NHS international intelligence scanning service

Like the UK, many countries are adopting models of integrated care to effectively manage elderly patients with multiple, chronic health conditions. The OECD has produced a new report examining 13 integrated care models in OECD and EU27 countries. Many findings are relevant to the NHS, and echo those of the recently published Hewitt Review of Integrated Care Systems in England. 

Key policy recommendations include:

• Governance: strengthen governance structures by breaking down inter- and intra-organisational silos. 
• Financing: existing payment models such as payment by activity do not encourage coordinated care, therefore new innovative payment models are required that support integration. 
• Workforce: invest in training programs to teach staff the hard and soft skills required for collaboration, and develop new professional roles specific to integrated care. For example, Poland has recently introduced specialist care coordinators. 
• Digital: digital tools are key to integration, but both patients and professionals must be supported to develop digital literacy. 
• Evaluation: to identify what works in integrated care, quality indicators should measure what matters and be comparable between countries. 
• Equity: there were few policies specific to vulnerable and deprived populations in the countries examined. Going forward, data-driven approaches should be used to create tailored interventions to address health inequalities.
• Scaling-up: as best practice in integrated care is shared between organisations and systems, effective dialogue and partnership is required to share ‘lessons learnt’.

Although structural racism and implicit bias pervade all parts of healthcare systems, these can have a particularly profound impact on the life trajectory and health of younger patients. This article by The Commonwealth Fund explores how paediatric care providers in the USA are addressing these factors, offering lessons for NHS organisations providing paediatric care to vulnerable communities.

In high-stress medical settings, Black families are more likely to be labelled as ‘aggressive’ by healthcare professionals. Instead of security as a first port of call, Children’s National Hospital in Washington, D.C., has established teams of social workers trained in conflict resolution, who successfully deescalated 84% of 216 such cases. Additionally, Wayne State University School of Medicine has established a Health Equity and Justice in Medicine training programme for internal medicine and paediatrics residents. This uses critical discussion and community engagement to help residents understand the wider socioeconomic disadvantages the communities that serve face. In a similar vein, Akron Children’s Hospital in Ohio is engaging with disadvantaged communities to identify areas of improvement. This has led to the training of over 500 employees in how to respond to suicide ideation, which is widespread in Black and Hispanic adolescent populations. 

Outside the hospital, researchers at the Feinberg School of Medicine are investigating how adverse childhood experiences (including racism) affect long-term cardiovascular health. Building on a randomised controlled trial demonstrating the health benefits for children with chronic health conditions of Housing Prescriptions (priority placements in affordable housing), Massachusetts is developing pools of housing vouchers for patients with significant medical needs. 

In April 2022, member states of the World Health Organisation formally endorsed the WHO acceleration plan to stop obesity. The WHO has just published the health systems component of this plan, the "Health service delivery framework for prevention and management of obesity". This sets out how to effectively organise and integrate services for the prevention and management of obesity, across different age groups, at the levels of self, community, primary, secondary and tertiary care. Although many of these strategies will be familiar to healthcare leaders in the UK, the framework was co-designed alongside clinical experts and healthcare systems seen as frontrunners, therefore may serve as a useful benchmark for NHS obesity services. As recent work published by the NHS Confederation highlights, obesity is overtaking smoking as the leading cause of preventable death in England and Scotland, therefore poses a significant challenge to the NHS (and will only be exacerbated by the rising cost of living). 

Drawing mainly from a case study of an Australian virtual hospital, this article explains how virtual hospitals provide one solution to the overwhelming pressures facing many healthcare systems worldwide. It grounds this argument in a description of the typical patient journey through a virtual hospital, and provides a 4-step general framework that NHS managers could consider when deciding whether to move hospital services online. 

Virtual hospitals have three main advantages:

• Expanded bed capacity: McKinsey’s analysis of Australian state-run hospitals suggests that 11% of inpatient admissions could be virtualised, freeing up beds in traditional ‘brick-and-mortar' hospitals. 
• Greater patient satisfaction and outcomes: patients prefer the convenience and flexibility of care at home, and this is also associated with reduced readmission rates, greater improvements in quality-adjusted life years and lower rate of hospital acquired infection. 
• Lower costs: independent of bed capacity and outcomes, virtual hospitals were found to have a cost of $1000 less per episode of care than traditional hospitals, primarily due the ability to scale up clinician-to-patient ratios. 

When considering a virtual hospital, the authors propose a four-step process:

1. Explore the feasibility of setting up a virtual hospital: in particular, define patient cohorts who will be targeted for at home care. This involves identifying Diagnosis Related Groups (groups of patients with a condition that lend itself to virtual treatment). Also consider funding environment, characteristics of local geography, and existing at home care arrangements.
2. Define a framework for measuring success: taking into account the hospital’s baseline, define the metrics (e.g. patient experience, financial impact) of success.
3. Assess readiness to begin implementation: determine maturity milestones required to begin treating patients virtually, in areas such as digital capabilities and clinical pathways. 
4. Plan to increase efforts: as the virtual hospital becomes more mature, develop a plan to increase the scale of this service – for example to new Diagnosis Related Groups or over a larger geographical area. 

One of the four core purposes given to Integrated Care Systems (ICSs) by NHS England is to ‘enhance productivity and value for money’. It is widely expected that ICSs will achieve this by shifting resources upstream; focussing on prevention and treating patients, who would traditionally be admitted to hospital, in the community by primary care.

An example of a similar upstream shift can be seen in the 2012 health reforms in Norway, which established Municipal Acute Wards (MAWs) within communities. These aim to treat exacerbations of chronic conditions and reduce admissions to general hospitals. This study exploited the staggered introduction of MAWs to determine the causal relationship between MAWs and general hospital admissions, finding a 3% reduction in acute admissions for the over-80 age group. On a population level, this is a significant result akin to widely accepted medicines like statins, therefore an important proof-of-concept of the effectiveness of integrated care. Furthermore, in her recent review of ICSs in England, Patricia Hewitt called for a move towards outcome quality indicators (and away from structure/process indicators) when judging the success of integrated care. The statistical methodology employed by the authors, which allowed them to isolate the impact of MAWs, may serve as an important guide for similar analyses within our healthcare system.

The Italian National Health Service is highly decentralised. The 19 regions and 2 autonomous provinces that make up the health service have legislative and executive powers, and oversee the financing, planning and provision of services at local level, delivered through Local Health Authorities. The role of central government is limited to mostly one of stewardship. Its role is to set the national benefits package and per capita budget in collaboration with the region, as well as defining health policy strategies. 

The Italian constitution currently allows for variation in the level of autonomy across the regions through a process called “differentiated regionalism”, which allows regions to exert, or not, different powers afforded them. New draft legislation from the Italian government proposes extending the autonomy of the regions, sparking a political debate and raising the potential for wider impact on the NHS (SSN).  

Areas that would see greater autonomy are: 

• Medical Education 
• governance and management of healthcare organisations
• Investment in building and technological capital, enabled by multiannual funding allocations

Find out more

A new scoping review published in the International Journal of Integrated Care, has assessed the evidence concerning the implementation of ICT-based tools with the purpose of integrating care for older adults. 

77 studies from 2000-2022 were identified for evaluation. These studies demonstrate that the implementation of ICT-based integration has supported the process of delivering care between patients and service providers, between independent service providers, and between clinicians. This was achieved through the establishment of 7 core elements:

• single entry point
• comprehensive geriatric assessment
• personalised care planning
• multidisciplinary case conferences
• coordinated care
• case management
• and patient empowerment

The authors conclude that despite the viewed benefits, the evidence and implementation of integrated care is far from complete and there remains a need to strengthen the supply of human resources, team training and collaboration, ICT systems and financial support to promote the wider use of ICT in integrated care.

In 2022, the New Zealand government passed the New Health Systems Act, removing the 20 District Health Boards (DHB), which, alongside 30 Primary Health Organisations (PHOs) and 12 Public Health Units (PHUs) were responsible for planning care at local level. The number and variation in scale of these organisations added significant complexity to the healthcare service and resulted in what was described by many as a ‘postcode lottery’. 

In a new article for "The Conversation", Professor Anna Matheson of Victoria University argues that it will take more than a reorganisation of the healthcare system to overcome this postcode lottery. Professor Matheson instead argues that the health inequality demonstrated by the postcode lottery is about an entire social system that influences health and is the result of policy systems that prefer blunt, siloed, distant approaches that work against learning and adapting as we go.

Professor Matheson points to the work of Māori, Pacific and other community organisations who have plugged the gap in health policy thinking and developed services to address wider socio-economic determinants through the provision of basic services, such as food and transport. Any reform needs to facilitate the further uptake of approaches like this across the health systems, by moving away from hierarchical, technocratic and historical approaches to organisations. New localities should instead be set up as learning systems that can respond to the changing contexts of the local population over the long term, she argues.

In this recent Rapid Review from the North American Observatory on Health Systems and Policies (NAO), authors examine and compare reforms to primary care models in relation to governance and financing in 11 jurisdictions within Canada and abroad.

Their findings, which were gathered through a systematic literature review and discussions with local experts, revealed wide support among general practitioners for policy reforms on a range of issues, including voluntary collaborations, interdisciplinary teams, and novel financing approaches. The authors conclude by detailing six policy considerations to assist decision makers accomplish primary care reforms in their jurisdictions. 

Patients from the LGBTQ+ community report negative healthcare experiences, such as healthcare professionals (HCPs) making assumptions about their identities and research shows that HCPs report not having enough knowledge to facilitate an open conversation with patients from the LGBTQ+ community, leading to patients feeling ignored.

This study aims to explore HCPs' experiences of supporting patients from the LGBTQ+ community. HCPs discussed how clinical practice could improve, for example, by developing more inclusive training that is specific to the HCPs' clinical group.

Published in "The Lancet", this new paper examines the socio-economic inequalities in cancer mortality within and between European countries.

The study found that everywhere in Europe lower-educated individuals have a higher rate of mortality for almost all cancer types compared to those classed as more highly educated. This is even true for northern European countries that have a long-established tradition of equitable welfare and social justice. In fact, for women there is a large and rising inequality across northern Europe (which includes England and Wales).

The study calls for measurement, monitoring and action upon socio-economic inequalities in cancer across Europe. It argues that inequities in the prevention, diagnosis, and treatment of cancer can be reduced by strengthening primary health care delivered in communities; equipping health-care professionals with skills and knowledge about how inequity influences cancer care; and implementing policies and programmes with more resources allocated to the most disadvantaged groups  

In a new policy briefing, the European Observatory on Health Systems and Policies argues that the growing focus on a Health in All Policies (HiAP) approach is limited because it is currently perceived as focussing on the benefits to the health sector, and not the mutual benefits of health and other sectors working together. This current out of step thinking limits the aims of governments to use HiAP as a vehicle for achieving Sustainable Development Goals (SDG).
The briefing shares six key messages that can help policy makers view HiAP as Health for All Policies: 

• Health in All Policies (HiAP) tends to focus on wins for the health sector but may not appeal to other sectors.
• Health for All Policies complements HiAP by drawing attention to win-win solutions for all sectors.
• Health co-benefits can be achieved directly, through improved health and health equity, and indirectly, through the impacts health systems and policies have on other areas of life.
• Identifying and quantifying practical health co-benefits is not easy but SDGs can help structure the way policymakers think about them.
• Good governance can help address the very real challenges of implementing and sustaining co-benefits.  
• Focusing on health co-benefits creates a chance to make real headway towards achieving SDGs and improving wellbeing more broadly.
   

In the early 1990s, Canada faced what many today might view as the antithesis of a problem: an oversupply of doctors. In the face of financial crisis and limited control over physician spending, Health Ministers from Canada’s Provinces and Territories commissioned economists Morris Barer and Greg Stoddart to report on medical resource policy. 

And the relevance to today? According to researchers at the University of Toronto, Barer and Stoddart's 50 recommendation where cherry picked by ministers. Instead of looking at physician supply through a long-term lens, where the requirement for physicians is influenced by factors including the care needs of the population, speciality and roles and responsibilities of other healthcare professionals, Ministers picked low hanging fruit that was easy to implement but less impactful than when delivered as part of a comprehensive package of interventions. 

This recent study from Canada presents a novel approach to measuring the performance of long-term care institutions during the pandemic, and identifies the factors behind their performance. Based on the findings, it proposes three areas for action that could inform federal, provincial and territorial government discussions on how to improve long-term care in Canada.

Instead of using the most common metric for measuring the performance of LTC institutions — the percentage of long-term care deaths relative to total deaths — the report measures the change in differential mortality between a non-pandemic year, 2018, and the first wave of the pandemic in 2020. Differential mortality compares deaths in institutions with deaths in similar age groups living in the community. This approach reflects the fact that the risk of dying in an institution is higher than in the community, even in non-pandemic years.

The report finds that the pandemic approximately doubled the risk of dying among residents of long-term care homes compared to comparable groups in the community.
It concludes that one third of the differential mortality can be attributed to factors determined by the way institutions are organised and funded, such as crowding, and a lack of adequate staffing and prevention and control practices. The remainder can be attributed to factors outside institutional control, including the higher COVID-related mortality risk among residents with certain underlying illnesses.

With the ongoing growth in digital and data led approachs to healthcare delivery, many governments, health systems and individual providers are considering how patients and citizens can be given greater access to their patient record. This can provide citizens with greater autonomy to manage their care and knowledge and control of how their data is used. 

Since January 2021 German sickness funds have also sought to provide patients with greater access to their electronic record. However, in two years just 1% of the insured German population is using their electronic patient record. 

A new paper, published in the International Journal of Integrated Care, identifies that despite national and international ambitions for investing more in electronic patient records, the feasibility of digital health projects is limited by contextual factors. In countries like Germany, high degrees of self-governance and federal structures can slow down and impede digitalisation. There are also cultural variations in attitudes towards digitalisation, such as concerns about data security and privacy. 

Colorectal cancer is one the most treatable cancers if caught early, but not enough people in Canada participate in regular screening. While screening programs for colorectal cancer are now in place in almost every jurisdiction, to date, no province or territory has achieved the 60 per cent screening target.

The low screening participation rate points to health inequities and barriers to access experienced by specific communities and also an overall lack of awareness in the general population when it comes to colorectal cancer.

However, with support from the Partnership Against Cancer, changes are underway across the country that will help programs expand their reach to populations with low colorectal cancer screening participation rates. With funding from the Canadian Partnership Against Cancer, five jurisdictions (Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, and the Northwest Territories) engaged communities to co-develop and implement evidence-based approaches for increasing colorectal cancer screening in their respective communities. So far, the results are encouraging, with some communities doubling their screening participation rates.

Good mental health is a vital part of people’s well-being and the COVID-19 pandemic brought renewed attention to its importance. However, discussions so far have not focused sufficiently on how governments should best monitor it at the broader population level.

This OECD report supports national statistical offices and other data producers in collecting high-quality measures of population mental health outcomes in a more frequent, consistent and internationally harmonised manner. It documents existing measurement practice across OECD countries, discusses the advantages and limitations of available measurement tools, and recommends priority measures to adopt in household, social and health surveys.

In the latest weekly podcast from "The Conversation", Kate Mulligan, Assistant Professor at the Dalla Lana School of Public Health in Canada, argues for the role of social prescribing in tackling the rise in loneliness seen across numerous nations.  

Dr Mulligan argues that whilst social prescribing may be a new approach, it is rooted in established evidence from other research which demonstrates that connecting individuals can help address some of their healthcare needs. Dr Mulligan points to harm reduction communities that have used the role of peer workers to create welcoming environments for individuals receiving treatment for drug use. 

Community engagement is seen as a method for overcoming entrenched inequalities and discrimination in the development, delivery and evaluation of healthcare services. By fostering trust and mutual respect, exposing unforeseen or unintended barriers to health, and improving program efficacy by accounting for the experiences of the people impacted by programs and policies, community engagement can promote equity.  

The Robert Wood Johnson Foundation has examined community engagement in the American healthcare context as a route to overcoming systemic inequalities and structural discrimination. Supported by case studies from the states of Virginia and Colorado, their research has three key findings:  

• Community engagement by nature is not a guaranteed tactic to advance equity. To actualise its full potential, community engagement must be designed with equity as its leading principle through engagement of diverse communities and accounting for power imbalances. 
• Transformational community engagement shares power with the community and is built on trust, transparency, and mutual accountability. 
• Shifting power to the community can be done in a variety of ways. In addition to sharing decision-making power with the community, increasing access to the decision-making process is key.  

The Italian national health system, like the NHS in the UK, is a predominantly publicly-funded health service, with Italy accounting for 74% of healthcare spending from public sources, compared to the UK’s 79%. The remaining spend comes from a combination of out of pocket payments (OOP) and private insurance. Similarly, the Italian health system is also seeing rising rates of regional inequality across Italy's 20 devolved health regions.

A new study published in "Health Policy" used the dataset of a large national company to record the use of private health insurance among its 200,000 to provide evidence for a growing regional variation in access to healthcare. The results demonstrated those employees enrolled in central northern regions and Metropolitan areas spent in the range of 30-60% more on healthcare services than their southern region and non-metropolitan counterparts. Read the full research.

In the lead up on the the Australian elections, the Labour Government of Anthony Albanese committed to establishing an Australian Centre for Disease Control (ACDC) with the prevention of chronic diseases as a core part of its mission. 

Chronic conditions are the biggest killer in Australia, contributing to nine in ten deaths, and the burden falls heaviest on the most disadvantaged, who are twice as likely to have two or more chronic conditions. This is only likely to grow further as many of the causes of chronic disease, such as obesity, are rising dramatically.  

A new paper from the Grattan Institute argues that changing course will require shifting policy focus from sickness to health, by encouraging more people to quit smoking, eat less sugar and salt, and exercise more and that Australian governments need to do more to prevent chronic disease before it starts. The report suggests that government is often distracted by urgent crises, or that vested interests in the tobacco, food and beverages industries use their financial power and political influence to stymie reform. 

The ACDC, the report argues, should advise federal and state governments on prevention strategies that work and set priorities for prevention research and that federal and state governments should commit to a new funding agreement for effective prevention programs identified by the ACDC and consider any regulatory changes it recommends. Additionally, the new ACDC must be independent, to keep governments on track.   

The International Hospital Federation Awards have been recognising excellence in hospitals and healthcare organisations around the world since 2015.

Last year, a new category was launched to recognise hospitals and health service providers which demonstrated excellence or outstanding achievements in ensuring the wellbeing and sustainability of healthcare workers through innovative projects or initiatives. 

In this podcast, Dr Lawrence Lai, Chairman of the IHF Awards Committee and Honorary Member of the International Hospital Federation, met with Dominic Tung, Assistant Director for HR Wellness at Tan Tock Seng Hospital, Singapore, to discuss his hospital's welfare programme which won the gold title for the Excellence Award for Healthcare Workers’ Wellbeing. 

Across the United States, only between 1% and 2% of total healthcare spend is dedicated to public health, which has contributed significantly to a rise in dissatisfaction and fall in public trust towards the public health system.  

The Commonwealth Fund has examined what might need to be done to restore trust in the fragmented public health systems of the United States and has profiled local initiatives that are working to build trust by listening to the needs of local communities. These initiatives don’t just focus on the traditional interventions of infection, disease and chronic conditions, but upstream factors such as transportation and unsafe housing.  

One example of these initiatives is the New Brunswick Health Housing Collaborative, which brings together county health departments, local health systems and community organisations to improve housing conditions for tenants in two neighbourhoods. The populations of the two neighbourhoods are 80% Latino, 40% immigrants and many Spanish speaking only.

The focus of the collaboration has been on the hiring of 12 Spanish speaking residents to serve as community health ambassadors. These ambassadors attend community events, churches, day centres and other community facilities to share information. In time, these ambassadors were able to earn the trust of the community and over 200 tenants allowed them to conduct inspections of their homes. Upon finding incidences of poor conditions, the ambassadors supported their residents to understand and exercise their rights. The Collaborative has also successfully changed the city’s housing policies by collating best practice in health-related housing policy and demonstrating how the city fell short of this.