Case Studies

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

Solutions for Public Health (SPH) 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

Clinical Audit in Secondary Care (releasing cash savings and improving patient pathways)

SPH, as an independent and credible NHS body with access to senior and respected Consultant clinicians, was commissioned by an STP group of CCGs to undertake a Clinical Audit of secondary care providers undertaking a range of procedures. We deployed an experienced Consultant clinician, utilising our proprietary 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 was able to engage 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 5 providers was substantial at £1.9m and ranged from 15% to 80% of the annual activity value of each provider.  
  • Delivered cash releasing savings
  • Identified root causes of systematic non-compliance
  • Leads to opportunities for patient pathway improvements and a reduction in inappropriate procedures undertaken outside national guidelines or commissioning policy eligibility criteria
  • Improves patient safety

Understanding variation to focus action

Working in partnership with our host, the Arden and Greater East Midlands Commissioning Support Unit, SPH produced Deep Dive Packs, building on the NHS England, Right Care and Public Health England ‘Commissioning for Value Packs’. These focused on specific programme areas, such as cancer, respiratory, musculo-skeletal, diabetes or trauma. Combining data analysis and expert public health commentary, the Deep Dive packs identify specific areas where focused action might lead to improved outcomes and / or reduced costs. SPH also facilitated workshops with individual clinical commissioning groups (CCGs) to explore the outputs in more detail and discuss potential follow-on service redesign opportunities. A case study of a Deep Dive, supporting respiratory pathway redesign in one CCG can be viewed on the Arden & GEM CSU website: Case Study - Deep Dives

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

During the summer of 2017 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:

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.

CAHBS Evaluation

SPH was commissioned by the Department of Health to evaluate a new Child and Adolescent Harmful Behaviour Service (CAHBS) for young people where there are concerns in relation to sexually harmful behaviours. The evaluation included analysis of the CAHBS activity database and interviews with key stakeholders, including staff making referrals to the service, senior managers and the families and carers of service users. The evaluation was used to inform future funding decisions about the service once the pilot funding period from the DH ended.  

FCAMHS Mapping

SPH completed a mapping exercise of community forensic child and adolescent mental health services (FCAMHS) provision in the UK. FCAMHS are concerned with the mental health assessment and treatment of young people aged under 18 who present with high risk of harm to others in a variety of settings or who are in contact with the youth justice system. Our report addressed specific questions around the needs addressed by community FCAMHS services, an overview of existing dedicated FCAMHS community provision and commissioning arrangements and an outline of proposals for core functions and models of service provision. The exercise identified gaps in the provision of appropriate community-based FCAMHS and recommended the need for agreed national minimum standards and a standard national commissioning framework.

National evidence reviews

SPH produce 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. Working to processes developed and agreed with the client, these expert reviews identify, summarise and critically appraise the latest published evidence and are used to inform the development of national policy. All of our national reviews include consultation on the draft report by clinical experts.

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, supporting commissioners to develop their commissioning decision making processes from topic selection through to preparing final policy statements. This 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 been involved in supporting commissioners in appeals against NICE guidance and have experience of supporting commissioners in two judicial reviews.

Bespoke evidence reviews

SPH undertook an evidence review on the impact and cost-effectiveness of self-management programmes on chronic disease management to inform local commissioning. This included working with a local public health team to identify evaluations of existing NHS Expert Patient and Improving Access to Psychological Therapies programmes and commenting on their impact.

An evaluation of continuing fitness to practice pilot for GPhC

The GPhC are in the process of implementing a new revalidation framework. After an extensive period of research and testing, they are now consulting on this 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:  Developing revalidation for pharmacy professionals

An evaluation of a cancer programme in a London borough

The programme aimed to promote 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.   Solutions for Public Health 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 was used by the customer 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.

Assessing evaluation processes for prevention and early diagnosis schemes

SPH conducted a pilot study systematically exploring how NHS organisations and clinical commissioning groups are implementing prevention and early diagnosis schemes that promote behaviour modification in specific areas of health risks. The project identified prevention and early diagnosis schemes in a specified geographical region, to collect information about each scheme and assess schemes that met the inclusion criteria against an agreed evaluation framework examining the robustness of their evaluation process and the clinical and economic potential of the interventions. SPH also developed a searchable database for customer use.

An evaluation of a community-based alcohol service

SPH conducted an independent evaluation of a specialist community-based alcohol assessment, support and detoxification service. This involved quantitative analysis of the services’ performance and activity data and qualitative interviews with staff involved in delivering the service, wider stakeholders who had dealings with the service and service users. SPH also assessed the service’s compliance with key elements of their service specification and compared the interventions offered against national guidance. The report provided a comprehensive overview of the service to inform future service provision.

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 within an area of England. 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.

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.

Healthcare demand arising from new housing developments

Solutions for Public Health (SPH) was commissioned to analyse 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 are 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 helps 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.