1. The nitty gritty detail of integrating complex systems

    17 Apr 2014

    Recently, on one of my clinical general practice days, I made 21 phone calls to a London hospital trying to leave a message asking a consultant to call me urgently. A patient I had seen at 9am had decided not to have a disfiguring operation for a cancer that was planned for 10 days later.

    I needed urgent advice about the options for reconstructive surgery so that I could have an informed discussion with her during the following week about the choice she had made. Had she understood the facts about her condition? The consequences of refusing treatment? Time was of the essence: I...

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  2. Informing the public on information

    17 Jan 2014
    Comments: 27

    Most of the services we receive nowadays (be it internet shopping, high street banking or health care) have a trail of data associated with them. We’ve come to expect that these trails will be used to help future interactions be more efficient for us and/or those providing the service.

    This applies as much to public as private sector services – though we’ve also come to expect that the public sector lags well behind the private sector when it comes to IT matters.

    In many cases this perception of the public sector is probably true (any luck making a GP appointment online...

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  3. Come again? What the data tells us about repeat A&E visits

    9 Jan 2014
    Comments: 5

    The BBC’s research, published yesterday, on frequent users of A&E makes for interesting reading. They found that nearly 12,000 people made more than 10 visits to the same unit in 2012/13, and a small number of those attended more than 50 times. This is an eye catching finding and it is important to consider what those numbers might actually mean.

    While the 200,000 attendances used by people attending A&E more than 10 times a year is a big number, it represents just a tiny fraction of the 14 million total attendances at...

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  4. Virtual reality: observations from the Nuffield Trust study of Virtual Wards

    6 Nov 2013

    Implementing new models of care is not easy – and especially so when organising community-based services that aim to tackle the challenges of more chronic disease and greater levels of emergency care.  

    One of the more interesting approaches of the past few years has been the Virtual Ward and we recently published a report, funded by the National Institute for Health Research Service Delivery and Organisation Programme, looking at three early examples of Virtual...

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  5. The future of pharmacy: just do it

    5 Nov 2013

    All too often in discussion of the NHS, pharmacy is seen as something of a niche concern. General practitioners, consultants, nurses and even managers loom large in parliamentary debates on the future of health care, in newspaper articles and the public mind.

    Pharmacists, meanwhile, punch well below their weight in policy and management circles despite being the third largest health care profession.

    The innovative, often inspiring services I saw as chair of the Royal Pharmaceutical Society’s...

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  6. A new start for the Care Quality Commission?

    12 Aug 2013

    Today we publish our response to the Care Quality Commission’s (CQC) consultation on changes to the way it inspects, regulates and monitors care services: A New Start.

    Our response builds on the findings from our review of provider ratings, commissioned by the Secretary of State for Health, as well as drawing on the expertise of various members of our team with a past in regulation.


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  7. Back to first principles: primary care for the future

    18 Jul 2013

    Looking back over recent blogs about primary care written by Jonathan Tomlinson, Clare Gerada, John Macaskill-Smith and Helen Parker, three things stand out.

    First, there is consensus that general practice is under significant pressure, struggling to meet demand from patients, blamed for contributing to the alleged crisis in accident and emergency care, and exhorted to reassume responsibility for out-of-hours patient care.

    Second, the ‘special sauce’ of general practice – the relationship between a patient and their family...

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  8. Community-based interventions: how do we know what works?

    26 Jun 2013
    Comments: 2

    Over the past four years the Nuffield Trust have been asked to look at a range of service innovations and assess whether they lead to a change in service use – most typically a reduction in inpatient hospital activity, which is something that seems to have become the holy grail of health service planning.

    Our new report summarises observations from our studies and efforts that might help those planning and evaluating new services in the future. In particular, the report should provide useful learning for the new...

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  9. Reconfiguration versus re-election: public expectations and health reform

    (Guest blogger)
    24 Jun 2013

    Clinicians and health service administrators can often identify ways of reconfiguring services, particularly hospital services. These reconfigurations usually appear to deliver improved outcomes but prove hard to sell to a sceptical public. On these occasions, local politicians are urged to be brave and support such moves.

    All too often though, the politician is found fanning the flames of popular discontent and those inside the NHS look upon them with varying degrees of sympathy, bewilderment, despair or contempt. The situation is actually made worse if health insiders believe that...

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  10. Would we know it if we saw it?

    30 May 2013
    Comments: 6

    A week after the Government's integrated care pioneer programme kicked off, the evaluation of North West London's integrated care pilot was published. The ingredients of the pilot were sensible, for example: investment in IT, risk stratification and targeting of high risk patients, leadership, coordination of multidisciplinary groups, and project management.

    The results so far: high commitment by professionals; greater collaborative working across teams and with social...

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  11. Transforming general practice: GP providers thinking big

    23 May 2013

    General practice seems to be considered by politicians and the media as both the cause of and solution to the current crisis in demand for urgent and emergency care.

    At the same time, the primary care community is recognising that the current business model of general practice is under threat due to increased demand by patients, growing regulatory workload and, for some this year, significantly less income.

    From discussions with GPs and policy makers, there appears to be some consensus that the current ‘small scale’...

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  12. How primary care providers can rise to the challenges of the public health agenda

    (Guest blogger)
    25 Apr 2013

    The release today of a crucial report written by the Nuffield Trust, commissioned by the National Association of Primary Care (NAPC) sets out the challenges that face primary care and general practice.

    In particular, the report looks at moving from a purely curative and reactive based approach to patient care, to one that is balanced against making significant inroads into the reduction of the rise in chronic ill health set against the backdrop of an ageing population.

    As the NHS struggles to meet unprecedented financial efficiency...

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  13. Preparing for the 'new' NHS: lessons from departing leaders

    28 Mar 2013

    Never in the field of NHS re-organisations can so many have left so few. Well, not literally. But April 1 sees some 160 NHS organisations, including all primary care trusts and strategic health authorities, abolished as hundreds more – 211 clinical commissioning groups plus a clutch of new national bodies and their regional arms – come formally into existence.

    The result is what must be an unprecedented turnover of NHS chief executives. Some retiring, some moving on to other jobs, some taking redundancy, some leaving the direct employment of the service, some willingly, some not....

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  14. Should there be 'Ofsted-style' ratings for health and social care providers?

    22 Mar 2013
    Comments: 2

    This was the question set by the Secretary of State.

    We’ve been there before, and the added value of previous ratings relative to the costs is not clear either way. Nor indeed is the potential for ratings to have an impact in the future if there were improvements in its design and use.

    So what might ratings add today? There are two obvious gaps.

    First, there is currently no independent comprehensive assessment of quality across all providers and across the full spectrum of performance. Second, there is nothing...

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  15. Clinical commissioning groups: ready for take off?

    1 Mar 2013
    Comments: 1

    As clinical commissioning groups (CCGs) prepare for 1 April, one has to wonder how ready they really are to take full responsibility for local strategic planning and purchasing of health care.

    The coming year will be one of immense challenge in terms of the quality and safety of health care, particularly in light of the Francis Inquiry’s call for a fundamental change in NHS culture.

    And all of this at a time when NHS funding is flat and the NHS Commissioning...

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  16. Principles matter: reforming social care funding

    11 Feb 2013

    There is almost universal agreement that the social care system needs urgent and fundamental reform. Despite this consensus the various attempts at reform over the last 20 years have all stalled.

    Against that background Andrew Dilnot could have been considered either brave or foolhardy to accept the Government’s request to head the latest commission on reforming social care funding in 2010. Last year when it looked like the Government was planning to kick funding reform into the long-grass once again, the evidence pointed towards...

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  17. Mergers, 24/7 working and ratings – mind the gaps

    30 Jan 2013
    Comments: 1

    The queasily thin amount of experienced medical cover in some hospitals at nights and weekends was the subject of BBC Radio 4's File on 4 last week. Juniors missing key symptoms and signs, not wanting to bother a consultant out of hours, with occasional tragic results or at best near misses.

    Suggestions for remedy included making consultants work 24/7 rotas. I sympathised with the experienced paediatrician who predicted that would be the last straw for many who have given their all for the NHS over many years.


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  18. Size versus quality? Examining hospital mergers

    (Guest blogger)
    16 Jan 2013
    Comments: 5

    Hospital mergers and reconfiguration are increasingly centre stage in the NHS. Several years of financial austerity, with more in prospect, is placing severe stress on hospital finances. The ability of hospitals to deliver the necessary annual cost reductions (in the order of five per cent per annum) through tactical savings schemes is fast diminishing.

    Instead, more radical options for cost saving are being considered, including merger and major reconfiguration – as evidenced by the Department of Health’...

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  19. The accountable lead provider: making integrated care a reality?

    (Guest blogger)
    19 Dec 2012

    The current exam question for commissioners charged with ensuring the sustainability of the NHS is 'how can we make sure the NHS delivers integrated and sustainable services?', or as patients and their carers are more likely to describe it – 'who will make sure that we get properly joined-up care that will meet our needs going forwards?'

    Providing integrated or joined-up care is an important challenge. However, it is not the only challenge and if effective co-ordination of care is to play a major role in sustaining the NHS, commissioners will also have to...

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  20. Pursuing nirvana

    27 Nov 2012
    Comments: 3

    At last! We found evidence of an intervention which improves quality and reduces hospital costs. Is it telehealth? No! Is it greater competition? No!

    It is care by Marie Curie at the end of life. People receiving the home-based Marie Curie Nursing Service were more likely than matched patients to die at home, according to their wishes, rather than in hospitals, and less likely to have unplanned hospital care.

    This was our first excursion into examining the impact of home-based care from the 'third' sector – hopefully the first of many.


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