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Charles Normand

Publications and source records attributed to Charles Normand.

34 records · Page 2Linked to original sources
PubMed2003

Economic evaluation of specialist cancer and palliative nursing: a literature review.

Little progress has been made in economic evaluation of specialist cancer and palliative care nursing. A literature review of economic studies of clinical nurse specialists (CNSs) was undertaken to assess how the measurement of economic outcomes has been tackled in the literature to date. The initial search found 400 studies. Abstracts from all the studies were reviewed but only 17 studies met the basic criteria for inclusion, reporting primary cost and outcomes data, and clearly specifying the role of a CNS. All of the studies but one focused on direct patient care rather than other CNS roles and were undertaken alongside effectiveness studies. The economic evaluations considered only a narrow range of costs, but a wide range of outcomes. Specific nursing outcomes were only reported in a minority of studies. None of the studies reported cost-effectiveness ratios. However, CNS interventions were reported to be both less costly and more effective than alternative forms of care, negating the need for further cost-effectiveness analysis. Overall, the papers were not of good quality, reducing the validity of the findings. Robust economic evaluations of the CNS role need to be undertaken. These should involve nursing researchers and practitioners so that evaluations reflect the complex and multidimensional nature of CNS care and meet the required standard of evidence to influence practice.

Cost-Benefit Analysis↗
PubMed2003

Economic evaluation of specialist cancer and palliative nursing: Macmillan evaluation study findings.

Economic evaluation of specialist nursing interventions is challenging because of the complex nature of interventions and the difficulty of describing nursing outcomes in simple ways. This article discusses data from a study of Macmillan specialist cancer nursing. Resource-use data and nursing-outcome data were collated from 76 case studies of patients referred to 12 specialist cancer and palliative nursing teams (home-based and hospital-based) in the UK. Specific outcomes related to nursing were defined, and cost and nursing outcome data were analysed together. The data suggested that patients who reported better nursing outcomes had a higher proportion of specialist nursing interventions than those reporting poor nursing outcomes (45% versus 25%). Also, the overall pattern of health-care use was different for those patients who reported positive nursing outcomes. This suggests that positive nursing outcomes can influence patients' access to other health services. The data supported specific hypotheses regarding ways that specialist nurses can influence the cost-effectiveness of care. These data do not constitute a comparative evaluation study, as no control group was identified. Such results are nevertheless important as this type of data has not been gathered previously.

Cost Control↗
PubMed2002

Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial.

OBJECTIVE: To assess the effectiveness of nurse led follow up in the management of patients with lung cancer. DESIGN: Randomised controlled trial. SETTING: Specialist cancer hospital and three cancer units in southeastern England. PARTICIPANTS: 203 patients with lung cancer who had completed their initial treatment and were expected to survive for at least 3 months. INTERVENTION: Nurse led follow up of outpatients compared with conventional medical follow up. OUTCOME MEASURES: Quality of life, patients' satisfaction, general practitioners' satisfaction, survival, symptom-free survival, progression-free survival, use of resources, and comparison of costs. RESULTS: Patient acceptability of nurse led follow up was high: 75% (203/271) of eligible patients consented to participate. Patients who received the intervention had less severe dyspnoea at 3 months (P=0.03) and had better scores for emotional functioning (P=0.03) and less peripheral neuropathy (P=0.05) at 12 months. Intervention group patients scored significantly better in most satisfaction subscales at 3, 6, and 12 months (P<0.01 for all subscales at 3 months). No significant differences in general practitioners' overall satisfaction were seen between the two groups. No differences were seen in survival or rates of objective progression, although nurses recorded progression of symptoms sooner than doctors (P=0.01). Intervention patients were more likely to die at home rather than in a hospital or hospice (P=0.04), attended fewer consultations with a hospital doctor during the first 3 months (P=0.004), had fewer radiographs during the first 6 months (P=0.04), and had more radiotherapy within the first 3 months (P=0.01). No other differences were seen between the two groups in terms of the use of resources. CONCLUSION: Nurse led follow up was acceptable to lung cancer patients and general practitioners and led to positive outcomes.

Aged↗
PubMed2002

Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis.

OBJECTIVE: To study the processes involved in and impact of mergers between NHS trusts, including the effect on management costs. DESIGN: Cross sectional study involving in depth interviews and documentary analysis; case study to compare savings in management costs between case trusts and control trusts. SETTING: Nine trusts (cross sectional study) and four trusts (case study) in London. PARTICIPANTS: 96 interviews with trust board members, other senior managers, clinicians, service managers, and representatives of health authorities, regional office, community health councils, local authorities, other trusts in the area, and primary care groups and trusts. MAIN OUTCOME MEASURES: Stated and unstated drivers, and impact of merger on delivery and development of services, management structures, and staff recruitment, retention, and morale. Effects of difference in trust size before and after the merger. Savings in management costs two years after merger. RESULTS: Some important drivers for merger are not publicly stated. Mergers had a negative effect on delivery of services because of a loss of managerial focus on services. Planned developments in services were delayed by at least 18 months. Trusts' larger sizes after mergers had unintended negative consequences, as well as predicted advantages. The tendency for one trust's management team to dominate over the other resulted in tension. No improvement in recruitment or retention of clinical and managerial staff was reported. Perceived differences in organisational culture were an important barrier to bringing together two or more organisations. Two years after merger, merged trusts had not achieved the objective of saving pound 500 000 a year in management costs. CONCLUSIONS: Important unintended consequences need to be accounted for when mergers are planned. Mergers can cause considerable disruptions to services, and require greater management support than previously acknowledged. Other organisations undergoing restructuring, such as primary care groups developing into primary care trusts and health authorities merging into strategic health authorities, should take these findings into account.

Attitude of Health Personnel↗
PubMed2002

Dual job holding practitioners in Bangladesh: an exploration.

This paper analyses the system of financial and non-financial incentives underlying job preferences of doctors in Bangladesh who work both in government health services and in private practice. The study is based on a survey of 100 government-employed doctors with private practice, across different levels of care and geographical areas. In-depth interviews were carried out in a sub-sample of 28 respondents. The study explores the beliefs and attitudes towards the arrangements of joint private/public practice, establishes profiles of fee levels and earnings and examines the options to change the incentive system in a way that ensures an increased involvement of dual job holding practitioners in the priority areas of care. Consultation fees were Tk120 on average (range Tk20-300) and found to be correlated with the qualification of the practice owner and the type of service offered. A majority of the respondents reported at least to double their government income by engaging in private practice. Significant predictors of total income included the number of patients seen in private practice (p=0.000), employment in a secondary or tertiary care facility (p=0.001) and ownership of premises for private practice (p=0.033). Age was found to be marginally significant (p=0.084). No association was found between total income and specialisation, private practice costs, level of government salary or a degree from abroad. The data suggest that doctors have adopted individual strategies to accommodate the advantages of both government employment and private practice in their career development, thus maximising benefit from the incentives provided to them e.g. status of a government job, and minimising opportunity costs of economic losses e.g. lower salaries. Commitment to government services was found to be greater among doctors in primary health care who reported they would give up private practice if paid a higher salary. Among doctors in secondary and tertiary care, the propensity to give up private practice was found to be low. Financial incentives that aim to increase numbers of doctors in rural areas, such as a non-private-practice allowance, are more likely to be appreciated by doctors who are at the beginning of their career. Improved training and career opportunities also appear to be of high importance for job satisfaction. Policy changes to ensure a better resource allocation to the priority areas of the health sector have to reflect an understanding of the incentives generated by the organisational and financial context within which dual job holding practitioners operate.

Ambulatory Care↗
PubMed2002

Livelihoods, nutrition and health in Dhaka slums.

OBJECTIVES: To identify groups within Dhaka slums that report similar patterns of livelihood, and to explore nutritional and health status. DESIGN: A random sample of households participated in a longitudinal study in 1995-1997. Socio-economic and morbidity data were collected monthly by questionnaire and nutritional status was assessed. Cluster analysis was used to aggregate households into livelihood groups. SETTING: Dhaka slums, Bangladesh. SUBJECTS: Five-hundred and fifty-nine households. MAIN OUTCOME MEASURES: Socio-economic and demographic variables, nutritional status, morbidity. RESULTS: Four livelihood groups were identified. Cluster 1 was the richest cluster with land, animals, business assets and savings. Loans as well as income were higher, which shows that this group was credit-worthy. The group was mainly self-employed and worked more days per month than the other clusters. The cluster had the second highest body mass index (BMI) score, and the highest children's nutrition status. Cluster 2 was a poor cluster and was mainly dependent self-employed. Savings and loans were lower. Cluster 3 was the most vulnerable cluster. Members of this group were mainly casual unskilled, and 40% were female-headed households. Total income and expenditure were lowest amongst the clusters. BMI and children's nutritional status were lowest in the slum. Cluster 4 was the second richest cluster. This group comprised skilled workers. BMI was the highest in this cluster and children's nutritional status was second highest. CONCLUSIONS: Cluster analysis has identified four groups that differed in terms of socio-economic, demographic and nutritional status and morbidity. The technique could be a practically useful tool of relevance to the development, monitoring and targeting of vulnerable households by public policy in Bangladesh.

Adult↗
PubMed2002

Clinical nurse specialists in palliative care. Part 1. A description of the MacMillan Nurse caseload.

Macmillan Nurses play a significant role in specialist palliative care services in the UK, providing direct and indirect services to patients with complex palliative care needs and to their families. Existing literature shows a developing understanding of the role; however, little detailed data exist regarding the clinical work that they undertake. This paper provides evidence from a major evaluation study, commissioned by Macmillan Cancer Relief. It reports the methods of data collection for the study and then goes on to use data from the evaluation to describe the caseload of Macmillan Nurses. Between September 1998 and October 1999, a team of researchers worked alongside 12 Macmillan teams for a period of 8 weeks with each team. Prospective data were gathered on all new referrals to the services within the 8-week period. This included demographic details, timing of referral, the nature and purpose of contacts, and interventions, recorded from case notes and Macmillan Nurse records. Where possible, a date of death was obtained for all patients. A total of 814 new patients were referred during the study period (range 45-114 per site). The most common reasons for referral were emotional care for the patient (57%), pain control (27%), and other physical symptoms (33%). Thirteen per cent of the patients referred to the services died within 1 week of referral while 40% died within 6 weeks; thus, a significant proportion of patient work is focused on care at the end of life. It is also noteworthy that one-third of patients were still alive, indicating that some patients are being cared for earlier in the illness trajectory. On average, each new patient referral received two or more 'face-to-face' visits and two follow-up phone calls within the 8-week period. It would appear that Macmillan Nurse teams have been successful in getting access to relevant patients. As with any service that provides a complex set of interventions, the Macmillan teams have to adapt and develop the services in each setting. Whilst it is clearly important for the development of a Macmillan service to be tailored to the local conditions, the evidence on diversity suggests that in some cases, stronger guidance, in partnership with both Macmillan Cancer Relief and core providers, may be justified.

Adult↗
PubMed2002

Clinical nurse specialists in palliative care. Part 2. Explaining diversity in the organization and costs of Macmillan nursing services.

In the UK, the work of Macmillan clinical nurse specialists in palliative care is now well established. There has been little research, however, into the organizational context in which these nurses operate and the implications for the services they deliver. We report on a major evaluation of the service delivery, costs, and outcomes of Macmillan nursing services in hospital and community settings. The study was based on eight weeks of fieldwork in each of 12 selected services. Data are presented from semi-structured interviews, clinical records, and cost analysis. We demonstrate wide variation across several dimensions: location and context of the services; activity levels; management patterns; work organization and content; links with other colleagues; and resource use. We suggest that such variation is likely to indicate the existence of both excellent practice and suboptimal practice. In particular, our study highlights problems in how teamwork is conceptualized and delivered. We draw on recent organizational theories to make sense of the heterogeneous nature of Macmillan nursing services.

Community Health Nursing↗
PubMed2002

Clinical nurse specialists in palliative care. Part 3. Issues for the Macmillan Nurse role.

The remit and boundaries of the Macmillan Nursing role in the UK have been called into question recently by a number of policy-driven changes. The rapid appointment of tumour site-specific nurses and the development of posts for palliative medicine, stemming originally from the Calman-Hine recommendations for reorganizing cancer services, have created unparalleled challenges of adaptation to new working practices and procedures. The extent to which Macmillan Nurses are adapting to these new demands was addressed as part of a major evaluation study of UK Macmillan Nursing in 12 sites commissioned by the UK charity Macmillan Cancer Relief. This paper draws upon semi-structured interviews with Macmillan Nurses (n = 44) and their key colleagues (n = 47). We found that differences of expectation between Macmillan Nurses and their managers about the appropriate focus of their work lead to problems of role ambiguity and role conflict; that Macmillan Nurses lack resources with which to develop an educative and consultative role and yet substitute for inadequacies in skills and knowledge of other health care staff; and that problems are associated in co-working with newly appointed cancer site-specific nurses and palliative medicine colleagues. Macmillan Nursing has a crucial role to play in meeting the objectives in the NHS Cancer Plan. However, in order to ensure that their expertise is used efficiently and effectively, there is an urgent need to clarify the nature and scope of the Macmillan Nurse role, to attend to issues of team working and to improve the skills of nonspecialist staff in palliative care.

Attitude of Health Personnel↗
PubMed2000

Assessing structure, process and outcome in palliative day care: a pilot study for a multicentre trial.

Palliative day care is an expanding service which remains under-researched. Study designs need to be developed to evaluate the costs and outcomes of the service in ways which are meaningful to patients, clinicians and policy-makers. At the same time, these must be open to the same criteria for rigour and reliability as techniques used elsewhere in health and social service evaluation. To this end, a developmental stage of exploratory research was undertaken at the start of a major multicentre trial of palliative day care to meet two clear aims: to understand more about the structure and processes of palliative day care, and to identify ways in which service outcomes could be evaluated and measured. In-depth observations at five palliative day care centres were undertaken across one health region. This provided a better understanding of the models, outcomes and processes of palliative day care in five different environments. Centres represented the spectrum of medical and social care models and findings were analysed using an organisational systems approach. The findings showed that, despite the lack of a national strategic approach to developing the service, the centres all provided a core set of services which were broadly similar. However, differences in philosophy, ownership, and organisation affected how the services were provided and may have an impact on the costs of the service. The study has provided a more in-depth understanding of palliative day care services in order to design an effective research strategy for evaluating a service which crosses the boundaries of health and social care.

Journal Article↗