"It was the whole picture" a mixed methods study of successful components in an integrated wellness service in North East England.

BACKGROUND: A growing number of Local Authorities (LAs) have introduced integrated wellness services as part of efforts to deliver cost effective, preventive services that address the social determinants of health. This study examined which elements of an integrated wellness service in the north east of England were effective in improving health and wellbeing (HWB). METHODS: The study used a mixed-methods approach. In-depth semi-structured interviews (IVs) were conducted with integrated wellness service users (n = 25) and focus groups (FGs) with group based service users (n = 14) and non-service users (n = 23) to gather the views of stakeholders. Findings are presented here alongside analysis of routine monitoring data. The different data were compared to examine what each data source revealed about the effectiveness of the service. RESULTS: Findings suggest that integrated wellness services work by addressing the social determinants of health and respond to multiple complex health and social concerns rather than single issues. The paper identifies examples of 'active ingredients' at the heart of the programme, such as sustained relationships, peer support and confidence building, as well as the activities through which changes take place, such as sports and leisure opportunities which in turn encourage social interaction. Wider wellbeing outcomes, including reduced social isolation and increased self-efficacy are also reported. Practical and motivational support helped build community capacity by encouraging community groups to access funding, helped navigate bureaucratic systems, and promoted understanding of marginalised communities. Fully integrated wellness services could support progression opportunities through volunteering and mentoring. CONCLUSIONS: An integrated wellness service that offers a holistic approach was valued by service users and allowed them to address complex issues simultaneously. Few of the reported health gains were captured in routine data. Quantitative and qualitative data each offered a partial view of how effectively services were working.

Embedded research: a promising way to create evidence-informed impact in public health?

Background: Embedded research (ER) is recognized as one way to strengthen the integration of evidence into public health (PH) practice. In this paper, we outline a promising example of the co-production of research evidence between Fuse, the UKCRC Centre for Translational Research in Public Health and a local authority (LA) in north east England. Methods: We critically examine attempts to share and use research findings to influence decision-making in a LA setting, drawing on insights from PH practitioners, managers, commissioners and academic partners involved in this organizational case study. We highlight what can be achieved as a co-located embedded researcher. Results: The benefits and risks of ER are explored, alongside our reflections on the added value of this approach and the institutional prerequisites necessary for it to work. We argue that while this is not a new methodological approach, its application in PH as a way to facilitate evidence use is novel, and raises pragmatic and theoretical questions about the nature of impact and the extent to which it can be engineered. Conclusion: With increased situated understanding of organizational culture and norms and greater awareness of the socio-political realities of PH, ER enables new co-produced solutions to become possible.

'It is not a quick fix' structural and contextual issues that affect implementation of integrated health and well-being services: a qualitative study from North East England.

OBJECTIVE: The objective of this article is to examine the factors affecting the design, commissioning and delivery of integrated health and well-being services (IHWSs), which seek to address multiple health-related behaviours, improve well-being and tackle health inequalities using holistic approaches. STUDY DESIGN: Qualitative studies embedded within iterative process evaluations. METHODS: Semi-structured interviews conducted with 16 key informants as part of two separate evaluations of IHWSs in North East England, supplemented by informal observations of service delivery. Transcripts and fieldnotes were analysed thematically. RESULTS: The study findings identify a challenging organisational context in which to implement innovative service redesign, as a result of budget cuts and changes in NHS and local authority capacity. Pressures to demonstrate outcomes affected the ability to negotiate the practicalities of joint working. Progress is at risk of being undermined by pressures to disinvest before the long-term benefits to population health and well-being are realised. The findings raise important questions about contract management and relationships between commissioners and providers involved in implementing these new ways of working. CONCLUSIONS: These findings provide useful learning in terms of the delivery and commissioning of similar IHWSs, contributing to understanding of the benefits and challenges of this model of working.

Investigating what works to support family carers of people with dementia: a rapid realist review.

Introduction: Advances in longevity and medicine mean that many more people in the UK survive life-threatening diseases but are instead susceptible to life-limiting diseases such as dementia. Within the next 10 years those affected by dementia in the UK is set to rise to over 1 million, making reliance on family care of people with dementia (PWD) essential. A central challenge is how to improve family carer support to offset the demands made by dementia care which can jeopardise carers' own health. This review investigates 'what works to support family carers of PWD'. Methods: Rapid realist review of a comprehensive range of databases. Results: Five key themes emerged: (1) extending social assets, (2) strengthening key psychological resources, (3) maintaining physical health status, (4) safeguarding quality of life and (5) ensuring timely availability of key external resources. It is hypothesized that these five factors combine and interact to provide critical biopsychosocial and service support that bolsters carer 'resilience' and supports the maintenance and sustenance of family care of PWD. Conclusions: 'Resilience-building' is central to 'what works to support family carers of PWD'. The resulting model and Programme Theories respond to the burgeoning need for a coherent approach to carer support.

Using interactive workshops to prompt knowledge exchange: a realist evaluation of a knowledge to action initiative.

INTRODUCTION: Interactive workshops are often the default mechanism for sharing knowledge across professional and sector boundaries; yet we understand little about if, and how, they work. Between 2009 and 2011, the Research to Reality programme in North East England ran eight stand-alone facilitated multi-agency workshops focused on priority public health issues. Local authorities, the health service, and academe collaborated on the programme to share latest evidence and best practice METHODS: A realist evaluation asked the overarching question 'what worked where, for whom, and under what conditions' regarding the knowledge exchange (KE) mechanisms underpinning any changes. Data were collected from fifty-one interviews, six observations, and analysis of programme documentation. RESULTS: 191 delegates attended (local authority 46%, NHS 24%, academia 22%, third sector 6%, other 2%). The programme theory was that awareness raising and critical discussion would facilitate ownership and evidence uptake. KE activity included: research digests, academic and senior practitioner presentations, and facilitated round-table discussions. Joint action planning was used to prompt informed follow-up action. Participants valued the digests, expert input, opportunities for discussion, networking and 'space to think'. However, within a few months, sustainability was lost. There was no evidence of direct changes to practice. Multiple barriers to research utilization emerged. DISCUSSION: The findings suggest that in pressured contexts exacerbated by structural reform providing evidence summaries, input from academic and practice experts, conversational spaces and personal action planning are necessary to create enthusiasm on the day, but are insufficient to prompt practice change in the medium term. The findings question makes assumptions about the instrumental, linear use of knowledge and of change focused on individuals as a driver for organizational change. Delegates' views of 'what would work' are shared. Mechanisms that would enhance interactive formats are discussed.

Diagnosing a learning practice: the validity and reliability of a learning practice inventory.

BACKGROUND: There is an increasing literature on learning organisations as a way of fostering communication, teamwork, collaboration and collective learning, thereby promoting quality improvement and enhancing patient safety. An increasing number of instruments are being developed in an attempt to measure learning organisation characteristics. However, the majority of these tools are created for a business setting, have not been scientifically tested and have not been applied in healthcare. OBJECTIVE: To evaluate elements of the validity and reliability of an instrument (ie, learning practice inventory (LPI)) for diagnosing learning practice characteristics in primary healthcare. METHOD: Content validity was evaluated using a modified nominal group technique and a content validity rating scale. Construct validity and reliability evaluation was undertaken with 10 staff members from 10 general practices in the west of Scotland. Staff completed the inventory twice, 4-6 weeks apart. Applying generalisability theory, a variance component analysis was performed. RESULTS: The main findings present evidence that the inventory has acceptable reliability and content validity. The results also demonstrate that the inventory can reflect the consistent and uniquely different perspectives of particular designations of staff within a practice. It is possible to compare practices' overall learning environments and to identify specific areas of practice strength as well as areas for development. CONCLUSION: This study demonstrates the psychometric properties of a learning practice diagnostic inventory. It highlights the consistently different perspectives that individual staff groups have on the function of their practice, suggesting that the success of quality improvement initiatives may be compromised without the involvement and true engagement of each staff group.

Healthcare-associated infection and the patient experience: a qualitative study using patient interviews.

There is an increasing emphasis on the need for further patient involvement within healthcare to ensure that the voice of the patient is heard. This exploratory study utilised in-depth face-to-face interviews with patients to explore narratives from their experiences around healthcare-associated infection (HCAI). Interviews were undertaken with patients who had been diagnosed with a Staphylococcus aureus bloodstream infection and patients who had been in the same hospital but had not been diagnosed with a bloodstream infection. The lack of both verbal and written communications was a major concern for most patients regardless of their infection status. Some patients also stated that they were not comfortable about asking questions, and only a small number of patients and relatives stated that they would challenge staff about their practice. Although some patients retained confidence in the National Health Service (NHS), the majority had very little or no confidence in the NHS in relation to HCAI and would have serious concerns about this if they were to return to hospital. The results suggest that there are a number of issues that must be addressed in order to enhance the quality of care, safety of patients and the patient experience in relation to infection prevention and control. In addition, policy-makers, managers and all healthcare workers must ensure that patients are involved in the design and evaluation of systems change and information.

MEASURE IT, IMPROVE IT: the Safer Patients Initiative and quality improvement in subcutaneous insulin therapy for hospital in-patients.

AIMS: NHS Tayside, UK, identified risks with subcutaneous insulin therapy for hospital in-patients: overlooked abnormal blood glucose readings; prescription errors and failure to administer insulin. Involvement in the Safer Patients Initiative provided opportunities to use different methods of quality improvement, to create a process that facilitated prevention, detection and mitigation of diabetes management problems for in-patients requiring subcutaneous insulin therapy. The aim was to explain these methods, their use and results obtained. METHODS: A failure modes effect analysis identified present risks in the process of subcutaneous insulin therapy. In response, an evidence-based care cluster was developed and used to design a new insulin prescribing chart. The chart was introduced and modified using small tests of change [plan-do-study-act cycles (PDSAs)]. Compliance data on completing the actions required by the chart were gathered (small-scale audits), and results displayed (process run charts) to those delivering care. RESULTS: Practice improved over the 9 months: patient identification: 97-100%; identification of insulin device 11-100%; insulin administration 75-95%; hypoglycaemic control 85-94%. The chart prompted compliance with the evidence base, identified trouble-shooting actions to mitigate arising problems and presented opportunities to educate non-specialist staff. CONCLUSION: Using these methods ensured changes were evidence-based, posed negligible risk to patients and provided a set of tasks against which compliance could be measured to assess changes to practice. Implementation through PDSAs allowed the chart to be adjusted to fit the context and meet the needs of those using it, while preserving the evidence base.

Unlearning in health care.

Learning in health care is essential if healthcare organisations are to tackle a challenging quality of care agenda. Yet while we know a reasonable amount about the nature of learning, how learning occurs, the forms it can take, and the routines that encourage it to happen within organisations, we know very little about the nature and processes of unlearning. We review the literature addressing issues pivotal to unlearning (what it is, why it is important, and why it is often neglected), and go further to explore the conditions under which unlearning is likely to be encouraged. There is a difference between routine unlearning (and subsequent re-learning) and deep unlearning--unlearning that requires a substantive break with previous modes of understanding, doing, and being. We argue that routine unlearning merely requires the establishment of new habits, whereas deep unlearning is a sudden, potentially painful, confrontation of the inadequacy in our substantive view of the world and our capacity to cope with that world competently.

What will it mean to have a flatter team-based NHS structure?

The Government has identified that the NHS should move towards flatter, devolved structures, more participation and flexibility. This article, the first of a two-part series, has two aims: first, to outline the effects that these changes may have on the organizational structure of the NHS; second, to identify the management 'buzzwords' associated with these changes and to place them in context and demystify their meaning, thus opening up the issues to debate. It also presents an overview of current changes in the NHS and explores their potential future ramifications.

Changing NHS structures: implications for nursing careers.

This article explores what implications the flatter NHS structures (after the restructuring of April 1999) might have for nursing careers. It examines issues of recognition, reward systems and career pathways and the problems these may pose for the retention of qualified staff within nursing. It is seen that flatter structures will offer little in the way of traditional vertical promotion opportunities and readers are invited to explore the possibility of lateral promotion, continuous development, career grids and the rise of the generic nurse. Speculation about the introduction of competency-based pay systems is introduced. The article attempts to progress the debate in the area of the links between structure and supporting human resource infrastructures within the public sector set against background context of severe cash constraints. It seeks to raise the issues and open debate among practitioners.

Technologies and health care in the 21st century.

The factors shaping the nature and scope of health care in the 21st century are examined. Included are the technically driven infusion of new and innovative research and clinical tools; the diversity and capability of modern imaging methods; the predominance of diagnostic capabilities over effective therapy in clinical medicine; the focus of basic research on engineering issues such as instrumentation, biomaterials, modeling, and physiological functions; the growing use of image-based therapy; and the quest for causation in chronic conditions.

Research directions in biomedical engineering.

The role of biomedical engineering and developments that affect it are outlined. Research areas that the authors believe will be of major importance at the beginning of the next century are discussed. They are: systems science and integrated biology; biomedical engineering in the cardiovascular system; biomaterials (metals, ceramics, and polymers); artificial organs; instrumentation and sensors; medical imaging (radiography, ultrasonic imaging, magnetic resonance imaging, and other techniques); biomedical computing; biomechanics; and rehabilitation. Some new areas for biomedical engineering research (molecular biology, minimally invasive surgery, home health care, and geriatric care) are examined.

Hereditary esophageal dysfunction in the Miniature Schnauzer dog.

Miniature Schnauzers maintained in a colony for 9 years were used to study the inheritance of esophageal dysfunction (canine achalasia, megaesophagus). All dogs were evaluated radiographically, using a barium swallow contrast technique which clearly distinguished normal and affected pups. At 4 to 6 months of age, all affected dogs had recovered clinically except one, and radiographic evidence of dysfunction was markedly diminished. None of the affected dogs required a special feeding regimen. Analysis of breeding pairs revealed a ratio of 9 affected/11 normal dogs when an affected male was mated with a normal female, and a 13/3 ratio was observed when two affected dogs were mated. These ratios were compatible with a simple autosomal dominant or a 60% penetrance autosomal-recessive mode of inheritance. Outbreeding to an affected Miniature Schnauzer/Poodle crossbred dog resulted in only two of 30 affected pups, indicating a polygenic mode of inheritance in outbred populations.

Blood flow measurement: future applications and prospects.

Blood flow measurements have great potential value for evaluating ventricular performance in humans in terms of dynamic properties--peak velocity, acceleration, and instantaneous power development. Transcutaneous ultrasonic Doppler flow sensors provide new and exciting opportunities as simple, noninvasive techniques for ready access to this kind of information under many different circumstances. Recent developments in laser-Doppler technology provide promise of new methods for measuring blood flow in superficial vessels (i.e., skin or retina) without even contact with the surface of the body.

Home care: a biomedical engineering challenge.

The contributions of biomedical engineering to health care delivery have focused on techniques for acquiring and processing patient data, primarily in the high technology setting of modern hospitals. The increased sophistication of hospitals is responsible in large measure for the soaring costs of health care. The current trend toward both ambulatory and home care provides new and challenging opportunities for biomedical engineering to bear on problems of great social and economic consequence in facilitating safe and effective care of the chronically ill in the security and comfort of their own homes. Techniques which are refined for use by the expanding population of both aged and handicapped individuals are also of potential value for the home care of younger patients with broader life expectancy. Projections into the future prospects for home care elicit a wide diversity of opportunities of great significance to the future of the health professions and society as a whole.