Six-month reviews for stroke survivors: a study of the modified Greater Manchester Stroke Assessment Tool with care home residents.

OBJECTIVES: To explore the feasibility of using a stroke-specific toolkit for six-month post-stroke reviews in care homes to identify unmet needs and actions. DESIGN: An observational study including qualitative interviews to explore the process and outcome of reviews. SETTING: UK care homes. PARTICIPANTS: Stroke survivors, family members, care home staff (review participants) and external staff involved in conducting reviews (assessors). INTERVENTIONS: Modified Greater Manchester Stroke Assessment Tool (GM-SAT). RESULTS: The observational study provided data on 74 stroke survivors across 51 care homes. In total, out of 74, 45 (61%) had unmet needs identified. Common unmet needs related to blood pressure, mobility, medicine management and mood. We conducted 25 qualitative interviews, including 13 review participants and 12 assessors. Three overarching qualitative themes covered acceptability of conducting reviews in care homes, process and outcomes of reviews, and acceptability of modified GM-SAT review toolkit. The modified GM-SAT review was positively valued, but stroke survivors had poor recall of the review event including the actions agreed. Care home staff sometimes assisted with reviews and highlighted their need for training to support day-to-day needs of stroke survivors. Assessors highlighted a need for clearer guidance on the use of the toolkit and suggested further modifications to enhance it. They also identified organizational barriers and facilitators to implementing reviews and communicating planned actions to GPs and other agencies. CONCLUSION: The modified GM-SAT provides a feasible means of conducting six-month reviews for stroke survivors in care homes and helps identify important needs. Further modifications have enhanced acceptability. Full implementation into practice requires staff training and organizational changes.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience.

BACKGROUND: Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. METHODS: Semi-structured interviews, with the data subjected to thematic analysis. RESULTS: Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. CONCLUSIONS: The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.

BACKGROUND: Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. METHODS AND FINDINGS: Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care. CONCLUSIONS: The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Facilitating large-scale implementation of evidence based health care: insider accounts from a co-operative inquiry.

BACKGROUND: Facilitators are known to be influential in the implementation of evidence-based health care (EBHC). However, little evidence exists on what it is that they do to support the implementation process. This research reports on how knowledge transfer associates (KTAs) working as part of the UK National Institute for Health Research 'Collaboration for Leadership in Applied Health Research and Care' for Greater Manchester (GM CLAHRC) facilitated the implementation of EBHC across several commissioning and provider health care agencies. METHODS: A prospective co-operative inquiry with eight KTAs was carried out comprising of 11 regular group meetings where they reflected critically on their experiences. Twenty interviews were also conducted with other members of the GM CLAHRC Implementation Team to gain their perspectives of the KTAs facilitation role and process. RESULTS: There were four phases to the facilitation of EBHC on a large scale: (1) Assisting with the decision on what EBHC to implement, in this phase, KTAs pulled together people and disparate strands of information to facilitate a decision on which EBHC should be implemented; (2) Planning of the implementation of EBHC, in which KTAs spent time gathering additional information and going between key people to plan the implementation; (3) Coordinating and implementing EBHC when KTAs recruited general practices and people for the implementation of EBHC; and (4) Evaluating the EBHC which required the KTAs to set up (new) systems to gather data for analysis. Over time, the KTAs demonstrated growing confidence and skills in aspects of facilitation: research, interpersonal communication, project management and change management skills. CONCLUSION: The findings provide prospective empirical data on the large scale implementation of EBHC in primary care and community based organisations focusing on resources and processes involved. Detailed evidence shows facilitation is context dependent and that 'one size does not fits all'. Co-operative inquiry was a useful method to enhance KTAs learning. The evidence shows that facilitators need tailored support and education, during the process of implementation to provide them with a well-rounded skill-set. Our study was not designed to demonstrate how facilitators contribute to patient health outcomes thus further prospective research is required.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative.

QUALITY PROBLEM: Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. INITIAL ASSESSMENT: Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses. CHOICE OF SOLUTION: An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. IMPLEMENTATION: A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. EVALUATION: Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. LESSONS LEARNED: An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.

Feasibility of assessing the needs of stroke patients after six months using the GM-SAT.

OBJECTIVE: To investigate the feasibility of administering the Greater Manchester Stroke Assessment Tool (GM-SAT), a structured evidence-based needs assessment tool, in a community setting and its acceptability to stroke patients and their carers. SETTING: Community stroke services. SUBJECTS: One hundred and thirty-seven stroke patients at six months post hospital discharge with no communication or cognitive difficulties residing in their own homes. INTERVENTION: Patients' needs were assessed by information, advice and support (IAS) coordinators from the UK Stroke Association using the GM-SAT. MAIN MEASURES: Number and nature of unmet needs identified and actions required to address these; patient/carer feedback; and IAS coordinator feedback. RESULTS: The mean number of unmet needs identified was 3 (min 0, max 14; SD 2.5). The most frequently identified unmet needs related to fatigue (34.3%), memory, concentration and attention (25.5%), secondary prevention non-lifestyle (21.9%) and depression (19.0%). It was found that 50.4% of unmet needs could be addressed through the provision of information and advice. Patients/carers found the assessment process valuable and IAS coordinators found the GM-SAT easy to use. CONCLUSIONS: Results demonstrate that the GM-SAT is feasible to administer in the community using IAS coordinators and is acceptable to patients and their carers, as well as staff undertaking the assessments. Further research is needed to determine whether the application of the GM-SAT at six months improves outcomes for patients.

Improving care for people after stroke: how change was actively facilitated.

PURPOSE: This paper aims to report on the approach to change used in the development of a tool to assess patient status six months after stroke (the Greater Manchester Stroke Assessment Tool: GM-SAT). DESIGN/METHODOLOGY/APPROACH: The overall approach to change is based on the Promoting Action on Research Implementation in Health Services (PARiHS) Framework, which involves extensive stakeholder engagement before implementation. A key feature was the use of a facilitator without previous clinical experience. FINDINGS: The active process of change involved a range of stakeholders--commissioners, patients and professionals--as well as review of published research evidence. The result of this process was the creation of the GM-SAT. PRACTICAL IMPLICATIONS: The details of the decision processes within the tool included a range of perspectives; the process of localisation led commissioners to identify gaps in care provision as well as learning from others in terms of how services might be provided and organised. The facilitator role was key at all stages in bringing together the wide range of perspectives; the relatively neutral perceived status of the facilitator enabled resistance to change to be minimised. SOCIAL IMPLICATIONS: The output of this project, the GM-SAT, has the potential to significantly improve patients' physical, psychological and social outcomes and optimise their quality of life. This will be explored further in future phases of work. ORIGINALITY/VALUE: A structured process of change which included multiple stakeholder involvement throughout, localisation of approaches and a dedicated independent facilitator role was effective in achieving the development of a useful tool (GM-SAT).

Organising Support for Carers of Stroke Survivors (OSCARSS): study protocol for a cluster randomised controlled trial, including health economic analysis.

BACKGROUND: Stroke often results in chronic disability, with partners and family members taking on the role of informal caregiver. There is considerable uncertainty regarding how best to identify and address carers' needs. The Carer Support Needs Assessment Tool (CSNAT) is a carer-led approach to individualised assessment and support for caregiving that may be beneficial in palliative care contexts. CSNAT includes an implementation toolkit. Through collaboration, including with service users, we adapted CSNAT for stroke and for use in a UK stroke specialist organisation providing long-term support. The main aims of OSCARSS are to investigate the clinical and cost-effectiveness of CSNAT-Stroke relative to current practice. This paper focuses on the trial protocol, with the embedded process evaluation reported separately. METHODS: Longitudinal, multi-site, pragmatic, cluster randomised controlled trial with a health economic analysis. Clusters are UK services randomised to CSNAT-Stroke intervention or usual care, stratified by size of service. Eligible carer participants are: adults aged > 18 years; able to communicate in English; referred to participating clusters; and seen face-to-face at least once by the provider, for support. The 'date seen' for initial support denotes the start of intervention (or control) and carers are referred to the research team after this for study recruitment. Primary outcome is caregiver strain (FACQ - Strain) at three months after 'date seen'. Secondary outcomes include: caregiver distress; positive caregiving appraisals (both FACQ subscales); Pound Carer Satisfaction with Services; mood (HADs); and health (EQ-5D5L) at three months. All outcomes are followed up at six months. Health economic analyses will use additional data on caregiver health service utilisation and informal care provision. DISCUSSION: OSCARSS is open to recruitment at the time of article submission. Study findings will allow us to evaluate the clinical and cost-effectiveness of the CSNAT-Stroke intervention, directed at improving outcomes for informal carers of stroke survivors. Trial findings will be interpreted in the context of our embedded process evaluation including qualitative interviews with those who received and provided services as well as data on treatment fidelity. OSCARSS will contribute to knowledge of the unmet needs of informal stroke caregivers and inform future stroke service development. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN58414120 . Registered on 26 July 2016.

Investigation of the demand for a 7-day (extended access) primary care service: an observational study from pilot schemes in England.

OBJECTIVES: To understand how the uptake of an extended primary care service in the evenings and weekend varied by day of week and over time. Secondary objectives were to understand patient demographics of users of the service and how these varied by type of appointment and to core hour users. DESIGN: Observational study. SETTING: Primary care extended access appointments data in 13 centres in Greater Manchester, England, during 2016. PARTICIPANTS: Appointments could be booked by 1 261 326 patients registered with a family practitioner in five Clinical Commissioning Group geographic areas. MAIN OUTCOME MEASURES: Primary outcome measure was whether an appointment was used (booked and attended), secondary outcome measures included whether used appointments were prebooked or booked the same day, and delivered by a family or nurse practitioner. Additional analyses compared patient demographics with patients reporting the use of core hour primary care services. RESULTS: 65.33% of 42 472 appointments were booked and attended (used). Usage of appointments was lowest on a Sunday at 46.73% (18.07 percentage points lower usage than on Mondays (95% CI -32.46 to -3.68)). Prebooked appointments were less likely to be booked among age group 0-9 and to result in patients not attending an appointment. Family practitioner appointments were increasingly less likely to be booked with age in comparison to nurse appointments. Patients attending extended access appointments tended to be younger in comparison to core hour patients. CONCLUSIONS: There is spare capacity in the extended access service, particularly on Sundays, suggesting reconfigurations of the service may be needed to improve efficiency of delivering the service. Patient demographics suggest the service is used by a relatively younger population than core hour services. Patient demographics varied with the types of appointment provided, these findings may help healthcare providers improve usage by tailoring appointment provision to local populations.

Opportunities for better value wound care: a multiservice, cross-sectional survey of complex wounds and their care in a UK community population.

BACKGROUND: Complex wounds impose a substantial health economic burden worldwide. As wound care is managed across multiple settings by a range of healthcare professionals with varying levels of expertise, the actual care delivered can vary considerably and result in the underuse of evidence-based interventions, the overuse of interventions supported by limited evidence and low value healthcare. OBJECTIVES: To quantify the number, type and management of complex wounds being treated over a two-week period and to explore variations in care by comparing current practices in wound assessment, prevention and treatment. DESIGN: A multiservice cross-sectional survey. SETTING: This survey spanned eight community services within five Northern England NHS Trusts. RESULTS: The point prevalence of complex wounds in this community-based population was 16.4 per 10 000 (95% CI 15.9 to 17.0). Based on data from 3179 patients, antimicrobial dressings were being used as the primary dressing for 36% of patients with complex wounds. Forty per cent of people with leg ulcers either had not received the recommended Doppler-aided Ankle Brachial Pressure Index assessment or it was unclear whether a recording had been taken. Thirty-one per cent of patients whose most severe wound was a venous leg ulcer were not receiving compression therapy, and there was limited use of two-layer compression hosiery. Of patients with a pressure ulcer, 39% were not using a pressure-relieving cushion or mattress. CONCLUSIONS: Marked variations were found in care, underuse of evidence-based practices and overuse of practices that are not supported by robust research evidence. Significant opportunities for delivering better value wound care therefore exist. Efforts should now focus on developing strategies to identify, assess and disinvest from products and practices supported by little or no evidence and enhance the uptake of those that are.

The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS.

In spite of their widespread use in policy making in the UK and elsewhere, there is a relatively sparse literature specifically devoted to policy pilots. Recent research on policy piloting has focused on the role of pilots in making policy work in accordance with national agendas. Taking this as a point of departure, the present paper develops the notion of pilots doing policy work. It does this by situating piloting within established theories of policy formulation and implementation, and illustrating using an empirical case. Our case is drawn from a qualitative policy ethnography of a local government pilot programme aiming to extend access to healthcare services. Our case explores the collective entrepreneurship of regional policy makers together with local pilot volunteers. We argue that pilots work to mobilise and manage the ambiguity and conflict associated with particular policy goals, and in their structure and design, shape action towards particular outcomes. We conclude with a discussion of the generative but managed role which piloting affords to local implementers.