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.

The African region has experienced significant growth in health workforce development due to concerted efforts and investments. This progress has improved access to healthcare services and addressed critical shortages of health workers. However, the region still struggles to meet the Sustainable Development Goal (SDG) indicator threshold of 44.5 medical doctors, nurses, and midwives per 10,000 population. An estimated deficit of 6.1 million health workers is anticipated by 2030 unless urgent actions are taken. This shortage is exacerbated by increased health worker migration, driven by the demand in high-income nations and the dual challenges of an ageing workforce and population. Addressing the factors driving healthcare worker migration is crucial to strengthen local healthcare systems and ensure quality medical services. Weak mechanisms for tracking health worker migration, due to limitations in health planning and workforce information systems, impede understanding of this situation. Countries in the African region can undertake initiatives such as pursuing mutually beneficial bilateral or multilateral agreements to manage international migration of health workers. Additionally, harnessing the potential benefits of migrant health workers in improving health systems and protecting their labour rights is essential. African countries should conduct thorough health labour market analyses to plan the production, funding, employment, and retention of sufficient health workers. Exploring contextual factors and policies that influence health workers' choices and potential incentives to encourage the return of migrant health workers is also vital. Dialogues among internal stakeholders and between countries can lead to mutually beneficial mechanisms for skills exchange and proportionate investment.

BackgroundVaccine hesitancy is known to be a significant issue for vaccination programmes. It has been shown to be particularly significant in communities marginalised by ethnicity, poverty and other social factors.ObjectiveIn this paper we report on the efforts of the UK COVID-19 vaccination programme to overcome vaccine hesitancy in one locality, and how those efforts were viewed by the people targeted by and delivering the initiatives.MethodWe conducted a qualitative study, interviewing staff delivering the vaccination programme (n = 8) and community members drawn from marginalised groups (n = 40). Framework thematic analysis was used.ResultsThe diversity of the marginalised communities in terms of their immigration status, language, cultural needs and other characteristics required extensive and varied efforts by services to deliver vaccine equity initiatives. These efforts included offering vaccines in community centres and places of worship, involving community and faith leaders to build trust among communities, delivering information in different languages and offering gift vouchers. Community members had a complex mixture of reasons for accepting or not accepting the vaccine. Reasons for not accepting the vaccine included a lack of trust in vaccine effectiveness and what were perceived as coercive measures by the state.ConclusionThe initiatives were perceived to be broadly successful in promoting COVID-19 vaccine uptake, however there were no precise measures of success or failure of individual components. Policy and health services need to consider the complex and dynamic nature of vaccine hesitancy and build trust and improve communication with marginalised groups.

ObjectivesTo explore the accessibility of mental health and gambling related support within the United Kingdom (UK) Armed Forces and investigate potential barriers to engagement.MethodsWe conducted a survey of Armed Forces service personnel (n = 438) and specialist healthcare and welfare staff (n = 94) regarding gambling harm and related challenges.ResultsPersonnel rarely sought on-base support and recognition of existing service provision was low. Among those who did seek help, healthcare and welfare staff were equally effective in engaging with personnel, with greater professional experience playing a key role in fostering meaningful interactions.ConclusionsImproving access to specialist gambling harm support may enhance help-seeking.

ObjectivesAccess to general practice is a pervasive health services concern. A tendency to conceptualise access narrowly in terms of supply of appointments may frustrate identification of better solutions. The Candidacy Framework offers an alternative conceptualisation of access as a dynamic and contingent process. We aimed to identify how the Candidacy Framework, and each of its seven features, has been applied and critiqued in research in general practice.MethodsWe conducted a scoping review involving a search across four databases to identify general practice articles, editorials, books, and theses that applied the Candidacy Framework. Included studies underwent data extraction and findings were analysed descriptively.ResultsOf 12,759 records screened, 73 studies published between 2007 and 2024 were included in the review. The Candidacy Framework was predominantly used in designing research or supporting interpretation of research findings. Sixty-seven papers explicitly used at least one of the seven features of candidacy; 'navigation' was the feature most mentioned and 'operating conditions' least. Candidacy appeared particularly helpful for: (1) exploring healthcare staff-patient interactions; (2) understanding barriers and enablers to accessing care; and (3) exploring complex access challenges faced by disadvantaged groups. Critiques of the framework focused on perceived linearity, lack of acknowledgement of the potential for multiple candidacies, and a need for more emphasis on contextual influences beyond local operating conditions.ConclusionThe Candidacy Framework is a useful approach for understanding access to general practice and may help in generating actionable solutions but may be enhanced by further customisation for the specifics of this setting.

ObjectivesThis study aims to combine the perspectives of patients and healthcare providers on the factors that influence the match between patients' needs for and providers' capacity to deliver services.MethodsA qualitative descriptive study design was used to examine perspectives and experiences of patients, family physicians and nurse practitioners in two jurisdictions in Canada: Nova Scotia and Ontario. Data from interviews were analyzed using the concept of comprehensiveness, the extent to which the approach to care and services delivered by providers meets patients' needs, to examine how decisions were made in each province for patients to become members of a providers' panel (the process known as 'empanelment').ResultsInterviews with 33 providers and 25 patients were conducted in Nova Scotia and Ontario. Three areas of tension were identified in patients' decision-making about choosing a regular primary care provider and providers' decision-making about accepting regular patients. Patients and providers discussed the success of such a match as being influenced by personal characteristics, including attitudes, gender and cultural background, scope of practice and panel composition.ConclusionsFindings support the value of team-based care that considers the needs for empanelment of both patients and providers. This study provides healthcare providers with information to improve matching processes by incorporating these considerations (e.g., patient and provider sex, gender and chronic care needs) into decisions about empanelment. Mechanisms that reflect the characteristics and range of skills of the whole team rather than the family physician and nurse practitioner alone are an avenue for optimizing the success of empanelment.

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.

BackgroundIntegrated Care Boards (ICBs) in England are responsible for commissioning healthcare services and setting access policies for procedures such as hip and knee replacement surgery. While the National Institute for Health and Care Excellence (NICE) advises against body mass index (BMI)-based restrictions, many ICBs impose such criteria. This study examines the prevalence and content of these policies to understand their impact on equitable healthcare access.MethodsA qualitative content analysis was conducted to systematically evaluate the policies set by all 42 ICBs in England regarding access to hip and knee replacement surgery for patients living with obesity. Policies were collected from official ICB websites and Google searches, completed in February 2025, and categorised as: no policy, restrictive policy, and non-restrictive policy. The alignment of these policies with clinical guidance was assessed, focusing on their potential impact on equitable healthcare access.ResultsPolicy documents were identified for 41 ICBs: 26 included weight management guidance and 15 imposed BMI-based restrictions on joint replacement referral eligibility. Policies varied in naming, terminology, and specificity, risking inconsistencies in interpretation and implementation. Some ICBs (n = 3) had revoked BMI-based restrictions in recent policy updates, reflecting a shift towards individualised clinical assessments. These findings highlight variability in policy approaches and the evolving stance on BMI-related eligibility criteria.ConclusionsOne third of ICBs still use policies that contradict NICE guidance by restricting access to joint replacement surgery for those with high BMI, while many others apply ambiguous language. These inconsistencies highlight concerns about policies that may influence equitable access to care. Further work is required to evaluate how BMI-related eligibility criteria are applied in practice and their impact on health inequalities.

Healthcare systems worldwide are grappling with workforce crises, prompting policy interventions that expand the clinical roles of healthcare professionals. This essay examines the challenges associated with the increasing responsibilities of pharmacists, particularly within the context of the UK's policy aimed at achieving a unified "one pharmacy workforce." This policy envisions pharmacists playing expanded roles in patient care, including enhanced clinical services with an increasing level of independent prescribing. However, there is currently a fragmented approach to training, support, and career progression, which varies substantially across hospital, primary care, and community pharmacy settings. This essay highlights the significant disparities in professional development opportunities across these settings, which hinder the realisation of a unified pharmacy workforce. To address this, we argue that the development of "pharmacist personas" can offer a tool to guide pharmacists' learning and career development in their evolving roles. Drawing on Goffman's dramaturgical theory, pharmacist personas can be seen as existing in the space between the "frontstage" (the social mask) and the "backstage" (the true self), becoming deeply embedded within pharmacists' professional identity work. Personas offer pharmacists a tool to visualise their future professional roles and elucidate the learning to attain them. By providing concrete examples of professional trajectories, personas can guide learning and career development. A policy focused solely on expanding the role of pharmacists is insufficient. It needs to be supported with systemic improvements in training and support to ensure a sustainable "one pharmacy workforce" that meets the evolving needs of healthcare systems.

ObjectivesIn care homes, safety incident reporting, and the policy framework that surrounds safety incident reporting, is not well understood. This study aims to review safety incident reporting and safety policies in residential and nursing care homes in England. It aims to better understand safety incident reporting practices and identify lessons for the sector regarding approaches to safety incident reporting to improve safety. The objectives were to investigate what policies exist, identify the methods and any technology used for safety incident reporting and consider the data captured in safety incident reports. It aims to contribute to discussions regarding developing systems-based approaches to safety management in care homes.MethodsA qualitative documentary analysis of safety incident reporting policies in residential and nursing care homes in England was undertaken. Policies were collected from 23 organisations whose staff participated in interviews (n = 75) regarding safety incident reporting between January 2021 until June 2022 and from a structured internet search using specified search terms between April 2022 and May 2022. To be included, a policy needed to refer to safety incident reporting in any capacity and be partially or wholly related to care homes or nursing homes in England. Safety incidents could include staff, residents, contractors, and visitors to the home. Data, extracted using a bespoke framework based on study objectives, were tabulated and analysed deductively and inductively. For the selected policies, the Care Quality Commission website was searched for the latest inspection report and the overall rating was extracted.ResultsForty-one policy documents were retrieved and screened for inclusion. Twenty-five policies (from 23 organisations) were reviewed. Three were from the internet search and 22 were obtained from interview participants. There was considerable variability in the length and comprehensiveness of the policies, with some homes using untailored, 'off-the-shelf' standardised policies produced by a specialist company. Twenty-two (88%) referred to other policy and legislative documents important to safety incident reporting and all but three (12%) policies identified a designated person or role with responsibility for the reports. Only one policy incorporated resident accounts and views into the incident report. Two policies referred exclusively to electronic recording systems with most (n = 19) referring to paper-based reporting systems.ConclusionsThe study identified the extent of, and gaps, in safety incident reporting policies, with reporting practices situated within a broad framework of governance. Incident reporting is as much a matter of governance as practice and there may be a greater opportunity to learn from incident reports than there is currently. Further research about how staff navigate multiple risks, develop adaptive approaches for the contextual conditions, and use safety incident