Evidence insights is a regular bulletin connecting you with the latest evidence in commissioning and service transformation.  We search a range of sources, selecting the highlights and presenting them to you in this concise bulletin.

Issue 56 -  July 2018

This month in Evidence insights: 

New Guidance from NICE

The following guidance was published in July which may be of value to commissioners.

Clinical guidelines
Brain tumours (primary) and brain metastases in adults [NG99] | Rheumatoid arthritis in adults: management [NG100] | Early and locally advanced breast cancer: diagnosis and management [NG101]

Technology Appraisals
Nivolumab for treating locally advanced unresectable or metastatic urothelial cancer after platinum-containing chemotherapy [TA530] | Crizotinib for treating ROS1-positive advanced non-small-cell lung cancer [TA529] | Niraparib for maintenance treatment of relapsed, platinum-sensitive ovarian, fallopian tube and peritoneal cancer [TA528] | Atezolizumab for untreated PD-L1-positive locally advanced or metastatic urothelial cancer when cisplatin is unsuitable [TA492] | Cenegermin for treating neurotrophic keratitis [TA532] | Pembrolizumab for untreated PD-L1-positive metastatic non-small-cell lung cancer [TA531] | Ocrelizumab for treating relapsing–remitting multiple sclerosis [TA533]   

Quality Standards
Rheumatoid arthritis in over 16s [QS33] | Medicines management for people receiving social care in the community [QS171]

New Commissioning Tools

Transforming Care Programme (TCP): template model agreements
This publication, from NHS England, presents three model funding transfer/pooling agreements, to be used depending on where local TCP partners are currently with existing pooled budgets.  It seeks to address the main financial challenges and drivers that need to be addressed to ensure successful delivery of 'Building the Right Support' by the 48 TCPs locally.  

Everybody active, every day: framework for physical activity
This updated framework, from Public Health England, provides an evidence-based approach for national and local action to address the physical inactivity epidemic.  

Inclusion health audit tool
This online tool, from VCSE Health and wellbeing alliance, aims to help organisations to audit their engagement with Inclusion Health groups. These are the groups identified as experiencing the worst health inequalities in the UK.  The tool consists of five sections and takes around 15 minutes to complete, it then produces a tailored guide to help the organisation to embed action on tackling health inequalities into its everyday activities.  

The long-stays dashboard
This dashboard has been developed by NHS Improvement to help providers, clinical commissioning groups and local authorities to monitor and mange hospital length of stay in acute hospitals.  The aim is that the dashboard will help to improve patient flow in acute hospitals and also assist in the management of bed capacity.  

New Musculoskeletal Core Capabilities Framework
This new framework, developed by Skills for Health, with Health Education England, NHS England, Public Health England and the Arthritis and Musculoskeletal Alliance (ARMA), is aimed at practitioners who will be the first point of contact for people with musculoskeletal conditions.   The framework sets out the essential skills and knowledge necessary for staff with a role as a first point of contact for adults presenting with undiagnosed MSK conditions.  

New Commissioning Guides

Excellence in Continence Care
This guidance document, from NHS England, gives practical guidance for commissioners, providers, health and social care staff to help ensure people receive excellent continence care consideration.  

Better Care Fund Operating Guidance for 2017-19
This guidance document, from NHS England, sets out the refreshed operating guidance for approved Better Care Fund (BCF) plans and is for local partners that agree and administer BCF 2017-19 plans.  

Report of the Review of the Quality and Outcomes Framework in England
This report, from NHS England, presents the findings of the Review of the Quality and Outcomes Framework (QOF) for general practice and supports wider discussion about how to reform the QOF, which will inform negotiations between NHS England and the British Medical Association.  The report concludes; there are aspects of QOF which are valued and valuable, but suggests there is a need to refresh the scheme to support a wider view of high quality care and to align better with professional values. Underpinning any change would be the clinical vision that change should increase the likelihood of improved patient outcomes, decrease the likelihood of harm from over treatment and improve the personalisation of care.
The three objectives that NHS England considered highest priority for a reformed scheme, following discussion with the Advisory Group, were that it:
  1. Delivers better patient care, particularly by enabling more holistic person-centred care, and incentivises on-going improvement
  2. Supports stability and sustainability in general practice, by creating space for professionalism, at a time when workload is high and the profession is reporting high levels of stress and concern
  3. Supports practices to move into a role in which they can optimally impact demand on the wider system, and so optimise the use of limited resources.  
In summary there was consensus around the benefits.  

Implementation - New 'know-how'

Every Nurse an E-nurse: Insights from a consultation on the digital future of nursing
This publication, from the Royal College of Nursing, presents the detailed findings of a consultation,  into the digital future of nursing. The consultation took place over January and February 2018. The consultation explored;
  1. Ideas for a shared vision of a digitally enabled health and social care service
  2. The barriers and enablers to the vision becoming a reality
  3. Examples of how data, information, knowledge and technology are already bringing that vision to life.  
Review of the National Childbirth Trust Hidden Half report and GP consultation
This review, from the Centre for Menatl Health, looked at; 'The National Childbirth Trust (NCT) report; The Hidden Half: bringing postnatal mental illness out of hiding' which found that up to half of women experiencing mental health difficulties during pregnancy and in the year after did not have their needs recognised by health professionals.  This review recommends that GPs should be incentivised and supported to provide all women with a six-week postbirth health check for themselves as well as one for their baby. It also suggests that having an automated system for sending out an appointment for the maternal check (and possibly also the baby’s) would help.  

The health and social care interface
This report, from the National Audit Office,  presents and discusses 16 challenges to improve joint working between health and social care.  It also highlights some of the work being carried out nationally and locally to overcome these challenges and the progress that has been made. It draws out the risks presented by inherent differences between the health and social care systems and how national and local bodies are managing these.  

All Party Parliamentary Group (APPG) on Eye Health and Visual Impairment
This report, from the All Party Parliamentary Group (APPG), outlines Eye Health and Visual Impairment solutions to the current capacity issues in eye care services in England.
The APPG conducted an inquiry to identify how capacity in NHS eye care services in England can be improved to ensure no one loses their sight unnecessarily. The report includes 16 recommendations, from providing staff with more extensive training to setting national targets.   

Fracture Liaison Service Database: Commissioner's Report 2018
This report, from the Royal College of Physicians, contains a summary of the audit’s national key findings and recommendations and results for fracture liaison services (FLSs) by region. It also explains what an FLS is and how FLSs could help clinical commissioning groups (CCGs) to reduce the number and cost of unplanned admissions and to make a significant reduction in morbidity and mortality for older people.

New Research 

Improving care for people with MS: the potential of data and technology
This report, from Nuffield Trust commissioned by the MS Society, maps out what technology is already available for people with MS, what more could be done with what is available and how data and technology could be better exploited in future to improve MS health care.  

The impact of dementia on service use by individuals with a comorbid health condition
This comparison of two cross-sectional analyses,  by Holly Bennett et al, looked at two studies conducted approximately 10 years apart.  Th analysis found; either due to the decrease in care home spaces or affordability, people with dementia are now relying on unpaid care more than people with other long-term health conditions.

The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups
This mixed-methods case study, by Helen Atherton et al, showed a low uptake of alternatives, lack of clarity about their purpose and potential for benefit but little evidence at present.  The study highlights key issues for practices and policy-makers to consider and makes recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.

Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality
This systematic review, by Denis Pereira Gray et al, found that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. It concluded that despite substantial, successive, technical advances in medicine, interpersonal factors remain important.

Beyond barriers: how older people move between health and care in England
This report, published by the Care Quality Commission (CQC), brings together key findings and recommendations for change, following the completion of 20 local authority area reviews exploring how older people move between health and adult social care services in England. 
'Beyond barriers' looks at how services are working together to support and care for people aged 65 and over.  The review found; 
  • Organisations intended to work together but mostly focused on their own goals
  • Although there was good planning between services, the way services were funded did not support them to work together
  • Organisations;
    • were prioritising their own goals over shared responsibility to provide person centred care
    • did not always share information with each other which meant they weren’t able to make informed decisions about people’s care
    • were not prioritising services which keep people well at home
    • planned their workforce in isolation to other services
  • The regulatory framework focuses only on individual organisations.
Research into physiotherapy for musculoskeletal conditions
This themed review, highlights evidence from the NIHR and others on why research in this area matters, assessment and matching patients to treatment, restoring musculoskeletal health and maintaining musculoskeletal wellbeing.  

A dangerous waiting game?  A review of patient access to inguinal hernia surgery in England
This report, from the Royal College of Surgeons and British Hernia Society, argues that thousands of predominately-male patients are being made to suffer in pain and, in rare cases, are at risk of death due to the NHS restricting access to groin hernia operations. The research findings reveal that 57 per cent of clinical commissioning groups are denying patients quick access to the surgical procedure, even though it is considered the only curative treatment for patients with a groin hernia.  It sets out the scale of CCG restrictions, the impact these are having on patients, and what needs to be done at a local and national policy level to address this.

Less help to quit
This report, from the British Lung Foundation, highlights how every year fewer patients are being given treatments to help them quit smoking.  It shows the most effective treatment for tobacco dependency – medication alongside behavioural support – is increasingly hard for patients to access through primary care.  The key findings were; 
  • In England, there has been a 75% decline in stop smoking treatments being prescribed by GPs and pharmacists
  • In Wales, the number of treatments dispensed has fallen by two thirds
  • In Scotland there was a 40% decline in the number of treatments prescribed in just two years
This decline in prescriptions greatly outpaces the steady decline in the number of people smoking across Britain.

Leadership in today's NHS: delivering the impossible
This report, from The King's Fund, is based on a survey of NHS trusts and foundation trusts carried out by NHS Providers in late 2017, qualitative interviews and a roundtable event with frontline leaders and national stakeholders.The report findings include: 
  • A culture of blaming individuals for failure is making leadership roles less attractive.
  • The survey showed that leadership vacancies are widespread, with director of operations, finance and strategy roles having particularly high vacancy rate and short tenures. 
  • To tackle high leadership churn, national programmes should target professional roles where concerns over the pipeline of future leaders is greatest. 
  • More attention should be given to addressing the environment NHS leaders operate in. 
Each baby counts: themed report on anaesthetic care, including lessons identified from Each Baby Counts babies born 2015 to 2017
This report, from the Royal College of Obstetricians and Gynaecologists, found that 76 per cent of babies in its study might have had a different outcome with different care. The report included recommendations highlighting critical factors in the care of the many of these babies that could prevent these incidents in the future. Detailed analysis of the anaesthetic care given to the mothers of 49 babies reported to Each Baby Counts between 2015 and 2017 has been completed. This report is part of a wider set of findings and recommendations, to be published in autumn 2018.

Associations between parental mental health and other family factors and healthcare utilisation among children and young people
This retrospective, cross-sectional study of linked healthcare data, by Kathryn Dreyer et al, concluded that Parental depression is associated with increased utilisation of Emergency departments, outpatient and inpatient services by children and young people (CYP), as well as with increased GP consultations among adolescents. The results demonstrate that healthcare utilisation by CYP is associated with the health-seeking behaviour of adults in their household.  

Outpatient video consultations are feasible but challenging for the NHS
This commentary, from NIHR Signals, discusses and NIHR funded study exploring the feasibility of video consultations.  The research found that when certain conditions are met, video consultations can provide safe and effective alternatives to hospital outpatient appointments. However, there are challenges for organisations and individuals, and this is unlikely to be a quick fix or suitable for all patients and clinicians.  The key findings include: 
  • By the end of this study, between 2 and 22% of consultations were being undertaken remotely by participating clinicians.
  • Video consultations worked well for people recovering from liver or pancreatic cancer operations as it avoided the need for them to travel. 
  • Ad hoc Skype appointments were thought to be successful in a service for adults and young adults with diabetes. Formal outcomes were not available. 
  • There were organisational challenges, and implementation took longer than expected, was more complex and included real or perceived issues with information governance. 
  • Video consultations were welcomed by some clinicians but not others.
  • Though policy makers were supportive of increased use of technology and believed it would lead to efficiency savings, there were limited resources for piloting and training.   
Enhanced recovery programmes after stomach cancer surgery reduce hospital stay without increasing complications
This commentary, from NIHR signals dicusses a meta-analysis that combined the results of 13 randomised controlled trials comparing outcomes for people after stomach cancer surgery with enhanced recovery (ERAS) or usual care.  The meta-analysis reinforces the evidence base supporting the UK policy of enhanced recovery programmes after most gastrointestinal surgery including stomach cancer surgery. It may also inform decision-making in hospitals where enhanced recovery is not in place or has not been implemented for stomach cancer surgery.  

Clinical Pharmacists (CPs) in General Practice: Pilot Scheme Evaluation
This executive summary, from the University of Nottingham,  presents an overview of the requested research questions and how they were answered including a review of current literature, methods, breakdown of data by type and an overview of the findings responding to the research questions. The findings of the mixed methods evaluation include: 
  • CPs have made a unique and valuable contribution to the primary care skill mix.
  • Costs and effects of the role were outlined. There remains some mismatch between GPs’ expectations of ROI and both the depth of cost and length of time for returns to be realised.  
  • CPs integration and availability in practice is important for continuity of care.
  • The CP in general practice role is already causing variance and potentially gaps in the wider pharmacy workforce. 
  • If integration of pharmacists into general practice is to be successful there is a need to be flexible to develop their roles based on individual general practice needs whilst performing within a recognised competency framework. 

New work from The Strategy Unit

Making the case for integrating physical and mental health services in England - National overview
This is a national overview report of the Strategy Unit's "Making the case for integrating physical and mental health services" reporting which took place in 2017. 
The original reports looked at the physical health of people who use mental health services; life expectancy, acute hospital use and opportunities to improve service quality and efficiency.  There are bespoke reports for each of the 44 STPs in England available here.  
We want to hear from you!

We welcome your feedback about this update, or if there is a specific area of evidence you would like covered that would benefit commissioning decision making and/or service transformation. E: or T: 0121 612 1538. 
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