Towards integrated care: using linked data to explore health and social care utilisation for adult residents of Barking and Dagenham in 2016/17

Background Better integration across all settings of care is a core ambition of the NHS to address the changing needs of an ageing population and achieve efficiency gains. This study created a novel individual level data resource to explore the use of health and social care services across five care settings, to evaluate the factors associated with this use, and the extent to which these factors vary by setting of care for residents of Barking and Dagenham in 2016/17. Methodology Mixed methods including: semi-structured interviews in Barking and Dagenham, Havering and Redbridge to understand system leaders’ perspectives on working across organisation and sector boundaries; descriptive analysis of service utilisation across five settings of care (hospital, primary, community, mental health and social care) to compare population and cost volumes for 32 possible combinations of service use; a two-part regression model to calculate the combined effect of the probability of service use and the level of service use if there was one across a wide range of co-variates overall and by setting of care; matched analysis of the impact having an informal carer has on cost-weighted utilisation. Results Improving system finances was a key motivator for integration. The 2016/17 total costs for the cohort (114,393 residents) was £180.1 million. Two combinations of service use dominated cost and volume for the system, with a further eight combinations dominant for an individual setting. The relative impact of socio-demographic, health and economic factors differed according to setting of care. Health and care costs were £2,662 higher for people registered in their primary care records to have a carer compared to those who did not. Conclusions Large, linked datasets, such as the one considered in this thesis, provide extensive opportunities to improve our understanding of service user patterns and the wider determinants of health

End-of-life care costs and place of death across health and social care sectors

Objectives: This study explores the relationship between end-of-life care costs and place of death across different health and social care sectors. // Methods: We used a linked local government and health data of East London residents (n=4661) aged 50 or over, deceased between 2016 and 2020. Individuals who died in hospital were matched to those who died elsewhere according to a wide range of demographic, socioeconomic and health factors. We reported mean healthcare costs and 95% CIs by care sectors over the 12-month period before death. Subgroup analyses were conducted to investigate if the role of place of death differs according to long-term conditions and age. // Results: We found that mean difference in total cost between hospital and non-hospital decedents was £4565 (95% CI £3132 to £6046). Hospital decedents were associated with higher hospital cost (£5196, £4499 to £5905), higher mental healthcare cost (£283, £78 to £892) and lower social care cost (−£838, −£1,209 to −£472), compared with individuals who died elsewhere. Subgroup analysis shows that the association between place of death and healthcare costs differs by age and long-term conditions, including cancer, mental health and cardiovascular diseases. // Conclusion: This study suggests that trajectories of end-of-life healthcare costs vary by place of death in a differential way across health and social care sectors. High hospital burden for cancer patients may be alleviated by strengthening healthcare provision in less cost-intensive settings, such as community and social care

Conditions associated with the initiation of domiciliary care following a hospital admission: a cohort study in East London, England

OBJECTIVE: Older people and people with complex needs often require both health and social care services, but there is limited insight into individual journeys across these services. To help inform joint health and social care planning, we aimed to assess the relationship between hospital admissions and domiciliary care receipt. DESIGN: Retrospective cohort study, using linked data on primary care activity, hospital admissions and social care records. SETTING: London Borough of Barking and Dagenham, England. PARTICIPANTS: Adults aged 19 and over who lived in the area on 1 April 2018 and who were registered at a general practice in East London between 1 April 2018 and 31 March 2020 (n=140 987). OUTCOME MEASURES: The outcome was initiation of domiciliary care. We estimated the rate of hospital-associated care package initiation, and of care packages unrelated to hospital admission. We also described the characteristics of hospital admissions that preceded domiciliary care, including primary diagnosis codes. RESULTS: 2041/140 987 (1.4%) participants had a domiciliary care package during a median follow-up of 1.87 years. 32.6% of packages were initiated during a hospital stay or within 7 days of discharge. The rate of new domiciliary care packages was 120 times greater (95% CI 110 to 130) during or after a hospital stay than at other times, and this association was present for all age groups. Primary admission reasons accounting for the largest number of domiciliary care packages were hip fracture, pneumonia, stroke, urinary tract infection, septicaemia and exacerbations of long-term conditions (chronic obstructive pulmonary disease and heart failure). Admission reasons with the greatest likelihood of a subsequent domiciliary care package were fractures and strokes. CONCLUSION: Hospitals are a major referral route into domiciliary care. While patients admitted due to new and acute illnesses account for many domiciliary care packages, exacerbations of long-term conditions and age-related and frailty-related conditions are also important drivers

Understanding health and care expenditure by setting – who matters to whom?

Objective: To assess service use and associated expenditure across a range of care settings in one local authority in London, United Kingdom. Methods: An analysis of linked electronic health and council records of adults living in the borough of Barking and Dagenham, east London, for the financial year 2016/17. Unit costs were applied to individual service use to provide expenditure at an individual and population level for five settings of care. Population and expenditure volumes were compared for 32 possible combinations of service use. Results: The total expenditure for the cohort (114,393 residents) for 2016/17 was £180.1 million. Almost half (47%) of total expenditure was incurred by community care, social care and mental health services, with hospital care and primary care incurring, respectively, 35% (£63.3 m) and 18% (£32.6 m). The two most common combinations in terms of total population volume and expenditure were primary and hospital care, and primary, hospital and community care. Primary care was present in all combinations. Mental health service use accounted for just over a tenth of all expenditure in the borough, but using mental health services substantially increased mean expenditure per patient. Conclusions: A whole system perspective across all settings of care improves understanding of service user patterns. Setting-level analysis remains important, particularly for mental health users

Variation in health visiting contacts for children in England: cross-sectional analysis of the 2–2½ year review using administrative data (Community Services Dataset, CSDS)

Objective: The 2–2½ year universal health visiting review in England is a key time point for assessing child development and promoting school readiness. We aimed to ascertain which children were least likely to receive their 2–2½ year review and whether there were additional non-mandated contacts for children who missed this review. Design, setting, participants: Cross-sectional analysis of the 2–2½ year review and additional health visiting contacts for 181 130 children aged 2 in England 2018/2019, stratified by ethnicity, deprivation, safeguarding vulnerability indicator and Looked After Child status. Analysis: We used data from 33 local authorities submitting highly complete data on health visiting contacts to the Community Services Dataset. We calculated the percentage of children with a recorded 2–2½ year review and/or any additional health visiting contacts and average number of contacts, by child characteristic. Results: The most deprived children were slightly less likely to receive a 2–2½ year review than the least deprived children (72% vs 78%) and Looked After Children much less likely, compared with other children (44% vs 69%). When all additional contacts were included, the pattern was reversed (deprivation) or disappeared (Looked After children). A substantial proportion of all children (24%), children with a ‘safeguarding vulnerability’ (22%) and Looked After children (29%) did not have a record of either a 2–2½ year review or any other face-to-face contact in the year. Conclusions: A substantial minority of children aged 2 with known vulnerabilities did not see the health visiting team at all in the year. Some higher need children (eg, deprived and Looked After) appeared to be seeing the health visiting team but not receiving their mandated health review. Further work is needed to establish the reasons for this, and potential solutions. There is an urgent need to improve the quality of national health visiting data

Using cross-sector data linkage to track patient journeys across health and social care.

Objectives Older people and people with complex needs often require both health and social care services, but there is limited insight into individual journeys across these services. To help inform joint health and social care planning, we aimed to assess the relationship between hospital admissions and domiciliary care receipt. Approach We used an individually linked dataset of primary care activity, hospital admissions and local authority-held social care records for adults living in Barking and Dagenham, a borough in London, England, on 1 April 2018, and followed them up until 31 March 2020. The outcome was initiation of a new domiciliary care package. We estimated the rate of hospital-associated care package initiation, and of care packages unrelated to hospital admissions. We also described the characteristics of hospital admissions that preceded domiciliary care and examined which primary diagnoses codes were associated with receiving domiciliary care after discharge. Results In our cohort, 1.4 of participants had a domiciliary care package during a median follow-up of 1.87 years. One in three domiciliary care packages were initiated during a hospital stay or within 7 days of discharge. The rate of new domiciliary care packages was 120 times greater (95% CI 110-130) during or after a hospital stay than at other times, and this association was present for all age groups. Primary admission reasons accounting for the largest number of domiciliary care packages were hip fracture, pneumonia, urinary tract infection, septicaemia, and exacerbations of long-term conditions (COPD and heart failure). Admission reasons with the greatest likelihood of a subsequent domiciliary care package were fractures and strokes. Conclusion Hospitals are a major referral route into domiciliary care. While new and acute illnesses account for many domiciliary care packages, exacerbations of long-term conditions and age- and frailty-related conditions are also an important driver. National-level linked datasets are needed for a better understanding of the relationship between health and social care receipt

Tackling barriers to COVID-19 vaccine uptake in London: a mixed-methods evaluation

BACKGROUND: In response to the COVID-19 pandemic, the first vaccine was administered in December 2020 in England. However, vaccination uptake has historically been lower in London than in other English regions. METHODS: Mixed-methods: This comprised an analysis of cumulative percentage uptake across London between 8 December 2020 and 6 June 2021 by vaccine priority cohorts and ethnicity. We also undertook thematic analyses of uptake barriers, interventions to tackle these and key learning from a qualitative survey of 27 London local authority representatives, vaccine plans from London's five Integrated Care Systems and interviews with 38 London system representatives. RESULTS: Vaccine uptake was lower in Black ethnic (57-65% uptake) compared with the White British group (90% uptake). Trust was a critical issue, including mistrust in the vaccine itself and in authorities administering or promoting it. The balance between putative costs and benefits of vaccination created uptake barriers for zero-hour and shift workers. Intensive, targeted and 'hyper-local' initiatives, which sustained community relationships and were not constrained by administrative boundaries, helped tackle these barriers. CONCLUSIONS: The success of the national vaccination programme depended on conceding local autonomy, investing in responsive and long-term partnerships to engender trust through in-depth understanding of communities' beliefs

Kailo: a systemic approach to addressing the social determinants of young people’s mental health and wellbeing at the local level [version 1; peer review: awaiting peer review]

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people’s mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people’s mental health and wellbeing at the local level

Translation Levels Control Multi-Spanning Membrane Protein Expression

Attempts to express eukaryotic multi-spanning membrane proteins at high-levels have been generally unsuccessful. In order to investigate the cause of this limitation and gain insight into the rate limiting processes involved, we have analyzed the effect of translation levels on the expression of several human membrane proteins in Escherichia coli (E. coli). These results demonstrate that excessive translation initiation rates of membrane proteins cause a block in protein synthesis and ultimately prevent the high-level accumulation of these proteins. Moderate translation rates allow coupling of peptide synthesis and membrane targeting, resulting in a significant increase in protein expression and accumulation over time. The current study evaluates four membrane proteins, CD20 (4-transmembrane (TM) helixes), the G-protein coupled receptors (GPCRs, 7-TMs) RA1c and EG-VEGFR1, and Patched 1 (12-TMs), and demonstrates the critical role of translation initiation rates in the targeting, insertion and folding of integral membrane proteins in the E. coli membrane