Journal of Health Services Research & Policy最新文献

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.

ObjectivesBetter integrated health and social or long-term care is high on government policy agendas in many countries. In England, successive pilot programmes, with related national evaluations, have been introduced to better integrate care to meet the needs of people requiring multi-agency help. However, researchers evaluating such programmes both in England and internationally face a daunting number of challenges produced by service delivery and research regulatory systems. This paper analyses the challenges encountered in seeking to undertake a prospective quasi-experimental evaluation of the impacts of community based multi-disciplinary teams (MDTs) on patient experience and outcomes, as part of a wider evaluation of the Integrated Care and Support Pioneers programme. The paper also identifies a number of general lessons for research commissioners, study site participants, and those tasked with undertaking such evaluative research.MethodsWe reviewed our research activities and timelines from the start of the evaluation. We created a narrative history - using reports to the funder, applications to research and ethics regulatory bodies and correspondence with Pioneer sites, regulatory bodies and data providers - to describe the challenges faced and our approaches to attempting to mitigate them.ResultsWe experienced four key challenges: (1) unrealistic commissioner research specifications; (2) negotiating with and recruiting multiple organisations and services at potential study sites; (3) navigating research ethics and governance systems; and (4) recruiting participants for primary data collection and obtaining (with their consent) their linked routine service use data. The first two challenges resulted from the lack of shared understanding of evaluation feasibility and constraints between local health and care system actors and national level commissioners of evaluation, plus no clear incentive for local sites to participate. The third and fourth challenges were the product of multiple, protracted, and unnecessarily risk-averse research approval processes which affected both the nature and quantity of the data we could collect.ConclusionsWe recommend that major changes are made to the regulation of policy research to enable more robust evaluation to take place and that disproportionately high levels of risk aversion in approval processes for non-interventional, low-risk studies are addressed. In addition, the evaluation commissioning process needs to be far better informed at an early stage about which elements in programmes can feasibly be evaluated before research specifications are advertised.

Objectives: The lack of Indigenous health care data in Canada makes it challenging to plan health care services and inform Indigenous leadership on the health care needs of their respective Nations and communities. Several Canadian health care organizations have implemented a voluntary Indigenous identifier of patients within their electronic medical records. This study examines facilitators and barriers to implementing such a voluntary self-reported Indigenous identifier, from the perspective of key stakeholders who work at four Canadian health providers where an Indigenous identifier has been implemented.

Methods: The four Canadian sites comprise three hospitals and one health authority. At each site, key stakeholders participated in semi-structured qualitative interviews. Interviews were transcribed and coded. Relevant documents that were publicly available or provided by each site were reviewed.

Results: There were four primary findings. First, for the introduction of an Indigenous identifier to be successful there must be pre-existing strong and trusting relationships between Indigenous communities and health care organizations. Second, health care organizations must provide training for those who ask clientele to self-identify as Indigenous, to overcome issues such as any patient backlash. Third, for the relationship between Indigenous people and health organizations to flourish, data governance must be Indigenous-led. Finally, the collection of Indigenous identifier data can enhance Indigenous health care services and health care service planning and delivery.

Conclusions: Due to the ongoing distrust of government and health care services among Indigenous peoples and communities, special considerations are required prior to the implementation of an Indigenous identifier. Of primary importance is how health care organizations can contribute to Indigenous data governance and minimize potential harms associated with the collection of such data. The findings of this study can be used to guide other health care sites and Indigenous leaders aspiring for more robust health data by implementing voluntary Indigenous identity data collection.

Objectives: Collaborative and integrated (C + I) working between general practice and community pharmacies has the potential to increase accessibility to services, improve service efficiency and quality of care, and reduce health care expenditures. Many existing studies report challenges and complexities inherent in establishing effective C + I ways of working. The aim of our review is to understand how, when and why working arrangements between General Practitioners (GP) and Community Pharmacists (CP) can provide the conditions necessary for effective communication, decision-making, and C + I working.

Methods: We conducted a realist review to explore the key contextual factors and mechanisms through which GP-CP C + I working may be achieved. MEDLINE, Embase, CINAHL, PsycINFO, HMIC, Web of Science, IBSS, ASSIA, Sociological Abstracts, Sociology Database and the King's Fund Library Database were searched for articles and grey literature published between January 2000 and April 2022.

Results: A total of 136 documents were included in the final synthesis. Our findings highlight the importance of mutually beneficial remuneration models to support effective integration of services; supportive organisational cultures and values; flexible and agile IT systems/technologies; adequate physical infrastructure and space design to support multidisciplinary teamworking; the importance of establishing patient's trust in collaborative processes between GP-CP; and the need to acknowledge, support and utilise effective triadic relationships.

Conclusions: Our research generates new insights regarding how, why and in which contexts C + I working can be achieved between GPs and CPs. The findings of our review can be used to inform future policy, research and clinical practice guidelines for designing and delivering C + I care.

Objectives: The purpose of this study is to investigate how organizational factors influence the ethical and economic problems of overtreatment of cancer patients.

Methods: The study applies a sequential mixed-method approach. First, our logistic regression model assesses how patient characteristics and hospital department variables influence the use of late cancer treatment (LCT), primarily chemotherapy, in stage IV non-small cell lung cancer cases using Danish registry data. Department-specific variations in LCT use across hospitals are identified, while controlling for population differences. Then, using qualitative data, we explore organizational factors that may influence hospitals' decisions regarding LCT for lung cancer patients.

Results: Between 13% and 33.3% of the studied lung cancer population receive LCT within their last 30 days of life. Variation in LCT can in part be explained by organizational factors specific to the hospital departments and their organization of their treatment decision-making process.

Conclusions: This article is among the first to show how organizational solutions can contribute to curbing overtreatment. Hospital managers can seek to reduce overtreatment by (a) adjusting the format and frequency of patient consultations, (b) improving the cross-disciplinary collaboration structures, and (c) utilizing team conferences for discussions of treatment cessation.

Objective: In England, most long-term care for older people with complex health care needs is provided by private care homes. They rely on primary care to provide medical care and access to specialist health care services. This study explored the working relationships between care homes and primary care in one region in England to inform a theory of change for achieving improved relationships.

Methods: We carried out a multi-method qualitative study using appreciative inquiry. We thematically analysed data from 33 survey responses, 15 interviews, and eight workshops with care home and primary care staff, family carers, and other community specialists to populate the theory of change. A patient and public involvement representative supported data collection, analysis, and write-up.

Results: Study participants described activities that encouraged role understanding, communication, and learning together benefitting staff, relationships, and quality of services. The lessons and experiences from the COVID-19 pandemic had shaped participants' understanding of what is required to sustain cross-sector collaboration. Key inputs included time, staff, and funding to facilitate learning how to work together effectively, as well as the capacity to adapt to diverse care settings and address the complex, individual needs of care home residents. Participants noted the few opportunities they had to share their learning and discuss best practice.

Conclusion: The theory of change identified different dimensions of good practice, providing insight into areas for action to inform service design and practice. Ongoing organisational changes should consider what is already working well and build on these achievements to enable positive care home and primary care working relationships and so foster high quality care and equitable access to services.

Objectives: Networks (multiple organizations or actors coordinating their activities towards a common goal) have been promoted in the cancer programs of a number of countries. But there is little empirical evidence on whether and how they overcome the siloed functioning endemic in specialized domains. This study examines how collaborative governance takes shape to support integrated network-based practices within a prescribed national cancer program.

Methods: A longitudinal qualitative single-case study was conducted of the Quebec cancer network in Canada. Data were collected in 2018-2020 through semi-structured interviews with stakeholders (n = 37) involved in regional and/or national cancer network structures and a review of documents (n = 45) generated at national and regional level. Abductive thematic analysis during and post-field work was based on Emerson's collaborative governance framework. It aimed to identify how collaborative governance mechanisms (principled engagement, shared motivation and capacity for joint action) were activated in the network, and their contribution to translating a national cancer program into network-based practices at the point of care.

Results: Principled engagement was driven through interdisciplinary committees at national and regional level, communities of practice and trajectory-development efforts. These mandated structures supported knowledge exchange and contributed to the recognition of interdependencies, distribution of leadership and development of mutual understanding and trust. Shared motivation benefitted from a vision of patient-centred care but was hindered by top-down communication vehicles that did not allow regional priorities to filter upwards to central level. Between care providers in different settings, trust and candidacy were identified as mechanisms important to shared motivation, though network actions did not sufficiently support trust across care settings, or even between members of the same profession. Candidacy issues hindered family physician participation in cancer network structures that mirrored ongoing difficulties to including them in cancer care practice. Institutional arrangements were important drivers of capacity for joint action in the network. Common indicators were recognized as important to generating efforts towards common goals; however, questions around their validity reduced their contribution to capacities for joint action.

Conclusions: Despite favorable starting conditions from the national cancer program and its central leadership promoting collaborative governance, tensions that emerge through the pursuit of network integration limit the transition to a more collaborative practice. Taking the time to work out these tensions as integration proceeds in waves appears essential to arrive at a governance model that is appropriate and acceptable for all network m