Journal of Health Services Research & Policy最新文献

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.

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.

ObjectivesTo describe the impact associated with congenital cytomegalovirus (cCMV) infection and experiences and perceptions of people with experience of CMV in pregnancy and families / caregivers of children diagnosed with cCMV, who responded to a UK National Screening Committee (UK NSC) public consultation on cCMV screening.MethodsThe public consultation was conducted in 2021-22 on a draft evidence review and was aimed at informing the UK NSC's decision on newborn screening for cCMV. Data were analysed using framework analysis: a subgroup of responses was inductively coded, codes were refined and initial themes identified, before targeted coding of the remainder of the data and identification of final themes and sub-themes.ResultsOf a total 155 responses, 125 (describing 128 pregnancy/child outcomes) contained information relevant to the coding framework and were included. Most (n = 109) described a live birth of a surviving child, of whom 90% (98/109) were living with symptoms or long-term sequelae of cCMV at the time of the response. Two main themes were identified: missed opportunities and emotional impacts attributed by respondents to not screening for cCMV. Many families described delays in their child's cCMV diagnosis, including due to healthcare professionals' lack of awareness of cCMV, and viewed newborn screening as a solution to avoid delays in diagnostic pathways. Diagnostic delays resulted in a lasting sense of injustice and unfairness due to possible missed opportunities to improve outcomes (e.g., through antiviral treatment or early therapies), as well as uncertainty and anxiety.ConclusionsResponses were predominantly from parents and caregivers of children with cCMV who experienced long term disability. They highlight significant gaps in awareness, support and health care for affected children that need addressing, regardless of national screening policy decisions. These responses contribute to the literature on lived experiences of individuals and families affected by cCMV.

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.

ObjectivesExercise is a frontline therapy for the management of chronic cardiometabolic disease, however traditional tertiary health care service models do not include exercise physiology. We aimed to explore professional roles, practices, and services regarding exercise care in chronic cardiometabolic disease from the perspectives of specialist doctors and nurses.MethodsUsing a qualitative description design, semi-structured individual interviews were conducted with 32 doctors and 26 nurses involved in the care of relevant patients with liver, kidney, or cardiac disease, or diabetes, across hospital and community settings in a Queensland metropolitan health service. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.ResultsFour overarching themes were identified. Despite universal acceptance of the multifactorial benefits of exercise, there was a lack of confidence in patients' capabilities to exercise and safety concerns due to complex comorbidities. Interviewees considered themselves 'promotors not prescribers' of exercise. There was no structured exercise history taken outside of cardiac rehabilitation units with significant variability in advice provided. Access to exercise specialist services was limited and disease-specific, with inconsistent and fragmented referral pathways. General Practitioners were considered responsible for facilitating exercise specialist involvement in ongoing care, with onus placed on patients to initiate.ConclusionsThere is an evidence-practice gap between the established benefits of exercise for chronic disease management and access to exercise professionals and services, resources, and knowledge. This deprioritises exercise as a frontline therapy with patient care implications. This study identified a need to transform the way that exercise care is accessed and delivered in tertiary settings.

ObjectivesThere is increasing demand for rapid evaluation in health care to inform timely policy and practice decision-making. This qualitative study explored the perceived benefits, limitations and challenges of rapid evaluation, focusing on how considerations of timescale and research quality are balanced in study design and delivery in England.MethodsWe conducted fifteen semi-structured interviews with researchers and research funders involved in rapid evaluation, based in England. Data were thematically analysed using the Framework Method.ResultsResults are reported around five major themes: (i) rapid evaluations are purpose driven; (ii) 'good enough' evidence; (iii) trade-offs and limitations; (iv) mitigating the speed and rigour trade-off; and (v) deciding if and when to evaluate rapidly. Study participants agreed that rapid evaluation reflected a drive to better align evaluative processes and outcomes to the needs of service planners and policymakers. It was seen to generate quick data for short-term requirements, and information to justify the need for, and inform the design of, longer-term assessments. However, working rapidly could restrict or prohibit some research activities, and there were particular concerns about recruitment being limited to sites and participants that were easier to access in short timescales. Rapid evaluation was considered less suitable for 'high stakes' topics or decisions, where evidence robustness and generalisability was paramount. Several study participants had built an infrastructure to facilitate rapid working which, at least in part, reduced the need to make methodological compromises.ConclusionsRapid evaluation can support real-time learning for innovation and improvement and inform time-critical decisions, but timeliness is only one factor in the production of useful and usable evidence. It is a tool for specific circumstances and purposes, to be used alongside, rather than instead of, long-term and longitudinal designs.

ObjectivesIdentify and explore risk factors associated with COVID-19 infection and mortality rates in care homes in the West of England and gain an understanding of challenges faced during the pandemic, how they were addressed and how care homes can be better equipped for future pandemics.MethodsA mixed-methods study combined observational analysis of numbers of infections and deaths with potential risk factors supported by semi-structured interviews. Thirty-three care homes within a single local authority (LA) in the West of England were included in the quantitative analysis and, in the qualitative study, five care homes were included, including those located outside the participating LA. The quantitative analysis assessed two outcomes: number of weekly COVID-19 cases and deaths between 31/08/2020 and 21/02/2021. Associations with potential care risk factors were analysed using Poisson regression. 14 interviews were conducted with care home staff in various roles between November 2022 and September 2023. Data were analysed thematically.ResultsCare home size was associated with higher COVID-19 infection (large compared with small care homes: incidence rate ratio (IRR) = 12.60, 95% confidence interval (CI) 2.54 to 62.51) and mortality rates (large compared with small care homes: IRR = 16.48, 95% CI 0.81 to 335.88). Qualitative data revealed that care home managers recognized these risks and were focussed on the challenges of implementing infection control within the limitations of their buildings. The primary challenge identified was staff shortages, requiring care home staff to assume expanded responsibilities. There was no evidence of association between hospital discharges and COVID-19 cases (IRR = 0.45, 95% CI 0.11 to 1.83) or deaths (IRR = 0.61, 0.11 to 3.22). The qualitative data highlighted care home staff had feelings of separation and felt under-valued in relation to the wider health care sector. There was also concern that COVID-19 prevention measures prioritised infection control over the psycho-social welfare of residents.ConclusionResearch on the risk factors for infection spread and associated mortality should be prioritised to better protect care homes in future pandemics. This requires making routine data in social care more readily available for research purposes. Proactive planning for future pandemics, by care homes and local authorities, should recognise the individual nature of buildings and the needs of residents.