NHS SERVICE DELIVERY AND ORGANISATION R&D PROGRAMME

NHS SERVICE DELIVERY AND ORGANISATION R&D PROGRAMME PROGRAMME OF RESEARCH ON ACCESS TO HEALTH CARE A Empirical studies to evaluate innovations to improve access repeat call B Empirical study of priority scoring tools and other systematic methods used to prioritise referrals from primary to secondary care for elective surgery. Introduction Access to health care was identified as one of the main themes from the NCCSDO Listening Exercise and remains currently one of the highest priorities within the NHS. 1 2 The Access Commissioning Group, within the SDO Programme has now approved both a repeat call for empirical work on innovations in this field and a new call for empirical work on a description of and evaluation of methods and processes currently used in the referral, selection and prioritisation of patients for elective surgery. The NCCSDO commissioned a Scoping Exercise from a multidisciplinary academic team to map the topic of access, to identify what is currently known and to identify areas for further research. 3 A contextual report was also commissioned to gain a better understanding of the current policy environment context within which a programme of research on access to healthcare should be commissioned. 4 It describes some of the many current innovations relating to access. As a result of this background work a broad picture of the issues relating to access has been built up, including attention to issues of access to health services, both in general and for deprived and minority ethnic communities and marginalised groups. Research proposals are now invited on innovations to improve access and on methods to prioritise referrals from primary to secondary care for elective surgery both of which reflect the priorities identified in these two reports. 1

PROGRAMME OF RESEARCH ON ACCESS TO HEALTHCARE Primary Research: Outline proposals are invited for empirical work to undertake: A Empirical studies to evaluate innovations to improve access repeat call B Empirical study of priority scoring tools and other systematic methods used to prioritise referrals from primary to secondary care for elective surgery. Call for proposals This current call for proposals covers empirically based projects. Potential applicants are advised to refer to the NCCSDO website for further details of relevant documents including the National Listening Exercise and the two access documents already produced for more detailed information. 3 4 All these documents can be downloaded from the web-site (www.sdo.lshtm.ac.uk). Those interested in submitting a proposal should note that a two stage commissioning process is being used. Applicants are invited to submit outline proposals by Wednesday 26 th February 2003. A Evaluation of innovative approaches to improving access The SDO programme is repeating the invitation for proposals to evaluate innovations in the organisation and delivery of health services which are aimed at improving access to those services. Background The concept of innovations in the organisation and delivery of health services covers a broad area. We are interested in commissioning research on different ways of organising and delivering health services which both challenge traditional practice and which have not yet been adopted on a national scale. These innovations may or may not be very recent. Examples of innovations which might be evaluated include service re-design projects to improve booking for outpatients or primary care appointments, innovations at the interfaces between primary and secondary care and between health and social care, innovative computerised or information systems which are aimed at improving access to different types of services. Note that access is recognised here as of two types access which allows entry into a service or system and access which allows progress through a service or system. 4 The SDO programme does not want to be prescriptive at this stage, given the range of possible innovations which might be evaluated. However, the programme is particularly interested in commissioning evaluations of innovations which clearly 2

relate to NHS priorities and implementation of the NHS Plan. We do not however, wish to commission research which duplicates other current evaluations of, for example, the national booked admissions programme, near patient testing, or NHS Direct. Applicants should note that this is a repeat call for proposals for evaluation of innovations to improve access, because we were not able to fund as many projects as we wished from the last round of applications. A number of points were noted by the Access Commissioning Group in assessing full applications in response to the previous call and it may be helpful to consider these: A very clear description of the innovation or intervention is required and of the means for ensuring standardisation of its implementation during the research where this is appropriate. Attention should be paid to improving access (using the definitions used in this call for proposals) as a key outcome of the innovation itself. The effectiveness of the intervention to which access is being promoted is also important and the links between access, appropriateness, effectiveness and equity need to be considered. This fund is not available for the development of innovations. Proposals will benefit from adequate multidisciplinary and methodological input where appropriate e.g. statistical input. Many of the innovations to improve access tend to be complex interventions and as such, care needs to be taken in the design of appropriate methods, for example in sampling, or in the unit of analysis to be considered. Some previous applications failed to take account of the whole population at risk, or the possibility of unmet need. In many cases it would not be appropriate to assess whether access had improved solely by assessing changes in service utilisation. The generalisability of the intervention to other sites and settings needs to be considered - for this reason it is less likely that research in a single site would be funded. We would normally expect that consumers, particularly the people or their representatives who might be affected by the innovations should be involved in the design and management of the research and in the dissemination of findings. Previous applicants may apply, but they should ensure that comments made by the commissioning group have been fully incorporated into a new outline proposal. The SDO programme has now also already commissioned three projects evaluating innovative approaches to improving access within our Access Programme. These projects are entitled: Evaluation of appropriateness methods to define and improve access across primary, secondary and tertiary care among people with angina, A study of general practitioner specialist clinics to evaluate their impact to specialist care, costs and patient and clinician satisfaction 3

Evaluation of a primary care dermatology service. Potential applicants should be aware that the SDO programme is also currently in the final stages of commissioning research projects under the topic of Evaluating Innovations. Details of all of these projects will appear on the SDO website shortly (www.sdo.lshtm.ac.uk). B Empirical study of priority scoring tools and other systematic methods used to prioritise referrals from primary to secondary care for elective surgery. As part of its programme of work on access to health care and in collaboration with the Demand Management Team from the Modernisation Agency, the SDO programme wishes to commission this work on referral, selection and prioritisation of patients for elective surgery. Applicants should note that the HSMC at Birmingham recently undertook a relevant scoping exercise. 5 Ruth Kipping from the Demand Management Team is the contact point for the Modernisation Agency in relation to this project. (Ruth. Kipping@doh.gsi.gov.uk). This work is very relevant to current policy. Thus although we are funding a three year project, we are requesting that a detailed 18 month report is produced, describing work undertaken to date and cataloguing methods and processes for referral from primary to secondary care and interim findings of practical value. Background NHS waiting list policy is now focused on reducing waiting times for outpatient assessments and for elective surgery, through increasing capacity, demand management and through the introduction of the Choice scheme. However, the focus on waiting time targets has generated anxieties about the possibility of distorting clinical practice and reducing equity. 5 Referral rates from primary to secondary care are known to vary widely and research has demonstrated unmet need at a population level. There are known to be problems with both the absolute level and the distribution of access to elective surgical care. Currently, there is interest in the development and use of explicit criteria to prioritise the referral and selection of patients for surgery and the timing of surgery and in many areas priority scoring tools are being used for this purpose. 5 The use of priority scoring tools in this context are however thought to be problematic, particularly because of their lack of attention to a patient s own estimates of their health status. The aim of using these tools is that those with the greatest ability to benefit should be referred for surgical assessment, and receive surgery more quickly than patients with lesser need and ability to benefit. However there are concerns that priority scoring tools may not achieve this aim. 4

There is a need for research to investigate systematic methods used to prioritise referrals, in particular the use of priority scoring tools, for assessment and selection for elective surgery. We envision this to be a two phase project, with the first phase being a detailed assessment of use of priority scoring tools (bullets 1,2,3) and the second phase of new primary research on the further development and evaluation of these tools (bullet 4). We require: 1. An assessment of the extent of use of priority scoring tools in this context; 2. An assessment of the degree to which the tools used are valid and reliable and of the variability that exists in their application; and 3. An assessment of the extent to which patients own views of their health status are taken into account in these tools. We will require a report on this first phase of the work at 18 months 4. A proposal should also be submitted describing a further phase of work (18 months) which should include further development of priority scoring tools in appropriate selected health areas. We anticipate that this further development will include attention to inclusion of patients own views of their health status and need for surgery. We anticipate that the work in both phases will be of a multidisciplinary nature incorporating both quantitative and qualitative research. Applicants should make themselves aware of other current relevant research and policy change in this area, particularly the relevant work of the Modernisation Agency Content Outline proposals for research funding in either of the areas described in A and B above, should be submitted. For both, a short review of current evidence should be included where applicable. Proposals should clearly demonstrate that the research will add to knowledge and that the proposed research has not already been or is not already being undertaken. Applicants should demonstrate how they will undertake the research. Methods described should be as detailed as possible, (including both qualitative and quantitative methods where appropriate). Proposed outputs should be listed and should include an assessment of implications for change and for methods, which change agents can use. Applicants will need to demonstrate clear conceptual frameworks to consider the issues relating to access. The conceptual framework for definitions of access may include attention both to entry into, and continuing access within a system 4 and to other literature which assists in defining this complex area. 3 Applicants will also be expected to demonstrate that they are able to draw on a broad range of both evidence and theory. Applicants should be able to demonstrate 5

a broad awareness of international research as well as UK-based research in this field. Relevance to the NHS should be made explicit. Applicants should familiarise themselves with relevant research already commissioned by SDO and by other NHS R&D programmes (such as the Policy Research Programme and the Health Technology Assessment Programme) to ensure that they can demonstrate that their proposals do not duplicate other research. Applicants should refer to the general criteria for prioritising research topics, developed and agreed by the SDO programme board, available on the SDO website (www.sdo.lshtm.ac.uk). Outputs Outline proposals for either A or B should demonstrate awareness that the principal final product for both research calls described in this document will be a detailed report that should: Critically describe the background and available literature on access to health care in relation to the particular topic area selected and provide a rigorous and detailed analysis and conclusions of what is currently known about the topic area and of the strength of the evidence on which this is based; Critically describe the methods used in the research; Provide a rigorous analysis of the data gathered; Draw justifiable conclusions; Identify areas for further research and how they might be addressed. This could include reviews of the literature and/or primary research; and Locate the findings in the current policy and practice context within the NHS. Successful applicants may be asked to make a short oral presentation of their completed research to the SDO Programme Board. Research outputs will need to be presented both in an academic format and in a format that will be helpful to endusers, particularly those with responsibility for increasing access to healthcare. The audience for the work will include those with responsibilities for implementing the NHS Plan, and those with direct clinical and clinical governance responsibilities. We anticipate that there might be informal discussions with NCCSDO during the research to clarify issues as they arise. Information to be included in an outline proposal Applicants should submit outline proposals for : A Evaluation of innovative approaches to improving access; or B Empirical study of priority scoring tools and other systematic methods used to prioritise referrals from primary to secondary care for elective surgery 6

They should identify the proposed research team and describe the location and context of the proposed study. They should include a description of the methods to be used, and the intended outputs of the research. They should also include arrangements for project management, such as an advisory board and user input. Applicants should clearly outline their plans for the dissemination of their findings. In addition, applicants should indicate how they will: Ensure that their team includes researchers whose knowledge and skills are sufficiently broad to deal with the variety of topic areas and methodologies which will need to be considered. Ensure the relevance of the research to bodies at national and local level which have an interest in access to healthcare, both within and outside the health and social care sectors. Demonstrate the involvement of users and other relevant stakeholders at each stage of the proposed research project; Build in an active programme for disseminating results, in discussion with the SDO Programme and relevant stakeholders. Funding up to a maximum of 350,000 per project is available for: Up to three projects under evaluating innovations (topic A); and One project on methods to prioritise referrals from primary to secondary care for elective surgery (topic B). Each should take no longer than three years to complete and start no later than 1 st October 2003. Guidance Notes The process of commissioning for each study will be in two stages. At this stage we are requesting applicants to submit outline proposals. Outline proposals will be shortlisted, and a number of applicants subsequently invited to submit full proposals. Applicants must submit proposals using the A4 Outline Proposal application form, which is available as a Word 97 file or Rich text format from: The SDO website, at: http://www.sdo.lshtm.ac.uk/accesscall.htm, or By Email from: kate.thomas@lshtm.ac.uk Please do not use any previously obtained version of an SDO programme application form. Applicants are asked to submit proposals by Wednesday 26 th February 2003 at 1pm to: Ms Kate Thomas Commissioning Manager NCCSDO 7

London School of Hygiene and Tropical Medicine 99 Gower Street London WC1E 6AZ TWENTY-FIVE HARD COPIES of the completed A4 Outline Proposal application form should be submitted, together with a copy on disk or CD. Please note we will not accept electronic submissions, faxed or hand written proposals. No late applications will be considered. Guidance notes for the completion of the A4 Outline Proposal application form can be found at the front of the application form. Teams should ensure that their proposal complies with the Research Governance Framework, which can be found on the Department of Health website, or via a link on the SDO website under the Call for proposals page. At the second stage, successful teams will be required to provide proof of research ethics committee approval for their project, if this is required (information regarding this can be found on the SDO website under the Calls for Proposals page). The proposal should cost no more than 350,000 and applicants should note that value for money is an important consideration in respect of this research and they should demonstrate that their proposal meets this criterion. The exact length and cost of the project should be determined by the applicant, as they think appropriate. Applicants should clearly justify the timescale and cost of their proposal. Proposed costs of the project should not exceed the limit stated above. Following submission of outline proposals, successful applicants will be notified of the outcome in early April 2003. Shortlisted applicants will then be invited to submit full proposals by the early June 2003. Applicants will be informed of the outcome of the full proposals by the end of July 2003. Please note that these dates are approximate and may be subject to change. 8

References 1 Fulop N, Allen P. National listening exercise: a report of the findings. London: NCCSDO, 2000. 2 NHS Executive. The NHS Plan Department of Health London. 2000. 3 Gulliford, M., D. Hughes, et al. Access to Health Care. Report of a Scoping Exercise. London, King s College London, NCCSDO 2001. http://www.sdo.lshtm.ac.uk/access.htm 4 Rosen, R., D. Florin, et al. Access to Health Care. Taking Forward the Findings from the Scoping Exercise. King s Fund, London, NCCSDO. 2001. http://www.sdo.lshtm.ac.uk/access.htm 5 Kipping R., Robert G., McLeod H., ClarkJ. A Review of Priority Scoring and Slot Systems for Elective Surgery. Health Services Management Centre, School of Public Policy, University of Birmingham 2002 9

Addendum This document was published by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme, managed by the London School of Hygiene & Tropical Medicine. The management of the Service Delivery and Organisation (SDO) programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Prior to April 2009, NETSCC had no involvement in the commissioning or production of this document and therefore we may not be able to comment on the background or technical detail of this document. Should you have any queries please contact sdo@southampton.ac.uk.