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Sex, gender identity, and sexual orientation are key indicators of the demographic diversity in the United States. Sex and gender are often conflated under the assumptions that they are mutually determined and do not differ from each other. However, the growing visibility of transgender and intersex populations, as well as efforts to improve the measurement of sex and gender across many scientific fields, has demonstrated the need to reconsider how sex, gender, and the relationship between them are conceptualised. This in turn affects sexual orientation, because it is defined on the basis of the relationship between a person's own sex or gender and that of their actual or preferred partners. Sex, gender, and sexual orientation are core aspects of identity that shape opportunities, experiences with discrimination, and outcomes through the life course, therefore, it is crucial that measures of these concepts accurately capture their complexity.
Recognition of the diversity within the lesbian, gay, bisexual, transgender, queer, intersex, and other sexual and gender minorities - the LGBTQI+ population - has also led to a reexamination of how the concepts of sex, gender identity, and sexual orientation are measured. Better measurement will improve the ability to identify sexual and gender minority populations and understand the challenges they face. LGBTQI+ people continue to experience disparate and inequitable treatment, including harassment, discrimination, and violence, which in turn affects outcomes in many areas of everyday life, including health and access to health care services, economic and educational attainment, and family and social support. Though knowledge of these disparities has increased significantly over the past decade, glaring gaps remain, often driven by a lack of reliable data.
"Measuring Sex, Gender Identity, and Sexual Orientation" recommends that the National Institutes of Health (NIH) adopt new practices for collecting data on sex, gender, and sexual orientation - including collecting gender data by default, and not conflating gender with sex as a biological variable. The report recommends standardised language to be used in survey questions that ask about a respondent's sex, gender identity, and sexual orientation. Better measurements will improve data quality, as well as the NIH's ability to identify LGBTQI+ populations and understand the challenges they face.
Despite the diversity of the population, some 235,000 people experiencing homelessness (PEH) in Canada face a range of common challenges and stigma, such as access to healthcare services, including primary care. One method for overcoming this exclusion from health and care services is the provision of care in non-traditional settings, such as shelters.
Based on a review of academic and grey literature, as well as interviews with researchers and practitioners, the North American Observatory on Health Systems and Policies (NAO) has evaluated the delivery of services for PEH in these non-traditional settings and their report makes six recommendations:
- Foster positive interpersonal relationships between PEH and healthcare providers
- Include peer support workers and inter-professional team members to address the complex needs of PEH
- Establish a welcoming and inclusive environment to encourage primary care access and social connectedness
- Support system navigation and build connections to mainstream care to reduce barriers
- Enable collection and sharing of health information to improve care continuity and support evaluation of primary care programmes
- Adopt sustainable and adaptive funding models
The WHO has published the findings of a global horizon scan, conducted by a group of international experts in 2020-21, on emerging technologies and trends relevant to global public health. The group identified 15 new and emerging technologies and scientific advances that may have a significant impact on global health over the next two decades.
The priorities described fall broadly into three overlapping areas: changes in science and technology, changes in practices and broader societal and global trends and include vaccine distribution logistics, addressing disinformation and misinformation, and using emerging technologies such as AI, machine learning and wearables for purposes including app-based diagnostics, clinical support systems and antibiotic discovery.
Similarly to the UK, the Netherlands has recently implemented an opt-out consent system for the donation of organs. A public information campaign was implemented to inform citizens of the law change. However, as 29% of the Dutch population is considered to have limited health literacy (LHL), it is possible that the new legislation could have been implemented without meeting the information needs of a sizable proportion Dutch people.
To determine what these information needs might be, the Dutch Institute for Health Services Research conducted a series of workshops and individual interviews with citizens. The engagement found that current messaging materials were too hard and abstract. People with LHL require personal support to tailor general information to their personal situation, and practical help to register their choice. The research recommended that information on the opt-out scheme should address 5 key questions:
- choice options
- the role of partners/family
- impact on quality of care
- the process of organ donation
A new blog from the Institute for Healthcare Improvement (IHI), discusses two quality improvement programmes from Australia to improve birthing outcomes for women and babies. Both programmes, The Better Birth for Women Collaborative and Safer Baby Collaborative sought to combine the value of quantitative data with lived narrative to understand what was working well and what could be done to improve outcomes.
The blog describes how the sharing of personal stories relating to the impact of still births and perineal trauma (the focuses of the two collaboratives) with clinicians and improvement teams added a previously missing source of insight to the improvement process, that had the effect of motivating teams and adding focus to their improvement efforts.
Both collaboratives have also sought to embed this process of co-development into the quality improvement process by developing measurement strategies for the collaboratives with expert panels of individuals with lived experience of perineal tears or stillbirth, midwives, obstetricians, maternity service leaders, and improvement experts.
Dr Carlsten Engel, CEO of the International Society for Quality in Healthcare (ISQua), joined HealthManagement.org for a 20-minute interview on his experience of how healthcare organisations can improve patient safety.
Dr Engel discusses what he sees as the plateauing of improvements in patient safety of the last 10 years, with 10% of patients still affected by some form of medical error, 50% or which are preventable. He describes how this is the result of healthcare being a complex system which means changes in rules and regulations can only go so far in improving patient safety.
He goes onto explain how changes in culture can overcome the limitations of regulations. This could be the shift away from a culture of blame to a ‘just culture’ that acknowledges healthcare professionals are typically operating within the limitations of the systems; organisational leadership championing for a safety-first approach; or even regulators shifting their methodology from one of compliance to a narrative discussion with providers, which he notes the Dutch Healthcare Inspectorate have already implemented.
The Nuffield trust has recently completed research, commissioned by NHS England, to understand how other countries are approaching the challenge of growing waiting lists, resulting from COVID-19.
Nuffield’s work, recently summarized in the BMJ, has shown that across the 16 OECD and EU countries there has been some degree of disruption to elective care, no matter how well prepared the relevant health systems.
Despite this, the research points to a number of areas where the NHS is still able to learn from the approaches of other healthcare systems. For example, the research points to the the interconnection between elective procedures taking place in hospitals and primary, social and mental health care. A connection that has been recognised in the recovery plans of Austria and Portugal.
The research also places an emphasis on the role of workforce in recovering the elective backlog, and points to the renewed pay agreements that have taken place in France and Belgium as one of the many ways that this can be recognised.
Ultimately, the overall argument of the research is that elective recovery cannot be viewed as a standalone act to be undertaken in the acute setting, but recognised that it is influenced across all parts of the healthcare system.
Health Canada, the federal department responsible for improving the health of Canadians, has published a new report ‘Health of Canadians in a Changing Climate’.
The report assesses the latest research and knowledge to inform Canadians about the effects of climate change on health and health systems, populations most at risk from these effects, and the mitigating measures being taken in Canada. The report is designed to help decision-makers plan for the health effects of climate change and take action to reduce risks, as well as to empower individuals.
Patient-reported measures are a critical tool for improving policy and practice in mental health care. However, to date, the use of patient-reported measures in mental health care is limited to a small number of countries and settings—and there is a pressing need, both within and across countries, to consistently and effectively measure the effects and impact of care for patients who use mental health care services.
The PaRIS pilot data collection on mental health includes 15 data sources from 12 countries, collected over the course of 2021. While the scope of included data varied, the results demonstrate increased adoption of national and subnational efforts to capture patient-reported information in mental health care systems.
Analysis of data collected through the PaRIS mental health pilot, in general, shows positive patient-reported experiences of mental health care. The results also suggest improvement in patient-reported outcomes for those receiving mental health care services.
The Commonwealth Fund has added to its series of comparisons between the USA and other high-income countries, this time examining primary care. Whilst the comparison focusses on the US health system, the UK is included in the comparison and some of the data may be of interest to those in the NHS.
Of potentially most interest is the gap between the UK and other high-income countries when it comes to the scale of multi-disciplinary working. For example, whilst Sweden and the Netherlands report that 93% and 94% of primary care centres have in-house mental health practitioners, that figure is just 31% in the UK.
And there is a further comparison between the Israeli and Danish healthcare systems from the Israel Journal of Health Policy Research from the perspective of spending and health outcomes, with researchers asking why Israel has better health outcomes despite spending less on health than the Danes.
One of the oft-cited positives of the covid-19 pandemic was its initial freeing of the NHS from its usual incremental approach to change, allowing frontline workers to implement innovative changes to meet constantly evolving demands. As the pandemic evolved, focus was lent to collecting and evaluating these innovations, supporting and scaling them up where they were found to be of sufficient value.
This was not only true of the NHS, but almost all health systems. One such example came from the Allied Health Professionals Office of Queensland, where an Allied Health Professionals COVID-19 Innovation Register was established.
Recent evaluation, the summary of which has been published by the Australia Hospital and Healthcare Association, highlighted three key enablers which supported innovation. Firstly, an adaptive management style was employed that saw managers facilitating the implementation of innovation, followed by review and refinement. Secondly, a devolved structure of authority allowed key staff to make decisions at a level they had not previously experienced. And thirdly, the trust managers placed in their staff to make decisions, whereby felt confident making decisions and implementing innovative ways of working.
The WHO regional office for Europe, in collaboration with Exeter University, has launched a new knowledge hub dedicated to behavioral and cultural health.
Featuring videos, podcasts, reports, toolkits and other resources, on topics including mental health, cancer and vaccination, the hub will act as a one-stop shop for all best practice developed across the region.
The knowledge will be continually added to, and currently features a WHO research report on how to increase COVID-19 vaccination, case studies on the role of social media in promoting health access and healthcare, and how the Portuguese health system has maintained patient-centered diabetes care throughout the COVID-19 pandemic.
Despite their many differences, the Danish and English healthcare systems have their fair share of similarities. GP’s act as gatekeepers, NCDs are on the rise and delayed discharge is a constant challenge for patients moving between hospital and social care.
As a means of addressing the latter of these challenges, Denmark's Capital Region and its municipalities have introduced temporary twenty-four-hour accommodations (TTAs). TTAs, managed by nurses and nursing assistants, act as something of a halfway house for patients fit enough to be discharged from hospital but who are yet unable to return to their homes. Whilst TTAs can smooth the transition of patients out of hospital, an audit noted that for patients aged over 65, there was an increased risk of preventable readmission to hospital whilst in a TTA.
One of the identified causes of this overrepresentation was inadequate communication channels which resulted in inadequate sharing of essential information leading to ambiguity about diagnosis, treatment, medication and further care for TTA teams. Establishing an intersectoral ward round consisting of a medical specialist in general medicine, a nurse, a pharmacist, a biomedical laboratory technician and TTA nurse/nursing assistant was trialed as a potential solution to this poor communication. Where possible, the patients next of kin and GP were also included.
Whilst the ward round model was demonstrated as successful in managing this over representation of over 65s in readmission statistics, the model required an unsustainable amount of time for the professionals involved and significantly increased costs. The researchers concluded that improving mechanisms for information sharing between providers would be the most sustainable means of improving the TTA model for elderly patients.
The TTA model presents an interesting example of how service pressure related to discharge could be managed in the NHS. If considered for use outside of Denmark, the challenges highlighted in this paper can provide valuable guidance, and empashise the importance of information sharing between providers of care underpinned by interoperability.
In response to the high levels of community anxiety resulting from COVID-19, the Darling Downs region in Queensland, Australia, established the Vulnerable Communities Group (VCG) to address this anxiety through open lines of communication to help strengthen community resilience. This case study reports the evaluation of the VCG, plus lessons learned while establishing and running an intersectoral group, with stakeholders from 42 rural organisations, with high levels of socioeconomic disadvantage and non-communicable disease prevalence.
The 42 organisations represented came from government (state and local), NGO, academic and charitable organisations, including representatives from domestic violence, homelessness disability organisations, among others.
Recent surveying of medical residents in Israel has demonstrated a high prevalence of unhealthy lifestyle habits and the potential negative impacts this can have on patients. New commentary in the Israel Journal of Health Policy Research argues that these unhealthy lifestyle habits form during medical training, owing to a ‘hidden curriculum’ of customs, rituals and norms that are experienced alongside formal training. The most prominent of these are an emphasis on being worked hard and toughened up by senior clinicians.
The author argues that it is these components of the hidden curriculum that lead to a deterioration in students' own wellbeing and ability to empathise with and care for patients.
The author goes on to argue that there must be a re-alignment of the formal and hidden curricula by supporting students through the stresses of their education and training, and by equipping faculty members with the means of constructively assisting students to handle challenging situations through constructive feedback.
The Canadian providence of Quebec has been implementing policies over the past two decades with the intention of forming primary health care teams that integrates care for vulnerable patients living with complex health and social care needs. A new paper from the Health Reform Observer has summarised the key policies between 2000 and 2020 that have been instrumental in forming PHC teams.
It is common for healthcare professionals from high income countries to travel to low- and middle-income countries (LMICs) to support health care services, typically through short term medical missions (STMMs). There is criticism that these STMMs are typically a process in which the high-income country retains control and power, with little collaboration or agency with the low-income partner.
One means for overcoming this imbalance is the development of guidelines that provide the STMM with a greater degree of regulation, continuity and sustainability. However, these guidelines have also been criticised as being developed with a bias towards high income countries' staff and organisations.
In an attempt to go some way in resolving this, research published in Globalization and Health evaluates the current best practice guideline documents from the perspective of three countries: Honduras, Malawi and the Philippines.
Based on 118 interviews and two focus groups with host country stakeholders, nine of the current best practice guidelines were reviewed. The key themes that emerged from these interviews included collaboration and coordination between host and sender teams, a recognition that guidelines must be adapted to the cultural context, and a shift away from the provision of clinical care to one of capacity building, potentially through the establishment of long-term institutional/community partnerships.
Twenty-first century health systems must be built around data and information. An integrated health information system enables the secure flow of data to where it can be used, to provide information to strengthen integrated care delivery, enable public health monitoring and management, and foster medical and health research and innovation.
This report from the Organisation for Economic Cooperation and Development describes the requirements and the benefits of an integrated health information system, outlining the current situation in the Netherlands in the context of progress across OECD countries, and recommends legal, policy and operational changes to overcome barriers to the efficient exchange and sharing of health data and to establishing an integrated health information system.
Mental health services had to implement innovations at pace to ensure that some of the most vulnerable people in society could continue to access mental health support, while protecting service users and staff during the COVID-19 pandemic.
The NHS Confederation’s Mental Health Network and the International Initiative for Mental Health Leadership (IIMHL) have worked together to capture these innovations. In this series of case studies from ten countries, we find examples of how mental health services have implemented innovations in response to COVID-19.
A number of key themes emerged from the case studies:
- The advantages of digital platforms in improving access
- The importance of supporting the wellbeing of staff
- Using data and evaluation to drive improvements and make the financial case for innovations
- Benefits of co-producing services with services users and staff
- Lessons in how the availability of innovations are communicated
While the pandemic will leave behind significant and long-lasting effects, it will also leave a legacy of accelerated innovations, the learning from which will not be soon forgotten. These innovations will improve mental health services across the globe long after the impact of the pandemic has abated.
Like the NHS in England, the Italian health system is a publicly funded system contending with an ageing population and a growing burden of non-communicable disease (NCDs). It is estimated that 40% of Italians live with one chronic condition and over 20% live with 2 or more.
Whilst the Italian national health service is far more devolved that that of the NHS in the UK (in Italy the planning, organisation and delivery of healthcare is a responsibility of the regional government) it has gone on a similar journey of integration in recent years as a means of contending with the similar demands of an ageing population living with worsening health.
In a new policy paper, published in the International Journal of Integrated Care, researchers from the University of Bocconi have analysed the policies developed across ten Italian regions between 2014 and 2020 with the intention of improving population health, quality of care and patient experience for those living with chronic conditions, whilst also reducing per-capita cost. The paper sought to identify the key strategic trends across these ten regions and potential lessons for other countries pursuing integrated care.
The key integration trends identified across Italy are in no way dissimilar to the known requirements for making integration a success in the English NHS. Strategic developments in Italy since 2014 have focused on using population health management to understand the needs of the population, strengthening community-based primary care and the relationship between GPs and hospitals, as well as the interdependency between health and social care providers.
That said, the authors emphasise four key lessons that can be taken from the Italian example:
- The need to acknowledge the importance of social needs, as well as health needs
- The need to produce strategies that can be used by the whole population, not just those with chronic conditions
- The need to provide professionals with the ability to collaborate. This could be through the funding of dedicated roles like ‘nurse care management’
- The need to create physical and procedural ‘bridges’ between providers, settings and levels of care. One approach to this could include the colocation of different professionals and services, an approach that has had benefits in other countries already
The Italian example reflects much of what we already know in the UK, that to make integration a success we must move away from a health-based model that focuses on a single pathology, through to a model that recognises the full spectrum of patient need. Underpinning all of this is a requirement to remove barriers that would make any integration strategy an additional challenge for frontline professionals, instead of a opportunity to make their working lives easier.
At Banner University Medical Centre in Phoenix, Arizona, 20% of all visits to the Emergency Department are for older adults, with 10% (1200) of these resulting from falls. As such improving the outcomes and experiences of patients presenting to the Division of Geriatric Medicine as a result of falls is a key focus for the hospital.
In a new case study, Dr Nimit Agarwal, Director of the Division of Geriatric Medicine, explains how being a member of the Institute for Health Improvement’s (IHI) Age-Friendly Health Systems (AFHS) initiative has helped them see improvements in mobility, delirium detection and early palliative care utilisation where required.
Underpinned by the four M’s of the AFHS initiative - what matters, medication, mobility and mentation - Dr Agarwal and his team implemented a model called virtual acute care for elders (vACE).
Making use of meeting platforms like Zoom and MS Teams, vACE involves a daily round of all patients in the division over 70 years of age. Led by a geriatrician and attended by an multi-disciplinary team, including an administrative assistant, nurse, therapist, pharmacist and care manager, the vACE reviews data in the electronic health record (EHR), including reason for visit, living situation, ability to perform activities of daily living prior to admission, distance walked yesterday, distance of fall, and the results of 4Ms screenings. In addition to these vACE rounds, Agarwal’s team supplements their testing for mobility and mentation with increased rates of physical intervention and data collection, conducted by nursing staff.
Since its implementation in 2017, the success of vACE rounds have led to the roll out of trauma acute care for elders (TrACE) rounds across the entire Banner Health system.
Whilst these rounds have demonstrated benefits for both patients and provider, at a time when healthcare professionals are already overburdened, the interventions requirement for increased patient monitoring and data collection described in the case study may present a challenging cost benefit decision for NHS teams.
The American think tank, the Commonwealth Fund, have produced an analysis comparing the mental health needs and access to treatment of older adults (those aged over 65) in the United States and other high-income countries (HICs), including the United Kingdom. Whilst the comparison is focused on understanding the differences between the US and other HICs, the analysis does allow for some comparison between the UK and other HICs.
Of greatest interest will be the finding that the UK has the lowest percentage of adults aged over 65 who have received help from a professional when they experienced emotional distress, who are currently receiving treatment, or are seeing a healthcare professional to help manage depression, anxiety, or other mental health condition.
Whilst UK participation in the survey was low (a 7.2% response rate was achieved), the finding that just 22% of UK respondents reported having received care puts the UK at the lowest level of self-reported access of any country survey. This is in comparison to the top OECD comparators of Canada, Germany and New Zealand, which all reported over 40%, with the US at 66%.
The authors point to the potential for institutional barriers limiting access to care and the introduction of programmes such as ‘Wellness Together Canada’ (featured in the NHS Confederation Mental Health Network report) which provides free to use virtual mechanisms for assessment and delivery of mental health care as being a potential reason for the greater access to care seen in countries like Canada.
EuroHealth magazine's first edition for 2022 has plenty of interesting articles for NHS leaders to enjoy, including:
- Addressing backlogs and managing waiting lists during and beyond COVID-19
- Enhancing participatory governance in health systems
- Creating surge capacity and rethinking skill mix and
- Supporting and protecting health workers
Addressing backlogs and managing waiting lists during and beyond Covid-19 (co-authored by Sarah Reed, Senior Fellow, Nuffield Trust) examines the determinants of growing waiting lists and the policies utilised to tackle non-COVID demand, whist also maintaining capacity to treat COVID patients.
Despite patchy data, it seems clear that there has been some degree of delay in treatment for patients in all European countries (ranging from just 6% in Denmark through to 36% in Hungary). The same is true for returns to pre-pandemic activity levels, with countries such as the Netherlands and Sweden able to return parts of their elective system back to pre-pandemic levels in 2021. More starkly though, even in countries like the Netherlands where surgery has returned to pre-pandemic levels in 2021, it is estimated that medical procedures would have to be 11-14% higher annually than pre-pandemic levels to compensate for delayed care.
Given the predicted extent of the challenges facing all health systems then, it will come as no surprise that the authors identified a range of strategies being used to manage this demand. The common theme through all approaches is one of enhanced efficiency, whether it be through the greater use of telemedicine, provider or regional collaboration, the use of new systems to optimise scheduling of procedures, or enhancing the roles of professionals.
The central point of the authors argument though is that of workforce. Given the scale of the elective backlogs many health systems are presented with, it should be expected that the most effective solutions will need to be long-term. As many current approaches place additional strain on an already burnt out workforce, sustainable solutions will be those that place the health and wellbeing of professionals at their centre.
Originally developed in the US during the 1990’s, the role of the ‘patient navigator’ has proliferated across Europe. With this expansion has come a variation in terminology, scope and skill mix associated with the roles across health systems, with opportunities arising for healthcare professionals (such as nurses and social workers), but also for lay people with lived experience. Despite this variability, the underlaying principal of the patient navigator role has remained to help patients overcome the complexity of health and social care systems by removing barriers of access in order to increase the utilisation of and satisfaction with care.
To date, the use of patient navigators has been on a small scale and therefore the evidence of the roles' effectiveness is limited. However, available literature does point to improvements in access and the continuity of care for patients where the role is utilised, suggesting that it could have great benefits for the integration of services.
This new policy briefing from the European Observatory on Health Systems and Policies (EOHSP) has explored the use of patient navigators across OECD health systems. The Observatory's research identified three commonly used fields for patient navigators:
- Cancer care
- Translational care between providers
- Targeted services for the vulnerable and social disadvantaged
The patient navigator role has already seen some implementation in the UK. However, with growing backlogs of treatment and the current workforce challenge having been exacerbated by successive waves of Covid-19, the further expansion of patient navigators may provide support to patients, professionals and systems alike by providing a means of adding extra efficiency during a period of immense strain of the health service. Additionally, as the patient navigator role has the potential to draw from a range of professional groups and provide them new challenges and skills, the enhanced role could appeal to professionals seeking variation and opportunities for professional growth.
Any implementation does come with national and organisational challenges though. Whilst provider and system leaders may have little control over national funding, training and regulation, they are able to address the organisational barriers highlighted in the briefing.
One such example is the experience that implementation of new roles can create friction among the existing workforce. Leaders can help overcome the scepticism and poor understanding of the patient navigator role by various health care professionals - most notably physicians - which can impact uptake, by promoting clear and regular communication between professionals and establishing a shared understanding of professional boundaries and an appropriate supervisory structure.