Journal of Health Services Research & Policy

To develop, implement and compare two lifestyle services for people at risk of developing type 2 diabetes.

Two localities were selected to implement two different service delivery models, telephone-based and face-to-face, supporting people at risk of developing type 2 diabetes. Impact was assessed by comparing weight, fasting plasma glucose and oral glucose tolerance test (OGTT) results at baseline and six months later.

Both services were associated with an improvement in OGTT 2-h plasma glucose and weight. In the telephone intervention, 47.3% of participants who completed the project achieved both normal fasting plasma glucose (≤6.0 mmol/l) and normal plasma glucose levels (≤7.7 mmol/l). Participants had a mean weight loss of 3.3 kg (SD 4.3), equating to 3.4% of body weight (p < 0.001). In the face-to-face intervention, 46.3% of participants achieved normal plasma glucose (≤7.7 mmol/l) and a mean weight loss of 2.9 kg (SD 4.5), equating to 3.1% of bodyweight (p < 0.001).

Local health providers can adapt existing service provision and tailor it to provide lifestyle programmes for people with impaired glucose tolerance. Both service delivery models offer effective diabetes prevention although each model may cater for different population needs and a choice of services might be the preferred option.

New and emerging health technologies (innovation outputs) do not always reflect conditions representing the greatest disease burden. We examine the role of research and development (R&D) funding in this relationship, considering whether areas with fewer innovative outputs receive an appropriate share of funding relative to their disease burden.

We report a retrospective observational study, comparing burden of disease with R&D funding and innovation output. UK disability-adjusted life years (DALYs) and deaths came from the World Health Organization (WHO) 2004 Global Burden of Disease estimates; funding estimates from the UK Clinical Research Collaboration’s 2006 Health Research Analysis; and innovation output was estimated by the number of new and emerging technologies reported by the National Institute for Health Research (NIHR) Horizon Scanning Centre between 2000 and 2009.

Disease areas representing the biggest burden were generally associated with the most funding and innovation output; cancer, neuropsychiatric conditions and cardiovascular disease together comprised approximately two-thirds of DALYs, funding and reported technologies. Compared with DALYs, funding and technologies were disproportionately high for cancer, and technologies alone were disproportionately high for musculoskeletal conditions and endocrine/metabolic diseases. Neuropsychiatric conditions had comparatively few technologies compared to both DALYs and funding. The relationship between DALYs and innovation output appeared to be mediated by R&D funding.

The relationship between burden of disease and new and emerging health technologies for different disease areas is partly dependent on the associated level of R&D funding (input). Discrepancies among key groups may reflect differential focus of research funding across disease areas.

To examine how organizational factors affect good care and mistreatment of older people in care homes.

Eight residential care homes for older people (including private sector, local authority and NHS providers) took part in a participatory observation-based study of organizational factors affecting care quality.

Grouping organizational factors into infrastructure, management and procedures, staffing, resident population characteristics and culture, we show the context-sensitive nature of interactions between these factors. These interactions could enhance care quality where factors combined positively. Conversely, they could amplify difficulties where one factor came to undermine another, thereby limiting care quality.

This analysis provides empirical insights into how and why similar sector-wide changes to care provision have differential effects at the care home level. It indicates the situated and unpredictable ways in which organizational factors interact, implying the need for locally contextualized quality assessment and improvement actions.

The UK National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Management Fellowship programme enabled health services managers and university researchers to collaborate on research projects with the aim of improving research, managers’ research knowledge and skills, and the use of research in management. Our aim was to evaluate whether the programme encouraged greater engagement, linkage and exchange between researchers and managers.

A case-study approach with each case-study centred on 11 health care managers appointed as Fellows, chief investigators (n = 13) and Fellows’ line managers (n = 12). Data were collected through semi-structured face-to-face and telephone interviews. Interviews were analysed thematically to explore the impact of the programme, reported issues and to identify any lessons learned.

Researchers benefited from the flow of (insider) knowledge and contacts from the workplace via the Fellow to the project. Engagement, linkage and exchange as a result of the Fellowship were less developed for the workplace. Reasons for this related to the fit of the research project with workplace interests, Fellows’ contact with the health care organization, feedback structures and training. The potential for co-production of knowledge was under-developed. A transactional notion of exchange was found in operation in workplaces.

The programme’s aim to enhance engagement, linkage and exchange was largely achieved, although exchange tended to be narrowly conceived. Knowing how models of exchange work in practice can ensure effort is put to best use.

To understand the barriers and enablers to commissioning vocational rehabilitation (VR) after stroke.

Interviews with health and social care commissioners responsible for stroke services across three counties were conducted to explore their views on the barriers and enablers to commissioning VR. Transcripts were subjected to thematic analysis, and validity checked with members of the research team.

The findings indicate that health commissioners have had to focus on demand-led and expensive acute stroke services, leaving little resource for community services. Though the benefits of VR to patient health are acknowledged, any cost savings would not be realized within the health budget. Social care commissioners, in times of budget restriction, focus on the most vulnerable, aiming to maintain independence and reduce care home admission. In the absence of evidence, there is a perception that the need for VR after stroke is relatively minor.

Factors which might facilitate commissioning of a VR service include adapting the service to align with commissioners’ requirements, making VR a targeted outcome of community stroke services, utilizing emerging opportunities for joint health and social care commissioning such as Health and Wellbeing Boards, and closer working with researchers to improve the evidence-base.

To assess whether variation in the provision of cancer specialist nurses is associated with the experiences of care for patients undergoing treatment for cancer.

This is a cross-sectional study using routinely collected national survey data in 158 acute hospital National Health Service (NHS) Trusts in England. Patients with a primary diagnosis of cancer who attended hospital as inpatients or day cases in the first three months of 2010 responded to a national survey (n = 67,713, response rate 67%). Patient perceptions of coordination of care, quality of information provision, emotional support and support for symptom management were studied.

Patients in Trusts that had the fewest patients per specialist nurse were more likely to report that people treating and caring for them worked well together (adjusted odds ratio 1.08, 95% confidence interval 1.01–1.15; p = 0.02) and provided enough emotional support during ambulatory treatment (1.15, 1.01–1.32; p = 0.04), but were no more likely to report being given the right amount of information (0.96, 0.88–1.05; p = 0.38) when compared to patients in Trusts with the most patients per specialist nurse. Breast cancer patients undergoing chemotherapy in the Trusts with fewer patients per specialist nurse were more likely to report good support for the control of side effects from chemotherapy (1.34, 1.02–1.75; p = 0.03).

Cancer patients’ experience of care coordination and emotional support was better in Trusts with more specialist nurses. The absolute differences were small, and it was unclear whether particular roles or service configurations are associated with better experience.

Whole system integration of health and social care has been positioned as key to improving care, increasing efficiency and controlling costs. However, evidence for the benefits of whole system integration is scarce. Drawing on organizational theory, this study uses the implementation of remote care services, viewed as an enabler for whole system working, to explore the reality of achieving this policy objective.

Qualitative, longitudinal data were collected across nine UK sites adopting remote care over three years. Three sites formed the Department of Health's Whole Systems Demonstrator (WSD) programme for remote care. In addition, the implementation of remote care was explored in six other sites unconstrained by the randomized control trial procedures of the WSD programme. The methods were ethnographic (including 235 hours of observations and 184 interviews). Participants were health and social care staff and Government policy makers.

Remote care did not lead to system redesign; however, local ‘ownership’ of new services did lead to more collaborative practices across the care system. Lack of integration was an enduring and endemic challenge across all sites, relating to differences in statutory responsibilities, absence of shared budgets and hybrid organizational roles, differences in work practices and organizational philosophies, and ambiguity around what ‘whole system working’ actually entailed.

Policy initiatives like the WSD programme provide opportunities to phase in collaborative practices and create an awareness of the need for joint working. However, the progress observed suggests that the concept of whole system redesign around remote care is currently unrealistic.

To test the effects of adding text messages to weekly email communications on recipients’ total physical activity (leisure-time; workplace; domestic and garden; and active transportation) in employees of universities and colleges in the UK.

A randomised trial with two study groups (email only or email plus text messaging for 12 weeks) was implemented at five workplaces. Data were collected at baseline, immediately after, and four weeks after the intervention. Intervention effects on physical activity were evaluated using latent growth modelling.

Total physical activity decreased over time in both groups but the decrease was non-significant. The only significant difference between groups was found for workplace physical activity, with the group receiving emails and text messages having a linear decrease of 2.81 Metabolic Equivalent h/week (β = −0.31, p = 0.035) compared to the email only group.

Sending employees two additional text messages resulted in less physical activity. Further investigation is needed to understand whether text messaging may play a beneficial role in promoting physical activity in workplace settings.