Gemma Frances Spiers

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.

Care closer to home for children and young people who are ill: developing and testing a model of service delivery and organization

AIMS To report findings of a national survey of care closer to home services for children and young people and a typology based on these findings. BACKGROUND Providing care closer to home for children is a policy and practice aspiration internationally. While the main model of such services is childrens community nursing, other models have also developed. Past research has proposed a relatively static typology of services, determined by where they are based, whether they are generic or specialist and whether they provide short- or longer-term input. As services develop, however, this typology needs further elaboration. METHODS A two-stage national survey of all primary care and hospital trusts in England, in mid-2008. RESULTS In all, 67% of trusts responded to the screening questionnaire and 75% of relevant services to the main stage questionnaire. Thirteen distinct types of services were identified initially. Cluster analysis of delivery and organization characteristics then identified a three-model typology: hospital-based, condition-specific services (36%); childrens community nurses and other community services (45%) and other (mainly therapy-based) services (19%). The models differed in staffing, costs, functions, type of care provided and geographical coverage. Only a third of nurses in teams were paediatric-trained. CONCLUSION Care closer to home services are an established part of care for children and young people who are ill. They deal with complex and technical care and can prevent or reduce the length of acute hospital admission. Lack of readily available information about caseloads, case mix and costs may hamper their further development.

“It goes against the grain”: A qualitative study of the experiences of parents’ administering distressing health-care procedures for their child at home

Parents caring for children with complex and long‐term conditions at home take on responsibility for technical health‐care procedures that may cause their child distress. Little evidence exists about parents’ experience of this specific aspect of their caring role.

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.

G10 Planning and implementing service change in children’s community nursing

Purpose This study aimed to examine the impact of introducing or expanding children’s community nursing (CCN) services, and understand the contextual mechanisms that mediate the success of planning and implementing such service change. This paper presents findings about the identified contextual mechanisms: the perceived factors that mediated efforts to plan and implement new or expanded CCN services. Methods A case study design was used with five health communities in England that had recently, or were in the process of, introducing or expanding their CCN provision. Data were collected through twenty-one longitudinal (time frame), in-depth interviews and 6 focus groups with 41 children’s community nurses, managers and commissioners. Interviews and focus groups explored the processes, barriers and facilitators to service change planning and implementation. Documentary evidence was also collected. Data were managed using the Framework approach, and analysed thematically. Results Service change was implemented as planned in three sites, and partially in one site. Intended change was not achieved in one site. Dedicated finance, medical buy-in of CCN, and (where multiple providers were involved) use of a centralised network, all facilitated the achievement of service change. Competition between providers and NHS reforms made service planning complex and time consuming. An absence of medical support for CCN services, and a lack of commitment from commissioners, prevented intended service change in two sites. Communicating service change was deemed important for integration with, and take up by, other local NHS services. However, CCN team staff struggled to do this alongside care delivery and talked of the need for ‘marketing’. Demonstrating value and impact of the new and expanded services was challenged by inadequate data collection systems and inaccessible or overly complex data. Staff were keen to explore ways of measuring quality-based outcomes. Conclusions Issues of visibility and acceptability of CCN services appear to pervade the reported difficulties and successes of planning and implementing service change. Implications for care ‘closer to home’ policy and practice will be discussed.