Working together - full abstract

Implementation of Health-Justice Partnerships

Sarah Beardon (1), Charlotte Woodhead (2), Silvie Cooper (1), Hazel Genn (3), Rosalind Raine (1)
(1)UCL Department of Applied Health Research, (2) King's College London Department of Psychological Medicine, (3) UCL Faculty of Laws

Background: Social welfare legal problems impact negatively on mental and physical health. These problems include issues with welfare benefits, debt, homelessness, family and employment. Services providing legal assistance with social welfare issues have developed collaborations with healthcare providers across the UK and the globe. These ‘health-justice partnerships’ are designed to address health-harming social and economic conditions: they aim to support health of the most disadvantaged groups and tackle the interconnected challenges of health inequalities and access to justice. International evidence on the delivery of these partnerships has never previously been reviewed. This study interrogates the state of current evidence and provides new insights from international practice.

Methods: A systematic scoping review of international literature was undertaken to map current evidence and guide the design of a primary research study. The review aimed to describe different service models and explore factors affecting successful implementation. A wide-ranging search was conducted across academic databases and grey literature sources, covering OECD countries from 1995 onwards. Data from included publications were extracted and analysed narratively.

Results: 118 studies were included. Publications largely originated from the UK and USA, with smaller numbers from Australia, Canada, New Zealand and Ukraine.

Health-justice partnerships were diverse in their healthcare settings and service designs. Target populations focussed on low income, vulnerable or underserved groups. Legal assistance was provided free by charitable and non-profit organisations. Approaches to service coordination included co-location, referral, or integration of legal advisors into care teams and care pathways.

Studies highlighted key factors influencing successful implementation of health-justice partnerships. Establishment of new partnerships benefited from a clear purpose, detailed planning, stakeholder involvement and responsiveness to local needs. Inter-professional collaboration was facilitated by co-location of services, regular communication, simple processes, trusting relationships, staff awareness and goodwill. Factors affecting sustainability included resourcing, leadership and governance, evaluation, joint commitments and service agreements. These results are discussed in relation to implementation theory and contrasted with wider literature on integration of care in other settings.

Implications: This is the first international review on the delivery of health-justice partnerships, bringing together evidence from across the world to map current knowledge on implementation. Integration of services aligns with policy priorities in both health and justice sectors: partnerships aim to prevent ill health, support wellbeing, reduce pressures on healthcare and improve individuals’ access to their social welfare rights. Cross-sector alignment and collaboration presents challenges, but is necessary to achieve successful service outcomes. Research into effective implementation of health-justice partnerships is important to facilitate their establishment, impact and sustainability. An ongoing primary research study explores implementation of health-justice partnerships in different settings across England to inform future policy and practice.

An ethnographic study into latent patterns of multidisciplinary working leading to delays in discharge from hospital of older people living with frailty

Heather Brant (1), Gill Coombes (2), Sarah Damery (2), Sheila Greenfield (2), Liz Hill (3), Adriano Maluf (2), Nadine Murigo (3), Kyra Neubauer (4), Clare Thomas (3), Zoe Wyrko (5), Sabi Redwood (3)
(1) National Institute for Health Research, Applied Research Collaboration West (NIHR ARC West), University of Bristol, (2) University of Birmingham, (3) National Institute for Health Research, Applied Research Collaboration West (NIHR ARC West) / University of Bristol, (4) North Bristol NHS Trust, (5) University Hospitals Birmingham NHS Foundation Trust

Background: Older people living with frailty (OPLWF) are often unable to leave hospital when they no longer need hospital care. Unnecessarily delayed discharges have potentially negative consequences for their health and independence and add significant costs to health services. Despite initiatives to reduce these delays, they continue to rise. While there are many guidelines and best practice principles indicating how discharges for OPLWF should be organised and coordinated, there are few studies addressing how these may successfully be put into practice and little is known about the barriers to joint working professionals in different organisational settings when planning discharges. The study aim was to understand why delays occur and identify obstacles that may be amenable to local solutions that could also have wider implications across other health and care systems.

Method: We conducted an ethnographic study at two large hospitals in two English cities and their respective systems of health and care delivery including primary, community and social care services. We followed and mapped 38 patient journeys from admission to post-hospital care, conducted 66 semi-structured interviews with patients, family members, and hospital-based and community professionals and mangers, and collected over 390 hours of direct observations over a period of 18-22 weeks. Data were analysed inductively using principles of thematic analysis to generate patient journeys and interpretive themes.

Results: Patient journeys revealed a wide range of expected sources of delays because patients had to wait for things to happen or to become available such as investigations and specialist team reviews, limited availability of equipment, packages of care or ‘step down’ beds, and delays in care home assessments. However, we also found evidence of how taken-for-granted working practices and communication methods between different professionals and across organisational boundaries inadvertently generated delays in patients being discharged. We describe what happened to patients during their admission to hospital as ‘de-construction’ followed by attempts at ‘re-construction’ to enable discharge planning.

During a hospital admission, OPLWF were ‘de-constructed’ into numerous information fragments which were collected, recorded and accessed in different ways by different professionals. In order to ‘reconstruct’ patients’ stories and facilitate discharge from hospital, these information fragments needed to be integrated. The key component of the reconstruction and integration process was information related to patients’ social, family and functional background, and ‘collateral’ history from other informants such as family members or carers. However, we found that this crucial component was often missing, or even if it was collected and stored, it was not necessarily accessed and was vulnerable to loss especially if patients were moved to other wards. It was also perceived to be of low value in relation to other more readily available information such as results from clinical investigations and clinical assessments. Patients’ re-construction was thus often incomplete, or insufficient to deal with the uncertainty and risk associated with frailty in a safe and informed manner. We found that where this key component for reconstruction was present and integrated into decision-making processes in multidisciplinary team working, uncertainty and risk were managed constructively and sometimes avoided an escalation of care needs.

Implications: Having a holistic knowledge of OPLWF was not only about compassionate healthcare, but also central to safe care and the appropriate use of resources. We are now sharing our findings with patients, carers and health and care services to explore potential mechanisms for collecting, storing and using patient stories and how these could feasibly be delivered in practice.

Aligning Health and Social Care in Practice - Observing Multi-Disciplinary Team Meetings

Nicolas Douglas (1), Mustafa Al-Haboubi (1), Tommaso Manacorda (1), Lavanya Thana (1), Mary Alison Durand (1), Gerald Wistow (2), Bob Erens (1), Nicholas Mays (1)
(1) London School of Hygiene & Tropical Medicine, (2) London School of Economics

Background: The Integrated Care and Support Pioneer Programme (2013-2018) aimed to promote the systemic ‘horizontal’ integration of health and social care services in 25 areas in England. Community-based multi-disciplinary teams (MDTs) serving the needs of a wide range of older people with multiple long-term conditions and living in their own homes were the most commonly reported approach to integrating health and social care in the Pioneers (Erens et al., 2016). While previous research has tended to focus on MDTs devoted to particular conditions (e.g. cancer, chronic diseases, primary care) (Quinlan, 2009, Soukup et al., 2016, Pullon et al., 2016, Raine et al., 2014), it is timely to consider the operation of more generic teams since they constitute so much of current efforts at health and social care integration at patient/client level in England.

Method: As part of a quasi-experimental evaluation of the impacts and costs of community-based integrated MDTs, we observed how these teams operated in practice at meetings where cases were discussed. The aim was to understand how participants worked together to coordinate integrated health and social care for their caseloads. The objectives were: 1) to describe the composition of MDTs, i.e. the mix of professionals present and any apparent gaps; 2) assess key aspects of team functioning and interaction between MDT members as conceptualised in a theoretical model developed for the research; 3) describe any logistical facilitators and/or barriers to the effective operation of MDT meetings; 4) understand the nature of decisions taken during meetings; 5) identify possible added value of the MDT meetings (over bilateral discussions between professionals) ; and 6) identify factors potentially salient but not initially known to us that appeared to significantly affect the operation of MDTs.

Two rounds of structured, non-participant observations of integrated care MDT meetings were undertaken in two Pioneer sites between June and December 2019 and in February 2020. We observed 29 MDT meetings involving 11 MDTs. Researchers used two structured data gathering tools to take notes in situ, gather additional information from MDT administrators following meetings and provide considered reflections soon after each meeting. 

A modified form of group analysis and thematic analysis of researcher notes and reflections was undertaken to generate key themes for reporting (Phoenix et al., 2016, Jackson, 2008, Braun and Clarke, 2012).

Results: Early findings indicated some variations in professional groups represented and there was scope to improve the meeting facilities in some locations. IT interoperability was a problem in all sites. We identified a pattern for deliberations about cases that appeared to be common across meetings. Leadership and decision-making were variable. Meetings were largely collegial but with scope to increase reflexivity and challenge. The presentation will report further on context, MDT membership and participation, patterns of engagement, deliberation and decision-making, leadership, patient-centredness, conflict, reflexivity and challenge. We will also reflect on our method as a potentially transferable approach to the qualitative evaluation of MDT operation.

Implications: The study is distinctive in the field of integrated care research in its focus on direct observation of practice (as opposed to reports from interviews and surveys) and attention to the activity of ‘front-line’ staff. It also allowed the development of a rigorous and potentially transferable approach to non-participant observation of MDTs.

Totaalbloedvergiftiging (Total Sepsis)

Helen Pardoe (1), Andrea Annoni (2), Marie Parsons (2), Georgia Lucas (2), Angela Bartolf (2), Nick Kroll (3)
(1) The Princess Alexandra Hospitals NHS Trust, (2) Princess Alexandra Hospitals NHS Trust, (3) University of Manchester

Background: Sepsis is a major cause of death worldwide. It's been identified that there are opportunities to reduce the mortality from sepsis in UK hospitals by improving the speed of identification and treatment of sepsis. In certain areas of the UK, district general hospitals (DGHs) are running with Emergency Department (ED) nursing and medical shift vacancy rates of 20-25% at times. In some trusts the achievement against the 4 hours standard is <75%. With financial deficits in the millions, how can we achieve improvements in outcomes from sepsis?

Methods: Totaalvoetbal (Total football) is a theoretical approach to football which was championed by the Dutch world cup team of 1974, with the basic principal that a player who moves out of position is replaced by another team member to maintain the organisational structure. We used the principles of totaalvoetbal to reduce our deaths from sepsis with a totaalbloedvergiftiging programme over 2 years, working with our patients and staff, supported by Quality Improvement methodology to save lives from sepsis in a DGH rated by the CQC as “inadequate”.  The program included the introduction of Procalcitonin blood testing in ED, trust wide “tea trolley training”, sepsis champions across the trust, installation of a blood culture analyser in the ED and redesigning the blood culture kits.  Outcomes were tracked using HSMR and SHMI, local health informatics, National CQUIN sepsis 6 performance, laboratory and training records.

Results: 70% of patients diagnosed with sepsis presented to ED in our hospital, supporting our strategy to focus on identification and immediate management of sepsis in the ED. Identification of patients with sepsis in ED is difficult as symptoms are non-specific and other conditions may mimic sepsis. Of patients presenting to ED with possible sepsis only 23% of patients had a confirmed diagnosis of sepsis. 30% of these patients had neutropenic sepsis. The monthly HSMR for the hospital increased whenever the ED 4 hour performance dropped below 75%. 

Ward based “tea trolley training” reached over 450 frontline clinical staff in a 2 week period. Redesign of the blood culture bags along with increased supply and the reporting of the CQUIN increased the percentage of blood cultures taken in cases of possible sepsis from 19% to 86%. The satellite blood culture analyser led to earlier diagnosis of positive blood cultures. Procalcitonin over 0.3 in ED was correlated with a significant increase in the risk of death as an inpatient (p=0.05). The level of serum Procalcitonin was non-specific in patients with neutropenic sepsis.  

75% of cases of sepsis (n= 1176) were in patients over 65 years old, with 82% of deaths in patients over 65 years old. 60% of patients with sepsis were admitted under the care of general medicine. Follow up of a cohort of survivors of sepsis over a 6-month period (n= 124) showed that only 37% survived 2 years from discharge from hospital. Over the period of the project the sepsis mortality reduced from 22.5% to 17% equating to over 15 lives saved per year as a result of the 2 years of totaalbloedvergiftiging

Implications: An organisational approach addressing many aspects of the early assessment and treatment of patients with sepsis can deliver significant improvements in survival. “Total Sepsis” is an engaging, cost effective and sustainable way to improve patient outcomes. PCT in ED can be used to identify a high-risk group of patients who may benefit from early senior medical review.
ED is the major area for the initial assessment and treatment of sepsis in the UK. In hospitals that are unable to maintain an ED 4-hour performance of >75%, avoidable deaths from sepsis may still occur.