Different stakeholder perspectives on NHS safety.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discuses some key NHS stakeholder perspectives on NHS patient safety.

Commissioning and co-production in health and care services in the United Kingdom and Ireland: An exploratory literature review.

INTRODUCTION: This exploratory literature review seeks to examine the literature around commissioning processes in the co-production of health and care services, focusing on two questions: How do health and care commissioning processes facilitate and/or pose barriers to co-production in service design and delivery? What are the contextual factors that influence these processes? METHOD: A systematic search of three databases (Medline, Public Health and Social Policy and Practice) and a search platform (Web of Science) was conducted for the period 2008-2023. A total of 2675 records were retrieved. After deduplication, 1925 were screened at title and abstract level. Forty-seven reports from 42 United Kingdom and Ireland studies were included in the review. A thematic synthesis of included studies was conducted in relation to the research questions. RESULTS: The review identified one overarching theme across the synthesised literature: the complexity of the commissioning landscape. Three interconnected subthemes illuminate the contextual factors that influence this landscape: commissioners as leaders of co-production; navigating relationships and the collective voice. CONCLUSION: Commissioning processes were commonly a barrier to the co-production of health and care services. Though co-production was an aspiration for many commissioners, the political and economic environment and service pressures meant that it was often not fully realised. More flexible funding models, longer-term pilot projects, an increased emphasis in social value across the health and care system and building capacity for strong leadership in commissioning is needed. PATIENT AND PUBLIC CONTRIBUTION: Patients and the public did not contribute to this review as it was a small piece of work following on from a completed project, with no budget for public involvement.

Data-Driven Exploration of National Health Service Talking Therapies Care Pathways Using Process Mining: Retrospective Cohort Study.

BACKGROUND: The National Health Service (NHS) Talking Therapies program treats people with common mental health problems in England according to "stepped care," in which lower-intensity interventions are offered in the first instance, where clinically appropriate. Limited resources and pressure to achieve service standards mean that program providers are exploring all opportunities to evaluate and improve the flow of patients through their service. Existing research has found variation in clinical performance and stepped care implementation across sites and has identified associations between service delivery and patient outcomes. Process mining offers a data-driven approach to analyzing and evaluating health care processes and systems, enabling comparison of presumed models of service delivery and their actual implementation in practice. The value and utility of applying process mining to NHS Talking Therapies data for the analysis of care pathways have not been studied. OBJECTIVE: A better understanding of systems of service delivery will support improvements and planned program expansion. Therefore, this study aims to demonstrate the value and utility of applying process mining to NHS Talking Therapies care pathways using electronic health records. METHODS: Routine collection of a wide variety of data regarding activity and patient outcomes underpins the Talking Therapies program. In our study, anonymized individual patient referral records from two sites over a 2-year period were analyzed using process mining to visualize the care pathway process by mapping the care pathway and identifying common pathway routes. RESULTS: Process mining enabled the identification and visualization of patient flows directly from routinely collected data. These visualizations illustrated waiting periods and identified potential bottlenecks, such as the wait for higher-intensity cognitive behavioral therapy (CBT) at site 1. Furthermore, we observed that patients discharged from treatment waiting lists appeared to experience longer wait durations than those who started treatment. Process mining allowed analysis of treatment pathways, showing that patients commonly experienced treatment routes that involved either low- or high-intensity interventions alone. Of the most common routes, >5 times as many patients experienced direct access to high-intensity treatment rather than stepped care. Overall, 3.32% (site 1: 1507/45,401) and 4.19% (site 2: 527/12,590) of all patients experienced stepped care. CONCLUSIONS: Our findings demonstrate how process mining can be applied to Talking Therapies care pathways to evaluate pathway performance, explore relationships among performance issues, and highlight systemic issues, such as stepped care being relatively uncommon within a stepped care system. Integration of process mining capability into routine monitoring will enable NHS Talking Therapies service stakeholders to explore such issues from a process perspective. These insights will provide value to services by identifying areas for service improvement, providing evidence for capacity planning decisions, and facilitating better quality analysis into how health systems can affect patient outcomes.

Powering into a new role as hospital director from outside the profession.

Julie Davis started her working life as a sports journalist then sought a change of direction and joined the NHS. Fifteen years later she is now applying her skills and knowledge in a veterinary referral hospital.

Problems with NICE's severity weights.

This essay examines the implications, plausibility, and justification of the severity weighting that NICE (The National Institute for Health and Care Excellence) has endorsed for technology assessments in the U.K. It argues that the assignment by NICE of additional weights to health conditions which involve a large absolute or proportional shortfall of future expected QALYs (Quality-Adjusted Life Years) as compared to those who do not have these health conditions is not well supported and has troubling implications. The literature concerned with attitudes toward prioritizing severity has found a variety of notions of severity, and it is questionable to what extent those studies bear on whether to assign greater weights to health states involving large absolute or proportional shortfalls. In addition, the severity weighting is not well supported by either egalitarian or prioritarian political philosophy, because it is concerned only with the future and focuses only on health rather than well-being in general.

'Kindling the fire' of NHS patient data exploitations: The care.data controversy in news media discourses.

This paper explores news media discourse about care.data: an NHS England programme of work for amalgamating and sharing patient data from primary care for planning and research. It was scrapped in 2016 after three years of public outcry, delays and around 1.5 million opt-outs. I examine UK news media coverage of this programme through the 'fire object' metaphor, focusing upon the visions of purpose and value it inspired, the abrupt discontinuities, juxtapositions and transformations it performed, and the matters of concern that went unheeded. Findings suggest that, in care.data's pursuit of a societal consensus on NHS patient data exploitations, various visions for new and fluid data flows brought to presence narratives of transforming the NHS, saving lives, and growing the economy. Other realities and concerns that mattered for certain stakeholders, such as data ownership and commercialisation, public engagement and informed consent, commitment and leadership, operational capabilities, and NHS privatisation agendas, remained absent or unsettled. False dichotomies kept the controversy alive, sealing its fate. I conclude by arguing that such failed programmes can turn into phantom-like objects, haunting future patient data schemes of similar aspirations. The paper highlights the role news media can have in understanding such energetic public controversies.

A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care.

BACKGROUND: Social and Therapeutic Horticulture (STH) is a process where trained practitioners work with plants and people to improve an individual's physical and psychological health, communication and thinking skills. Evidence suggests that STH can support individuals with mental ill-health, however, current commissioning of STH within mental health care is limited. This study aimed to understand the barriers to commissioning STH in mental health care and to identify potential solutions to barriers, to support more widespread availability of services.  METHODS: Individuals with a role in mental health care commissioning from across the UK were invited to take part in semi-structured interviews via zoom. Interviews explored factors influencing the mental health services they commission or refer to, their perception of the role of STH in mental health care and the barriers to commissioning STH, together with potential solutions to any barriers identified. RESULTS: Commissioners identified a lack of knowledge of STH and evidence of its effectiveness, and a culture which prioritises traditional medical models, as barriers to commissioning. Challenges for STH providers in responding to large-scale commissioning requirements were also highlighted as a barrier. CONCLUSIONS: To upscale commissioning of STH in mental health care, STH interventions need to be embedded within NHS priorities and information on STH services and their effectiveness needs to be easily accessible to practitioners. The sector should also be supported in working collaboratively to enable commissioning of services at scale.

Implementing strategies to improve uptake of patient-reported outcome measures (PROMs) in gender-affirming care: a mixed-methods implementation study.

IMPORTANCE: The Practical Guide to Implementing PROMs in Gender-Affirming Care (PG-PROM-GAC) is an evidence-based resource, which was developed in response to international calls for improved patient-reported outcome measure (PROM) implementation in gender-affirming care. The PG-PROM-GAC has the potential to improve PROM implementation; however, its real-world effectiveness has not yet been investigated. OBJECTIVE: Investigate effectiveness and fidelity of three implementation strategies from the PG-PROM-GAC in a real-world gender clinic setting. DESIGN: Interrupted time series mixed-methods study investigating response rates to a PROM deployed alongside implementation strategies from the PG-PROM-GAC; and open-ended feedback on the fidelity and effectiveness of implementation strategies. SETTING: Participants were recruited from a National Health Service (NHS) gender clinic. PARTICIPANTS: Eligible participants were being seen at an NHS gender clinic for an appointment during the study period, and were invited to participate in this study via email. INTERVENTION: Three implementation strategies from the PG-PROM-GAC deployed alongside a PROM. MAIN OUTCOMES AND MEASURES: Response rates were calculated at 2-week intervals, in line with the deployment of each implementation strategy. Open-ended responses were thematically analysed by two researchers following guidance from implementation science and interpretation from Normalisation Process Theory. RESULTS: A total of 28 participants were included in this study with a mean (SD) age of 39 (17) years. In general, participants rated education material for PROMs as the most important for PROM implementation, and accessibility options for PROMs as the second most important. Response rates to PROM completion dropped as the study progressed, as the burden of reviewing implementation strategies increased. Results were used to construct recommendations for future PROM implementation efforts. CONCLUSIONS AND RELEVANCE: The PG-PROM-GAC and implementation strategy materials developed from this study (ie, educational video on PROMs co-developed with key stakeholders) can be used by clinicians, researchers and policymakers to lead PROM implementation efforts in gender-affirming care.

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation.

BACKGROUND: Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS: We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS: GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION: GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.

Locum doctor working and quality and safety: a qualitative study in English primary and secondary care.

BACKGROUND: The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety. METHODS: Qualitative semi-structured interviews and focus groups were conducted with 130 participants, including locums, patients, permanently employed doctors, nurses and other healthcare professionals with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS. Data were collected between March 2021 and April 2022. Data were analysed using reflexive thematic analysis and abductive analysis. RESULTS: Participants described the implications of locum working for quality and safety across five themes: (1) 'familiarity' with an organisation and its patients and staff was essential to delivering safe care; (2) 'balance and stability' of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) 'discrimination and exclusion' experienced by locums had negative implications for morale, retention and patient outcomes; (4) 'defensive practice' by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors. CONCLUSION: Locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.

Mitigating the impact of blood shortages in England.

The supply of blood components and products in sufficient quantities is key to any effective health care system. This report describes the challenges faced by the English blood service, NHS Blood and Transplant (NHSBT), towards the end of the COVID-19 pandemic, which in October 2022 led to an Amber Alert being declared to hospitals indicating an impending blood shortage. The impact on the hospital transfusion services and clinical users is explained. The actions taken by NHSBT to mitigate the blood supply challenges and ensure equity of transfusion support for hospitals in England including revisions to the national blood shortage plans are described. This report focuses on the collaboration and communication between NHSBT, NHS England (NHSE), Department of Health and Social Care (DHSC), National Blood Transfusion Committee (NBTC), National Transfusion Laboratory Managers Advisory Group for NBTC (NTLM), National Transfusion Practitioners Network, the medical Royal Colleges and clinical colleagues across the NHS.

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.