Rapid Evaluation of the Special Measures for Quality and Challenged Provider Regimes: A Mixed-Methods Study

Background: Healthcare organisations in England rated as inadequate for leadership and one other domain enter Special Measures for Quality (SMQ) to receive support and oversight. A ‘watch list’ of challenged providers (CPs) at risk of entering SMQ also receive support. Knowledge is limited about whether the support interventions drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. Objective: Analyse trust responses to the implementation of a) interventions for SMQ trusts and b) interventions for CP trusts to determine their impact on these organisations' capacity to achieve and sustain quality improvements. Design: Rapid research comprising five inter-related workstreams: 1. Literature review using systematic methods. 2. Analysis of policy documents and interviews at national level. 3. Eight multi-site, mixed method trust case studies. 4. Analysis of national performance and workforce indicators. 5. Economic analysis. Results: SMQ/CP were intended to be “support” programmes. SMQ/CP had an emotional impact on staff. Perceptions of NHSI interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of SMQ trusts exited within 24 months. Relative to national trends, entry into SMQ/CP corresponded to positive changes in 4-hour waits in Emergency Departments, mortality and delayed transfers of care. Trends in staff sickness and absence improved after trusts left SMQ/CP. There was some evidence that staff survey results improve. No association was found between SMQ/CP and referral to treatment times or cancer waiting times. The largest components of NHSI spending in case studies were interventions directed at 'training on cultural change' (33.6%), 'workforce quality and safety' (21.7%) and 'governance and assurance' (18.4%). Impact of SMQ on financial stability was equivocal; most trusts exiting SMQ experienced the same financial stability before and after exiting. Limitations: The rapid research design and one-year timeframe precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measuring workforce effects was limited by data availability. Conclusions: Empirical evidence of positive impacts from SMQ/CP were identified, however, perceptions were mixed. Key lessons: • Time is needed to implement and embed changes. • Ways to mitigate emotional costs and stigma are needed. • Support strategies should be more trust specific. • Poor organisational performance needs to be addressed within local systems. • Senior leadership teams with stability, strong clinical input and previous SMQ experience helped enact change. • Organisation-wide quality improvement strategies and capabilities are needed. • Staff engagement and an open listening culture promote continuous learning and a quality improvement ‘mindset’, critical for sustainable improvement. • Need to consider level of sustainable funds required to improve patients’ outcomes. Future work: Evaluating recent changes to the regimes; role of local systems; longitudinal approaches. Study registration: Review protocol registered with PROSPERO (CRD: 42019131024). Funding: The National Institute for Health Research Health Services and Delivery Research programme (16/138/17 – Rapid Service Evaluation Research Team)

Undertaking rapid evaluations during the COVID-19 pandemic: Lessons from evaluating COVID-19 remote home monitoring services in England

Introduction: Rapid evaluations can offer evidence on innovations in health and social care that can be used to inform fast-moving policy and practise, and support their scale-up according to previous research. However, there are few comprehensive accounts of how to plan and conduct large-scale rapid evaluations, ensure scientific rigour, and achieve stakeholder engagement within compressed timeframes. / Methods: Using a case study of a national mixed-methods rapid evaluation of COVID-19 remote home monitoring services in England, conducted during the COVID-19 pandemic, this manuscript examines the process of conducting a large-scale rapid evaluation from design to dissemination and impact, and reflects on the key lessons for conducting future large-scale rapid evaluations. In this manuscript, we describe each stage of the rapid evaluation: convening the team (study team and external collaborators), design and planning (scoping, designing protocols, study set up), data collection and analysis, and dissemination. / Results: We reflect on why certain decisions were made and highlight facilitators and challenges. The manuscript concludes with 12 key lessons for conducting large-scale mixed-methods rapid evaluations of healthcare services. We propose that rapid study teams need to: (1) find ways of quickly building trust with external stakeholders, including evidence-users; (2) consider the needs of the rapid evaluation and resources needed; (3) use scoping to ensure the study is highly focused; (4) carefully consider what cannot be completed within a designated timeframe; (5) use structured processes to ensure consistency and rigour; (6) be flexible and responsive to changing needs and circumstances; (7) consider the risks associated with new data collection approaches of quantitative data (and their usability); (8) consider whether it is possible to use aggregated quantitative data, and what that would mean when presenting results, (9) consider using structured processes & layered analysis approaches to rapidly synthesise qualitative findings, (10) consider the balance between speed and the size and skills of the team, (11) ensure all team members know roles and responsibilities and can communicate quickly and clearly; and (12) consider how best to share findings, in discussion with evidence-users, for rapid understanding and use. / Conclusion: These 12 lessons can be used to inform the development and conduct of future rapid evaluations in a range of contexts and settings

Rethinking “democratic backsliding” in Central and Eastern Europe – looking beyond Hungary and Poland

This essay introduces contributions to a special issue of East European Politics on “Rethinking democratic backsliding in Central and Eastern Europe”, which seeks to expand the study of democratic regression in CEE beyond the paradigmatic cases of Hungary and Poland. Reviewing these contributions, we identify several directions for research: 1) the need to critique “democratic backsliding”, not simply as a label, but also as an assumed regional trend; 2) a need to better integrate the role of illiberal socio-economic structures such as oligarchical structures or corrupt networks; and 3) a need to (re-)examine the trade-offs between democratic stability and democratic quality. We also note how insights developed researching post-communist regions such as Western Balkans or the post-Soviet space could usefully inform work on CEE backsliding. We conclude by calling for the study of CEE democracy to become more genuinely interdisciplinary, moving beyond some narrowly institutionalist comparative political science assumptions

In Search of New Imaging For Historical Earthquakes: A New Geophysical Survey Offshore Western Calabria (Southern Tyrrhenian Sea, Italy)

During the summer of 2010 we carried out a survey to acquire a multidisciplinary dataset within the Gulf of Sant'Eufemia (SE Tyrrhenian sea, Italy), with the aim of studying the active tectonics affecting the region, including that potentially responsible for key, elusive earthquakes such as the to-date unexplained 8 September 1905 (Mw 7 - 7.5) earthquake. The data here analysed highlight the presence of several tectonic and morphologic features characterizing the investigated area. We have recognized the Angitola Channel, a deep and wide canyon showing a straight trend in its coastward segment, and a meandering trend in the seaward segment. Based on morpho-structural elements, we maintain that the Angitola Channel could be tectonically controlled. Moreover, several gravitational instabilities as slumps and collapses affect the flanks of the morpho-structural high, detected offshore Capo Vaticano. Very high resolution seismic data have unveiled the presence of numerous fluid escape features and several mud volcanoes straddling the sector from the coastline to seaward.INOGS (RIMA Department) supported the acquisition of the entire dataset.Published385-4013.2. Tettonica attivaJCR Journalrestricte

How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: Results of logit and OLS models using Albanian LSMS 2005

Abstract Background Informal payments for health care are common in most former communist countries. This paper explores the demand side of these payments in Albania. By using data from the Living Standard Measurement Survey 2005 we control for individual determinants of informal payments in inpatient and outpatient health care. We use these results to explain the main factors contributing to the occurrence and extent of informal payments in Albania. Methods Using multivariate methods (logit and OLS) we test three models to explain informal payments: the cultural, economic and governance model. The results of logit models are presented here as odds ratios (OR) and results from OLS models as regression coefficients (RC). Results Our findings suggest differences in determinants of informal payments in inpatient and outpatient care. Generally our results show that informal payments are dependent on certain characteristics of patients, including age, area of residence, education, health status and health insurance. However, they are less dependent on income, suggesting homogeneity of payments across income categories. Conclusions We have found more evidence for the validity of governance and economic models than for the cultural model.</p

Informal payments and intra-household allocation of resources for health care in Albania

<p>Abstract</p> <p>Background</p> <p>Informal payments for health care services can impose financial hardship on households. Many studies have found that the position within the household can influence the decision on how much is spent on each household member. This study analyses the intra-household differences in spending on informal payments for health care services by comparing the resources allocated between household heads, spouses and children.</p> <p>Methods</p> <p>Pooled data from two cross sectional surveys, the Albanian Living Standard Measurement Survey 2002 and 2005, are used to analyse both the probability and the amount paid in inpatient and outpatient health care services. A generalised Hausman specification test is used to compare the coefficients of probit and OLS models for nuclear and extended households.</p> <p>Results</p> <p>We find that due to the widespread informal payments there are no significant differences between households in the incidence of informal payments for households' members, but there are more differences in the amount paid informally. Results suggest that households strategically allocate their resources on health care by favouring individuals with higher earning potential who have invested more in human capital. Extended households pay higher amounts for spouses with higher education compared to nuclear households. On the other hand, nuclear households choose to pay higher amounts for children with a higher level of education compared to extended households.</p> <p>Conclusions</p> <p>The differences between households should be taken into account by public policies which should compensate this by redistribution mechanisms targeting disadvantaged groups. Governments should implement effective measures to deal with informal patient payments.</p> <p><b>JEL Codes: </b>I10, I19, D10</p

Rapid evaluation of the Special Measures for Quality and challenged provider regimes: a mixed-methods study

Background: Health-care organisations in England that are rated as inadequate for leadership and one other domain enter the Special Measures for Quality regime to receive support and oversight. A ‘watch list’ of challenged providers that are at risk of entering Special Measures for Quality also receive support. Knowledge is limited about whether or not the support interventions drive improvements in quality, the costs of the support interventions and whether or not the support interventions strike the right balance between support and scrutiny. Objective: To analyse the responses of trusts to the implementation of (1) interventions for Special Measures for Quality trusts and (2) interventions for challenged provider trusts to determine their impact on these organisations’ capacity to achieve and sustain quality improvements. Design: This was rapid research comprising five interrelated workstreams: (1) a literature review using systematic methods; (2) an analysis of policy documents and interviews at the national level; (3) eight multisite, mixed-methods trust case studies; (4) an analysis of national performance and workforce indicators; and (5) an economic analysis. Results: The Special Measures for Quality/challenged provider regimes were intended to be ‘support’ programmes. Special Measures for Quality/challenged provider regimes had an emotional impact on staff. Perceptions of NHS Improvement interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input being vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of Special Measures for Quality trusts exited the regime in 24 months. Entry into Special Measures for Quality/challenged provider regimes resulted in changes in quality indicators (such the number of patients waiting in emergency departments for more than 4 hours, mortality and the number of delayed transfers of care) that were more positive than national trends. The trends in staff sickness and absence improved after trusts left Special Measures for Quality/challenged provider regimes. There was some evidence that staff survey results improved. No association was found between Special Measures for Quality/challenged provider regimes and referral to treatment times or cancer treatment waiting times. NHS Improvement spending in case study trusts was mostly directed at interventions addressing ‘training on cultural change’ (33.6%), ‘workforce quality and safety’ (21.7%) and ‘governance and assurance’ (18.4%). The impact of Special Measures for Quality on financial stability was equivocal; most trusts exiting Special Measures for Quality experienced the same financial stability before and after exiting. Limitations: The rapid research design and 1-year time frame precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measurement of workforce effects was limited by data availability. Conclusions: Empirical evidence of positive impacts of Special Measures for Quality/challenged provider regimes were identified; however, perceptions were mixed. Key lessons were that (1) time is needed to implement and embed changes; (2) ways to mitigate emotional costs and stigma are needed; (3) support strategies should be more trust specific; (4) poor organisational performance needs to be addressed within local systems; (5) senior leadership teams with stability, strong clinical input and previous Special Measures for Quality experience helped to enact change; (6) organisation-wide quality improvement strategies and capabilities are needed; (7) staff engagement and an open-listening culture promote continuous learning and a quality improvement ‘mindset’, which is critical for sustainable improvement; and (8) consideration of the level of sustainable funds required to improve patients’ outcomes is needed. Future work: Future work could include evaluating recent changes to the regimes, the role of local systems and longitudinal approaches. Study registration: The review protocol is registered with PROSPERO (CRD42019131024). 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. 11, No. 19. See the NIHR Journals Library website for further project information

Response to Letter to the Editor Regarding "Abiraterone Acetate for the Treatment of Chemotherapy-Naive Metastatic Castration-Resistant Prostate Cancer: An Evidence Review Group Perspectiveaof a NICE Single Technology Appraisal"

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programm

Abiraterone Acetate for the Treatment of Chemotherapy-Naive Metastatic Castration-Resistant Prostate Cancer: An Evidence Review Group Perspective of an NICE Single Technology Appraisal

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (see the HTA programme website for further project information [http://www.hta.ac.uk])