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					29/05/09 Innovation and Improvement Bulletin

This bulletin includes research which focuses on improving and developing services to improve the patient journey and make services more effective and efficient. It also includes information on service evaluations and future challenges for services that need to be considered in planning.

Urgent care Intermediate Care Patient Choice Long term conditions Health informatics Innovation and improvement policy Innovation and improvement tools and techniques Urgent care

Contents Workforce innovation and improvement Patient and community involvement Public health Older people Children and young people Mental health Other

Cycles in emergency admissions. Jones, Rod. British Journal of Health Care Management 2009; 15 (5): 239-246 (May 2009) Part one of this series discussed how the more widely recognised factors such as an ageing population and readmissions only contribute to a baseline increase in emergency admissions. Short stay admissions (mainly zero day stay) account for the bulk of the increase. Most diagnoses appear to show a roughly linear trend over time. These are unable to explain the observed cyclical events occurring about every four to six years in medicine, and even longer cycles in surgical and trauma admissions. 4 figs. 1 table 43 refs. [Abstract] Urgent care : a practical guide to transforming same-day care in general practice. Carson, David, et al. McIntosh, Kaye, editor.. Primary Care Foundation Lewes : ESRC, 2009

Back to top Intermediate care
Exploring patients' experiences of a nurse-led follow-up service after critical care. Pattison, Natalie and Dolan, Shelley. Nursing Times 2009; 105 (19): 16-19 (19 May 2009) AIM: To explore the impact of critical care experiences on patients' long-term health. METHOD: This was a mixedmethod interview and questionnaire study that involved patients in the design. Patients were interviewed at different times up to twelve months after critical care discharge. RESULTS: Thirty-seven interviews were carried out with 28 patients. Themes included: rehabilitation from critical care; memories; uncertainty and fear; and empathy; with reassurance as a core theme. Psychological implications need to be considered and nurses' sensitivity and preventative care can help patients deal with the stress and aftermath of critical care. CONCLUSION: Follow-up services, such as the nurse-led service described here, are important in supporting patients.

Back to top Patient Choice
Towards a history of choice in UK health policy. Greener, Ian Sociology of Health and Illness 2009; 31 (3): 309-324 (April 2009) This paper examines health policy documents from the period in which the NHS was planned through to New Labour's reforms, to examine how the terms 'choice' and 'responsiveness' are used to position both users and the public in particular roles.

Back to top Long term conditions
Commissioning for stroke prevention in primary care: the role of atrial fibrillation

NHS Improvement has published 'Commissioning for stroke prevention in primary care: the role of atrial fibrillation'. This document aims to develop a concerted strategy towards the management of atrial fibrillation (AF) in primary care, in particular anticoagulant management and its significance in relation to reduction in the risk of stroke. The document considers the evidence that a review of AF management in primary care is needed to develop more systematic strategies for the identification, diagnosis and optimal treatment of patients with AF to reduce the risk of stroke. It is aimed at cardiac and stroke networks, PCTs, commissioners, medical directors, cardiac and stroke leads, public health colleagues, GPs.

Back to top Health informatics
Patients' views on managing their insulin-dependent diabetes using a remote monitoring option. Wilson, Valerie Journal of Assistive Technologies 2009; 3 (1): 15-20 (March 2009) With the government emphasis on promoting autonomy and independence for patients to control their own health (Department of Health, 2006), choice and flexible healthcare for patients with diabetes is necessary. However, little exploration of patients' perceptions of diabetes remote monitoring and the patient/health provider interaction has taken place. A qualitative survey of 25 motivated and concordant patients using insulin pump therapy to effectively self-manage their diabetes showed a remote review and feedback option was unwelcome. The main reasons for this were that patients preferred to self-manage their diabetes and did not trust health professionals to interpret their data correctly and, for the small minority, their blood glucose monitor and/or insulin pump were not compatible with the hospital diabetes clinic's computer software. This study suggests that a diabetes remote monitoring service may not meet the needs of long duration pump users because it hands over their diabetes self-management to someone else. Health information technology and physician perceptions of quality of care and satisfaction. Davis, Karen, et al. Health Policy 2009; 90 (2/3): 239-246 (May 2009) OBJECTIVE: To examine across seven countries the relationship between physician office information system capacity and the quality of care. DESIGN: Multivariate analysis of a cross-sectional 2006 random survey of primary care physicians in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Coordination and safety of care, care for chronically ill patients, and satisfaction with practice of medicine. RESULTS: The study finds significant disparities in the quality of health care between practices with low information system capacity and those with high technical capacity after controlling for within country differences and practice size. There were significant physician satisfaction differences with the overall experience of practicing medicine by information system level. CONCLUSIONS: For policy leaders, the seven-nation survey suggests that health systems that promote information system infrastructure are better able to address coordination and safety issues, particularly for patients with multiple chronic conditions, as well as to maintain primary care physician workforce satisfaction. Improving the quality of telecare services : the role of audit and training. Doughty, Kevin Journal of Assistive Technologies 2009; 3 (1): 24-28 (March 2009) There is a significant body of evidence from small-scale trials and pilot studies that show telecare services can be costeffective as well as popular with service users and their carers. However, the results of serious external audits and evaluations suggest that many services are inefficient and that telecare technology prescriptions are not always optimised. This appears to be the case especially when referral numbers are small and when many staff are asked to match technology to identified risk. The emerging best practice is for much greater emphasis on making professional staff and members of the public aware of the potential of the technology, and then using a small, highly-trained and experienced team to ensure that telecare solutions are person-centred and tailored to the individual's needs. A major gap in training for these teams has been identified. Indicated benefits of bed epilepsy sensors to users of a telecare service in the Republic of Ireland. Fisk, Malcolm J. Journal of Assistive Technologies 2009; 3 (1): 37-40 (March 2009) This paper examines, by reference to a telecare service evaluation in the Republic of Ireland, the role and potential of bed epilepsy sensors. It points to benefits for both users and carers that arise from the sensors both enabling speedy responses in the event of a seizure, and in their providing reassurance and a better quality of life for both parties.] Physical and digital proximity : emerging ways of health care in face-to-face and telemonitoring of heart-failure patients. Oudshoorn, Nelly Sociology of Health and Illness 2009; 31 (3): 390-405 (April 2009) This paper provides a comparative study of health-care services for heart-failure patients based on face-to-face contacts in a polyclinic (department of a health care facility treating outpatients) and remote consultations at a telehealth-care centre. The Information Standard The Department of Health has published details of the Information Standard. The Information Standard is a new certification scheme for health and social care information producers. Those organisations that meet the criteria of The Information Standard will then be entitled to place a quality mark on their information materials so people searching for health and social care information can easily identify it as coming from a reliable, trustworthy source.

Primary care information for the public The Health Services Management Centre has recently completed a series of evidence reviews exploring the provision of public information about the quality of primary care services. Each review addresses a specific question including: what information about the quality of primary care services do patients and the public want; which information formats are most accessible and effective; and how can information be presented to empower patients to make an informed choice of primary care provider?

Back to top Innovation and improvement policy
Joined up thinking. Hawkes, Nigel BMJ 2009; 338 (7705): 1238-1239 (23 May 2009) The government hopes that integration of services will improve care, but as Nigel Hawkes reports the pilot schemes have a lot to prove. Common Assessment Framework for Adults The Department of Health has published 'Common Assessment Framework for Adults demonstrator site programme: overview of phase 1 sites'. Nine local authority led partnerships have been selected as phase 1 demonstrator sites and will develop and test improved information sharing across health, social care and wider community support services. This document provides an overview for interested parties of what each site will be addressing and the organisations involved in the partnership. The sites are led by the local adult social services and involve a range of community and acute health services, mental health trusts, housing support services and IT suppliers as well as wider partners in the voluntary and private sector. Primary Care Service Framework for gypsies and travellers NHS Primary Care Contracting has published a primary care service framework for gypsies and travellers. Payment by Results benchmarking tool As part of the PbR Data Assurance Framework, the Audit Commission has developed an online tool to assist with Payment by Results benchmarking. This tool covers both inpatient and outpatient data, and is based on over 40 separate data quality indicators. The analysis uses indirect standardisation and funnel plots to ensure the process of identifying outliers is as representative and equitable as possible. It allows commissioners and providers to undertake their own investigations, encouraging self-monitoring and helping trusts to identify issues independently of the clinical coding audits. Access to the National Benchmarker is free to the NHS. To gain access you need to go to the Economic incentives in general practice : the impact of pay-for-participation and pay-for-compliance programs on diabetes care. Lippi Bruni, Matteo, et al. Health Policy 2009; 90 (2/3): 140-148 (May 2009) OBJECTIVES: We investigate the impact on quality of care of the introduction of two financial incentives in primary care contracts in the Italian region Emilia Romagna: pay-for-participation and pay-for-compliance with best practices programs. METHODS: We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of general practitioners (GPs) receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examine the combined influence of physician, organisational and patient factors by means of multilevel modelling for the year 2003. RESULTS: Programs aimed at stimulating GP assumption of responsibility in disease management significantly reduce the probability of hyperglycaemic emergencies for their patients. Using pay-for-performance to introduce changes in primary healthcare centres in Spain : first year results. Benavent, Jaume, et al. Quality in Primary Care 2009; 17 (2): 123-131 This study aimed to evaluate the changes and to describe the experience of a variable payment scheme linked to quality objectives in two primary healthcare centres in Spain. The impact of pay-for-performance on professional boundaries in UK general practice : an ethnographic study. Grant, Suzanne, et al. Sociology of Health and Illness 2009; 31 (2): 229-245 (March 2009) The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating

long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.

Back to top Innovation and improvement tools and techniques
Practitioner-led rapid cycle change. Powell, Alison, et al. British Journal of Health Care Management 2009; 15 (5): 218-222 (May 2009) The practitioner-led 'rapid cycle change' approach uses the Plan-Do-Study-Act cycle widely promulgated by the U.S. Institute for Healthcare Improvement (IHI). It has been used in many healthcare organisations, particularly as a key component of quality improvement collaboratives. As a small-scale, bottom-up approach, rapid cycle change has several advantages over other quality improvement approaches, but like them it runs into a range of obstacles in healthcare settings. Further studies are needed to establish its impact on practice patterns and outcomes. Towards a new transatlantic zone. Cantle, Florence British Journal of Health Care Management 2009; 15 (5): 229-233 (May 2009) Transatlantic learning is something I always want to do. In order to know more about what transatlantic learning is and what the benefits are, the author conducted a first-hand investigation, the overall aim of which was to increase knowledge of the area. In addition, the author aims to apply the knowledge gained to current practice. The Oxford NOTECHS system : reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Mishra, A., et al. Quality and Safety in Health Care 2009; 18 (2): 104-108 (April 2009) The frequency of adverse events in the operating theatre has been linked to the quality of teamwork and communication. Developing suitable measures of teamwork may play a role in reducing errors in surgery. This study reports on the development and evaluation of a method for measuring operating-theatre teamwork quality. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. McCulloch, P., et al. Quality and Safety in Health Care 2009; 18 (2): 109-115 (April 2009) Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before-after study of the effects of 'nontechnical' skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. The setting was the theatre suite of a UK teaching hospital. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Marshall, S., et al. Quality and Safety in Health Care 2009; 18 (2): 137-140 (April 2009) INTRODUCTION: Suboptimal communication between health professionals has been recognised as a significant causative factor in incidents compromising patient safety. The use of a structured method of communication has been suggested to improve the quality of information exchange. The aim of this RCT was to determine if the teaching of a communication tool, ISBAR (Identify, Situation, Background, Assessment, Recommendation), a modification of SBAR (Situation, Background, Assessment, Recommendation), improved the content and clarity of a telephone referral in an immersive simulated clinical scenario conducted in real time. RESULTS: Communication content was higher from a mean score of 10.2 to 17.4 items (p<0.001) with the intervention. Clarity of the delivery of information on a five-point scale was also higher in the intervention group ( = 0.903, p<0.001). Assessing organisational culture for quality and safety improvement : a national survey of tools and tool use. Mannion, R., et al. Quality and Safety in Health Care 2009; 18 (2): 153-156 (April 2009) BACKGROUND: There is growing international interest in managing organisational culture as a lever for healthcare improvement. This has prompted a practical need to understand what instruments and tools exist for assessing cultures in healthcare contexts. The present study was undertaken to determine the culture assessment tools being used in the English NHS and assess their fitness for purpose. METHODS: Postal questionnaire survey of clinical governance leads in 275 English NHS organisations, with a response rate of 77 per cent. RESULTS: A third of the organisations were currently using a culture assessment instrument to support their clinical governance activity. Although we found a high degree of satisfaction with existing instruments, in terms of ease of use and relevance, there is an immediate practical need to develop new and better bespoke culture assessment tools to bridge the gap between the cultural domains covered by extant instruments and the broader range of concerns of clinical governance managers. CONCLUSION: There is growing interest in understanding and shaping local cultures in healthcare, which is not yet matched by widespread use of available instruments. Even though extant tools cover many of the most important cultural attributes identified by clinical governance managers, the over-riding focus of tools in use is on safety rather than a holistic assessment of the dimensions of healthcare quality and performance.

Back to top Workforce innovation and improvement
Effective team leadership : techniques that nurses can use to improve teamworking. Nash, Sue and Govier, Ian. Nursing Times 2009; 105 (19): 22-24 (19 May 2009) This is the second article in a two-part series on leadership. The first examined transformational approaches to effective leadership in healthcare settings. This article describes the strategies that nurses can use to ensure healthcare teams are effective: team reflection; ensuring all members participate; and establishing ground rules. Current ward manager roles do not reflect nurses' career ambitions. Scott, Janet Nursing Times 2009; 105 (19): 11 (19 May 2009) The change in role from ward sister to ward manager has caused significant recruitment problems, as nurses want to provide expert care, not balance books, says Janet Scott. Interprofessional learning in practice. Simpson, Trevor British Journal of Health Care Management 2009; 15 (5): 223-228 (May 2009) The NHS provides a rich culture of innovation, change and opportunities to improve patient care. This article will discuss the setting required to enable the inclusion of interprofessional learning (IPL) and interprofessional working (IPW) to become an inherent part of an organisation's learning and working strategy. This article argues the need for NHS trusts and social care organisations to embrace interprofessional learning and working in a more unified and coordinated way. This will need extensive investment with controlled change management programmes from central government. Collaboration between pharmacists, physicians and nurse practitioners : a qualitative investigation of working relationships in the inpatient medical setting. Makowsky, Mark J., et al. Journal of Interprofessional Care 2009; 23 (2): 169-184 (March 2009) While collaborative, team-based care has the potential to improve medication use and reduce adverse drug events and cost, less attention is paid to understanding the processes of well functioning teams. This paper presents the findings from key informant interviews and reflective journaling from pharmacists, physicians and nurse practitioners participating in a multicentre, controlled clinical trial of team-based pharmacist care in hospitalized medical patients. A phenomenological approach guided the data analysis and content analysis was the primary tool for unitizing, categorizing and identifying emerging themes. Pharmacists experienced highs (developing trusting relationships and making positive contributions to patient care) and lows (struggling with documentation and workload) during integration into the medical care team. From the perspective of the participating pharmacists, nurse practitioners and physicians, the integration of pharmacists into the teams was felt to have facilitated positive patient outcomes by improving team drug-therapy decision-making, continuity of care and patient safety. Additionally, the study increased the awareness of all team members' potential roles so that pharmacists, nurses and physicians could play a part in and benefit from working together as a team. Focussed attention on how practice is structured, team process and ongoing support would enable successful implementation of team-based care in a larger context.

Back to top Patient and community involvement
Balancing patient preferences and clinical needs: community versus hospital based care for patients with suspected DVT. Clark, Michael, et al. Health Policy 2009; 90 (2/3): 313-319 (May 2009) OBJECTIVE: To establish patients' preferences and willingness to pay (WTP) for different service models for suspected deep vein thrombosis (DVT). METHODS: We analysed patient responses to a discrete choice experiment (DCE) questionnaire which had been targeted at patients in Leicester, UK. The questionnaire elicited preferences/WTP for attributes of DVT provision including speed of diagnosis; access; continuity of care; and minimizing hospital visits. Additionally we evaluated trade-offs between clinical and service attributes. We analysed responses from 256 patients with suspected DVT (65 per cent response rate). RESULTS: Respondents are WTP £4.82 per extra hour of dedicated DVT service provision; £17.12 per hospital visit avoided; £115.73 per day's reduction in diagnostic wait; and £179.32 for 'much' not 'some' continuity, or £56.88 for 'some' not 'lack' of continuity in nursing. CONCLUSIONS: Research evaluating different DVT service models usually reports on clinical efficacy in centres of excellence. Results show prompt diagnosis is valued by patients and may improve efficacy by reducing unnecessary anticoagulation. However, patients value 'process' measures such as continuity of care also. To ensure optimal provision, clinical benefit Development of a patient experience questionnaire for primary care mental health. Mavaddat, N., et al. Quality and Safety in Health Care 2009; 18 (2): 147-152 (April 2009) INTRODUCTION: There are no validated measures available for use in assessing patients' views of the quality of primary care mental healthcare at practice level. METHODS: The Patient Experience Questionnaire was developed through an initial information-gathering phase with focus groups followed by questionnaire development and validation with patients in nine general practices in the West Midlands. Statistical analyses were performed to test the internal consistency, validity and

reliability of the questionnaire. RESULTS: Fifty-six patients participated in focus groups, and 241 patients completed the questionnaire. The 20-item questionnaire had good internal consistency (Cronbach = 0.94) and test-retest reliability (r = 0.859; p = 0.01). DISCUSSION: The Patient Experience Questionnaire appears to be a valid and reliable instrument, able to assess patients' views of the quality of primary care mental healthcare at practice level. National NHS patient survey programme : survey of adult inpatients 2008 : full national results with historical comparisons. London : Care Quality Commission, 2009 Detailed results for individual NHS trusts Using the EQ-5D as a performance measurement tool in the NHS. Devlin, Nancy J., et al. Office of Health Economics, et al. London : City University, 2009 Department of Economics Discussion Paper ; Series No. 09/03 The Department of Health is introducing the routine use of Patient Reported Outcome Measures (P.R.O.M.s) as a means of measuring the performance of health care providers in improving patient health. From April 2009 all patients will be asked to complete both generic (EQ-5D) and condition specific PROMs before and after surgery for four elective procedures; the intention is to extend this to a wide range of other NHS services. The aim of this paper is to report analysis of the EQ-5D data generated from a pilot study commissioned by the DH, and to consider the implications of the results for their use as performance indicators and measures of patient benefit. A guide to using patient feedback to transform care The Department of Health has published 'Understanding what matters: A guide to using patient feedback to transform care'. This guide sets out best practice in terms of collecting, analysing and using patient feedback to transform services. It also includes examples of how the NHS is already using feedback from patients to get results. This resource is one of a number being produced to help services understand and respond to what really matters to patients and their experiences of care.

Back to top Public health
Betting on health. McColl, Karen BMJ 2009; 338 (7704): 1173-1175 (16 May 2009) U.S. websites are encouraging people to make public commitments to change their behaviour. Karen McColl investigates whether they work and the implications for public health policy. Can syndromic thresholds provide early warning of national influenza outbreaks? Cooper, D. L., et al. Journal of Public Health 2009; 31(1): 17-25 (March 2009) BACKGROUND: Influenza incidence thresholds are used to help predict the likely impact of influenza and inform health professionals and the public of current activity. We evaluate the potential of syndromic data (calls to a UK health helpline NHS Direct) to provide early warning of national influenza outbreaks. METHODS: Time series of NHS Direct calls concerning 'cold/flu' and fever syndromes for England and Wales were compared against influenza-like-illness clinical incidence data and laboratory reports of influenza. Poisson regression models were used to derive NHS Direct thresholds. The early warning potential of thresholds was evaluated retrospectively for 2002-06 and prospectively for winter 2006-07. RESULTS: NHS Direct 'cold/flu' and fever calls generally rose and peaked at the same time as clinical and laboratory influenza data. We derived a national 'cold/flu' threshold of 1.2 per cent of total calls and a fever (5-14 years) threshold of nine per cent. An initial lower fever threshold of 7.7 per cent was discarded as it produced false alarms. Thresholds provided two weeks advanced warning of seasonal influenza activity during three of the four winters studied retrospectively, and six days advance warning during prospective evaluation. CONCLUSION: Syndromic thresholds based on NHS Direct data provide advance warning of influenza circulating in the community. We recommend that age-group specific thresholds be developed for other clinical influenza surveillance systems in the UK and elsewhere. What a difference a decade makes : rethinking teenage pregnancy as a problem. Arai, Lisa Social Policy and Society 2009; 8 (2): 171-183 (April 2009) The Teenage Pregnancy Strategy (TPS) has been implemented in England since 1999 and has two aims: to halve under 18s conceptions; and to reduce the risk of social exclusion among young mothers. The TPS portrays young motherhood as problematic, the cause of poor outcomes. Yet, the problematisation of teenage fertility has been contested, especially by qualitative researchers who have demonstrated that early motherhood can be experienced positively. This research is discussed here, as are findings from a small-scale study in three English locations, where teenage mothers reported good experiences of parenthood. The discrepancy between these accounts of motherhood and policy is considered. Food and eating as social practice : understanding eating patterns as social phenomena and implications for public health. Delormier, Treena, et al. Sociology of Health and Illness 2009; 31 (2): 215-228 (March 2009)

We propose a theoretical framework for the examination of eating patterns as social phenomena. Giddens' structuration theory, in particular his concept of social practices understood as an interplay of 'agency' and 'social structure' (rules and resources), is used to study food choice patterns. We discuss the application of these concepts for understanding routine food choice practices of families, elaborating how rules and resources configure the enabling or constraining conditions under which actors make food choices. The framework assists in characterising how social structural properties are integral to food choice practices, and could direct attention to these when considering nutrition interventions aimed at changing population eating patterns. Economic inequality and population health : looking beyond aggregate indicators. Bockerman, Petri, et al. Sociology of Health and Illness 2009; 31 (3): 422-440 (April 2009) This paper studies the sensitivity of various health indicators to income inequality as measured by regional Gini coefficients, using individual microdata from Finland over the period 1993-2005. There is no overall association between income and health at the regional level. We discovered that, among men, there are no significant associations between income inequality and several measures of health status. Among women or among both sexes combined, there are some indications of associations in the predicted direction between income inequality and physical health, disability retirement, sick leave, and consumption of medicines, but none are robust to different model specifications. Only among the population aged less than 30 there is some indication that mental health is associated with inequality. Our findings confirm that income inequality in small populations (not large enough to measure the overall class pyramid of the society) is often immaterial for health outcomes. Alcohol statistics The Information Centre has published 'Statistics on Alcohol, England 2009'. This statistical report presents a range of information on alcohol use and misuse drawn together from a variety of published sources. Heatwave plan 'Heatwave plan for England 2009' has been published by the Department of Health. The Plan's purpose is to enhance resilience in the event of a heatwave. Healthy Schools programme reports Three reports have been published on the Healthy Schools website: - An evaluation of the National Healthy Schools Programme: interim report - Relationship between National Healthy School Status (NHSS) and selected school outcomes - National Healthy Schools Programme: developing the evidence base Alcohol primary care service framework The NHS Primary Care Contracting 'Alcohol primary care service framework' for those drinking to hazardous and harmful or dependent levels has been updated to include recent policy changes and includes enhanced tools to support implementation. This document provides examples of good practice in alcohol services in primary care and can be adapted and used as a basis for an enhanced service via a schedule within a local primary care contract or service level agreement.

Back to top Older people
Modernising social care services for older people : scoping the United Kingdom evidence base. Jacobs, Sally, et al. Ageing and Society 2009; 29 (4): 497-538 (May 2009) The authors were commissioned to examine the evidence base for the modernisation of social care services for older people, and for this purpose conducted a systematic review of the relevant peer-reviewed UK research literature published from 1990 to 2001. Publications that reported descriptive, analytical, evaluative, quantitative and qualitative studies were identified and critically appraised under six key themes of modernisation: integration, independence, consistency, support for carers, meeting individuals' needs, and the workforce. The account provides a systematic portrayal both of the state of social care for older people prior to the modernisation process and of the relative strengths and weaknesses of the evidence base. It suggests that, for evidence-based practice and policy to become a reality in social care for older people, there is a general need for higher quality studies in this area. Inequalities in health in an aging population: patterns, causes and consequences : full research report. Nazroo, James, et al. Swindon : ESRC, 2009 Economic and Social Research Council End of Award Report ; RES-000-23-0590

Back to top Children and young people
European children still at high risk of injury.

Hyde, Rob Lancet 2009; 373 (9677): 1752 (23 May 2009) Unintentional injury remains Europe's leading cause of death for children aged 5-19 years, according to a pan-European initiative designed to improve child safety. Housing for disabled children and their families The Joseph Rowntree Foundation has published 'Housing for disabled children and their families: an information resource'. This resource draws together information from multiple sources to aid access to relevant research, law and policy guidance. Its aim is to present key messages about housing for disabled children and their families to workers who are not specialists in housing, their managers and affected families. It is intended both as a resource to be read and as a guide about the provision of training. Preventing harm to children from parents with mental health needs The National Patient Safety Agency has issued a Rapid Response Report 'Preventing harm to children from parents with mental health needs'. Staff in adult mental health services caring for a parent must always consider the child’s needs and the potential for physical and psychological harm as primary task of the Care Programme Approach (CPA) and as part of multiagency risk assessment processes. Risks should also be considered for service users who are not parents but are in contact with children e.g. service users with child siblings or grandchildren. This report sets out actions which must be completed by mental health organisations by 27 November 2009.

Back to top Mental health
Development and implementation of early intervention services for young people with psychosis: case study. Lester, Helen, et al. British Journal of Psychiatry 2009; 194 (5): 446-450 (May 2009) BACKGROUND: The development of early intervention services for young people with first-episode psychosis is a priority internationally. AIMS: To evaluate the development, implementation and impact of existing and newly formed early intervention services in England. METHOD: Multiple-case study involving staff, users, carers and commissioners of 14 early intervention services. RESULTS: Service numbers increased in response to national policy directives. They were still actively working with 90.6 per cent of service users twelve months after inception. They were highly valued by users and carers as providing a personal service that contrasted with previous experiences of care. Tensions between providing a quality service and meeting case-load targets linked to future funding led teams to adopt a series of survival strategies with some unintended consequences. CONCLUSIONS: Early intervention services are highly valued by consumers and engage users effectively after twelve months. Implementation of these services is threatened unless sufficient consistent funding is made available. In-patient and residential alternatives to standard acute pyschiatric wards in England. Johnson, Sonia, et al. British Journal of Psychiatry 2009; 194 (5): 456-463 (May 2009) BACKGROUND: Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years. AIMS: Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations. METHOD: National cross-sectional survey of alternatives to standard acute in-patient care. RESULTS: We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions. CONCLUSIONS: Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care. Healthy mind, healthy body : how liaison psychiatry services can transform quality and productivity in acute settings. NHS Confederation Briefing 2009; (179): (April 2009) One quarter of acute inpatients have mental health problems. Evidence suggests that identifying and treating the mental health needs of acute inpatients early has a direct impact on the recovery of their physical health. Liaison services can improve care and bring costs savings as patients can be discharged earlier if their mental health needs are addressed. Services can also bring savings for primary care trusts (PCTs) by reducing re-attendances. First-episode psychosis : primary care experience and implications for service development. El-Adl, Mamdouh, et al. Psychiatric Bulletin 2009; 33 (5): 165-168 (May 2009) AIM AND METHODS: To capture the local primary care experience of first-episode psychosis before developing a local early intervention in psychosis service. A survey of Northamptonshire general practitioners (GPs) using a confidential questionnaire was carried out. RESULTS: Out of 284 GPs, 123 (43 per cent) responded. General practitioners are unlikely to start treatment before referring to a specialist service: 63 GPs (51 per cent of responders) start treatment in ten per cent or less of individuals with first-episode psychosis and 19 (15.5 per cent) GPs start treatment in 75 per cent or more

before referring them to psychiatric service; 42 GPs (34 per cent) refer those who request/accept a referral and 66 GPs (53 per cent) refer all even if they refuse. Overall, 92 GPs (74 per cent) agreed that an early intervention in psychosis service is needed and 77 (63 per cent) GPs welcome having a mental health clinic in their surgery. CLINICAL IMPLICATIONS: Individuals are more likely to accept referral to a psychiatric service if offered than to ask for it. People disengaging, stigma, the service being difficult to access/inappropriate and carers' lack of knowledge about mental illness are the likely causes for delayed referral. Childhood mental health and life chances in post-war Britain : insights from three national birth cohort studies. Richards, Marcus, et al. This report was co-sponsored by SCMH and The Smith Institute with Unison and the Medical Research Council (MRC). Executive summary

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[Operational Research Applied to Health Services (ORAHS) 2007 : special issue.] Dexter, Franklin, et al., editors Health Care Management Science 2009; 12 (2) (June 2009) This issue is made up of the following papers: 'Optimizing nursing human resources planning in British Columbia', Mariel S. Lavierie and Martin L. Puternam, pages 119-128; 'Patient mix optimisation and stochastic resource requirements : a case study in cardiothoracic surgery planning', Ivo Adan, et al., pages 129-141; 'What is the best workflow for an operating room? : a simulation study of five scenarios', Riitta A. Marjamaa, et al., page 142-146; 'Speed and quality in coronary artery bypass graft (CABG) surgery : is there a connection?', Juha-Matti Lehtonen, et al., pages 147-154; 'Restructuring patient flow logistics around patient care needs :implications and practicalities from three critical case', Stefano Villa, et al.; 'Redesigning pharmacy delivery processes of a health care complex', Vincent Augusto and Xiaolan Xie, pages 166- 178; 'Exploring new operational research opportunities within the home care context : the chemotherapy at home', Salma Chahed, et al., pages 179-191; and 'The economics of cancer care : longitudinal changes in provider efficiency', James R. Langabeer II and Yasar A. Ozcan, pages 192-200. Market-based control mechanisms for patient safety. Coiera, E. and Braithwaite, J. Quality and Safety in Health Care 2009; 18 (2): 99-103 (April 2009) A new model is proposed for enhancing patient safety using market-based control (MBC), inspired by successful approaches to environmental governance. Emissions trading, enshrined in the Kyoto protocol, set a carbon price and created a carbon market - is it possible to set a patient safety price and let the marketplace find ways of reducing clinically adverse events? To 'cap and trade,' a regulator would need to establish system-wide and organisation-specific targets, based on the cost of adverse events, create a safety market for trading safety credits and then police the market. Organisations ar e given a clear policy signal to reduce adverse event rates, are told by how much, but are free to find mechanisms best suited to their local needs. The market would inevitably generate novel ways of creating safety credits, and accountability becomes hard to evade when adverse events are explicitly measured and accounted for in an organisation's bottom line. The Week The Department of Health has published the latest issue of 'the week' (Issue 97, 22-28 May 2009)

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This bulletin is produced by NHS Rotherham Knowledge Service on behalf of NHS Rotherham Innovation and Improvement team. This issue draws from The King’s Fund Current Awareness Service 11th – 22nd May 2009 and the Daily Health th th Bulletin 18 – 29 May. Copies of articles and documents mentioned in this bulletin may be available from your local library or knowledge service. If you would like to subscribe to the Innovation and Improvement bulletin please contact the NHS Rotherham Knowledge Service using the contact details below. You may be interested to know that the Sheffield Health Informatics Service produces the Daily Health Bulletin which covers the latest health news stories. Knowledge Service NHS Rotherham Oak House Tel: 01709 302096

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