Understanding responsibility for health inequalities in children's hospitals in England: a qualitative study with hospital staff.

OBJECTIVES: This study aimed to understand how staff in children's hospitals view their responsibility to reduce health inequalities for the children and young people who access their services. DESIGN: We conducted an exploratory qualitative study. SETTING: The study took place at nine children's hospitals in England. PARTICIPANTS: 217 members of staff contributed via interviews and focus groups conducted January-June 2023. Staff were represented at all levels of the organisations, and all staff who volunteered to contribute were included in the study. ANALYSIS: Data were analysed using Rapid Research Evaluation and Appraisal (RREAL) methodology for rapid assessment procedures (RAP). RESULTS: All of the children's hospitals were taking some action to reduce health inequalities. Two key themes were identified. First, it was clear that reducing health inequalities was seen as something that was of vital import and should be part of staff's day-to-day activity, framed as 'everyone's business.' Many staff felt that there was an obligation to intervene to ensure that children and young people receiving hospital treatment were not further disadvantaged by, for example, food poverty. Second, however, the deeply entrenched and intersectional nature of health inequalities sometimes meant that these inequalities were complex to tackle, with no clear impetus to specific actions, and could be framed as 'no-one's responsibility'. Within a complex health and social care system, there were many potential actors who could take responsibility for reducing health inequalities, and staff often questioned whether it was the role of a children's hospital to lead these initiatives. CONCLUSIONS: Broadly speaking, senior leaders were clear about their organisational role in reducing health inequalities where they impacted on access and quality of care, but there was some uncertainty about the perceived boundaries of responsibility. This led to fragility in the sustainability of activity, and a lack of joined-up intervention. Most hospitals were forging ahead with activity, considering that it was more important to work to overcome health inequalities rather than debate whose job it was.

Gender, flexibility and workforce in the NHS: A qualitative study.

Data from the General Medical Council show that the number of female doctors registered to practise in the UK continues to grow at a faster rate than the number of male doctors. Our research critically discusses the impact of this gender-based shift, considering how models of medical training are still ill-suited to supporting equity and inclusivity within the workforce, with particular impacts for women despite this gender shift. Drawing on data from our research project Mapping underdoctored areas: the impact of medical training pathways on NHS workforce distribution and health inequalities, this paper explores the experiences of doctors working in the NHS, considering how policies around workforce and beyond have impacted people's willingness and ability to continue in their chosen career path. There is clear evidence that women are underrepresented in some specialties such as surgery, and at different career stages including in senior leadership roles, and our research focuses on the structural factors that contribute to reinforcing these under-representations. Medical education and training are known to be formative points in doctors' lives, with long-lasting impacts for NHS service provision. By understanding in detail how these pathways inadvertently shape where doctors live and work, we will be able to consider how best to change existing systems to provide patients with timely and appropriate access to healthcare. We take a cross-disciplinary theoretical approach, bringing historical, spatiotemporal and sociological insights to healthcare problems. Here, we draw on our first 50 interviews with practising doctors employed in the NHS in areas that struggle to recruit and retain doctors, and explore the gendered nature of career biographies. We also pay attention to the ways in which doctors carve their own career pathways out of, or despite of, personal and professional disruptions.

How do children's hospitals address health inequalities: a grey literature scoping review.

OBJECTIVES: Health inequalities are systematic differences in health between people, which are avoidable and unfair. Globally, more political strategies are required to address health inequalities, which have increased since the global SARS-CoV-2/COVID-19 pandemic, with a disproportionate impact on children. This scoping review aimed to identify and collate information on how hospitals around the world that deliver care to children have addressed health inequalities. DESIGN: Scoping review focused solely on grey literature. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Following Joanna Briggs Institute guidelines, a four-step approach to identifying literature was adopted. DATA SOURCES: Overton, OpenGrey, OpenMD, Trip Database, DuckDuckGo, Google, targeted websites and children's hospital websites were searched on March 2023 for items published since 2010. DATA EXTRACTION AND SYNTHESIS: Retrieved items were screened against clear inclusion and exclusion criteria before data were extracted by two independent reviewers using a data extraction tool. Studies were tabulated by a hospital. A meta-analysis was not conducted due to the varied nature of studies and approaches. RESULTS: Our study identified 26 approaches to reduction of health inequalities, from 17 children's hospitals. Approaches were categorised based on their size and scope. Seven approaches were defined as macro, including hospital-wide inequality strategies. Ten approaches were classed as meso, including the establishment of new departments and research centres. Micro approaches (n=9) included one-off projects or interventions offered to specific groups/services. Almost half of the reported approaches did not discuss the evaluation of impact. CONCLUSIONS: Children's hospitals provide a suitable location to conduct public health interventions. This scoping review provides examples of approaches on three scales delivered at hospitals across high-income countries. Hospitals with the most comprehensive and extensive range of approaches employ dedicated staff within the hospital and community. This review indicates the value of recruitment of both public health-trained staff and culturally similar staff to deliver community-based interventions.

Assessing the health needs of children and young people accessing paediatric hospital services: a scoping review protocol.

INTRODUCTION: Health needs are issues that face a population or specific groups, which can benefit from healthcare and wider social and environmental changes. They are inextricably linked to health inequalities, which are largely determined by non-health-related factors such as socioeconomic deprivation or belonging to ethnic minority groups. The hospital-accessing paediatric population, with higher rates of morbidity and mortality, are likely to have higher levels of met and unmet health needs related to social determinants, compared with their peers. As the gap in health inequalities widens globally, paediatric health services may now have an increasingly important role to play in identifying and acting on inequalities affecting their patient population. This scoping review aims to collate information on how children's hospitals assess the health and wider health-related social needs of patients using a health inequalities lens. On a broader level, the review may also reveal themes about healthcare and other health needs of children accessing hospitals globally. METHODS AND ANALYSIS: This scoping review will follow Joanna Briggs Institute guidance. A search strategy will be described to identify published articles from healthcare databases worldwide as well as healthcare-related grey literature. Literature will be examined to identify methods that aim to assess the health and related social needs of hospital-accessing paediatric patients and will exclude literature published before 2010. Two or more reviewers will independently review the results of the searches using the inclusion and exclusion criteria. Study findings will be presented in tabular form detailing the assessments identified. ETHICS AND DISSEMINATION: The review will synthesise information on hospital approaches to understand and assess the health and health-related social needs of children and young people worldwide. The findings will be used to inform guidelines for children's hospitals in the UK and will be disseminated through national and international professional bodies, conferences and research papers.

The wider health and wellbeing needs of those accessing paediatric care in England: engaging with the hidden voices of children and young people.

BACKGROUND: Health need is inextricably linked with inequalities. Health outcomes are worse for those in lower socio-economic groups, ethnic minority groups, and those with protected characteristics. In the UK, this has been compounded by the COVID-19 pandemic and the cost-of-living crisis. Children and young people accessing hospitals can have unmet health and wellbeing needs, yet the role of hospitals in addressing these is not clear. We engaged with children and young people and caregivers from under-represented groups, often excluded from patient and public involvement, to understand their experiences, in order to support the co-design of future research and interventions. METHODS: A series of virtual and physical engagement events were held in Northwest England between March 9, and May 19, 2023. Community groups in areas of high socioeconomic deprivation, carers of children living with disabilities, adolescent care leavers, and school children were contacted through local websites. The concept of health inequalities was introduced at the start of sessions, and participants were encouraged to reflect on their own experiences. Discussions were co-facilitated with community leaders. Events focused on exploring experiences of health inequalities in relation to health care and views on future research. Ethics approval was not required as this was preparatory work; however, written consent was sought. Financial compensation was provided. FINDINGS: A total of 30 participants (aged 10 years and older) participated in four, 90 min events. Themes included: difficulties with transport and navigating services, lack of staff awareness about disabilities, and concerns about transitioning to adult services. Groups expressed varied opinions about research into health inequalities. The topic was considered to be important, and remuneration for participation was felt to be crucial. This is important because of the long-term nature of health inequality outcomes, which result in no immediate benefit to participants themselves. INTERPRETATION: Users of health-care services-including rarely heard groups-welcome research into health inequalities, but they identified important future considerations. Limitations of the work include its small scale and its location in a single geographical area. The outputs of this study will be combined with a scoping review and a review of local population data and will be essential in designing future research and producing recommendations for health-care services. FUNDING: Manchester University NHS Foundation Trust Charity.

How do hospitals address health inequalities experienced by children and young people: a grey literature scoping review protocol.

INTRODUCTION: Health inequalities are unfair, systematic differences in health between people. In the UK, the Health and Social Care Act 2012 recognised health inequalities as a responsibility of the National Health Service (NHS). Health inequalities were foregrounded in the publication of 2019 NHS Long Term Plan and during the SARS-CoV-2/COVID-19 pandemic. Hospitals are well placed to address health inequalities through their role as anchor institutions. While many hospitals have begun to address inequalities, children are often overlooked or assumed to have the same needs as adult populations. This grey literature scoping review aims to identify, collate and present approaches taken by hospitals to address health inequalities in children and young people. METHODS AND ANALYSIS: This scoping review will follow Joanna Briggs Institute guidance. A four-step approach to identifying grey literature will be used. Literature will be examined to identify approaches that aim to address health inequalities. Literature must describe the health inequality they aim to address and be initiated by the hospital. It will exclude literature not available in English and published before 2010. Two reviewers will independently review the results of the searches using the inclusion and exclusion criteria. Data will be extracted using a data extraction tool. Study findings will be presented in tabular form detailing the interventions identified. DISSEMINATION: The review will synthesise information on worldwide hospital approaches to addressing child health inequalities. The findings will be used to inform guidelines for children's hospitals in the UK and will be disseminated through national and international professional bodies, conferences and research papers.

Who cares where the doctors are? The expectation of mobility and its effect on health outcomes.

Doctors are typically portrayed as active agents in their work lives. However, this paper argues that this construction of agency ignores the effects of the healthcare structures that constrain choice, which in turn affects population health outcomes. Medical training pathways, regional boundaries, and rationalisation all have a long-lasting impact on the provision of healthcare. Using a mobilities lens to examine the movement of doctors, this paper examines how the expectation of movement built into training programmes perpetuates unequal access to healthcare. Long waiting times, poor care quality and lack of preventative care all perpetuate health inequalities; as one of the socio-economic determinants, access to healthcare affects health outcomes.

Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care.

BACKGROUND: Context is important in implementation-we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. OBJECTIVE: To explore some of the distinctive features of the primary care environment that may influence implementation. METHODS: We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. RESULTS: Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. CONCLUSIONS: Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context.

'Quality signposting': the role of online information prescription in providing patient information.

BACKGROUND: Information prescriptions (IPs) are part of a Department of Health (DH) initiative to improve patient care. IPs aim to meet health information needs by providing personalised, high quality patient information about conditions and treatment. OBJECTIVES: This paper identifies current online IP provision and evaluates a sample of IP websites against the original DH aims of IP provision; British Medical Association usability criteria; and information seeking vignettes. METHODS: Five UK and one international IP website were randomly selected as a sample. Two checklists designed to appraise the websites were used to review each IP provider. Two patient information seeking vignettes were developed to enable the websites to be assessed from a patient-centred perspective. RESULTS: Information prescriptions currently vary in content, accessibility and quality. National IP websites score more highly than local IP websites, which are often weak on content for specific conditions and poorly designed but strong on signposting to local services. CONCLUSIONS: Guidelines for IP provision need to be improved to ensure higher quality, more easily accessible information is available. A synthesis of expertise included in national and local websites would improve usability for patients. IP websites should conform to standards of web design and accessibility.

The implications of nurse prescribing in stoma care.

It has become apparent that the bewildering array of appliances available in stoma care has led to confusion and misuse. This article looks at the implications and benefits of nurse prescribing for patients with stomas.