Journal of Health Services Research & Policy最新文献

Objective: To investigate how health and care leaders navigate the micro-politics of major system change (MSC) as manifest in the formulation and implementation of Sustainability and Transformation Partnerships (STPs) in the English National Health Service (NHS).

Methods: A comparative qualitative case study of three STPs carried out between 2018-2021. Data collection comprised 72 semi-structured interviews with STP leaders and stakeholders; 49h of observations of STP executive meetings, management teams and thematic committees, and documentary sources. Interpretative analysis involved developing individual and cross case reports to understand the 'disagreements, 'people and interests' and the 'skills, behaviours and practice'.

Findings: Three linked political fault-lines underpinned the micro-politics of formulating and implementing STPs: differences in meaning and value, perceptions of winners and losers, and structural differences in power and influence. In managing these issues, STP leaders engaged in a range of complementary strategies to understand and reconcile meanings, appraise and manage risks and benefits, and to redress longstanding power imbalances, as well as those related to their own ambiguous position.

Conclusion: Given the lack of formal authority and breadth of system change, navigating the micro-politics of MSC requires political skills in listening and engagement, strategic appraisal of the political landscape and effective negotiation and consensus-building.

Objective: Racism acts as a major barrier to accessing health services for Indigenous communities in Canada, often leading to delayed, avoided or lack of treatment altogether. The Métis population is uniquely positioned in urban settings, as they experience discrimination from both Indigenous and mainstream health and social services due to Canada's long colonial history that is ongoing. Yet, Métis are often left out of discussions regarding racism and health service access. This study explores the experiences of racism and health service access among Métis peoples in Victoria, British Columbia.

Methods: We allied a conversational interview method to explore and understand experiences of self-identifying Métis women, Two-Spirit and gender diverse people (n = 24) who access health and social services in Victoria. Data analysis followed Flicker and Nixon's six-stage DEPICT model.

Results: In this paper, we share the experiences of racism and discrimination of those who accessed health and social services in Victoria, British Columbia Such experiences include passing as White, experiencing racism following Métis identity disclosure and witnessing racism. Passing as White was viewed as a protective factor against discrimination as well as harming participants' sense of identity. Experiences of racism took the form of discriminatory comments, harassment and mistreatment, which influenced the willingness of disclosing Métis identity. Witnessing racism occurred in participants, personal and professional lives, negatively impacting them in indirect ways. Each experience of racism had a negative influence on participants' wellbeing and shaped their experience of accessing health and social services.

Conclusions: Métis people confront racism and discrimination when attempting to access health and social services through first-hand experiences, witnessing and/or avoidance. While this study contributes to the all too often unacknowledged voices of Métis in Canada, there is a continued need for Métis-specific research to accurately inform policy and practice.

Objective: We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and system leaders to understand the impact of the implementation of remote provision of antenatal care during the COVID-19 pandemic and beyond.

Methods: We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 health care professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy.

Results: We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy. It altered women's own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy and sociocultural capital. Services became less permeable, meaning that they were more difficult to use and demanding of the personal and social resources of users. Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs - both clinical and social - known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were consequential. There were suggestions that a shift to remote provision of antenatal care might increase risks of inequities in access to care in relation to every feature of candidacy we characterised.

Conclusion: It is important to recognise the implications for access to antenatal care of a shift to remote delivery. It is not a simple swap: it restructures many aspects of candidacy for care in ways that pose risks of amplifying existing intersectional inequalities that lead to poorer outcomes. Addressing these challenges through policy and practice action is needed to tackle these risks.

Objective: In 2014, the Primary Care Plus (PC+) model was introduced in the Netherlands to shift low-complex specialised care from the hospital to the primary care setting. While positive effects of PC+ have been documented at individual patient level concerning health-related quality of life, perceived quality of care and care costs, its impacts on service use at the population level remain uncertain.

Methods: In this observational study, we used retrospective health insurance reimbursement claims data from the largest health insurer in the intervention region to determine service use. We assessed PC+ and secondary care insurance claims (i.e. claims of the regional hospital and claims of other secondary care settings in and outside the region visited by patients from the intervention region) from 2015 to 2018 and compared these to the national level.

Results: The total number of claims related to low-complex specialised care in the intervention region showed an increase over time. The increase in claims was related to PC+. The number of claims related to the regional hospital and other secondary care settings decreased over time. During the same period, a declining trend in claims at the national level was observed.

Conclusion: The introduction of the PC+ model in one region in the Netherlands was associated with an increase in the use of low-complex specialised care. This suggests that the ability of the PC+ model to substitute for specialist care at population level may be limited. Going forward, it will be important to continue monitoring and evaluating service use as substitution effects may materialise only over a longer timeframe.

Objectives: Remote home monitoring services for patients at risk of rapid deterioration introduced during the COVID-19 pandemic had important implications for the health workforce. This study explored the nature of 'work' that health care staff in England undertook to manage patients with COVID-19 remotely, how they were supported to deliver these new services, and the factors that influenced delivery of COVID-19 remote home monitoring services for staff.

Methods: We conducted a rapid mixed-methods evaluation of COVID-19 remote home monitoring services during November 2020 to July 2021 using a cross-sectional survey of a purposive sample of staff involved in delivering the service (clinical leads, frontline delivery staff and those involved in data collection and management) from 28 sites across England. We also conducted interviews with 58 staff in a subsample of 17 sites. Data collection and analysis were carried out in parallel. We used thematic analysis to analyse qualitative data while quantitative survey data were analysed using descriptive statistics.

Results: A total of 292 staff responded to the surveys (39% response rate). We found that prior experience of remote monitoring had some, albeit limited benefit for delivering similar services for patients diagnosed with COVID-19. Staff received a range of locally specific training and clinical oversight along with bespoke materials and resources. Staff reported feeling uncertain about using their own judgement and being reliant on seeking clinical oversight. The experience of transitioning from face-to-face to remote service delivery led some frontline delivery staff to reconsider their professional role, as well as their beliefs around their own capabilities. There was a general perception of staff being able to adapt, acquire new skills and knowledge and they demonstrated a commitment to continuity of care for patients, although there were reports of struggling with the increased accountability and responsibility attached to their adapted roles at times.

Conclusions: Remote home monitoring models can play an important role in managing a large number of patients for COVID-19 and possibly a range of other conditions. Successful delivery of such service models depends on staff competency and the nature of training received to facilitate effective care and patient engagement.

Objective: Research exploring the enablers and barriers that exist for military veterans seeking to address their poor mental health has produced ambiguous results. To identify the enablers and barriers correctly, this study systematically reviews the literature, including research that included alcohol and had a clearly defined veteran population.

Methods: Six databases were searched. Inclusion criteria specified that empirical studies related to veterans that had ceased military service and were seeking help for poor mental health and/or alcohol difficulties. Critical Appraisal Skills Programme and AXIS appraisal tools were used to assess quality and bias. A narrative synthesis approach was adopted for analysis. From 2044 studies screened, 12 were included featuring 5501 participants.

Results: Forty-four enablers and barriers were identified, with thirty-two being statistically significant. Post-traumatic stress disorder had the greatest number of enabler/barrier endorsements to veterans seeking help. Depression, anxiety, experience and attitudes also acted as enablers/barriers. Most studies were of fair methodological quality. Limitations included that samples were skewed towards US army veterans. Little research exists concerning those that have ceased military service.

Conclusions: Veteran help-seeking is likely enabled by poor mental health symptomology and comorbidity, which suggests veterans reach a crisis point before they seek help. Further research on alcohol misuse and attitude formation is required. The field would also benefit from alternative study designs including qualitative studies with non-US participants.

Objective: Breast cancer incidence is rising among Pakistani women in the United Kingdom. However, uptake of breast screening remains low. This study aimed to improve access to breast screening for British-Pakistani women by exploring their knowledge of breast cancer and the role of primary care and community networks to support screening access amongst British-Pakistani women.

Methods: We undertook a secondary qualitative analysis of 18 semi-structured interviews with British-Pakistani women from East Lancashire in the United Kingdom. Anonymized transcripts of the interviews were used for a thematic analysis.

Results: Three themes were identified in the interviewees' responses: (i) 'Women's knowledge of breasts and breast cancer', which described how a cultural taboo exists around Pakistani women's bodies and around breast cancer; (ii) 'Role of primary care', which detailed how General Practitioners can support informed decisions and offer a trusted and valued information source; (iii) 'Community engagement', which described the potential to disseminate breast-screening information through the whole community, including primary care providers, all family members and mosques.

Conclusions: Our analysis suggested three main targets for future interventions to improve access to breast screening for British-Pakistani women: (i) co-produced strategies to increase knowledge of breasts and breast screening; (ii) greater collaboration with local General Practitioners to support women to make informed choices about screening; and (iii) community engagement involving General Practitioners and community leaders, to inform everyone - not just screening-age women - about breast cancer and screening.