Melbourne Institute of Applied Economic and Social Research - Research Publications
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ItemContemporary women's secure psychiatric services in the United Kingdom: A qualitative analysis of staff views(WILEY, 2017-11)UNLABELLED: WHAT IS KNOWN ON THE SUBJECT?: Three pilot UK-only Women's Enhanced Medium Secure Services (WEMSS) was opened in 2007 to support women's movement from high secure care and provide a bespoke, women-only service. Evidence suggests that women's secure services are particularly challenging environments to work in and staffing issues (e.g., high turnover) can cause difficulties in establishing a therapeutic environment. Research in this area has focused on the experiences of service users. Studies which have examined staff views have focused on their feelings towards women in their care and the emotional burden of working in women's secure services. No papers have made a direct comparison between staff working in different services. WHAT DOES THIS STUDY ADD TO EXISTING KNOWLEDGE?: This is the first study to explore the views and experiences of staff in the three UK WEMSS pilot services and contrast them with staff from women's medium secure services. Drawing upon data from eighteen semi-structured interviews (nine WEMSS, nine non-WEMSS), key themes cover staff perceptions of factors important for women's recovery and their views on operational aspects of services. This study extends our understanding of the experiences of staff working with women in secure care and bears relevance for staff working internationally, as well as in UK services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study reveals the importance of induction and training for bank and agency staff working in women's secure services. Further, regular clinical supervision should be mandatory for all staff so they are adequately supported. ABSTRACT: Introduction Women's Enhanced Medium Secure Services (WEMSS) is bespoke, gender-sensitive services which opened in the UK in 2007 at three pilot sites. This study is the first of its kind to explore the experiences of WEMSS staff, directly comparing them to staff in a standard medium secure service for women. The literature to date has focused on the experiences of service users or staff views on working with women in secure care. Aim This qualitative study, embedded in a multimethod evaluation of WEMSS, aimed to explore the views and experiences of staff in WEMSS and comparator medium secure services. Methods Qualitative interviews took place with nine WEMSS staff and nine comparator medium secure staff. Interviews focused on factors important for recovery, barriers to facilitating recovery and operational aspects of the service. Discussion This study provides a rare insight into the perspectives of staff working in UK women's secure services, an under-researched area in the UK and internationally. Findings suggest that the success of services, including WEMSS, is compromised by operational factors such as the use of bank staff. Implications for practice Comprehensive training and supervision should be mandatory for all staff, so best practice is met and staff adequately supported.
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ItemDoes paying service providers by results improve recovery outcomes for drug misusers in treatment in England?(WILEY, 2018-02)AIM: To compare drug recovery outcomes in commissioning areas included in a 'payment by results' scheme with all other areas. DESIGN: Observational and data linkage study of the National Drug Treatment Monitoring System, Office for National Statistics mortality database and Police National Computer criminal records, for 2 years before and after introduction of the scheme. Pre-post controlled comparison compared outcomes in participating versus non-participating areas following adjustment for drug use, functioning and drug treatment status. SETTING: Drug services in England providing publicly funded, structured treatment. PARTICIPANTS: Adults in treatment (between 2010 and 2014): 154 175 (10 716 in participating areas, 143 459 non-participating) treatment journeys in the 2 years before and 148 941 (10 012 participating, 138 929 non-participating) after the introduction of the scheme. INTERVENTION: Scheme participation, with payment to treatment providers based on patient outcomes versus all other areas. MEASUREMENTS: Rate of treatment initiation; waiting time (> or < 3 weeks); treatment completion; and re-presentation; substance use; injecting; housing status; fatal overdose; and acquisitive crime. FINDINGS: In participating areas, there were relative decreases in rates of: treatment initiation [difference-in-differences odds ratio (DID OR) = 0.17, 95% confidence interval (CI) = 0.14, 0.21]; treatment completion (DID OR = 0.60, 95% CI = 0.53, 0.67); and treatment completion without re-presentation (DID OR = 0.63, 95% CI = 0.52, 0.77) compared with non-participating areas. Within treatment, relative abstinence (DID OR = 1.50, 95% CI = 1.30, 1.72) and non-injecting (DID OR = 1.32, 95% CI = 1.10, 1.59) rates were improved in participating areas. No significant changes in mortality, recorded crime or housing status were associated with the scheme. CONCLUSION: Drug addiction recovery services in England that are commissioned on a payment-by-results basis tend to have lower rates of treatment initiation and completion but higher rates of in-treatment abstinence and non-injecting than other services.
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ItemHow do hospitals respond to price changes in emergency departments?(Wiley, 2019-07-01)Little is known about how prospective provider payment affects the provision of services led by unpredictable demand. We investigate hospital responses to a 32% increase in price for two treatments in emergency departments in England in April 2011 using data on 11,532,304 attendances (79 hospitals) between 2009/2010 and 2013/2014. We compare changes in the volumes of these two treatments to a treatment not attracting additional reimbursement using a difference‐in‐differences framework. Additional reimbursement led to 76% and 152% increases in the volumes of the two incentivised treatments. Hospitals received an additional £64.4 M between April 2011 and March 2014 for providing these treatments, of which 40% (£25.9 M) was attributable to the unanticipated hospital response to the price increase. We use time in treatment to distinguish real increases in treatment from reductions in undercoding or increases in upcoding. The association between the recorded receipt of these treatments and time spent in treatment was the same before and after the price increase, and there was no association between hospital‐specific increases in recorded treatment volumes and changes in treatment times. The persistence of the treatment time increment suggests the increase in recorded treatment was a real increase in provision of treatments.
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ItemAssociation between symptom duration and patient-reported outcomes before and after hip replacement surgery.(Wiley, 2020-03-01)BACKGROUND: Patients experience discomfort and compromised quality of life whilst waiting for hip replacement. Symptom duration may affect quality of life attained following surgery, but no population-level evidence exists on the impact of symptom duration on pre- and post-surgical outcomes. METHODS: National observational data collected before and after hip replacement surgery in England between 2009 and 2016 was used to investigate determinants of symptom duration prior to surgery, and the relationship between symptom duration and pre- and post-surgical patient-reported outcomes. Multivariable linear regression models were used to estimate associations between patient-reported outcomes and symptom duration, controlling for a range covariates. RESULTS: The sample included 209,192 patients; most (69%) experienced symptoms for 1-5 years. Few patients (14%) experienced symptoms for less than a year, for longer than 5 years (6-10 years (11%), or for more than 10 years (5%). Symptom duration decreased overall over the studied time period, and was shorter among males, older and less deprived patients. Patients with a symptom duration less than one year had better post-surgical pain and function (Oxford Hip Score: 0.875, 95% CI 0.777 to 0.973) than those with 1-5 years symptom duration in an adjusted model. Conversely, those with symptom duration exceeding five years had increasingly poorer post-surgical outcomes (Oxford Hip Score: 6-10 years -0.730, 95% CI -0.847 to -0.613; >10 years -1.112, 95% CI -1.278 to -0.946). CONCLUSION: Symptom duration prior to hip replacement has become more standardised in England over time but increasing duration remains a significant predictor of poorer outcome after surgery.
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ItemThe worse the better? Quantile treatment effects of a conditional cash transfer programme on mental health(Oxford University Press (OUP), 2020-11-20)Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries. Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects. However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness. We use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial. We estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer. We find that the cash transfer improves mental health on average by 0.1 of a standard deviation. The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect. These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity. Our results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health.
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ItemChanges in patient experience associated with growth and collaboration in general practice: observational study using data from the UK GP Patient Survey(Royal College of General Practitioners, 2020-12-01)Abstract Background For the last few years, English general practices — which are, traditionally, small — have been encouraged to serve larger populations of registered patients by merging or collaborating with each other. Meanwhile, patient surveys have suggested that continuity of care and access to care are worsening. Aim To explore whether increasing the size of the practice population and working collaboratively are linked to changes in continuity of care or access to care. Design and setting This observational study in English general practice used data on patient experience, practice size, and collaborative working. Data were drawn from the English GP Patient Survey, NHS Digital, and from a previous study. Method The main outcome measures were the proportions of patients at practice level reporting positive experiences of both access and relationship continuity of care in the GP Patient Survey. Changes in proportions between 2013 and 2018 among practices that had grown and those that had, roughly, stayed the same size were compared, as were patients’ experiences, categorised by whether or not practices were working in close collaborations in 2018. Results Practices that had grown in population size had a greater fall in continuity of care (by 6.6%, 95% confidence interval = 4.3% to 8.9%), than practices that had roughly stayed the same size, after controlling for other factors. Differences in falls in access to care were smaller (4.3% difference for being able to get through easily on the telephone; 1.5% for being able to get an appointment; 0.9% in satisfaction with opening hours), but were statistically significant. Practices collaborating closely with others had marginally worse continuity of care than those not working in collaboration, and no differences in access. Conclusion Larger general practice size in England may be associated with slightly poorer continuity of care and may not improve patient access. Close collaborative working did not have any demonstrable effect on patient experience.
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ItemVariability in size and characteristics of primary care networks in England: observational study(Royal College of General Practitioners, 2020-12-01)Abstract Background General practices in England have been encouraged by national policy to work together on a larger scale by creating primary care networks (PCNs). Policy guidance recommended that they should serve populations of 30 000–50 000 people to perform effectively. Aim To describe variation in the size and characteristics of PCNs and their populations. Design and setting Cross-sectional analysis in England. Method Using published information from January 2020, PCNs were identified that contained <30 000, between 30 000–50 000, and >50 000 people. Percentiles were calculated to describe variation in size and population characteristics. PCN composition within each commissioning region was also examined. Results In total, 6758 practices had formed 1250 PCNs. Seven hundred and twenty-six (58%) PCNs had the recommended population of 30 000–50 000 people. Eighty-four (7%) PCNs contained <30 000 people. Four hundred and forty (35%) PCNs contained >50 000 people. Thirty-four (3%) PCNs comprised just one practice and 77 (6%) PCNs contained >10 practices. Some PCNs contained more than double the proportions of older people and people with chronic conditions compared to other PCNs. More than half of the population were from very socioeconomically deprived areas in 172 (14%) PCNs. Only six (4%) of the 135 commissioning regions ensured all PCNs were in the recommended population range. All practices had joined a single PCN in three (2%) commissioning regions. Conclusion More than 40% of the PCNs were not of the recommended size, and there was substantial variation in their composition and characteristics. This high variability between PCNs is a risk to their future performance.
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ItemPay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research.(Kerman University of Medical Sciences, 2020-09-01)Pay-for-performance (P4P) is the provision of financial incentives to healthcare providers based on pre-specified performance targets. P4P has been used as a policy tool to improve healthcare provision globally. However, researchers tend to cluster into those working on high or low- and middle-income countries (LMICs), with still limited knowledge exchange, potentially constraining opportunities for learning from across income settings. We reflect here on some commonalities and differences in the design of P4P schemes, research questions, methods and data across income settings. We highlight how a global perspective on knowledge synthesis could lead to innovations and further knowledge advancement.
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ItemNo Preview AvailableRoad to Nowhere? A Critical Consideration of the Use of the Metaphor 'Care Pathway' in Health Services Planning, Organisation and Delivery(Cambridge University Press (CUP), 2020-04-01)Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring 'practice languages' is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor 'care pathway' is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as 'designing a pathway' may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.
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ItemWorking lives of GPs in Scotland and England: cross-sectional analysis of national surveys(BMJ Journals, 2020-10-30)OBJECTIVES: The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced. DESIGN AND SETTING: Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation. PARTICIPANTS: 2048 GPs in Scotland and 879 GPs in England. MAIN OUTCOME MEASURES: Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree'). RESULTS: Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes. CONCLUSION: Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.
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