Is the end in sight? A study of how and why services are decommissioned in the English National Health Service.

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews.

BACKGROUND: As people are living longer with higher incidences of long-term health conditions, there is a move towards greater integration of care, including integration of health and social care services. Integrated care needs to be comprehensively and systematically evaluated if it is to be implemented widely. We performed a systematic review of reviews to identify measures which have been used to assess integrated care across health and social care services for people living with long-term health conditions. METHODS: Four electronic databases (PUBMED; MEDLINE; EMBASE; Cochrane library of systematic reviews) were searched in August 2018 for relevant reviews evaluating the integration of health and social care between 1998 and 2018. Articles were assessed according to apriori eligibility criteria. A data extraction form was utilised to collate the identified measures into five categories. RESULTS: Of the 18 articles included, system outcomes and process measures were most frequently identified (15 articles each). Patient or carer reported outcomes were identified in 13 articles while health outcomes were reported in 12 articles. Structural measures were reported in nine articles. Challenges to measuring integration included the identification of a wide range of potential impacts of integration, difficulties in comparing findings due to differences in study design and heterogeneity of types of outcomes, and a need for appropriate, robust measurement tools. CONCLUSIONS: Our review revealed no shortage of measures for assessing the structures, processes and outcomes of integrated care. The very large number of available measures and infrequent use of any common set make comparisons between schemes more difficult. The promotion of core measurement sets and stakeholder consultation would advance measurement in this area.

Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives.

BACKGROUND: Integrated care has the potential to ease the increasing pressures faced by health and social care systems, however, challenges around measuring the benefits for providers, patients, and service users remain. This paper explores stakeholders' views on the benefits of integrated care and approaches to measuring the integration of health and social care. METHODS: Twenty-five semi-structured qualitative interviews were conducted with professional stakeholders (n = 19) and patient representatives (n = 6). Interviews focused on the benefits of integrated care and how it should be evaluated. Data was analysed using framework analysis. RESULTS: Three overarching themes emerged from the data: (1) integrated care and its benefits, with stakeholders defining it primarily from the patient's perspective; (2) potential measures for assessing the benefits of integration in terms of system effects, patient experiences, and patient outcomes; and (3) broader considerations around the assessment of integrated care, including the use of qualitative methods. CONCLUSIONS: There was consensus among stakeholders that patient experiences and outcomes are the best measures of integration, and that the main measures currently used to assess integration do not directly assess patient benefits. Validated health status measures are readily available, however, a substantial shift in practices is required before their use becomes commonplace.

What is the best way to evaluate social prescribing? A qualitative feasibility assessment for a national impact evaluation study in England.

OBJECTIVES: Despite significant investment in social prescribing in England over the last decade, we still do not know if it works, or how models of social prescribing fit within wider health and care policy and practice. This study explores current service delivery structures and assesses the feasibility of a national evaluation of the link worker model. METHODS: Semi-structured interviews were conducted between May and September 2020, with 25 key informants from across social prescribing services in England. Participants included link workers, voluntary, community and social enterprise staff, and those involved in policy and decision-making for social prescribing services. Interview and workshop transcripts were analysed thematically, adopting a framework approach. RESULTS: We found differences in how services are provided, including by individual link workers, and between organisations and regions. Standards, referral pathways, reporting, and monitoring structures differ or are lacking in voluntary services as compared to clinical services. People can self-refer to a link worker or be referred by a third party, but the lack of standardised processes generated confusion in both public and professional perceptions of the link worker model. We identified challenges in determining the appropriate outcomes and outcome measures needed to assess the impact of the link worker model. CONCLUSIONS: The current varied service delivery structures in England poses major challenges for a national impact evaluation. Any future rigorous evaluation needs to be underpinned with national standardised outcomes and process measures which promote uniform data collection.

Patient and relative experiences of the ReSPECT process in the community: an interview-based study.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community. OBJECTIVES: To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form. METHODS: Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis. RESULTS: Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility. CONCLUSIONS: When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.

GPs' views on emergency care treatment plans: an online survey.

BACKGROUND: A holistic approach to emergency care treatment planning is needed to ensure that patients' preferences are considered should their clinical condition deteriorate. To address this, emergency care and treatment plans (ECTPs) have been introduced. Little is known about their use in general practice. AIM: To find out GPs' experiences of, and views on, using ECTPs. DESIGN & SETTING: Online survey of GPs practising in England. METHOD: A total of 841 GPs were surveyed using the monthly online survey provided by medeConnect, a market research company. RESULTS: Forty-one per cent of responders' practices used Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans for ECTP, 8% used other ECTPs, and 51% used Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms. GPs were the predominant professional group completing ECTPs in the community. There was broad support for a wider range of community-based health and social care professionals being able to complete ECTPs. There was no system for reviewing ECTPs in 20% of responders' practices. When compared with using a DNACPR form, GPs using a ReSPECT form for ECTP were more comfortable having conversations about emergency care treatment with patients (odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.1 to 2.69) and family members (OR =1.85, 95% CI = 1.19 to 2.87). CONCLUSION: The potential benefits and challenges of widening the pool of health and social care professionals initiating and/or completing the ECTP process needs consideration. ReSPECT plans appear to make GPs more comfortable with ECTP discussions, supporting their implementation. Practice-based systems for reviewing ECTP decisions should be strengthened.

Working the Edge: The Emotional Experiences of Commissioning and Funding Arrangements for Service Leaders in the Sexual Violence Voluntary Sector.

The specialist voluntary sector plays a crucial role in supporting survivors of sexual violence. However, in England, short-term funding underpins the sector's financial stability. This article examines sector leaders' ways of coping, resisting and being affected by funding practices. Using the concept of edgework, we show how funding and commissioning dynamics push individuals to the edge of service sustainability, job satisfaction, and emotional well-being. We examine how these edges are "worked," for example, by circumventing and remolding the edge. We offer an original way to theorize participants, make visible the emotional toll of service precarity and offer suggestions for support.

Use, characteristics and influence of lay consultation networks on treatment-seeking decisions in slums of Nigeria: a cross-sectional survey.

OBJECTIVES: To describe the use, characteristics and influence of lay consultants on treatment-seeking decisions of adults in slums of Nigeria. DESIGN: Cross-sectional survey using a pre-piloted questionnaire. SETTINGS: Two slum communities in Ibadan city, Nigeria. PARTICIPANTS: 480 adults within the working age group (18-64). RESULTS: Most respondents (400/480, 83.7%) spoke to at least one lay consultant during their last illness/health concern. In total, 683 lay consultants were contacted; all from personal networks such as family and friends. No respondent listed online network members or platforms. About nine in 10 persons spoke to a lay consultant about an illness/health concern without intending to seek any particular support. However, almost all (680/683, 97%) lay consultants who were contacted provided some form of support. Marital status (OR=1.92, 95% CI: 1.10 to 3.33) and perceiving that an illness or health concern had some effects on their daily activities (OR=3.25, 95% CI: 1.94 to 5.46) had a significant independent association with speaking to at least one lay consultant. Age had a significant independent association with having lay consultation networks comprising non-family members only (OR=0.95, 95% CI: 0.92 to 0.99) or mixed networks (family and non-family members) (OR=0.97, 95% CI: 0.95 to 0.99), rather than family-only networks. Network characteristics influenced individual treatment decisions as participants who contacted networks comprising non-family members only (OR=0.23, 95% CI: 0.08 to 0.67) and dispersed networks (combination of household, neighbourhood and distant network members) (OR=2.04, 95% CI: 1.02 to 4.09) were significantly more likely to use informal than formal healthcare, while controlling for individual characteristics. CONCLUSIONS: Health programmes in urban slums should consider engaging community members so, when consulted within their networks, they are able to deliver reliable information about health and treatment-seeking.

Systematic review of lay consultation in symptoms and illness experiences in informal urban settlements of low-income and middle-income countries.

OBJECTIVES: Lay consultation is the process of discussing a symptom or an illness with lay social network members. This can have positive or negative consequences on health-seeking behaviours. Understanding how consultation with lay social networks works in informal urban settlements of low-income and middle-income countries (LMICs) is important to enable health and policy-makers to maximise its potential to aid healthcare delivery and minimise its negative impacts. This study explored the composition, content and consequences of lay consultation in informal urban settlements of LMICs. DESIGN: Mixed-method systematic review. DATA SOURCES: Six key public health and social science databases, Google Scholar and reference lists of included studies were searched for potential articles. ELIGIBILITY CRITERIA: Papers that described discussions with lay informal social network members during symptoms or illness experiences. DATA ANALYSIS AND SYNTHESIS: Quality assessment was done using the Mixed Methods Appraisal Tool. Data were analysed and synthesised using a stepwise thematic synthesis approach involving two steps: identifying themes within individual studies and synthesising themes across studies. RESULTS: 13 studies were included in the synthesis. Across the studies, three main categories of networks consulted during illness: kin, non-kin associates and significant community groups. Of these, kin networks were the most commonly consulted. The content of lay consultations were: asking for suggestions, negotiating care-seeking decisions, seeking resources and non-disclosure due to personal or social reasons. Lay consultations positively and negatively impacted access to formal healthcare and adherence to medical advice. CONCLUSION: Lay consultation is mainly sought from social networks in immediate environments in informal urban settlements of LMICs. Policy-makers and practitioners need to utilise these networks as mediators of healthcare-seeking behaviours. PROSPERO REGISTRATION NUMBER: CRD42020205196.

Supporting survivors of sexual violence: protocol for a mixed-methods, co-research study of the role, funding and commissioning of specialist services provided by the voluntary sector in England.

INTRODUCTION: The voluntary sector provides a range of specialist services to survivors of sexual violence, many of which have evolved from grass roots organisations responding to unmet local needs. However, the evidence base is poor in terms of what services are provided to which groups of survivors, how voluntary sector specialist (VSS) services are organised and delivered and how they are commissioned. This will be the first national study on the role of the voluntary sector in supporting survivors in England. METHODS AND ANALYSIS: This study uses an explanatory sequential naturalistic mixed-methods design with two stages. For stage 1, two national surveys of providers' and commissioners' views on designing and delivering VSS services will facilitate detailed mapping of service provision and commissioning in order to create a taxonomy of VSS services. Variations in the national picture will then be explored in stage 2 through four in-depth, qualitative case studies using the critical incident technique to explain the observed variations and understand the key contextual factors which influence service provision. Drawing on theory about the distinctive service contribution of the voluntary sector, survivors will be involved as co-researchers and will play a central role in data collection and interpretation. ETHICS AND DISSEMINATION: Ethical approval has been granted by the University of Birmingham research ethics committee for stage 1 of the project. In line with the sequential and co-produced study design, further applications for ethical review will be made in due course. Dissemination activities will include case study and end-of-project workshops; good practice guides; a policy briefing; project report; bitesize findings; webinars; academic articles and conference presentations. The project will generate evidence about what survivors want from and value about services and new understanding about how VSS services should be commissioned and provided to support survivors to thrive in the long term.

Contribution of the voluntary sector to mental health crisis care in England: protocol for a multimethod study.

INTRODUCTION: Timely access to the right kind of support for people experiencing a mental health crisis can be problematic. The voluntary sector (VS) plays a key role in providing support and enabling access, but there is a knowledge gap concerning its contribution and interface with public services in mental health crisis care. This study aims to address this. METHODS AND ANALYSIS: The study has three empirical elements: (1) a national survey of voluntary sector organisations (VSOs) in England and national stakeholder interviews to develop a typology of organisations and interventions provided by VSOs; (2) detailed mapping of VS services in two regions through interviews and extending the national survey; (3) four case studies, identified from the regional mapping, of VS mental health crisis services and their interface with National Health Service (NHS) and local authority services, at both a system and individual level. Data collection will involve interviews with commissioners; VSO and NHS or local authority providers; and focus groups with people who have experience of VSO crisis support, both service users and carers; and mapping the crisis trajectory of 10 service users in each study site through narrative interviews with service users and informal carers to understand the experience of VSO crisis care and its impact. ETHICS AND DISSEMINATION: The University of Birmingham Humanities and Social Sciences Ethical Review Committee granted ethical approval (reference ERN_16-1183) for the national and regional elements of the study. Ethical review by the Health Research Authority will be required for the case study research once the sites have been identified from the first two elements of the study. A range of methods including a policy seminar, publication in academic journals and a tool kit for commissioners and practitioners will be produced to maximise the impact of the findings on policy and practice.

Disentangling rhetoric and reality: an international Delphi study of factors and processes that facilitate the successful implementation of decisions to decommission healthcare services.

BACKGROUND: The need to better understand processes of removing, reducing, or replacing healthcare services that are no longer deemed essential or effective is common across publicly funded healthcare systems. This paper explores expert international opinion regarding, first, the factors and processes that shape the successful implementation of decommissioning decisions and, second, consensus as to current best practice. METHODS: A three round Delphi study of 30 international experts was undertaken. In round one, participants identified factors that shape the outcome of decommissioning processes; responses were analysed using conventional content analysis. In round two, responses to 88 Likert scale statements derived from round one were analysed using measures of the degree of consensus. In round three the statements that achieved low consensus were then repeated but presented alongside the overall results from round two. The responses were re-analysed to observe whether the degree of consensus had changed. Any open comments provided during the Delphi study were analysed thematically. RESULTS: Participants strongly agreed that three considerations should ideally inform decommissioning decisions: quality and patient safety, clinical effectiveness and cost-effectiveness. Although there was less consensus as to which considerations informed such decisions in practice, those that drew the most agreement were: cost/budgetary pressures, government intervention and capital costs/condition. Important factors in shaping decommissioning were: strength of executive leadership, strength of clinical leadership, quality of communications, demonstrable benefits and clarity of rationale/case for change. Amongst the 19 best practice recommendations high consensus was achieved for: establishing a strong leadership team, engaging clinical leaders from an early stage, and establishing a clear rationale for change. CONCLUSIONS: There was a stark contrast between what experts thought should determine decommissioning decisions and what does so in practice; a contrast mirrored in the distinction the participants drew between the technical and political aspects of decommissioning processes. The best practice recommendations which we grouped into three categories--change management and implementation; evidence and information; and relationships and political dimensions--can be seen as contemporary responses or strategies to manage the tensions that emerged between the rhetoric and reality of implementing decommissioning decisions.