PCT commissioning: how community nurse involvement can be encouraged

Commissioning is the process by which PCTs identify the health needs of their population and make prioritized decisions to secure care to meet those needs within available resources. It includes longer term strategic planning, medium term planning (three year Local delivery Plans) and the shorter term agreement and performance management of service level agreements. The process should involve the public, engage clinicians, and be conducted on a whole system basis, informed by health equity audits, and carried through with the full participation of other stakeholders including NHS Trusts, local authority(s) and the voluntary sector (NHS Modernization Agency, 2004)

Do reviews of healthcare interventions teach us how to improve healthcare systems?

Planners, managers and policy makers in modern health services are not without ingenuity e they will always try, try and try again. They face deep-seated or ‘wicked’ problems, which have complex roots in the labyrinthine structures though which healthcare is delivered. Accordingly, the interventions devised to deal with such stubborn problems usually come in the plural. Many different reforms are devised to deal with a particular stumbling block, which may be implemented sequentially, simultaneously or whenever policy fashion or funding dictates. This paper examines this predicament from the perspective of evidence based policy. How might researchers go about reviewing the evidence when they are faced with multiple or indeed competing interventions addressing the same problem? In the face of this plight a rather unheralded form of research synthesis has emerged, namely the ‘typological review’. We critically review the fortunes of this strategy. Separating the putative reforms into series of subtypes and producing a scorecard of their outcomes has the unintended effect of divorcing them all from an understanding of how organisations change. A more fruitful approach may lie in a ‘theory-driven review’ underpinned by an understanding of dynamics of social change in complex organisations. We test this thesis by examining the primary and secondary research on the many interventions designed to tackle a particularly wicked problem, namely the inexorable rise in demand for healthcare

Unmeasured improvement work: the lack of routinely collected, service-related data in NHS endoscopy units in England involved in "modernisation"

Contains fulltext : 70532.pdf (publisher's version ) (Open Access)BACKGROUND: The availability of routinely collected service-related endoscopy data from NHS endoscopy units has never been quantified. METHODS: This retrospective observational study asked 19 endoscopy units to submit copies of all in-house, service-related endoscopy data that had been routinely collected by the unit - Referral numbers, Activity, Number of patients waiting and Number of lost slots. Nine of the endoscopy units had previously participated in the Modernising Endoscopy Services (MES) project during 2003 to redesign their endoscopy services. These MES sites had access to additional funding and data collection software. The other ten (Control sites) had modernised independently. All data was requested in two phases and corresponded to eight specific time points between January 2003 and April 2006. RESULTS: Only eight of 19 endoscopy units submitted routinely collected, service-related data. Another site's data was collected specifically for the study. A further two units claimed to routinely collect service-related data but did not submit any to the study. The remaining eight did not collect any service-related endoscopy data routinely and liaised with their Trust for data. Of the eight sites submitting service-related data, only three were MES project sites. Of these three, the data variables collected were limited and none collected the complete set of endoscopy data variables requested. Of the other five sites, two collected all four endoscopy data types. Data for the three MES project sites went back as far as January 2003, whilst the five Control sites were only able to submit data from December 2003 onwards. CONCLUSION: There was a lack of service-related endoscopy data routinely collected by the study sites, especially those who had participated in the MES project. Without this data, NHS endoscopy services cannot have a true understanding of their services, cannot identify problems and cannot measure the impact of any changes. With the increasing pressures placed on NHS endoscopy services, the need to effectively inform redesign plans is paramount. We recommend the compulsory collection of service-related endoscopy data by all NHS endoscopy units using a standardised format with rigorous guidelines

A national survey of obstetric early warning systems in the United Kingdom: five years on.

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas

Exploration of contextual factors in a successful quality improvement collaborative in English ambulance services: cross-sectional survey

Rationale, aims and objectives Clinical leadership and organizational culture are important contextual factors for quality improvement (QI) but the relationship between these and with organizational change is complex and poorly understood. We aimed to explore the relationship between clinical leadership, culture of innovation and clinical engagement in QI within a national ambulance QI Collaborative (QIC). Methods We used a self-administered online questionnaire survey sent to front-line clinicians in all 12 English ambulance services. We conducted a cross-sectional analysis of quantitative data and qualitative analysis of free-text responses. Results There were 2743 (12% of 22 117) responses from 11 of the 12 participating ambulance services. In the 3% of responders that were directly involved with the QIC, leadership behaviour was significantly higher than for those not directly involved. QIC involvement made no significant difference to responders’ perceptions of the culture of innovation in their organization, which was generally considered poor. Although uptake of QI methods was low overall, QIC members were significantly more likely to use QI methods, which were also significantly associated with leadership behaviour. Conclusions Despite a limited organizational culture of innovation, clinical leadership and use of QI methods in ambulance services generally, the QIC achieved its aims to significantly improve pre-hospital care for acute myocardial infarction and stroke.We postulate that this was mediated through an improvement subculture, linked to the QIC, which facilitated large-scale improvement by stimulating leadership and QI methods. Further research is needed to understand success factors for QI in complex health care environments

A patient survey of out-of-hours care provided by Emergency Care Practitioners

© 2007 Halter et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice