Determinants of Referral Outcomes for Victim-Survivors Accessing Specialist Sexual Violence and Abuse Support Services.

Sexual violence and abuse (SVA) is highly prevalent globally, has devastating and wide-ranging effects on victim-survivors, and demands the provision of accessible specialist support services. In the UK, Rape Crisis England & Wales (RCEW), a voluntary third sector organization, is the main provider of specialist SVA services. Understanding the profile of victim-survivors who are referred to RCEW and their referral outcomes is important for the effective allocation of services. Using administrative data collected by three Rape Crisis Centres in England between April 2016 and March 2020, this study used multinomial regression analysis to examine the determinants of victim-survivors' referral outcomes, controlling for a wide range of potentially confounding variables. The findings demonstrate that support needs, more so than the type of abuse experienced, predicted whether victim-survivors were engaged with services. Particularly, the presence of mental health, substance misuse and social, emotional, and behavioral needs were important for referral outcomes. The referral source also influenced referral outcomes, and there were some differences according to demographic characteristics and socioeconomic factors. The research was co-produced with stakeholders from RCEW, who informed interpretation of these findings. That victim-survivors' engagement with services was determined by their support needs, over and above demographic characteristics or the type of abuse they had experienced, demonstrates the needs-led approach to service provision adopted by RCEW, whereby resources are allocated effectively to those who need them most.

Rapid evaluation of the Special Measures for Quality and challenged provider regimes: a mixed-methods study.

Background: Health-care organisations in England that are rated as inadequate for leadership and one other domain enter the Special Measures for Quality regime to receive support and oversight. A 'watch list' of challenged providers that are at risk of entering Special Measures for Quality also receive support. Knowledge is limited about whether or not the support interventions drive improvements in quality, the costs of the support interventions and whether or not the support interventions strike the right balance between support and scrutiny. Objective: To analyse the responses of trusts to the implementation of (1) interventions for Special Measures for Quality trusts and (2) interventions for challenged provider trusts to determine their impact on these organisations' capacity to achieve and sustain quality improvements. Design: This was rapid research comprising five interrelated workstreams: (1) a literature review using systematic methods; (2) an analysis of policy documents and interviews at the national level; (3) eight multisite, mixed-methods trust case studies; (4) an analysis of national performance and workforce indicators; and (5) an economic analysis. Results: The Special Measures for Quality/challenged provider regimes were intended to be 'support' programmes. Special Measures for Quality/challenged provider regimes had an emotional impact on staff. Perceptions of NHS Improvement interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input being vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of Special Measures for Quality trusts exited the regime in 24 months. Entry into Special Measures for Quality/challenged provider regimes resulted in changes in quality indicators (such the number of patients waiting in emergency departments for more than 4 hours, mortality and the number of delayed transfers of care) that were more positive than national trends. The trends in staff sickness and absence improved after trusts left Special Measures for Quality/challenged provider regimes. There was some evidence that staff survey results improved. No association was found between Special Measures for Quality/challenged provider regimes and referral to treatment times or cancer treatment waiting times. NHS Improvement spending in case study trusts was mostly directed at interventions addressing 'training on cultural change' (33.6%), 'workforce quality and safety' (21.7%) and 'governance and assurance' (18.4%). The impact of Special Measures for Quality on financial stability was equivocal; most trusts exiting Special Measures for Quality experienced the same financial stability before and after exiting. Limitations: The rapid research design and 1-year time frame precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measurement of workforce effects was limited by data availability. Conclusions: Empirical evidence of positive impacts of Special Measures for Quality/challenged provider regimes were identified; however, perceptions were mixed. Key lessons were that (1) time is needed to implement and embed changes; (2) ways to mitigate emotional costs and stigma are needed; (3) support strategies should be more trust specific; (4) poor organisational performance needs to be addressed within local systems; (5) senior leadership teams with stability, strong clinical input and previous Special Measures for Quality experience helped to enact change; (6) organisation-wide quality improvement strategies and capabilities are needed; (7) staff engagement and an open-listening culture promote continuous learning and a quality improvement 'mindset', which is critical for sustainable improvement; and (8) consideration of the level of sustainable funds required to improve patients' outcomes is needed. Future work: Future work could include evaluating recent changes to the regimes, the role of local systems and longitudinal approaches. Study registration: The review protocol is registered with PROSPERO (CRD42019131024). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 19. See the NIHR Journals Library website for further project information.

When health-care trusts in England have serious failings in the quality of care that they provide, they can be placed in 'Special Measures for Quality' and receive additional support from the NHS. There is also a list of 'challenged providers' at risk of entering Special Measures for Quality that receive support. In January 2019, of the 234 trusts in England, one-quarter had at some point been a challenged provider and/or entered Special Measures for Quality. We studied how trusts responded to entering the Special Measures for Quality or challenged provider regimes. We wanted to understand if the support that the trusts receive can help the trust to improve the quality of care provided to patients. We did this by reviewing the relevant literature; speaking to a range of staff in eight trusts and nearby health organisations; analysing costs; and observing meetings in four of these trusts. We also compared national performance information between Special Measures for Quality/challenged provider trusts and non-Special Measures for Quality/challenged provider trusts. We found that when a trust enters the Special Measures for Quality regime there is often an emotional impact on staff, who may experience low morale. Some staff thought that their trust received the right type of support, but others saw Special Measures for Quality as heavy-handed scrutiny or punishment. With hindsight, Special Measures for Quality was sometimes viewed more positively, as a pathway to make changes that were needed. Looking at all trusts in England, we found that when trusts entered Special Measures for Quality or became challenged providers they started to get better at seeing emergency department patients within 4 hours and reduced avoidable deaths. We also found that some parts of the staff survey results improved. We found that staff need time and space to make changes. Looking after staff and having a leadership and culture that supports continuous learning are important for making improvements. Regional health-care systems and local organisations have an important role to play in supporting trusts to make improvements.

Evaluating the impact of post-trial implementation of RHIVA nurse-led HIV screening on HIV testing, diagnosis and earlier diagnosis in general practice in London, UK.

BACKGROUND: UK and European guidelines recommend HIV testing in general practice. We report on the implementation of the Rapid HIV Assessment trial (RHIVA2) promoting HIV screening in general practice into routine care. METHODS: Interrupted time-series, difference-in-difference analysis and Pearson-correlation on three cohorts comprising 42 general practices in City & Hackney (London, UK); covering three periods: pre-trial (2009-2010), trial (2010-2012) and implementation (2012-2014). Cohorts comprised practices receiving: "trial intervention" only (n = 19), "implementation intervention" only (n = 13); and neither ("comparator") (n = 10). Primary outcomes were HIV testing and diagnosis rates per 1000 people and CD4 at diagnosis. FINDINGS: Overall, 55,443 people were tested (including 38,326 among these cohorts), and 101 people were newly diagnosed HIV positive (including 65 among these cohorts) including 74 (73%) heterosexuals and 69 (68%) people of black African/Caribbean background; with mean CD4 count at diagnosis 357 (SD=237). Among implementation intervention practices, testing rate increased by 85% (from 1·798 (95%CI=(1·657,1·938) at baseline to 3·081 (95%CI=(2·865,3·306); p = 0·0000), diagnosis rate increased by 34% (from 0·0026 (95%CI=(0·0004,0·0037)) to 0·0035 (95%CI=(0·0007,0·0062); p = 0·736), and mean CD4 count at diagnosis increased by 55% (from 273 (SD=372) to 425 (SD=274) cells per µL; p = 0·433). Implementation intervention and trial intervention practices achieved similar testing rates (3·764 vs. 3·081; 6% difference; 95% CI=(-5%,18%); p = 0·358), diagnosis rates (0·0035 vs. 0·0081; -13% difference; 95%CI=(-77%,244%; p = 0·837), and mean CD4 count (425 (SD=274) vs. 351 (SD=257); 69% increase; 95% CI=(-61%,249%); p = 0·359). HIV testing was positively correlated with diagnosis (r = 0·114 (95% CI=[0·074,0·163])), and diagnosis with CD4 count at diagnosis (r = 0·011 (95% CI=[-0·177,0·218])). INTERPRETATION: Implementation of the RHIVA programme promoting nurse-led HIV screening into routine practice in inner-city practices with high HIV prevalence increased HIV testing, and may be associated with increased and earlier diagnosis. HIV screening in primary care should be considered a key strategy to reduce undiagnosed infection particularly among high risk persons not attending sexual health services. FUNDING: National Institute for Health Research ARC North Thames, and Barts and The London School of Medicine and Dentistry.

Mixed methods evaluation of a hospital group model using an embedded research approach: study protocol.

INTRODUCTION: Hospital group models represent an organisational form that aims to bring together multiple provider organisations with a central headquarters and unified leadership responsible for locally managed operating units, standardised systems and a value-set shared across the group. These models seek to improve outcomes by reducing unwarranted variations in care provision and reducing costs through economies of scale. There is limited evidence on the impact and processes of implementing these models, so this study aims to evaluate one case study of a hospital group model. METHODS AND ANALYSIS: We will conduct a formative, mixed-methods evaluation using an embedded research approach to analyse the implementation of the model and its impact on outcomes and costs. We will carry out a multisited ethnography to analyse the programme theory for model design and implementation, the barriers and facilitators in the implementation; and wider contextual issues that influence implementation using semi-structured interviews (n=80), non-participant observations (n=80 hours), 'shadowing' (n=20 hours) and documentary analysis. We will also carry out an economic evaluation composed of a cost-consequence analysis and a return on investment analysis to evaluate the costs of creating and running the model and balance these against the potential cost-savings. ETHICS AND DISSEMINATION: The study protocol was reviewed by the local R&D Office and University College London Ethics Committee and classified as a service evaluation, not requiring approval by a research ethics committee. We will follow guidelines for informed consent, confidentiality and information governance, and address issues of critical distance prevalent in embedded research. Findings will be shared at regular time points to inform the implementation of the model. The evaluation will also generate: an evaluation framework to evaluate future changes; recommendations for meaningful baseline data and measuring improvement; identification of implementation costs and potential cost-savings; and lessons for the National Health Service on implementing these models.

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

BACKGROUND: Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England. METHODS: We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents. RESULTS: Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of 'slack'-expressed by participants as the 'space to think' and 'someone to do the doing'-and the presence of a functioning board. CONCLUSIONS: Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.