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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.

Identifies the factors associated with the over utilisation of emergency services or the under utilisation of primary care services. Uses a two year abstraction of medical records containing 2035 visits across 253 children under the age of two. Shows that parents who used less primary care services and too much emergency care provision were often black, single unsupported mother from low income families with low education and little insurance. Cites barriers as location, lack of transport and cost.

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.

This paper aims to report on research undertaken in an National Health Service (NHS) emergency department in the north of England, UK, to identify which patients, with which clinical conditions are returning to the emergency department with an unscheduled return visit (URV) within seven days. This paper analyses the data in relation to the newly introduced Integrated Care Boards (ICBs). The continued upward increase in demand for emergency care services requires a new type of “upstreamist”, health system leader from the emergency department, who can report on URV data to influence the development of integrated care services to reduce further demand on the emergency department.

Patients were identified through the emergency department symphony data base and included patients with at least one return visit to emergency department (ED) within seven days. A sample of 1,000 index visits between 1 January 2019–31 October 2019 was chosen by simple random sampling technique through Excel. Out of 1,000, only 761 entries had complete data in all variables. A statistical analysis was undertaken using Poisson regression using NCSS statistical software. A review of the literature on integrated health care and its relationship with health systems leadership was undertaken to conceptualise a new type of “upstreamist” system leadership to advance the integration of health care.

Out of all 83 variables regressed with statistical analysis, only 12 variables were statistically significant on multi-variable regression. The most statistically important factor were patients presenting with gynaecological disorders, whose relative rate ratio (RR) for early-URV was 43% holding the other variables constant. Eye problems were also statistically highly significant (RR = 41%) however, clinically both accounted for just 1% and 2% of the URV, respectively. The URV data combined with “upstreamist” system leadership from the ED is required as a critical mechanism to identify gaps and inform a rationale for integrated care models to lessen further demand on emergency services in the ED.

At a time of significant pressure for emergency departments, there needs to be a move towards more collaborative health system leadership with support from statistical analyses of the URV rate, which will continue to provide critical information to influence the development of integrated health and care services. This study identifies areas for further research, particularly for mixed methods studies to ascertain why patients with specific complaints return to the emergency department and if alternative pathways could be developed. The success of the Esther model in Sweden gives hope that patient-centred service development could create meaningful integrated health and care services.

This research was a large-scale quantitative study drawing upon data from one hospital in the UK to identify risk factors for URV. This quality metric can generate important data to inform the development of integrated health and care services. Further research is required to review URV data for the whole of the NHS and with the new Integrated Health and Care Boards, there is a new impetus to push for this metric to provide robust data to prioritise the need to develop integrated services where there are gaps.

To the best of the authors’ knowledge, this is the first large-scale study of its kind to generate whole hospital data on risk factors for URVs to the emergency department. The URV is an important global quality metric and will continue to generate important data on those patients with specific complaints who return back to the emergency department. This is a critical time for the NHS and at the same time an important opportunity to develop “Esther” patient-centred approaches in the design of integrated health and care services.

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).

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.

This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.

An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.

High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management’s commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.

This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.

This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.

This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department's value stream maturity.

A process that does not include the customer's value may not be effective in providing care. This study aimed to identify value and waste in an emergency department (ED) patient flow process from a patient and clinician perspective.

A qualitative case study was conducted in an ED in Trinidad and Tobago. Observations and informal conversational interviews with clinicians (n = 33) and patients (n = 50) explored patient flow, value and waste. Thematic analysis was used to create a framework on valuable and wasteful aspects in the ED patient flow process.

Valuable aspects led to direct improvements in the patient's health or an exchange of information in the process. Wasteful aspects were those with no patient activity, no direct ED clinical involvement, or resulted in a perceived inappropriate use of ED resources. However, there was a disparity in responses between clinicians and patients with clinicians identifying more features in the process.

The single case study design limits the generalizability of findings to other settings. This study did not specifically explore the influence of age and gender on what mattered to patients in ED services. Future studies would benefit from exploring whether there are any age and gender differences in patient perspectives of value and waste. Further research is needed to validate the usefulness of the framework in a wider range of settings and consider demographic factors such as age and gender.

The study has produced a framework which may be used to improve patient flow in a way that maximized value to its users. A collaborative approach, with active patient involvement, is needed to develop a process that is valuable to all. The single case study design limits the generalizability of findings to other settings.

Qualitative methods were used to explicitly explore both value and waste in emergency department patient flow, incorporating the patient perspective. This paper provides an approach that decision makers may use to refine the ED patient flow process into one that flows well, improves quality and maximizes value to its users.

There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. The purpose of this paper is to explore the differing staff perceptions in emergency ambulance services in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety.

Drawing on the evidence from an empirical study in a large National Health Service ambulance trust in England, this paper examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition.

Research findings highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences. Need for greater management to explore the relationship between high sickness levels and implications for patient safety including the need for policy and research attention follows from this study. The implications of work intensity on gender equality within the ambulance settings are also discussed.

Ambulance services around the world are witnessing a strain on their operational budgets with increasing demand for their services. Study evidence support inconclusive evidence for patent safety despite the growing specialist paramedic roles. Organisational implications of high staff sickness rates have been largely overlooked in the management literature. This study makes an original contribution while building upon the earlier conceptions of work intensification.

The study findings have significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand. Study findings will help prepare the organisational policies and design appropriate response.

Societal understanding about the organisational implications of the work intensity in an important emergency response service will encourage further debate and discussion.

This study makes an original contribution by providing insights into the intra-organisational dynamics in an unusual organisational setting of the emergency ambulance services. Study findings have implications for further research inquiry into staff illness, patient safety and gender issues in ambulance services. Evidence cited in the paper has further relevance to ambulance services globally.

Most UK ambulance services undertake remote assessments of 999 calls with nurses and paramedics to manage demand and reduce inappropriate hospital admissions. However, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they offer.

The retrospective descriptive study analysed data collected at Welsh Ambulance Services University NHS Trust (WAST) from prioritisation, triage, and audit tools between the 17th May 2022 to 8th November 2022. A total of 21,076 cases and 728 audits were included for review.

There was little difference in the type and frequency of the presenting complaints assessed, and clinical outcomes reached in percentage terms. Whilst paramedics had more highly compliant call audits and fewer non-compliant call audits, there was, again, little difference in percentage terms between the two, indicating positive levels of safety across the two professional groups.

There continues to be a substantial difference between UK paramedics to those in the Middle East, the United States, and some African nations, which may limit the applicability of findings. This study also looked at a six-month window from only one UK service using one type of prioritisation and triage tool. Future research could explore longer periods from multiple services using various tools. It is important to note that this study did not link outcome data with primary, secondary or tertiary care settings. Thus, it is impossible to determine if the level of care aligned closely with the final diagnosis.

The practical implications of this work include better workforce planning for agencies who have perhaps only employed one type of clinician or a reaffirmation to those who have employed both. The authors suggest that the training and education of both sets of clinicians could remain general in nature, with no overt requirement for specificity based on professional registration alone. Commissioners and stakeholders in the wider health economy should consider ensuring equitable access to alternative pathways for patients assessed by both nurses and paramedics.

It has been posited that UK nurses and paramedics are, by virtue of their consistency in education, skill set, licensure, and general experience, both able to achieve safe and effective remote outcomes in 999 settings. This study provides evidence to support that hypothesis. These results say more about the two professions' ability to work together rather than just the professions themselves. The multidisciplinary team approach is well-established in acute care settings, and is broadly considered to improve communication, coordination decision making, adherence to up-to-date treatment recommendations, and be positive for shared learning and development for younger colleagues.

Most UK services use a mix of nurses and paramedics; however, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they each offer. The most recent studies of this nature were published in 2003 and 2004 and looked only at low-acuity 999 calls when remote assessment was not even an established role for UK paramedics. This study updates the literature, identifies areas for future research, and applies to the international setting for the most part.