Needs assessment in Scotland: collaboration in publichealth

The National Health Service reforms revitalised the national emphasis on the public's health and health needs assessment. In Scotland, in contrast with England, there was no central investment in the development of methods and programmes for needs assessment in the context of the new NHS. To achieve a concerted effort, therefore, a self-help network—the Scottish Needs Assessment Programme (SNAP)—was created by the Scottish Forum for Public Health Medicine. This paper describes its evolution to the point where it is now supported as part of a national network of information for purchasing.     

Evaluation of physician assistants in National Health Service Scotland

Physician assistants (PAs) have medical training and work supervised by a doctor. In 2006-2008 the Scottish Government piloted use of USA-trained PAs. The aim of the paper is to evaluate the impact and contribution made by PAs to delivering effective health care in National Health Service (NHS) Scotland. Mixed methods, longitudinally, including interviews, feedback forms and activity data collection. Data analysis used nVivo, SPSS and Excel. Participants were 15 USA-trained PAs, medical supervisors and team members, 20 patients, four NHS senior managers and three trade union representatives. Settings were four Scottish NHS Boards where PAs worked in primary care, out of hours clinics, emergency medicine, intermediate care and orthopaedics. Two minor patient safety issues arose. Patients were satisfied with PAs. Scope of practice did not replicate US working. Inability to prescribe was a hindrance. PAs tended to have longer consultations, but provided continuity and an educational resource. They were assessed to be mid-level practitioners approximating to nurse practitioner or generalist doctor. Valued features were generalism, medical background, confidence differential diagnosis and communication. Interviewees suggested PAs could fulfil roles currently filled by medical staff, potentially saving resources. In conclusion, there is potential for PAs to fulfil distinctive mid-level roles in the Scottish NHS adding value in continuity, communication and medical approach.     

New Role, New Country: introducing US physician assistants to Scotland

This paper draws from research commissioned by the Scottish Executive Health Department (SEHD). It provides a case study in the introduction of a new health care worker role into an already well established and "mature" workforce configuration It assesses the role of US style physician assistants (PAs), as a precursor to planned "piloting" of the PA role within the National Health Service (NHS) in Scotland.     

NHS occupational health services in England and Wales--a changing picture

AIMS: To establish the extent of doctor input to occupational health (OH) service provision in the UK National Health Service (NHS) in 2001 and to compare this with inputs in 1998. METHOD: A postal questionnaire was used to obtain information from OH medical staff employed by the NHS in England and Wales. RESULTS: The NHS OH service has seen an increase between 1998 and 2001 in the amount of doctor time per employee. Doctors tend to work now for more sessions per week. The proportion of doctors holding specialist qualifications has also increased. An increased number of NHS employees now have access to consultant care for occupational medicine. OH departments increasingly tend to provide services to employees beyond the NHS and are thereby able to generate income to further the development of the service. CONCLUSIONS: Steady progress is being made in improving the provision of OH services within the NHS. However, substantial variation exists in the apparent level of access to such provision. The government policy for all NHS staff to have access to a consultant-led service is not yet met. NHS Plus will impact on this picture and deserves study in the future.     

Clinical leadership: the elephant in the room

The article explores the concept of clinical leadership in the National Health Service in the UK by seeking to establish a workable definition and by contrasting it with managerial leadership, focussing on the 'disconnected hierarchy' in professional organizations. It proposes that the problems faced by clinical leadership relate to the current nature of general management in the NHS and concludes by suggesting that clinical leadership is the 'elephant in the room'-often ignored or unaddressed.     

Indicator-based systems of performance management in the National Health Service: a comparison of the perceptions of local- and national-level managers.

Historically, the UK Government has policed the use of National Health Service (NHS) resources through the centralization of control. With the majority of resource-draining decisions being taken by clinicians, however, professional financial accountability is becoming more important within the NHS management structure. Variations in clinical performance can be monitored through the use of performance indicators, although these are not without their problems. The use of league tables of such indicators in the national press is now infamous and there is much anecdotal evidence about the intraorganizational conflict arising from the use of such tables. A questionnaire survey and interview study of clinical directors, clinical service directors and business managers in several Scottish NHS Trusts was undertaken to ascertain the perceptions of local-level managers on the issue of performance indicators. Interviews were also carried out with a number of personnel in the Scottish Office Department of Economics and Information, the Division of Health Gain and the Finance Directorate. This paper explores the differences between the perceptions of the managers at these two levels of the NHS with regards to issues of performance measurement, intraorganizational conflict and corporate vision.     

Health Visiting—The end of a UK wide service?

In 1997 Health Visiting was deemed by New Labour to be an important player in reducing health inequalities. It was acknowledged that if Health Visiting was to fulfill this vision it would have to work out with its traditional child health role and also engage with groups, communities and populations to tackle the determinants of ill health. Twelve years on, external factors such as, NHS cut backs, recent changes to how Health Visitors are regulated throughout the UK and devolved Health Visiting policy making structures have led to the rapid demise in status and legitimacy of Health Visiting and its wider public health role. This article argues that the unintended consequences of devolved Health Visiting policy has resulted in 3 recent community nursing and health-visiting reviews in Scotland and England which have made divergent policy recommendations about the role of the Health Visitor in tackling health inequalities. The recommendations outlined in the Scottish review in particular threatened to jeopardise the very future provision of a UK wide Health Visiting service. If Health Visiting is to survive as a UK wide entity, a radical independent rethink as to its future direction and its public health role is urgently required.     

Benchmarking clinical photography services in the NHS

Benchmarking is used in services across the National Health Service (NHS) using various benchmarking programs. Clinical photography services do not have a program in place and services have to rely on ad hoc surveys of other services. A trial benchmarking exercise was undertaken with 13 services in NHS Trusts. This highlights valuable data and comparisons that can be used to benchmark and improve services throughout the profession.     

Designing and implementing E-health Applications in the UK's National Health Service

Telemedicine/e-health applications have the potential to play an important role in Britain's National Health Service (NHS), including the NHS in Scotland. The Scottish Telemedicine Action Forum (STAF) was established by the Scottish Executive Department of Health in 1999 to take a range of applications, targeted on national priorities, into routine service. In the process it has provided insights into how advanced information and communication technologies (ICTs) can be moved from the research stage into routine service. In this article four of the projects are described and analysed focusing on the key issues that have emerged as critical for carrying projects successfully through to implementation in service as follows: 1. A multisite videoconferencing network linking 15 minor injury units to the main accident and emergency (A&E) centre. 2. A single-site neonatal intensive care "cotside" laptop system to assist communication between parents and clinical staff. 3. A single-site outpatient chronic disease management system. 4. A multisite software audit tool to support the care of cleft lip and palate patients from birth onward.     

A difference-in-differences analysis of the effect of free dental check-ups in Scotland

The Scottish Government introduced free NHS dental check-ups in April 2006 as a way of encouraging utilisation and improving the oral health of residents. We use data from the British Household Panel Survey (BHPS), a nationally representative data of 117761 individual respondents in the United Kingdom covering the period between 2001 and 2008 to evaluate the impact of this policy on utilisation of NHS dental check-ups in Scotland, using a difference-in-difference approach. Results show that there was a 3–4 percent increase in NHS dental check-up in Scotland, compared to the rest of the UK. Results suggest that a removal of financial barrier to dental check-ups does indeed lead to a modest increase in utilisation, and may have wider implications for the delivery of dental care in Scotland.     

The third way in health care reform: does the emperor have any clothes?

The Labour government elected in the UK in May 1997 has described its approach to the National Health Service (NHS) as a third way in health care reform. This article seeks to analyse the defining features of the third way. It argues that the government has adopted an approach which combines central direction and local autonomy, sanctions and incentives, and planning and competition. The third way therefore entails a cocktail of different approaches and is both electic and pragmatic. In pursuing this policy, the government is seeking to deal with dilemmas that are as old as the NHS itself and is seeking a synthesis between approaches that in the past have been seen as exclusive. It can be argued that the search for a synthesis is unlikely to succeed and the government will have to decide whether it is really committed to a centralised health service in which the main emphasis is on planning and sanctions or whether it is willing genuinely to devolve power to a local level with reliance on incentives and elements of competition. The alternative interpretation is that by making use of a variety of instruments the government is increasing its chances of delivering its objectives. From this perspective, to insist on absolute consistency is to fail to recognise the complexity of the steering mechanisms required in modern public services. In the international context, the third way may find favour as a rhetorical device among politicians seeking to carve out a distinctive niche in the political market place, but its specific characteristics are likely to vary between systems.     

National Services--the role of the National Services Division of the Common Services Agency in commissioning specialist services on behalf of the NHS in Scotland

The National Services Division of the Common Services Agency provides a central function commissioning designated national services on behalf of the NHS in Scotland. Services are nationally designated and commissioned only where it would not be possible or sensible to do so on a more local basis because of the rarity of the condition, the need to concentrate expertise and/or to avoid duplication of expensive equipment. The Division also has important central functions in ensuring the effective delivery of national screening programmes and in facilitating the development of national managed clinical networks. The work programme of the Division is overseen by advisory bodies whose membership reflects the key stakeholders in the Scottish NHS. In discharging its role, the Division's aim is to work with clinicians and managers to ensure the delivery of high quality specialist clinical care and screening services in an equitable fashion to patients throughout Scotland.     

Consultants in nhs scotland: a survey of work commitments, remuneration, job satisfaction and retirement plans

BACKGROUND AND AIMS: UK consultants have reported working long hours, increased stress and reduced morale. This study set out to elicit consultants' views on flexible working and to gather data on consultants' workloads, remuneration, job satisfaction and retirement plans. As such it is the first comprehensive study of consultants in NHS Scotland. METHODS: The Information and Statistics Division of the Scottish Executive Health Dept provided a list of consultants working in NHS Scotland Focus groups and interviews informed the design of a postal self-completion, questionnaire. RESULTS: The response ratewas 61%. Almost two-thirds (65%) of respondents felt their workloads were unreasonable and unsustainable and 67% were unable to provide their desired standards of patient care. Two-thirds (67%) did not normally take meal breaks, 63% had insufficient time for outside interests, whilst 44% felt their health was being adversely affected Many (84%) believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity. CONCLUSIONS: In 2003, a majority of consultants in the UK voted in favour of the new consultant contract. This will improve consultant pay and introduce a standard 40-hour working week, including worked on-call. This should address tow of the main areas of consultant dissatisfaction in NHS Scotland. However, staff shortages will require to be addressed if the contract is to be successfully implemented.     

Providing guidance to the NHS: The Scottish Medicines Consortium and the National Institute for Clinical Excellence compared

There is wide acceptance that cost-effectiveness is a relevant consideration when deciding which treatments to make available in publicly funded health services. An unresolved issue concerns the timing and the extent of such evaluations. The United Kingdom provides examples of two distinct approaches. The Scottish Medicines Consortium (SMC) provides guidance to the NHS in Scotland based on a rapid early review of the evidence. The National Institute for Health and Clinical Excellence (NICE) provides guidance to the NHS in England and Wales based on a later, more extensive review of the evidence. This paper explores how the difference in approach affects the role of the pharmaceutical industry, clinical experts and other stakeholders. It compares the guidance produced when both bodies have evaluated the same medicines. It addresses the general question of when to assess the cost-effectiveness of medicines. It concludes that there are important differences between the approaches of SMC and NICE, relating primarily to the timing of the review of evidence on clinical and cost-effectiveness. The difference in timing means that the activities of the two bodies are to a large extent complementary.     

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

The UK National Health Service (NHS) workforce has recently seen the arrival of the Graduate Mental Health Worker (GMHW) in primary care. We established a Quality Improvement Collaborative to assist in embedding this new workforce in one Strategic Health Authority Area of England. The intervention utilised 'collaborative' technology which involves bringing together groups of practitioners from different organizations to work in a structured way to improve the quality of their service. The process was evaluated by an action research project in which all stakeholders participated. Data collection was primarily qualitative. During the project, there was an increase in throughput of new patients seen by the GMHWs and increased workforce satisfaction with a sense that the collaborative aided the change process within the organizations. Involvement of managers and commissioners from the Primary Care Trusts where the GMHWs were employed appeared to be important in achieving change. This was not, however, sufficient to combat significant attrition of the first cohort of workers. The project identified several barriers to the successful implementation of a new workforce for mental health problems in primary care, including widespread variation in the level and quality of supervision and in payment and terms of service of workers. A collaborative approach can be used to support the development of new roles in health care; however, full engagement from management is particularly necessary for success in implementation. The problems faced by GMHWs reflect those faced by other new workers in healthcare settings, yet in some ways are even more disturbing given the lack of governance arrangements put in place to oversee these developments and the apparent use of relatively unsupported and inexperienced novices as agents of change in the NHS.     

Sickness absence and health at work in the NHS

Presents summary results from two surveys which the Institute for Employment Studies conducted in 1994 for the Health Education Authority. The first of these surveys reports national benchmarking data on rates of sickness absence and accidents at work in NHS provider and purchaser organizations. The second survey concerns implementation of the Health at Work (HaW) in the NHS initiative in NHS hospital worksites. Discusses structures and processes of HaW implementation.     

Scottish survey of diabetes services for minority ethnic groups

Background  

In the UK, all ethnic minority groups have higher rates of diabetes than the general population. Although there have been a number of projects to assess diabetic care amongst minority ethnic groups in the United Kingdom, little is known about the extent to which the needs of ethnic minority groups are actually met by the National Health Service (NHS) Scotland. Therefore we conducted this study to understand of the current situation for diabetes care available to minority ethnic groups in Scotland.     

Cost-effectiveness of linaclotide compared to antidepressants in the treatment of irritable bowel syndrome with constipation in Scotland

Presently, linaclotide is the only EMA-approved therapy indicated for the treatment of irritable bowel syndrome with constipation (IBS-C). This study sought to determine the cost-effectiveness of linaclotide compared to antidepressants for the treatment of adults with moderate to severe IBS-C who have previously received antispasmodics and/or laxatives. A Markov model was created to estimate costs and QALYs over a 5-year time horizon from the perspective of NHS Scotland. Health states were based on treatment satisfaction (satisfied, moderately satisfied, not satisfied) and mortality. Transition probabilities were based on satisfaction data from the linaclotide pivotal studies and Scottish general all-cause mortality statistics. Treatment costs were calculated from the British National Formulary. NHS resource use and disease-related costs for each health state were estimated from Scottish clinician interviews in combination with NHS Reference costs. Quality of life was based on EQ-5D data collected from the pivotal studies. Costs and QALYs were discounted at 3.5 % per annum. Uncertainty was explored through extensive deterministic and probabilistic sensitivity analyses. Over a 5-year time horizon, the additional costs and QALYs generated with linaclotide were £659 and 0.089, resulting in an incremental cost-effectiveness ratio of £7370 per QALY versus antidepressants. Based on the probabilistic sensitivity analysis, the likelihood that linaclotide was cost-effective at a willingness to pay of £20,000 per QALY was 73 %. Linaclotide can be a cost-effective treatment for adults with moderate-to-severe IBS-C who have previously received antispasmodics and/or laxatives in Scotland.     

Integrating the promotion of physical activity within a smoking cessation programme: Findings from collaborative action research in UK Stop Smoking Services

Background  

Within the framework of collaborative action research, the aim was to explore the feasibility of developing and embedding physical activity promotion as a smoking cessation aid within UK 6/7-week National Health Service (NHS) Stop Smoking Services.