IT Evaluation of Foundation Healthcare Group NHS Vanguard programme: IT simultaneously an enabler and a rate limiting factor.

The goal of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use, and implementation of the IT infrastructure based on qualitative interviews focused mainly on the perspectives of the IT staff and the clinicians' perspectives. METHODS: In total, 24 interview transcripts, along with 'Acute Care Collaboration' questionnaire responses, were analyzed using a thematic framework for IT infrastructure, sharing themes across the vascular, pediatric, and cardiovascular strands of the FHG programme. RESULTS: Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project but later appreciated that remote access to most clinical applications including scans between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient traveling time by providing locally based shared care. CONCLUSION: Lesson learnt is that ensuring patient benefit and priorities is a strong driver to implementation and one needs to identify IT rate-limiting steps at an early stage and on a regular basis and then focus on rapid implementation of solutions. In fact, future work may also assess how the IT infrastructure developed by FHG vanguard project might have helped/boosted the 'digital health' practice during the COVID-19 times. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders. After COVID-19, the use of IT is scaled up and now, the challenges in the use of IT are much less compared to the pre-COVID-19 time when this project was evaluated.

Navigating new organisation forms: a qualitative study of primary care networks.

BACKGROUND: NHS England (NHSE) instigated primary care networks (PCNs) as a collaboration of general practices working together at scale to improve population health in the local community. AIM: To capture GP PCN leaders' perceptions of the opportunities and pitfalls of PCNs, as well as points of learning, during their inception and development, in order to guide the future development of PCN form and function. DESIGN & SETTING: A qualitative study in UK primary care. METHOD: Nine PCN GP leaders were interviewed in depth to gather their views and experiences of PCNs. In addition, 31 free-text survey responses pertaining to how participants perceived the purpose of PCNs were collated. RESULTS: Four key themes were identified: defining purpose and managing ambiguity; bureaucracy versus local autonomy; relational working; and facilitative leadership. The need for purpose setting to remain adaptive was seen as crucial in avoiding the constraints of too rigid a structure in order to retain local ownership, while remaining focused around meeting complex population needs and reducing variation. Participants reported navigating their way through striking a balance between the 'top-down' mandate and recognising local need. Of importance to the success of PCNs was the necessity of effective relational working and facilitative leadership. CONCLUSION: While the desire to be proactive and collaborative was emphasised by the PCN leaders, the importance of distributed leadership and time given to building trust and effective working relationships within new organisational forms cannot be underestimated.

"Let us define ourselves": forced migrants' use of multiple identities as a tactic for social navigation.

BACKGROUND: The article examines how and why multiple identities are altered, used and discarded by forced migrants. METHODS: The research is located in the constructivist paradigm. We used thematic analysis to analyse data gathered through interviews with nineteen forced migrants. RESULTS: We found that, though individual migrants can make deliberate choices about which identities to be associated with, they are constrained in the process by external socio-economic factors that lead them to adopt identities that are perceived to be advantageous to navigate the new social system. Moreover, the construction of forced migrants' identity includes significant contextuality, transactionality and situatedness. CONCLUSIONS: Our research contributes to the literature on migrant identity practice concerning the stigma associated with forced migrant status and the extent to which migrants appraise their reception in exile as undignified. Additionally, examining migrant identities allows the researchers to apprehend the diverse facets of identity as far as migrants are concerned. Future research may draw a larger sample to examine other impactful dimensions of identity fluctuation, e.g. gender, education, social media, the extent of prior trauma, etc.

IT Evaluation of Foundation Healthcare Group Vanguard Project.

The aim of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use and implementation of the IT infrastructure; based on qualitative interviews and focused mainly on the perspectives of the IT staff and the clinicians' perspectives. In total 24 interview transcripts, along with 'Acute Care Collaboration' questionnaire responses, were analysed using a thematic framework for IT infrastructure, sharing themes across the vascular, paediatric and cardiovascular strands of the FHG programme. Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project, but later appreciated that remote access to most clinical applications between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient travelling time by providing locally based shared care. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders.

Attention-deficit/hyperactivity disorder: parent/carer perceptions of barriers to healthcare access.

BACKGROUND: Children and young people (CYP) with attention-deficit/hyperactivity disorder (ADHD) face delays in diagnosis and barriers to accessing appropriate interventions. Evidence is limited on how these barriers are perceived by their parents and carers. METHODS: Focus group in South London with parents/carers of CYP with ADHD. Data were thematically analysed using an inductive/deductive hybrid approach. RESULTS: Participants (n=8) described the challenge of accessing services within a disjointed, multiagency system for their CYP's ADHD and broader health needs. They described feeling judged and overlooked by healthcare professionals, which could negatively impact the health, relationships and educational progress of their children. Pragmatic solutions were proposed, including providing parents with information on navigating services at an early stage of ADHD symptom recognition. CONCLUSIONS: Parents/carers sought improved continuity of care within and between services. They are a key group for consultation on the development of interventions to improve access for CYP with ADHD.

Community assets and multimorbidity: A qualitative scoping study.

Little is known of how community assets can play a role in multimorbidity care provision. Using a rapid ethnographic approach, the study explored perceptions of the role of community assets in how multimorbidity is managed within Southwark and Lambeth in Southeast London, England. The scoping work comprised of four micro-studies covering (1) Rapid review of the literature (2) Documentary analysis of publicly available local policy documents (3) Thematic analysis of community stories and (4) Semi-structured stakeholder interviews. The data were analysed using framework thematic analysis. Themes are presented for each of the microstudies. The literature review analysis highlights the role of attitudes and understandings in the management of multiple long-term conditions and the need to move beyond silos in their management. Documentary analysis identifies a resource poor climate, whilst recognising the role of community assets and solution-focussed interventions in the management of multimorbidity. Community patient stories underline the lack of joined up care, and psychosocial issues such as the loss of control and reducing isolation. The stakeholder interview analysis reveals again a sense of disjointed care, the need for holism in the understanding and treatment of multimorbidity, whilst recognising the important role of community-based approaches, beyond the biomedical model. Recommendations stemming from the study's findings are proposed. Upholding access to and resourcing community assets have key practical importance.

Exploring the relationship between intimate partner violence and contraception use by Tanzanian women.

Intimate partner violence (IPV) can be described as a global epidemic which has long term effects on numerous aspects of life. The effect of IPV on contraception use is also wide-ranging and culturally bound. Among the continents, Africa has the highest IPV prevalence. The relationship between IPV on contraception use by Tanzanian women is explored in this study as an illustrative case. This is a descriptive cross-sectional design study, for which we utilized the Tanzania Demographic and Health Survey Data 2015-2016. Data from the responses of 13,266 ever-partnered women were used in this study. The mean age of the respondents was 28.69 years, median 27. 63% of respondents used contraceptives. Women with more than three pregnancies were more likely to use contraceptives (OR: 1.56, 95% CI, p < .001). Education levels also correlated with contraceptive use. Notably, contraceptive use was also significantly lower among the Tanzanian women who were exposed to IPV, suggesting a need for appropriately tailored social interventions and support. The need for interventions relating to IPV to take into account the multifactorial nature of a woman's uptake of contraceptive methods is underlined.

Lean implementation within healthcare: imaging as fertile ground.

PURPOSE: The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective. DESIGN/METHODOLOGY/APPROACH: An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme. FINDINGS: Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean. PRACTICAL IMPLICATIONS: When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean. ORIGINALITY/VALUE: This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.

Healthcare professionals' perspectives on lung cancer screening in the UK: a qualitative study.

BACKGROUND: Lung cancer screening with low-dose computed tomography (LDCT) has been shown to decrease mortality. Low lung cancer survival rates in the UK, driven primarily by late-stage presentation, provide the impetus for implementing screening. Nascent guidance on screening in the UK recommends primary care case-finding. However, the potential impact and acceptability on primary care, and the opportunistic utilisation of other case-finding routes, such as pharmacies, smoking cessation services, and respiratory clinics, have not been fully explored. AIM: To explore healthcare professionals' views and perspectives about lung cancer screening and their preparedness and willingness to be involved in its implementation. DESIGN & SETTING: A qualitative study was carried out with semi-structured interviews conducted with GPs, pharmacists, staff from smoking cessation services within Southwark and Lambeth in London, and staff from respiratory clinics in Guys' and St Thomas' NHS Foundation Trust in London between April 2018 and December 2018. METHOD: Sixteen participants were interviewed and the interview transcripts were analysed thematically. RESULTS: Participants described lung cancer screening as an important diagnostic tool for capturing lung cancer at an earlier stage and in increasing survivorship. However, the majority expressed a lack of awareness and understanding, uncertainty and concerns about the validity of screening, and the potential impact on their patients and workload. CONCLUSION: Study participants had mixed opinions about lung cancer screening and expressed their concerns about its implementation. Addressing these concerns by providing resources and effective and detailed guidelines for their use may lead to greater engagement and willingness to be involved in lung cancer screening.

Healthcare professionals' perspectives on lung cancer screening in the UK: a qualitative study.

BACKGROUND: Lung cancer screening with low-dose CT has been shown to decrease mortality. Low lung cancer survival rates in the UK, driven primarily by late-stage presentation, provide the impetus for implementing screening. Nascent guidance on screening in the UK recommends primary care case-finding. However, the potential impact and acceptability on primary care, and the opportunistic utilisation of other case-finding routes such as pharmacies, smoking cessation services and respiratory clinics, have not been fully explored. AIM: To explore healthcare professionals' views and perspectives about lung cancer screening and their preparedness and willingness to be involved in its implementation. METHOD: A qualitative study was carried out with semi-structured interviews conducted with GPs, pharmacists and staff from smoking cessation services within Southwark and Lambeth and from respiratory clinics in Guy's and St. Thomas' NHS Trust in London in 2018. Sixteen participants were interviewed, and the interview transcripts were analysed thematically. RESULTS: Participants described lung cancer screening as an important diagnostic tool for capturing lung cancer at an earlier stage and in increasing survivorship. However, the majority expressed a lack of awareness and understanding, uncertainty and concerns about the validity of screening, its misuse and the potential impact on their patients and workload. CONCLUSION: Study participants had mixed opinions about lung cancer screening and expressed their concerns about its implementation. Addressing these concerns by providing resources and effective and detailed guidelines for their use may lead to greater engagement and willingness to be involved in lung cancer screening.

PSYCHLOPS in Polish primary care: how do clients conceptualise their problems on a patient-generated outcome measure?

BACKGROUND: PSYCHLOPS, a patient-generated mental health outcome questionnaire, invites clients to describe the problem that troubles them most. PSYCHLOPS was utilised in Polish primary care in the context of a brief CBT-based intervention for mild to moderate mental health problems. AIM: To explore how patients conceptualise their problems and the consequences of these problems with the aid of PSYCHLOPS. METHOD: 243 patients were recruited from a primary care setting; 241 completed PSYCHLOPS. Free-text data were obtained from the Problem and Function domains of PSYCHLOPS, blind translated into English and independently analysed using a pre-existing thematic framework. A total of 780 free-text responses were analysed. RESULTS: The most commonly reported responses to the pre-therapy Problem domain category were "somatic" (denoting responses relating to physical health); the most common responses to the Function domain category were "competence/performance" (denoting responses relating to the respondents' perceived ability to achieve, cope, function). Compared with pre-therapy Problem 1 domain categories, during-therapy responses revealed a higher proportion of the "interpersonal" category (denoting responses relating to social relationships) and a lower proportion of the "somatic" category. CONCLUSIONS: Despite the brevity of clients' responses, PSYCHLOPS allowed an insight into patients' most troubling problems and their consequences. Possible reasons underlying the transition from a somatic to an interpersonal problem reporting during the course of talking therapy are discussed.

Ethnic differences in psychosis-Lay epidemiology explanations.

BACKGROUND: Much research attention has been given to the high rates of psychosis diagnosed in the Black community. However, little has been heard about possible reasons for this from Black African and Caribbean mental health service users themselves. AIMS: To determine how Black African and Caribbean service users perceive and explain these apparent differences. METHODS: We conducted four focus groups between 2014 and 2015 with 35 participants from the Black African and Black Caribbean community in Lambeth and Southwark, South East London, diagnosed with a psychotic illness. Recruitment was through a local voluntary sector organization and other community contacts. RESULTS: Each group described an elevated risk of psychosis in their community and explanations followed the following themes, with increased rates due to: (a) an accumulation of stressors due to disadvantaged ethnic minority status, (b) further disadvantage due to inequitable experiences of mental health services, (c) an absence of community support and (d) a double stigma: as a result of external discrimination, due to ethnicity, and internal stigma about mental illness from within the Black community itself. CONCLUSIONS: Black mental health service users attributed an elevated risk of psychosis in their community to an accumulation of stressors directly related to ethnic minority status.

Individualised or Standardised Outcome Measures: A Co-habitation?

Mental health outcome measurement is conflicted between two different schools of thought which underlie the division between standardised (nomothetic) and individualised or patient-generated (idiographic) measures. The underpinning philosophies of both approaches have very different starting points in terms of how we understand the world. And yet the strengths of both may contribute something useful for patients and mental health services. We suggest a convergence of approaches with new thinking on options for co-habitation.

The development and testing of PSYCHLOPS Kids: a new child-centred outcome measure.

BACKGROUND: There are currently no client generated measures able to capture a child's perspective of the value of generic therapeutic mental health interventions. We have developed a new measure called 'PSYCHLOPS Kids'. It measures areas of individual importance to the respondent and contains both quantitative and qualitative elements. We aimed to pilot this new outcome measure and determine its psychometric properties. METHODS: PSYCHLOPS Kids was adapted from the adult PSYCHLOPS questionnaire, a validated and reliable client-generated measure used in primary care mental health. Development of PSYCHLOPS Kids involved an expert group, pilot testing with dramatherapists followed by psychometric testing with children receiving dramatherapy aged 7-13 years. RESULTS: One hundred and thirty-two children completed pre- and postintervention questionnaires. Mean initial PSYCHLOPS Kids scores (scale of 0-12) were 4.98 (SD: 3.42); mean post-therapy, 3.24 (SD: 3.03); mean effect size of change, 0.51. The Strengths and Difficulties Questionnaire (SDQ) was used as a comparator instrument completed by parent/carers of 32 children; mean effect size, 0.39. The effect size difference between both instruments was not significant (t = 1.05; p = .30); the PSYCHLOPS Kids Problem domain effect size (mean, 0.68) was significantly greater than for the SDQ (t = 2.06; p = .04). Concurrent validity was demonstrated by strong predictive power of change scores for the self-assessment of change item in PSYCHLOPS Kids; therapist-assessment of change was not a significant predictor of change scores. PSYCHLOPS Kids and SDQ change scores were not significantly correlated. CONCLUSIONS: PSYCHLOPS Kids is the first client generated mental health outcome measure focussing on problems for generic use in children. It has demonstrated moderate responsiveness to change and satisfactory testing for measured aspects of validity and reliability. PSYCHLOPS Kids now requires further validity, reliability and qualitative testing.

Using a patient-generated mental-health measure 'PSYCHLOPS' to explore problems in patients with coronary heart disease.

BACKGROUND: Patients with coronary heart disease (CHD) who are depressed have an increased risk of further cardiac events and higher mortality. AIM: To use a patient generated instrument (PSYCHLOPS) to define categories of concerns in patients with CHD. To define the psychometric characteristics of patients in each category. DESIGN AND SETTING: Cross-sectional study set in general practices in south London. METHOD: Of 3325 patients on the CHD registers in 15 general practices, 655 completed six baseline psychometric and functional instruments: PSYCHLOPS, HADS-Depression, HADS-Anxiety, Clinical Interview Schedule-Revised, SF12-Mental and SF12-Physical. Content analysis was used to categorise patients based on their main problem, as elicited by PSYCHLOPS. Mean psychometric scores were adjusted for confounding by age, sex, deprivation and ethnicity and calculated for each response category. RESULTS: Response categories were: physical problems, both non-cardiac (23.2%) and cardiac (6.0%); social problems: relationship/family (18.2%), money (7.5%), work (3.1%); functional (9.8%); psychological (6.9%); miscellaneous (7.3%); 'no problem' (18.2%). The highest psychological distress scores were found in 'physical, cardiac' and 'psychological' categories. The 'no problem' category had significantly lower psychological distress and higher functional capacity than other categories. CONCLUSIONS: PSYCHLOPS enabled the identification of subtypes of CHD patients, based on a classification of self-reported problems. A high proportion of CHD patients report social problems. Psychological distress was highest in those reporting cardiac or psychological symptoms. Services should be aligned to the reported needs of patients.

Identifying poorly performing general practices in England: a longitudinal study using data from the quality and outcomes framework.

OBJECTIVE: to determine the characteristics of general practices which perform poorly in terms of Quality and Outcome (QOF) performance indicators in England's NHS. METHOD: retrospective, four year longitudinal study, 2005 to 2008. Data were obtained from 8515 practices (99% of practices in England) in year 1, 8264 (98%) in year 2, 8192 (98%) in year 3 and 8256 (99%) in year 4. OUTCOME MEASURES: QOF performance scores; social deprivation (IMD-2007) and ethnicity from the 2001 national census; general practice characteristics. RESULTS: we identified a cohort of 212 (2.7%) practices which remained in the lowest decile for total QOF scores in the four years following the introduction of the QOF. A total of 705,386 patients were registered at these practices in year 4. These practices were more likely to be singlehanded (odds ratio [OR], 13.8), non-training practices (OR, 3.9) and located in deprived areas (OR, 2.6; most vs least deprived quintiles). General practitioners (GPs) in these practices were more often aged ≥ 65 years or more (OR, 7.3; mean GP age ≥ 65 years vs <45 years), male (OR 2.0), UK qualified (OR 2.0) with small list sizes (OR 3.2; list size <1000 vs 1500-2000 patients). We identified individual QOF indicators which were poorly achieved. The reported prevalence of most chronic diseases was lower in the poorly performing cohort. CONCLUSIONS: a small minority of practices have remained poor performers in terms of measurable performance indicators over a four-year period. The strongest predictors of poor QOF performance were singlehanded and small practices, and practices staffed by elderly GPs.

How does an accreditation programme drive improvement on acute inpatient mental health wards? An exploration of members' views.

BACKGROUND: Concerns have been raised about inpatient mental health care. An accreditation model can improve compliance with standards associated with improved quality of health care. AIMS: To explore the effects of a standards-based, peer review, accreditation model on standards of care in acute inpatient wards and explore how staff achieved change. METHOD: Quality of care was assessed by independent peer review against evidence-based standards in an accreditation process. Staff from the 11 wards receiving subsequent accreditation were interviewed to find out what processes had enabled accreditation. RESULTS: Sixteen wards enrolled: four achieved immediate and 11 subsequent accreditation. The most common reasons for initial failure of accreditation were lack of psychological therapies or 1:1 time for patients, and presence of ligature points. Ward staff perceived the accreditation process improved communication, gave power to negotiate for resources, clear guidance how to practice, rewarded good practice and led to additional unrelated improvements in care. CONCLUSIONS: Acute wards need to attend to basic safety and provide talking treatments (both formal psychotherapy and basic time spent with patients). An accreditation, peer-reviewed, standards-based process can enable staff to feel confident about improvements in the quality of care.