Purpose:
The research project is a three-and-a-half year study which started in December 2009 and finished at the end of May 2013. It is an evaluation of the effectiveness of the North East Transformation System (NETS). NETS was originally introduced by NHS North East and is centred on the so-called three-legged stool – Vision, Compact, and Method – as the mechanism to bring about large-scale transformational change.
Design/Approach:
The research comprised a longitudinal (involving repeated observations of the same variables) mixed-methods study. Research methods used included open interviews, observation, focus groups, documentary analysis, and interrupted time series (ITS). The ITS component comprised five case studies in two of the sample sites. Two rounds of interviews were conducted in Years 1 and 2 of the study with staff in our sample of 14 sites comprising a range of NHS organisations. These comprised acute hospital trusts, mental health trusts, community services, an ambulance trust, and commissioners in the form of PCTs. To examine the NETS method in greater detail four Rapid Process Improvement Workshops (RPIWs) were observed. Focus groups were conducted among human resource managers and knowledge process outsourcing (KPO) leaders.
Qualitative data analysis proceeded using Pettigrew et al’s ‘receptive contexts for change’ framework to explain transformational change in NHS North East. The framework comprises eight factors:
Findings:
Undertaking successful transformational change in a complex system takes time and demands consistency, constancy of purpose and organisational stability. The NETS was seriously disrupted by the NHS changes announced in July 2010. Given these ever-shifting changes in the overall context and external environment in which the NETS was occurring, combined with the numerous complexities to be found in any health care setting, it is extremely difficult to arrive at any final conclusions about its success (or otherwise) or impact either on services or the public’s health status in the North East. Even where there may be evidence of change and improvement, attributing these with confidence to the NETS is impossible. Establishing strong causal links as distinct from strong associations and/or correlations has not proved possible.
Notwithstanding the variable impact of the changes on the overall NETS programme, four of the study sites in the sample demonstrated positive impacts. Progress in the other study sites was either slowed, halted or seriously disrupted by the NHS upheaval which resulted in the NETS losing momentum. Leadership style is critical to the success of transformational change and while it was clearly a factor in the progression of the NETS overall, it was also critical in respect of each of the participating organisations.
The four sites which made progress in implementing the NETS were all notable for clear, visible and relatively stable leadership. Despite this, the commitment to embedding deep cultural change proved challenging and fragile. It is also the case that most of the attention of managers and other practitioners was devoted to the Lean tools rather than to the more difficult issues around values and culture which the Vision and Compact (two legs of the NETS stool) sought to address.
Compared with Lean in the manufacturing sector, its application to the NHS involved a far greater degree of being able to manage complexity and numerous competing objectives. Perhaps four, maybe five, of the study sites remained truly committed to the NETS approach while other sites tended to adopt a pick and mix approach combining elements of the NETS approach with other inputs which had been decided upon locally as being of greater value. The absence of adopting a pure NETS approach did not preclude some sites from achieving success in quality improvement and patient safety.
Analysis of the ITS component of the study gave rise to mixed findings with some statistically significant improvements observed; some ambiguous results; several where no evidence of impact of the RPIW could be detected; and some counter-expectation findings. Clear improvements included a reduction in time from arrival of patients with abdominal pain in A&E to being x-rayed (surgical pathway RPIW); reduction of length of stay on the ward for women (purposeful in-patient admissions RPIW); and a large impact on the proportion of patients allocated on the day of referral (community psychosis-admission RPIW). In general, it is difficult to draw definitive lessons from the ITS analysis. Given the reliance on routine administrative data and absence of data on the range of clinical outcomes, it may be the case that the ITS has missed significant impacts in some key outcomes.
Project award:
£509,000
Funder:
NIHR Health Services and Delivery Research Programme
Project dates:
From December 2009 to May 2013
Practical implications:
Two dissemination workshops have been held in the NHS North East to share the findings and to heed the lessons for future change initiatives. The key lessons are explored in the publications listed under Outputs. The final report will be available shortly on the NIHR website.
Contact information:
Principal Investigator: Prof David Hunter
Please direct all queries to Gill McGowan, Centre for Public Policy and Health Administrator, Durham University, email: gill.mcgowan@durham.ac.uk
Purpose:
School meal provision was introduced in the mid-19th Century as a public health response to under-nutrition of children. In the late 20th Century, the focus for public health shifted as the obesity epidemic in children emerged, and a number of nutrition-related public health initiatives were introduced. One such initiative was the introduction of the school food policy in England in 2006; primary and middle schools were to be fully compliant by September 2009.
Design/Approach:
A mixed methods approach was used to collect data at both school and individual level from two age-groups in Newcastle and Northumberland, North East England. Dietary, anthropometric (body measurement) and socio-economic data were collected using identical quantitative methods pre, mid and post-implementation of the school food policy. Data on food eaten at school (school lunch or packed lunch) and throughout the day were collected. A qualitative approach was used to examine the process of implementation of the policy.
Findings:
There were significant improvements in the nutrient content of both school and packed lunches in children aged 4-7yrs; the extent of change was greatest in school lunches. There was less evidence of such changes for children aged 11-12yrs.
The effect of lunch type choice (school or packed lunch) on total dietary intake changed from pre to post-implementation of the school food policy in that those having school lunch had intakes more in line with recommendations. For some nutrients, this was a reversal of intakes prior to the school food policy and demonstrates the impact of the school food policy not only on lunch time intake but also on the total dietary intake of 4-7yr olds.
In contrast to our findings in 4-7yr olds there was limited evidence of the effect of school lunch type on the total diet of 11-12yr olds; the exception was in percentage energy from fat. Mean daily intakes from iron and folate fell from 1999-00 to 2009-10; it is important to note these were both below the Reference Nutrient Intake (RNI) in 1999-00 and remained so in 2009-10.
The process evaluation suggested that schools coped well with challenges involved in implementing the school food policy. The knowledge and skills of catering staff, their ability to adapt to new processes and ways of working were important factors as was the level of commitment from senior managers. It was evident for both age groups that the food choice available was only one factor in the decision to have school lunch or packed lunch; the dining room experience and encouragement offered to children is part of this choice.
Project award:
£459,480
Funder:
Department of Health, Public Health Research Consortium
Practical implications:
Our findings, particularly for 4-7yr olds, have demonstrated the potential for school lunch to have a positive impact on the total diet. To maximise this impact there is a need for a concerted effort to ensure full compliance with the policy for all age groups and to encourage and facilitate children to take advantage of school lunch.
Project outputs:
Full report available from Public Health Research Consortium (PHRC) website
Publications
Spence S, Delve J, Stamp E, Matthews JNS, White M, Adamson AJ. The Impact of Food and Nutrient-Based Standards on Primary School Children's Lunch and Total Dietary Intake: A Natural Experimental Evaluation of Government Policy in England. PLoS One 2013, 8(10), e78298
Adamson, A., Spence, S., Reid, L., Conway, R., Palmer, A., Stewart, E., McBratney, J., Cather, L., Beattie, S. and Nelson, M. (2013) 'School food standards in the United Kingdom: implementation and evaluation', Public Health Nutrition, 16(6), pp. 968-981.
Contact information:
Principal Investigator: Professor Ashley Adamson (Programme Leader, Early Life and Adolescence programme)
Please direct all queries to Sue Bell, Public Health Improvement Administrator, Newcastle University, email sue.bell@ncl.ac.uk
Purpose:
There is increased urgency to demonstrate return on investment in relation to public health interventions and explore methods of decision-support for public health priority-setting. The return of the responsibility for public health commissioning to local authorities means that priority-setting will take place within new organisational and cultural settings, which presents new challenges. With local authority ring-fenced public health budgets confirmed, difficult decisions about investment, and particularly in a time of economic stringency, about disinvestment, will have to be made, not just within the ring-fenced public health budget but also across different departments of the local authority.
Design/Approach:
This two year study is supporting public health priority-setting in three local authority case study sites across England, through bringing together specialist input from health economics and public health in a series of seminars and targeted decision-making support for public health commissioners. The relevance of prioritisation methods and their impact on spending patterns within and across programmes will be evaluated through a series of initial and follow up interviews with decision-makers in each site.
Findings:
No findings available yet.
Project award:
£294,263.27
Funder:
NIHR School for Public Health Research
Project dates:
From April 2012 to July 2015
Practical implications:
The project is seeking to show which priority-setting tools local authority commissioners find useful for public health investment, assessing enablers and barriers to decision-making and deliver recommendations about appropriate decision-making support for determining priorities in public health commissioning within local authorities.
Contact information:
Principal Investigator: Prof David Hunter
Please direct all queries to Michelle Cook, Project Administrator, Durham University, email: michelle.cook@durham.ac.uk
Purpose:
The function of the NIHR School for Public Health Research is to conduct research, the findings from which can be used to inform decision-making in public health practice, particularly at the local level. The evidence base for effective alcohol and sexual health education in young people in the UK is weak, as has been highlighted in a number of systematic reviews over the last 20 years. The intention of this research project is to develop an evidence and theory-based sexual health and alcohol education programme to reduce risky sexual behaviour and alcohol misuse, for use in all types of secondary schools in England. It is intended that this intervention should be shown to be acceptable, capable of implementation with fidelity, scalable, sustainable, effective and cost effective.
Design/Approach:
The long term project is planned in three phases. The first phase of the research involves a number of discrete work packages which will be led by members who have particular expertise in the methods required. The second phase will comprise the design or redesign of an existing intervention and a preliminary pilot in one or two schools. The third phase would be a feasibility study for a definitive randomised controlled trial (RCT). In the first phase, we will carry out 4 work packages: a review of reviews; case studies of secondary schools’ approaches to and views of sex and relationships and alcohol education; a study of best practice for local authorities; exploration of data from Natsal 3/Health Survey for England.
Findings:
Project started in October 2013. No findings available yet.
Project Award:
£561,581
Funder:
NIHR School for Public Health Research (SPHR)
Project Dates:
From October 2013 to September 2015
Practical Implications:
Ensuring that public health interventions are evaluated for their capacity to diminish and not widen inequalities in health is a fundamental part of the NIHR SPHR’s mission. While there are substantial inequalities in sexual health and alcohol misuse in young people it is a complex picture because, for example, high levels of alcohol consumption are associated with affluence, but alcohol-attributable hospital admissions and teenage conceptions are strongly related to deprivation. A well designed sexual health and relationships education (SHRE) programme, including a component on alcohol, has the potential to impact favourably on such inequalities.
Contact Information:
This is a collaborative project being carried out amongst the SPHR partners (Fuse, University of Bristol, University of Cambridge, London School of Hygiene and Tropical Medicine (LSHTM), Peninsula College of Medicine and Dentistry, University of Sheffield, LiLaC collaboration between University of Liverpool and University of Lancaster, and University College London (UCL).
Professor Rona Campbell from the University of Bristol is the overall project lead, Fuse’s contribution is led by Professor Janet Shucksmith of Teesside University (contact j.shucksmith@tees.ac.uk for further information).
View the outputs from this research [INSERT LINK]
Purpose:
Alcohol consumption increases throughout adolescence. Approximately 33% of 15-16 year olds in England report being drunk every month with young people in the UK being amongst the heaviest young drinkers in Europe; leading to high social and economic costs. It is now well known that young people are much more vulnerable than adults to the adverse effects of alcohol due to a range of physical, mental and social factors which often interact. It is recommended that children should abstain from alcohol before the age of 15 and those aged 15-17 are advised not to drink. If they do drink it should be no more than 3-4 units and 2-3 units per week in men and women respectively, on no more than one day per week. Parenting ‘style’ and ‘good’ family relationships have been demonstrated to have a positive effect on young people’s drinking behaviour regardless of family structure or whether parents consume alcohol. Excessively strict or lenient parenting is associated with earlier alcohol use or higher levels of drinking behaviour. Only a few primary prevention programmes - to prevent underage drinking before it has happened - have reported positive outcomes. Thus secondary prevention i.e. targeting interventions at young people who are already drinking alcohol is likely to be a more effective strategy, since the interventions will be more pertinent to the individuals receiving them.
Design/Approach:
We worked with year 10 pupils (aged 14-15) in seven schools across one area in the North-East of England. Young people who screened positive on a single alcohol screening question and consented to take part were randomly allocated to one of three groups and either provided with: an advice leaflet (control condition, two schools); a 30-minute brief interactive session which combined structured advice and motivational interviewing techniques delivered by the school learning mentor (Intervention 1, two schools); or the level 1 intervention and then a 60-minute session involving family members delivered by the school learning mentor (Intervention 2, three schools). Young people were followed-up at 12-months. The purpose of the study was to assess the feasibility of trial processes, recruitment and retention and an evaluation examined the pros and cons of the alcohol screening and brief intervention approaches in the school setting in this age group.
Findings:
Two hundred and twenty two (222) young people were eligible for the trial. Of these 182 (82%) agreed to take part (53 in the control group; 54 in Intervention 1; and 75 in Intervention 2). Of the 75 in the Intervention 2 group, 67 received Intervention 1 (89%). Eight received both Intervention 1 and Intervention 2 (11%). In total 160/182 were successfully followed up at 12 months (88%). Interviews were carried out with six school lead liaisons; 13 learning mentors; 27 young people and seven parents. Results show that the school setting is a feasible and acceptable place to carry out alcohol screening and brief intervention with learning mentors seen as suitable people to do this. Intervention 2 was not seen as feasible or acceptable by school staff, parents or young people and therefore a definitive study should not include a parental arm.
Patient and public involvement (PPI) was sought at different time-points and at multiple levels throughout the study. PPI representatives included local authority employees, parents, young people and members of staff at participating school sites. Their contribution to the development, management and delivery of this research included input into the design and conduct of the feasibility study (the local authority lead for education was a co-applicant for this research) and piloting of study documentation and intervention materials (parents and young people) to ensure readability and understanding. Participating schools were also heavily involved in the conduct of the feasibility study (trial and survey) and were regarded as key stakeholders and were imperative in decision making regarding modifications for a definitive trial application.
Project Award:
£374,033
Funder:
NIHR Public Health Research Programme commissioned call 10/3002 Alcohol and Young People
Project Dates:
From 1 October 2011 to 31 July 2013
Practical Implications:
This present work builds on the evidence base by focusing on alcohol screening and brief intervention to reduce risky drinking in young people (aged 14-15). It is highly likely that if a brief intervention was effective at reducing harmful drinking, it might also result in a range of other positive behavioural outcomes as has been found in studies with adults and older adolescents.
Contact Information:
For further information contact project lead Dr Dorothy Newbury-Birch (email: dorothy.newbury-birch@ncl.ac.uk) or project manager Dr Stephanie O’Neil (email: stephanie.o'neil@newcastle.ac.uk)
Links:
Related project pages
SIPS JR-High - Newcastle University Institute of Health & Society project page
SIPS JR-High - NIHR project page
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