Expanding arts therapies provision: a pilot project in Older Adult Mental Health Services, Aneurin Bevan University Health Board.

OBJECTIVES: The aim of the report is to summarise the progress made during a six-month pilot project expanding arts therapies provision from an inpatient service to community services, in a National Health Service health board's Older Adult Mental Health Services, in response to the need for direct therapy with older adults who have severe cognitive impairment and communication difficulties arising from dementia and/or complex mental health difficulties. STUDY DESIGN: This is a case report on a pilot project. METHODS: The level of need for the service was explored, and indicators of effectiveness were gathered using evaluation forms-observer feedback forms and ARM-5 (Agnew Relationship Measure - 5) - to indicate the therapeutic alliance, team review and feedback from colleagues. RESULTS: To gather indications about the level of need, we recorded the following: number of referrals (n = 125) and waiting list numbers at the end of the project (n = 34). CONCLUSIONS: This pilot project indicates that there is need for psychological interventions in older adult community mental health services that arts therapies provision can help address. The number of referrals is one indicator of the level of need, and positive feedback from clients, families and colleagues, is an indicator that the team delivered effectively. The areas of client need addressed in sessions as documented in observer feedback forms indicate that for these clients, arts therapies was a valuable resource in addressing challenges arising from mental health difficulties and/or dementia.

Environmentally sustainable emergency medicine.

Emergency clinicians worldwide are demonstrating increasing concern about the effect of climate change on the health of the populations they serve. The movement for sustainable healthcare is being driven by the need to address the climate emergency. Globally, healthcare contributes significantly to carbon emissions, and the healthcare sector has an important role to play in contributing to decarbonisation of the global economy. In this article, we consider the implications for emergency medicine of climate change, and suggest ways to improve environmental sustainability within emergency departments. We identify examples of sustainable clinical practice, as well as outlining research proposals to address the knowledge gap that currently exists in the area of provision of environmentally sustainable emergency care.

Expertise, experience, and excellence. Twenty years of patient involvement in health technology assessment at NICE: an evolving story.

From its inception in 1999, the National Institute for Health and Care Excellence (NICE) committed to including the expertise, experiences, and perspectives of lay people, patients and carers, and patient organizations in its health technology assessments (HTAs). This is our story of patient involvement in HTA: from early methods designed for use when assessing medicines, widening to address the different requirements of HTAs for interventional procedures, medical technologies, and diagnostic technologies. We also chart the evolution and development of all our patient involvement methods over the past 20 years through regular evaluation and by responding to external challenge. However, we know that processes and methods alone are not enough. Through case studies we demonstrate the value of patient involvement in HTA and highlight the unique perspectives and experiences that patients bring to HTA committees. Finally, we discuss the underpinning principles and commitments that have made NICE a world leader in delivering meaningful and legitimate patient involvement.

A systematic review of the factors - barriers and enablers - affecting the implementation of clinical commissioning policy to reduce health inequalities in the National Health Service (NHS), UK.

OBJECTIVE: The aim of the present study is two-fold. First, it attempts to identify the barriers and enablers of implementing clinical commissioning policy. Second, it synthesises how these barriers and enablers affect the success of National Health Service (NHS) efforts to reduce health inequalities in the UK. METHODS: A systematic review was conducted. We searched large biomedical bibliographic databases, namely MEDLINE, EMBASE, CINAHL, Allied & Complementary Medicine, DH-DATA, Global Health and CINAHL for primary studies, conducted in the UK, that assessed the factors - barriers and enablers related to health inequalities, published from 2010 onwards and in English, and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We used Joanna Briggs Institute (JBI) Critical Appraisal and Mixed Methods Appraisal tools to assess the methodological qualities, and synthesised by performing thematic analysis. Two reviewers independently screened the articles and extracted data. RESULTS: We included six primary studies (including a total of 1155 participants) in the final review. The studies reported two broad categories, under four separate themes: (1) the agenda of health inequalities has not been given priority; (2) there was very little evidence for reducing health inequalities through the clinical commissioning (CC) process; (3) CC was positively associated with the restructuring of NHS; and (4) CC brings better collaboration and engagement, which led to some improvements in health services access, utilisation and delivery at the local level. CONCLUSION: This study provides useful factors - barriers and enablers - to implement and deliver clinical commissioning policy in improving health and well-being. These factors could be assessed in future to develop objective measures and interventions to establish the link between commissioning and health inequalities.

Understanding parent preferences for NHS paediatric allergy services.

OBJECTIVES: To understand parent preferences for NHS paediatric allergy services. DESIGN: A stated preference study (discrete choice experiment). SETTING: West Midlands, UK. PARTICIPANTS: A sample of parents of children aged 16 years or younger recruited from the general population through a third party company approved by the University of Birmingham. INTERVENTION: An online questionnaire with 18 choice questions describing two hypothetical paediatric allergy specialist clinics described in terms of the clinician, information provision, additional facilities, waiting times and out of pocket expenses. Main outcome measures Preference and willingness to pay estimates for each of the specified attributes. RESULTS: Parents strongly preferred that their children be reviewed by consultants or specialist nurses formally trained in allergy compared with consultants with no formal allergy training [Willingness to pay (WTP) estimates for nurse specialist £150.9 (138.8-163.2), trained allergy consultants £218.7 (205.7-231.9), compared with consultants without formal training]. They were willing to wait longer to see trained practitioners. Parents also expressed a strong preference for improving online information regarding allergies [WTP for written information £18.4 (6.1-30.6) and £72.6 for improved online information (59.9-85.3), compared with verbal information]. Specialist clinics with additional dietician and eczema support were also preferred [WTP £29.9 (19.8-40.1), compared with no additional support]. CONCLUSIONS: Parents showed strong preference for formally trained practitioners in specialist allergy clinics. Access to improved online allergy information and additional facilities within allergy clinics were also preferred. These findings have implications for future commissioning of paediatric allergy services in the UK.

Economic evaluation of a dedicated cardiac resynchronisation therapy preassessment clinic.

INTRODUCTION: Patient evaluation before cardiac resynchronisation therapy (CRT) remains heterogeneous across centres and it is suspected a proportion of patients with unfavourable characteristics proceed to implantation. We developed a unique CRT preassessment clinic (CRT PAC) to act as a final review for patients already considered for CRT. We hypothesised that this clinic would identify some patients unsuitable for CRT through updated investigations and review. The purpose of this analysis was to determine whether the CRT PAC led to savings for the National Health Service (NHS). METHODS: A decision tree model was made to evaluate two clinical pathways; (1) standard of care where all patients initially seen in an outpatient cardiology clinic proceeded directly to CRT and (2) management of patients in CRT PAC. RESULTS: 244 patients were reviewed in the CRT PAC; 184 patients were eligible to proceed directly for implantation and 48 patients did not meet consensus guidelines for CRT so were not implanted. Following CRT, 82.4% of patients had improvement in their clinical composite score and 57.7% had reduction in left ventricular end-systolic volume ≥15%. Using the decision tree model, by reviewing patients in the CRT PAC, the total savings for the NHS was £966 880. Taking into consideration the additional cost of the clinic and by applying this model structure throughout the NHS, the potential savings could be as much as £39 million. CONCLUSIONS: CRT PAC appropriately selects patients and leads to substantial savings for the NHS. Adopting this clinic across the NHS has the potential to save £39 million.

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.

The landscape of psoriasis provision in the UK.

Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.

Implementing continuity of midwife carer - just a friendly face? A realist evaluation.

BACKGROUND: Good quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan. METHODS: Participatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed context-mechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context. RESULTS: Trusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women's care journey, which in turn changed their perspective of how they provided care and of women's care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed. CONCLUSION: Leadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women's care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change.

Shift length and working practices in UK hospital settings: An online survey of heads of midwifery.

OBJECTIVE: There is currently a lack of data that records how midwives are expected to work in hospital settings. The aim of this study was to determine the prevalence of 12-h shifts and current working practices of hospital-based midwives. DESIGN: An online survey conducted between December 2018 and March 2019. Descriptive data are summarised regionally and nationally. SETTING: NHS Trusts providing maternity services in hospital settings in the UK PARTICIPANTS: The link to the survey was emailed to Heads of Midwifery in 155 NHS Trusts FINDINGS: Responses were received from 94 of the 155 NHS Trusts (60.65%). Some responses included data for more than one hospital, so results are summarised for 97 hospitals. 12-h shifts were the most prevalent shift length, with only 4.1% of hospitals still routinely operating shorter shifts. 55% of hospitals limit the maximum number of consecutive shifts to three, but this can be influenced by different factors. More than half of midwives (55.67%) will be rostered to start a day shift within 24-h of finishing a night shift. 70% of hospitals do not currently record the number of midwives working beyond their contracted hours but 68% report formal methods of recording missed rest breaks. Regional differences were seen in the use of other personnel to support the midwifery workforce. CONCLUSIONS: Shift schedules and the lack of formal methods to record the number of midwives working beyond their contracted hours may be a cause for concern due to the potential impact on recovery times. Further research is required to explore how working practices may affect midwives and their ability to provide care for women and their babies.

Complex programme evaluation of a 'new care model' vanguard: a shared commitment to quality improvement in an integrated health and care context.

NHS vanguards, under-pressure to perform, required better contracting and data management arrangements with evaluation teams, to ensure that integrated service outcomes could be reported effectively. This communication reflects the experience of evaluating an NHS vanguard and suggests how academic teams can improve capacity for complex programme evaluation of rapid improvements in integrated services. This should be based on a shared commitment to data collection and management. Also, robust knowledge exchange processes can enable systems change and sustainability. The identifying features of the particular site have been withheld.

Challenges in turning a great idea into great health policy: the case of integrated care.

BACKGROUND: In the organization of health care and health care systems, there is an increasing trend towards integrated care. Policy-makers from different countries are creating policies intended to promote cooperation and collaboration between health care providers, while facilitating the integration of different health care services. Hopes are high, as such collaboration and integration of care are believed to save resources and improve quality. However, policy-makers are likely to encounter various challenges and limitations when attempting to turn these great ideas into effective policies. In this paper, we look into these challenges. MAIN BODY: We argue that the organization of health care and integrated care is of public concern, and should thus be of crucial interest to policy-makers. We highlight three challenges or limitations likely to be encountered by policy-makers in integrated care. These are: (1) conceptual challenges; (2) empirical/methodological challenges; and (3) resource challenges. We will argue that it is still unclear what integrated care means and how we should measure it. 'Integrated care' is a single label that can refer to a great number of different processes. It can describe the integration of care for individual patients, the integration of services aimed at particular patient groups or particular conditions, or it can refer to institution-wide collaborations between different health care providers. We subsequently argue that health reform inevitably possesses a political context that should be taken into account. We also show how evidence supporting integrated care may not guarantee success in every context. Finally, we will discuss how promoting collaboration and integration might actually demand more resources. In the final section, we look at three different paradigmatic examples of integrated care policy: Norway, the UK's NHS, and Belgium. CONCLUSIONS: There seems widespread agreement that collaboration and integration are the way forward for health care and health care systems. Nevertheless, we argue that policy-makers should remain careful; they should carefully consider what they hope to achieve, the amount of resources they are willing to invest, and how they will evaluate the success of their policy.