Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland

What and how do different stakeholders contribute to intervention development? A mixed methods study

Background: UK Medical Research Council guidelines recommend end-user involvement in intervention development. There is limited evidence on the contributions of different end-users to this process. The aim of this Study Within A Trial (SWAT) was to identify and compare contributions from two groups of end-users - people with diabetes' (PWD) and healthcare professionals' (HCPs), during consensus meetings to inform an intervention to improve retinopathy screening uptake. Methods: A mixed method, explanatory sequential design comprising a survey and three semi-structured consensus meetings was used. PWD were randomly assigned to a PWD only or combined meeting. HCPs attended a HCP only or combined meeting, based on availability. In the survey, participants rated intervention proposals on acceptability and feasibility. Survey results informed the meeting topic guide. Transcripts were analysed deductively to compare feedback on intervention proposals, suggestions for new content, and contributions to the final intervention. Results: Overall, 13 PWD and 17 HCPs completed the survey, and 16 PWD and 15 HCPs attended meetings. For 31 of the 39 intervention proposals in the survey, there were differences (≥10%) between the proportion of HCPs and PWD who rated proposals as acceptable and/or feasible. End-user groups shared and unique concerns about proposals; both were concerned about informing but not scaring people when communicating risk, while concerns about resources were mostly unique to HCPs and concerns about privacy were mostly unique to PWD.  Fewer suggestions for new intervention content from the combined meeting were integrated into the final intervention as they were not feasible for implementation in general practice. Participants contributed four new behaviour change techniques not present in the original proposals: goal setting (outcome), restructuring the physical environment, material incentive (behaviour) and punishment. Conclusions: Preferences for intervention content may differ across end-user groups, with feedback varying depending on whether end-users are involved simultaneously or separately.

What and how do different stakeholders contribute to intervention development? A mixed methods study

Background: UK Medical Research Council guidelines recommend end-user involvement in intervention development. There is limited evidence on the contributions of different end-users to this process. The aim of this Study Within A Trial (SWAT) was to identify and compare contributions from two groups of end-users - people with diabetes' (PWD) and healthcare professionals' (HCPs), during consensus meetings to inform an intervention to improve retinopathy screening uptake. Methods: A mixed method, explanatory sequential design comprising a survey and three semi-structured consensus meetings was used. PWD were randomly assigned to a diabetes only or combined meeting. HCPs attended a HCP only or combined meeting, based on availability. In the survey, participants rated intervention proposals on acceptability and feasibility. Survey results informed the meeting topic guide. Transcripts were analysed deductively to compare feedback on intervention proposals, suggestions for new content, and contributions to the final intervention. Results: Overall, 13 PWD and 17 HCPs completed the survey, and 16 PWD and 15 HCPs attended meetings. For 31 of the 39 intervention proposals in the survey, there were differences (≥10%) between the proportion of HCPs and PWD who rated proposals as acceptable and/or feasible. End-user groups shared and unique concerns about proposals; both were concerned about informing but not scaring people when communicating risk, while concerns about resources were mostly unique to HCPs and concerns about privacy were mostly unique to PWD.  Fewer suggestions for new intervention content from the combined meeting were integrated into the final intervention as they were not feasible for implementation in general practice. Participants contributed four new behaviour change techniques not present in the original proposals: goal setting (outcome), restructuring the physical environment, material incentive (behaviour) and punishment. Conclusions: Preferences for intervention content may differ across end-user groups, with feedback varying depending on whether end-users are involved simultaneously or separately.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration

OBJECTIVES

This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems.

METHODS

This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales.

RESULTS

Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach.

CONCLUSIONS

We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice.

The drivers and impact of emergency care reconfiguration in Ireland: Results from a large mixed-methods research programme

Ireland, like many countries, has reconfigured emergency care in recent years towards a more centralised model. Although centralisation is presented as 'evidence-based', the relevance of this evidence is challenged by groups which hold values beyond those implicit in the literature. The Study of the Impact of Reconfiguration on Emergency and Urgent Care Networks (SIREN) programme was funded to evaluate the development and performance of emergency and urgent care systems in Ireland. SIREN found that the drivers of reconfiguration in Ireland are based on safety and efficiency claims which are highly contestable. Reconfiguration was not associated with improvements in safety or efficiency and may have exacerbated the growing capacity challenges for acute hospitals. These findings are consistent with UK research. Our study adds to an emerging literature on the interaction between a narrow technocratic approach to health system planning and the perspectives of the public and patients.

The problems of smaller, rural and remote hospitals: Separating facts from fiction

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

OBJECTIVES

To understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis.

SETTING

EDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015.

PARTICIPANTS

All patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015.

INTERVENTION

The system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question.

RESULTS

Three of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration.

CONCLUSIONS

Findings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.

A sociology of public responses to hospital change and closure

The "problem" of public resistance to hospital closure is a recurring trope in health policy debates around the world. Recent papers have argued that when it comes to major change to hospitals, "the public" cannot be persuaded by clinical evidence, and that mechanisms of public involvement are ill-equipped to reconcile opposition with management desire for radical change. This paper presents data from in-depth qualitative case studies of three hospital change processes in Scotland's National Health Service, including interviews with 44 members of the public. Informed by sociological accounts of both hospitals and publics as heterogeneous, shifting entities, I explore how hospitals play meaningful roles within their communities. I identify community responses to change proposals which go beyond simple opposition, including evading, engaging with and acquiescing to changes. Explicating both hospitals and the publics they serve as complex social phenomena strengthens the case for policy and practice to prioritise dialogic processes of engagement. It also demonstrates the continuing value of careful, empirical research into public perspectives on contentious healthcare issues in the context of everyday life.

A study of nurse-based Injury Units in Ireland: An emergency care development for consideration worldwide

The aim of this 2018 research study was to determine why nurse-based Injury Units were developed in Ireland and how they function in the Irish healthcare system, including what they contribute in relation to addressing the healthcare needs of Irish citizens. A document review was completed and interviews of nurse practitioners and physicians working in Irish Emergency Rooms (ERs) and Injury Units, as well as nurse managers with responsibility for Injury Units and health service executives who helped design Injury Units. A new model of emergency care was needed 20 years ago when two issues were apparent. The first was concern over unsafe care in small ERs as a result of low patient volumes and staff not having ER expertise. The second issue was long waits for ER care. Considerable opportunity for change was present, including financial imperatives and nurse, physician, and political leaders who were together ready to design and move a new-to-Ireland ER services model and nurse practitioner education forward. The Injury Unit model is based on nurse practitioners providing a defined set of services to nonurgent patients in daytime hours. This model was pilot tested and is being implemented across Ireland after it was determined that quality services were being rapidly and safely provided. Nurse practitioner education was also initiated and is now in expansion mode to gain 700 more nurse practitioners by the year 2021 over the current 240.

Development of a surgical site infection surveillance programme in a Scottish neurosurgical unit

Purpose

Surgical site infection (SSI) is a common complication in surgical practice. SSIs represent almost a fifth of healthcare-associated infections in Scotland, and have deleterious effects on mortality, morbidity, length of stay, and cost to the health service. SSIs in neurosurgery may be more consequential than in other specialities given the potentially devastating effects of central nervous system infection. The paper aims to discuss these issues.

Design/methodology/approach

In 2014, the authors became concerned about an anecdotal increase in infection rates in the authors’ unit. While national guidance on SSI surveillance existed in England and Scotland, the authors had no relevant procedures or policies in Glasgow, and began the process of establishing a surveillance programme. This was driven by clinicians but faced challenges due to a lack of involvement of the wider organisation in the early stages.

Findings

SSIs were initially reported via a form-filling system. This developed into an editable hospital intranet database, but still suffered from the problems of voluntary entries and under-reporting. Following the formal engagement of management structures and the funding of a surveillance nurse, the authors’ programme developed robustness, and resilience. With the advent of an SSI committee, the authors now have a well-established programme that ingrains SSI prevention in the collective learning and organisational memory of the authors’ unit.

Originality/value

Clinicians must lead on the development of these programmes, but long-term durability requires engagement and support from the wider organisation.

Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland

BACKGROUND

There is an increasing tendency to reconfigure acute hospital care towards a more centralised and specialised model, particularly for complex care conditions. Although centralisation is presented as "evidence-based", the relevant studies are often challenged by groups which hold perspectives and values beyond those implicit in the literature. This study investigated stakeholder perspectives on the rationale for the reconfiguration of urgent and emergency care in Ireland. Specifically, it considered the hypothesis that individuals from different stakeholder groups would endorse different positions in relation to the motivation for, and goals of, reconfiguration.

METHODS

Documentary analysis of policy documents was used to identify official justifications for change. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for reconfiguration.

RESULTS

While there was some within-group variation, internal and external stakeholders generally vocalised different lines of argument. Clinicians and management in the internal stakeholder group proposed arguments in favour of reconfiguration based on efficiency and safety claims. External stakeholders, including hospital campaigners and local political representatives expressed arguments that focused on access to care. A "voter" argument, focused on the role of local politicians in determining the outcome of reconfiguration planning, was mentioned by both internal and external stakeholders, often in a critical fashion.

CONCLUSION

Our study adds to an emerging literature on the interaction between a technocratic approach to health system planning advocated by clinicians and health service managers, and the experiential "non-expert" claims of the public and patients.