This thesis through three interrelated research papers examines how to ration elective healthcare in the Northern Ireland hospital sector and investigates the policy option of waiting. Paper one contributes to knowledge on rationing in a healthcare setting by examining demand and supply rationing including the policy option of rationing by waiting. Paper one explores the key demand and supply drivers of waiting times in healthcare with specific focus on the hospital sector. Paper two makes an original contribution to the existing empirical knowledge on the demand and supply drivers of hospital waiting times by employing econometric analysis to estimate a waiting time equation, a demand equation and a supply equation for elective inpatient procedures for each of the twenty one key clinical specialties. Thirteen years of quarterly NHS hospital data (Quarter 1, 1995/1996 to Quarter 3,2007/2008) for Northern Ireland, is employed. The policy implication from the results in paper 2 is that a policy which may be effective for managing waiting times in one speciality may not be effective in other specialities. Paper three provides an original contribution to knowledge on healthcare rationing through an evaluation of the policy of a maximum waiting time guarantee in the Northern Ireland hospital sector. The evaluation includes quantitative and qualitative research. The qualitative study investigates the limitations of principal-agency theory when applied to healthcare. The research approach of grounded theory is employed to identify key themes from the ten hospital consultant and eleven hospital manager interviews undertaken to inform the research. The theme of professional power emerged from the study as significantly influencing the behaviour of the hospital consultants. It was also found that targets, the monitoring of performance and penalties for non-compliance will increase the success of a waiting time guarantee policy.

Rising global healthcare expenditures, the fallout from the global financial crisis and a commitment to improving patient outcomes have increased pressure on the budget of the National Health Service (NHS) in England to unprecedented levels. Therefore, ensuring services are delivered efficiently is key both politically and economically. In the context of the NHS, the large share of spending in secondary care means that this area is well analysed in the literature. However, the scale of the savings needed requires that both (a) more research is needed to identify further possible gains; and (b) the potential for improvement that has been identified by these studies is captured. To these ends, there are two specific aims of this thesis. The first is to examine the regulation of NHS hospital efficiency. Drawing from health care and other sectors of the economy, a number of lessons for regulators to promote hospital efficiency in the NHS and beyond are proposed. The second is to look to areas of hospital activity for which empirical evidence on efficiency is limited to identify further available gains. Many studies in the UK and beyond have sought to measure efficiency in health: the so-called “supply” of efficiency analysis is booming. However, despite their potential, the use of these studies has been limited in the NHS. In response to this, this thesis seeks to answer some of the methodological and practical issues raised around efficiency measurement and its application to the setting of NHS hospital efficiency targets. How these findings are useful more widely to health care systems around the world is also discussed.

Background: Almost all NHS hospitals regularly place patients on wards that are not clinically appropriate if there are no beds available on the correct specialty ward. Such patients are commonly called outliers. Approximately one in ten NHS inpatients experience an adverse event that causes them harm as a direct result of the care they receive while in hospital. It was hypothesised that placement on a ward that is not clinically appropriate for patients’ needs could act as an underlying (latent) condition which may increase patients’ susceptibility to adverse events. Methods: A descriptive quantitative study of the outliers and other inpatients in a single large NHS Foundation Trust was conducted using routinely available data. The aims were to investigate: the trend of outliers over the course of one year, age, gender, specialty, internal transfers between wards, length of stay in hospital and mortality. Two separate qualitative interview studies were conducted at the Trust to ascertain NHS staff members’ and patients’ perceptions and experiences of the quality and safety of care received by outlying patients. Results: Medical and elderly outliers increased over the winter months. Outliers were transferred between wards a significantly greater number of times than other inpatients. Multivariate analyses demonstrated no differences in age, gender, or mortality; however, outliers stayed in hospital significantly longer than other inpatients and outliers were significantly more likely to come from medicine than from any other specialty. Both staff and patients identified a number of factors which may contribute to healthcare errors experienced by outlying patients. Placement of patients on clinically inappropriate wards creates competing demands on staff members’ time and consequently results in delays, poses a number of communication barriers, compromises input from knowledgeable staff, may provide an unsuitable ward environment, and can be inappropriate for individual patients’ needs. Conclusions: The placement of patients on clinically inappropriate wards is a specific patient safety concern and constitutes a latent condition which may expose patients to a number of contributory factors that underlie adverse events. The quality of care may be compromised as outliers are often prioritised beneath other inpatients.

This thesis considers numerical, physical and theoretical modelling approaches to investigate the influence of a person's wake on the dispersion of an airborne pathogen in a hospital corridor and the implications this has in terms of infection risk. The various physical and computational modelling approaches were conducted using geometries corresponding to a 1:15 reduction in length-scale, when compared to the full-scale, and then interpreted in the context of a full-scale scenario in a hospital corridor. The movement of people in a corridor was approximated using a translating circular cylinder. A physical water-bath model was used to investigate contaminant transport using food-dye in a channel with different sized cylinders and translation frequencies. Dye concentrations were quantified through a calibration method dependent upon changes in light-intensity, leading to accurate tracking of the dye and allowing the amount of dye in different regions of the water-bath to be calculated over time. The centre of mass of the dye cloud was found to be dependent upon the square root of the translation frequency, amplitude, cylinder diameter and elapsed time. Based on the hypothesis that the dispersal of the dye could be described by a turbulent diffusion process, a theoretical model was constructed to predict the evolution of the dye concentration using a Gaussian function, which agrees well with experimental data for a broad range of cylinder diameters and translation properties. Two and three-dimensional computational fluid dynamics (CFD) models were developed to investigate the transport of a passive scalar due to a translating cylinder in a channel, their geometries and boundary conditions bearing close resemblance to the water-bath. Seven turbulence models were tested to determine the most suitable, using the water-bath data for validation. The shear-stress transport (SST) model was found to offer solutions in closest agreement with experimental results and theoretical predictions, as well as offering up to a 70% reduction in computation time compared to SAS, DES and LES turbulence models. The commonly used k-epsilon model was found to be inappropriate for modelling the flows encountered here. The numerical and theoretical models were used to investigate a number of scenarios in a corridor at the full-scale where an infectious contaminant is released. This includes a unidirectional flow applied along the corridor, where it was shown that the wake of the cylinder was still able to transport contaminant `upstream' against the direction of the flow. This implies that a walking person may be able to transport an airborne contaminant in their wake even in the presence of ventilation. Infection risks were calculated for a person making a single pass and multiple passes of the corridor based on the amount of contaminant inhaled and published data on the infectiousness of different pathogens. Results showed that the theoretical model developed here led to each individual breath having its own infection risk based on temporal and spatial differences, whereas a model assuming a well-mixed contaminant distribution did not. Results demonstrate that a person's wake is likely to influence the spread of an airborne contaminant in a hospital corridor, even if ventilated within current recommended guidelines. This highlights that a person's risk of infection, in the presence of airborne pathogens, is partly determined by any human traffic passing through the space before them and not solely on any ventilation within the space, as is often assumed in airborne infection models. Furthermore, the experimental work has provided strong validation data for the CFD models and allowed for the construction of uncomplicated yet powerful theoretical models. It has been shown that, when appropriate modelling assumptions are taken, confidence can be had in CFD predictions of contaminant transport involving complex flow behaviour, such as eddy shedding, within a built environment. The study also confirms that poor selection of `default' modelling assumptions, for example use of the k-epsilon turbulence model, will provide very poor predictions, highlighting need for careful selection of each aspect of a model.

Background. Reducing unplanned hospital admissions and achieving timely discharge are key issues for healthcare systems worldwide. Policymakers have focussed on admissions for ambulatory care sensitive conditions (ACSCs) as they are potentially avoidable. Exploring geographic variation could identify variable care pathways. Aims. To investigate the magnitude and causes of geographic variation in unplanned ACSC care. To explore key methodological issues pertinent to small-area variation studies and how this data can inform local decisions. Methods. I conducted a systematic review exploring the magnitude and causes of geographic variation. I estimated geographic variation in ACSC admission rates, length of stay and.readmission rates between PCTs and general practices. I investigated what might be driving these differences. I contrasted geographic variation across patient subgroups. I examined how methodological issues impacted the conclusions of small-area variation studies. I explored how benchmarking is used locally. Results. ACSCs are a large and growing problem. Care processes were highly variable for most, although not all, conditions. Admissions for younger patients, or those with low illness severity, were consistently more variable. Areas with greater bed availability, reduced care continuity and increased A&E proximity had consistently higher admission rates. A range of methodologies were used to quantify geographic variation which can impact conclusions and hinder comparisons. Benchmarking is widely used locally however perceptions of poor data reliability sometimes undermined its utility. Conclusions. There are important differences in ACSC care processes across England. Further work is needed to understand the causes of these differences and should initially focus on the most variable conditions and patient subgroups. Several factors are strongly associated with admission rates; where possible the causal effect of these should be tested using more robust study designs. Improvements in the reliability of routinely collected data, and the methodological rigor of small-area variation studies, is needed to improve their utility.

No description available.

No description available.

This thesis contains the analysis of data on hospitalisations that people on the Northern Finland Birth Cohort 1966, had during the Iifecourse The cohort consists of information obtained from 12,231 children and their mothers living in the provinces of Oulu and Lapland with expected delivery dates in the year 1966. The document presents a detail explanation of the theoretical and practical aspects around the study of hospitalisations viewed from a general epidemiological perspective.. The objective of the investigation was focused on identifying factors from lifecourse affecting the risk of being hospitalised. The 9ccurrence of hospital admissions is analysed considering time to event, length, type (all diagnoses taken into account) and number. Factors from the lifecourse potentially associated to such information were selected from a new set of combined characteristics such as clinical and biological, demographic, socioeconomic, and behavioural, neurobehavioral and developmental. Multivariate statistical methods for the reduction of dimensionality were used in the variable selection proce.ss. Exploratory and descriptive techniques were used to identify patterns of occurrence per group of diagnosis, determining the stratification of subsequent studies. Poisson regression was applied to study predictors for the number of hospitalisations per period of life. Binary and multinomial logistic regressions were applied to identify factors affecting repeated hospitalisations. Finally, survival analyses, in partiCUlar competing risks models, were used to study risk factors influencing the occurrence within specific groups of diagnosis. The study consists of an analysis of a complex structure of multi-factorial associations between hospitalisations and their possible predictors. The data comes from a large prospective cohort and the time sequence of factors is very well defined. It provides epidemiological evidence at an individual level and very precise information on patterns of hospital admissions.

Background: In England, a National Campaign to raise awareness and improve Dignity in Care was launched in November 2006 by the then Care Services Minister, Ivan Lewis amid increasing concerns around dignity in a number of health and social care settings. Review ofthe literature identified that no evaluation of this Dignity in Care campaign has beenundertaken to date within an acute healthcare NHS Trust. Aims and objectives: To examine patient experience in hospital related to dignity; Explore the understanding, attitude, roles and responsibilities of healthcare professionals to the Dignity in Care campaign; Explore their views on the range of initiatives developed to address the Dignity in Care campaign and; Gain an in-depth understanding of the challenges and enablers to changing practice to improve patient dignity. Methods: An illuminative evaluation was used to undertake this study, which has drawn on qualitative data from one to one interviews and a review of key documents within this acute healthcare Trust. Ten patients, fourteen healthcare professionals and ten senior managers and executives were interviewed with data analysed using framework analysis. Results: Six themes were identified: Patients experiences in hospital; understanding of, and attitude towards the dignity in care campaign; challenges and enablers related to the Dignity in Care campaign; improvements identified as supporting dignity for patients; dignity training workshops; and the wider issues raised around dignity. Conclusions: Aspects of vulnerability where patients were less able to advocate and protect themselves from a loss of dignity have been considered, as well as the distress caused by patients observing indignities towards other patients. A contrast in emphasis was revealed between the day to day experiences of patients and the focus of healthcare professionals, senior managers and executives on systems and initiatives to improve dignity that often failed to address the simple requirements of patients. In particular patients continued to experience mixed sex accommodation and a lack of care for patient’s privacy. However two enablers were identified, firstly, the use of ‘Red Pegs’ on closed curtains around bed spaces to improve privacy and prevent intrusions was a particularly effective tool that engaged a wide range of staff; there are currently no published studies evaluating their effectiveness. Secondly, a key enabler to improve patient dignity was the use of personal commitments from Dignity Training workshops which was identified as an effective tool to stimulate both practical and behavioural change. The particular context of this Trust and challenges relating to a recent merger can be seen to have influenced the change processes and outcomes from the Dignity in Care campaign within the organisation.

In hospitals, evacuation of those with severe movement impairments can be highly problematic – for the patients, for the staff and for the other evacuees. It is critical to understand the performance of horizontal and vertical evacuation strategies, including the means by which people with reduced mobility can be assisted in stair descent. The work presented herein quantifies the performance of trained hospital staff in evacuating people with reduced mobility and specifies algorithms to explicitly represent the dynamics of these devices within evacuation models. Data collected from 32 trials in which a test subject was evacuated through 11 floors of Ghent University Hospital using four commonly used movement assistance devices: stretcher, carry chair, evacuation chair and rescue sheet are presented and analysed. From this, performance results are calculated for both male and female assist teams that include device preparation time, horizontal speeds, vertical speeds and overtaking potential in stairwells. By deriving a device performance evaluation metric a direct comparison of the relative efficiency of each device is made. The performance results form the basis of integrating movement devices into evacuation models. To demonstrate this, the buildingEXODUS model is enhanced to represent movement devices in hospital evacuation. Moving objects, including evacuation devices, are explicitly specified in the existing model functionality. Algorithms are developed to calculate the movement of devices along corridors, through doorways and in stairway descent, including a method of geometric decomposition of the hospital geometry. This new functionality addresses the key evacuation components of repeated patient collection, and has numerous applications, both in simulating hospital evacuation and in representing evacuation of other premises that include people with reduced mobility. This is demonstrated by a series of systematic test cases designed to highlight both the validity and the predicting capability of this method. The latter can be used to significantly enhance planning and diagnostic capabilities related to the evacuation of hospital and other healthcare facilities. It should help ensure that the adoption of new procedural and structural designs are better informed and that risk assessments and evidence-based analyses are better supported by data, understanding and simulation tools in the future.