Large-scale health system transformation in the United Kingdom

Awareness of healthcare workers regarding the healthcare sector transformation program in Saudi Arabia

BACKGROUND

Healthcare transformation is a multifaceted process that hinges on the collaborative efforts of various stakeholders. The success of a significant transformational project is contingent upon the readiness and acceptance among the healthcare workers.

AIMS

This study aims to assess the level of understanding and awareness of healthcare workers regarding healthcare transformation, with a specific focus on Vision 2030.

METHODS

A cross-sectional quantitative study was undertaken involving Saudi healthcare workers. The research employed bivariate correlations and multivariate linear regressions for statistical analysis. Survey data were collected from 456 healthcare workers to gauge their perspectives on healthcare transformation.

RESULTS

The findings reveal a robust correlation between awareness of healthcare transformation and the perceived significance of the transformation. Notably, participation in the planning and execution stages significantly enhances awareness levels. Conversely, a negative correlation is observed between awareness levels and concerns related to job security and other challenges faced by healthcare workers.

CONCLUSION

To ensure the success of the national transformation program, decision-makers should actively involve all potential stakeholders, particularly during the planning and execution stages. Reassuring healthcare workers about job security and addressing their concerns are crucial steps in overcoming resistance and fostering the necessary support for healthcare transformation initiatives.

Improving uptake of population health management through scalable analysis of linked electronic health data

Population Health Management - often abbreviated to PHM - is a relatively new approach for healthcare planning, requiring the application of analytical techniques to linked patient level data. Despite expectations for greater uptake of PHM, there is a deficit of available solutions to help health services embed it into routine use. This paper concerns the development, application and use of an interactive tool which can be linked to a healthcare system's data warehouse and employed to readily perform key PHM tasks such as population segmentation, risk stratification, and deriving various performance metrics and descriptive summaries. Developed through open-source code in a large healthcare system in South West England, and used by others around the country, this paper demonstrates the importance of a scalable, purpose-built solution for improving the uptake of PHM in health services.

Reducing uncertainty in evidence-based health policy by integrating empirical and theoretical evidence: An EbM+theory approach

BACKGROUND

To reduce their decisional uncertainty, health policy decision-makers rely more often on experts or their intuition than on evidence-based knowledge, especially in times of urgency. However, this practice is unacceptable from an evidence-based medicine (EbM) perspective. Therefore, in fast-changing and complex situations, we need an approach that delivers recommendations that serve decision-makers' needs for urgent, sound and uncertainty-reducing decisions based on the principles of EbM.

AIMS

The aim of this paper is to propose an approach that serves this need by enriching EbM with theory.

MATERIALS AND METHODS

We call this the EbM+theory approach, which integrates empirical and theoretical evidence in a context-sensitive way to reduce intervention and implementation uncertainty.

RESULTS

Within this framework, we propose two distinct roadmaps to decrease intervention and implementation uncertainty: one for simple and the other for complex interventions. As part of the roadmap, we present a three-step approach: applying theory (step 1), conducting mechanistic studies (EbM+; step 2) and conducting experiments (EbM; step 3).

DISCUSSION

This paper is a plea for integrating empirical and theoretical knowledge by combining EbM, EbM+ and theoretical knowledge in a common procedural framework that allows flexibility even in dynamic times. A further aim is to stimulate a discussion on using theories in health sciences, health policy, and implementation.

CONCLUSION

The main implications are that scientists and health politicians - the two main target groups of this paper-should receive more training in theoretical thinking; moreover, regulatory agencies like NICE may think about the usefulness of integrating elements of the EbM+theory approach into their considerations.

Navigating the micro-politics of major system change: The implementation of Sustainability Transformation Partnerships in the English health and care system

OBJECTIVE

To investigate how health and care leaders navigate the micro-politics of major system change (MSC) as manifest in the formulation and implementation of Sustainability and Transformation Partnerships (STPs) in the English National Health Service (NHS).

METHODS

A comparative qualitative case study of three STPs carried out between 2018-2021. Data collection comprised 72 semi-structured interviews with STP leaders and stakeholders; 49h of observations of STP executive meetings, management teams and thematic committees, and documentary sources. Interpretative analysis involved developing individual and cross case reports to understand the 'disagreements, 'people and interests' and the 'skills, behaviours and practice'.

FINDINGS

Three linked political fault-lines underpinned the micro-politics of formulating and implementing STPs: differences in meaning and value, perceptions of winners and losers, and structural differences in power and influence. In managing these issues, STP leaders engaged in a range of complementary strategies to understand and reconcile meanings, appraise and manage risks and benefits, and to redress longstanding power imbalances, as well as those related to their own ambiguous position.

CONCLUSION

Given the lack of formal authority and breadth of system change, navigating the micro-politics of MSC requires political skills in listening and engagement, strategic appraisal of the political landscape and effective negotiation and consensus-building.

Evaluating the translation of implementation science to clinical artificial intelligence: a bibliometric study of qualitative research

Introduction

Whilst a theoretical basis for implementation research is seen as advantageous, there is little clarity over if and how the application of theories, models or frameworks (TMF) impact implementation outcomes. Clinical artificial intelligence (AI) continues to receive multi-stakeholder interest and investment, yet a significant implementation gap remains. This bibliometric study aims to measure and characterize TMF application in qualitative clinical AI research to identify opportunities to improve research practice and its impact on clinical AI implementation.

Methods

Qualitative research of stakeholder perspectives on clinical AI published between January 2014 and October 2022 was systematically identified. Eligible studies were characterized by their publication type, clinical and geographical context, type of clinical AI studied, data collection method, participants and application of any TMF. Each TMF applied by eligible studies, its justification and mode of application was characterized.

Results

Of 202 eligible studies, 70 (34.7%) applied a TMF. There was an 8-fold increase in the number of publications between 2014 and 2022 but no significant increase in the proportion applying TMFs. Of the 50 TMFs applied, 40 (80%) were only applied once, with the Technology Acceptance Model applied most frequently (n = 9). Seven TMFs were novel contributions embedded within an eligible study. A minority of studies justified TMF application (n = 51,58.6%) and it was uncommon to discuss an alternative TMF or the limitations of the one selected (n = 11,12.6%). The most common way in which a TMF was applied in eligible studies was data analysis (n = 44,50.6%). Implementation guidelines or tools were explicitly referenced by 2 reports (1.0%).

Conclusion

TMFs have not been commonly applied in qualitative research of clinical AI. When TMFs have been applied there has been (i) little consensus on TMF selection (ii) limited description of selection rationale and (iii) lack of clarity over how TMFs inform research. We consider this to represent an opportunity to improve implementation science's translation to clinical AI research and clinical AI into practice by promoting the rigor and frequency of TMF application. We recommend that the finite resources of the implementation science community are diverted toward increasing accessibility and engagement with theory informed practices. The considered application of theories, models and frameworks (TMF) are thought to contribute to the impact of implementation science on the translation of innovations into real-world care. The frequency and nature of TMF use are yet to be described within digital health innovations, including the prominent field of clinical AI. A well-known implementation gap, coined as the "AI chasm" continues to limit the impact of clinical AI on real-world care. From this bibliometric study of the frequency and quality of TMF use within qualitative clinical AI research, we found that TMFs are usually not applied, their selection is highly varied between studies and there is not often a convincing rationale for their selection. Promoting the rigor and frequency of TMF use appears to present an opportunity to improve the translation of clinical AI into practice.

The forgotten dimension of integrated care: barriers to implementing integrated clinical care in English NHS hospitals

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary-secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

Behaviour change, the itchy spot of healthcare quality improvement: How can psychology theory and skills help to scratch the itch?

Despite the clear utility and transferability, National Health Service (NHS) quality improvement initiatives have yet to benefit fully from what is already known within health psychology. Thus far, evidence from established, seminal behaviour change theory and practice have been ignored in favour of newly developed models and frameworks. Further, whilst there is a growing interest in what is commonly referred to as 'human factors' of change and improvement, there is scant transferability of known psychologically informed implementation skills into routine NHS Improvement practice. The science and practice of healthcare improvement is growing, and the behaviour change aspect is critical to sustainable outcomes. Therefore, this paper offers practical guidance on how seminal psychological behaviour change theory and motivational interviewing (a person-centred skills-based approach specifically developed to support people through change) can be combined to better address individual and organisational change within a healthcare improvement context.

Scale and spread of innovation in health and social care: Insights from the evaluation of the New Care Model/Vanguard programme in England

OBJECTIVE

Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up.

METHODS

We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation.

RESULTS

A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models.

CONCLUSIONS

This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

UK Healthcare Workers' Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

METHODS

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.

RESULTS

Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.

CONCLUSION

Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.

Implementation of significant mental health service change: perceptions and concerns of a mental health workforce in the context of transformation

Purpose

As part of an evaluation of the nationally mandated Child and Adolescent Mental Health Services (CAMHS) “transformation” in one foundation NHS trust, the authors explored the experiences of mental health staff involved in the transformation.

Design/methodology/approach

The authors employed a qualitative methodology and followed an ethnographic approach. This included observation of mental health staff involved in the transformation and informal interviews (80 h). The authors also undertook semi-structured interviews with key staff members ( n  = 16). Data were analysed thematically.

Findings

The findings fall into three thematic areas around the transformation, namely (1) rationale; (2) implementation; and (3) maintenance. Staff members were supportive of the rationale for the changes, but implementation was affected by perceived poor communication, resulting in experiences of unpreparedness and de-stabilisation. Staff members lacked time to set up the necessary processes, meaning that changes were not always implemented smoothly. Recruiting and retaining the right staff, a consistent challenge throughout the transformation, was crucial for maintaining the service changes.

Originality/value

There is little published on the perceptions and experiences of mental health workforces around the CAMHS transformations across the UK. This paper presents the perceptions of mental health staff, whose organisation underwent significant “transformational” change. Staff demonstrated considerable resilience in the change process, but better recognition of their needs might have improved retention and satisfaction. Time for planning and training would enable staff members to better develop the processes and resources necessary in the context of significant service change. Developing ways for services to compare changes they are implementing and sharing good practice around implementation with each other are also vital.

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions

Background

Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies.

Methods

Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes.

Results

CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8–8.1) versus 7.5 (CI: 7.4–7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5–13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8–9.0%) and 8.8% (95% CI:4.5–13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3–7.2%). The slowdown largely occurred in the final year of both programmes.

Conclusions

Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06692-x.

What if something happens tonight? A qualitative study of primary care physicians' perspectives on an alternative to hospital admittance

BACKGROUND

Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians' (PCPs') perspectives on admission to a MAW as an alternative to hospitalisation.

METHODS

The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach.

RESULTS

The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients' condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients' and relatives' participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients' wishes conflicted with what PCPs considered professionally sound.

CONCLUSIONS

The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.

Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency

Purpose

The purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.

Design/methodology/approach

A qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.

Findings

While each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.

Practical implications

The paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.

Originality/value

The paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.