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The purpose of this paper is to show how the new arrangements for commissioning services in the English NHS can facilitate innovations in service delivery leading to improvements in outcomes and cost effectiveness.

The study uses cost modelling based upon the Hospital Episodes Statistics compiled by the NHS Information Centre to calculate recent expenditure upon treatment of routine childhood illnesses managed as short stay hospital admissions, and then uses a case study of a children's walk‐in centre to show how an alternative service can be provided, and a new service embedded in general practice to show a further alternative type of provision.

The study finds that large sums are currently being spent on inappropriate treatment of routine childhood conditions, especially in large urban conurbations. It demonstrates that in the case studies, the alternative provision can provide a viable and effective alternative.

The research is based upon historical data by necessity. The new commissioning groups are not co‐located with the historical PCTs on which this study is based. The data are collected by providers and co‐ordinated by the NHS Information Centre. Therefore the investigators do not have control over the data quality. The second case study is a new service and therefore is used as an illustration of other service types.

This study suggests that paediatric ambulatory services can be provided at lower cost with better outcomes.

This study provides the basis for a pilot study in Salford, where additional social benefits are targeted including better school attendance and increased self‐awareness over child health amongst local families.

The study provides quantitative evidence for commissioning alternative paediatric ambulatory services.

Many countries have developed hospital-at-home (HAH) models to bring hospital services closer to home. Although some countries already have a long tradition of HAH for adults, paediatric HAH has been developed more recently. Specificities of paediatric care make it difficult to directly extend an adult HAH model to the paediatric population. The objective of this study is to compare the organisation of paediatric HAH in four countries: France, Australia (states of Victoria and New South Wales), the Netherlands and Belgium. Ultimately, lessons can be drawn for further development in the countries analysed and/or for implementation in other countries.

Legal documents and other grey literature were analysed to describe the legal context for the provision of paediatric HAH in the selected countries. In addition, semi-structured in-depth interviews were conducted with key informants from paediatric HAH organisations in these countries, addressing the following topics: historical background, legal framework, functioning of HAH models, workforce, number of services, profile of children, type of care activities, funding, coordination with other providers and quality of care. Results were reviewed by a content expert from the respective country.

Organisational differences were highlighted in terms of coordinating actor (hospital or home nursing care services), decision-making process, range of clinical conditions treated, territorial organisation, qualifications and expertise of the team members, medical expertise, financing, responsibilities, etc.

There is no single preferred model for the provision of HAH care for children. There is a large variety in almost all aspects of organisation. There are, however, also some common characteristics across the different models. Notably, paediatric expertise of nurses within the HAH team was considered indispensable in all programmes.

Given that the workforce constitutes a principal resource of primary care, appraisal of models of care requires thorough investigation of the health workforce in all Models of Child Health Appraised (MOCHA) countries. This chapter explores this in terms of workforce composition, remuneration, qualifications and training in relation to the needs of children and young people. We have focused on two principal disciplines of primary care; medicine and nursing, with a specific focus on training and skills to care for children in primary care, particularly those with complex care needs, adolescents and vulnerable groups. We found significant disparities in workforce provision and remuneration, in training curricula and in resultant skills of physicians and nurses in European Union and European Economic Area Countries. A lack of overarching standards and recognition of some of the specific needs of children reflected in training of physicians and nurses may lead to suboptimal care for children. There are, of course, many other professions that also contribute to primary care services for children, some of which are discussed in Chapter 15, but we have not had resources to study these to the same detail.

The 30 MOCHA (Models of Child Health Appraised) countries are diverse socially, culturally and economically, and differences exist in their healthcare systems and in the scope and role of primary care. An economic analysis was undertaken that sought to explain differences in child health outcomes between countries. The conceptual framework was that of a production function for health, whereby health outputs (or outcomes) are assumed affected by several ‘inputs’. In the case of health, inputs include personal (genes, health behaviours) and socio-economic (income, living standards) factors and the structure, organisation and workforce of the healthcare system. Random effects regression modelling was used, based on countries as the unit of analysis, with data from 2004 to 2016 from international sources and published categorisations of healthcare system. The chapter describes the data deficiencies and measurement conundrums faced, and how these were addressed. In the absence of consistent indicators of child health outcomes across countries, five mortality measures were used: neonatal, infant, under five years, diabetes (0–19 years) and epilepsy (0–19 years). Factors found associated with reductions in mortality were as follows: gross domestic product per capita growth (neonatal, infant, under five years), higher density of paediatricians (neonatal, infant, under five years), less out-of-pocket expenditure (neonatal, diabetes 0–19), state-based service provision (epilepsy 0–19) and lower proportions of children in the population, a proxy for family size (all outcomes). Findings should be interpreted with caution due to the ecological nature of the analysis and the limitations presented by the data and measures employed.

This paper investigates the informal learning processes through which family physicians develop an understanding of the social context shaping the health of marginalized patients. The paper is based on the results of a qualitative study, informed by institutional ethnography, involving individual interviews with 10 family physicians working in and around Halifax, Nova Scotia, Canada. The analysis explores what knowledge of social context is for family physicians, emphasizing its hybrid, socio-clinical character. We also explore key aspects of the informal processes through which this knowledge is developed including learning about ‘the other,’ the reflexive unlearning of medical school training, and learning from clinical doing where we discuss patient-based epiphanies and learning from other health care providers.

The purpose of this paper is to outline considerations and steps taken to introduce electronic reporting and verification from systems design and multidisciplinary collaborations to gap analysis and devising solutions. It also evaluates carefully placed forcing functions’ impact on verification rates.

A multidisciplinary workgroup was formed to stop print and establish electronic reporting. The electronic verification's success was assessed by weekly activity analysis.

Introducing a verification forcing function markedly improved verification activity. Thereafter, non-verified results stabilized at 7 percent up to 75 weeks post-implementation.

This paper illustrates how results reporting and verification could be implemented in a tertiary hospital using a mixed electronic and paper record. Factors that were critical to success include stakeholder engagement and applying systems design that focussed on patient safety as a key priority. The electronic reporting system was augmented by strategically inserted forcing functions, clear clinical-responsibility lines and ancillary alert systems.

The systems design method's value in managing non-critical but abnormal results appears to have been under-appreciated. This paper describes how systems design could be used to improve health information delivery and management.

The purpose of this paper is to identify and describe the international and New Zealand (NZ) evidence for models of integrated ambulatory care and describe key implementation issues and lessons learnt.

A scoping review was conducted for published and grey literature on integrated care. Publications from 2000 to February 2019 that described integrated ambulatory care were included.

A total of 34 articles were included. Internationally and in NZ, the most common models of integrated care found were: transfer, relocation and joint working. The international literature showed that transferring care from hospitals to community and other integrated models of care between the primary–specialist interface increased access and convenience for patients. However, there was insufficient evidence of clinical and economic outcomes. Very few NZ-based studies reported on effectiveness of models of care. Key implementation issues were: no viable and sustainable funding, lack of infrastructure, lack of confidence, trust and communication between providers, increased workload and time and knowledge and skills gap to perform new roles. The NZ literature highlighted the need for an appropriate location for services, committed leadership, development of a governance group representing different provider groups, strong communication mechanisms, new workforce skills and overall change management.

The review provides an overview of key components of integrated care models in ambulatory settings and identifies some common elements across the models of care. The findings can inform the design and implementation of integrated ambulatory care in health systems.

Whereas many researchers have examined the way in which health institutions have been transformed through funding modalities, and particularly through prospective payment systems (PPS), few have investigated the architecture of these systems, that is, costs and cost variance. Focusing on the study of costs and on the production of hospital rates, this chapter shows that the French PPS, called “rate per activity” made possible what we call a policy of variance. For health policymakers, the aim was to make the different accounting figures between hospitals, and between ways of practising healthcare, visible, in order to reduce these variances. This policy was attended by uncertainty in the processes of quantification, which led to metrological controversies. As a consequence of the issues around the way of calculating costs, some accounts and calculations were redone. In this chapter, we consider the case of metrological controversy over the remuneration of costs for cystic fibrosis patients’ hospital stays, and over the action of a patient organization that criticized the costs calculated officially. It leads to the analysis of the way calculative infrastructures, as cost accounting and rates, are challenged, and how some actors try to stabilize them.