OBJECTIVES: To establish the extent of Occupational Health (OH) service provision in the National Health Service (NHS). METHODS: Two postal questionnaires were used to obtain information from purchasers and providers in the NHS in England and Wales. RESULTS: 99.6% of trust and health authority employers claim to provide some form of OH service to their employees indicating widespread recognition of need, but virtually no service is provided to other staff such as general practitioners (GPs), general dental practitioners (GDPs), and their staff. There is a wide variability in the range and quality of OH services, suggested by the enormous differences in medical staffing levels, and the contractual restrictions where the OH service is provided by another NHS employer. Only about a third (highest estimate) to a quarter (lowest estimate) of NHS staff have access to a specialist occupational physician. CONCLUSIONS: Substantial inequality of access to OH services exists for the NHS workforce, despite previous guidance. There is no real evidence to suggest why the extent of provision of OH services varies so greatly between institutions.
Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work–life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs.
To analyse which factors influence an individual GP's decision to re-provide OOH care when their practice has opted out.
Design of study
Cross-sectional questionnaire survey.
Rural and urban general practices in Scotland, UK.
A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation.
Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services.
The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.
health care reform; out-of-hours medical care; primary care; workforce
Over the past two decades, the service delivery landscape across health and social care in England has been reshaped in order to separate the commissioning of services from their delivery.
The market ethic that underpinned this move has depicted the previously roles as unresponsive to the needs of service users and dominated by provider interests. As well as seeming to offer commissioners the chance to change the nature of provision and type of provider, this policy model also created a further new opportunity—for joint commissioning across organisational boundaries. The logic here is that if two or more commissioners can jointly shape their programmes then they will be better able to secure integrated provision across a range of separate agencies and professions.
This article reviews the experience of joint commissioning across health and social care over the past decade in England. It contrasts the proliferation of policies against the paucity of achievements, seeks explanations for this situation, and offers pointers for future development.
joint commissioning; health and social care; policy developments; top-down implementation; front-line professionals; network development
The aim of this study is to develop, apply and evaluate an economics-based framework to assist commissioners in their management of finite resources for local dental services. In April 2006, Primary Care Trusts in England were charged with managing finite dental budgets for the first time, yet several independent reports have since criticised the variability in commissioning skills within these organisations. The study will explore the views of stakeholders (dentists, patients and commissioners) regarding priority setting and the criteria used for decision-making and resource allocation. Two inter-related case studies will explore the dental commissioning and resource allocation processes through the application of a pragmatic economics-based framework known as Programme Budgeting and Marginal Analysis.
The study will adopt an action research approach. Qualitative methods including semi-structured interviews, focus groups, field notes and document analysis will record the views of participants and their involvement in the research process. The first case study will be based within a Primary Care Trust where mixed methods will record the views of dentists, patients and dental commissioners on issues, priorities and processes associated with managing local dental services. A Programme Budgeting and Marginal Analysis framework will be applied to determine the potential value of economic principles to the decision-making process. A further case study will be conducted in a secondary care dental teaching hospital using the same approach. Qualitative data will be analysed using thematic analysis and managed using a framework approach.
The recent announcement by government regarding the proposed abolition of Primary Care Trusts may pose challenges for the research team regarding their engagement with the research study. However, whichever commissioning organisations are responsible for resource allocation for dental services in the future; resource scarcity is highly likely to remain an issue. Wider understanding of the complexities of priority setting and resource allocation at local levels are important considerations in the development of dental commissioning processes, national oral health policy and the future new dental contract which is expected to be implemented in April 2014.
A survey was carried out to ascertain the current provision of general paediatric surgery (GPS) in all hospitals in England, Wales and Northern Ireland with 100% return rate. The provision of GPS is at a crossroads with a drift of these cases to the overstretched, tertiary referral hospitals.
The regional representatives on the council of the Association of Surgeons of Great Britain and Ireland (ASGBI) obtained data from their regions. Any gaps in the data were completed by the author telephoning the remaining hospitals to ascertain their current provision.
A total of 325 acute hospitals are potentially available to admit elective and/or emergency paediatric patients, of which 25 hospitals provide a tertiary paediatric surgical service. Of the remaining ‘non-tertiary’ hospitals, 138 provide elective GPS and 147 provide emergency GPS. The ages at which GPS is carried out varies considerably, but 76% of non-tertiary hospitals provide elective GPS to those over the age of 2 years. The ages of emergency cases are 24% over the age of 2 years and 51.5% over the age of 5 years. The age at which surgery is carried out is dependent on the anaesthetic provision. Subspecialisation within each hospital has taken place with a limited number of surgeons providing the elective surgery. ‘Huband-spoke’ provision of GPS to a district general hospital (DGH) from a tertiary centre is embryonic with only 11 surgeons currently in post. An estimate of the annual elective case load of GPS based on the average number of cases done on an operation list works out at 23,000 cases done outwith the tertiary centres.
Almost 10 years ago, a change in the training of young surgeons took place. An increase in training posts in Tertiary centres was made available following advice from the British Association of Paediatric Surgeons (BAPS) but these posts were often not taken up. Many DGH surgeons became uncertain whether they should continue GPS training. A subtle change in the wording of the general guidance by the Royal College of Anaesthetists altered the emphasis on the age at which it was appropriate to anaesthetise children. Change in clinical practice, reducing need, and a drift towards tertiary centres has reduced DGH operations by 30% over a decade. Young surgeons are now seldom exposed to this surgery, and are not being trained in it. The large volume of these low-risk operations in well children cannot be absorbed into the current tertiary centres due to pressure on beds. The future provision of this surgery is at risk unless action is taken now. This survey was carried out to inform the debate, and to make recommendations for the future. The principal recommendations are that: (i) GPS should continue to be provided as at present in those DGHs equipped to do so; (ii) GPS training should be carried out in the DGHs where a high volume of cases is carried out; (iii) management of these cases should use a network approach in each region; (iv) hospital trusts should actively advertise for an interest in GPS as a second subspecialty; and (v) the SAC in general surgery develop a strategy to make GPS relevant to trainee surgeons.
Child; Surgical procedures; Elective; Hospitals; General
Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.
We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.
In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.
In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.
Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.
The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.
To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.
Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.
Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.
Three ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.
Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.
Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
Health Services Administration & Management; Qualitative Research
OBJECTIVE: To compare the commissioning of contraception services by London
health authorities with accepted models of good practice. DESIGN: Combined
interview and postal surveys of all health authorities and National Health
Service (NHS) trusts responsible for running family planning clinics in the
Greater London area. MAIN OUTCOME MEASURES: Health authority commissioning
was assessed on the presence of four key elements of good
practice--strategies, coordination, service specifications, and quality
standards in contracts--by monitoring activity and quality. RESULTS: Less
than half the health authorities surveyed had written strategies or service
specifications for contraception services. Arrangements for coordination of
services were limited and monitoring was underdeveloped. CONCLUSION: The
process of commissioning services for contraception seems to be relatively
underdeveloped despite the importance of health problems associated with
unplanned pregnancy in London. These findings raise questions about the
capacity of health authorities to improve the quality of these services
through the commissioning process.
Changes in the contractual responsibilities of primary care practitioners and health boards have resulted in a plethora of arrangements relating to out-of-hours healthcare services. Rather than being guaranteed access to a GP (usually either their own or another through a local GP co-operative), patients have a number of alternative routes to services. Our objective was to identify and assess the availability and adequacy of relevant standards, responsibilities and information systems in Scotland to monitor the impact of contractual changes to out-of-hours healthcare services on equity of access.
All providers of primary care out-of-hours services in Scotland.
Main outcome measures
First, identification and policy review of current standards and performance monitoring systems, data and information, primarily through directly contacting national and local organizations responsible for monitoring out-of-hours care, supplemented by literature searches to highlight specific issues arising from the review; and second, mapping of data items by out-of-hours provider type to identify overlap and significant gaps.
In Scotland, data monitoring systems have not kept pace with changes in the organization of out-of-hours care, so the impact on access to services for different population groups is unknown. There are significant gaps in information collected with respect to workforce, distribution of services, service utilisation and clinical outcomes.
Since 2004 there have been major changes to the way patients access out-of-hours healthcare in the UK. In Scotland, none of the current systems provide information on whether the new services satisfy the key NHS principle of equity of access. There is an urgent need for a comprehensive review of data standards and systems relating to out-of-hours care in order to monitor and evaluate inputs, processes and outcomes of care not least in respect of access and fairness of distribution of resources.
For over 20 years, the National Health Service in England has run a system of national planning for highly specialised healthcare services. The aim is to ensure that very rare diseases are treated, and very complex procedures performed, in only a few centres, each of which maintains a volume high enough to maintain excellent outcomes. The commissioning strategy for the provision of these national services in England is strongly centralising. Centralising does however create a duty to ensure that patients distant from the treatment centres are not thereby disadvantaged. The commissioning process ensures sufficient capacity to treat the entire national caseload of clinically eligible patients. The aim of this paper is to apply the Systematic Component of Variation (SCV) to study access to services commissioned by the National Specialised Commissioning Team (NSCT) in England. The discussion focuses on the potential explanations for a high level of systematic variation between areas and on the use of the SCV to support the monitoring and development of these nationally commissioned services.
Data from nationally commissioned services for the year ending 2011 were received from treating hospital. Mid year age and sex appropriate population estimates were then obtained to provide denominator data. Data were analysed at the geographic level of strategic health authority.
30 services met all requirements for analysis. There is no apparent relationship between SCV and number of locations from which the service is provided. On inspection high SCV is more common among recently commissioned services.
The importance of the SCV lies in its ability to support the development of highly specialised services. Once the random variation has been accounted for, the reasons for a systematic component can be explored. While no absolute cut- off exists, the SCV can be used to gauge and explore services that are potentially not covering the national caseload. The reason for a high SCV may not be immediately apparent; thus the SCV can aid those responsible for commissioning the service to seek potential explanations and identify improvements.
We have reviewed spatial variation in access to a set of highly specialised services in England. On inspecting our results, we believe that they suggest that equity of access can usually be achieved at about five years after establishing a service, and this is not dependent, within the geography of England, on the number of centres designated.
Specialised services; Monitoring; Access; Commissioning; Systematic component of variation; National case load
Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.
To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.
Design of study
Cross-sectional comparison of admission rates; postal survey.
Three OOH providers in south-west England.
Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.
There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).
GPs' threshold of risk is important for explaining variations in referral to hospital.
emergency service, hospital; out-of-hours medical care; risk
The provision of the sexually transmitted disease clinic service in the regional health authorities of England and Wales has been compared by relating the opening hours of clinics to the size of the population served. Relatively low levels of service were provided in the West Midlands and South-west Thames regions and high levels in the North-east and North-west Thames regions. When the service in the Greater London area health authorities was examined in relation to both resident and day-time populations, provision was relatively high in both instances, particularly in certain central London areas. Valid conclusions, however, about the equality of the service in different areas can only be drawn if the needs of the population for that service are known.
OBJECTIVE--To ascertain general practitioners' views about the future provision of out of hours primary medical care. DESIGN--Self completing postal questionnaire survey. SETTING--Wessex and north east England. SUBJECTS--116 general practitioners in the Wessex Primary Care Research Network and 83 in the Northern Primary Care Research Network. MAIN OUTCOME MEASURES--Intention to reduce or opt out of on call; plans for changing out of hours arrangements; the three most important changes needed to out of hours care; willingness to try, and perceived strengths and limitations of, three alternative out of hours care models--primary care emergency centres, telephone triage services, and cooperatives. RESULTS--The overall response rate was 74% (Wessex research network 77% (89/116), northern research network 71% (59/83)). Eighty three per cent of respondents (123/148) were willing to try at least one service model, primary care emergency centres being the most popular option. Key considerations were the potential for a model to reduce time on call and workload, to maintain continuity of care, and to fit the practice context. Sixty one per cent (91/148) hoped to reduce time on call and 25% (37/148) hoped to opt out completely. CONCLUSIONS--General practitioners were keen to try alternative arrangements for out of hours care delivery, despite the lack of formal trials. The increased flexibility in funding brought about by the recent agreement between the General Medical Services Committee and the Department of Health is likely to lead to a proliferation of different schemes. Careful monitoring will be necessary, and formal trials of new service models are needed urgently.
BACKGROUND: The need for closer coordination between primary care medical and dental services has been recognized. AIM: To assess the attitudes of general medical practitioners (GMPs), general dental practitioners (GDPs), and patients to an integrated medical-dental patient-held record (integrated medical-dental PHR); to examine patients' use of these records, and the utility of the records for doctors and dentists. METHOD: A three-phase study was carried out: (1) postal survey of GMPs and GDPs; (2) randomized trial of patients, using postal questionnaires before and one year after the issue of integrated medical-dental PHRs to cases; (3) assessment by doctors and dentists of anonymized integrated medical-dental PHRs from this trial. The study was carried out in medical and dental practices in affluent and deprived areas in Greater Glasgow Health Board. Two hundred and thirteen GMPs, 183 GDPs, and 369 patients registered with GMPs and GDPs were surveyed. Eighteen GDPs and GMPs assessed the integrated medical-dental PHRs. RESULTS: Eighty per cent of dentists had contacted a doctor and 16% of doctors had contacted a dentist in the previous three months; 87% of dentists and 68% of doctors thought an integrated medical-dental PHR would be of some use. Twenty-one per cent of dentists and 85% of doctors had practice computers. Most patients wanted to be able to see and read their own records. Twenty-four per cent of patients said there were mistakes and 30% noticed omissions in the integrated medical-dental PHR issued. Experience of having an integrated medical-dental PHR made patients more positive towards the idea of having a patient-held record and being able to check the accuracy of records. Integrated medical-dental PHRs contained important information for half the GDPs and one-third of the GMPs. CONCLUSION: Both professionals and patients have reasonably positive attitudes towards the use of patient-held records. Among patients, the experience of having the integrated medical-dental PHR led to greater enthusiasm towards the idea. Dentists in particular would benefit from the transfer of information from doctors, but better methods are needed to ensure that patients take the integrated medical-dental PHR with them. Given the current lack of ability to easily produce an integrated medical-dental PHR, further examination of the routine issue of a copy of their medical summary, by GMPs, to all patients would be worthwhile.
The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services.
A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative.
The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory).
The study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system.
Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services.
Study design and setting
A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases.
Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis.
Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations.
Background and objective
Provision of out‐of‐hours care in the UK National Health Service (NHS) has changed in recent years with new models of provision and the introduction of national quality requirements. Existing survey instruments tend to focus on users' satisfaction with service provision; most were developed without undertaking supporting qualitative fieldwork. In this study, a survey instrument was developed taking account of these changes in service provision and undertaking supporting qualitative fieldwork. This paper reports on the development and psychometric properties of the new survey instrument, the Out‐of‐hours Patient Questionnaire (OPQ), which aims to capture information on the entirety of users' experiences of out‐of‐hours care, from the decision to make contact through to completion of their care management.
An iterative approach was undertaken to develop the new instrument which was then tested in users of out‐of‐hours services in three geographically distributed UK settings. For the purposes of this study, “service users” were defined as “individuals about whom contact was made with an out‐of‐hours primary care medical service”, whether that contact was made by the user themselves, or via a third party. Analysis was undertaken of the acceptability, reliability and validity of the survey instrument.
The OPQ tested is a 56‐item questionnaire, which was distributed to 1250 service users. Respondents were similar in respect of gender, but were older and more affluent (using a proxy measure) than non‐respondents. Item completion rates were acceptable. Respondents sometimes completed sections of the questionnaire which did not equate to their principal mode of management as recorded in the record of the contact. Preliminary evidence suggests the OPQ is a valid and reliable instrument which contains within it two discrete scales—a consultation satisfaction scale (nine items) and an “entry‐access” scale (four items). Further work is required to determine the generalisability of findings obtained following use of the OPQ, especially to non‐white user populations.
The OPQ is an acceptable instrument for capturing information on users' experiences of out‐of‐hours care. Preliminary evidence suggests it is both valid and reliable in use. Further work will report on its utility in informing out‐of‐hours service planning and configuration and standard‐setting in relation to UK national quality requirements.
Public-private partnerships (PPPs) are potential instruments to enable private collaboration in the health sector. Despite theoretical debate, empirical analyses have thus far tended to focus on the contractual or project dimension, overlooking institutional PPPs, i.e., formal legal entities run by proper corporate-governance mechanisms and jointly owned by public and private parties for the provision of public-health goods. This work aims to fill this gap by carrying out a comparative analysis of the reasons for the adoption of institutional PPPs and the governance and managerial features necessary to establish them as appropriate arrangements for public-health services provisions.
A qualitative analysis is carried out on experiences of institutional PPPs within the Italian National Health Service (Sistema Sanitario Nazionale, SSN). The research question is addressed through a contextual and comparative embedded case study design, assuming the entire population of PPPs (4) currently in force in one Italian region as the unit of analysis: (i) a rehabilitation hospital, (ii), an orthopaedic-centre, (iii) a primary care and ambulatory services facility, and (iv) a health- and social-care facility. Internal validity is guaranteed by the triangulation of sources in the data collection phase, which included archival and interview data.
Four governance and managerial issues were found to be critical in determining the positive performance of the case examined: (i) a strategic market orientation to a specialised service area with sufficient potential demand, (ii) the allocation of public capital assets and the consistent financial involvement of the private partner, (iii) the adoption of private administrative procedures in a regulated setting while guaranteeing the respect of public administration principles, and (iv) clear regulation of the workforce to align the contracts with the organisational culture.
Findings suggests that institutional PPPs enable national health services to reap great benefits when introduced as a complement to the traditional public-service provisions for a defined set of services and goals.
Recommendations exist for the optimal management of vascular surgical emergency patients. A telephone survey of on-call surgical registrars was performed to assess the current state of emergency vascular service provision across the Wessex and South West regions in the UK. Of the 24 hospitals surveyed, 10 had formal on-call arrangements for vascular surgical cover, 14 had informal arrangements where the general surgical consultant on-call provided cover and could contact a vascular surgeon if they were available and 3 hospitals had no such arrangements. No difficulties had been experienced by the on-call staff surveyed with any of the existing arrangements. Only 5 of the hospitals had formal on-call arrangements for interventional radiologists. We conclude that current emergency vascular service provision is suboptimal compared to national guidelines and patients may be subject to unequitable access to services. This may not be tenable in the new era of clinical governance.
Independent healthcare, most of it NHS-funded, provides a significant and growing proportion of inpatient mental healthcare in the UK, but information about patients in these providers is limited. This paper examines differences in the profiles of mental health inpatients in NHS and independent providers in England and Wales, and assesses whether current information systems are adequate for monitoring patient flows and care, given the plurality of service provision.
Data from the national censuses of inpatients in mental health services in England and Wales in 2006 and 2007 were analysed to examine differences in demographic and other characteristics between inpatients in NHS and independent providers.
All NHS and independent providers of inpatient mental health services in England and Wales in 2006 and 2007.
Main outcome measures
Patients in independent providers were younger, 60% were on low/medium secure wards (compared with 16% in the NHS), they were 44% more likely to be detained and referrals were predominantly from NHS inpatient services. For all ethnic groups, ratios of detention on admission were higher in independent providers.
This analysis highlights differences between inpatients in NHS and independent providers of mental health services. We also highlight the inadequacy of current information systems for monitoring care, and the urgent need for standardized data across all NHS-commissioned mental healthcare, irrespective of whether it is publicly or privately provided. This is especially important in view of the increases in independent sector provision, and the specialist nature of their services. Such information is critical for commissioners, regulators of health and social care, and other audiences for monitoring patient flows, the quality of care provided, usage of the Mental Health Act 2007 and compliance with equality legislation.
Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services.
We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes.
1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (≤10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087–0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care.
Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services.
Every day throughout the UK, ambulance services seek medical assistance in providing critically ill or injured patients with pre-hospital care.
To identify the current availability and utilisation of physician-based pre-hospital critical care capability across England, Wales and Northern Ireland.
A postal and telephone survey was undertaken between April and December 2009 of all 13 regional NHS ambulance services, 17 air ambulance charities, 34 organisations affiliated to the British Association for Immediate Care and 215 type 1 emergency departments in England, Wales and Northern Ireland. The survey focused on the availability and use of physician-based pre-hospital critical care support.
The response rate was 100%. Although nine NHS ambulance services recorded physician attendance at 6155 incidents, few could quantify doctor availability and utilisation. All but one of the British Association for Immediate Care organisations deployed ‘only when available’ and only 45% of active doctors could provide critical care support. Eleven air ambulance services (65%) operated with a doctor but only 5 (29%) operated 7 days a week. Fifty-nine EDs (27%) had a pre-hospital team but only 5 (2%) had 24 h deployable critical care capability and none were used regularly.
There is wide geographical and diurnal variability in availability and utilisation of physician-based pre-hospital critical care support. Only London ambulance service has access to NHS-commissioned 24 h physician-based pre-hospital critical care support. Throughout the rest of the UK, extensive use is made of volunteer doctors and charity sector providers of varying availability and capability.
Major incidents; prehospital care; prehospital care; critical care transport, prehospital care, doctors in PHC
St Bartholomew's Hospital, in the City of London, has for many years run a Coronary Ambulance service, called by the public via the 999 system. During a 9-month period only 55% of 214 cardiac emergencies arriving at St Bartholomew's Hospital came with Coronary Ambulance support, although the service was available if called. In cases where the Coronary Ambulance was summoned, the call-out was inappropriate in 57% of cases. In addition, 153 cardiac emergencies arrived at the Accident and Emergency Department during hours when the Coronary Ambulance was not available. Reasons for breakdowns in the call-out system are discussed and remedies involving the public and London Ambulance Control are suggested.
To characterize paediatric presentations of stabbing to emergency departments across London and to audit existing referral rates to the police and social services against the new standard set by the General Medical Council.
Retrospective multi-centre service evaluation/audit.
All emergency departments within London.
Patients under 18 years of age presenting to emergency departments with non-accidental stabbing between 1 April 2007 and 30 April 2009.
Main outcome measures
Patient age, nature of assault, assailant, injuries and management. Rates of documented referral to police and social services, as mandated by GMC guidance.
A total of 381 presentations were identified from 20 out of the 32 hospitals in London, 160 of whom were less than 16 years old. The majority were seen only by emergency department staff and only a minority (28%) were admitted. Three died in the departments. A knife was the commonest weapon and the limbs the most common site of injury. Referrals to police were documented in only 30% of patients (43% if <16 years old) and to social services in 16% (31% if <16 years old) of those discharged. In the majority, there was no documentation (police 64%, social services 79%).
A significant number of paediatric stabbings present to emergency departments across London. The majority of these are discharged directly from departments. Of those discharged, documentation regarding referral rates to Police and Social Services was poor, and documented referral rates low. This study covered a period prior to the introduction of new General Medical Council guidance and a repeat audit to assess subsequent documented referrals is required.