Oral health promotion and homelessness:a theory-based approach to understanding processes of implementation and adoption

Objective: To use the Theory of Diffusion of Innovations as a framework to explore the qualitative data gleaned from a process evaluation of the Smile4life intervention across Scottish National Health Service (NHS) Boards and to inform future oral health promotion and homelessness.Design: A qualitative exploration.Setting: In 2012, the Smile4life programme to promote the oral health of homeless people was launched in Scotland. Practitioners received training to ensure its successful implementation and adoption. A process evaluation began in February 2013.Method: A total of 20 oral health officers from the 11 participating NHS Boards took part in the process evaluation. They were interviewed each month for a 17-month period. Boards were placed into adoption categories based on the time taken to adoption. The data were analysed using a framework approach.Results: The Theory of Diffusion of Innovations was used to define ‘time to adoption’ and to classify participating NHS Boards’ adoption categories. It was also used to identify diffusion variables that underpinned Smile4life adoption. For Boards that more readily adopted Smile4life, the diffusion variables of familiarity and good social exchanges appeared to promote implementation. Numerous conflicts emerged, however, in late adoption Boards. These included a lack of resources and practitioner ambivalence, which slowed up implementation.Conclusion: The Theory of Diffusion of Innovations provided a useful theoretical framework for understanding the processes in the implementation and adoption of the Smile4life programme. It allowed specific training requirements for the practitioners to emerge to facilitate diffusion of the programme in their Boards

Stakeholder perspectives on new ways of delivering unscheduled health care: the role of ownership and organisational identity

<b>Rationale, aims and objectives</b>: To explore stakeholder perspectives of the implementation of a new, national integrated nurse-led telephone advice and consultation service (NHS 24), comparing the views of stakeholders from different health care organisations. <b>Methods</b>: Semi-structured interviews with 26 stakeholders including partner organisations located in primary and secondary unscheduled care settings (general practitioner (GP) out-of-hours co-operative; accident and emergency department; national ambulance service), members of NHS 24 and national policymakers. Attendance at key meetings, documentary review and email implementation diaries provided a contextual history of events with which interview data could be compared. <b>Results</b>: The contextual history of events highlighted a fast-paced implementation process, with little time for reflection. Key areas of partner concern were increasing workload, the clinical safety of nurse triage and the lack of communication across the organisations. Concerns were most apparent within the GP out-of-hours co-operative, leading to calls for the dissolution of the partnership. Accident and emergency and ambulance service responses were more conciliatory, suggesting that such problems were to be expected within the developmental phase of a new organisation. Further exploration of these responses highlighted the sense of ownership within the GP co-operative, with GPs having both financial and philosophical ownership of the co-operative. This was not apparent within the other two partner organisations, in particular the ambulance service, which operated on a regional model very similar to that of NHS 24. <b>Conclusions</b>: As the delivery of unscheduled primary health care crosses professional boundaries and locations, different organisations and professional groups must develop new ways of partnership working, developing trust and confidence in each other. The results of this study highlight, for the first time, the key importance of understanding the professional ownership and identity of individual organisations, in order to facilitate the most effective mechanisms to enable that partnership working

Prescription for nursing informatics in pre-registration nurse education.

Nurses need to be able to use information and communications technology not only to support their own practice, but also to help their patients make best use of it. This article argues that nurses are not currently adequately prepared to work with information and technology through their pre-registration education. Reflecting the lack of nursing informatics expertise, it is recommended that all pre-registration nursing programmes should have access to a nursing informatics specialist. A prescription to meet the informatics needs of the newly qualified nurse is proposed. This places the areas that need to be included in pre-registration education into broad groups that both articulate the competencies that nurses need to develop, and indicate why they are needed, rather than providing context-free checklists of skills. This is presented as a binary scatter chart with two axes, skill to knowledge and technology to information

Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people

Background This paper describes a study protocol designed to evaluate a programme of smoking cessation interventions targeting pregnant women and young people living in urban and rural locations in Northeast Scotland. The study design was developed on so-called 'realist' evaluation principles, which are concerned with the implementation of interventions as well as their outcomes. Methods/design A two-phased study was designed based on the Theory of Change (TOC) using mixed methods to assess both process and outcome factors. The study was designed with input from the relevant stakeholders. The mixed-methods approach consists of semi-structured interviews with planners, service providers, service users and non-users. These qualitative interviews will be analysed using a thematic framework approach. The quantitative element of the study will include the analysis of routinely collected data and specific project monitoring data, such as data on service engagement, service use, quit rates and changes in smoking status. Discussion The process of involving key stakeholders was conducted using logic modelling and TOC tools. Engaging stakeholders, including those responsible for funding, developing and delivering, and those intended to benefit from interventions aimed at them, in their evaluation design, are considered by many to increase the validity and rigour of the subsequent evidence generated. This study is intended to determine not only the components and processes, but also the possible effectiveness of this set of health interventions, and contribute to the evidence base about smoking cessation interventions aimed at priority groups in Scotland. It is also anticipated that this study will contribute to the ongoing debate about the role and challenges of 'realist' evaluation approaches in general, and the utility of logic modelling and TOC approaches in particular, for evaluation of complex health interventions

Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments

Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards contributing to the reduction of avoidable health inequalities. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods

Paying for the quantity and quality of hospital care : the foundations and evolution of payment policy in England

Prospective payment arrangements are now the main form of hospital funding in most developed countries. An essential component of such arrangements is the classification system used to differentiate patients according to their expected resource requirements. In this article we describe the evolution and structure of Healthcare Resource Groups (HRGs) in England and the way in which costs are calculated for patients allocated to each HRG. We then describe how payments are made, how policy has evolved to incentivise improvements in quality, and how prospective payment is being applied outside hospital settings

The organisational and human resource challenges facing primary care trusts : protocol of a multiple case study

BACKGROUND: The study is designed to assess the organisational and human resource challenges faced by Primary Care Trusts (PCTs). Its objectives are to: specify the organisational and human resources challenges faced by PCTs in fulfilling the roles envisaged in government and local policy; examine how PCTs are addressing these challenges, in particular, to describe the organisational forms they have adopted, and the OD/HR strategies and initiatives they have planned or in place; assess how effective these structures, strategies and initiatives have been in enabling the PCTs to meet the organisational and human resources challenges they face; identify the factors, both internal to the PCT and in the wider health community, which have contributed to the success or failure of different structures, strategies and initiatives. METHODS: The study will be undertaken in three stages. In Stage 1 the key literature on public sector and NHS organisational development and human resources management will be reviewed, and discussions will be held with key researchers and policy makers working in this area. Stage 2 will focus on detailed case studies in six PCTs designed to examine the organisational and human resources challenges they face. Data will be collected using semi-structured interviews, group discussion, site visits, observation of key meetings and examination of local documentation. The findings from the case study PCTs will be cross checked with a Reference Group of up to 20 other PCG/Ts, and key officers working in organisational development or primary care at local, regional and national level. In Stage 3 analysis of findings from the preparatory work, the case studies and the feedback from the Reference Group will be used to identify practical lessons for PCTs, key messages for policy makers, and contributions to further theoretical development

Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training?

<p>Background: The Trigger Review Method (TRM) is a structured approach to screening clinical records for undetected patient safety incidents (PSIs) and identifying learning and improvement opportunities. In Scotland, TRM participation can inform GP appraisal and has been included as a core component of the national primary care patient safety programme that was launched in March 2013. However, the clinical workforce needs up-skilled and the potential of TRM in GP training has yet to be tested. Current TRM training utilizes a workplace face-to-face session by a GP expert, which is not feasible. A less costly, more sustainable educational intervention is necessary to build capability at scale. We aimed to determine the feasibility and impact of TRM and a related training intervention in GP training.</p> Methods We recruited 25 west of Scotland GP trainees to attend a 2-hour TRM workshop. Trainees then applied TRM to 25 clinical records and returned findings within 4-weeks. A follow-up feedback workshop was held. <p>Results: 21/25 trainees (84%) completed the task. 520 records yielded 80 undetected PSIs (15.4%). 36/80 were judged potentially preventable (45%) with 35/80 classified as causing moderate to severe harm (44%). Trainees described a range of potential learning and improvement plans. Training was positively received and appeared to be successful given these findings. TRM was valued as a safety improvement tool by most participants.</p> <p>Conclusion: This small study provides further evidence of TRM utility and how to teach it pragmatically. TRM is of potential value in GP patient safety curriculum delivery and preparing trainees for future safety improvement expectations.</p&gt

The current provision of community-based teaching in UK medical schools: an online survey and systematic review

Objective: To evaluate the current provision and outcome of community-based education (CBE) in UK medical schools. Design and data sources: An online survey of UK medical school websites and course prospectuses and a systematic review of articles from PubMed and Web of Science were conducted. Articles in the systematic review were assessed using Rossi, Lipsey and Freeman’s approach to programme evaluation. Study selection: Publications from November 1998 to 2013 containing information related to community teaching in undergraduate medical courses were included. Results: Out of the 32 undergraduate UK medical schools, one was excluded due to the lack of course specifications available online. Analysis of the remaining 31 medical schools showed that a variety of CBE models are utilised in medical schools across the UK. Twenty-eight medical schools (90.3%) provide CBE in some form by the end of the first year of undergraduate training, and 29 medical schools (93.5%) by the end of the second year. From the 1378 references identified, 29 papers met the inclusion criteria for assessment. It was found that CBE mostly provided advantages to students as well as other participants, including GP tutors and patients. However, there were a few concerns regarding the lack of GP tutors’ knowledge in specialty areas, the negative impact that CBE may have on the delivery of health service in education settings and the cost of CBE. Conclusions: Despite the wide variations in implementation, community teaching was found to be mostly beneficial. To ensure the relevance of CBE for ‘Tomorrow’s Doctors’, a national framework should be established, and solutions sought to reduce the impact of the challenges within CBE. Strengths and limitations of this study: This is the first study to review how community-based education is currently provided throughout Medical Schools in the UK. The use of Rossi, Lipsey and Freeman’s method of programme evaluation means that the literature was analysed in a consistent and comprehensive way. However, a weakness is that data from the online survey was obtained from online medical school prospectuses. This means the data may be incomplete or out of date. Data in the literature review may also be skewed by publication bias

England’s Electronic Prescription Service: Infrastructure in an Institutional Setting

We describe the development of the Electronic Prescription Service (EPS), the solution for the electronic transmission of prescriptions adopted by the English NHS for primary care. The chapter is based on both an analysis of data collected as part of a nationally commissioned evaluation of EPS, and on reports of contemporary developments in the service. Drawing on the notion of an installed infrastructural base, we illustrate how EPS has been assembled within a rich institutional and organizational context including causal pasts, contemporary practices and policy visions. This process of assembly is traced using three perspectives; as the realization and negotiation of constraints found in the wider NHS context, as a response to inertia arising from limited resources and weak incentive structures, and as a purposive fidelity to the existing institutional cultures of the NHS. The chapter concludes by reflecting on the significance of this analysis for notions of an installed base