Journal of Health Services Research & Policy

School-based health services (SBHS) have been shown to improve access to mental health services but the evidence of their effectiveness on students’ mental health is lacking. Our objective was to examine associations between variation in the provision of SBHS and students’ mental health.

A cross-sectional analysis of a nationally representative health and well-being survey of 8500 New Zealand high school students conducted in March–November 2012. Students’ mental health is related to data on school health services obtained from clinic leaders and clinicians from 90 participating high schools.

After adjustment for socio-demographic differences in students between schools, increasing levels of services were associated with progressively lower levels of student-reported depressive symptoms (p = 0.002), emotional and behavioural difficulties (p = 0.004) and suicidality (p = 0.008). Services with greater levels of nursing hours (p = 0.02) and those that performed routine, comprehensive psychosocial assessments (p = 0.01) were both associated with lower levels of student-reported depressive symptoms. Greater levels of nursing hours and doctor hours were associated with lower self-reported suicidality among students.

Although a causal association between school-based health services and students’ mental health cannot be demonstrated, these findings support the benefit of such services and the need for a cluster randomized trial.

To investigate the effects of four factors on perceptions of fairness in access to outpatient services: proportions of walk-in versus scheduled registration, consultation queues, regulations for late patients and particular categories of patients getting better access.

A total of 124 young adults were asked to consider nine different scenarios and report their views of the fairness of each one.

As regards the balance of types of patients, 60% walk-in registration was seen as fair to both walk-in and scheduled patients. The fairness to both types of patients was higher in the queue with a 1:1 ratio of walk-in to scheduled patients. The policy that a late patient should wait for three on-time patients to be seen was considered to be fair to both on-time and late patients. Immediate consultation for some particular categories of patient (e.g. the elderly) was fair, but for other categories was unfair (e.g. paying an addition amount).

Fairness in outpatient care is based on equality and need principles. Shorter waiting time does not mean patients view the system as fairer.

Patients discharged from hospitals on a Friday (Friday discharges) are readmitted sooner (a shorter time-to-emergency-readmission) than those discharged on any other day of the week. To evaluate the cost-effectiveness of increasing weekend capacity, the effect estimate of Friday discharge on time-to-emergency-readmission needs to be precise. However, precise effect estimation is complicated by the confounding effect of differing healthcare-seeking behaviour and admission practices, and therefore different admission probability, by day of the week. The objective of this research was to examine how differing admission probability by day of the week influences the effect of discharge day on time-to-emergency-readmission.

We used a Markov model to determine how day of the week admission probability would theoretically affect the time-to-emergency-readmission for Friday and Wednesday discharges. We tested this in a cohort of patients who have had a history of respiratory illness, using a Cox proportional hazards model to fit the time-to-emergency-readmission to any Quebec hospital as a function of the day of the week of discharge and admission. We fitted another Cox model with an additional time-varying covariate for the current day of the week, to model differing admission probabilities by day of the week.

Our Markov model showed that if admission probability is lower on the weekends, Friday discharges will be readmitted later (longer time-to-emergency-readmission) than Wednesday discharges. Using hospital admission data, we found that Friday discharges were readmitted slightly earlier than Wednesday discharges (HR: 1.03, 95% CI: (1.02, 1.05)). After adding a time-varying covariate for the current day of the week, the length of time-to-emergency-readmission for a Friday discharge increased, but it was still earlier than a Wednesday discharge (HR: 1.04, 95% CI: (1.01, 1.07)).

The lower admission probabilities on the weekend confound the effect of Friday discharge on time-to-emergency-readmission by increasing the time-to-emergency-readmission. This confounding effect causes an underestimate of the effect of Friday discharge on time-to-emergency-readmission.

Calls for major reconfigurations of health services have been accompanied by recommendations that wide ranging stakeholders be involved. In particular, patients and the wider public are seen as critical contributors as both funders and beneficiaries of public health care. But public involvement is fraught with challenges, and little research has focused on involvement in the health service transformation initiatives. This paper examines the design and function of public involvement in reconfiguration of health services within the English NHS.

Qualitative data including interviews, observation and documents were collected in two health service ‘transformation’ programmes; interviews include involved public and professional participants. Data were analysed using parallel deductive and inductive approaches.

Public involvement in the programmes was extensive but its terms of reference, and the individuals involved, were restricted by policy pressures and programme objectives. The degree to which participants descriptively or substantively represented the wider public was limited; participants sought to ‘speak for’ this public but their views on what was ‘acceptable’ and likely to influence decision-making led them to constrain their contributions.

Public involvement in two major service reconfiguration programmes in England was seen as important and functional, and could not be characterized as tokenistic. Yet involvement in these programmes fell short of normative ideals, and could inadvertently reduce, rather than enlarge, public influence on health service reconfiguration decisions.

To compare a new co-designed, patient incident reporting tool with three established methods of detecting patient safety incidents and identify if the same incidents are recorded across methods.

Trained research staff collected data from inpatients in nine wards in one university teaching hospital during their stay. Those classified as patient safety incidents were retained. We then searched for patient safety incidents in the corresponding patient case notes, staff incident reports and reports to the Patient Advice and Liaison Service specific to the study wards.

In the nine wards, 329 patients were recruited to the study, of which 77 provided 155 patient reports. From these, 68 patient safety incidents were identified. Eight of these were also identified from case note review, five were also identified in incident reports, and two were also found in the records of a local Patient Advice and Liaison Service. Reports of patients covered a range of events from their immediate environment, involving different health professionals and spanning the entire spectrum of care.

Patient safety incidents reported by patients are unlikely to be found through other established methods of incident detection. When hospitalized patients are asked about their care, they can provide a unique perspective on patient safety. Co-designed, real-time reporting could be a helpful addition to existing methods of gathering patient safety intelligence.

Data from the Academy of American Physician Assistants have suggested there are no differences in salaries by race and ethnic group. Our objective was to compare salaries of physician assistants for different racial and ethnic groups and sexes using another data source.

Data from the American Community Surveys (2010–2012) to examine pay differentials of physician assistants. Ordinary least squares regression analysis to compare the salaries of males and females, and those of racial and ethnic groups.

The majority of physician assistants in recent decades have been women. Their salaries are substantially below those of their male counterparts. The number from racial and ethnic minorities remains low. American Community Surveys data show salaries to be lower than that reported by the American Academy of Physician Assistants. The salaries of Black and Hispanic physician assistants lag significantly behind the salaries of those who are White.

American Community Surveys data suggest that previously published Academy of American Physician Assistants survey data may have been biased with a low percentage of physician assistants from racial and ethnic minorities which suggests that the Academy of American Physician Assistants need to focus on recruiting greater numbers of minorities.

The Health and Social Care Act 2012 introduced Clinical Commissioning Groups to take responsibility for commissioning (i.e. planning and purchasing) the majority of services for local populations in the English NHS. Constituted as ‘membership organizations’, with membership compulsory for all GP practices, Clinical Commissioning Groups are overseen by, and are accountable to, a new arm’s-length body, NHS England. This paper critically engages with the content and policy narrative of the 2012 Act and explores this in relation to the reality of local policy enactment.

Set against a careful review of the 2012 Act, a case study of a nascent Clinical Commissioning Groups was conducted. The research included observations of Clinical Commissioning Group meetings and events (87 h), and in-depth interviews (16) with clinical commissioners, GPs, and managers.

The 2012 Act was presented as part of a broader government agenda of decentralization and localism. Clinical Commissioning Group membership organizations were framed as a means of better meeting the needs and preferences of local patients and realizing a desirable increase in localism. The policy delineated the ‘governing body’ and ‘the membership’, with the former elected from/by the latter to oversee the organization. ‘The membership’ was duty bound to be ‘good’, engaged members and to represent their patients’ interests. Fieldwork with Notchcroft Clinical Commissioning Group revealed that Clinical Commissioning Groups’ statutory duty to NHS England to ‘ensure the continuous improvement’ of GP practice members involved performance scrutiny of GP practices. These governance processes were carried out by a varied cast of individuals, many of whom did not fit into the binary categorization of membership and governing body constructed in the policy. A concept, the governing assemblage, was developed to describe the dynamic cast of people involved in shaping the work and direction of the Clinical Commissioning Group, many of whom were unelected and of uncertain status. This was of particular significance in Notchcroft Clinical Commissioning Group because the organization explicitly pursued a governance system based on developing positions of consensus. The governing assemblage concept is valuable in articulating the actual practices of Clinical Commissioning Group governance, how these relate to the normative content of the 2012 Act, and the tensions that emerge.

The governing assemblage concept provided clarity in discussion of the dynamics of organizational governance in Notchcroft Clinical Commissioning Group, which did not follow the simple template articulated in the 2012 Act. The concept merits application in the study of other Clinical Commissioning Groups and may prove valuable in illuminating governance processes within a range of other health care organizations in different contexts. The governing assemblage holds promise for the analysis of ongoing changes to NHS organization, as well as international health care organizations such as accountable care organizations in the US.

Internationally, there has been considerable debate about the role of data in supporting quality improvement in health care. Our objective was to understand how, why and in what circumstances the feedback of aggregated patient-reported outcome measures data improved patient care.

We conducted a realist synthesis. We identified three main programme theories underlying the use of patient-reported outcome measures as a quality improvement strategy and expressed them as nine ‘if then’ propositions. We identified international evidence to test these propositions through searches of electronic databases and citation tracking, and supplemented our synthesis with evidence from similar forms of performance data. We synthesized this evidence through comparing the mechanisms and impact of patient-reported outcome measures and other performance data on quality improvement in different contexts.

Three programme theories were identified: supporting patient choice, improving accountability and enabling providers to compare their performance with others. Relevant contextual factors were extent of public disclosure, use of financial incentives, perceived credibility of the data and the practicality of the results. Available evidence suggests that patients or their agents rarely use any published performance data when selecting a provider. The perceived motivation behind public reporting is an important determinant of how providers respond. When clinicians perceived that performance indicators were not credible but were incentivized to collect them, gaming or manipulation of data occurred. Outcome data do not provide information on the cause of poor care: providers needed to integrate and interpret patient-reported outcome measures and other outcome data in the context of other data. Lack of timeliness of performance data constrains their impact.

Although there is only limited research evidence to support some widely held theories of how aggregated patient-reported outcome measures data stimulate quality improvement, several lessons emerge from interventions sharing the same programme theories to help guide the increasing use of these measures.