in health and social care funding in a selection of high-income countries. We focus on where the money to pay for care comes from, not on how it is then spent. Drawing on a review of the literature and interviews with 30 key informants in a range of high-income countries, we explore current thinking on the options for funding health care and social care. Our aim is to add to the evidence base and improve the quality of the debate, rather than make recommendations. Specifically, we: • provide examples of funding configurations for health and social care, as well as changes that have been implemented, or are being considered, in a range of high income countries • explore the drivers of recent or planned health and social care funding changes and reforms and the contexts within which decisions around funding were taken • highlight key points that can inform the range of conceivable options for funding health care and social care in the four countries of the UK. Overall we find that: • most reviewed countries fund health care primarily from public sources, such as taxation and mandatory health insurance, while social care often relies to a comparatively greater extent on individuals paying privately • health and social care funding reforms tend to be incremental rather than radical, are path-dependent, and are catalysed by changes in economic conditions rather than by rising demand for care • high-income countries have taken diverse approaches to tackling the need to increase health and social care funding and there is no single optimal, or commonly preferred, solution to achieving sustainable revenues

Rapid prioritisation of topics for rapid evaluation: the case of innovations in adult social care and social work.

BACKGROUND: Prioritisation processes are widely used in healthcare research and increasingly in social care research. Previous research has recommended using consensus development methods for inclusive research agenda setting. This research has highlighted the need for transparent and systematic methods for priority setting. Yet there has been little research on how to conduct prioritisation processes using rapid methods. This is a particular concern when prioritisation needs to happen rapidly. This paper aims to describe and discuss a process of rapidly identifying and prioritising a shortlist of innovations for rapid evaluation applied in the field of adult social care and social work. METHOD: We adapted the James Lind Alliance approach to priority setting for rapid use. We followed four stages: (1) Identified a long list of innovations, (2) Developed shortlisting criteria, (3) Grouped and sifted innovations, and (4) Prioritised innovations in a multi-stakeholder workshop (n = 23). Project initiation through to completion of the final report took four months. RESULTS: Twenty innovations were included in the final shortlist (out of 158 suggested innovations). The top five innovations for evaluation were identified and findings highlighted key themes which influenced prioritisation. The top five priorities (listed here in alphabetical order) were: Care coordination for dementia in the community, family group conferencing, Greenwich prisons social care, local area coordination and MySense.Ai. Feedback from workshop participants (n = 15) highlighted tensions from using a rapid process (e.g. challenges of reaching consensus in one workshop). CONCLUSION: The method outlined in this manuscript can be used to rapidly prioritise innovations for evaluation in a feasible and robust way. We outline some implications and compromises of rapid prioritisation processes for future users of this approach to consider