Health and Social Care Delivery Research

Background During pregnancy and the postpartum period, women’s mental health can deteriorate quickly. Timely and easy access to services is critically important; however, little is known about the pathways women take to access services. Previous research has shown that women from ethnic minority groups in the United Kingdom experience more access issues compared to the White British women. Aim To describe pathways taken to specialist community perinatal mental health services and explore how they vary across services and ethnic groups. Methods This is a two-site, longitudinal retrospective service evaluation conducted in Birmingham and London during 6 months (1 July–31 December 2019). Electronic records of 228 women were accessed and data were extracted on help-seeking behaviour, referral process and the type of pathway (i.e. simple or complex). Data were collected using the adapted World Health Organization encounter form and analysed using uni- and multivariable analyses. Results The median time from the start of perinatal mental illness to contact with perinatal mental health services was 20 weeks. The majority of patients accessed perinatal mental health services through primary care (69%) and their pathway was simple, that is they saw one service before perinatal mental health services (63%). The simple pathway was used as a proxy for accessible services. In Birmingham, compared to London, more referrals came from secondary care, more women were experiencing current deterioration in mental health, and more women followed a complex pathway. Despite differences between ethnic groups regarding type of pathway and duration of patient journey, there was no evidence of difference when models controlled for confounders such as clinical presentation, general characteristics and location. The service’s location was the strongest predictor of the type of pathway and duration of patient journey. Limitations The heterogeneity among categorised ethnic groups; data extracted from available electronic records and not validated with patient’s own accounts of their pathways to care; unanalysed declined referrals; the study was conducted before the COVID-19 pandemic and pathways may be different in the post-COVID-19 period. Conclusion The study provides important insights into how patients find their way to community perinatal mental health services. It shows that there is a great degree of variability in the time taken to get into these services, and the pathway taken. This variation does not come from different needs of patients or different clinical presentations but rather from service-level factors. Future work The studied community perinatal mental health services in the United Kingdom operate with a significant degree of variability in the types and characteristics of patient pathways. Future research should explore these issues on the national and international levels. Additionally, future research should explore the reasons for the different pathways taken and the outcomes and risks associated with them. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 17/105/14.

Nikolina Jovanović

Žan Lep

Jelena Janković

Aysegul Dirik

Anna Rees

Maev Conneely

Pathways to specialist community perinatal mental health services: a two-site longitudinal retrospective service evaluation

专科社区围产期心理健康服务路径：一项两地点纵向回顾性服务评估

Background People in prison are generally in poorer health than their peers in the community, often living with chronic illness and multimorbidity. Healthcare research in prisons has largely focused on specific problems, such as substance use; less attention has been paid to conditions routinely managed in primary care, such as diabetes or hypertension. It is important to understand how primary care in prisons is currently delivered in the United Kingdom and how it can be improved, in order to reduce health inequalities. Objective To understand the quality of primary care in prison, including gaps and variations in care, in order to recommend how quality of prison health care can be improved. Design A mixed-methods study with six interlinked work packages. Setting Predominantly the North of England. Methods Between August 2019 and June 2022, we undertook the following work packages: (1) International scoping review of prison healthcare quality indicators. (2) Stakeholder consensus process to identify United Kingdom focused prison healthcare quality indicators. (3) Qualitative interview study with 21 people who had been in prison and 22 prison healthcare staff. (4) Quantitative analysis of anonymised, routinely collected data derived from prison healthcare records (~ 25,000 records across 13 prisons). (5) Stakeholder deliberation process to identify interventions to improve prison health care. (6a) Secondary analysis of the qualitative data set, focusing on mental health and (6b) analysis of the quantitative data set, focusing on health care of three mental health subgroups Findings Our scoping review found predominantly only papers from the United States of America and of variable rigour with the main finding being that performance measurement is very challenging in the prison healthcare setting. In collaboration with stakeholders, we prioritised, refined and applied a suite of 30 quality indicators across several healthcare domains. We found considerable scope for improvement in several indicators and wide variations in indicator achievement that could not be attributed to differences in prison population characteristics. Examples of indicators with scope for improvement included: diabetes care, medicines reconciliation and epilepsy review and control. Longer length of stay in prison was generally associated with higher achievement than shorter stays. Indicator achievement was generally low compared to that of community general practice. We found some encouraging trends and relatively good performance for a minority of indicators. Our qualitative interviews found that quality of health care is related to factors that exist at several levels but is heavily influenced by organisational factors, such as understaffing, leading to a reactive and sometimes crisis-led service. Our stakeholder deliberations suggested opportunities for improvement, ideally drawing on data to assess and drive improvement. Our mental health work package found that coded mental illness had mixed associations with indicator achievement, while the interviews revealed that mental distress is viewed by many as an inevitable facet of imprisonment. Limitations Our analyses of indicator achievement were limited by the quality and coverage of available data. Most study findings are localised to England so international applicability may differ. Conclusions Marked variations in the quality of primary care in prisons are likely to be attributable to the local organisation and conditions of care delivery. Routinely collected data may offer a credible driver for change. Study registration This study is registered at researchregistry.com (Ref: 5098). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/26) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 46. See the NIHR Funding and Awards website for further award information.

Sue Bellass

Krysia Canvin

Tracey Farragher

Kate McLintock

Nat Wright

Pip Hearty

Nicola Seanor

Marie Cunningham

Robbie Foy

Laura Sheard

Understanding and improving the quality of primary care for people in prison: a mixed-methods study

理解和改善监狱中人员初级保健质量的混合方法研究

Background Older people living in care homes are at high risk of poor health outcomes and mortality if they contract coronavirus disease 2019. Protective measures include social distancing and isolation, although implementation is challenging. Objectives To explore the real-life experiences of social distancing and isolation in care homes for older people, and to develop a toolkit of guidance and resources. Design A mixed-methods, phased design. Setting Six care homes in England caring for older adults. Participants Care home staff ( n = 31), residents ( n = 17), family members ( n = 17), senior health and care leaders ( n = 13). Methods A rapid review to assess the social distancing and isolation measures used by care homes to control the transmission of coronavirus disease 2019 and other infectious diseases (phase 1), in-depth case studies of six care homes, involving remote individual interviews with staff, residents and families, collection of policies, protocols and routinely collected care home data, remote focus groups with senior health and care leaders (phase 2) and stakeholder workshops to co-design the toolkit (phase 3). Interview and focus group data and care home documents were analysed using thematic analysis and care home data using descriptive statistics. Results The rapid review of 103 records demonstrated limited empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. The case studies found that social distancing and isolation measures presented moral dilemmas for staff and often were difficult, and sometimes impossible to implement. Social distancing and isolation measures made care homes feel like an institution and denied residents, staff and families of physical touch and other forms of non-verbal communication. This was particularly important for residents with cognitive impairment. Care homes developed new visiting modalities to work around social distancing measures. Residents and families valued the work of care homes to keep residents safe and support remote communication. Social distancing, isolation and related restrictions negatively impacted on residents’ physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government was described as chaotic, and trauma was inflicted on care home staff, residents, families and friends. These multiple data sources have informed the co-design of a toolkit to care for residents, families, friends and care home staff. Limitations The review included papers published in English language only. The six care homes had a Care Quality Commission rating of either ‘good’ or ‘outstanding’. There was a lack of ethnic diversity in resident and family participants. Conclusions Care homes implemented innovative approaches to social distancing and isolation with varying degrees of success. A legacy of learning can help rebuild trust at multiple levels and address trauma-informed care for residents, families, friends and staff. Future work can include evaluation of the toolkit, research to develop a trauma-informed approach to caring for the care home sector and co-designing and evaluating an intervention to enable residents with different needs to transition to living well in a care home. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information.

Joanne M Fitzpatrick

Anne Marie Rafferty

Shereen Hussein

Richard Adams

Lindsay Rees

Sally Brearley

Sarah Sims

Amit Desai

Ruth Harris

Challenges and guidance for implementing social distancing for COVID-19 in care homes: a mixed methods rapid review

COVID-19疫情期间在养老院实施社交距离的挑战与指导：一项混合方法快速综述

Background Hospital ‘command centres’ use digital technologies to collect, analyse and present real-time information that may improve patient flow and patient safety. Bradford Royal Infirmary has trialled this approach and presents an opportunity to evaluate effectiveness to inform future adoption in the United Kingdom. Objective To evaluate the impact of the Bradford Command Centre on patient care and organisational processes. Design A comparative mixed-methods study. Operational data from a study and control site were collected and analysed. The intervention was observed, and staff at both sites were interviewed. Analysis was grounded in a literature review and the results were synthesised to form conclusions about the intervention. Setting The study site was Bradford Royal Infirmary, a large teaching hospital in the city of Bradford, United Kingdom. The control site was Huddersfield Royal Infirmary in the nearby city of Huddersfield. Participants Thirty-six staff members were interviewed and/or observed. Intervention The implementation of a digitally enabled hospital command centre. Main outcome measures Qualitative perspectives on hospital management. Quantitative metrics on patient flow, patient safety, data quality. Data sources Anonymised electronic health record data. Ethnographic observations including interviews with hospital staff. Cross-industry review including relevant literature and expert panel interviews. Results The Command Centre was implemented successfully and has improved staff confidence of better operational control. Unintended consequences included tensions between localised and centralised decision-making and variable confidence in the quality of data available. The Command Centre supported the hospital through the COVID-19 pandemic, but the direct impact of the Command Centre was difficult to measure as the pandemic forced all hospitals, including the study and control sites, to innovate rapidly. Late in the study we learnt that the control site had visited the study site and replicated some aspects of the command centre themselves; we were unable to explore this in detail. There was no significant difference between pre- and post-intervention periods for the quantitative outcome measures and no conclusive impact on patient flow and data quality. Staff and patients supported the command-centre approaches but patients expressed concern that individual needs might get lost to ‘the system’. Conclusions Qualitative evidence suggests the Command Centre implementation was successful, but it proved challenging to link quantitative evidence to specific technology interventions. Staff were positive about the benefits and emphasised that these came from the way they adapted to and used the new technology rather than the technology per se. Limitations The COVID-19 pandemic disrupted care patterns and forced rapid innovation which reduced our ability to compare study and control sites and data before, during and after the intervention. Future work We plan to follow developments at Bradford and in command centres in the National Health Service in order to share learning. Our mixed-methods approach should be of interest to future studies attempting similar evaluation of complex digitally enabled whole-system changes. Study registration The study is registered as IRAS No.: 285933. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129483) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 41. See the NIHR Funding and Awards website for further award information.

Owen Ashby Johnson

Carolyn McCrorie

Ciarán McInerney

Teumzghi F Mebrahtu

Josh Granger

Naeem Sheikh

Tom Lawton

Ibrahim Habli

Rebecca Randell

Jonathan Benn

Implementing an artificial intelligence command centre in the NHS: a mixed-methods study

在英国国民医疗服务体系中实施人工智能指挥中心：一项混合方法研究

Background Chronic obstructive pulmonary disease affects nearly 400 million worldwide – over a million in the United Kingdom – and is the third leading cause of death. However, there is limited understanding of what prompts a diagnosis, how long this takes from symptom onset and the different approaches to clinical management by primary care professionals. Objectives Map out the clinical management and National Health Service contacts from symptom presentation to chronic obstructive pulmonary disease diagnosis and first acute exacerbation of chronic obstructive pulmonary disease in three time periods; construct risk prediction for first acute exacerbation of chronic obstructive pulmonary disease. Design Retrospective cohort study and cross-sectional survey. Setting Primary care. Participants Patients with incident chronic obstructive pulmonary disease aged &gt; 35 years in England. Interventions None. Main outcome measures First acute exacerbation of chronic obstructive pulmonary disease. Data sources Clinical Practice Research Datalink Aurum; new online survey. Results Forty thousand five hundred and seventy-seven patients were diagnosed between April 2006 and March 2007 (cohort 1), 48,249 between April 2016 and March 2017 (cohort 2) and 4752 between March and August 2020 (cohort 3). The mean (standard deviation) age was 68.3 years (12.0); 47.3% were female. Around three-quarters were diagnosed in primary care, with a slight fall in cohort 3. Compliance with National Institute for Health and Care Excellence diagnostic guidelines was slightly higher in cohorts 2 and 3 for all patients; 35.8% (10.0% in the year before diagnosis) had all four elements met for all cohorts combined. Multilevel modelling showed considerable between-practice variation in spirometry. The survey on the charity website had 156 responses by chronic obstructive pulmonary disease patients. Many respondents had not heard of the condition, hoped the symptoms would go away and identified various healthcare-related barriers to earlier diagnosis. Clinical Practice Research Datalink analysis showed notable changes in post-diagnosis prescribing from cohort 1 to 2, such as increases in long-acting muscarinic antagonist (21.7–46.3%). Triple therapy rose from 2.9% in cohort 2 to 11.1% in cohort 3. Documented pulmonary rehabilitation rose from just 0.8% in cohort 1 to 13.7% in cohort 2 and 20.9% in cohort 3. For all patients combined, the median time to first acute exacerbation of chronic obstructive pulmonary disease in patients who had one was 1.4 years in cohorts 1 and 2. Acute exacerbation of chronic obstructive pulmonary disease prediction models identified some consistent predictors, such as age, deprivation, severity, comorbidities, post-diagnosis spirometry and annual review. Models without post-diagnosis general practitioner actions had a c -statistic of around 0.70; the highest c -statistic was 0.81, for cohort 2 with post-diagnosis general practitioner actions and 6-month follow-up. All models had good calibration. The three most important predictors in terms of their population attributable risks were being a current smoker and offered smoking cessation advice (32.8%), disease severity (30.6%) and deprivation (15.4%). The highest population attributable risks for variables with adjusted hazard ratios &lt; 1 were chronic obstructive pulmonary disease review (–27.3%) and flu vaccination (–26.6%). Limitations Symptom recording and chronic obstructive pulmonary disease diagnosis vary between practice; predicted forced expiratory volume in 1 second had many missing values. Conclusions There has been some improvement over time in chronic obstructive pulmonary disease diagnosis and management, with large changes in prescribing, though patient and system barriers to further improvement exist. Data available to general practitioners cannot generate risk prediction models with sufficient accuracy. Future work It will be important to expand the COVID-era cohort with longer follow-up and augment general practitioner data for better prediction. Study registration This study is registered as Researchregistry.com: researchregistry4762. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/72) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 43. See the NIHR Funding and Awards website for further award information.

Alex Bottle

Alex Adamson

Xiubin Zhang

Benedict Hayhoe

Jennifer K Quint

What happens between first symptoms and first acute exacerbation of COPD – observational study of routine data and patient survey

COPD首次症状与首次急性加重之间发生了什么——常规数据观察性研究与患者调查

Emergency care treatment plans provide recommendations about treatment, including cardiopulmonary resuscitation, to be considered in emergency medical situations. In 2016, the Resuscitation Council United Kingdom developed a standardised emergency care treatment plan, the recommended summary plan for emergency care and treatment, known as ReSPECT. There are advantages and potential difficulties in initiating the ReSPECT process in primary care. Hospital doctors and general practitioners may use the process differently and recommendations do not always translate between settings. There are no large studies of the use of ReSPECT in the community.

Anne-Marie Slowther

Jenny Harlock

Celia J Bernstein

Katie Bruce

Karin Eli

Caroline J Huxley

Jacqui Lovell

Claire Mann

Angela Noufaily

Sophie Rees

Julia Walsh

Chris Bain

Hazel Blanchard

Jeremy Dale

Paramjit Gill

Claire A Hawkes

Gavin D Perkins

Rachel Spencer

Chris Turner

Amy M Russell

Martin Underwood

Frances Griffiths

Using the Recommended Summary Plan for Emergency Care and Treatment in Primary Care: a mixed methods study

使用基层医疗应急护理和治疗推荐总结方案：一项混合方法研究

涉及主题	public healthhealth caresocial carehealth serviceshealthcare delivery
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基本数据	创刊年份: 2022，原创研究文献占比: ，自引率:， Gold OA占比:
平均审稿周期	75 weeks

Health and Social Care Delivery Research

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Pathways to specialist community perinatal mental health services: a two-site longitudinal retrospective service evaluation

Understanding and improving the quality of primary care for people in prison: a mixed-methods study

Challenges and guidance for implementing social distancing for COVID-19 in care homes: a mixed methods rapid review

Implementing an artificial intelligence command centre in the NHS: a mixed-methods study

What happens between first symptoms and first acute exacerbation of COPD – observational study of routine data and patient survey

Understanding and improving the quality of primary care for people in prison: a mixed-methods study

Challenges and guidance for implementing social distancing for COVID-19 in care homes: a mixed methods rapid review

Pathways to specialist community perinatal mental health services: a two-site longitudinal retrospective service evaluation

What happens between first symptoms and first acute exacerbation of COPD – observational study of routine data and patient survey

Using the Recommended Summary Plan for Emergency Care and Treatment in Primary Care: a mixed methods study

ISSN	2755-0060, 2755-0079
h-index	3