Understanding the processes underpinning IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a process evaluation within a cluster randomised controlled implementation trial.

BACKGROUND: Providing supported self-management for people with asthma can reduce the burden on patients, health services and wider society. Implementation, however, remains poor in routine clinical practice. IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a UK-wide cluster randomised implementation trial that aims to test the impact of a whole-systems implementation strategy, embedding supported asthma self-management in primary care compared with usual care. To maximise opportunities for sustainable implementation beyond the trial, it is necessary to understand how and why the IMP2ART trial achieved its clinical and implementation outcomes. METHODS: A mixed-methods process evaluation nested within the IMP2ART trial will be undertaken to understand how supported self-management was implemented (or not) by primary care practices, to aid interpretation of trial findings and to inform scaling up and sustainability. Data and analysis strategies have been informed by mid-range and programme-level theory. Quantitative data will be collected across all practices to describe practice context, IMP2ART delivery (including fidelity and adaption) and practice response. Case studies undertaken in three to six sites, supplemented by additional interviews with practice staff and stakeholders, will be undertaken to gain an in-depth understanding of the interaction of practice context, delivery, and response. Synthesis, informed by theory, will combine analyses of both qualitative and quantitative data. Finally, implications for the scale up of asthma self-management implementation strategies to other practices in the UK will be explored through workshops with stakeholders. DISCUSSION: This mixed-methods, theoretically informed, process evaluation seeks to provide insights into the delivery and response to a whole-systems approach to the implementation of supported self-management in asthma care in primary care. It is underway at a time of significant change in primary care in the UK. The methods have, therefore, been developed to be adaptable to this changing context and to capture the impact of these changes on the delivery and response to research and implementation processes.

Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services.

BACKGROUND: Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization. METHODS: A discrete-choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery. RESULTS: Responses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups. CONCLUSION: Respondents' preferences in this selected sample were consistent with centralization.

Costing the Australian National Hand Hygiene Initiative.

BACKGROUND: The Australian National Hand Hygiene Initiative (NHHI) is a major patient safety programme co-ordinated by Hand Hygiene Australia (HHA) and funded by the Australian Commission for Safety and Quality in Health Care. The annual costs of running this programme need to be understood to know the cost-effectiveness of a decision to sustain it as part of health services. AIM: To estimate the annual health services cost of running the NHHI; the set-up costs are excluded. METHODS: A health services perspective was adopted for the costing and collected data from the 50 largest public hospitals in Australia that implemented the initiative, covering all states and territories. The costs of HHA, the costs to the state-level infection-prevention groups, the costs incurred by each acute hospital, and the costs for additional alcohol-based hand rub are all included. FINDINGS: The programme cost AU$5.56 million each year (US$5.76, £3.63 million). Most of the cost is incurred at the hospital level (65%) and arose from the extra time taken for auditing hand hygiene compliance and doing education and training. On average, each infection control practitioner spent 5h per week on the NHHI, and the running cost per annum to their hospital was approximately AU$120,000 in 2012 (US$124,000, £78,000). CONCLUSION: Good estimates of the total costs of this programme are fundamental to understanding the cost-effectiveness of implementing the NHHI. This paper reports transparent costing methods, and the results include their uncertainty.

Understanding issues associated with attending a young adult diabetes clinic: a case study.

AIMS: To study the reasons for attendance behaviour from the patient viewpoint at a young adult diabetes outpatient clinic. METHODS: Attendance rates for 231 clinic appointments over 19 months for 102 patients were calculated. Semi-structured interviews were conducted with a purposive sample of 17 of the 102. The interviews encouraged participants to describe routines, thoughts and feelings around clinic appointments. Observations were made of the clinic system. Themes arising from patients' emotional and practical issues around attendance were generated from the data. RESULTS: 'Did not attend' rates for the clinic over the study period were 15.7%. However, bureaucratic problems created many 'missed' appointments; most instances of 'did not attend' investigated were attributable to communication failures. Participants did not divide neatly into 'attenders'/'non-attenders'; many had complex mixed attendance records. Most weighed the value of attendance against immediate obstacles such as incompatible work/clinic hours. Reminders were seen as important, particularly for this age group. Respondents identified fear of being judged for 'poor control' as a major factor in attendance decisions, suggesting that having a high HbA1c level may lead to non-attendance, rather than vice versa. CONCLUSIONS: Health professionals' supportive, non-judgemental attitude is important to patients considering clinic attendance. In this study, improved communication, reminders and flexible hours might reduce 'did not attend' rates.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers.

OBJECTIVE: To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process. METHOD: A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK). RESULTS: Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI. CONCLUSION: While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

Perceptions of partnership. A documentary analysis of Health Improvement Programmes.

Health Improvement Programmes (HImPs) are at the heart of the UK government's partnership agenda for the National Health Service (NHS). This paper assesses the nature of HImP partnerships in England by analysing 50/99 first-round HImP strategies (randomly selected). The documentary analysis quantifies the structures and mechanisms of partnership, the degree of inter-sectoral participation and the extent of voluntary sector involvement.Three-quarters of responding health authorities (37/50) appear to have set up formal partnership structures to produce the HImP, or are planning to do so. After health authorities, local authorities (47/50) appear to be most involved in contributing to the HImP, particularly social services departments. Within the NHS 'family', acute and community trusts (43/50) appear to be the most involved, with Primary Care Groups (PCGs) contributing less (39/40). Community Health Councils (CHCs) appear to be similarly involved (40/50). The voluntary sector appear to be involved in all but four HImPs, mainly through umbrella organisations represented on strategic partnership boards (34/50). User and carer and community groups appear to participate far less. Lack of endorsement of HImPs by partner organisations, poor delineation of responsibilities and absence of transparency in resource allocation suggest that ownership of, and commitment to HImPs may be weak. HImPs appear to have focused on creating structures rather than developing aspects of partnership process. If levels of inter-sectoral involvement and voluntary sector participation are to be maintained or increased in future, Primary Care Trusts (PCTs) will need to develop a strategic approach to partnership.

Determinants of unsafe sex in women.

We aimed to identify determinants of condom usage and unsafe sex in women having sex with a new partner. One hundred women attending either a genitourinary medicine (GUM) clinic or a family planning clinic participated in the study. Respondents were interviewed about last 3 new male partners, from the beginning of the sexual relationship through its development, if any. Data analysis was primarily qualitative, quantitative analysis was conducted where appropriate. Alternative contraceptive use was the most commonly reported determinant of condom usage overall. The most commonly reported determinant of condom use for prophylaxis was the woman's perception of her partner and the risks he presented. Models of risky sexual behaviour have focused on the individual's generalized estimation of risks of acquiring STDs. Existing models are poor predictors of risky sexual behaviour. We propose that it is the perceived risk presented by a particular individual partner, not global risk, which influences behaviour. An individual risk model is put forward.

The influence of health needs assessment on health care decision-making in London health authorities.

OBJECTIVES: Health needs assessment gained prominence under the model of health care purchasing developed to support the 1991 reforms of the UK National Health Service (NHS). The objectives of this paper are to determine how needs assessment has been used in the NHS, to assess the influence it has had on decision-making, and to relate the observed uses of needs assessment to competing theoretical models of health care policy-making. METHODS: A survey of needs assessment activity in 14 London health authorities identified 217 needs assessments conducted between 1993 and 1996. Semi-structured interviews were conducted with public health and commissioning staff in each authority. RESULTS: The survey indicated that needs assessment directly supported decision-making and action in two-thirds of the studies identified, but up to 20% of needs assessments had no impact on service provision. Four key functions of health needs assessment were observed: identifying a problem; planning detailed changes to services; providing post hoc justification for earlier decisions; and using participation in needs assessment to build 'ownership' of subsequent decisions. CONCLUSIONS: The survey suggests that needs assessment is, in practice, consistent with a 'mixed scanning' model of decision-making. Needs assessment is used to help select issues for detailed investigation and to direct analytical and decision-making resources. However, certain key areas are not amenable to technical analysis and solution, and are resolved through bargaining.

Shifting care: GP opinions of hospital at home.

Hospital at home (HaH) has become an increasingly popular model of care over the past few years. However, there is little evidence to suggest that this is a superior form of care when compared with standard inpatient care in terms of cost, satisfaction, or clinical outcomes. Despite concerns that these schemes increase general practitioner (GP) workload, there is also no published evidence on the effect of HaH on GPs. As part of a broader study, a survey was undertaken of all GPs in an inner London health authority for their views of HaH. Overall, GPs felt that such schemes increased their workload, but GPs who had used HaH were more strongly in favour of these schemes for a range of conditions.

Drink, illicit drugs and unsafe sex in women.

AIMS: To establish the extent and nature of linkages between illicit drug and alcohol use and sexual behaviour in women. PARTICIPANTS AND SETTING: One hundred women attending either a Genitourinary Medicine Clinic or a Family Planning Clinic. DESIGN: Respondents were interviewed using a semi-structured interview schedule covering the effect of drink/illicit drug use on the incidence of sex, on condom use, and on specific sexual activities, and deliberate use of drink/illicit drugs to affect sex. Interviews focused on the last three new male partners, from the beginning of the sexual relationship through its development. Data analysis was primarily qualitative, quantitative analysis was conducted where appropriate. RESULTS: There were few cases in which women reported that consumption of drink/illicit drugs caused them to engage in sexual behaviour which they would not have engaged in if they had not had drink/drugs. Associations between drink and illicit drugs and sexual behaviour were, mainly, either because encounters took place in social situations where drugs or drink were being consumed or because the woman used drink or drugs instrumentally to engage in desired behaviours. There was some evidence to suggest that greater use of drugs and alcohol might be part of a wider pattern of social behaviour including more sexual partners. CONCLUSIONS: The women's self-reported behaviour suggested that illicit drug and alcohol use in itself did not usually result in unsafe or undesired sexual behaviour.

Ethnicity and use of acute psychiatric beds: one-day survey in north and south Thames regions.

BACKGROUND: Previous studies have shown higher rates of psychiatric admissions, compulsory admissions, and diagnosed schizophrenia in Black ethnic groups compared with other population groups. METHOD: In a point-prevalence study, demographic and clinical data were collected for adult acute and low-level secure psychiatric in-patients in all National Health Service and seven private psychiatric units in North and South Thames regions on 15 June 1994. RESULTS: A total of 3710 adult acute and 268 low-level secure psychiatric patients were surveyed; 75% of the patients were White, 16% were Black, and 4% were Asian. Analysis reveals that a high proportion of the Black population were admitted to a psychiatric unit; that Black patients are more likely to be admitted under Section; to be located in locked wards; have an inpatient diagnosis of schizophrenia; and not be registered with a general practitioner. CONCLUSIONS: These findings demonstrate the over-representation of Black ethnic groups within current psychiatric provision. The complement of services to all minority ethnic groups should be examined in terms of access, appropriateness and quality of care. Racism awareness and staff training need to be incorporated into mental health service provision as a matter of priority.

Does the National Health Service want hospital-at-home?

There has been increasing interest in the development of hospital-at-home within the National Health Service (NHS) as a way of shifting resources from secondary to primary care. We describe the development of hospital-at-home schemes in London and draw on data from an evaluation of five such schemes to discuss support for hospital-at-home within the NHS. The study has identified a small but important group of patients who do not want hospital-at-home, as well as resistance to it from some health care professionals and managers, particularly in hospitals. These organizational issues must be taken into account in any evaluation of hospital-at-home, along with issues of quality, outcome and cost. Feasibility studies are needed to identify possible organizational barriers to hospital-at-home and the development work that is required. This service innovation should not be considered in isolation from other services, but rather within the context of a wider debate about the pattern of acute care.

Does hospital-at-home make economic sense? Early discharge versus standard care for orthopaedic patients.

Hospital-at-home has been promoted as a potentially effective means of replacing costly inpatient care with cheaper domiciliary care. We studied three hospital-at-home schemes in West London providing intensive home care for early discharge orthopaedic patients, comparing their costs with those of standard inpatient care. Although costs per day of hospital-at-home care were lower than those of inpatient care, the schemes appeared to increase the total duration of orthopaedic episodes, so that the costs of standard care, per episode, were lower than those of hospital-at-home. While hospital-at-home may offer considerable future potential, substitution of home care for inpatient care will not necessarily save resources.

What impact do annual public health reports have?

Each district health authority is required to produce an annual report on the health of their population. Although they consume considerable resources, there is little evidence as to their impact on their intended audiences. We describe the results of a postal survey of how these reports are viewed by health authority and local government managers in one region. Eighty-nine out of 139 responded (64%). Over half of the managers had read the reports in their entirety. Most were discussed by health authorities but few by relevant local government committees. There was some disagreement between directors of public health and other health authority managers about the impact of the reports on commissioning. The paper discusses the difficulties in evaluating the impact of annual public health reports. The survey reveals a fundamental disagreement about whether the intended audience should be health care purchasers or the public. This reflects an underlying tension about the role of public health and the debate about its independence.