A critical systems evaluation of the introduction of a ‘discharge to assess’ service in Kent (original) (raw)
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BMC Health Services Research
Background: Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions. Methods: We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data. Results: Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions. Conclusions: Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Øvretveit's cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.
The field of health and social care in the UK has been very receptive to systemic thinking in recent years and has been extensively and successfully modelled. This paper describes two trends in health care thinking in the UK which build upon this receptivity and are creating market pulls for whole systems ideas. These are the related areas of health needs analysis and service-line reporting, two concepts that are in search of a language and methodology to help deliver their potential. The paper describes how system dynamics is being applied to both these trends. The work is creating a natural progression for communicating system dynamics models and improving their impact on the thinking of clinicians and managers, particularly in mental health as epitomized by the contribution to this paper of the general manager responsible for the case study used.
System Dynamics and Action Research in Aged Care
Care Centre providing aged care and psychogeriatric, inpatient, outpatient, community and residential care in Victoria, Australia. The context of this research is a health system which has been under pressure to reduce costs. Bundoora Extended Care Centre (BECC) is one stage of a care process through which aged patients are moved as their clinical situation improves. The action research project used SD modelling and group modelling techniques to examine and improve patient stay times, specifically the period of time patients remained at BECC until they could be discharged. In the first part of the paper, the success of the project, not only in terms of reduction of patient stay times but also team work and staff morale, is documented. In the second part, the systemic adaptations of the rest of the system to the success of the project are documented. The reduction of patient stay times at BECC effectively left it with excess capacity. This capacity was filled by upstream providers who swamped BECC with intractable patients who returned BECC's patient stay times to pre-intervention levels while simultaneously reducing the up-stream providers patient stay times.
Evaluation of complex integrated care programmes: the approach in North West London
International journal of integrated care
Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect.
Background Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat ‘illusive’ impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015–2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside cont...
Health systems research and critical systems thinking: the case for partnership
Systems Research and Behavioral Science, 2019
There has been a considerable growth in interest in Health Systems Research over the last 25 years. It is only recently, however, that health systems researchers have started to examine the key conceptual tool in their armoury – the notion of ‘system'; – and only then in a sporadic fashion. This paper argues that the failure to undertake this challenge has held back the field both theoretically and in terms of practice. Critical systems thinkers have, by contrast, spent the last 30 years conducting a second‐order analysis of different systems and complexity approaches, the way they employ the concept of ‘system';, and the difference this makes to the theories espoused and the modes of intervention endorsed. They have also explored how different systems approaches can be used in combination to bring about improvement by addressing the multi‐dimensional complexity thrown up by wicked problems. What critical systems thinkers have failed to do is get their hands dirty and demons...
Health and Social Care Delivery Research
Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances...
Exploring implementation and sustainability of models of care: can theory help?
BMC Public Health, 2011
Objective: Research on new models of care in health service provision is complex, as is the introduction and embedding of such models, and positive research findings are only one factor in whether a new model of care will be implemented. In order to understand why this is the case, research design must not only take account of proposed changes in the clinical encounter, but the organisational context that must sustain and normalise any changed practices. We use two case studies where new models of maternity care were implemented and evaluated via randomised controlled trials (RCTs) to discuss how (or whether) the use of theory might inform implementation and sustainability strategies. The Normalisation Process Model is proposed as a suitable theoretical framework, and a comparison made using the two case studiesone where a theoretical framework was used, the other where it was not.