Journal of Health Services Research & Policy最新文献

ObjectivesTo explore the quality of end-of-life care in England and Wales using the experiences of bereaved family carers, and to develop person-centred quality of care domains for end-of-life care.MethodsQualitative analysis of free-text responses from a nationally-representative cross-sectional post-bereavement survey. Inductive thematic analysis of free-text responses to open-ended questions about care in last 3 months of life, circumstances of death, and experiences of care and bereavement, guided by the Institute of Medicine's quality domains. Participants were adults who registered the death of an adult relative in England and Wales between August and December 2022, identified using mortality data and stratified sampling (by age, gender, cause of death, place of death and geographical area).ResultsOf 1194 respondents, 1083 (90.7%) gave at least one free-text response. Six themes about quality of end-of-life care were identified: (1) accessing care; (2) timely and coordinated care; (3) individualised care; (4) the nature of communication and care; (5) family-centred care and support; and (6) safe and equitable care. Difficulty accessing care, challenges navigating a complex system, and poorly-coordinated care were interpreted as leading to a lack of physical and psychological safety. Timeliness of care was considered paramount but often not achieved. How care was provided was as important as what was provided: empathic relational care (in contrast to transactional, task-based care) led to dying people and their families reporting feeling reassured, supported and safe.ConclusionsWe identify aspects of quality important for care which are currently not always achieved, and provide a refined model of the quality of end-of-life care to guide policy and research.

BackgroundMedicaid provides health insurance for 40% of the United States (US) pediatric population. There is an increasing trend among states to transition from a fee-for-service model for Medicaid reimbursement to relying on risk-based delivery systems using Managed Care Organizations (MCOs). In 2021, most beneficiaries in North Carolina (NC) transitioned to one of five MCOs from Medicaid Direct. While research has examined the effects of these transitions, less is known on the impact of MCOs on the experiences of caregivers of children getting care for themselves and their children. This study aimed to explore the experiences of caregivers following the NC Medicaid Transformation, both in enrolling and accessing care for themselves, when applicable, and for their children.MethodsWe conducted a qualitative descriptive study to examine experiences of caregivers of children during the NC Medicaid Transformation. We identified participants from clinic sites and health services organizations in North Carolina. Nineteen caregivers participated in semi-structured interviews or a focus group. We conducted rapid qualitative analysis of transcripts for timely, action-oriented analysis. Rapid qualitative analysis involved developing a summary template with inductive domains from the interview guide categories.ResultsAmong caregivers, all were mothers, and the majority resided in urban areas. Eleven caregivers were adult Medicaid beneficiaries in addition to their child receiving Medicaid. Caregivers described a variety of experiences and three themes were identified: increased obstacles among families with health conditions requiring additional care and non-English speakers; crucial role of clinical staff in navigating the transformation and accessing care; satisfaction with MCOs despite challenges.ConclusionsIncreasing access to specialty care by strengthening network adequacy standards, investing trained support staff within MCOs on how to best serve families with health conditions requiring additional care and non-English speaking families, and reimbursing clinical staff who are already performing a care management role, could positively impact families receiving care through Medicaid MCOs.

BackgroundThere is a global health care workforce crisis with staff shortages and difficulties with recruitment and retention, including in the UK's National Health Service (NHS). To address this, it is important to understand why people decide to leave the NHS. Previous reviews have focused on specific NHS professions and have rarely considered factors in other settings which attract staff away from the NHS. This review aimed to include all professions in a systematic review of factors which "push" clinical staff to leave, or consider leaving, the NHS and which "pull" them to other destinations.MethodsWe searched PubMed, Web of Science, CINAHL, and EMBASE for peer-reviewed articles and Google Scholar for grey literature using search terms related to all NHS professions and intentions to leave the NHS. We included qualitative, quantitative, and mixed methods studies and analysed data using a textual narrative synthesis with an integrated design.ResultsThirty-two papers were eligible for inclusion. We identified four key push factors: (1) high job demands due to, for example, staff shortages and increased workload; (2) failing organisational structures including poor pay and limited opportunities for career development; (3) personal and emotional factors such as work-related health issues and poor work/life balance, and (4) wider factors, including Brexit. The majority of factors identified as being responsible for high turnover were related to job demands and the organisational structure within the NHS. Factors pulling people to other destinations were discussed less frequently than push factors, but included perceptions of better: pay, working conditions, and work/life balance in other countries. Limitations to the studies included in the review were that evidence on all NHS professions was not available, and many of the studies were based on data collected retrospectively with the risk of recall bias.ConclusionPull and push factors affect multiple NHS professions. Further comparative studies comparing the UK with other countries can help inform potential interventions to improve staff retention.

ObjectivesPerinatal death review programmes collect perinatal mortality data and identify modifiable factors in preventable perinatal deaths. Reviews may provide closure and answers to bereaved parents. Many parents remain uninvolved in the review process. This qualitative study aimed to explore the opinions of maternity staff regarding the existing review system, parent involvement in reviews and standardising the review system.MethodsThis study involved interviews with staff from three maternity units in different locations around Ireland. A topic guide was used to guide the discussion. We spoke with staff members from different backgrounds and managerial levels, including doctors, midwives, patient advocates, risk managers and pastoral care. Thematic analysis was conducted to analyze the results.Results32 interviews were conducted between May and December 2022. Three themes and six associated subthemes were generated relating to communication with parents regarding review and their involvement in this process. Participants felt that parents were not involved enough in the review process and that communication with parents about reviews needed improvement. A parent advocate was viewed as important for guidance and support for parents during the review process. Facilitators included an easy-to-use, electronic review form and providing education about the review process. Barriers included local resistance to changing the process and lack of time to complete reviews.ConclusionPerinatal death reviews are not standardised in Ireland. Communication with parents and parent involvement in reviews could be improved. Highlighted facilitators and barriers should be addressed prior to implementing any proposed changes to the review system.

As a solution to the current international workforce crisis in general practice, many countries are introducing initiatives of task-shifting. These initiatives involve a tendency to 'taskification', which means that complex work is dissected into smaller tasks that are delegated between different healthcare professionals. Drawing on existing academic literature and international policy developments, this essay aims to problematise the idea of taskification as a solution to the workforce crisis in general practice. The concept of taskification is introduced and elaborated by tracing its roots to the theories of Taylorism and New Public Management. Like these organizational paradigms, the concept of taskification reflects a prioritization of efficiency, standardization, and managerial control, which may fragment healthcare delivery and undermine the holistic and discretionary nature that traditionally characterizes general practice. Furthermore, taskification is discussed in relation to challenges in general practice and international policy developments, which illustrate that taskification, while aimed at reducing workloads, often adds new pressures through supervision, "rescue" work, and the complexity of care, ultimately risking burnout and reduced efficiency. We conclude that while taskification offers potential solutions to workforce challenges in general practice, it risks unintended consequences such as care fragmentation, increased workload pressures, and compromised patient safety. A nuanced approach with adequate training, supervision, and protection of GP time is suggested to ensure these strategies benefit healthcare systems, practitioners, and patients.

ObjectivesTo present the findings from a national survey of senior leaders in NHS and independent hospitals in England concerning the effectiveness of shared arrangements for clinical governance. To provide a comprehensive overview of shared arrangements for the oversight of consultants' practice, processes for appraisal and revalidation, and the management of significant concerns. The results from this study will improve understanding of the practical functioning of clinical governance processes at the interface between the NHS and the independent sector.MethodsBetween December 2023 and April 2024, an online survey was distributed to senior leads with governance responsibilities in NHS and independent hospitals in England.Results320 responses were received (response rate 42%), 235 from individuals working in NHS trusts (response rate 40%) and 85 from individuals in independent hospitals (response rate 48%). Respondents reported that some clinical governance arrangements are established across both sectors, with some relationships characterised as positive and relatively strong. However, relationships often depended on goodwill, personal connections, and consultant probity, rather than the systematic implementation of recommended processes. Respondents expressed concerns regarding the non-mandatory and unregulated nature of processes for sharing concerns, believing this led to insufficient resources and challenges in verifying information. They called for improved data quality, better communication and information sharing and more robust and formalised processes.ConclusionsShared clinical governance arrangements between the NHS and independent sectors are in place in some but not all of the organisations where respondents' consultants worked. This raises concerns about progress towards implementing the Paterson inquiry recommendations, including access to consultants' whole practice information and sharing concerns about consultants working across different providers. The findings may also hold relevance for international audiences where medical staff work across multiple healthcare providers. Further empirical research is needed to compare clinical governance arrangements between the NHS and independent sectors, and suggest how shared clinical governance can be organised to assure the quality and safety of care.

ObjectiveInternational health systems had the opportunity to assess the resilience of core health services to severe disruption following the onset of the COVID-19 pandemic. This paper examines the resilience of a core health service to shocks from COVID-19. We compare outcomes following emergency admissions in England during the second (Winter 2020/21) and third (Winter 2021/22) major waves of COVID-19 with the first wave and historic admissions from 2016 to 2019.MethodsThis cohort study included adult emergency admissions for five common acute surgical conditions: appendicitis, symptomatic gallstone disease, intestinal obstruction, symptomatic diverticular disease, and abdominal wall hernia in 122 acute hospital Trusts in England. Participants were 647,367 admissions in the hospital episode statistics (HES) inpatient database including 34,560 in the second wave and 36,628 in the third wave. Outcome was all-cause mortality at 90 days.ResultsThere were 1308 deaths in wave two (3.8% of admissions) and 1235 (3.4%) in wave three compared with 3431 (3.4%) in the historic cohort and 577 (4.7%) in wave one. Compared with pre-COVID admissions, we found weak evidence of increased mortality in the second wave. There was no evidence of increased mortality in the third wave, compared to historic cohorts the case-mix adjusted odds ratios were: appendicitis 0.96 (95% CI 0.49-1.87); gallstone disease 1.27 (95% CI 0.94-1.72); diverticular disease 1.04 (95% CI 0.79-1.36); hernia 1.06 (95% CI 0.76-1.47); and intestinal obstruction 1.02 (95% CI 0.87-1.19).ConclusionsBy the end of wave three, outcomes for emergency admissions with five common acute conditions had returned to pre-pandemic levels. Lessons learnt during the disruption of the first wave of COVID-19 helped the NHS in England adapt emergency surgical services during subsequent waves. These findings emphasise the importance of maintaining, or quickly restoring core service capacity to help patient outcomes return to pre-pandemic levels.

ObjectivesMany different approaches are used to manage demand and reduce waiting lists in outpatient and community health settings. This systematic review aimed to synthesise evidence for models of care which are based on the principle of protecting capacity for new patients.MethodsWe conducted a systematic search of Medline (Ovid), Embase, PyscINFO and CINAHL from inception until April 2024. Eligible studies included use of a protected appointment model in an outpatient and community health service and compared data on measures of waiting. Two reviewers independently extracted data and assessed risk of bias. Methodological quality was assessed using the Downs and Black checklist. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used to evaluate evidence certainty for meta-analyses.ResultsA total of 26 studies were included in the review. Most studies described a specific, named model incorporating protected appointments, such as Open Access (n = 7), Advanced Access (n = 6), the Specific Timely Assessment and Triage Model (n = 6), and the Choice and Partnership Approach (n = 4). A single stepped wedge randomised controlled trial (n = 3,113) provided moderate certainty evidence of a large reduction in time from referral to first appointment (IRR -0.66, 95% CI -0.85 to -0.52), with a median reduction of 34%. Eight non-randomised studies of intervention (n = 43,655) provided moderate certainty evidence of a moderate to large reduction in waiting time (SMD = -0.66, 95% CI -0.95 to -0.36) with a weighted mean reduction of 81%. Studies that could not be included in the meta-analyses supported these findings. Five studies measured waiting list size and all reported reductions ranging from 44% to 98%. Other findings associated with interventions included increased service productivity and improved patient satisfaction.ConclusionsWaiting list reduction strategies incorporating protected appointments are associated with moderate to large reductions in waiting time in outpatient and community health services.