Community matrons as problem-solvers for people living with multi-co-morbid disease.

Working with patients in their own homes gives community matrons an advantage of seeing patients in the context of their everyday lives. This allows comprehensive assessment of need with an aim of promoting health or promoting stability for people living with chronic disease. Complex issues are resolved through problem-solving and this can result in patients being maintained in their own homes and thus in reduced unplanned hospitalisation. Data were collected from participants using semi-structured interviews and audio diaries. The sample comprised professionals: CMs (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). In this article, data from community matrons is discussed. Community matrons often drew on the social determinants model of health to problem solve and to create meaningful strategies that work for patients in their care. Raising awareness of the high-level skills of community matrons and promoting appreciation of the importance of a social determinants model of health is important in explaining why nurses are such a crucial element of the primary health care workforce.

'I can't walk away': understanding the complexities in embedding a new nurse role.

BACKGROUND: The community matron (CM) role was introduced in England to provide a single point of access to patients living with comorbid long-term conditions who had, or were at risk of, frequent emergency hospitalisation. AIM: This study explored the factors that affected embedding of the CM role. The qualitative study was undertaken in community health services in two cities and a rural area in central England. METHOD: Participants comprised health professionals (n=30) including CMs, community service managers, and service commissioners; patients (n=10); and their family carers (n=5). RESULTS: Findings reveal that participants were largely positive about the role. However, difficulties with role setup had led to numerous changes in service delivery, which affected how the role has embedded. CONCLUSION: Many aspects of the CM role are invisible to other health professionals. Invisibility of community nursing, rather than autonomy of the CM role, seems to be a key factor in the challenges of embedding the role.

Public health systems analysis--where the River Kabul meets the River Indus.

In this paper we review two recent paradigmatic shifts and consider how a two-way flow in innovation has been critical to the emergence of new thinking and new practices. The first area relates to our understanding of the nature of public health systems and the shift from a medical paradigm to a more holistic paradigm which emphasises the social, economic and environmental origins of ill-health and looks to these as key arenas in which to tackle persistent inequalities in populations' health experiences. In respect of this paradigmatic shift, it is argued, developing countries were in advance of their more developed counterparts. Specifically, the Alma Ata Declaration and the Primary Health Care Approach which was central to its implementation pre-figured elements of what was to be called in developed countries The New Public Health such as the need for greater community involvement and recognition of the importance of other sectors in determining health outcomes. But this paradigmatic shift added a new complexity to our understanding which made the identification of appropriate policy responses increasingly difficult. However, a parallel shift was taking place in the cognate field of operational research/systems analysis (OR/SA) which was adding greatly to our ability to analyse and to identify key points of intervention in complex systems. This led to the emergence of new techniques for problem structuring which overcame many of the limitations of formal mathematical models which characterised the old paradigm. In this paradigmatic shift developed countries have led the way, specifically in the new fields of Community Operational Research and Operational Research for Development, but only by drawing strongly on the experience and philosophies to be found in developing countries.

How can health systems be strengthened to control and prevent an Ebola outbreak? A narrative review.

The emergence and re-emergence of infectious diseases are now more than ever considered threats to public health systems. There have been over 20 outbreaks of Ebola in the past 40 years. Only recently, the World Health Organization has declared a public health emergency of international concern (PHEIC) in West Africa, with a projected estimate of 1.2 million deaths expected in the next 6 months. Ebola virus is a highly virulent pathogen, often fatal in humans and non-human primates. Ebola is now a great priority for global health security and often becomes fatal if left untreated. This study employed a narrative review. Three major databases - MEDLINE, EMBASE, and Global Health - were searched using both 'text-words' and 'thesaurus terms'. Evidence shows that low- and middle-income countries (LMICs) are not coping well with the current challenges of Ebola, not only because they have poor and fragile systems but also because there are poor infectious disease surveillance and response systems in place. The identification of potential cases is problematic, particularly in the aspects of contact tracing, infection control, and prevention, prior to the diagnosis of the case. This review therefore aims to examine whether LMICs' health systems would be able to control and manage Ebola in future and identifies two key elements of health systems strengthening that are needed to ensure the robustness of the health system to respond effectively.

Case management of individuals with long-term conditions by community matrons: report of qualitative findings of a mixed method evaluation.

AIM: To consider findings from a study that evaluated case management of individuals with long-term conditions (LTCs) by a community matron (CM) service. The paper highlights issues related to the implementation of a new role and the impact this had on the experience of care across hospital and community settings for patients and their carers. BACKGROUND: The introduction of the role of CM was intended to increase effective management of patients with complex comorbid LTCs through the introduction of case management, thereby reducing unplanned hospital admissions. METHODS: The overall methodological approach was one of mixed methods. This paper reports the qualitative findings from CMs (n = 15); patients (n = 13); family carers (n = 8); and secondary care staff who interface with the CM service (n = 7). Data were collected between October 2009 and May 2010. FINDINGS: A thematic analysis resulted in the identification of four themes: (1) visibility; (2) interpersonal relationships; (3) leadership; and (4) systems/professional boundaries. Patients enjoyed being seen as a whole and family carers appreciated the coordination aspect of the role. Difficulties arose from the limited understanding of the CM role and from a lack of a shared vision across healthcare professionals concerning the role and its goals.

Public health systems analysis--the transfer of learning between developed and developing countries.

This paper explores the role of systems thinking and operational research in furthering our understanding of and our control over complex public health systems. First, it tracks the evolution of our current perception and conceptual modelling of public health systems and the emerging recognition of the need for a whole systems approach. It gives examples of how methods of operational research, particularly those derivative of problem structuring methods, have been used to assist in clarifying the nature of the complexities that surround public health systems, identifying key change agents within public health systems, supporting these agents in making a meaningful contribution, and thereby planning and implementing effective interventions. These examples are drawn from work conducted within the public health systems of both developed and developing countries highlighting the importance of viewing the transfer of 'soft systems' technology as a two-way street with developed nations having (at least) as much to learn from their developing counterparts as they have to teach.