Service-user involvement in nurse education: partnership or tokenism?

Following on from the Francis Report (2013) the need for a framework of service user involvement is required not just in the Health Service but also in Higher Education. There are wide variances globally on the levels of service user interaction and involvement in healthcare education. Health policy internationally has indicated a move towards developing partnerships with service users but to date this still remains elusive with the majority of user involvement consultative in approach. This paper aims to discuss the Health policy background and the current approaches taken in the involvement of service users in healthcare education.

Impact of different health systems on the burden of type 2 diabetes in two populations

Objectives: Health policy directs the management of patients with chronic disease in a country, but evaluating nationwide policies is difficult, not least because of the absence of suitable comparators. This paper examines the management of patients with type 2 diabetes in two demographically comparable populations with different health care systems to see if this represents a viable approach to evaluation.

Methods: A secondary analysis of centralized prescribing databases for 2010 was undertaken to compare the levels and costs of care of patients with type 2 diabetes in Northern Ireland’s National Health Service (NHS) (NI, n = 1.8 million) which has structured care, financial incentives related to diabetes care and an emphasis on generic prescribing, with that of the Republic of Ireland (ROI, n = 4.3 million) where management of diabetes care is guided solely by clinical and other guidelines.

Results: The prevalence of treated type 2 diabetes was 3.59% in NI and 3.09% in ROI, but there were similar and high levels of prescribing of secondary cardiovascular medications. Medication costs per person for anti-diabetic, anti-obesity and cardiovascular medication were 46% higher in ROI than NI, due to differences in levels of generic prescribing.

Conclusions: These different health care systems appear to be producing similar levels of care for patients with type 2 diabetes, although at different levels of cost. The findings question the need for financial incentives in NI and highlight the large cost savings potentially accruing from a greater shift to generic prescribing in ROI. Cross-country comparison, though not without difficulties, may prove a useful adjunct to within-country analysis of policy impact.

Neonatal intensive care and late preterm infants:Health and family functioning at three years

Background: Late preterm infants (LPIs), born at 34 + 0 to 36 + 6 weeks of gestation contribute a significant proportion of all neonatal intensive care (NIC) admissions and are regarded as being at risk of adverse outcomes compared to term-born infants.

Aim: To explore the health outcomes and family functioning of LPIs who required neonatal intensive care, at three years of age.

Study design and subjects: This cohort study included 225 children born late preterm, between 1 January and 31 December 2006 in Northern Ireland. Children admitted for NIC (study group, n = 103) were compared with children who did not require NIC or who required special care only for up to three days (comparison group, n = 122).

Outcome measures
Health outcomes were measured using the Health Status Questionnaire, health service usage by parent report and family functioning using the PedsQL™ Family Impact Module.

Results: LPIs who required NIC revealed similar health outcomes at three years in comparison to those who did not. Despite this, more parents of LPIs who required NIC reported visiting their GP and medical specialists during their child's third year of life. Differences in family functioning were also observed with mothers of LPIs who required NIC reporting, significantly lower levels of social and physical functioning, increased difficulties with communication and increased levels of worry.

Conclusions: LPIs were observed to have similar health outcomes at three years of age regardless of NIC requirement. The increase in GP and medical specialist visits and family functioning difficulties observed among those infants who required NIC merits further investigation.

Abbreviations: LPI, late preterm infant; NIC, neonatal intensive care; HSQ, Health Status Questionnaire; GP, general practitioner

Responding to mental health statutory drivers: experience of a low intensity cognitive behavioural therapy programme

Objectives Stress control (SC), a brief psycho-education course, was implemented to increase access to psychological therapies in line with Northern Irish mental health service statutory drivers. The first aim of this study was to gauge the efficacy of SC in a robust manner with clinical significance testing. The second aim was to assess whether demographics traditionally ‘hard-to-reach’ – males, younger adults and those from deprived areas – accessed SC. The third aim was to elucidate what prompted their access and the experiences of attendees at SC. Methods Attendees at SC were 170 adults over six iterations of the course. Pre- and post-questionnaires included the Depression Anxiety Stress Scales – 21, captured demographic details and qualitative feedback, which was subject to a mixed-methods analysis. Results SC attendees reported significant decreases on depression, anxiety and stress sub-scales post-intervention. Moreover, 38.71% ( n =36) of attendees who completed SC exhibited clinically significant improvement afterwards on one or more sub-scale. Attendance figures for males, younger adults and those classified as socioeconomically deprived were modest. Patterns within the data suggested prospective success for targeting these cohorts. Conclusions SC attracted people in need of mental healthcare input and affected quantifiable change within those people’s lives, while satisfying statutory demands for service delivery in an accessible community context. Recommendations to increase engagement with those traditionally ‘hard-to-reach’ for psychological services are provided, which, if implemented, have the potential to achieve further compliance with Northern Irish mental health statutory drivers.

Monitoring ocular hypertension, how much and how often? A cost-effectiveness perspective

OBJECTIVE: To assess the efficiency of alternative monitoring services for people with ocular hypertension (OHT), a glaucoma risk factor.

DESIGN: Discrete event simulation model comparing five alternative care pathways: treatment at OHT diagnosis with minimal monitoring; biennial monitoring (primary and secondary care) with treatment if baseline predicted 5-year glaucoma risk is ≥6%; monitoring and treatment aligned to National Institute for Health and Care Excellence (NICE) glaucoma guidance (conservative and intensive).

SETTING: UK health services perspective.

PARTICIPANTS: Simulated cohort of 10 000 adults with OHT (mean intraocular pressure (IOP) 24.9 mm Hg (SD 2.4).

MAIN OUTCOME MEASURES: Costs, glaucoma detected, quality-adjusted life years (QALYs).

RESULTS: Treating at diagnosis was the least costly and least effective in avoiding glaucoma and progression. Intensive monitoring following NICE guidance was the most costly and effective. However, considering a wider cost-utility perspective, biennial monitoring was less costly and provided more QALYs than NICE pathways, but was unlikely to be cost-effective compared with treating at diagnosis (£86 717 per additional QALY gained). The findings were robust to risk thresholds for initiating monitoring but were sensitive to treatment threshold, National Health Service costs and treatment adherence.

CONCLUSIONS: For confirmed OHT, glaucoma monitoring more frequently than every 2 years is unlikely to be efficient. Primary treatment and minimal monitoring (assessing treatment responsiveness (IOP)) could be considered; however, further data to refine glaucoma risk prediction models and value patient preferences for treatment are needed. Consideration to innovative and affordable service redesign focused on treatment responsiveness rather than more glaucoma testing is recommended.

Improving health and wellbeing independently of GDP: dividends of greener and prosoical economies

Increases in gross domestic product (GDP) beyond a threshold of basic needs do not lead to further increases in well-being. An explanation is that material consumption (MC) also results in negative health externalities. We assess how these externalities influence six factors critical for well-being: (i) healthy food; (ii) active body; (iii) healthy mind; (iv) community links; (v) contact with nature; and (vi) attachment to possessions. If environmentally sustainable consumption (ESC) were increasingly substituted for MC, thus improving well-being and stocks of natural and social capital, and sustainable behaviours involving non-material consumption (SBs-NMC) became more prevalent, then well-being would increase regardless of levels of GDP. In the UK, the individualised annual health costs of negative consumption externalities (NCEs) currently amount to £62 billion for the National Health Service, and £184 billion for the economy (for mental ill-health, dementia, obesity, physical inactivity, diabetes, loneliness and cardiovascular disease). A dividend is available if substitution by ESC and SBs-NMC could limit the prevalence of these conditions.

Obama's law : analysis of a breakthrough law on healthcare access and lessons for the Portuguese health system management

ABSTRACT - The Patient Protection and Affordable Care Act shook the foundations of the US health system, offering all Americans access to health care by changing the way the health insurance industry works. As President Obama signed the Act on 23 March 2010, he said that it stood for “the core principle that everybody should have some basic security when it comes to their health care”. Unlike the U.S., the Article 64 of the Portuguese Constitution provides, since 1976, the right to universal access to health care. However, facing a severe economic crisis, Portugal has, under the supervision of the Troika, a tight schedule to implement measures to improve the efficiency of the National Health Service. Both countries are therefore despite their different situation, in a conjuncture of reform and the use of new health management measures. The present work, using a qualitative research methodology examines the Affordable Care Act in order to describe its principles and enforcement mechanisms. In order to describe the reality in Portugal, the Portuguese health system and the measures imposed by Troika are also analyzed. The intention of this entire analysis is not only to disclose the innovative U.S. law, but to find some innovative measures that could serve health management in Portugal. Essentially we identified the Exchanges and Wellness Programs, described throughout this work, leaving also the idea of the possibility of using them in the Portuguese national health system.

Essays in health economics: Volume-Outcome Effect, upcoding behaviour and the evaluation of a short-term intervention program

Evidence in the literature suggests a negative relationship between volume of medical procedures and mortality rates in the health care sector. In general, high-volume hospitals appear to achieve lower mortality rates, although considerable variation exists. However, most studies focus on US hospitals, which face different incentives than hospitals in a National Health Service (NHS). In order to add to the literature, this study aims to understand what happens in a NHS. Results reveal a statistically significant correlation between volume of procedures and better outcomes for the following medical procedures: cerebral infarction, respiratory infections, circulatory disorders with AMI, bowel procedures, cirrhosis, and hip and femur procedures. The effect is explained with the practice-makes-perfect hypothesis through static effects of scale with little evidence of learning-by-doing. The centralization of those medical procedures is recommended given that this policy would save a considerable number of lives (reduction of 12% in deaths for cerebral infarction).

Practice variations in the production of health

This study investigates three questions related to medical practice variation. First, it tests whether average length of stay across Portuguese National Health Service hospitals varies when controlling for differences in patients’ characteristics. Second, it looks at hospital-level characteristics in order to find out whether these are able to explain differences in average length of stay across hospitals. Finally, it proposes a best practice average length of stay for each of the six episodes of care analyzed. To perform the analysis, administrative data from the Diagnosis-Related groups’ data set for the year of 2012 was used. A replication of a hierarchical two-stage model with hospital fixed effects was carried out. The results show that after taking patients’ characteristics into account, variation in average length of stay across hospitals exists. This variation cannot be explained by hospital-level characteristics.

Decentralization and privatization in Portuguese health reforms

ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.

Sustaining Health Care Practice Change: The Experience of Best Practice Spotlight Organizations Implementing and Sustaining RNAO Best Practice Guidelines

Sustainability of change for improvement initiatives has been widely reported as a global challenge both within and outside health care settings. The purpose of this study was to examine the extent to which factors related to staff training and involvement, staff behaviour, and clinical leaders’ and senior leaders’ engagement and support impact the long term sustainability of practice changes for BPSO health care organizations who have implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines. Semi structured interviews with eleven organizational leaders’ from ten health care organizations were conducted to explore the unique experiences, views and perspectives on factors related to staff, clinical leaders and senior leaders and their involvement and impact on the long term sustainability of clinical practice changes within organizations who had implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines (BPGs). The interviews were coded and analyzed using thematic content analysis. Further analysis identified patterns and themes in relation to: 1. The National Health Service (NHS) Sustainability Model which was used as the theoretical framework for this research; and 2. Organizations found to have sustained practice changes longer term verses organizations that did not. Six organizations were found to have sustained practice changes while the remaining four were found to have been unsuccessful in their efforts to sustain the changes. Five major findings in relation to sustainability emerged from this study. First is the importance of early and sustained engagement and frontline staff, managers, and clinical leaders in planning, implementation and ongoing development of BPGs through use of working groups and champions models. Second is the importance of ongoing provision of formal training, tools and resources to all key stakeholders during and after the implementation phase and efforts made to embed changes in current processes whenever possible to ensure sustainability. Third is to ensure staff and management are receptive to the proposed change(s) and/or have been given the necessary background information and rationale so they understand and can support the need for the change. Fourth is the need for early and sustained fiscal and human resources dedicated to supporting BPG implementation and the ongoing use of the BPGs already in place. Fifth is ensuring clinical leaders are trusted, influential, respected and seen as clinical resources by frontline staff. The significance of this study lies in a greater understanding of the influence and impact of factors related to staff on the long term sustainability of implemented practice changes within health care organizations. This study has implications for clinical practice, policy, education and research in relation to sustainability in health care.

Impact of the elderly on household health expenditure in Bihar and Kerala, India

Dans le contexte d’une population vieillissante, nous avons étudié l’impact de la présence de personnes âgées sur les dépenses catastrophiques de santé (DCS), ainsi que leur impact sur trois effets reliés (le fait d’éviter des traitements, la perte de revenu, et l’utilisation de sources de financement alternatives). Nous avons utilisé les données d’une enquête du National Sample Survey Organization (Inde) en 2004, portant sur les dépenses reliées à la santé. Nous avons choisi un état développé (Kerala) et un état en voie de développement (Bihar) pour faire une comparaison des effets de la présence de personnes âgées sur les ménages. Nous avons trouvé qu’il y avait plus de DCS au Kerala et que ceci était probablement lié à la présence accrue de personnes âgées au Kerala ce qui mène à plus de maladies chroniques. Nous avons supposé que l’utilisation de services de santé privés serait lié à une augmentation de DCS, mais l’effet a varié en fonction de l’état, du présence d’une personne âgée, et du type de service utilisé (ambulatoire ou hospitalisation). Nous avons aussi trouvé que les femmes âgées au Bihar utilisait les services de santé moins qu’elle ne devrait, que les ménages ayant plus de 4 personnes ont possiblement un effet protecteur pour les personnes âgées, et que certains castes et group religieux ont dû emprunter plus souvent que d’autres groupes pour payer les frais de santé. La présence de personnes âgées, les maladies chroniques, et l’utilisation de services de santé privées sont tous liés aux DCS, mais, d’après nos résultats, d’autres groupes retardent les conséquences économiques en empruntant ou évitant les traitements. Nous espérons que ces résultats seront utilisés pour approfondir les connaissances sur l’effet de personnes âgées sur les dépenses de santé ou qu’ils seront utilisés dans des discussions de politiques de santé.

Self-exclusion from health care in women at high risk for postpartum depression

Background A significant proportion of women who are vulnerable to postnatal depression refuse to engage in treatment programmes. Little is known about them, other than some general demographic characteristics. In particular, their access to health care and their own and their infants' health outcomes are uncharted. Methods We conducted a nested cohort case-control study, using data from computerized health systems, and general practitioner (GP) and maternity records, to identify the characteristics, health service contacts, and maternal and infant health outcomes for primiparous antenatal clinic attenders at high risk for postnatal depression who either refused (self-exclusion group) or else agreed (take-up group) to receive additional Health Visiting support in pregnancy and the first 2 months postpartum. Results Women excluding themselves from Health Visitor support were younger and less highly educated than women willing to take up the support. They were less likely to attend midwifery, GP and routine Health Visitor appointments, but were more likely to book in late and to attend accident and emergency department (A&E). Their infants had poorer outcome in terms of gestation, birthweight and breastfeeding. Differences between the groups still obtained when age and education were taken into account for midwifery contacts, A&E attendance and gestation;the difference in the initiation of breast feeding was attenuated, but not wholly explained, by age and education. Conclusion A subgroup of psychologically vulnerable childbearing women are at particular risk for poor access to health care and adverse infant outcome. Barriers to take-up of services need to be understood in order better to deliver care.

Roles of the non-medical prescribing leads within organisations across a Strategic Health Authority: perceived functions and factors supporting the role

Objectives Extending the roles of nurses, pharmacists and allied health professionals to include prescribing has been identified as one way of improving service provision. In the UK, over 50 000 non-medical healthcare professionals are now qualified to prescribe. Implementation of non-medical prescribing ( NMP) is crucial to realise the potential return on investment. The UK Department of Health recommends a NMP lead to be responsible for the implementation of NMP within organisations. The aim of this study was to explore the role of NMP leads in organisations across one Strategic Health Authority (SHA) and to inform future planning with regards to the criteria for those adopting this role, the scope of the role and factors enabling the successful execution of the role. Methods Thirty-nine NMP leads across one SHA were approached. Semi-structured telephone interviews were conducted. Issues explored included the perceived role of the NMP lead, safety and clinical governance procedures and facilitators to the role. Transcribed audiotapes were coded and analysed using thematic analytical techniques. Key findings In total, 27/39 (69.2%) NMP leads were interviewed. The findings highlight the key role that the NMP lead plays with regards to the support and development of NMP within National Health Service trusts. Processes used to appoint NMP leads lacked clarity and varied between trusts. Only two NMP leads had designated or protected time for their role. Strategic influence, operational management and clinical governance were identified as key functions. Factors that supported the role included organisational support, level of influence and dedicated time. Conclusion The NMP lead plays a significant role in the development and implementation of NMP. Clear national guidance is needed with regards to the functions of this role, the necessary attributes for individuals recruited into this post and the time that should be designated to it. This is important as prescribing is extended to include other groups of non-medical healthcare professionals.

Problems with accessibility to health services by persons with disabilities in Sao Paulo, Brazil

Purpose. To describe the occurrence of self-reported problems of accessibility to health services used by persons with disabilities in terms of social and health services variables. Methods. We performed a cross-sectional household survey designed to assess problems with accessibility to health services faced by persons with disabilities. We interviewed 333 persons in Sao Paulo city, in 2007. Variables related to the presence of accessibility problems, disabilities, gender, age, family head income, ethnicity, use of health services and others were analysed using frequencies, percentages, chi(2)-test, ANOVA and Poisson regression models. Results. 15.92% of the interviewed persons reported problems with accessibility to health services. Persons having multiple (prevalence ratios; PR = 2.91) or mobility disability (PR = 6.46) had more problems with accessibility than persons with hearing disability. Persons younger than 78 years old had more problems with accessibility; those who needed help to go to the health service (PR = 3.01) also. Conclusions. Persons with multiple or mobility disability, younger than 78 years, and those who needed help of others to go to the health service were more likely to have problems with accessibility to health services. This information could be one of the first steps to the management and/or planning of appropriate health services for persons with disabilities.