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The long-term plan for the National Health Service (NHS, 2019) identifies a blueprint to make the NHS fit for the future with a greater focus on prevention, improving services for patients and the importance of integrating services to make them more effective and efficient. The challenge is in the delivery and who is responsible to implement changes. The key is to enable staff at local levels to have responsibility for ensuring that the health and social needs of their local population are met.

Established to oversee the implementation is the NHS Assembly with 50 individuals from across the health and care sector to advise NHS England and NHS Improvement on the implementation. This requires shared commitment and motivation to change; ensuring patient centred care is at the forefront of any changes to delivering care. At regional level, Sustainability and Transformation Partnerships and Integrated Care Systems are groups of local NHS organisations, local councils and other partners, who are working together in the region to develop and implement the NHS plan. There are many challenges ahead to ensure the plan delivers better regional health and social care, including the impending UK’s decision to leave the European Union. Brexit may present some opportunities but if freedom of movement and membership of the single market and customs union end as planned, NHS and social care face several significant threats in the region.

Telephone triage or hear and treat (H&T) describes the process of UK ambulance services nurses and paramedics undertaking enhanced telephone assessments of patients to determine the most appropriate response, which can sometimes result in no ambulance being sent. Given, however, that 999 is not considered an advice service, it may be reasonable to assert that the expectation of those calling 999 is always an immediate ambulance response. This may not always be realised and may affect patient experience. The purpose of this paper is to ascertain the following: to what extent are the views of UK ambulance telephone triage service users being gathered? In answering this research question, this review also aims to explore the findings to determine service users’ expectations of ambulance telephone triage and the possibility that these expectations are influenced by the UK media. The findings of which could be used to inform the need and nature of future research.

Phase one consisted of a computerised literature search of online databases CINAHL, Pubmed, Science Direct, Cochrane library, Web of Science and UK government-funded databases. Phase two consisted of searches of all UK ambulance services websites and the submission of freedom of information requests. Phase three consisted of a computerised literature search of the ProQuest international news-stream database.

A total of 78 results were identified and after further screening 34 results were excluded, leaving 44 for final review. The extent to which users experience of ambulance service telephone triage are being gathered is low; and often limited to one off pieces of non-peer reviewed work. Patients felt overall that they were treated with respect, dignity and care. However, being listened to, reducing anxiety and a need for prompt assurances remain important to those whose overriding expectation is that an ambulance should attend every time a 999 call is made. There appears to be a balanced media portrayal of H&T with the UK media. However, unrealistic public expectations represent a significant barrier to providing sustainable care that users consider to be of high quality.

Some user experiences may have been gathered in more broad research exercises which explored various aspects of 999 ambulance service experience. This was not included if it could not be clearly differentiated as being related to H&T and thus may have resulted in data being omitted. It was not possible to systematically search social media platforms (such as facebook or twitter) for any media results related to this search strategy; only traditional print and online media platforms. This also may have resulted in data being omitted. The inclusion of non-peer reviewed research results and grey literature represents a possible limitation to the conclusions drawn within this review. The concept of Insider Research Bias cannot be ignored within this review. The author himself practices in telephone triage within a UK ambulance service; however, this insider bias is mitigated by the clearly articulated systematic methodology and use of the Critical Appraisal Skills framework. In a similar vein, reviews of this nature are also often conducted as part of a team, to reduce bias, increase objectivity and ensure the validity of findings. This review was a sole effort, and while this is not uncommon, there were no cross checks by peers of the search terms, strategy, paper selection, exclusion criteria or data extraction. This lack of peer critique is considered a possible limitation in mitigating selection and reviewer bias.

The results of this review would suggest a need to increase the amount of research and patient feedback gathered from those being assessed and managed by ambulance service telephone triage within the UK. Ambulance services could hold regular monthly small-scale qualitative interviews with patients and families to ascertain their views, perceptions and anxieties which can then provide an up-to-date understanding of user expectations and the health educational needs of local communities. Patient feedback received directly to ambulance services or via the Patient Advice and Liaison Service could be retrospectively analysed by researchers to determine key themes of positive practice or negative patient experience. Such feedback can be tracked through time and be used as a pre and post community intervention measure, to determine any changes. Moving forward, nationally standardised research frameworks should be adopted to provide more easily collated local and national data, which can monitor improvement strategies and provide a comparison between services to aid the sharing of best practice principles.

There is no other piece of work published which has reviewed the data in this area of clinical practice within the UK.

NHS 111 is a non-emergency telephone triage service that provides immediate access to urgent care 24 h a day. This study explored the recruitment, retention and development of one integrated urgent care (IUC) workforce in England, specifically the NHS 111 service and Clinical Hub.

An online survey was distributed to the NHS 111 and Clinical Hub workforce. The data from 48 respondents were summarised and analysed thematically.

The survey respondents held a variety of clinical and non-clinical roles within NHS 111 and the Clinical Hub. The findings indicate that the IUC workforce is motivated to care for their patients and utilise a range of communication and cognitive skills to undertake their telephone triage roles. In total, 67% of respondents indicated that their work was stressful, particularly the volume and intensity of calls. Although the initial training prepared the majority of respondents for their current roles (73%), access to continuing professional development (CPD) varied across the workforce with only 40% being aware of the opportunities available. A total of 81% of respondents stated that their shifts were regularly understaffed which indicates that the retention of IUC staff is problematic; this can put additional pressure on the existing workforce, impact on staff morale and create logistical issues with managing annual leave entitlements or scheduling time for training.

This small-scale study highlights some of the complexities of telephone triage work and demonstrates the challenges for IUC service providers in retaining an appropriately skilled and motivated workforce.

The purpose of this paper is to explore the human work entailed in the deployment of digital health care technology. It draws on imagined configurations of computers and machines in fiction and social science to think about the relationship between technology and people, and why this makes implementation of digital technology so difficult. The term hubots is employed as a metaphorical device to examine how machines and humans come together to do the work of healthcare.

This paper uses the fictional depiction of hubots to reconceptualise the deployment of a particular technology – a computer decision support system (CDSS) used in emergency and urgent care services. Data from two ethnographic studies are reanalysed to explore the deployment of digital technologies in health services. These studies used comparative mixed-methods case study approaches to examine the use of the CDSS in eight different English NHS settings. The data include approximately 900 hours of observation, with 64 semi-structured interviews, 47 focus groups, and surveys of some 700 staff in call centres and urgent care centres. The paper reanalyses these data, deductively, using the metaphor of the hubot as an analytical device.

This paper focuses on the interconnected but paradoxical features of both the fictional hubots and the CDSS. Health care call handling using a CDSS has created a new occupation, and enabled the substitution of some clinical labour. However, at the same time, the introduction of the technology has created additional work. There are more tasks, both physical and emotional, and more training activity is required. Thus, the labour has been intensified.

This paper implies that if we want to realise the promise of digital health care technologies, we need to understand that these technologies substitute for and intensify labour.

This is a novel analysis using a metaphor drawn from fiction. This allows the authors to recognise the human effort required to implement digital technologies.

The purpose of this paper is to assess failure demand as a lean concept that assists in waste analysis during quality improvement activity. The authors assess whether the concept’s limited use is a missed opportunity to help us understand improvement priorities, given that a UK Government requirement for public service managers to report failure demand has been removed.

The authors look at the literature across the public sector and then apply the failure demand concept to the UK’s primary healthcare system. The UK National Health Service (NHS) demand data are analysed and the impact on patient care is elicited from patient interviews.

The study highlighted the concept’s value, showing how primary care systems often generate failure demand partly owing to existing demand and capacity management practices. This demand is deflected to other systems, such as the accident and emergency department, with a considerable detrimental impact on patient experience.

More research is needed to fully understand how best to exploit the failure demand concept within wider healthcare as there are many potential barriers to its appropriate and successful application.

The authors highlight three practical barriers to using failure demand: first, demand within the healthcare system is poorly understood; second, systems improvement understanding is limited; and third, need to apply the concept for improvement and not just for reporting purposes.

The authors provide an objective and independent insight into failure demand that has not previously been seen in the academic literature, specifically in relation to primary healthcare.

Review of major policy paper in relation to the ambulance service [in England] efficiency and productivity with reference to observed “unacceptable variation”.

Critical review of ambulance service/EMS policy approach in England.

Lord Carter’s review describes failings in performance of UK ambulance service/EMS. However, the identified failings are essentially a repetition of many almost identical similar findings. There is a tendency of policy in respect of the ambulance service in England, as exemplified by Lord Carter’s report to consider analysis of the problem a more significant task that actually addressing the shortcoming defined.

This viewpoint comment piece is produced as a viewpoint with all the attendant limitations implied in this approach. However, it has been produced from an informed position.

Challenge to current UK ambulance policy. Previous repetitious finding need to be addressed definitively.

The efficiency of UK ambulance services/EMS is seriously impaired, and indeed these findings have been acknowledge previously. However, little by way of active remediation has been attempted. The current approach as exemplified in Lord Carter's recent review appears to ensure that analysis of the long- standing problems that exist is sufficient and possible preferable to active remediation and improvement.

No previous critical review of this type has been attempted (as it would be career-limiting).

Following publication of a new vision for the English National Health Service (NHS) in 2014, known as the NHS Five-Year Forward View, a Vanguard programme was introduced by NHS England charged with the task of designing and delivering a range of new care models (NCMs) aimed at tackling deep-seated problems of a type facing all health systems to a greater or lesser degree. Drawing upon recent theoretical developments on the multilevel nature of context, we explore factors shaping the implementation of five NCM initiatives in the North East of England.

Data collection was based on semi-structured interviews (66 in total) between December 2016 and May 2017 with key informants at each site and a detailed review of Trusts' internal documents and policies related to the implementation of each NCM. Our analysis explores factors shaping the implementation of five NCM pilot sites as they touched on the multiple levels of context ranging from the macro policy level to the micro-level setting of workforce redesign.

It is far too early to conclude with any confidence that a successful outcome for the NCM programme will be forthcoming although the NHS Long-Term Plan seeks to build on the earlier vision set out in the Five-Year Forward View. Early indications show some signs of promise, especially where there is evidence of the ground having been prepared and changes already being put in place prior to the official launch of NCM initiatives. At the same time our findings demonstrate that all five pilot sites experienced, and were subject to, unrealistic pressure placed upon them to deliver outcomes.

Our findings demonstrate the need for a deeper understanding of the multilevel nature of context by exploring factors shaping the implementation of five NCMs in the North East of England. Exploring the wider national policy context is desirable as well as understanding the perceptions of front-line staff and service users in order to establish the degree of alignment or, conversely, to identify where policy and practice are at risk of pushing and pulling against each other.

This chapter will set the scene for the need of sustainable development in the healthcare curriculum by discussing the contemporary context of healthcare provision and its associated challenges. This is specifically in the context of wicked or complex problems. An exploration of what gives rise to such problems is used to lead into integrated care as a proposed solution and its associated drivers. This is considered in relation to sustainability and curriculum development with a focus on two examples: the creation of a post-graduate curriculum to teach sustainable integrated care to clinical staff and a new pedagogical approach called socially immersive learning. Through this the challenges of barriers and enablers to integrated care will be considered and the extent to which a global mind-set transition might occur among participants to align sustainable development goals.

The purpose of this paper is to describe how NHS Sutton Clinical Commissioning Group (Sutton CCG) is working with nursing homes, residential homes and other health and social care organisations in Sutton to improve the quality of provision for residents in nursing and residential homes “care homes”.

The paper explains how Sutton CCG engaged with care homes initially to seek their views on whether they wanted support and what support they would value. It describes what arrangements Sutton CCG put in place for managers and staff in local care homes to provide support face-to-face. The paper outlines the key areas for improvement that Sutton CCG and the care homes are focusing on. It includes examples of work carried out jointly by the care homes and Sutton CCG to improve the quality of care for residents. It goes on to describe joint-working arrangements between the CCG, London Borough of Sutton and other health and social care organisations to ensure the overall quality of care homes in Sutton.

The paper outlines feedback from care home managers and staff who were invited to share their views about what support they wanted from Sutton CCG. It includes early feedback from care homes about the support put in place and the areas where they have found it most useful.

In the UK many older people live in care homes. Britain has an ageing population so the need for residential and nursing homes and the numbers of people living in care homes is only likely to increase. Our ageing population also places additional demands on the NHS, with residents in care homes often spending time in A&E and lengthy spells in hospital. This paper highlights how CCGs and other health and social care organisations can work with care homes to improve the health and wellbeing of older residents in care homes and reduce pressures on other health services.

Sutton CCG has put in place new arrangements for working with care homes that aim to support carers to improve the lives of their older residents. The paper shares practical examples of support that the CCG has provided which has successfully improved care and decision making in care homes; early indications show this has reduced 999 calls and conveyances to hospital. Sutton CCG, London Borough of Sutton and other statutory organisations with responsibility for care homes in Sutton have also set up a joint intelligence group to gain an overall picture of the quality of the borough’s care homes.