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1.  National evaluation of general practitioner commissioning pilots: lessons for primary care groups. 
BACKGROUND: The national evaluation of general practitioner (GP) commissioning pilots was commissioned by the Department of Health in 1997 as part of its Policy Research Programme. It was conducted by the Health Services Management Centre at the University of Birmingham. AIM: To monitor the development of the 40 national pilot sites, identify the factors that inhibited or facilitated progress, and consider the implications for the implementation and development of primary care groups (PCGs). METHOD: Semi-structured face-to-face interviews with GPs, health authority (HA) managers, and pilot managers from each of the 40 pilot sites (141 interviews in total) and focus group discussions with nurses, social services officers, and community health council officers in the 40 sites. RESULTS: Stakeholders reported the key achievements of the pilots during their first six months as being improved collaboration between GPs, the establishment of organisational arrangements, and work towards managing the group prescribing budget. Obstacles for the groups included changes to government policy regarding primary care, the workload involved for clinical staff, the pilots' relationship with the local HA, and problems with information management and technology (IM&T). A more detailed analysis of the pilots' management arrangements, prescribing work, IM&T support, and stakeholder involvement points to a set of lessons for emerging PCGs. CONCLUSIONS: In their early stages of development, PCGs are likely to focus on issues of structure and process. Prescribing will be an area receiving particular attention, prefiguring some of the challenges of clinical governance in primary care. IM&T will prove to be more problematic than first assumed. The involvement of a wider range of stakeholders will be addressed by primary care groups, particularly in relation to GPs and nurses.
PMCID: PMC1313725  PMID: 10962785
2.  Collaborations for Leadership in Applied Health Research and Care: lessons from the theory of communities of practice 
The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)--partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice.
The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared 'collaborative' identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of 'bridges' involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification.
The CoP approach can complement traditional 'stage-of-change' theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging--an assumption that needs to be explored by further empirical research.
PMCID: PMC3130688  PMID: 21699712
3.  A toolkit for incorporating genetics into mainstream medical services: Learning from service development pilots in England 
As advances in genetics are becoming increasingly relevant to mainstream healthcare, a major challenge is to ensure that these are integrated appropriately into mainstream medical services. In 2003, the Department of Health for England announced the availability of start-up funding for ten 'Mainstreaming Genetics' pilot services to develop models to achieve this.
Multiple methods were used to explore the pilots' experiences of incorporating genetics which might inform the development of new services in the future. A workshop with project staff, an email questionnaire, interviews and a thematic analysis of pilot final reports were carried out.
Seven themes relating to the integration of genetics into mainstream medical services were identified: planning services to incorporate genetics; the involvement of genetics departments; the establishment of roles incorporating genetic activities; identifying and involving stakeholders; the challenges of working across specialty boundaries; working with multiple healthcare organisations; and the importance of cultural awareness of genetic conditions.
Pilots found that the planning phase often included the need to raise awareness of genetic conditions and services and that early consideration of organisational issues such as clinic location was essential. The formal involvement of genetics departments was crucial to success; benefits included provision of clinical and educational support for staff in new roles. Recruitment and retention for new roles outside usual career pathways sometimes proved difficult. Differences in specialties' working practices and working with multiple healthcare organisations also brought challenges such as the 'genetic approach' of working with families, incompatible record systems and different approaches to health professionals' autonomous practice.
'Practice points' have been collated into a Toolkit which includes resources from the pilots, including job descriptions and clinical tools. These can be customised for reuse by other services.
Healthcare services need to translate advances in genetics into benefits for patients. Consideration of the issues presented here when incorporating genetics into mainstream medical services will help ensure that new service developments build on the body of experience gained by the pilots, to provide high quality services for patients with or at risk of genetic conditions.
PMCID: PMC2887834  PMID: 20470377
4.  Integrated care pilot in north-west London: a mixed methods evaluation 
This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support.
The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study).
The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes.
Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.
PMCID: PMC3807631  PMID: 24167455
integrated health care systems; health services research; health care; reform; patient-centred care; evaluation studies
5.  'Reaching the hard to reach' - lessons learned from the VCS (voluntary and community Sector). A qualitative study 
The notion 'hard to reach' is a contested and ambiguous term that is commonly used within the spheres of social care and health, especially in discourse around health and social inequalities. There is a need to address health inequalities and to engage in services the marginalized and socially excluded sectors of society.
This paper describes a pilot study involving interviews with representatives from eight Voluntary and Community Sector (VCS) organisations. The purpose of the study was to explore the notion of 'hard to reach' and perceptions of the barriers and facilitators to accessing services for 'hard to reach' groups from a voluntary and community sector perspective.
The 'hard to reach' may include drug users, people living with HIV, people from sexual minority communities, asylum seekers, refugees, people from black and ethnic minority communities, and homeless people although defining the notion of the 'hard to reach' is not straight forward. It may be that certain groups resist engaging in treatment services and are deemed hard to reach by a particular service or from a societal stance. There are a number of potential barriers for people who may try and access services, including people having bad experiences in the past; location and opening times of services and how services are funded and managed. A number of areas of commonality are found in terms of how access to services for 'hard to reach' individuals and groups could be improved including: respectful treatment of service users, establishing trust with service users, offering service flexibility, partnership working with other organisations and harnessing service user involvement.
If health services are to engage with groups that are deemed 'hard to reach' and marginalised from mainstream health services, the experiences and practices for engagement from within the VCS may serve as useful lessons for service improvement for statutory health services.
PMCID: PMC2856561  PMID: 20377850
6.  Key Working for Families with Young Disabled Children 
Nursing Research and Practice  2011;2011:397258.
For families with a disabled child, the usual challenges of family life can be further complicated by the need to access a wide range of services provided by a plethora of professionals and agencies. Key working aims to support children and their families in navigating these complexities ensuring easy access to relevant, high quality, and coordinated care. The aim of this paper is to explore the key worker role in relation to “being a key worker” and “having a key worker”. The data within this paper draw on a larger evaluation study of the Blackpool Early Support Pilot Programme. The qualitative study used an appreciative and narrative approach and utilised mixed methods (interviews, surveys and a nominal group workshop). Data were collected from 43 participants (parents, key workers, and other stakeholders). All stakeholders who had been involved with the service were invited to participate. In the paper we present and discuss the ways in which key working made a difference to the lives of children and their families. We also consider how key working transformed the perspectives of the key workers creating a deeper and richer understanding of family lives and the ways in which other disciplines and agencies worked. Key working contributed to the shift to a much more family-centred approach, and enhanced communication and information sharing between professionals and agencies improved. This resulted in families feeling more informed. Key workers acted in an entrepreneurial fashion, forging new relationships with families and between families and other stakeholders. Parents of young disabled children and their service providers benefited from key working. Much of the benefit accrued came from strong, relational, and social-professional networking which facilitated the embedding of new ways of working into everyday practice. Using an appreciative inquiry approach provided an effective and relevant way of engaging with parents, professionals, and other stakeholders to explore what was working well with key working within an Early Support Pilot Programme.
PMCID: PMC3169910  PMID: 21994827
7.  Models of inter professional working for older people living at home: a survey and review of the local strategies of english health and social care statutory organisations 
Most services provided by health and social care organisations for older people living at home rely on interprofessional working (IPW). Although there is research investigating what supports and inhibits how professionals work together, less is known about how different service models deliver care to older people and how effectiveness is measured. The aim of this study was to describe how IPW for older people living at home is delivered, enacted and evaluated in England.
An online survey of health and social care managers across England directly involved in providing services to older people, and a review of local strategies for older people services produced by primary care organisations and local government adult services organisations in England.
The online survey achieved a 31% response rate and search strategies identified 50 local strategies that addressed IPW for older people living at home across health and social care organisations. IPW definitions varied, but there was an internal consistency of language informed by budgeting and organisation specific definitions of IPW.
Community Services for Older People, Intermediate Care and Re-enablement (rehabilitation) Teams were the services most frequently identified as involving IPW. Other IPW services identified were problem or disease specific and reflected issues highlighted in local strategies. There was limited agreement about what interventions or strategies supported the process of IPW. Older people and their carers were not reported to be involved in the evaluation of the services they received and it was unclear how organisations and managers judged the effectiveness of IPW, particularly for services that had an open-ended commitment to the care of older people.
Health and social care organisations and their managers recognise the value and importance of IPW. There is a theoretical literature on what supports IPW and what it can achieve. The need for precision may not be so necessary for the terms used to describe IPW. However, there is a need for shared identification of both user/patient outcomes that arise from IPW and greater understanding of what kind of model of IPW achieves what kind of outcomes for older people living at home
PMCID: PMC3295707  PMID: 22168957
8.  Integrated policy making in England for adults with long-term neurological conditions (LTNCs): some preliminary findings from a scoping study 
Long-term neurological conditions are a major cause of disability in the UK and internationally. Their successful management, in order to enhance health and well-being, requires both sophisticated organisation across a number of health, social care and other service boundaries, and the real involvement of people with neurological conditions and members of their support networks.
Policy development
This paper reports on part of the preliminary scoping phase of a study designed to evaluate the impact of the National Service Framework for long-term neurological conditions on integrated care. It describes current policies in England and reports on discussions with a range of people involved in the planning, provision or use of services, which took place during the scoping exercise. These interviews inform how policy affecting people with long-term neurological conditions has been received and implemented so far.
Conclusion and discussion
Findings suggest that progress towards integrated service provision is patchy and slow. In the competing priorities within government policy, neurological conditions have tended to be marginalised, within healthcare policy generally and in initiatives to support people with long-term conditions in particular. The reasons for this are explored and will inform the next stages of the research.
PMCID: PMC2504699  PMID: 18695746
long-term neurological conditions; integrated care; health and well-being
9.  Money for value: the Kinzigtal-way to measure the produced value and health gain in a local area 
‘Triple Aim’ is the buzzword for the initiatives of the Obama-administration in the US and is referring to a famous article of Don Berwick et al. in 2008 in health affairs asking for better health, better health care, and lower per capita costs. A similar venture started already in 2006 in Germany. One of the most challenging ventures towards reorienting health care in the direction of outcome-orientation is the measurement of the produced value and health gain in a local area. In this keynote the financial architecture and the specific way to measure the produced value and health gain in the integrated care pilot ‘Gesundes Kinzigtal’ will be described—as well some of the operating details and the results within.
Located in Southwest Germany, Gesundes Kinzigtal is the only population-based integrated care approaches in Germany, organising care across all health service sectors and indications, that is thoroughly scientifcally evaluated on its medical outcomes in regard to normal care. The system serving nearly half of the population of the region is run by a regional health management company in cooperation with the physicians’ network in the region, a German health care management company with a background in medical sociology and health economics and with two statutory health insurers.
Having started in 2006 the more effective trans-sector organisation of the local health care system and increased investments in well-designed preventive and health promotion programmes have led to a reduction in morbidity and mortality, and in particular to reduced overall costs for the insurees of these sickness funds. The results for one of the insurers show a substantial morbidity adjusted efficiency gain already for the years 2007–2010, rising to more than 16% of total costs (included are pharmaceutical, hospital, nursing, emergency as well as physiotherapist and sick leave costs).
More Information can be found on and and on the evaluation (in German and English)
PMCID: PMC3617771
preventive and health promotion programmes; trans-sector organisation; Gesundes Kinzigtal; population-based integrated care; integrated care pilot; Germany
10.  Evaluation of complex integrated care programmes: the approach in North West London 
Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect.
Study design
We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context.
Theory and discussion
This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them.
We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important.
PMCID: PMC3653284  PMID: 23687478
integrated; evaluation; delivery; complexity
11.  Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multi-site case study of the Audit and Best Practice for Chronic Disease project 
Experimentation with continuous quality improvement (CQI) processes is well underway in Indigenous Australian primary health care. To date, little research into how health organizations take up, support, and embed these complex innovations is available on which services can draw to inform implementation. In this paper, we examine the practices and processes in the policy and organisational contexts, and aim to explore the ways in which they interact to support and/or hinder services' participation in a large scale Indigenous primary health care CQI program.
We took a theory-driven approach, drawing on literature on the theory and effectiveness of CQI systems and the Greenhalgh diffusion of innovation framework. Data included routinely collected regional and service profile data; uptake of tools and progress through the first CQI cycle, and data collected quarterly from hub coordinators on their perceptions of barriers and enablers. A total of 48 interviews were also conducted with key people involved in the development, dissemination, and implementation of the Audit and Best Practice for Chronic Disease (ABCD) project. We compiled the various data, conducted thematic analyses, and developed an in-depth narrative account of the processes of uptake and diffusion into services.
Uptake of CQI was a complex and messy process that happened in fits and starts, was often characterised by conflicts and tensions, and was iterative, reactive, and transformational. Despite initial enthusiasm, the mixed successes during the first cycle were associated with the interaction of features of the environment, the service, the quality improvement process, and the stakeholders, which operated to produce a set of circumstances that either inhibited or enabled the process of change. Organisations had different levels of capacity to mobilize resources that could shift the balance toward supporting implementation. Different forms of leadership and organisational linkages were critical to success. The Greenhalgh framework provided a useful starting point for investigation, but we believe it is more a descriptive than explanatory model. As such, it has limitations in the extent to which it could assist us in understanding the interactions of the practices and processes that we observed at different levels of the system.
Taking up CQI involved engaging multiple stakeholders in new relationships that could support services to construct shared meaning and purpose, operationalise key concepts and tools, and develop and embed new practices into services systems and routines. Promoting quality improvement requires a system approach and organization-wide commitment. At the organization level, a formal high-level mandate, leadership at all levels, and resources to support implementation are needed. At the broader system level, governance arrangements that can fulfil a number of policy objectives related to articulating the linkages between CQI and other aspects of the regulatory, financing, and performance frameworks within the health system would help define a role and vision for quality improvement.
PMCID: PMC2847538  PMID: 20226066
12.  Community care and social services. 
BMJ : British Medical Journal  1996;313(7061):869-872.
The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government's aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care.
PMCID: PMC2359081  PMID: 8870580
13.  Joint inspection of services for people with learning disabilities in Scotland: compliance or commitment? 
The article describes the development of a practical model of joint, integrated inspection of managed care services for people with learning disabilities in Scotland. The model will give a reliable measure of the impact services are making to people's lives and the quality of service that individuals are actually receiving.
Context of case
At present health, social services and education services for people with learning disabilities in Scotland are inspected separately, by up to nine different agencies. The first joint, integrated inspections of all services for people with learning disabilities in Scotland will take place in 2006. This is the first inspection of its kind in the UK, and the first to involve carers and people with learning disabilities on the inspection team.
Data sources
Quality Outcome Indicators were developed in 21 different areas, or domains. Evidence based best practice, and evaluative data from previous inspections were the primary sources of data.
Case description
This paper reviews the background and rationale for the integrated, joint inspection process. Strengths and constraints of this approach to inspection are discussed, including the crucial importance of commitment from services and from inspectors, rather than mere compliance with demands. Some guidance on how to fully involve staff, carers and services users in the inspection process is given.
Conclusions and discussion
The model will produce data to inform decision-making for managers in integrated services and give services users clear information about how well local needs are being met, what areas need development, and what capacity the organisations have to improve. The model of inspection may be of interest to practitioners in a national and international context. The model will be evaluated, following the first joint inspection.
PMCID: PMC1590515  PMID: 17024244
quality of care; clinical efficiency; client perspective; integrated care
14.  The Linked Response: Lessons Emerging from Integration of HIV and Reproductive Health Services in Cambodia 
AIDS Research and Treatment  2013;2013:504792.
A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission.
PMCID: PMC3574657  PMID: 23424679
15.  Better and more efficient care through ICT-enabled integration of social care and healthcare services: experiences from two European projects 
Unsynchronised social and health care service delivery leads to inefficiencies, duplication of resources and reduced levels of quality of care. Older people are particularly affected by this situation. They often need both types of services, such as support with daily living activities and chronic disease management. ICT has the potential to support integrated service delivery to achieve high quality independent living and wellbeing for older people across Europe and elsewhere. Against this background, the presentation will demonstrate experiences and results derived from the development and piloting of ICT-supported integrated care services in eight sites across Europe, namely Dublin, Hull, Milton Keynes, Malaga, Veldhoven, Geldrop, Eindhoven and Bielefeld. Through innovative usage of ICT, current ‘silos’ in service delivery are broken up to allow for cooperation across relevant care sectors and participation of family members. The integrated services are to support the effective management of chronic diseases, and to address issues which affect independence, such as reduced agility, vision or hearing, in order to significantly improve the quality of life for older people and their carers.
A dedicated programme of service process innovation complemented by adaptation of technology is being pursued in order to develop an integrated digital support infrastructure and related services: using appropriate existing technology to provide as many older people as possible with digital access to support services they needaugmenting and opening sectoral care platforms to enable coordinated cross-sector support deliveryadopting a clearly demand-driven inclusive approach and avoiding a technology ‘push’.
Wider deployment of the services is supported by a dedicated programme of socio-economic service evaluation. The evaluation framework utilises a multi-method and multi-perspective approach, involving end users, family carers, service provider staff and key informants at corporate level. Triangulation is used to cross-reference data from different sources in order to maximize the reliability and robustness of conclusions drawn from the evaluation. Based on an overall framework taking into account themes such as integration, user outcomes, staff impact, organisational impact, technology, implementation and overall satisfaction, the specifics of each site are taken into account in operationally applying the overall framework in each case. The designs to be employed at each site have been developed to be as robust as possible, taking into account the constraints of the realities of the interventions.
The evaluation is accompanied by a business case modelling approach that builds largely on a cost-benefit analysis covering the service development and implementation activities as well as the pilots and modelling the further deployment of services in each of the pilot sites. The presentation builds upon experiences gained within the framework of two European projects, CommonWell and INDEPENDENT. They are both co-funded under the EU’s Competitiveness and Innovation Framework Programme (CIP) focus on better joining-up of formal social/healthcare services and strengthening participation of the so-called ‘third sector’.
PMCID: PMC3571140
integrated care; ICT; telecare; telehealth; service innovation
16.  "There's no place like home" A pilot study of perspectives of international health and social care professionals working in the UK 
Many countries are reporting health workforce shortages across a range of professions at a time of relatively high workforce mobility. Utilising the global market to supply shortage health skills is now a common recruitment strategy in many developed countries. At the same time a number of countries report a 'brain drain' resulting from professional people leaving home to work overseas. Many health and social care professionals make their way to the UK from other countries. This pilot study utilises a novel 'e-survey' approach to explore the motives, experiences and perspectives of non-UK health and social care professionals who were working or had worked in the UK. The study aims to understand the contributions of international health and social care workers to the UK and their 'home' countries. The purpose of the pilot study is also in part to test the appropriateness of this methodology for undertaking a wider study.
A 24-item questionnaire with open-ended and multiple choice questions was circulated via email to 10 contacts who were from a country outside the UK, had trained outside the UK and had email access. These contacts were requested to forward the email to other contacts who met these criteria (and so on). The email was circulated over a one month pilot period to 34 contacts. Responses were from physiotherapists (n = 11), speech therapists (n = 4), social workers (n = 10), an occupational therapist (n = 1), podiatrists (n = 5), and others (n = 3). Participants were from Australia (n = 20), South Africa (n = 10), New Zealand (n = 3) and the Republic of Ireland (n = 1). Motives for relocating to the UK included travel, money and career opportunities. Participants identified a number of advantages and disadvantages of working in the UK compared to working in their home country health system. Respondents generally reported that by working in the UK, they had accumulated skills and knowledge that would allow them to contribute more to their profession and health system on their return home.
This pilot study highlights a range of issues and future research questions for international learning and comparison for the health and social care professions as a result of international workforce mobility. The study also highlights the usefulness of an e-survey technique for capturing information from a geographically diverse and mobile group of professionals.
PMCID: PMC1283969  PMID: 16253132
17.  Integrated inspection of services for people with learning disabilities in Scotland: the way forward? 
The article summarises the process and the results of the first, integrated inspection of managed care services for people with learning disabilities in Scotland. The multi-agency model used was developed to be congruent with the existing performance inspection models, used by single agency inspection. The inspection activities and main outcomes are described, and suggestions are made for improvements.
Context of case
In 2006 an inspection model was devised to assess the quality of health, social services and education services for people with learning disabilities in one geographical area of Scotland, as a precursor to a programme of inspections nationally. The first joint, integrated inspection of all services for people with learning disabilities in Scotland took place in June 2006, and the report was published in March 2007. This was the first multi-agency inspection of its kind in the UK, and the first to involve carers and people with learning disabilities on the inspection team.
Data sources
A number of data sources were used to check existing practice against agreed Quality Outcome indicators. Primary sources of data were social work records, health records, education records, staff surveys, carer surveys, interviews with staff, family carers and people with learning disabilities, and self evaluations completed by the services being inspected. Eleven different domains, each with sub-indicators were investigated.
Case description
This paper summarises the process of an integrated, multi-agency inspection, how the inspection activities were conducted and the main findings of this inspection. Practical improvements to the process are suggested, and these may be of use to other services and inspectorates.
Conclusions and discussion
The integrated inspection was a qualified success. Most major objectives were achieved. The sharing of data amongst inspection agencies, establishing the level of commitment to integrated inspection and conducting multiple, integrated inspections nationally in a reasonable timescale are the main barriers remaining. The data were collected in an innovative way during this inspection, to make the analysis directly relevant to services, by providing domain specific and area specific details about how well local needs are being met.
The lessons from this integrated inspection may be of interest to other practitioners in the UK and beyond, both in terms of process and outcomes.
PMCID: PMC2092399  PMID: 18043724
integrated inspection; quality of care; clinical efficiency; client perspective
18.  Integrated working between residential care homes and primary care: a survey of care homes in England 
BMC Geriatrics  2012;12:71.
Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services.
A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods.
The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of .39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff.
Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of care in a cost- effective manner, but strategic decisions to create more formal arrangements are required to bring this about. Commissioners of services for older people need to capitalise on good working relationships and address idiosyncratic patterns of provision to care homes.The low response rate is indicative of the difficulty of undertaking research in care homes.
PMCID: PMC3534387  PMID: 23151009
19.  Primary Medical Care Provider Accreditation (PMCPA): pilot evaluation 
The British Journal of General Practice  2010;60(576):e295-e304.
While practice-level or team accreditation is not new to primary care in the UK and there are organisational indicators in the Quality and Outcomes Framework (QOF) organisational domain, there is no universal system of accreditation of the quality of organisational aspects of care in the UK.
To describe the development, content and piloting of version 1 of the Primary Medical Care Provider Accreditation (PMCPA) scheme, which includes 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment, and medicines management; provider teams; learning organisation; and patient experience/involvement, and to present the results from the pilot service evaluation focusing on the achievement of the 30 core criteria and feedback from practice staff.
Design of study
Observational service evaluation using evidence uploaded onto an extranet system in support of 30 core summative pilot PMCPA accreditation criteria.
Thirty-six nationally representative practices across England, between June and December 2008.
Study population: interviews with GPs, practice managers, nurses and other relevant staff from the participating practices were conducted, audiotaped, transcribed, and analysed using a thematic approach. For each practice, the number of core criteria that had received either a‘good’or‘satisfactory’rating from a RCGP-trained assessment team, was counted and expressed as a percentage.
Thirty-two practices completed the scheme, with nine practices passing 100% of core criteria (range: 27–100%). There were no statistical differences in achievement between practices of different sizes and in different localities. Practice feedback highlighted seven key issues: (1) overall view of PMCPA; (2) the role of accreditation; (3) different motivations for taking part; (4) practice managers dominated the workload associated with implementing the scheme; (5) facilitators for implementation; (6) patient benefit — relevance of PMCPA to quality improvement; (7) recommendations for improving the scheme.
Version 1 of PMCPA has been piloted as a primary care accreditation scheme and shown to be relevant to different types of practice. The scheme is undergoing revision in accordance with the findings from the pilot and ongoing consultation.
PMCID: PMC2894404
accreditation; primary care; quality of health care
20.  Developing the educational needs of Telehealthcare support staff at SCQF/QCF level 6 
The use, monitoring and care of individuals through the use of technology have played a key role in the delivery of health and social care services for decades (Wooton et al. 2006). Contemporary changes in how health and social care is provided in Scotland have focussed on using Telehealthcare as a medium to improve access, efficiency and equity of services across the country for a range of service users and the management of a range of conditions (JIT 2011). The Scottish Government Joint Improvement Team (JIT) and the Scottish Centre for Telehealth (SCT) published an Education and Training Strategy for Telehealthcare in Scotland in March 2010. The Strategy acknowledged that the provision of education and training to support unqualified staff working in telehealthcare service delivery was limited to locally developed, non-accredited training delivered in-house by telehealthcare service providers. It identified that although accredited frameworks do exist in Higher Education at SCQF/QCF 9, 10 and 11, the context, content and academic level was not appropriate for support staff. To meet the education and training needs of unqualified staff working in telehealthcare, the Strategy Action Plan included a workstream to develop a Competency Framework for Telehealthcare Support Staff. A subsequent workstream within the Action Plan focussed on the design and development of an academic award based on the competencies identified within the new Framework. This involved setting up a Qualification Design Team (QDT) made up of telehealthcare and education service providers and specialists. The Qualification Design Team worked with the Scottish Qualifications Authority (SQA) to design and accredit a Professional Development Award (PDA) in Telehealthcare at SCQF/QCF level 6. This paper outlines the design and development of the Professional Development Award.
Project objectives
To design a Professional Development Award in Telehealthcare to meet the educational needs of unqualified support staff working in telehealthcare service delivery.
To achieve National accreditation of a Professional Development Award in Telehealthcare at SCQF/QCF level 6.
Proposed next stage objectives
To evaluate the telehealthcare support staff experience of undertaking the Professional Development Award.
To evaluate the modes of delivery and geographical contexts in which the Professional Development Award is delivered.
To describe the impact the educational experience has on the candidates personal and professional development.
Proposed design/method
A mixed method research design will be used to evaluate the candidate’s experiences of undertaking the Professional Development Award in Telehealthcare. Structured interviews and surveys will be used to gather information to analyse the candidate’s experience. A random sample of candidates will be drawn from all SQA approved sites to deliver the Professional Development Award.
Findings and points of interest
It is anticipated that a positive outcome will be achieved from the project evaluation as this award was driven and led by Telehealthcare staff working in the field. Further awards and specific modules are likely to emerge from this work to underpin advancements in career pathways and to address innovations and developments in telehealthcare.
PMCID: PMC3571146
education; telehealthcare staff development; competency framework
21.  Ten years of jointly commissioning health and social care in England 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e005.
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.
PMCID: PMC3111886  PMID: 21677843
joint commissioning; health and social care; policy developments; top-down implementation; front-line professionals; network development
22.  Evaluation of UK Integrated Care Pilots: research protocol 
In response to concerns that the needs of the aging population for well-integrated care were increasing, the English National Health Service (NHS) appointed 16 Integrated Care Pilots following a national competition. The pilots have a range of aims including development of new organisational structures to support integration, changes in staff roles, reducing unscheduled emergency hospital admissions, reduced length of hospital stay, increasing patient satisfaction, and reducing cost. This paper describes the evaluation of the initiative which has been commissioned.
Study design and data collection methods
A mixed methods approach has been adopted including interviews with staff and patients, non-participant observation of meetings, structured written feedback from sites, questionnaires to patients and staff, and analysis of routinely collected hospital utilisation data for patients/service users. The qualitative analysis aims to identify the approaches taken to integration by the sites, the benefits which result, the context in which benefits have resulted, and the mechanisms by which they occur.
Methods of analysis
The quantitative analysis adopts a ‘difference in differences’ approach comparing health care utilisation before and after the intervention with risk-matched controls. The qualitative data analysis adopts a ‘theory of change’ approach in which we triangulate data from the quantitative analysis with qualitative data in order to describe causal effects (what happens when an independent variable changes) and causal mechanisms (what connects causes to their effects). An economic analysis will identify what incremental resources are required to make integration succeed and how they can be combined efficiently to produce better outcomes for patients.
This evaluation will produce a portfolio of evidence aimed at strengthening the evidence base for integrated care, and in particular identifying the context in which interventions are likely to be effective. These data will support a series of evaluation judgements aimed at reducing uncertainties about the role of integrated care in improving the efficient and effective delivery of healthcare.
PMCID: PMC2948682  PMID: 20922068
integrated care; evaluation; protocol
23.  The SINTEF/Norwegian health and care services case 
SINTEF Health Services Research is part of the SINTEF Foundation. Research areas are evaluation of health and welfare services. The health and welfare authorities are the main commissioners of our research.
Policy practice
SINTEF is the main supplier of research on health and social service reports to the authorities. The institute has competence on hospital and outpatient services to somatic and psychiatric patients (acute treatment, rehabilitation and joint efforts from different agencies). The same principles apply to delivery of services, irrespective of whether it is disability or old age: hospitals provide specialist competence in diagnostics and treatment. Rehabilitation is provided both by specialists and community services. Long-term care is provided in the person’s home as long as possible, both for people with disabilities and people of old age.
Independent research and evaluation are used by policy makers to continually evaluate and improve services.
Health and welfare policies in Norway are generally the same for both elderly persons and persons with disabilities, provided by hospitals and community services.
PMCID: PMC2707582
monitoring services; research; integrated health and social services
24.  The long term importance of English primary care groups for integration in primary health care and deinstitutionalisation of hospital care 
This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care.
Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital) services and also, potentially, social care.
This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts.
Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals.
The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.
PMCID: PMC1484401  PMID: 16896416
primary care; integrated care; managed care; England
25.  Greater than the sum of our parts? Emerging lessons for UK health and social care 
Background and introduction
Although most developed countries are currently pursuing greater integration of health and social care, the current evidence base is limited by a number of key weaknesses in the existing literature. Chief amongst these is the tendency to focus on issues of process (‘how well are we working together’?) not on outcomes (does it make any difference to people who use services?). As a result, there is a danger that integration can become an end in itself, rather than a means to an end (of better services and better outcomes).
Understanding context, process and outcomes
To guard against this danger, this policy paper sets out a number of theoretical and conceptual frameworks to help policy makers, managers and practitioners remain focused on the outcomes that their joint work is meant to achieve. This includes different approaches to being clear about what integration is trying to deliver (outcomes), understanding where we are now (context) and how we get from where we are now to where we want to be (process).
Rather than assume that integration is automatically a ‘good thing’, the frameworks presented in this paper suggest a more critical approach in which policy makers, managers and practitioners focus in more detail on what they are trying to achieve for the people they serve, viewing integration as a means to an end and never an end in itself.
PMCID: PMC2581669  PMID: 18997881
inter-agency collaboration; UK health and social care; integrated care

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