Case Studies

A clinical review of drugs and treatments for the States of Guernsey

Solutions for Public Health was commissioned by the States of Guernsey to undertake an independent review to identify the extent to which new treatments recommended by the National Institute of Health and Care Excellence (NICE) were funded for Guernsey patients, and how the gap might be addressed to reduce health inequalities and improve health outcomes. Click the link to read the full case study. Case Study - SPH - Clinical Review for Guernsey

Evidence based case studies on reducing cardiovascular disease

SPH developed evidence-based case studies about programmes to reduce cardiovascular disease for PHE and the British Heart Foundation, by identifying successful initiatives worldwide. Programmes to identify and manage people at high risk of CVD were identified and their approach and research outcomes were assessed for relevance and applicability to a UK setting. Ten programmes were selected and a combination of methods used to collate information about the programmes including appraising published peer reviewed and grey literature and interviews with the research leads. The dynamic health systems framework was used to organise the relevant information into a case study template. SPH prepared a report, standalone case studies, presented a poster of the work at two conferences and worked with PHE to write a blog and article for dissemination. International Cardiovascular Disease Prevention case studies

An evaluation of a community organising pilot

SPH was commissioned by a County Council to evaluate a community organising initiative that had been operating across three electoral wards in a large local town.  The community organising project involved recruiting community leaders from local civic institutions to form a network.  The network engaged with their local communities to identify and prioritise issues impacting on health and wellbeing in the local area.  Actions to address the prioritised issues were developed and taken forward either by the network or by statutory agencies or both of these following a period of negotiation with community leaders.  The agreed actions were presented to the public at a specially convened event.  The County Council commissioned two external organisations to help establish the network and support its community organising activities. SPH completed a qualitative impact evaluation of the community organising project through a combination of face to face and telephone interviews with stakeholders and a document review.

An evaluation of a competency framework to facilitate genomic testing

Health Education England’s Genomics Education Programme (GEP) commissioned SPH to carry out an evaluation to understand early progress in the implementation of a competency framework. As the numbers and types of clinical staff involved in the process of offering tests to patients grows, the GEP has worked to help ensure that those staff have the knowledge and skills they need to maximise the benefits of genomic medicine.  To support staff involved in consent conversations, the GEP has developed a competency framework to facilitate and consent patients for genomic testing. Competency areas have been defined against which users can identify in which areas, if any, they feel they need to develop further knowledge or skills. SPH carried out an evaluation to understand the communications strategy, how early adopters were using the framework, any improvements they might suggest and to identify any enablers and barriers encountered by users.

Clinical Audit in Secondary Care

SPH was commissioned by an STP group of CCGs to carry out a clinical audit of secondary care providers undertaking a range of procedures. We deployed an experienced consultant clinician, utilising our audit tool to review hip and knee replacements, cataracts, grommets and spinal injections across a mix of NHS Trusts and non-NHS providers. Patient records were selected randomly from a data extract and the audit tool was adapted to take full account of the complex eligibility criteria for each procedure. Our consultant clinician engaged with provider consultants/surgeons, to discuss and agree whether or not there was evidence in the patient notes that demonstrated each patient met the eligibility criteria in the commissioning policies. The aim of the audit was to establish the non-compliance rate for each procedure and provider, and also to uncover the key reasons underpinning any systematic non-compliancy. The aggregated annualised value of non-compliant procedures undertaken across the five providers was substantial at £1.9m and ranged from 15% to 80% of the annual activity value of each provider.

Evaluation of the Discharge to Assess initiative ‘Home First’ for a Clinical Commissioning Group

SPH was commissioned by a CCG to evaluate a ‘Discharge to Assess’ initiative aimed at reducing the secondary care inpatient length of stay of elderly frail people who no longer have any medical needs. Home First is the name given to these Discharge to Assess schemes that aim to safely support the transfer and short-term recuperation of elderly people home. Once people are at home and have recovered as much as possible of their day to day functioning they can be assessed, if necessary, for on-going home care or transfer to residential care. The evaluation SPH undertook was based on a mixed model of quantitative and qualitative measures. It provided a number of functions including:
  • Providing a detailed understanding of all aspects of the initiative for commissioners
  • Linking the original strategic objectives of the initiative with the day to day experience of people providing the service in managerial and operational roles and the challenges they face
  • Linking the original strategic objectives with activity and cost of the initiative
  • Recommending improvements and a plan for future evaluation
The key outcome of the evaluation was to inform the commissioning of the service in the longer term and identify immediate actions needed to strengthen the service in the short term in order for it to play a significant role in easing winter pressures at the local hospital NHS Trust. For a more in depth look at the rationale behind Home First schemes see this article published by The Guardian on 10 October 2017: https://www.theguardian.com/social-care-network/2017/oct/10/home-first-model-aims-to-stop-patients-being-stranded-on-hospital-wards The Local Government Association website signposts to national guidance and some examples of local initiatives: https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/overall-approach/discharge-to-assess

Screening programmes; commissioning and co-ordination

Between 2002 and the NHS re-structure in 2013, SPH provided commissioning and public health support and advice to the commissioners of all cancer and non-cancer screening programmes across one region, including nine cancer screening programmes, two Diabetic Eye screening programmes and one Abdominal Aortic Aneurysm screening programme. SPH also supported all antenatal and new-born screening programmes in up to four NHS hospital trusts over an 11-year period. The types of activity that SPH undertook for this work included:
  • Supporting commissioners to meet the requirements and standards of national and local service specifications
  • Ensuring that all screening programme contracts are monitored regularly and action plans implemented where necessary to recover performance
  • Providing public health advice and expertise to commissioners and screening programmes about national and local policies, standards and pathways
  • Co-ordination of all relevant service providers along the screening pathway to support performance management of programmes
  • Identifying differences in access to screening programmes and developing actions to address them
  • Responding to enquiries from stakeholders
  • Participating in the investigation of serious untoward incidents and putting systems in place to ensure they are not repeated
  • Identifying and disseminating best practice

Individual funding requests

SPH have provided public health support and advice for individual funding request (IFR) processes in London and the East Midlands. This included reviewing case summaries, attending panel meetings and undertaking rapid evidence work to support potential service developments as a result of patterns of cases identified in IFR panels. Producing evidence-based guidelines SPH were commissioned to produce evidence-based guidelines on screening for adult non-communicable diseases (diabetes mellitus, chronic kidney disease and cardiovascular disease), and on the implementation of new-born and antenatal screening for an international health organisation. SPH developed the guidelines using a three stage process, encompassing literature reviews to identify policies in other high-income countries and the evidence base underpinning those policies, surveys gathering the views of clinical leaders and two interactive clinical engagement events with clinical leaders.

National evidence reviews

SPH produces a number of high profile rapid evidence reviews for national clients every year assessing the effectiveness and cost-effectiveness of a wide range of treatments or potential interventions. Rapid evidence reviews for NHS England SPH has produced rapid evidence reviews for NHS England Specialised Services since 2012. These high-profile reviews consider the clinical and cost-effectiveness of treatments and interventions for a variety of conditions. The requirements of this contract include:
  • Supporting development of research questions through liaison with the commissioner and senior stakeholders
  • Supporting development of a PICOS table
  • Liaising with a healthcare information scientist in Libraries to design the literature search
  • Reviewing abstracts and selecting papers according to the agreed methodology
  • Producing the review to an agreed template
  • Internal quality assurance
  • Consultation on the review with clinical specialists
  • Producing a final report following consultation comments.
  Commissioned evidence reviews We also produce bespoke evidence reviews to assist customers address specific commissioning issues, for example:
  • Reviews to inform national policy on population screening for the UK National Screening Committee
  • Reviews to inform strategy design for preventing alcohol exposed pregnancies through understanding the predictors of alcohol consumption and the effectiveness of interventions for Blackpool Better Start
  • A review on the development and use of early warning indicators in qualitative information for the Care Quality Commission
  • A review on the contribution of community pharmacy in supporting/delivering lifestyle interventions and health protection/prevention for the Pharmacy and Public Health Forum
  • A review on the impact and cost-effectiveness of self-management programmes on chronic disease management for a Public Health team.

Supporting Priorities Committees

Our work with Priorities Committees enables NHS commissioners to balance complex choices, backed up with independent evidence reviews and ethical frameworks. We provide an end-to-end service which includes the development of an ethical framework to inform the decision-making process, topic selection, evidence reviews, consultation with clinical specialists, operational support to priorities committees and drafting of clinical commissioning recommendations. We have also worked with commissioners around the country in developing and advising on setting up their own decision-making processes. We have experience of supporting commissioners in appeals against NICE guidance and in judicial reviews.

An evaluation of continuing fitness to practice pilot for GPhC

The GPhC recently implemented a new revalidation framework. After an extensive period of research and testing, they consulted on the proposed new framework. SPH supported the GPhC by evaluating their pilot of the new process.  After developing and testing our evaluation logic model with the customer, we used a mixed methods approach including phone interviews, an online survey, analysis of entries made into the pilot system, a focus group and desk-based research.  From analysing and presenting the wealth of information gathered in a clear and concise way we were able to give the GPhC valuable insights to help them in their next steps. More background and the report are available here: Continuing Fitness to Practice Pilot - evaluation  

An evaluation of a cancer programme in a London borough

The programme promoted the early detection of cancer by improving population awareness of the signs and symptoms of cancer and to remove barriers to seeking help. The programme also sought to ensure that GPs had the knowledge and skills to make the most appropriate referrals and supported pharmacists to engage with customers to increase their awareness of cancer signs and symptoms and visit their GPs if appropriate. SPH used a combination of quantitative and qualitative methods to assess the overall effectiveness of the programme. These included analysis of routinely available cancer indicators along with locally available data, reviewing data collected by the programme such as survey responses, reviewing project documentation including costings, and conducting interviews and focus groups. These were collated to form a comprehensive and insightful evaluation report, which the customer used to support future priorities setting.

An evaluation of an end of life care education programme

SPH evaluated an education programme, targeted at staff within GP practices to improve end of life care. The evaluation included an assessment of the effectiveness and efficiency of the training visits through interviews and analysis of service data, an audit of the impact of the programme on practice, including changes in behaviour and the accuracy of end of life care registers, and an analysis of hospital admissions data. The evaluation found improvements in the skills, behaviours and competence of staff around end of life care in the period following the training programme.

Mental health needs assessments

SPH completed a mental health needs assessments focusing variously on children and young people, working age adults and older people for a number of local authority customers. The aims of these needs assessments included identifying the prevalence of risk and protective factors for mental wellbeing, quantifying proxy measures for the burden of mental illness and benchmarking these against regional and national averages. Current service provision across the statutory and voluntary sectors was described and service providers, wider stakeholders and service users and carers participated though workshops, interviews and focus groups. Accompanying literature reviews considered prevention and early intervention for mental health conditions. The reports identified gaps and issues to inform future commissioning plans.

Substance misuse needs assessment

SPH recently completed a substance misuse needs assessment. This included identifying national and local policy for substance misuse provision, identifying the local prevalence of substance misuse conditions and quantifying proxy measures for the burden of drug and alcohol misuse. SPH also mapped existing substance misuse services and facilitated a workshop with commissioners, service providers and service users and conducted telephone interviews with stakeholders. The needs assessment also included a literature review on primary prevention for substance misuse. A number of recommendations were made around gaps in service provision and capacity, including recommendations for specific groups of service users.

Reviewing maternity services

As part of this review we:
  • Modelled current and future demand
  • Analysed patterns of hospital utilisation and catchment area
  • Analysed of births by place of birth, age and deprivation quintile
  • Reported on trends in risk factors for adverse outcomes from pregnancy and indicators of the quality of maternity services
  • Reported on compliance of service providers against national standards
  • Conducted interviews with local services to discuss how projected future need could be met

Providing evidence to support the reconfiguration of acute hospital services

SPH provided public health support to a programme established to reconfigure acute hospital services. SPH analysed comparative population health outcomes to inform the case for change that was presented to CCGs, and completed a comprehensive review of the literature on the relationship between volume and outcome to identify where there was robust evidence to support the case for service reconfiguration. SPH also provided data and evidence to some of the Clinical Reference Groups that were established to consider future options for specific clinical services, and sourced and analysed detailed travel time information to inform decisions about service delivery options.

Audits on diagnostic pathways in primary care

SPH has undertaken primary care audits on diagnostic pathways for patients newly diagnosed with cancer for two regions of England. Commissioned by local clinical commissioning groups, together these audits included data from ~150 GP practices and ~3,600 cancer patients diagnosed within a 12 month period. The audits collected data on patient characteristics, symptoms, cancer type, location of first presentation and intervals in the diagnostic pathway, including identifying areas of potential delay. The analysis of the audit data highlighted variations between geographical areas and groups of cancer patients. They also provided an opportunity for GPs to reflect on their practice in the diagnosis and onward referral of patients with symptoms that might indicate cancer, build upon current good practice and inform service improvements.

Healthcare demand arising from new housing developments

SPH analysed the new healthcare demands which might arise from two new housing developments. This involved using local knowledge to understand the likely population profile of these developments and using activity data and trends from a number of sources relating to primary care, secondary care, emergency care and mental health to estimate the demands that the housing developments were likely to put on the NHS in ten years’ time. It included a set of sensitivity analyses and discussion about the potential effects on these estimates of the new models of healthcare provision that are evolving in the NHS.  This work helped to inform planning of future healthcare infrastructure and models of healthcare provision in the area, as well as contributing to the CCGs’ negotiations with developers regarding developers’ section 106 funding contributions for provision of healthcare infrastructure for the population of the new housing developments.