Is partnership the answer? Delivering the national immunisation programme in the new English health system: a mixed methods study.

BACKGROUND: The English national health system experienced a major reorganisation in April 2013. This mixed methods study examined how staff managed to deliver the national immunisation programme within a new health infrastructure and explored the role and contribution of 'partnership working' to programme implementation. METHODS: A cross-sectional online questionnaire survey and a qualitative evaluation of an urban immunisation board were conducted in 2016. The questionnaire included 38 questions about immunisation responsibilities, collaboration, service evaluation and programme support. It was completed by 199 immunisation providers and 70 people involved in the management of the immunisation programme. The evaluation involved 12 semi-structured interviews, 3 observations of forum meetings and the review of forum meeting minutes. Descriptive statistical analysis of the survey data was performed using SPSS version 23 and qualitative data from both study components were uploaded to NVivo 11 and analysed thematically. RESULTS: Screening and Immunisation Teams were cited as responsible for programme leadership by 56% of survey respondents, but concerns were raised about their capacity to oversee larger geographies and a case made for decentralised accountability mechanisms. Only 44% of immunisation managers stated that poor performance was addressed adequately, and half of respondents thought that support given to providers was inadequate. Managers reported that partnership working improved the organisation (83%) and performance (78%) of immunisation, but stated it was more beneficial for information-sharing than implementation. A preference for a "locality working approach" with committees covering smaller health economies rather than larger commissioning areas was voiced. The immunisation board examined in the qualitative evaluation sought to achieve this by forging links with locally based steering committees, but also had to address internal challenges related to the role of the board and contribution of members to programmatic decision-making. CONCLUSIONS: Key challenges in delivering the immunisation programme were rooted in the new health infrastructure, which had created greater distance between commissioners and providers and resulted in the fragmentation of programme responsibilities. Partnership working bridged gaps but more needs to be done to strengthen accountability mechanisms and ensure that collaborative activities are outcome oriented and sustainable in the shifting environment of reorganisation.

An audit of tuberculosis health services in prisons and immigration removal centres.

Background: Tuberculosis (TB) is the second leading cause of death worldwide due to a single infectious agent. Rates of active TB in places of prescribed detention (PPD), which include Prisons, Young Offender Institutions and Immigration Removal Centres, are high compared with the general population. PPD therefore present an opportunity to develop targeted health programmes for TB control. This audit aims to assess current service provisions and identify barriers to achieving best practice standards in PPD across London. Methods: Twelve healthcare teams within PPD commissioned by NHS England (London Region) were included in the audit. Services were evaluated against the National Institute for Health and Care Excellence standards for TB best practice. Results: None of the health providers with a digital X-ray machine were conducting active case finding in new prisoners and no health providers routinely conduct Latent TB infection testing and preventative treatment. Barriers to implementing standards include the lack of staff skills and staff skills mix, structural and technical barriers, and demands of custodial and health services. Conclusions: This audit restates the importance of national public health TB strategies to consider healthcare provisions across PPD.

"It's a complex mesh"- how large-scale health system reorganisation affected the delivery of the immunisation programme in England: a qualitative study.

BACKGROUND: The English health system experienced a large-scale reorganisation in April 2013. A national tri-partite delivery framework involving the Department of Health, NHS England and Public Health England was agreed and a new local operational model applied. Evidence about how health system re-organisations affect constituent public health programmes is sparse and focused on low and middle income countries. We conducted an in-depth analysis of how the English immunisation programme adapted to the April 2013 health system reorganisation, and what facilitated or hindered the delivery of immunisation services in this context. METHODS: A qualitative case study methodology involving interviews and observations at national and local level was applied. Three sites were selected to represent different localities, varying levels of immunisation coverage and a range of changes in governance. Study participants included 19 national decision-makers and 56 local implementers. Two rounds of interviews and observations (immunisation board/committee meetings) occurred between December 2014 and June 2015, and September and December 2015. Interviews were audio recorded and transcribed verbatim and written accounts of observed events compiled. Data was imported into NVIVO 10 and analysed thematically. RESULTS: The new immunisation programme in the new health system was described as fragmented, and significant effort was expended to regroup. National tripartite arrangements required joint working and accountability; a shift from the simpler hierarchical pre-reform structure, typical of many public health programmes. New local inter-organisational arrangements resulted in ambiguity about organisational responsibilities and hindered data-sharing. Whilst making immunisation managers responsible for larger areas supported equitable resource distribution and strengthened service commissioning, it also reduced their ability to apply clinical expertise, support and evaluate immunisation providers' performance. Partnership working helped staff adapt, but the complexity of the health system hindered the development of consistent approaches for training and service evaluation. CONCLUSION: The April 2013 health system reorganisation in England resulted in significant fragmentation in the way the immunisation programme was delivered. Some of this was a temporary by-product of organisational change, other more persistent challenges were intrinsic to the complex architecture of the new health system. Partnership working helped immunisation leaders and implementers reconnect and now the challenge is to assess how inter-agency collaboration can be strengthened.

Seasonal influenza vaccination delivery through community pharmacists in England: evaluation of the London pilot.

OBJECTIVE: To evaluate the effectiveness and cost of the pan-London pharmacy initiative, a programme that allows administration of seasonal influenza vaccination to eligible patients at pharmacies. DESIGN: We analysed 2013-2015 data on vaccination uptake in pharmacies via the Sonar reporting system, and the total vaccination uptake via 2011-2015 ImmForm general practitioner (GP) reporting system data. We conducted an online survey of London pharmacists who participate in the programme to assess time use data, vaccine choice, investment costs and opinions about the programme. We conducted an online survey of London GPs to assess vaccine choice of vaccine and opinions about the pharmacy vaccine delivery programme. SETTING: All London boroughs. PARTICIPANTS: London-based GPs, and pharmacies that currently offer seasonal flu vaccination. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparison of annual vaccine uptake in London across risk groups from years before pharmacy vaccination introduction to after pharmacy vaccination introduction. Completeness of vaccine uptake reporting data. Cost to the National Health Service (NHS) of flu vaccine delivery at pharmacies with that at GPs. Cost to pharmacists of flu delivery. Opinions of pharmacists and GPs regarding the flu vaccine pharmacy initiative. RESULTS: No significant change in the uptake of seasonal vaccination in any of the risk groups as a result of the pharmacy initiative. While on average a pharmacy-administered flu vaccine dose costs the NHS up to £2.35 less than a dose administered at a GP, a comparison of the 2 recording systems suggests there is substantial loss of data. CONCLUSIONS: Flu vaccine delivery through pharmacies shows potential for improving convenience for vaccine recipients. However, there is no evidence that vaccination uptake increases and the use of 2 separate recording systems leads to time-consuming data entry and missing vaccine record data.

NICE guidance and mental health: supporting change.

PURPOSE: The purpose of this article is to give those in the psychology and psychotherapy fields an overview of the work the National Institute for Health and Clinical Excellence (NICE) is doing to encourage change in response to its guidance. METHODS: A summary is provided of the work NICE undertakes to motivate others to use guidance and the practical support that is made available. Findings of selected studies are highlighted that demonstrate some of the successes and challenges relating to the uptake of NICE guidance. RESULTS: Key aspects of NICE work include liaison with partners at a national level to ensure work programmes are aligned and provision of practical support, such as the commissioning guide on cognitive behavioural therapy (CBT). A range of studies show that there have been successes in increasing the provision of psychological therapies but there are still variations which present challenges. CONCLUSIONS: NICE provides a substantial programme of support for the implementation of guidance which impacts on psychologists and psychotherapists. Successes in the uptake of guidance can be demonstrated but it is acknowledged that this is challenging area. NICE is keen to provide the most effective support possible for implementation so continually evaluates and seeks feedback on its implementation programme.