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 55 -  June 2018

This month in Evidence insights: 

New Guidance from NICE

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

Clinical guidelines
Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and  over [NG36] | Dementia: assessment, management and support for people living with dementia and their carers [NG97] | Hearing loss in adults: assessment and management [NG98]

Technology Appraisals
Arsenic trioxide for treating acute promyelocytic leukaemia [TA526] | Atezolizumab for treating locally advanced or metastatic urothelial carcinoma after platinum-containing chemotherapy [TA525] | Brentuximab vedotin for treating CD30-positive Hodgkin lymphoma [TA524] | Midostaurin for untreated acute myeloid leukaemia [TA523] | Pembrolizumab for untreated locally advanced or metastatic urothelial cancer when cisplatin is unsuitable [TA522] | Guselkumab for treating moderate to severe plaque psoriasis [TA521] | Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease [TA217] | Beta interferons and glatiramer acetate for treating multiple sclerosis [TA527] 

Quality Standards
Spondyloarthritis [QS170]

New Commissioning Tools

Making Every Contact Count (MECC): How NICE resources can support local priorities
Making Every Contact Count (MECC) is an evidence-based approach to improving people's health and wellbeing by helping them change their behaviour.  The approach enables health and care workers to engage people in conversations about improving their health by addressing risk factors such as alcohol, diet, physical activity, smoking and mental wellbeing.  NICE has developed a suite of practical resources to navigate relevant NICE guidance, standards, tools and shared learning on NICE website.   

NHS RightCare Scenario: Sepsis
This Scenario, produced with the NHS England-led Cross-system Sepsis Programme Board, demonstrates the opportunities to reduce the unwarranted variation in sepsis care.  This document is intended to help local health economies understand the implications on quality of life and costs of shifting the sepsis pathway to deliver evidence-based excellence.  

Work, worklessness and health: local infographic tool
This tool, from Public Health England, includes a slide set with regional and local level data relating to work, worklessness and health for each county or unitary authority in England.

New Commissioning Guides

Childhood obesity: a plan for action, chapter 2
This guidance document, from Public Health England,  presents Part 2 of the government’s plan for action to significantly reduce childhood obesity by supporting healthier choices.  It outlines the actions the government will take towards its goal of halving childhood obesity and reducing the gap in obesity between children from the most and least deprived areas by 2030.  

Health matters: reproductive health and pregnancy planning
This guidance, from Public Health England, provides a resource focusing on reproductive choice and ensuring that pregnancy, if desired, occurs at the right time and when health is optimised.  

The Improving Access to Psychological Therapies Manual
This guidance manual, from NHS England has been produced to help the IAPT programme improve delivery of, and access to, evidence-based psychological therapies within the NHS.  The manual is for all commissioners, providers and clinicians of services that deliver psychological therapies. It describes the IAPT model in detail and how to deliver it, with a focus on the importance of providing National Institute for Health and Care Excellence (NICE)-recommended care.  The accompanying resource pack provides commissioners and providers with examples of positive practice and resources to support IAPT service expansion, development and delivery.

People with dementia and learning disabilities: reasonable adjustments
This guide, from Public Health England, is intended to help staff in public health, health services and social care to ensure that their services are accessible to people with learning disabilities who may have, or be developing, dementia.  

Developing pathways for alcohol treatment
This guidance, from Public Health England, is about developing pathways for referral and care and for patients whose routine alcohol screening in secondary care suggests that they may be alcohol dependent.  It can be used by people implementing the Preventing ill health by risky behaviours – alcohol and tobacco CQUIN in acute, mental health and community trusts. It can also be used by NHS commissioners and planners and those planning, commissioning and providing community alcohol treatment.  The guidance aims to:
  • Show the components of treatment for dependent drinking
  • Describe what helps patients’ smooth passage through their treatment for alcohol dependence 

Implementation - New 'know-how'

Integrated care: organisations, partnerships and systems 
This report presents findings of an enquiry, undertaken by the  Health and Social Care Committee, into Sustainability and Transformation Partnerships (STPs), Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs).  The report suggests priorities for change including recommendations of legislative changes that may need to be considered.  

Developing new care models through NHS vanguards
The report, from the National Audit Office, examines whether the NHS is well placed to get value for money from its investment in developing new care models through vanguards. In particular, it focuses on:
  • Set up and management of the vanguard programme 
  • National support and evaluation
  • Progress made by the vanguards 
  • Readiness for the spread of these new care models 
This report focuses primarily on the two types of vanguards which were designed to test integrated models of health and social care for a local population: integrated primary and acute care systems (PACs) and multispecialty community providers (MCPs).  

Unleashing Healthy Communities
This summary report, from Bromley by Bow Insights, presents the experiences from the Bromley by Bow model.  These includes; stories development of the model, impact of the model in relation to staff and volunteer work and the community context.  The report draws on evidence from approximately 4000 hours of embedded, ethnographic, research as well as 62 interviews, 46 workshops, 3 exhibitions, and 500 comments that the community research team collected from fellow residents and also presents a conceptual framework for further evidencing the Bromley by Bow model.  

The role of cities in improving population health: international insights
The report, from the Kings Fund,  draws on case studies and interviews with local leaders in 14 world cities including New York, Madrid and Copenhagen to find new ways of tackling public health challenges in England. It finds that the same characteristics that make cities engines of growth, innovation and creativity often lead to inequalities and concentrations of poverty and ill health.  The report highlights the role that further devolution could play in boosting public health and reducing health inequalities. It calls on the government to consider extending further tax-raising and regulatory powers to cities and finds that international cities which have stronger powers have been able to use them to have a positive impact on the health of their populations.  

Driving improvement: Case studies from 10 GP practices
These case studies, published by the Care Quality Commission, presents findings from interviews conducted with 10 GP practices that had achieved a significant improvement on their rating.  The experiences of GPs, practise nurses, clinical staff, practice managers, administrators and patients highlight the actions that helped them learn and improve.  

Taking the value-based agenda forward: The five essential components of value-based approaches to health and care
This paper, from NHS Confederation explores the challenge of how to take value-based healthcare to the next stage and embed it across the whole system. It aims to support those across  the health and care system who are working to embed value-based approaches in their organisations and across their health and care systems.  It explores five key characteristics/factors to support the wholesale adoption of value-based healthcare approaches. These are:
  1. Learning and adapting through the adoption of innovation
  2. Managing risk
  3. Making best use of data
  4. Thinking about pathways across the whole system
  5. Listening to patients

Transforming care: the challenges and solutions
This report, from Volunatry Organisations Disability Group (VODG), outlines the challenges and solutions to moving people with learning disabilities, autism and/or mental health conditions out of long-stay inpatient care.  The learning comes from the Provider Taskforce’s; the London Demonstrator project which was commissioned by NHS England. The primary aim of the pilot was to develop support assessment and proposals for 27 people originally from London who have been in inpatient settings for longer than five years.

The state of care in urgent primary care services
This report, from the Care Quality Commission (CQC), presents findings from the CQC programme of comprehensive inspections of urgent care centres, NHS 111 services and GP out-of-hours services.  It presents common themes and characteristics from inspections, including the perspectives of both providers and voluntary groups representing patients.  

Making the money work in the health and care system
This report, from PwC and HFMA, sets out why the current complex system of funding flows do not support the proposed new models of more integrated care introduced in the Five-year forward view and therefore need to change. It proposes that; 
  • Financial flows should be aligned with the emerging place based architecture, 
  • Systems should be provided with more clarity through longer-term funding and 
  • Money should be focused towards achieving better outcomes. 
It presents a number of detailed recommendations are made covering both long and short term, including the restructuring of debt, system-wide control totals, the capital regime, certainty over long-term funding and outcome based payment systems. 

The NHS at 70
To mark this anniversary, the BBC asked the Health Foundation, Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust to look at five central issues currently facing the NHS. These issues are the relative strengths and weaknesses of the national health service, its funding, the state of social care, the public’s expectations of the NHS, and the potential of technology to change things in the future. Five separate briefings, supported and informed by opinion polls, that looked into these five issues, were published as follows: 
  1. How good is the NHS?
  2. What’s the problem with social care, and why do we need to do better?
  3. Does the NHS need more money, and how could we pay for it?
  4. Are we expecting too much from the NHS?
  5. What will new technology mean for the NHS and its patients?

IPC and Personal health budget support and development programme: Learning and next steps
This report, from the Voluntary Voices consortium, was commissioned by the Integrated Personal Commissioning (IPC) Programme through NHS England.  It summarises the experiences of those organisations collaborating to deliver Personal Health Budgets and proposes next steps to enhance collaboration.  Its is based on input from Clinical Commissioning Groups and voluntary and community sector organisations.  

New Research 

Importance of accessibility and opening hours to overall patient experience of general practice
This analysis of repeated cross-sectional data from a national patient survey examines associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours.  The study finds patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience.

A recipe for action: using wider evidence for a healthier UK
This collection of essays, from the Health Foundation, explores trans-disciplinary approaches too improve the public's health.  The selection of essays are written by individuals from a diverse range of industries and specialisms reflecting on the case study of child obesity.

Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions
This study, aims to describe and classify the components of the burden of treatment for patients with chronic conditions from the patient's perspective. This qualitative study gathered data from patients with different chronic conditions, in different contexts and countries. This taxonomy is presented described;
i) the tasks imposed on patients by their diseases and by their healthcare system
ii) the factors that exacerbate the burden associated with these tasks
iii) how these tasks affected patients’ lives 

Innovative models of general practice
This report, from the Kings Fund, looks at innovative models of general practice from the UK and other countries and seeks identify key design features in designing effective GP services in the future.  It sets out five attributes that underpin general practice: person-centred, holistic care; access; co-ordination; continuity and community focus. 

Behind the Headlines: the battle to get care at home
This report, from Age UK, presents the experiences from queries from older people and families asking questions about social care at home on Age UK's information and advice line.  The issues highlighted included; 
  • Long waits to get an assessment
  • Services that are disjointed or simply unresponsive
  • Social services refusing to get involved
  • Fundamental lack of capacity in the system
  • Poor quality services and support
  • Support and services being cut back
  • Help for families providing care being withdrawn
Listening to our future
This report, from the Health Foundation, is the first report from the 'Young people’s future health inquiry' a research and engagement project that aims to build an understanding of the influences affecting the future health of young people.  

Implementing new models of care: Lessons from the new care models programme in England
This paper, from Anna starling on behalf of the Health Foundation, presents findings from interviews with leaders in the vanguard sites and draws on the literature on cross-organisational change and improvement.  It presents a framework of 10 lessons for health and care leaders seeking to develop and implement new models of care. The framework emphasises the importance of developing relationships and building capability locally to enable areas to continuously develop and test new ideas.  

From programme theory to logic models for Multispecialty Community Providers (MCPs)
This realist synthesis, by Rod Sheaff et al in the NIHR Health Services and Delivery Research journal, uses policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and compares this with published secondary evidence to revise the programme theory accordingly.  The paper finds multidisciplinary teams(MDTs) are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. It suggests further primary research would be required to test elements of the revised logic model, in particular about;
  1. How MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks
  2. Under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

Reducing emergency admissions 
This parliamentary report, suggests where some progress may be made by the NHS in reducing emergency admissions this has not an impact on the emergency admissions that could have been avoided, it suggests  hospitals, GPs, community services and social care need to work together more effectively to prevent emergency admissions to hospitals. 

Mental health, human rights and standards of care (2018)
This publication, from the Worlds Health Organization (WHO), examines and rates the quality of care and protection of human rights in selected institutions in over 20 countries in the Region using the WHO Quality Rights toolkit. It identifies steps to take to continue progress toward deinstitutionalization and to ensure respect for the rights of people with psychosocial and intellectual disabilities.  

Delivery and impact of the NHS Health Check in the first 8 years: a systematic review
This review, by Adam Martin et al in the British Journal of General Practice, presents findings of a systematic review and quantitative data synthesis of 26 observational studies and one data set.  It found that since 2013 45.6% of eligible individuals received a health check.  Coverage was higher amongst older people, those with a family history of coronary heart disease, those living in the most deprived areas, and some ethnic minority groups. Uptake was found to be higher in older people and females, but lower in those living in the most deprived areas. Attendance was associated with small increases in disease detection, decreases in modelled cardiovascular disease risk, and increased statin and anti-hypertensive prescribing.

New work from The Strategy Unit

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis
This realist synthesis, from members of the Strategy Unit team and Andrew Booth from School of Health and Related Research (ScHARR) University of Sheffield, was funded by the National Institute of Health Research (NIHR). The report; 
  1. Articulates the underlying programme theories for the Multispecialty Community Provider (MCP) model of care
  2. Identifies sources of theoretical, empirical and practice evidence to test the programme theories
  3. Explains how mechanisms used in different contexts contribute to outcomes and process variables.
The report concludes that MCPs can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working. 

Horizontal or Vertical: Which way to integrate?
This case study report co-authored by Dr Robin Miller (Health Services Management Centre, University of Birmingham) discusses the approaches to community services integration and consequences for emergency hospital activity.  In 2010 The Transforming Community Services policy required a complete break of commissioner and provider functions, where PCTs considered what to do with the community health services they delivered; vertically integrate with an acute trust, horizontally integrate with a mental health trust, or set up a stand-alone community trust or Community Interest Company.  This report explores the impact this choice had on the level and growth in emergency hospital use in older people and considers the wider implications for the NHS as it develops new models of care and integrated care systems.

Risk and Reward Sharing for NHS Integrated Care Systems
Risk and reward sharing is a key feature of the policy agenda for Accountable Care Organisations in the US and Integrated Care Systems in England. It offers commissioners the opportunity to co-opt and incentivise a provider to moderate growth in healthcare demand by sharing in the savings or cost over-runs. The Centers for Medicare and Medicaid Services (CMS), a US government agency, has established a comprehensive approach to risk and reward sharing for US Accountable Care Organisations: the Shared Savings Program.  This paper draws out the central themes from the Shared Savings Program and translates these into an NHS context.
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