Integrated health and care systems in England : can they help prevent disease?

Objectives: Over the past 12 months, there has been increasing policy rhetoric regarding the role of the NHS in preventing disease and improving population health. In particular, the NHS Long Term Plan sees integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) as routes to improving disease prevention. Here, we place current NHS England integrated care plans in their historical context and review evidence on the relationship between integrated care and prevention. We ask how the NHS Long Term Plan may help prevent disease and explore the role of the 2019 ICS and STP plans in delivering this change. Methods: We reviewed the evidence underlying the relationship between integrated care and disease prevention, and analysed 2016 STP plans for content relating to disease prevention and population health. Results: The evidence of more integrated care leading to better disease prevention is weak. Although nearly all 2016 STP plans included a prevention or population health strategy, fewer than half specified how they will work with local government public health teams, and there was incomplete coverage across plans about how they would meet NHS England prevention priorities. Plans broadly focused on individual-level approaches to disease prevention, with few describing interventions addressing social determinants of health. Conclusions: For ICSs and STPs to meaningfully prevent disease and improve population health, they need to look beyond their 2016 plans and fill the gaps in the Long Term Plan on social determinants

Global Perspectives on Sustainable Exit from Prostitution: An analysis of social enterprise approaches adopted by faith-based projects supporting women to leave prostitution

Prostitution is highly contested and extensively researched yet despite the amount of research that has been carried out there has, until recently, been little focus on how people leave prostitution. Within the literature that does exist, the complexity of leaving prostitution is widely acknowledged. Exiting is seen as a process not an event, and one which is not necessarily linear, and studies recognise that those who seek to leave face multi-faceted barriers. The role of support organisations in facilitating transitions from prostitution is acknowledged but such organizations remain largely unexamined, as do the associations with faith traditions that have been noted amongst some of these organisations. The existing literature attests to the role of alternative employment in enabling women to exit and remain out of prostitution and a small number of empirical studies have begun to explore the role of micro-enterprise development and vocational skills training in the context of prostitution. The provision of alternative employment through the operation of a social enterprise, has, however, received scant attention. This thesis contributes to understandings of the process of exiting prostitution through an exploration of the phenomenon of faith-based projects that support women to leave prostitution through the operation of social enterprises. Based on data from an internet mapping study and ethnographic research with two case studies, a project in India and a project in the US, both of which are running social enterprises, the research examines the nature of such projects; how they support women to exit prostitution; how the social enterprise models employed by these projects operate; the salience of faith in the nature and work of such projects; and the experiences of the women engaging with these projects. In doing so, this thesis contributes to knowledge in three areas: (1) exiting prostitution, (2) social enterprise, and (3) faith

Policy and organisational responses to public inquiries in health:will we ever learn?

There have been over 100 public or otherwise independent inquiries in the UK National Health Services, dating back to the Ely Hospital Inquiry of 1969. Inquiries usually address major or serial lapses in duty of care to patients, seeking to set out what happened, explore possible causes and learn lessons for the future. In this paper, we explore the historical context to public inquiries in health, including their purpose and aim and identify the key themes that have recurred over five decades. These include hearing and heeding the patient voice; enabling staff to raise concerns with confidence; the impact of pressures in the health system; NHS top-down organisation culture; and regulation and inspection as a ‘cure’. This thematic framework is then used to assess the health policy, organisational and service progress that appears to have been made in response to public inquiries, taking the Francis Inquiry into the Mid-Staffordshire NHS Foundation Trust as a case study. We use the case of the Francis Inquiry to identify and explore the progress (or absence of progress) of the main developments for NHS organisations resulting from the Francis Inquiry including the strengthening of national regulatory bodies for health care quality; having greater transparency of staffing levels and deficits by regular reporting of local workforce data; introducing new ways in which staff can raise concerns or ‘whistle-blow’ where they fear harm is being done to patients; understanding better the potential harms from dysfunctional organisational culture; and how far the ‘duty of candour’ is working in practice. Drawing on this, we present an analysis of apparently persistent gaps in learning from inquiries in health, this being used to propose a set of potential policy recommendations for health and care in the UK context. These include the need for formal accountability processes to track progress with public inquiry recommendations; exploring how best to manage and support smaller or isolated hospitals; the need for formal accreditation and training standards for all NHS managers; heeding the evidence of the distraction caused by most health service reorganisation; and having a formal and funded long-term workforce plan for health and social care.The paper concludes by suggesting how this analysis offers insights into how publicly funded and accountable health systems can secure deep and sustained learning and improvement from holding public or other independent inquiries. <br/

Policy and organisational responses to public inquiries in health: will we ever learn?:Paper presented at a Reading University Law Faculty Symposium

There have been over 100 public or otherwise independent inquiries in the UK National Health Services, dating back to the Ely Hospital Inquiry of 1969. Inquiries usually address major or serial lapses in duty of care to patients, seeking to set out what happened, explore possible causes and learn lessons for the future. In this paper, we explore the historical context to public inquiries in health, including their purpose and aim and identify the key themes that have recurred over five decades. These include hearing and heeding the patient voice; enabling staff to raise concerns with confidence; the impact of pressures in the health system; NHS top-down organisation culture; and regulation and inspection as a ‘cure’. This thematic framework is then used to assess the health policy, organisational and service progress that appears to have been made in response to public inquiries, taking the Francis Inquiry into the Mid-Staffordshire NHS Foundation Trust as a case study. We use the case of the Francis Inquiry to identify and explore the progress (or absence of progress) of the main developments for NHS organisations resulting from the Francis Inquiry including the strengthening of national regulatory bodies for health care quality; having greater transparency of staffing levels and deficits by regular reporting of local workforce data; introducing new ways in which staff can raise concerns or ‘whistle-blow’ where they fear harm is being done to patients; understanding better the potential harms from dysfunctional organisational culture; and how far the ‘duty of candour’ is working in practice. Drawing on this, we present an analysis of apparently persistent gaps in learning from inquiries in health, this being used to propose a set of potential policy recommendations for health and care in the UK context. These include the need for formal accountability processes to track progress with public inquiry recommendations; exploring how best to manage and support smaller or isolated hospitals; the need for formal accreditation and training standards for all NHS managers; heeding the evidence of the distraction caused by most health service reorganisation; and having a formal and funded long-term workforce plan for health and social care.The paper concludes by suggesting how this analysis offers insights into how publicly funded and accountable health systems can secure deep and sustained learning and improvement from holding public or other independent inquiries. <br/

Prospects for progress on health inequalities in England in the post-primary care trust era : professional views on challenges, risks and opportunities

Background - Addressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario. Methods - Semi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations. Results - In general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs’ clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards. Conclusions - There is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.</p

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities. Aims The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice. Methods We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff. Findings Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely. Future Research Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc

Insights of private general practitioners in group practice on the introduction of National Health Insurance in South Africa

Background: The South African government intends to contract with ‘accredited provider groups’ for capitated primary care under National Health Insurance (NHI). South African solo general practitioners (GPs) are unhappy with group practice. There is no clarity on the views of GPs in group practice on contracting to the NHI. Objectives: To describe the demographic and practice profile of GPs in group practice in South Africa, and evaluate their views on NHI, compared to solo GPs. Methods: This was a descriptive survey. The population of 8721 private GPs in South Africa with emails available were emailed an online questionnaire. Descriptive statistical analyses and thematic content analysis were conducted. Results: In all, 819 GPs responded (568 solo GPs and 251 GPs in groups). The results are focused on group GPs. GPs in groups have a different demographic practice profile compared to solo GPs. GPs in groups expected R4.86 million ($0.41 million) for a hypothetical NHI proposal of comprehensive primary healthcare (excluding medicines and investigations) to a practice population of 10 000 people. GPs planned a clinical team of 8 to 12 (including nurses) and 4 to 6 administrative staff. GPs in group practices saw three major risks: patient, organisational and government, with three related risk management strategies. Conclusions: GPs can competitively contract with NHI, although there are concerns. NHI contracting should not be limited to groups. All GPs embraced strong teamwork, including using nurses more effectively. This aligns well with the emergence of family medicine in Africa