Journal of Health Services Research & Policy最新文献

ObjectivesHorizontal integration of health and social care in England is frequently supported by multi-disciplinary (MDT) case management focused on high-risk older people with multiple chronic conditions living in the community. This paper analyses MDT working in two of the 25 areas participating in the Integrated Care and Support Pioneer Programme in England. The analysis aims to understand the experience of frontline staff in such MDTs of working with professionals and staff from multiple sectors, and their perceptions of their roles and the benefits of integrated working.MethodsWe conducted semi-structured interviews with a purposive sample of 54 frontline staff from a range of professional backgrounds working in 11 community-based MDTs in two Integrated Care and Support Pioneers. A largely inductively developed coding frame was used to thematically code and guide analysis of verbatim interview transcripts from audio recordings.FindingsStaff conceptualised the team as a cohesive yet 'porous' entity, able to evolve a shared sense of purpose to deliver holistic care that helped to level traditional professional hierarchies, enable collective problem-solving and share responsibility for patient care. MDT working was seen as benefiting staff and patients. Despite strong similarities between the MDTs in members' understandings of the role and purpose of a MDT, each MDT was adapted to its context and the needs of the population served. The process of working through inter-professional tensions seemed to strengthen relationships within the team and enhance its ability to work effectively in the local health and care system. However, without performance or outcome measures, these perceptions were driven by 'soft' intelligence alone.ConclusionsFrontline staff accounts of MDT working demonstrate their strong commitment to this way of working, as a mechanism enabling them to deliver more holistic care with perceived benefits to patients.

ObjectivesCommunity pharmacies play a crucial role in China's primary health care system. This study aimed to assess the impact of stringent COVID-19 policy responses - such as lockdowns, travel restrictions and operational closures - on unannounced standardized patients' (USPs) satisfaction with community pharmacy services.MethodsA cross-sectional study was conducted from April 2021 to September 2022, using an USPs approach in community pharmacies across China. USPs' satisfaction was measured using validated tools, with closure policies related to COVID-19 as the primary exposure variable.ResultsThe study included 1076 eligible USP visits to community pharmacies. Results indicated that stricter closure policies had a significant negative impact on USPs' satisfaction (β = -0.18, p = 0.019). This negative effect may be attributed to worsened capability of pharmaceutical service providers (β = -0.17, p = 0.002) and accessibility (β = -0.12, p = 0.019). Subgroup analyses demonstrated a negative correlation between stricter closure policies and lower satisfaction levels with regard to accessibility, capability, and communication.ConclusionsCOVID-19 closure policies in China had adverse consequences for the quality of pharmacy services. These findings highlight that governments must act with urgency when addressing abrupt infectious diseases or public health emergencies. Enhancing access to pharmacy services and capability of providers are critical strategies to ensure an effective response to sudden public health crises.

ObjectivesCentral government has been promoting closer integration between the National Health Service (NHS) and local government social services in England for more than five decades. Improved coordination between primary, hospital, community health and social services has been advocated as a cost-effective response to growing care needs in an ageing population. This paper concentrates on one of the principal local care coordination mechanisms: community-based multidisciplinary teams (MDTs) involving NHS and social services staff. It reports local leaders' perceptions of MDTs' current and future contributions to more coordinated care and support systems in two integrated care Pioneer sites.MethodsThirty-two qualitative semi-structured interviews with 25 local system leaders and operational managers in two contrasting Integrated Care and Support Pioneer areas were conducted between October 2018 and April 2021, as part of a wider evaluation of the Integrated Care and Support Pioneer Programme. Eight of those interviews took place after the start of the COVID-19 pandemic and between lockdowns. Interviews were analysed thematically.ResultsLocal leaders in both areas broadly shared a vision of integrated care in which MDTs were essential mechanisms for coordinating improvements in health and wellbeing, especially for older people who are frail, experience falls and have long-term health conditions. Organisational differences between and within sites influenced local decisions about the purpose and structure of MDTs, but, despite such variations, interviewees identified similar challenges to implementation. Staff turnover, often linked to funding uncertainties, and the lack of shared information systems, were among the most frequent operational challenges noted. System leaders valued national policy frameworks as potential enablers of integrated care but also recognised the role of local contexts in shaping local implementation decisions. Interviewees highlighted benefits emerging from multidisciplinary working, including its potential to deliver more holistic care, fewer instances of work duplication, speedier access to care and enhanced home care provision. However, they were concerned such benefits were not always captured by commonly used performance indicators and thus the value of MDTs could be under-estimated.ConclusionsLocal contextual variables and local understandings of these variables appeared to be the main influences on variations in local responses to national expectations of improvements in care integration. Local leaders in both areas broadly shared a vision of integrated care in which MDTs provided essential mechanisms for securing interdependent improvements in both the health and wellbeing of local populations and improvements in workforce job satisfaction.

ObjectiveScreening for lung cancer with low dose computed tomography aims to reduce lung cancer mortality, but there is a lack of knowledge about how target populations consider its potential benefits and harms.MethodsWe conducted a systematic review of primary empirical studies published in any jurisdiction since 2002 using an integrative meta-synthesis technique. We searched six health and social science databases. Two reviewers independently screened titles, abstracts, and potentially eligible full-text studies. Quantitative assessments and open-ended perspectives on benefits and harms were extracted and convergently integrated at analysis using a narrative approach. Study quality was assessed.ResultsThe review included 26 quantitative, 18 qualitative, and 5 mixed methods studies. Study quality was acceptable. Lung cancer screening was widely perceived to be personally beneficial for early detection and reassurance. Radiation exposure and screening accuracy were recognised as harms, but these were frequently considered to be justified by early detection of lung cancer. Stigma, anxiety, and fear related to screening procedures and results were pervasive among current smokers. People with low incomes reported not participating in screening because of potential out-of-pocket costs and geographic access.ConclusionsPopulations targeted for lung cancer screening tended to consider screening as personally beneficial and rationalised physical, but not psychological, harms. Screening programmes should be clear about benefits, use non-stigmatising design, and consider equity as a guiding principle.

This paper introduces an evaluation of community-based, integrated health and social care multi-disciplinary teams (MDTs), primarily serving older people with long-term conditions, undertaken as part of the wider evaluation (2015-2022) of the Integrated Care and Support Pioneer Programme in England (2013-2018). To explain the context within which the MDT evaluation was undertaken, we first outline a brief history of health and social care integration policy in England, describe the Pioneer Programme and the requirements of the national 'longer-term' evaluation of the Pioneers. We then explain our rationale for focusing on MDTs, describe our conceptual framework of MDT functioning and provide a brief description of the evaluation design and methods, highlighting four overarching challenges we faced in undertaking it. We then briefly describe the individual papers that constitute the current supplement.

ObjectivesThe COVID-19 pandemic severely disrupted health and social care (HSC) services in many countries, including England. At the same time, it forced systems to respond innovatively to radically changed circumstances and challenges. This study identifies the impacts and emerging legacy of the pandemic for community-based multidisciplinary teams (MDTs) supporting older people with multiple long-term conditions living in their own homes.MethodsThirty-eight strategic, operational, and frontline staff involved with MDTs in seven areas in England were interviewed between July 2020 and August 2021, as part of a wider evaluation of the Integrated Care and Support Pioneers programme. Interview transcripts were analysed thematically.ResultsInterviewees described an initial period of pandemic disruption characterised by uncertainty, shifting of priorities and resources within the HSC system towards emergency care, and redeployment of staff away from MDTs. These circumstances required the development of new ways of working with MDT patients/clients and with one another. Remote, mostly virtual, MDT working between professionals was seen by most as a positive adaptation, though some felt that in-person meetings were better for the development of working relationships. Others raised concerns about access to, and quality of, care provided to vulnerable patients remotely, or in person but with a delay. At the local system level, the crisis response lowered barriers to collaboration between organisations, blurred professional roles, increased flexibility in the use of resources, and engendered a stronger sense of local cohesion among a wide range of staff in HSC. Most respondents wished to retain these attributes of the local system permanently.ConclusionsThe pandemic's legacy seemed to accelerate innovations in health and care provision and increased cohesion and closer working relationships. Remote ways of working were perceived to have improved the efficiency of MDT meetings and facilitated involvement of professionals external to MDTs. The implications for patient/client care were more complex. We suggest that the potential impact on inequalities of remote access to, and provision of, care for people served by MDTs will need to be considered if these changes are to be maintained. The resilience of MDTs and the HSC system may be improved by upskilling staff and creating a more flexible workforce capable of working across organisations during future crises.

ObjectiveDigital services in primary care are becoming more common, yet access to and use of services can create inequities. Our aim was to explore the drivers, priorities, and evolving policy context influencing digital facilitation in primary care as reported by national, regional and local level stakeholders in England.MethodsWe conducted online semi-structured qualitative interviews with stakeholders, including those in NHS England organisations, local commissioners for health care, statutory and third sector organisations, those working within the research community, and digital platform providers. Interviews were analysed using a thematic approach.ResultsThe majority of stakeholders worked in national level roles, in commissioning or statutory and third sector organisations working in relation to digital inclusion and patient access. Demographic inequalities, poor usability of digital primary care services, and low digital skills were perceived to comprise some of the barriers facing patients in accessing and using digital primary care services. Demand pressures in general practice, inconsistent training opportunities in digital services for staff, and conflicting perceptions around who should be responsible in organising digital facilitation were reported as barriers in the organisation and provision of digital facilitation in primary care. Stakeholders shared future visions for digital primary care and recommended focusing on establishing the concept of digital facilitation and promoting the benefits in its adoption.ConclusionsPolicy that is specific to digital facilitation and not just to digital services is required to establish clear lines of responsibility, investment in staff time and training, and the development of digital services that work well for various groups of patients and practice staff. A multi-organisational working team involving decision-makers and those working on the ground in general practice is encouraged to establish principles for supporting patients and staff in accessing and using digital primary care services in the NHS in England.

ObjectivesLarger, more complex inter-organisational networks with strong, centralised governance structures, often in the form of a network administrative organisation (NAO), have developed in recent years in response to wicked health and social problems. Set in Ontario, Canada, this study explored how NAOs and networks are structured, how they function, and how they evolve.MethodsWe conducted a case study of a NAO and network consisting of 40 member networks in the province of Ontario, Canada. We analysed secondary sources, including policy documents, legislation, contracts, websites, and existing qualitative data.ResultsThe NAO and member networks developed in tandem and dialectically. They ultimately took on a form that defies categorisation within the existing literature due to their structure as a 'network of member networks' and by acting simultaneously as a policy network, service delivery coordination network, and governance network, by executing numerous complex mandates and functions in service of multiple stakeholders, and by exemplifying both high control and high collaboration.ConclusionsWe classified the NAO and its network as a 'misfit' and 'jack of all trades'. These features may help explain its perceived effectiveness. The complexity and hybrid nature of the NAO and network may position it to best address multifaceted health care problems.