Fiona Aspinal

Can general practitioner commissioning deliver equity and excellence? : Evidence from two studies of service improvement in the English NHS

Objectives To explore some of the key assumptions underpinning the continued development of general practitioner-led commissioning in health services. Methods Qualitative data from two studies of service improvement in the English NHS were considered against Englands plans for GP-led commissioning. These data were collected through in-depth interviews with a total of 187 professionals and 99 people affected by services in 10 different primary care trust areas across England between 2008 and 2009. Results Internationally, GPs are seen to have a central position in health systems. In keeping with this, the English policy places emphasis on the ‘pivotal role’ of general practitioners, considered to be ideally placed to commission in the best interests of their patients. However, our evidence suggests that general practitioners do not always have a pivotal role for all patients. Moreover, it is planned that the new commissioning groups in England will not be subject to top-down performance management and this raises the question of how agreed quality standards will be met under the proposed new system. Conclusions This paper questions the assumption that GPs are best placed to commission health services in a way that meets quality standards and leads to equitable outcomes. There is little evidence to suggest that GPs will succeed where others have failed and a risk that, without top-down performance management, service improvement will be patchy, leading to greater, not reduced, inequity.

New horizons: Reablement - supporting older people towards independence

As the overwhelming majority of older people prefer to remain in their own homes and communities, innovative service provision aims to promote independence of older people despite incremental age associated frailty. Reablement is one such service intervention that is rapidly being adopted across high-income countries and projected to result in significant cost-savings in public health expenditure by decreasing premature admission to acute care settings and long-term institutionalisation. It is an intensive, time-limited intervention provided in peoples homes or in community settings, often multi-disciplinary in nature, focussing on supporting people to regain skills around daily activities. It is goal-orientated, holistic and person-centred irrespective of diagnosis, age and individual capacities. Reablement is an inclusive approach that seeks to work with all kinds of frail people but requires skilled professionals who are willing to adapt their practise, as well as receptive older people, families and care staff. Although reablement may just seem the right thing to do, studies on the outcomes of this knowledge-based practice are inconsistent-yet there is an emerging evidence and practice base that suggests that reablement improves performance in daily activities. This innovative service however may lead to hidden side effects such as social isolation and a paradoxical increase in hospital admissions. Some of the necessary evaluative research is already underway, the results of which will help fill some of the evidence gaps outlined here.

Developing methods to improve the quality of end-of-life care

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Did anyone notice the transformation of adult social care? An analysis of Safeguarding Adult Board Annual Reports

Purpose – The purpose of this paper is to report on a part of a study examining the interrelationships between personalisation and safeguarding practice. Specifically the authors aimed to examine how safeguarding practice is affected by the roll out of personalisation in adult social care, particularly when the adult at risk has a personal budget or is considering this. Design/methodology/approach – A sample of annual reports from Adult Safeguarding Boards in England was accessed for content analysis covering the period 2009-2011. One part of this sample of local authorities was selected at random; the other authorities selected had been early adopters of personalisation. The reports were analysed using a pro forma to collect salient information on personalisation that was cross-referenced to identify common themes and differences. Findings – The authors found variable mentions of personalisation as part of the macro policy context reported in the annual reviews, some examples of system or process changes...

Benchmarking integrated care for people with long‐term neurological conditions

Purpose – This paper aims to report results from a national survey of primary care trusts (PCTs) that explored the strategic, organisational and practice context of services for people with long‐term neurological conditions (LTNCs). It seeks to provide benchmarks for integrated service provision and to discuss possible reasons for the variability in progress.Design/methodology/approach – Earlier phases of the research identified three models of care that promoted continuity of care for people with LTNCs: community interdisciplinary neurological rehabilitation teams, nurse specialists and pro‐active day opportunities. Based on this evidence, a benchmarking questionnaire was developed and a telephone survey of PCTs in England undertaken in 2009.Findings – The survey found that the prevalence of models of good practice varied widely across and within PCT areas. Strategic support and commissioning arrangements were also variable. A little over half of responding PCTs had completed a joint strategic needs asse...

Do Personal Budgets Increase the Risk of Abuse? Evidence from English National Data

With the continued implementation of the personalisation policy, Personal Budgets (PBs) have moved to the mainstream in adult social care in England. The relationship between the policy goals of personalisation and safeguarding is contentious. Some have argued that PBs have the potential to empower recipients, while others believe PBs, especially Direct Payments, might increase the risk of abuse. This paper provides empirical evidence about levels of uptake of PBs and safeguarding referrals in England based on in-depth analysis of national data at aggregate, local council level in England, covering 152 Councils. This is complemented by analysis of 2,209 individual referral records obtained from three purposively selected study sites. The aim is to explore whether available data could provide evidence of association between the uptake of PBs and safeguarding referrals. Analysis of the national dataset found no significant relationships between PB uptake and the level and type of alleged abuse. However, analysis of individual level referral data, from the three selected sites did find some significant associations particularly with financial abuse; and t the main perpetrators of the alleged abuse to be home care employees. The findings are discussed within the context of current policy and practice context.With the continued implementation of the personalisation policy, Personal Budgets (PBs) have moved to the mainstream in adult social care in England. The relationship between the policy goals of personalisation and safeguarding is contentious. Some have argued that PBs have the potential to empower recipients, while others believe PBs, especially Direct Payments, might increase the risk of abuse. This paper provides empirical evidence about levels of uptake of PBs and safeguarding referrals in England based on in-depth analysis of national data at aggregate, local council level in England, covering 152 Councils. This is complemented by analysis of 2,209 individual referral records obtained from three purposively selected study sites. The aim is to explore whether available data could provide evidence of association between the uptake of PBs and safeguarding referrals. Analysis of the national dataset found no significant relationships between PB uptake and the level and type of alleged abuse. However, analysis of individual level referral data, from the three selected sites did find some significant associations particularly with financial abuse; and t the main perpetrators of the alleged abuse to be home care employees. The findings are discussed within the context of current policy and practice context.

Services that promote continuity of care: key findings from an evaluation of the national service framework for long‐term neurological conditions

Purpose – This paper seeks to report key findings of a study, whose purpose was to: understand what helps or hinders the commissioning and provision of integrated services for people with long‐term neurological conditions (LTNCs); identify models of best practice from the perspectives of people with LTNCs and the professionals who work with them; and develop a benchmarking system to assess the extent to which these models are available in England.Design/methodology/approach – The research had three main components: a rapid systematic literature review of evidence; in‐depth case studies of six neurology “service systems”; and a survey of all English PCTs to audit progress towards implementation of the National Service Framework (NSF) for LTNCs.Findings – A number of elements that contribute to the experience of continuity and three service models that incorporate these elements were identified: community interdisciplinary neurological rehabilitation teams; nurse specialists and proactive, holistic day oppo...

Integrating safety concepts in health and social care

Keeping individuals safe from harm and exploitation is a clearly articulated goal within both the health and social care sectors. Two key concepts associated with achieving this common aim are safety and safeguarding. The purpose of this paper is to critically appraise the differences in safety terminology used in health and social care, including opportunities and challenges for greater integration of safety systems across health and social care in England.,This paper presents the authors’ viewpoint based on personal, professional and research experience.,In healthcare, safety is usually conceptualised as the management of error, with risk considered on a universal level. In social care, the safeguarding process balances choice and control with individualised approaches to keeping adults safe, but lacks the established reporting pathways to capture safety incidents. Efforts to safely integrate health and social care services are currently constrained by a lack of shared understanding of the concepts of safety and safeguarding without further consideration of how these approaches to keeping people safe can be better aligned. As such, there is a need for a single, unified discourse of patient safety that cuts across the patient safety and safeguarding concepts and their associated frameworks in health and social care settings.,A single unified concept of safety in health and social care could coincide with an integrated approach to the delivery of health and social care, improving the care of patients transitioning between services.

What outcomes are important to people with long-term neurological conditions using integrated health and social care?

Measuring the outcomes that are meaningful to people with long-term neurological conditions (LTNCs) using integrated health and social care services may help to assess the effectiveness of integration. Conventional outcomes tend not to be derived from service user experiences, nor are they able to demonstrate the impact of integrated working. This paper reports findings about outcomes identified as being important to people with LTNCs using integrated services. We undertook qualitative work with five community neuro-rehabilitation teams that were integrated in different ways and to different degrees. In-depth, semi-structured interviews were conducted with 35 people with LTNCs using these teams. Data were collected between 2010 and 2011 and analysed using an adapted version of the Framework approach. We identified 20 outcomes across three domains: personal comfort outcomes, social and economic participation outcomes, and autonomy outcomes. Inter-relationships between outcomes, both within and across domains, were evident. The outcomes, and the inter-relationships between them, have implications for how individuals are assessed in practice.