Realizing policy aspirations of voluntary sector involvement in integrated care provision: Insights from the English National Health Service

Integrating voluntary sector organizations (VSOs) into complex health and social care provision is a priority in global healthcare policy. However, realization of these policy aspirations in practice is limited, as VSOs struggle to collaborate with health and social care professionals, or influence the wider healthcare system, undermining their potential involvement in care provision. This paper aims to increase understandings of how the policy implementation gap could be addressed, by asking: how do new workforce roles support VSO involvement in delivering integrated care? Drawing on 40 interviews with VSO workers, healthcare commissioners, and healthcare professionals, conducted over 18 months in the English NHS, we outline how workforce capacity development through the introduction of coordinating roles, coupled with increasing regulatory control of VSO involvement, resulted in enhanced VSO integration in service provision. However, we also warn against the potential for exploitation of VSOs whereby they become replacements for health and social care provision, rather than a complementary service within an integrated team, resulting in patient harm. Our findings have important implications for policy makers, practitioners, VSO leaders and healthcare commissioners. We conclude that policy realization is dependent on the development of coordinating roles, coupled with levels of regulation which protect against exploitation without becoming normatively restrictive, thereby losing the important flexibility of VSOs.     

From patients to providers: prospects for self-care skills trainers in the National Health Service

Changes in the National Health Service (NHS) workforce and user involvement have been key areas of contemporary health care policy. Potentially, the current separation of the agendas for patient participation and reconfiguration of the workforce are being brought closer together in the NHS through the Expert Patients Programme (EPP), and its potential to create a new community health 'workforce' of self-management and self-care skills trainers and tutors. The aim of the present paper is to assess the establishment and prospects of these trainers as a new workforce role in the EPP and the NHS. This is done through policy analysis and process evaluation recording the development and implementation of the EPP in the NHS. Telephone interviews with individual trainers were undertaken in order to identify the way in which they are being introduced into the NHS. A representative sample of 19 trainers from the 26 teams covering all the primary care trusts (PCTs) in England were interviewed. The EPP trainers are employed and appointed by the Department of Health and assist PCTs to run EPP courses. The analysis of trainer perspectives illuminated some of the tensions inherent in this new role, which emerge from the consequences of having a long-term condition, their relationship to other occupations operating within primary care and their structural position within the NHS. Prospects for the future development of self-management trainers remain uncertain. Two likely outcomes are examined. The first is that trainers and volunteer tutors will become increasingly integrated as a semi-professionalised group within the primary care workforce. The other option is for trainers to become freelance consultants commissioned by PCTs to run local self-management, self-care support or EPP programmes with the consequence of establishing a more distant relationship with mainstream NHS provision.     

Growing your own: community health workers and jobs to careers

This article evaluates the implementation and impact of 5 workforce development programs aimed at achieving skills upgrades, educational advancement, and career development for community health workers (CHWs). Quantitative and qualitative case study data from the national evaluation of the Jobs to Careers: Transforming the Front Lines of Health Care initiative demonstrate that investing in CHWs can achieve measurable worker (eg, raises) and programmatic (eg, more skilled workers) outcomes. To achieve these outcomes, targeted changes were made to the structure, culture, and work processes of employing organizations. These findings have implications for other health care employers interested in developing their CHW workforce.     

Social work roles in collaborative research

Social workers in health care settings may be most effective in the development and implementation of collaborative research studies which jointly involve academic and health service institutions. This article describes: organizational issues significant to the integration of research into a health service system; interpersonal issues that effect the perspectives of research and service professionals in the daily operation of the research project; and social work skills for collaborative research studies. An on-going 5-year collaborative research study of approximately 7,000 participants will be used as a case example.     

Sustainability of the workforce: government policies and the rural fit

OBJECTIVES: Critical workforce issues among health care workers have raised public concerns about the ability of health care systems to provide adequate service. Services, however, are influenced by geographical and social factors. One important source of variation is rurality. This study evaluated the perception of the applicability of health human resource policies for rural areas. METHODS: An exploratory design was used. Twenty-one nurse administrators and 44 staff nurses from a sampling of 19 rural health care settings were interviewed. Hospitals with less than 100 beds were targeted. RESULTS: The government policies most frequently mentioned by study participants were the goal of 70% full-time employment, the new graduate policy and the late career initiative. Each presented challenges to managers attempting implementation. Urban bias is apparent in health care policy including health human resource policies. Little data is available about rural health care workers because health care statistics tend to be reported regionally. CONCLUSION: Rural institutions have difficulty accessing government funding intended to build sustainable workforces. Policies meant to be broadly implemented across jurisdictions may not fit the needs of rural institutions and their clients. Health care databases should include a rural variable to enhance understanding about this population.     

What sort of networks are public health networks?

BACKGROUND: Re-organization of the English National Health Service (NHS) has fragmented the public health workforce, relocating teams from about 100 health authorities into over 300 primary care trusts (PCTs). The UK Government announced the setting up of public health networks (PHNs) as a solution to the problems created by fragmentation. METHODS: Fifty-seven semi-structured telephone interviews were held with key players in PHNs in all strategic health authority areas in England in early 2003. RESULTS: PHNs appeared to be primarily networks of public health professionals rather than of organizations. Informants were unsure about PCTs' commitment to public health. Predominantly, members were those NHS personnel with a clear and explicit public health role. Most PHNs intended to include others later (e.g. health visitors, environmental health officers), although a few thought that inclusivity was essential from the start. Continuing professional development for public health personnel dominated the work being undertaken, with some collaborative work across PCTs. PHNs were seen as a compulsory reconfiguration of existing networks, and informants doubted that they were appropriate for the many levels of networking that public health work requires. CONCLUSION: The formation of PHNs does not appear to have been either necessary or sufficient. However, the public health community has a well-established tradition of networking, and therefore has the skills to use PHNs advantageously.     

Social Work Roles in Collaborative Research

Social workers in health care settings may be most effective in the development and implementation of collaborative research studies which jointly involve academic and health service institutions. This article describes: (1) organizational issues significant to the integration of research into a health service system; (2) interpersonal issues that effect the perspectives of research and service professionals in the daily operation of the research project; and (3) social work skills for collaborative research studies. An on-going 5-year collaborative research study of approximately 7,000 participants will be used as a case example.     

IS/IT market support systems: augmenting UK primary health care groups

The election of the Labour government in May 1997 has seen the continuation of advanced market reforms intended to modernize the UK National Health Service (NHS). The planning and implementation of information systems and technology (IS/IT) following these structural changes is both widespread and significant. An information strategy for the NHS, published recently, is intended to provide an initial seven-year program of life-long electronic health records for everyone in the United Kingdom. This article explores the potential role of these systems in the specific provision of the new primary health care groups. It argues that, if primary care physicians adopt appropriate delivery channels and service packages and are proactive in the use of IS/IT, then the outcome will produce more patient choice, less nonattendance, and consequently improved primary health care provision.     

宁波市城乡基层卫技人员素质提升工程实施成效及评价

文章分析了宁波市实施城乡基层卫技人员素质提升工程的主要内容及其成效,通过营造良好政策环境、建立项目实施组织体系、保障项目经费、创新合作培训机制等措施,开展各类项目培训计划,3年累计培训基层卫技人员20552人,使宁波市基层卫生技术人员整体素质明显提升,卫生服务能力显著提高,社区卫生服务机构门急诊人次比项目实施前增加了58.54%,96.2%的群众对社区卫生服务表示认同,居民健康素质不断提高。     

Back to the market: yet more reform of the National Health Service.

Yet more reform of the National Health Service in England has been announced by the Department of Health. In opposition, the Labour Party criticized the creation of an "internal market" for health care by the Conservative government, but five years into the Blair administration, market incentives are to be reinvigorated and the private sector is to be embraced in ways not seen hitherto. New guidance signals the introduction of competitive contracting using cost-per-case currencies, more choice for patients in where they will receive hospital treatment, and the freeing of NHS care providers from the direct political control of ministers. It is intended that the monopolistic features of the NHS in England should give way to greater pluralism, in particular through contracts with privately owned health care organizations. However, there is little evidence to suggest that these policies will be effective, and a number of practical problems may obstruct implementation.     

The UCLan community engagement and service user support (Comensus) project: valuing authenticity, making space for emergence

OBJECTIVE: To develop and evaluate service user, carer and community involvement in health and social care education. BACKGROUND: Despite the high policy profile of involvement issues, there appear to be no published accounts of schemes that have used a systematic whole-faculty approach to community engagement in health and social care higher education. FOCUS OF THIS PAPER: The set up and early development of a faculty-wide community engagement project. SETTING AND PARTICIPANTS: Staff from the faculty of health in one University, local service users and carers and community group project workers and local National Health Service (NHS) and public sector staff. DESIGN: Participatory action research including document review, field notes, questionnaires and interviews. ANALYSIS: Thematic analysis. The emerging themes were tested by seeking disconfirming data, and through verification with stake-holders. RESULTS: Prior to the study, there were examples of community engagement in the participating faculty, but they occurred in specific departments, and scored low on the 'ladder of involvement'. Some previous attempts at engagement were perceived to have failed, resulting in resistance from staff and the community. Despite this, an advisory group was successfully formed, and project framing and development evolved with all stake-holders over the subsequent year. The four themes identified in this phase were: building accessibility; being 'proper' service users/carers;moving from suspicion to trust: mutually respectful partnerships as a basis for sustainable change; and responses to challenge and emergence. CONCLUSIONS: Successful and sustainable engagement requires authenticity. Many problems and solutions arising from authentic engagement are emergent, and potentially challenging to organizations.     

Valuable human capital: the aging health care worker

With the workforce growing older and the supply of younger workers diminishing, it is critical for health care managers to understand the factors necessary to capitalize on their vintage employees. Retaining this segment of the workforce has a multitude of benefits including the preservation of valuable intellectual capital, which is necessary to ensure that health care organizations maintain their competitive advantage in the consumer-driven market. Retaining the aging employee is possible if health care managers learn the motivators and training differences associated with this category of the workforce. These employees should be considered a valuable resource of human capital because without their extensive expertise, intense loyalty and work ethic, and superior customer service skills, health care organizations could suffer severe economic repercussions in the near future.     

Results of a survey of cardiovascular risk factor prevalence amongst health care workers. The Executive Committee of SHARP--(Scottish Heart and Arterial Risk Prevention)

Summary analyses of screening data were used to ascertain the cardiovascular risk profile in a sample of health care workers in Scotland. A sample of NHS staff (298 women and 78 men) were screened during visits to Perth Royal Infirmary (PRI) in 1996 and 1997. Comparisons were made within subsets and with previous screening studies. Health care workers have been a neglected component of the workforce for receiving education about risk factors. The high prevalence of smokers found in this sample should be a cause for concern.     

Workforce planning. A force for good

A workforce development confederation facing a shortage of 2,000 clinical staff by 2004 has initiated a programme to train assistant practitioners. The programme is aimed at drawing workers into the NHS who have some care experience but not the educational requirements for traditional professional courses. The project, which involves 14 organisations across health and social care, has attracted 216 entrants. The course takes two years full time, or three years part time.     

From Planning to Implementation of the YouthCan IMPACT Project: a Formative Evaluation

In order to improve the youth mental health system, there is an international movement toward developing community-based service hubs that provide integrated, collaborative care to youth. However, the implementation of multisystem collaboration is complex and can be hampered by barriers. This paper presents a formative evaluation of the YouthCan IMPACT integrated youth services project based on the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers to successful implementation. Results highlight that previous positive working relationships along with collaborative investment of resources from partnering organizations are essential to implement an integrated youth service model. In addition, it is important that representative members of all key stakeholder groups, including staff, youth, and caregivers, be involved in the development and execution of the project to ensure effective implementation. Attention to the facilitators and barriers to implementation may help teams seeking to implement highly collaborative, integrated models of service delivery for youth in the community.

     

The process to develop a meaningful community health assessment in New York State.

Conducting and producing a meaningful Community Health Assessment (CHA) is an important and essential public health service and a mandatory biennial activity for New York State's (NYS) Local Health Departments. The Assessment Initiative project has allowed the NYS Department of Health to better understand and identify strategies to strengthen CHAs and to develop training, education, and technical assistance programs. The Assessment Initiative project has benefited from participation, coordination, and sharing of resources and expertise with other community health improvement initiatives in NYS, including those that emphasize collaborative approaches to health improvement, workforce development, and expanding access to data.     

Health disparities among America's health care providers: evidence from the Integrated Health Interview Series, 1982 to 2004

OBJECTIVE:: To examine whether health status and obesity prevalence differ by race or ethnicity and health care workforce category. METHODS:: Data representing US health care workers aged 20 to 64 between 1982 and 2004 were retrieved from the Integrated Health Interview Series. Trends, as well as disparities, in health status and obesity are examined by workforce category using logistic regression. RESULTS:: Self-reported health status of health care workers has declined over time and the prevalence of obesity is rising. Moreover, there is a clear social gradient across workforce categories, which is widening over time. Within workforce categories, there are significant racial disparities in health status and prevalence of obesity. CONCLUSIONS:: Health of health care workers needs to be taken into account when setting policies intended to increase access to health care and create a healthy diverse workforce.     

The impact of a quasi-market on sexually transmitted disease services in the UK.

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.     

Restructuring the health workforces of the NIS countries: report of an unprecedented multinational conference

Health professionals, educators, and policy-makers in the US and the Newly Independent States met in Tashkent, Uzbekistan, and shared concerns on health workforce planning, access to care, and training. The International Conference on the Health Care Workforce for the 21st Century recognized the scope and interdependence of workforce strategies that must be employed to achieve health reform objectives in the new political system. Specific issues addressed in the conference include health workforce planning; interdisciplinary and multidisciplinary education; primary care, family medicine, and general practice; the supply of physicians; medical education; supply and role of nurses; assessing the competency of practitioners; continuing education and training; the role of professional organizations; accreditation; and international collaboration. Conclusions of the deliberations provide insight into present conditions, prospects for change and how future development assistance can most usefully be targeted.     

Rural and remote health research: key issues for health providers in southern Queensland

OBJECTIVE: To determine what community health service providers in rural southern Queensland considered were major issues affecting their efficacy. Results will inform the future research strategy of the Centre for Rural and Remote Area Health with the aim of addressing specific regional needs. DESIGN: Interactive research workshops. SETTING: Health providers and other key stakeholders. SUBJECTS: Participants from organisations directly involved with health care were complemented by representatives from local government, the police service and church groups. MAIN OUTCOME MEASURES: The workshops used the nominal group technique to identify what participants considered were key health issues in their locations. These issues were then prioritised by the participants. Thematic analysis of the issues generated a ranking of themes by importance. Results were compared with a similar exercise undertaken in 2003. RESULTS: Seventeen themes were identified, with workforce by far the major concern of health providers. Recruitment and retention of health workers were the principal issues of concern. The other four highest ranked themes across all workshops were mental health care, access to health services, perceptions and expectations of consumers, and interagency cooperation. The workshops provided important information to the Centre for Rural and Remote Area Health for developing research strategy. Additionally, new alliances among health providers were developed which will support sharing of information and resources. CONCLUSION: The workshops enabled organisations to meet and identify the key health issues and supported research planning. New alliances among health providers were forged, and collaborative research avenues are being explored. The workshop forum is an excellent means of information exchange.