Hospital care at home; a review of the literature on the effects of a form of transmural care

OBJECTIVE: To evaluate the effects of hospital at home on health outcomes and quality of life of patients and carers; to evaluate the costs of this form of care and the experiences of the (para)medics involved. DESIGN: Literature study. METHOD: Using Medline, EMBASE-Excerpta Medica, Sci-search and Cinahl, a search was carried out for Dutch- and English-language studies from 1990-2001 which compared hospital at home with conventional inpatient care. RESULTS: Twenty-seven (randomised) controlled trials and cross-over studies from seven different countries were found, which resulted in 37 publications. No differences were found in health outcomes between patients allocated to hospital at home and inpatient care, providing there was careful patient selection and the home met a number of basic conditions. Patients and their carers rated hospital at home positively. The expected reduction in costs to the health services was disappointing. Good organisation, communication and funding were essential boundary conditions to the success of this form of care. Health benefits appear to be primarily attained with schemes designed to avoid admission to hospital for the elderly.     

Openness and Specialisation: Dealing with Patients in a Hospital Emergency Service

The hospital is characterised by a dual orientation: being open to the heterogenous demands for medical care that are spontaneously directed to it, and selecting patients in terms of their match with medical specialties represented in its different services. This tension is at the heart of the functioning of emergency services. Based on ethnographic fieldwork in a French teaching hospital, the article examines the consequences of this duality on the concrete organisation of work. It shows the main dimensions that go to make up the patient's mobilising worth : closeness to the core of real emergencies; social demands; the intellectual interest of the case; questions raised by transfers of responsibility between doctors. For each dimension, it studies staff reactions and gives some indications about their complexity. Finally it suggests some comparisons between these results and the observations made by several studies conducted in American and UK hospitals since the 1970s.     

A bed too far. The implementation of freedom of choice policy in the NHS

Freedom of hospital choice has become a popular policy among the European public health services to ensure better patient rights, reduce waiting times and improve efficiency and quality in public hospitals. The English National Health Service has recently adopted this policy. This organisation needs to introduce important reforms in order to implement this policy, in particular in the information that it provides to patients. This paper presents the Andalusian Health Service (SAS) initiative in the disclosure of information, based on patient surveys, so it can be understood by patients. Andalusia implemented a freedom of choice policy 10 years ago. This paper also studies how SAS hospitals are scored by patients and how the quality of hospitals may affect their choice. Regression analyses indicate that two hospital dimensions, a 'human dimension' and a 'facilities dimension', significantly explain how patients assess the quality of the Andalusian hospitals. Nonetheless, these two dimensions do not explain the reputation of the hospitals, a main aspect when choosing a hospital, to the same extent. The lessons provided by looking at the SAS experience may give an insightful knowledge on whether patients in England will finally opt for the best hospitals.     

Management matters: the link between hospital organisation and quality of patient care

Some hospital trusts and health authorities consistently outperform others on different dimensions of performance. Why? There is some evidence that "management matters", as well as the combined efforts of individual clinicians and teams. However, studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically. A larger, and arguably more rigorous, body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management. Studies in these traditions have focused on the effects of decentralisation, participation, innovative work practices, and "complementarities" on outcome variables such as job satisfaction and performance. The aim of this paper is to identify a number of reviews and research traditions that might bring new ideas into future work on the determinants of hospital performance. Ideally, future research should be more theoretically informed and should use longitudinal rather than cross sectional research designs. The use of statistical methods such as multilevel modelling, which allow for the inclusion of variables at different levels of analysis, would enable estimation of the separate contribution that structure and process make to hospital outcomes.     

Contracting for services and limits to managed competition

The introduction of market forces into the NHS has led to an operational divorce between health care providers and those who need health-care. Central to this change has been the widespread use of contracts. As a management problem, contract negotiation must incorporate consideration of full cost recovery to establish prices for hospital services sold and to ensure that available information is employed in assessing external services purchased. Ignoring the important issue of information availability in identifying relevant costs, it is the difficulty in specifying the cost of an episode of treatment, for example, that has led to contracts being negotiated in block form. Argues that this may be the only contract that can be effectively established. An important consequence of this is that the complexity of hospital services and requirements will work against a wider implementation of piecemeal managed competition and will form a natural barrier to market forces in the NHS.     

Decentralisation, integration and accountability: perceptions of New Zealand's top health service managers.

This paper reports on the findings of a representative survey of senior managers within New Zealand's health system. Respondents report most favourably upon the implementation of a new organisational structure, service management, which appears to have largely replaced the traditional division of health services into hospitals and community services. Service management, which is the decentralisation of decision making to integrated patient groupings, i.e. medicine, surgery, mental health, women's health, primary health care etc., appears to have been remarkably successful, in the view of the respondents, in achieving greater efficiencies, better quality care, better decision making about priorities and greater accountability of doctors. A majority of respondents consider that services have replaced hospitals as organisational entities. Significant progress is reported in the integration of hospital and community services, primary and secondary care, preventive and treatment services and of public, private and voluntary services through service management. The findings point to a new paradigm which may be of fundamental significance in the future organisation of health services.     

The stakes for hospital organization: users' point of view

In France, a hospital must rely upon its patients' perspectives and other users' points of view in order to set objectives for the improvement in the organisation of care and services provided. This article presents the principle learnings from a study conducted on the users' perception of their care received at a university hospital centre. Three main results surfaced: a strong expectation of consideration which was common among all users; the significance of the care's context as a determining factor in the users' opinion on the care received: and finally, the level and investment of consideration expected by the users simultaneously concerns a number of tasks, namely medical care and follow-up services, the moral and emotional relationship of the hospital's staff with the users, the catering and cleaning services, the emergency services and the hospital's check-out procedures and conditions. This third point could serve as mandatory principle in any project aiming to improve the operation of a hospital's structure and the organisation of services and care.     

The Norwegian approach to integrated quality development

The UK NHS quality proposals require all NHS organisations to develop an "integrated approach " to quality. In other countries, health care organisations are also working to ensure that the many different quality methods and systems used in health organisations do not duplicate or conflict with each other. The question this paper addresses is "what would an integrated approach to quality look like and how might managers and clinicians develop such an approach in their organisation?" The findings from the Norwegian total quality management experiment in six hospitals were that TQM could not be applied in its pure form in public health care services to ensure integration. The paper draws on this research to describe these hospitals' approach to integrate the different projects and systems which were stimulated by their initial quality programmes. The paper describes the "integrated quality development" approach which characterised these programmes.     

Insurance status and waiting times for hospital-based services in Ireland

In Ireland long waits for public hospital services are a feature of the healthcare system, with limited evidence that waits for private hospital services (delivered in both public and private hospitals) are shorter. In 2008, in an attempt to ensure more equitable access to hospital-based services, a ‘common waiting list’ for all patients within public hospitals was proposed. The aim of this paper is to analyse waiting times in Ireland for hospital services for patients with and without private health insurance (PHI) and to examine whether the 2008 reform reduced the differential in waiting. The analysis used data from the 2007 and 2010 health module of the Quarterly National Household survey (QNHS). The impact of insurance status on waiting times was analysed for the period before and after the reforms. A higher proportion of those without PHI were waiting more than three months for hospital services relative to those with PHI. There was no evidence that the 2008 reforms reduced the differential. Anecdotal evidence suggests that the proposals were not fully implemented, although expansion of capacity for private patients’ treatment in private hospitals is a possible confounding factor.     

Organising habilitation services: team structures and family participation

This study is part of a project focusing on co-operation between receivers of habilitation services (families) and professionals. The study focuses on the organisation and co-ordination of the services, and compares two structures for their accomplishment. The first is the typical multiprofessional habilitation team (MHT), and the second is the individualised team (ISP). MHT teams are organised within the habilitation agency, while ISP teams span institutional boundaries. An ISP team is formed around the individual child who receives services from the habilitation centre, and includes parents (sometimes the child), professionals from the habilitation centre, and professionals from other service-providing institutions that are actively involved (for instance pre-school teacher, schoolteacher etc.). The team maps child and family needs, organises assessments and services and formulates goals that subsequently are monitored and followed up. A questionnaire (Measures of Processes of Care) was used to assess the experiences of 385 service receivers. The questionnaire focuses on service receivers' experiences of the family-centredness of the service, operationalised in 56 items, along with five items concerning perceptions of level of control over service provision. The experiences of families having individualised teams were compared to those not having these teams. Significant differences were obtained, suggesting the impact of the form of service organisation on the content. Families having ISP teams report both more family-centred service, and a greater level of control over service provision. Results are discussed in terms of organising structures and co-ordination of services, and in terms of family participation.     

Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge

In recent years, there has been significant concern, and policy activity, in relation to the problem of delayed discharges from hospital. Key elements of policy to tackle delays include new investment, the establishment of the Health and Social Care Change Agent Team, and the implementation of the Community Care (Delayed Discharge) Act 2003. Whilst the problem of delays has been widespread, some authorities have managed to tackle delays successfully. The aim of the qualitative study reported here was to investigate discharge practice and the organisation of services at sites with consistently low rates of delay, in order to identify factors supporting such good performance. Six 'high performing' English sites (each including a hospital trust, a local authority, and a primary care trust) were identified using a statistical model, and 42 interviews were undertaken with health and social services staff involved in discharge arrangements. Additionally, the authors set out to investigate the experiences of patients in the sites to examine whether there was a cost to patient care and outcomes of discharge arrangements in these sites, but unfortunately, it was not possible to secure sufficient patient participation. Whilst acknowledging the lack of patient experience and outcome data, a range of service elements was identified at the sites that contribute to the avoidance of delays, either through supporting efficiency within individual agencies or enabling more efficient joint working. Sites still struggling with delays should benefit from knowledge of this range. The government's reimbursement scheme appears to have been largely helpful in the study sites, prompting efficiency-driven changes to the organisation of services and discharge systems, but further focused research is required to provide clear evidence of its impact nationally, and in particular, how it impacts on staff, and patients and their families.     

Public release of performance data and quality improvement: internal responses to external data by US health care providers

Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.     

Community mental healthcare in England: associations between service organisation and quality of life

The present authors set out to explore the relationship between different forms of service organisation and quality of life (QoL) for service users. Four mental health trusts and their corresponding social services departments were recruited to exemplify: (1). high and low levels of integration between health and social services; and (2). high and low levels of targeting at users with severe mental health problems. The authors used the Lancashire Quality of Life Profile, and chose their sample size to be able to detect a difference of 0.5 in subjective satisfaction scales. Analysis of covariance was used to investigate the simultaneous impact of variables representing user characteristics, objective and subjective QoL, and service organisation. Two hundred and sixty users selected at random from the active caseloads of mental health services in the four districts were interviewed at time 1 and 232 people were interviewed 6 months later (time 2). No bias was detected in the non-respondents at time 2. The authors found few differences between districts. As in other similar studies, QoL seemed to be stable for the whole sample over time. In 6 months, general satisfaction with leisure increased and the number of people who had been in hospital fell. Negative affect score was the only variable found to be associated with subjective QoL, and no predictors of objective QoL were identified. There was some evidence of better objective outcomes for people in receipt of integrated mental health services. They socialised more, and seemed to have less difficulty accessing police and legal services. The results also suggest that interventions targeted at negative affect could have benefits for subjective QoL.     

From health technology assessment to research on the organisation and delivery of health services: addressing the balance

This paper argues that the focus of research to improve health services has, until recently, been on health technology assessment. The authors make the case for a greater emphasis on research on how health services are managed, organised and delivered, and refer to initiatives in a number of countries which are seeking to address this balance. The way two such initiatives in England and Canada have set priorities for this type of research, involving a wide range of stakeholders is described. The authors argue that a wide range of disciplines needs to be applied to research on the organisation and delivery of health services. Important theoretical differences between and within disciplines, and their implications for research methods, are discussed. An example of an issue in the delivery of organisation of health services (how best to deliver orthopaedic care) is used to illustrate how a number of different disciplines can be applied. The challenge for researchers from these disciplines is to see how far they can work together to carry out research in this important field. The challenge for this research is that the findings are valued and used by health service professionals, managers and users.     

An integrated health and social care organisation in Sweden: Creation and structure of a unique local public health and social care system

Research and citizens have noted failures in coordinating health and social services and professionals, and the need to address this issue to realize benefits from increasing specialisation. Different methods have been proposed and one has been structural integration of separate services within one organisation. This paper reports an empirical longitudinal study of the development of an integrated health and social care organisation in Sweden combining service provision, purchasing and political governance for a defined population.The study found a combination of influences contributed to the development of this new organisation. The initial structural macro-integration facilitated, but did not of itself result in better clinical care coordination. Other actions were needed to modify the specialised systems and cultures which the organisation inherited. The study design was not able to establish with any degree of certainty whether better patient and cost outcomes resulted, but it did find structural and process changes which make improved outcomes likely. The study concludes that coordinated actions at different levels and of different types were needed to achieve care coordination for patients and that a phased approach was necessary where management capacity and outside expertise are limited.     

Future organisation of therapy service

Therapists are considering the best organisation for their services and how to draw up contracts. This article is based on consultancy research into these subjects with physiotherapists, occupational therapists, speech therapists, psychologists, chiropodists, and dietitians. John Ovretveit presents models and a series of steps to help therapists and general managers clarify the options for the future and decide which form of organisation to work towards.     

联勤体制下医院的职能定位与建设发展探讨

全军联勤卫生改革经过一年多努力,已基本实现卫生大联勤。联勤体制下医院的基本任务具有保障范围扩大,保障内容增多,保障需求多样,保障任务艰巨等特点。要求医院建设把握:加强卫生战备建设以适应联勤保障;重视特勤科室及人才建设;建立联勤保障良性机制;推进医院卫勤信息化建设以提高联勤保障效率;积极开展医院模块化建设。此外,医院要把握服务要点;改进保障模式;优化联勤卫生保障环境、采取有效措施确保公平保障。     

Perspective: lessons from the past

A considered analysis of some factors used in the past 50–70 years in medical education, care on a hospital ward, organisation of health services, medical research and the attitudes of media and politics to health services is described. The possible reasons for changes in these areas over time are considered, and recommendations are made in each area on how current practice could be improved in the light of past experience. Copyright © 2014 John Wiley & Sons, Ltd.     

Peer audit and community dental health services

Dentists and patients are becoming increasingly aware of the need to ensure highstandards of care. This awareness is just as true of practitioners working within community dental services as in general dental practice. The paper discusses peer review as a form of audit and then goes on to describe such a programme of clinical evaluation in one particular community dental health service.