Naomi Fulop

Systematic review of involving patients in the planning and development of health care

Abstract Objective: To examine the effects of involving patients in the planning and development of health care. Data sources:Published and grey literature. Study selection: Systematic search for worldwide reports written in English between January 1966 and October 2000. Data extraction: Qualitative review of papers describing the effects of involving patients in the planning and development of health care. Results: Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported. Conclusions: Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.

Challenges to implementing the national programme for information technology (NPfIT) : a qualitative study

Abstract Objectives To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. Design Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. Setting Four acute NHS trusts in England. Participants Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. Results The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. Conclusions: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.

Patients or partners? Case studies of user involvement in the planning and delivery of adult mental health services in London

User or patient involvement (UI) in the planning and delivery of health services is an aspiration of many industrialized economies, and has been promoted by United Kingdom (UK) governments for over two decades. This paper reports the findings of qualitative case studies of UI in two mental health provider Trusts in London. Semi-structured interviews were conducted with a variety of stakeholders, including Trust staff at all levels and user group members, to compare the expectations of diverse stakeholders and the extent to which these were achieved. We found that UI remained in the gift of provider managers: providers retained control over decision making, and expected users to address Trust agendas and conform to Trust management practices. Users wanted to achieve concrete changes to policies and services, but had broader aspirations to improve the status and condition of people with mental health problems. Suggestions are made about the direction of future strategies to improve UI.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

Objective:  To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis

Objective To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay. Design Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics. Setting Acute stroke services in Greater Manchester and London, England. Participants 258 915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012. Interventions “Hub and spoke” model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke. Main outcome measures Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay. Results In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was −1.1% (95% confidence interval −2.1 to −0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: −2.0 days in Greater Manchester (95% confidence interval −2.8 to −1.2; 9%) and −1.4 days in London (−2.3 to −0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke. Conclusions A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions.

Over the past 50 years, two things have changed for women giving birth in high-income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in ‘alternative’ settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for ‘alternative’ settings for birth, these discourses constrain women’s decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.

The hospital of the future: Better out than in? Alternatives to acute hospital care

This is the fourth in a series of seven articles. Changing technology is probably the main force driving the substitution of healthcare resources. This is because new treatments, procedures, and diagnostic techniques allow conditions to be managed in different settings by different staff. Such change is generally incremental, but occasionally new technologies fundamentally change the organisation of care. For example, the development of effective chemotherapy in the 1940s allowed tuberculosis to be managed on an outpatient basis, which led directly to the closure of nearly 30 000 hospital beds and the elimination of an entire class of hospital. Advances in primary prevention might also, in the long term, lead to a reduced need for admission to hospital. Yet such step changes are ultimately outside the hands of clinicians, managers, and policymakers, despite their intimate concern with the organisation, scale, and cost of the hospital sector. The policy debate has tended to focus on what might be described as the “appropriateness gap”—how to provide substitute care for inpatients who do not strictly need to be in hospital because of current technologies. #### Summary points Changes in diagnostic and treatment technologies, rather than policy interventions, are the most potent force leading to the substitution of one form of healthcare service for another. Many inpatient bed days and admissions are deemed inappropriate—but the appropriateness of admission to hospital can tell us nothing about whether patients would be more cost effectively cared for outside hospital. Several services that attempt to be substitutes for hospital care—either by preventing admission or by hastening discharge—have been experimented with. Many apparent substitutes for hospital care seem, in the United Kingdom, to increase overall demand for services, with little impact on overall hospitalisation or costs. Most patients admitted to hospital in the United Kingdom have no alternative but to be admitted: they …

Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?

Introduction National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety. Methods To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members. Findings The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospitals governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance. Conclusion M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.

Investigating the use of patient involvement and patient experience in quality improvement in Norway: rhetoric or reality?

BackgroundPatient involvement in health care decision making is part of a wider trend towards a more bottom-up approach to service planning and provision, and patient experience is increasingly conceptualized as a core dimension of health care quality.The aim of this multi-level study is two-fold: 1) to describe and analyze how governmental organizations expect acute hospitals to incorporate patient involvement and patient experiences into their quality improvement (QI) efforts and 2) to analyze how patient involvement and patient experiences are used by hospitals to try to improve the quality of care they provide.MethodsThis multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews and non-participant observation of key meetings and shadowing of staff at the meso and micro levels in two purposively sampled Norwegian hospitals. Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012).ResultsGovernmental documents and regulations at the macro level demonstrated wide-ranging expectations for the integration of patient involvement and patient experiences in QI work in hospitals. The expectations span from systematic collection of patients’ and family members’ experiences for the purpose of improving service quality through establishing patient-oriented arenas for ongoing collaboration with staff to the support of individual involvement in decision making. However, the extent of involvement of patients and application of patient experiences in QI work was limited at both hospitals. Even though patient involvement was gaining prominence at the meso level − and to a lesser extent at the micro level − relevant tools for measuring and using patient experiences in QI work were lacking, and available measures of patient experience were not being used meaningfully or systematically.ConclusionsThe relative lack of expertise in Norwegian hospitals of adapting and implementing tools and methods for improving patient involvement and patient experiences at the meso and micro levels mark a need for health care policymakers and hospital leaders to learn from experiences of other industries and countries that have successfully integrated user experiences into QI work. Hospital managers need to design and implement wider strategies to help their staff members recognize and value the contribution that patient involvement and patient experiences can make to the improvement of healthcare quality.