Now showing items 21-40 of 74

    • Learning from lockdown: support for people experiencing homelessness

      Caswell, Rachel; Battye, Fraser; Callaghan, David (The Strategy Unit, 2021-02)
      There are few clearer measures of societal health than homelessness. On this count, and despite its enormous material wealth, England is in poor shape. Relative to the recent past, and any country we might want to compare ourselves to, we have a problem with homelessness. The causes of homelessness are undoubtedly complex. But the above comparisons show that the problem can be addressed: policy choices make a difference. This was shown in dramatic fashion last March with the Ministry of Housing, Communities & Local Government decision to house people rough sleeping (‘Everyone In’) in response to the first national lockdown. So Lockdown 1 was a period of great policy innovation. It was also a time of radical service innovation as health and social care services responded to a world of social distancing, remote working and PPE. At that time many Strategy Unit projects were focused on what could be learnt from this period of innovation. What changes were being made? Which changes seemed to be an improvement on pre-lockdown practice? Which ones were a step back? Which needed more evidence and further study? We were asked these questions so frequently, we produced a Guide to working through them. It was a great privilege to be asked by NHS England & Improvement to examine these questions in relation to the service response for people experiencing homelessness. Alongside this, we were also asked to look at how data collection and use could be improved. The reports below contain the detailed results of this work. These results resonated strongly with similar projects from Groundswell, St Mungo’s and Crisis. Above and beyond the results set out in the reports, we also found that: Innovation was taking place on the frontline. Changes made by services were pragmatic responses to changes in circumstance; they were not done in response to plans from ‘on high’. Policy is now running to catch up with practice. Existing problems were exposed. Data were patchy and weak; services were often strained (and sometimes unwelcoming). These pre-existing weaknesses came more sharply into focus. The hope is that temporary measures to cope with the crisis – less hiding behind ‘IG’ for example – can be now nurtured into everyday practice. The basic right of access to healthcare, that has too often eluded those experiencing homelessness, is assured. While seeing that standard administrative data was lacking, we found that it was possible to gather near live information from people experiencing homelessness. We joined forces with (the excellent) Groundswell to bring together our work on services’ experiences with their peer-led work looking at people’s experiences of this support. This combination proved powerful and we shared many lessons during a session at our INSIGHT 2020 festival. The NHS can be criticised for its approach to addressing health inequalities. The hope here must be that the inequalities exposed by Covid draws a fuller and better response in future. Recent reasons for this hope include: the content of NHSE/I’s ‘Phase 3 letter’, which focused heavily on inequality; the recent appointment of Dr Bola Owolabi as Director of Inequalities; and the energy shown by Olivia Butterworth, who led NHSE/I’s response to homelessness. Homelessness is a source of shame for our society. The best way to improve outcomes is not to tweak services, but to prevent the problem. But while homelessness remains, the NHS must feel a sense of duty and responsibility to do the best it can do, and to work closely with local government and the voluntary sector in support of this. This work gave us the chance to combine personal interests and passions with professional skills. It was part of the Strategy Unit’s ongoing commitment to addressing health inequalities and we relished the chance to contribute to a significant and vital agenda. We look forward to working with others to do so again in future.
    • Reviewing the evidence on digital inclusion

      Aldridge, Shiona (The Strategy Unit, 2021-04)
      Digital technology is a significant part of our daily lives. It has changed the way we interact with each other, the services we use, and the ways we work. The NHS is no exception. Digital technology has begun to change the way health and care services are delivered. And the Covid-19 pandemic radically accelerated the use of these technologies – speeding the transition to delivering remote care, for example. Every technological change brings advantages and drawbacks. The best uses of new technology will realise the gains while minimising the risks: both sides of this equation need to be identified and planned for. Widening inequalities is a widely cited risk. A significant proportion of people are currently digitally excluded, meaning they are unable to engage in digital care. Furthermore, people who are digitally excluded are more likely to be socially disadvantaged and already experience health inequality. So how can we reap the benefits of digital health while not worsening inequalities? What barriers do digitally excluded people face, and how can they be overcome? We have published an evidence signpost and an evidence scan on digital inclusion covering such questions (links below). This work was commissioned by Hereford and Worcestershire ICS prior to the Covid-19 pandemic to help support their ‘Primary Care Accelerator Programme’. Findings are likely to be of use to others planning digital health care. Please get in touch with any comments or questions by emailing
    • Socio-economic inequalities in access to planned hospital care: causes and consequences

      Wyatt, Steven; Parsons, Jake (The Strategy Unit, 2021-05)
      Tacking inequalities in health is a long-standing NHS policy objective. Variation in the experiences and outcomes of different communities during the COVID-19 pandemic served to bring this issue back into focus. In the Summer and Autumn of 2020, as the first wave of the pandemic subsided, concern grew about reduced access to routine hospital care: diagnostics, outpatient care and planned surgery. Waiting lists and waiting times began to grow. The network of Decision Support Units in the Midlands recognised the potential for this issue to exacerbate existing inequalities. They jointly commissioned this analysis to explore the extent, causes and consequences of socio-economic inequalities in access to planned hospital care. The recent NHS Planning Guidance emphasises the importance of identifying and tackling these inequalities. The report has four objectives: To describe socio-economic inequalities in access to planned hospital care To identify where in the patient pathways these, inequalities in planned care emerge To explore potential drivers of these inequalities To explore whether poor access to planned care in some communities leads to increased demand for unplanned care. The report builds on earlier research, advancing our understanding in some key areas. Although further analysis may certainly add benefit, this report is sufficient to support some immediate and targeted actions. We look forward to working with the network of Decision Support Units in the Midlands to improve the outcomes for people living in the most deprived parts of the region.
    • Measuring the effect of the coronavirus pandemic on population health

      Seamer, Paul (The Strategy Unit, 2021-07)
      One feature of the pandemic has been the fast-flowing stream of facts and numbers about the impact of Covid-19. At the same time, we’ve had to absorb the meaning of terms that were previously the preserve of epidemiologists and public health professionals. This has made it hard to see the ‘real’ story. There has been so much information – some of it seemingly contradictory – that, at times, we have all found ourselves struggling to understand why advice has changed or numbers differ. And now, as we (hopefully) move out of the pandemic itself, there is an important societal and political process of reckoning. In approaching this, the task of explanation will be aided by a solid, factual foundation. So this report examines some basic questions: How many people have died from Covid-19? How many more people have died from the wider impact of the pandemic, including policy responses? How many years of life have been lost to Covid-19? Were most victims of Covid-19 going to die of other causes within a short timeframe? What has been the effect of the pandemic on life expectancy? We walk carefully and neutrally through these questions, using data to help provide answers. In each case, we explain the strengths and limitations of the different sources of data, and how choice of methods might lead to different results, before implementing a set of public health and actuarial techniques to deliver a rounded assessment of the pandemic’s effect on population health. Initiated as part of the Analytical Collaboration, this report is our contribution to establishing a solid, empirical basis for learning from the pandemic:
    • Risk and Reward Sharing for NHS Integrated Care Systems

      Wyatt, Steven (The Strategy Unit, 2018-06)
      Risk and reward sharing is a simple and attractive concept, offering a commissioner the opportunity to co-opt and incentivise a provider to moderate growth in healthcare demand by sharing in the savings or cost over-runs. The Centers for Medicare and Medicaid Services (CMS), a US government agency, has established a comprehensive approach to risk and reward sharing for US Accountable Care Organisations: the Shared Savings Program. This paper draws out the central themes from the Shared Savings Program and translates these into an NHS context. The rationale that underpins the development of Accountable Care Organisations in the US and Integrated Care Systems in England is similar: to moderate healthcare costs through service coordination and integration. However, US ACOs and English ICSs are vastly different in scale (on average, US ACOs provide services to c. 19,000 enrolled patients) and operate in radically different political, financial and cultural contexts. In the US, ACOs are required to sign up to one of three risk-sharing ‘tracks’. Track 1 is a one-sided risk-sharing model where providers have the potential to share in savings if priced activity falls below expected levels, but are not required to pay a share of any cost over-runs. Tracks 2 and 3 are two-sided models, exposing providers to an increasing proportion of upside and downside risks. Six years since the first ACOs were established more than 90% of ACOs remain on track 1. This suggests that to date, providers have a limited appetite for risk. It also offers some insight into the level of confidence that US ACOs have in their ability to moderate demand growth. Complexity is a key feature of any robust risk-reward sharing arrangement and is likely to increase transaction costs above those associated with fee-for-service arrangements. The complexity arises as the commissioner or system designer attempts to ensure that the incentives accurately reflect the policy intention, and do not instead reward cost shunting, quality reductions or chance variations in costs. It is possible to extend risk-reward sharing to multiple partners within an Integrated Care System and to organisations outside the scope of an ICS. But these extensions add further complexity. The notion of a ‘counterfactual’ is central to risk-reward sharing. In this context a counterfactual is the price of healthcare activity that might be expected under normal circumstances. It is the benchmark against which priced activity levels are assessed at year end. If priced activity falls below this level, then the provider may be entitled to a reward payment. If it exceeds this level, then a penalty may be applied. There are many approaches to calculating and agreeing counterfactuals, but none are simple. These calculations determine the allocation of significant sums of money. If the NHS is to make best use of risk and reward sharing, then it must be aware of the complexities and hazards inherent in these arrangements as well as the potential benefits.
    • Outcomes based commissioning: A framework for local decision making

      de Lacy, James; Frith, David (The Strategy Unit, 2020-04)
      The Strategy Unit has developed a local decision-making framework to empower systems as they look to design new contracting approaches aimed at improving outcomes. It is free to use for all NHS and Third Sector organisations. The NHS Long Term Plan (LTP) calls for a shift to a new service model with patients receiving joined up care, at the right time and in the most optimal care setting. Central to achieving this will be the health and care system working together in alignment and coordinating resources towards these shared goals. The LTP also sets the NHS’s priorities for outcomes and quality improvement for the next 10 years. It is unlikely that any single provider will be able to achieve these outcomes alone. Progress will instead be dependent upon the work of a range of organisations across health, social care, local government, the third sector and beyond. Local systems will need to design approaches to contracting and payment that align with their approaches to quality and outcomes improvement, and that reflect the population covered, the scope of services and the associated provider configuration. Without that alignment, the risk of conflicting incentives and ineffectual interventions is high. In the absence of a nationally-determined approach, each local system should determine how it will proceed. This resource provides a framework, based on relevant national guidance and the international evidence base, to support local decision-makers embarking on a new approach. The framework guides systems in: Confirming system aims and objectives; Determining the scope of populations and services to be included in contracts, and the priority outcomes; Determining the local provider configuration model; Assessing the appropriateness of the mechanisms available for – Allocating resource to providers, and Generating improvement in quality and outcomes; Understanding the drivers of system behaviours likely to operate as a result of, or independent of, those mechanisms.
    • Changes in Dementia Incidence, Prevalence, Severity and Mortality

      Hood, Andy (The Strategy Unit, 2017-09)
      Dementia is a key priority for NHS England and is estimated to affect around 676,000 people in the country. Our analysis is intended to help understand the need for future dementia diagnosis and treatment services in a specific area and to help commissioners to identify and prioritise interventions.
    • Palliative and End of Life Care Report for Children and Young People

      Jones, Andrew; Wiltshire, Justine (The Strategy Unit, 2018-04)
      Commissioned by NHS England, this report describes the the characteristics and levels of resource required by children and young people (CYP) (0-25 years) with life limiting conditions and/or life threatening conditions (LLC). The scope of this report does not attempt to explain or address the complexity of life threatening conditions and palliative end of life care for children and young people; it does however highlight a new and emerging population of significance for the NHS in England. People aged 0-25 span both paediatric and adult services, Clinical Commissioning Groups and Specialised and Direct Commissioning. It is much reported that there is a broad and complex age transition period in this cohort and this report therefore covers this whole period. This report draws on information from a range of primary sources including Hospital Episode Statistics (HES), Secondary Users Service (SUS) and ONS population projections and death registrations to provide intelligence on the prevalence, acute utilisation and characteristics of these complex patients. Also available is a companion report commissioned by NHS England describing the status and context of palliative and end of life care services in the West Midlands, it may be helpful and provide additional context to read these two reports in conjunction. The main chapters of the report focus on; Chapter 2 – Prevalence analyses – Identifies CYP with an LLC registered with a GP practice in the West Midlands who have been in contact with hospital services since April 2006. The chapter examines how prevalence has changed over the past decade and summarises the cohorts by demographics and condition characteristics. Chapter 3 - Acute healthcare utilisation – Identifies and summarises all acute hospital activity in HES for the cohort including A&E, Inpatients and Outpatients. Activity is identified whether it is related to the LLC or not, and is described in terms of overall trends and demographic and condition characteristics between 2011/12 and 2015/16. The cost of activity by CCG, STP and provider is also summarised in this section. Activity in the 12 months prior to death has been examined at each point of delivery for those who died in 2015/16. Chapter 4 – Historical deaths and forecasts - Examines the trend in deaths for all CYP in the West Midlands (0-25 years) over the past decade and compares this to deaths in our cohort. Deaths for all CYP are forecasted until 2022/23.
    • Palliative and End of Life Care in the West Midlands

      Wyatt, Steven (The Strategy Unit, 2017-10)
      Commissioned by NHS England, this report describes the status and context of palliative and end of life care services in the six Sustainability and Transformation Partnerships in the West Midlands. The report contains data on trends and forecast numbers of deaths, place of death, palliative care registers, acute healthcare use prior to death, availability of specialist-level palliative care and summarises the results of recent palliative care reviews and audits. The number of deaths in England has reduced year on year since the early 1980’s despite increases in population size. In 2011 there were four hundred and fifty thousand deaths in England, lower than at any point since the NHS was founded, but since 2011 the number of deaths per annum has increased and ONS forecast that this upward trend will continue for the foreseeable future with a 25% increase in annual deaths by 2039. This implies that demand for end of life care has been comparatively low in recent years but will rise considerably in the years ahead. Hospital remains the most common place of death, although all parts of the West Midlands have seen decreases in the proportion of deaths in this setting. There are now five thousand fewer deaths per year in hospital than in 2006. A very large proportion of deaths from frailty and degenerative conditions occur in either a hospital or care home setting. Without service redesign, we might expect these settings to experience most demand pressure as frailty deaths increase rapidly. Palliative care registers are intended to assist GP practices to manage the care of patients in their last 12 months of life and evidence suggests that patients on palliative care registers are more likely to receive well-coordinated care. Despite significant improvements in recent years, the number of patients on palliative care registers in the West Midlands falls well short of the expected number. Acute hospital utilisation increases significantly in the last 12 months of life. Despite unprecedented pressure on hospital beds, patients continue to receive non-beneficial treatments in hospitals in the last months of life. A&E attendances and emergency admissions rise sharply in the last year of life, often peaking in the month of death. In May 2017, there were 52 Consultants in Palliative Medicine working a total of 450 (half-day) sessions per week. One fifth of these sessions were delivered as part of a community palliative care team with the remaining sessions shared between hospitals and hospices. In their most recent CQC inspection,6 12 hospitals in the West Midlands received ‘Good’ ratings for end of life care. A further 6 were assessed as ‘requiring improvement’ and one was assessed as ‘inadequate’. All of the hospices in the West Midlands received a ‘good’ or ‘’outstanding’ rating in their most recent CQC inspection.
    • Health service use in the last two years of life

      Wiltshire, Justine; Battye, Fraser; Wyatt, Steven; Spilsbury, Peter (The Strategy Unit, 2020-10)
      Health and care services get just one opportunity to support people at the end of their life. When this support is compassionate and appropriate, unnecessary suffering can be avoided and grieving can be eased. When this is not the case, harm and distress can result. The difference in these experiences can be profound. Providing the best possible end of life care, within the limited resources available, is not a simple task. It requires a dispassionate assessment of the current situation; it demands detailed insight into the local population; and it needs the perspectives of professionals and the people they serve. Good care is founded on the intelligent use of this information. The Strategy Unit has produced a series of reports that describe the health services that patients use in the last 2 years of their lives. Reports are available for the Midlands region as a whole and for each of the 11 Sustainability and Transformation Partnerships (STP) or Integrated Care Systems in the region. The reports contain important insights into the services that patients use, how the patterns of service use change as patients approach death, differences in experience by ethnicity, deprivation and cause of death the costs of hospital treatment at the end of life and how this varies by STP levels of non-beneficial treatments the additional hospital capacity that may be required to accommodate the projected increase in deaths over the next decade These reports present a detailed account of ‘what is’. Moving on from this and deciding ‘what ought to be’ is a more complex undertaking. It involves professional judgement, evidence and clinical standards. But it also involves personal preference, values and cultural differences. Combining such diverse perspectives requires care, humanity, and skill.
    • The Effect of Demographic Change on Acute Hospital Utilisation

      Seamer, Paul (The Strategy Unit, 2015-12)
      Recognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.
    • Changes to Admission Thresholds

      Wyatt, Steven (The Strategy Unit, 2017-07)
      This analysis builds on a paper, Changes in Admission Thresholds in English Emergency Departments, which explores changes in the casemix of patients attending emergency departments (EDs) and the propensity of EDs to admit patients. The report incorporates additional analysis commissioned by NHS England, extending the scope of the analysis and refining the methodology.
    • Waiting Times and Attendance Durations at English A&E Departments

      Wyatt, Steven (The Strategy Unit, 2019-02)
      Waiting times in A&E have become the defining healthcare performance issue of our time, much like elective waiting times and hospital acquired infections have been in the past. Since 2004, the NHS in England has sought to ensure that patients spend no more than 4 hours in Accident and Emergency Departments. In recent years reported performance has deteriorated and, in the winter of 2017/18, almost one quarter of attendances at major A&E departments breached the target maximum duration. The decline in performance has been steady, sustained and almost ubiquitous. Attempts to restore performance levels have waxed and waned whilst the media’s interest in the target continues to grow. In 2018, NHS England announced plans to review all constitutional waiting times targets, reopening the intense debate about the value and impact of the 4-hour A&E target. Whilst there is no shortage of commentary on the subject, there have been few detailed analyses of the factors that are driving increases in A&E attendance durations and 4-hour breaches. In the absence of clear causal explanations, responsibility for ‘poor performance’ is often levelled at A&E departments, with implications of poor management and inefficiency. This report presents a detailed review of the demand-side, supply-side, practice and emergent factors that lead to 4-hour breaches with a particular focus on changes that have taken place since 2010. The report reviews both commonly cited causal factors and a range of more novel hypotheses. It sets out the causal theories underpinning each factor and seeks statistical evidence in support of them. Finally, the analysis scales the relative impact of each causal factor and aims to provide an explanation for the recent deterioration in A&E waiting times within the limits of national datasets. New insights emerge which have the potential to reshape the received wisdom about the performance of A&E departments, carrying important implications for healthcare policy and system leadership.
    • Modelling Patients Flows under Potential Configurations of Emergency Centres with Specialised Services

      Wyatt, Steven (The Strategy Unit, 2015-07)
      Onsite, 24/7 access to complex vascular surgery, hyper acute stroke services and primary percutaneous coronary interventions are expected to be a pre-requisite for a hospital to be designated as an emergency centre with specialised services. This paper sets out the patient access and patient flow implications of reconfiguring and centralising these three services within the West Midlands.
    • Change on Acute Hospital Utilisation

      Seamer, Paul (The Strategy Unit, 2015-12)
      Recognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.
    • Unplanned admissions: rapid evidence scan

      Turner, Alison; Aldridge, Shiona (The Strategy Unit, 2016-04)
      The summary builds on our previous work exploring interventions to reduce unplanned admissions (Aldridge and Turner, 2013) and provides an update of the literature published since 2013. In the interests of time, this review has focused on secondary research only, in the form of syntheses of evidence and systematic reviews. This helps to ensure a focus on research-based findings which have been tested and validated; however, learning from practice may offer valuable lessons, particularly on new and emerging approaches, if highly contextual.
    • Referral management: rapid evidence scan

      Aldridge, Shiona (The Strategy Unit, 2016-10)
      This rapid scan of the evidence base on demand management formed part of a broader analysis of the current challenges and opportunities to manage demand, specifically within the context of a primary-care led model. The aim of the review was to identify relevant research and practice-based evidence to inform an overall approach to demand management.
    • Integrated Impact Assessment for Major Hospital Reconfiguration

      Frith, David (The Strategy Unit, 2016-11)
      The Strategy Unit worked as a strategic partner of the NHS Future Fit Programme in Shropshire and Telford and Wrekin from its initiation and until it was able to move to public consultation. A key output was a comprehensive Integrated Impact Assessment of acute hospital options that enabled commissioners to make a unanimous decision in a very sensitive context. This included an additional focus around women’s and children’s services.
    • Future Fit - Acute hospitals options appraisal

      Frith, David (The Strategy Unit, 2016-11)
      The Strategy Unit worked as a strategic partner of the NHS Future Fit Programme in Shropshire and Telford & Wrekin from its initiation and until it was able to move to public consultation. A key output was the comprehensive appraisal of acute hospital options, the recommendations from which were unanimously approved by a Joint Commissioning Committee of two CCGs with their partners.
    • Stage 2 Clinical Assurance Evidence Framework

      Frith, David (The Strategy Unit, 2017-06)
      Service change assurance exists to give confidence to the NHS and public that proposals are well thought through, have taken on board a wide range of views and will deliver real benefits. At the heart of the NHS England assurance process are the ‘five tests for service change’ that are in the government’s mandate to NHS England, as updated in Next Steps on the Five Year Forward View. One of these five mandatory tests is that a clear clinical evidence base underpins service change proposals. Working with Clinical Senates nationally, the West Midlands Clinical Senate commissioned the Strategy Unit to develop this evidence framework in order to help sponsoring organisations ensure that they are building the required evidence from the outset, minimising the risk of any delay.