Search

Objective: Long waiting times for elective hospital treatments are common in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. Methods: We carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ('Treatments') and people not on a waiting list ('Controls'). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited hospital treatment, with healthcare usage assessed over various healthcare settings. Wilcoxon signed-rank tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. Results: A total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. There was an increase (p < 0.0004) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, with 17.9 [interquartile-range: 4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. Conclusion: People waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible 'false economy' in failing to promptly resolve long elective waits. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to critically examine the effects of COVID-19 social discourses and policy decisions specifically on older adult volunteers in the UK, comparing the responses and their effects in England, Scotland, Wales and Northern Ireland, providing perspectives on effects of policy changes designed to reduce risk of infection as a result of COVID-19, specifically on volunteer involvement of and for older adults, and understand, from the perspectives of volunteer managers, how COVID-19 restrictions had impacted older people's volunteering and situating this within statutory public health policies. Design/methodology/approach: The study uses a critical discourse approach to explore, compare and contrast accounts of volunteering of and for older people in policy, and then compare the discourses within policy documents with the discourses in personal accounts of volunteering in health and social care settings in the four nations of the UK. This paper is co-produced in collaboration with co-authors who have direct experience with volunteer involvement responses and their impact on older people. Findings: The prevailing overall policy approach during the pandemic was that risk of morbidity and mortality to older people was too high to permit them to participate in volunteering activities. Disenfranchising of older people, as exemplified in volunteer involvement, was remarkably uniform across the four nations of the UK. However, the authors find that despite, rather than because of policy changes, older volunteers, as part of, or with the help of, volunteer involving organisations, are taking time to think and to reconsider their involvement and are renewing their volunteer involvement with associated health benefits. Research limitations/implications: Working with participants as co-authors helps to ensure the credibility of results in that there was agreement in the themes identified and the conclusions. A limitation of this study lies in the sampling method, as a convenience sample was used and there is only representation from one organisation in each of the four nations. Originality/value: The paper combines existing knowledge about volunteer involvement of and for older adults. [ABSTRACT FROM AUTHOR]

Background: Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. Methods: The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. Anticipated impact: SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. Conclusion: People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. Trial registration: ISRCTN12541454 https://doi.org/10.1186/ISRCTN12541454 [ABSTRACT FROM AUTHOR]

Background: There has been growing concern regarding increasing levels of post-traumatic stress (PTS) symptoms experienced by healthcare workers (HCW) in the UK, particularly following the COVID-19 pandemic. Objectives: PTS symptom typologies have been investigated in other adult populations using person-centred latent variable approaches, revealing profiles showing differing symptom levels and patterns. We aimed to explore typologies among clinical and non-clinical healthcare staff to elucidate heterogeneity of presentation. Methods: This was a retrospective study using referral data from treatment-seeking healthcare staff in the North of England (N = 1600). We employed latent profile analysis using the PTSD International Trauma Questionnaire domains as profile indicators. We included covariates relating to role-type, depression, anxiety and mental health concerns before March of 2020. Results: A model with six profiles fit the data best. Profile names were given as follows: ‘No symptom’; ‘Low symptom’; ‘Low symptom (moderate Sense of current threat (Th_dx) and Functional impairment (FI))’; ‘Moderate symptom (low Th_dx and high Avoidance (Av_dx))’; ‘Moderate symptom’; and ‘High symptom’. Covariates were shown to have differential predictive power on profile membership. Conclusions: The finding of profiles with pattern differences suggests a need for both differential and specifically targeted treatments, as well as a consideration of early intervention for those individuals with subclinical PTS symptoms. As expected, anxiety and depression were both predictors of several of the symptomatic profiles, with anxiety producing a larger effect. Further research is required [ABSTRACT FROM AUTHOR]

Current research ethics frameworks were developed on the footprint of biomedical, experimental research and present several pitfalls when applied to non-experimental social sciences. This work explores how the normative principles underpinning policy and regulatory frameworks of research ethics and the related operational processes work in practice in the context of collaborative health and social care research. The work was organised in three phases. First, UK research ethics policy documents were analysed thematically, with themes further organised under the categories of 'Principles' and 'Processes'. Next, we conducted a scoping review of articles about research ethics in the context of collaborative health and social care research, published in English between 2010 and 2022. We then held an exploratory focus group with ten academic researchers with relevant experience to gather their views on how the research ethics system works in practice in England (UK). The thematic framework developed in the first phase supported the analysis of the articles included in the scoping review and of focus group data. The analysis of policy documents identified twelve themes. All were associated to both a principle and a related operational process. The scoping review identified 31 articles. Across these, some themes were barely acknowledged (e.g., Compliance with legislation). Other themes were extensively covered (e.g., The working of Research Ethics Committees), often to discuss issues and limitations in how, in practice, the research ethics system and its processes deal with collaborative research and to suggest options for improvement. Focus group data were largely consistent with the findings of the scoping review. This work provides evidence of the poor alignment between how the research ethics system is normatively expected to work and how it works in practice and offers options that could make research ethics more fit for purpose when addressing collaborative research in health and social care. [ABSTRACT FROM AUTHOR]

Background: The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. Methods and findings: Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. Conclusions: These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable. Fabiola Eto and co-workers study variations in comorbidity, service use and health outcomes by ethnicity and socioeconomic position, among people aged 16-39 years. Author summary: Why was this study done?: Most studies of multimorbidity focus on older adults, and only a few have investigated multimorbidity in younger populations. The prevalence of multimorbidity is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. There is evidence showing that individuals with socioeconomic vulnerability experience poorer health outcomes, such as lower quality healthcare provision, premature death, and higher mortality rates. The association between early onset multimorbidity and poor health outcomes in ethnically and socially diverse populations in England remains underinvestigated. What did the researchers do and find?: We used primary and secondary healthcare electronic health records from 837,869 individuals of White, South Asian, and Black African/Caribbean ethnicity in England with early onset of multimorbidity who were registered with an English general practice between 2010 and 2020. We found that the early onset of multimorbidity was more common among minority ethnic groups (59% and 56%, in the South Asian and Black populations, respectively) than in the White population (42%) living in the UK. South Asians and Black individuals with early onset multimorbidity died earlier than White individuals with early onset multimorbidity (52 and 48 years old in the median, respectively, versus 61 years old). South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. In White groups, the cluster of individuals with the highest rates/odds of the outcomes was more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. What do these findings mean?: Our findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work highlights the need to ensure that public health policies are equitable and reach those living in socioeconomic deprivation and minority ethnic groups who are disproportionately and more severely affected by early onset multimorbidity. [ABSTRACT FROM AUTHOR]

Background: Community-based palliative out-of-hours services operate outside normal working hours. However, little is known about the provision and delivery of such care. Aim: The aim of this study was to describe types of provision and delivery of out-of-hours palliative care services provided by UK hospices. Methods: Survey questionnaires were emailed to 150 adult hospices in the UK. Quantitative data were analysed using SPSS and qualitative data subjected to thematic analysis. Findings: Responding hospices (n=57) provided the following types of support: telephone advice 72% (n=41); care at home 70% (n=40); and rapid response 35% (n=20). There were variations between services regarding referral mechanisms, availability and workforce, and integration with statutory services was limited. Conclusion: Variation in the type of provision and delivery of out-of-hours palliative care services alongside limited integration with statutory care have contributed to inequity of access to community-based palliative care, and potentially suboptimal patient and informal caregiver outcomes. [ABSTRACT FROM AUTHOR]

Background: In the United Kingdom, Emergency Departments (EDs) are under significant pressure due to an ever-increasing number of attendances. Understanding how the capacity of other urgent care services and the health of a population may influence ED attendances is imperative for commissioners and policy makers to develop long-term strategies for reducing this pressure and improving quality and safety. Methods: We developed a novel multi-granular stacked regression (MGSR) model using publicly available data to predict future mean monthly ED attendances within Clinical Commissioning Group regions in England. The MGSR combines measures of population health and health service capacity in other related settings. We assessed model performance using the R-squared statistic, measuring variance explained, and the Mean Absolute Percentage Error (MAPE), measuring forecasting accuracy. We used the MGSR to forecast ED demand over a 4-year period under hypothetical scenarios where service capacity is increased, or population health is improved. Results: Measures of service capacity explain 41 ± 4% of the variance in monthly ED attendances and measures of population health explain 62 ± 22%. The MGSR leads to an overall improvement in performance, with an R-squared of 0.79 ± 0.02 and MAPE of 3% when forecasting mean monthly ED attendances per CCG. Using the MGSR to forecast long-term demand under different scenarios, we found improving population health would reduce peak ED attendances per CCG by approximately 1000 per month after 2 years. Conclusion: Combining models of population health and wider urgent care service capacity for predicting monthly ED attendances leads to an improved performance compared to each model individually. Policies designed to improve population health will reduce ED attendances and enhance quality and safety in the long-term. [ABSTRACT FROM AUTHOR]

Objective: To explore the views, attitudes, and experiences of South Asian women in the UK regarding sexual health services.Methods: We performed virtual semi-structured interviews with South Asian women 18 and over living in the UK. We explored participants' experiences of accessing sexual health services, including contraception, smear tests and sexually transmitted infection (STI) tests. We coded interview transcripts and analysed them thematically.Results: From February to April 2021, we conducted 14 interviews with South Asian women between the ages of 18 and 40 living in England and Wales, from February to April 2021. We identified four overarching themes: Access to sexual health services, entry to sexual health services, quality of sexual health services and stigma associated with sexual health services. Important barriers to sexual health services include limited knowledge of local provision, stigma and shame, and concerns about confidentiality. Participants found it difficult to discuss their sexual health (with anyone) and were often being met with judgement and a lack of partnership from clinicians.Conclusion: Our results suggest that South Asian women are uncomfortable accessing sexual health services and communicating their sexual health concerns with health care professionals. Service providers should collaborate with community-based organisations to ensure that services are discrete, confidential, and culturally appropriate. [ABSTRACT FROM AUTHOR]

Background: Inter-organisational collaborations (IOCs) in healthcare have been viewed as an effective approach to performance improvement. However, there remain gaps in our understanding of what helps IOCs function, as well as how and why contextual elements affect their implementation. A realist review of evidence drawing on 86 sources has sought to elicit and refine context-mechanism-outcome configurations (CMOCs) to understand and refine these phenomena, yet further understanding can be gained from interviewing those involved in developing IOCs. Methods: We used a realist evaluation methodology, adopting prior realist synthesis findings as a theoretical framework that we sought to refine. We drew on 32 interviews taking place between January 2020 and May 2021 with 29 stakeholders comprising IOC case studies, service users, as well as regulatory perspectives in England. Using a retroductive analysis approach, we aimed to test CMOCs against these data to explore whether previously identified mechanisms, CMOCs, and causal links between them were affirmed, refuted, or revised, and refine our explanations of how and why interorganisational collaborations are successful. Results: Most of our prior CMOCs and their underlying mechanisms were supported in the interview findings with a diverse range of evidence. Leadership behaviours, including showing vulnerability and persuasiveness, acted to shape the core mechanisms of collaborative functioning. These included our prior mechanisms of trust, faith, and confidence, which were largely ratified with minor refinements. Action statements were formulated, translating theoretical findings into practical guidance. Conclusion: As the fifth stage in a larger project, our refined theory provides a comprehensive understanding of the causal chain leading to effective collaborative inter-organisational relationships. These findings and recommendations can support implementation of IOCs in the UK and elsewhere. Future research should translate these findings into further practical guidance for implementers, researchers, and policymakers. [ABSTRACT FROM AUTHOR]

Background: Health services are increasingly using digital tools to deliver care, and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care.Aim: To identify and understand the unintended consequences of online consultations in primary care.Design and Setting: Qualitative interview study in eight general practices using online consultation tools in South West and North West England between February 2019 and January 2020.Method: Thematic analysis of semi-structured interviews with 19 patients and 18 general practice staff.Results: Consequences of online consultations were identified that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with, and whether practices used online consultations as their preferred method for patients to contact the practice. Consequences were identified that limited increases in practice efficiency by creating additional work, isolation, and dissatisfaction for some staff.Conclusion: Unintended consequences often present operational challenges that are foreseeable and partly preventable. However, these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Process changes tailored to local circumstances are critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated information exchange that leads to diffuse relationships and a more transactional style of medicine. [ABSTRACT FROM AUTHOR]

Background: Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.Methods: A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.Results: Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.Conclusions: The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs. [ABSTRACT FROM AUTHOR]

This article explores one nation-one language ideology, which holds that a language is the glue and marker of an identity that fosters national unity and linguistic assimilation ideologies in the context of Latin-American migration to the United Kingdom. From ethnographic and sociocognitive approaches within critical discourse studies, the linguistic experiences of two Latin American immigrant mothers seeking health services and legal advice are analyzed. The study of their linguistic experiences sheds light on the social and political effects that language ideologies have by bringing about such consequences as physical aggression and family separation in underexplored institutions articulated by neoliberal policies. In this context, a nationalist ideology emerges that constructs borders and marginal social identities. [ABSTRACT FROM AUTHOR]

This study explored the perceptions of NHS employees working within a UK mental health trust in relation to the social impacts of the COVID‐19 pandemic. Questioning focussed on social isolation and desire to interact with others before and since COVID‐19; effects of safety measures including personal protective equipment and social distancing; and perceived influences of the pandemic on service users and social aspects of service delivery. All employees at an English NHS mental health service were invited to complete an anonymous online questionnaire (July–September 2020), resulting in 464 completed questionnaires. Response frequencies were summed across the total sample, and the influence of patient contact, age, and vulnerability to COVID‐19 were explored using pairwise comparisons. Approximately two thirds of employees felt there had been a fundamental change in how they felt about interacting with others, and many had lost confidence in their ability to relate emotionally to others. Respondents were keen to adhere to safety guidance, but the majority believed that face masks and social distancing could have a detrimental effect on communication and rapport within the workplace. Other concerns included passing on the virus, social isolation of employees and service users, and a reduction in community services. COVID‐19 safety measures may impact morale, communication, empathy, and the provision of client‐centred care. More generally, the pandemic has changed the attitudes of mental health workers towards social interaction, with younger employees reporting more mental health difficulties that may be linked to concerns about longer term social change. [ABSTRACT FROM AUTHOR]

Objectives: Cognitive stimulation therapy (CST) is a brief, non-pharmacological intervention for people with dementia, with an established evidence base for improving cognition and quality of life. It is widely implemented in National Health Service (NHS) settings, but little is known about its naturalistic use. The aim of this survey was to identify and explore inclusion criteria, dose and quality of CST across services in Great Britain (England, Scotland and Wales). Methods: All NHS memory clinics and services for people with dementia were contacted and asked to complete a mixed methods online survey on CST delivery in their service. Questions were centred on who provided CST, who received CST, the dose of CST and any outcomes that were routinely measured. Results: A total of 57/186 services responded, giving a response rate of 30.7%. While the majority reported offering CST (87.7%), there was variability in how this was delivered. Differing inclusion criteria included the use of varying cognitive and behavioural outcome measures, and CST was reported as being offered once and twice weekly. Services also differed in how they evaluated the quality of CST and how this evidence was incorporated for future sessions. Conclusion: While there was a low response rate, this survey indicates that there is significant variability in how CST is used in clinical practice, with many trusts not adhering to the evidence base. To ensure that people with dementia are consistently offered evidence-based, high-quality CST across NHS settings, further standardisation of inclusion criteria, dose and outcomes is needed. [ABSTRACT FROM AUTHOR]

Background: Families of children with developmental delays (DD) prior to the COVID-19 pandemic experienced inequalities in accessing health and social care services. Measures put in place to combat the spread of the coronavirus have potentially exacerbated existing inequalities and have led to additional pressures for these families. Methods: We carried out a cross-sectional online survey of parents of young children with moderate to severe DD and challenging behaviors living in England, UK. We asked about the impact the pandemic has had on their family well-being, receipt of support, and post COVID-19 concerns. Results: Eighty-eight parents who are participants in an ongoing clinical trial (EPICC-ID) reported a broad range of challenges they faced during the pandemic: lack of information specific to children with DD; difficulties following social distancing and isolation rules; disruption or pause of health and social care services; deterioration in parental mental health and regression of the child's skills. Future access to services, negative long-term impact of school closures, parental unemployment were the parents' main post-COVID-19 concerns. Conclusions: Families of children with significant developmental delays fear lasting impact of the pandemic on their own psychological and material wellbeing and on their child's health. These families require urgent help to meet major health and social care needs and should be prioritized within an overall children's mental health strategy. The article includes a commentary from parents with lived experience. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to explore the effects of COVID-19 and the lockdown measures adopted in England on patients with acute mental illness.Methods: The authors analyzed referrals to the crisis resolution and home treatment (CRHT) team and inpatient admissions to acute adult wards, at Leicestershire Partnership National Health Service Trust, an integrated community and mental health trust in the United Kingdom. Number of CRHT referrals and inpatient admissions during a 4-week period starting March 16, 2020 ("COVID-19 period"), was studied and compared with the same period in 2018 and 2019 ("control periods"). Demographic and clinical characteristics of patients admitted during the COVID-19 period were compared with those admitted during the 2019 control period.Results: The number of CRHT referrals and inpatient admissions were lower during the COVID-19 period, compared with the control periods, by approximately 12% and 20%, respectively. Patients admitted during the COVID-19 period were significantly more often detained under the Mental Health Act and were considered to pose a risk of aggression. The pattern of diagnoses differed significantly between 2020 and 2019. A higher percentage of patients admitted during the COVID-19 period were diagnosed as having nonaffective psychotic disorders (52% versus 35%) or bipolar disorder (25% versus 15%), and fewer received a diagnosis of depression (8% versus 16%), anxiety disorder (0% versus 3%), adjustment disorder (0% versus 8%), emotionally unstable personality disorder (6% versus 15%), or any other personality disorder (0% versus 5%) (p=0.01).Conclusions: These findings suggest that the pandemic has profoundly affected care by acute mental health services. [ABSTRACT FROM AUTHOR]

Psychological problems are common among people with inflammatory bowel disease (IBD) following stoma surgery. However, the ways in which stoma-related psychological needs are identified and addressed in health care settings remain unexplored. In this study, we investigated the perspectives of young people with a stoma and health care professionals about access to psychological support. Semi-structured interviews were conducted with young people with an IBD stoma (18–29 years, n = 13) and health care professionals (n = 15), including colorectal surgeons, gastroenterologists, specialist nurses in IBD and stoma care, and general practitioners in England. Data collection and analysis were informed by constructivist grounded theory. Three analytic categories were developed: "initiating support-seeking," "affirming psychological needs," and "mobilizing psychological support," which capture young peoples' trajectory to access psychological support. Based on the findings, we highlight the need for both patients and health care professionals to assign greater priority to the identification of psychological symptoms post-stoma surgery. More effective care pathways, which include responsive psychological services, would enhance access to psychological support for young people with a stoma. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems. Methods: This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales. Results: Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach. Conclusions: We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice. [ABSTRACT FROM AUTHOR]

Background - Across the UK there has been a reduction in children and young people (CYP) presenting acutely to hospital during the COVID-19 pandemic. Automated telephone messages have been used as a tool by General Practice to direct service users to the correct service or point of care for some time. As such, it is unsurprising that automated messages may be used to try to address some questions about the pandemic prior to speaking t impossible o a call handler at a practice. Aim - To investigate the initial advice that parents and carers may be receiving from their first point of contact when telephoning their local General Practice (GP) and whether this considered CYP specifically. Design and Setting - This descriptive study was conducted in response to rapid changes which GP have had to undergo in response to the current global pandemic. Method - GPs within four Clinical Commissioning Groups (CCGs) in England were telephoned and the researches recorded whether they had automated messaging and whether certain key pieces of information were given in these messages. It was particularly noted whether any age segmentation was applied in the advice given. Results - Of the 537 practices included, 81.9% (n=440) had an automated message, and of those, 65.9% (n=290) mentioned 'coronavirus' or 'COVID-19' in their message. Only 1.1% (n=5) practices mentioned children specifically. Conclusion - Adapting the messaging that parents receive when they first contact GP to include CYP would be possible and may reduce the number of unwell CYP who have delays in receiving medical care. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to make the case that there is a need to move beyond a focus on an approach to leadership development which is confined to health care only. It argues that, given the economic, financial, social and organisational context within which health and social care organisations in the UK operate, there is a need to develop leadership within health and social care systems, rather than within the existing "siloed" sectors. Design/methodology/approach: The paper considers the context within which health and social care organisations in the UK operate; examines the nature of those organisations; makes the case for focusing on the health and social car system through systems leadership; and identifies the need for leadership, rather than leader development. Findings: There is a danger of health and social care organisations "walking backwards into the future" with eyes fixed on the past. The future lies with treating health and social care as a system, rather than focusing on organisations. The current model is individual leader focused, but the emerging model is one of collective multi-agency teams. Originality/value: The paper seeks to go beyond a health-care-only focus, by asserting that there is a need to regard health and social care as a single system, delivered by a multiplicity of different organisations. This has implications for the kind of leadership involved and for how this might be developed. [ABSTRACT FROM AUTHOR]

Survival times for prostate cancer have increased substantially, meaning more survivors will be discharged to General Practitioners' (GP) services. The detection of recurrence and monitoring of symptoms and long‐term side‐effects in prostate cancer survivors requires the active involvement of GPs in their follow‐up care. In order to address this, the transition and discharge from hospital to primary care must be managed effectively. The objective of this study was to examine the preparedness, concerns and experiences of GPs in relation to their role in providing follow‐up care to prostate cancer survivors. Purposive sampling was used to recruit GPs with experience in providing care to prostate cancer survivors. Twenty semi‐structured telephone interviews were conducted with GPs across England. The interviews were audio‐recorded, transcribed verbatim and analysed using thematic analysis. Participants described their current role in the follow‐up pathway, a number of challenges and barriers in assuming this role, and potential ways to resolve these and improve their involvement. They expressed a range of views about their preparedness and willingness to take over follow‐up care after discharge for this group of patients. GPs had reservations about workload, lack of resources, expertise and deficiencies in communication with hospitals. Findings from this study suggest that GPs will be ready to take over the follow‐up care of prostate cancer survivors if better information, additional training and adequate resources are provided and communication lines with hospital specialists are clear. Understanding the issues faced by GPs and overcoming identified barriers to providing follow‐up care to prostate cancer survivors will provide the insight necessary to make the process of transferring care from secondary to primary teams a more straightforward task for all stakeholders. [ABSTRACT FROM AUTHOR]

Background: Provision of care and support for people with dementia and family carers is complex, given variation in how dementia manifests, progresses and affects people, co-morbidities associated with ageing, as well as individual preferences, needs, and circumstances. The traditional service-led approach, where individual needs are assessed against current service provision, has been recognised as unfit to meet such complexity. As a result, people with dementia and family members often fail to receive adequate support, with needs remaining unmet. Current research lacks a conceptual framework for explaining variation in satisfaction of care needs. This work develops a conceptual framework mapped onto the care delivery process to explain variations in whether, when and why care needs of people with dementia are met and to expose individual-, service-, system-level factors that enable or hinder needs satisfaction.Methods: Data collected through 24 in-depth interviews and two focus groups (10 participants) with people with dementia and family carers living in the North East of England (UK) were analysed thematically to develop a typology of care needs. The need most frequently reported for people with dementia (i.e. for support to go out and about) was analysed using themes stemming from the conceptual framework which combined candidacy and discrepancy theories.Results: The operationalisation of the framework showed that satisfaction of the need to go out was first determined at the point of service access, affected by issues about navigation, adjudication, permeability, users' resistance to offers, users' appearance, and systems-level operating conditions, and, subsequently, at the point of service use, when factors related to service structure and care process determined (dis)satisfaction with service and, hence, further contributed to met or unmet need.Conclusion: The conceptual framework pinpoints causes of variations in satisfaction of care needs which can be addressed when designing interventions and service improvements. [ABSTRACT FROM AUTHOR]

In this article the author talks about health professionals who are members of CoramBAAF are at the frontline of the fight with the virus and some medical advisers and health professionals working with looked after children have been redeployed from their substantive roles to work in other areas of health care provision. It mentions that Health service interventions and assessments are critical components of adoption and fostering work.

Background/Introduction: In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STIs), but it is unclear whether this varies by their region of birth. Aim(s)/Objectives: To examine differences in STI diagnoses among UK- and Caribbean-born BC people. Methods: Data on STI diagnoses in BC people attending specialist sexual health services (SHSs) during 2015 and living in England were obtained from the GUMCAD STI surveillance system, the national surveillance system for STIs in England. Associations between being UK- or Caribbean-born and each of several STI diagnoses were examined, using univariate and multivariable generalised estimated equations logistic regression models adjusted for sexual orientation, place of residence (London vs. non-London), HIV status, area-level deprivation, and STI diagnosis in the last year. All analyses were stratified by age (<25 vs. ≥25 years). Results: In 2015, 63,568 BC people made 108,881 attendances at specialist SHSs; 81.9% of these attendances were made by UK-born BCs. The median age (years) was 26 for UK-born and 35 for Caribbean-born people (p≤0.001). Chlamydia, gonorrhoea and non-specific genital infection (NSGI) were the most commonly diagnosed STIs among UK- (5.8%, 2.1% and 2.8%) and Caribbean-born people (4.5%, 1.7% and 3.5%) respectively. Among BCs aged under 25, no significant differences in STIs were found between UK- and Caribbean-born people. Among BCs aged ≥25, compared to Caribbean-born people, those who were UK-born were more likely to be diagnosed with chlamydia (AOR 1.15 [95%C.I. 1.04–1.27]); gonorrhoea (AOR 1.23 [95%C.I. 1.06–1.45]) and genital herpes (AOR 1.23 [95% C.I. 1.10–1.56]) and less likely to be diagnosed with NSGI (AOR 0.89 [95% C.I. 0.80–0.99]) and Trichomoniasis (AOR 0.84 [95% C.I. 0.71–0.99]). Discussion/Conclusion: STI diagnoses in BC people aged ≥25 attending specialist SHSs vary by region of birth. Country of birth may have an influence on social and sexual networks and therefore transmission of STIs. [ABSTRACT FROM AUTHOR]

Background routine frailty identification and management is national policy in England, but there remains a lack of evidence on the impact of frailty on healthcare resource use. We evaluated the impact of frailty on the use and costs of general practice and hospital care. Methods retrospective longitudinal analysis using linked routine primary care records for 95,863 patients aged 65–95 years registered with 125 UK general practices between 2003 and 2014. Baseline frailty was measured using the electronic Frailty Index (eFI) and classified in four categories (non, mild, moderate, severe). Negative binomial regressions and ordinary least squares regressions with multilevel mixed effects were applied on the use and costs of general practice and hospital care. Results compared with non-frail status, annual general practitioner consultation incidence rate ratios (IRRs) were 1.24 (95% CI: 1.21–1.27) for mild, 1.41 (95% CI: 1.35–1.47) for moderate, and 1.52 (95% CI: 1.42–1.62) for severe frailty. For emergency hospital admissions, the respective IRRs were 1.64 (95% CI 1.60–1.68), 2.45 (95% CI 2.37–2.53) and 3.16 (95% CI: 3.00–3.33). Compared with non-frail people the IRR for inpatient days was 7.26 (95% CI 6.61–7.97) for severe frailty. Using 2013/14 reference costs, extra annual cost to the healthcare system per person was £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty. This equates to a total additional cost of £5.8 billion per year across the UK. Conclusions increasing frailty is associated with substantial increases in healthcare costs, driven by increased hospital admissions, longer inpatient stay, and increased general practice consultations. [ABSTRACT FROM AUTHOR]

The National Institute for Health Research (NIHR) aims to improve national 'health and wealth' by providing infrastructural support to enable clinical research in National Health Service settings in England and Wales. Cognisant of the consequences of studies' failure to achieve required numbers of participants, it also actively campaigns to promote patient awareness of research, and willingness to participate in trials. In this paper, we analyse recent NIHR campaigns and policies designed to encourage patients to participate in clinical research to interrogate how they are implicated in the national bioeconomy. In doing so we expand the notion of 'clinical labour' to include the work of patient recruitment and highlight an emergent obligation on patients to contribute to research processes. Whereas once patient knowledge and experience may have been devalued, here we draw on the concept of 'assetisation' (Birch 2012) to explore the emergent relationship between healthcare system and patient as research participant. We consider how patients' contribution goes beyond the provision of standardised objects of valuation so that patients themselves may be perceived as assets to, not only recipients of, the national healthcare system. [ABSTRACT FROM AUTHOR]

This paper analyses how the UK national press has covered local decision-making on options for the integration of health and social care. In England, as part of a major restructuring of health services, the UK government has devolved significant decisions on reorganising services to local areas. This increasing 'localism' in healthcare has been a global trend, albeit an uneven one. The article assesses the insights of Amitai Etzioni and others, as applied to national newspaper coverage of local decisions. It finds Etzioni's analysis to be not fully supported. Following other journalism research on the NHS, we show that contentious points of wider public interest were little reported on, such as international corporate influence and the potential for fragmentation across a national health service. [ABSTRACT FROM AUTHOR]

Aim: To test the hypothesis that children and young people with neurological conditions who missed outpatient appointments have more emergency inpatient admissions and Accident and Emergency centre (A&E) visits than those who missed none.Method: Retrospective cohort of individuals aged up to 19 years with neurological conditions, identified from routine hospital data in England, UK from April 1st, 2003 to March 31st, 2015 using an International Statistical Classification of Diseases and Related Health Problems, coding framework. Counts of emergency inpatient admissions and A&E visits per person per year were modelled (random intercept negative binomial regression) with outpatient attendance the independent variable of interest.Results: The cohort numbered 524 613 individuals. Those who missed outpatient appointments had 19 per cent (95% confidence interval [CI] 18-19) more emergency inpatient admissions and 16 per cent (95% CI 15-17) more A&E visits per year than those who missed none. 'Did not attends' had a larger increase in unplanned health care than patient or provider cancellations. If no appointments were missed, the models predict there would have been 107 000 fewer A&E visits from 2007/2008 to 2014/2015 and 104 000 fewer emergency inpatient admissions from 2003/2004 to 2014/2015.Interpretation: Missed outpatient appointments were associated with increased unplanned health care. Improving outpatient attendance may have the potential to reduce emergency inpatient admissions and A&E visits.What This Paper Adds: Missed outpatient appointments by children and young people with neurological conditions are associated with increased unplanned health care. Both emergency inpatient admissions and Accident and Emergency centre visits are increased. 'Did not attends' are more strongly associated with unplanned health care than cancellations. [ABSTRACT FROM AUTHOR]

Applying the main principles of the social model of disability as a guide, this article argues that the attitudes and beliefs of staff and volunteers employed in frontline service delivery can play an important role in the achievement of dementia-friendly communities, particularly through influencing the types of services offered. This position is supported by findings from an evaluation of an awareness-raising intervention run by Age UK, aimed at organisations which provide services for people living with dementia in England. The article contributes to an understanding of the cultural climate within frontline service delivery, which is often neglected in favour of discussions around meeting more immediate care and support needs. More specifically, the article reflects on whether there is a need for an additional conceptualisation within the discourse around dementia-friendly communities which ensures inclusion of the cultural environment. [ABSTRACT FROM AUTHOR]

This study examines how patients conceptualize "responsibility" for their healthcare and make sense of the complex boundaries between patient and professional roles. Focusing on the specific case of patient safety, narrative methods were used to analyze semistructured interviews with 28 people recently discharged from hospital in England. We present a typology of attribution, which demonstrates that patients' attributions of responsibility to staff and/or to patients are informed by two dimensions of responsibility: basis and contingency. The basis of responsibility is the reason for holding an individual or group responsible. The contingency of responsibility is the extent to which that attribution is contextually situated. The article contributes to knowledge about responsibility in complex organizational environments and offers a set of conceptual tools for exploring patients' understanding of responsibility in such contexts. There are implications for addressing patient engagement in care, within and beyond the field of patient safety. [ABSTRACT FROM AUTHOR]

Background: Nausea and vomiting of pregnancy (NVP) is the most prevalent medical condition associated with pregnancy. The Royal College of Obstetricians and Gynaecologists published its first guidelines for management of NVP in 2016, although many current treatments are off label, with only one recently licensed treatment for NVP in the UK.Aim: To identify the current practices for NVP management across the patient pathway, and estimate the economic burden to NHS services.Design and Setting: This was an observational, retrospective research study conducted in the Newcastle Gateshead Clinical Commissioning Group (CCG) health economy area in England.Method: Data were collected from GP practices, local hospital datasets, ambulance services (April 2013-March 2016), and the Hospital Episode Statistics dataset (2006-2016).Results: Eight GP practices participated in the study. In all, 15.2% of the total pregnant population presented with NVP. Treatment varied significantly between GP practices, and 33.6% of women re-presented to their GP. There was an annual increase in women admitted to hospital for NVP symptoms, with increasing length of stay per admission. Almost half (44.6%) of the calls to 999/111 from women experiencing NVP symptoms resulted in an ambulance dispatch. The annual cost of NVP to this health economy was estimated to be £199 804, which crudely extrapolates to £25 758 731 at UK level. Due to underestimations of costs, the impact to the UK NHS could be up to £62 373 961.Conclusion: There is considerable variation in current management practices for NVP outside of recently published guidelines, and this may result in substantial resource use and avoidable financial impact to the NHS. [ABSTRACT FROM AUTHOR]

COVID-19 is a significant worldwide challenge to many healthcare systems. In Trauma and Orthopaedics, there has been a significant change in the workload but departments have been compelled to change their practice in order to match the demand, as well as respond to the escalating situation of COVID. Some guidance is available on these changes from bodies such as the National Health Service (NHS), Public Health England and the British Orthopaedic Association (BOA). We have implemented certain changes in our university district general hospital trauma and orthopaedic department with regard to staff roles, outpatient and inpatient care and operative protocols. We aim to present some of these changes and their effects on patient care in an attempt to share these with colleagues who may face similar pressures and make some recommendations to help others prepare for a possible second wave of COVID-19. [ABSTRACT FROM AUTHOR]

Phosphodiesterase inhibitors (such as sildenafil) and endothelin receptor antagonist, bosentan, are effective for digital ulcer disease in systemic sclerosis (SSc-DU) and are endorsed in international treatment recommendations. Commissioning of high-cost drugs, such as bosentan, however, differs across devolved nations of the UK. We report a multicentre service evaluation project to examine 'real world' management of SSc-DU before and following the 2015 UK Scleroderma Study Group (UKSSG) guidance, across southwest (SW) England and Wales. Results showed that iloprost and sildenafil use for SSc-DU was higher in patients in Wales prior to 2015. Between 2015-2017, sildenafil use for SSc-DU increased in SW England while remaining stable in Wales. Bosentan use for SSc-DU after 2015 in SW England increased, while remaining stable and proportionately lower in Wales. These findings demonstrate that differing commissioning guidance across devolved nations of the UK seems to contribute to geographic variation in patient care. [ABSTRACT FROM AUTHOR]

Background: A '1-hour protected supervision model' is well established for Psychiatry trainees. This model is also extended to GP trainees who are on placement in psychiatry. Aim: To explore the experiences of the '1-hour protected supervision model' for GP trainees in psychiatry placements in the UK. Methods: Using a mixed methods approach, an anonymous online questionnaire was sent to GP trainees in the North West of England who had completed a placement in Psychiatry between February and August 2015. Results: Discussing clinical cases whilst using the e-portfolio was the most useful learning event in this model. Patient care can potentially improve if a positive relationship develops between trainee/ supervisor, which is impacted by the knowledge of this model at the start of the placement. Trainees found that clinical pressures were impacting on the occurrence of supervision. Conclusion: The model works best when both GP trainees and their supervisors understand the model. The most frequently used and educationally beneficial aspect for GP trainees in psychiatry is the exploration of clinical cases using the learning portfolio as an educational tool. For effective delivery of this model of supervision, organisations must reflect on the balance between service delivery and allowing the supervisor and trainee adequate time for it to occur. [ABSTRACT FROM AUTHOR]

Objectives To explore the role of integrated commissioning in improving the transition of young people with long-term conditions from child to adult services. We aimed to identify organizational and policy gaps around transition services and provide recommendations for integrated commissioning practice. Methods Semi-structured in-depth interviews were conducted with two groups of participants: (1) twenty-four stakeholders involved in the commissioning and provision of transition services for young people with long-term conditions in two regions in England; (2) five professionals with national roles in relation to planning for transition. Transcripts were interrogated using thematic analysis. Results There is little evidence of integrated commissioning for transitional care for young people with long-term conditions. Commissioners perceive there to be a lack of national and local policy to guide integrated commissioning for transitional care; and limited resources for transition. Furthermore, commissioning organizations responsible for transition have different cultures, funding arrangements and related practices which make inter- and intra-agency co-ordination and cross-boundary continuity of care difficult to achieve. Conclusions Integrated commissioning may be an effective way to achieve successful transitional care for young people with long-term health conditions. However, this innovative relational approach to commissioning requires a national steer together with recognition of common values and joint ownership between relevant stakeholders. [ABSTRACT FROM AUTHOR]

Background: The objective of the study is to analyze procedural and safety outcomes associated with bariatric surgery and describe the characteristics of patients undertaking bariatric procedures in England between April 2006 and March 2012.Methods: This is a retrospective cohort study of all adult patients in England diagnosed with obesity and undergoing bariatric surgery as a primary procedure in NHS-funded sites between April 2006 and March 2012 using data sourced from the Hospital Episode Statistics dataset. Length of stay (LOS), 30-day readmission, and post-surgery complication were analyzed as primary outcomes. Socio-demographic background, provider type, procedure volume, and comorbidities were all analyzed as potential explanatory variables.Results: Gastric bypass (GBP, 12,628) was the most utilized procedure, followed by gastric banding (GB, 6872) and sleeve gastrectomy (SG, 3251). The most prevalent comorbidity was type 2 diabetes (23%). Inpatient mortality was low (≤ 0.15%) for all procedure types. LOS and the risks of both post-operative complication and 30-day readmission were significantly lower for GB, relative to those for GBP and SG. Ethnicity, geographical area, surgery type, and volume were all associated with LOS, risk of readmission, and complication. Provider type and deprivation were further associated with LOS while age correlated with readmission only. An increasing comorbidity burden was associated with an increased risk of both readmission and complication.Conclusions: Gastric bypass was the most frequently reported procedure in England across the observation period. While utilization across all procedure types increased between 2007 and 2010, overall uptake of bariatric surgery in England represents only a small proportion of the eligible population. Readmission and complication rates were lower for gastric banding relative to those for either gastric bypass or sleeve gastrectomy. The observed inpatient mortality rate was low across all procedure types. [ABSTRACT FROM AUTHOR]

Purpose: Forensic services provide care for mentally disordered offenders. In England this is provided at three levels of security-low, medium and high. Significant number of patients within these settings remain detained for protracted periods of time. This is both very costly and restrictive for individuals. No national studies have been conducted on this subject in England.Methods: We employed a cross-sectional design using anonymised data from medical records departments in English secure forensic units. Data were collected from a large sample of medium secure patients (n = 1572) as well as the total high secure patient population (n = 715) resident on the census date (01-04-2013). We defined long-stay as a stay of more than 10 years in high, 5 years in medium or 15 years in a mix of high and medium secure settings. Long-stay status was assessed against patient demographic and admission information.Results: We identified a significant proportion of long-stayers: 23.5% in high secure and 18.1% in medium secure care. Amongst medium secure units a large variation in long-stay prevalence was observed from 0 to 50%. Results indicated that MHA section, admission source and current ward type were independent factors associated with long-stay status.Conclusion: This study identified a significant proportion of long-stayers in forensic settings in England. Sociodemographic factors identified in studies in individual settings may be less important than previously thought. The large variation in prevalence of long-stayers observed in the medium secure sample warrants further investigation. [ABSTRACT FROM AUTHOR]

Background: The English community pharmacy New Medicine Service (NMS) significantly increases patient adherence to medicines, compared with normal practice. We examined the cost effectiveness of NMS compared with normal practice by combining adherence improvement and intervention costs with the effect of increased adherence on patient outcomes and healthcare costs.Methods: We developed Markov models for diseases targeted by the NMS (hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma and antiplatelet regimens) to assess the impact of patients' non-adherence. Clinical event probability, treatment pathway, resource use and costs were extracted from literature and costing tariffs. Incremental costs and outcomes associated with each disease were incorporated additively into a composite probabilistic model and combined with adherence rates and intervention costs from the trial. Costs per extra quality-adjusted life-year (QALY) were calculated from the perspective of NHS England, using a lifetime horizon.Results: NMS generated a mean of 0.05 (95% CI 0.00-0.13) more QALYs per patient, at a mean reduced cost of -£144 (95% CI -769 to 73). The NMS dominates normal practice with a probability of 0.78 [incremental cost-effectiveness ratio (ICER) -£3166 per QALY]. NMS has a 96.7% probability of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY. Sensitivity analysis demonstrated that targeting each disease with NMS has a probability over 0.90 of cost effectiveness compared with normal practice at a willingness to pay of £20,000 per QALY.Conclusions: Our study suggests that the NMS increased patient medicine adherence compared with normal practice, which translated into increased health gain at reduced overall cost.Trial Registration: ClinicalTrials.gov Trial reference number NCT01635361 ( http://clinicaltrials.gov/ct2/show/NCT01635361 ). Current Controlled trials: Trial reference number ISRCTN 23560818 ( http://www.controlled-trials.com/ISRCTN23560818/ ; DOI 10.1186/ISRCTN23560818 ). UK Clinical Research Network (UKCRN) study 12494 ( http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=12494 ).Funding: Department of Health Policy Research Programme. [ABSTRACT FROM AUTHOR]

Background: Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death.Methods: We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors.Results: One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40-9.90) and living with someone (OR 2.19, 1.33-3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14-5.03). Conversely, functional independence (OR 1.05, 1.04-1.06) and valuing quality of life (OR 3.11, 2.89-3.36) were associated with dying at home. There was a mismatch between preferences and achievements - of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference.Conclusion: Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply 'achieved preferences'. [ABSTRACT FROM AUTHOR]

Background: Risky drinking is associated with risky sexual experiences, however the relationship between alcohol and sex is complex. The aim of the study was to assess the feasibility of delivering alcohol screening and brief interventions in genitourinary medicine (GUM) clinics. The objectives were to; understand the levels of alcohol use amongst patients; report on the number of alcohol interventions delivered; and to analyse the relationship between alcohol use with demographic data as well as diagnosed sexually transmitted infections (STIs) to see if there were any associations.Methods: All new patients attending GUM between April 2012 and March 2013 self-completed the Alcohol Use Disorder Identification Test (AUDIT) prior to their clinical consultation. Where appropriate (scoring 8+ on AUDIT) the clinician would deliver up to 2-3 min of alcohol brief intervention. Descriptive statistics, t-tests, ANOVA and logistic regression were carried out as appropriate.Results: AUDIT scores were available for 90% of all new patients (3058/3390) with an average mean score of 7.75. Of those who drank alcohol, 44% were categorised as being AUDIT positive, including 2% who had a score indicative of probable alcohol dependence (20+). 55 % (n = 638) of patients who screened positive on the AUDIT received a brief intervention whilst 24% (n = 674) of drinkers were diagnosed with a STI. Logistic regression modelling revealed that males, younger age groups and those of 'white' ethnicity were more likely to score positive on AUDIT. Patients classified as non-students, living in deprivation quintiles one to four and categorised as probable alcohol dependence on the AUDIT were more likely to be diagnosed with an STI.Conclusion: It is possible to embed alcohol screening into routine practice within sexual health services however further work is required to embed brief interventions particularly amongst increasing risk drinkers. If resources are limited, services may consider more targeted rather than universal alcohol screening to specific population groups. The study was undertaken in one GUM service in the North East of England and therefore findings may not be generalizable. The study did not assess efficacy of alcohol brief intervention in this setting. [ABSTRACT FROM AUTHOR]

Background: For the past decade, Maternal Mortality Reports, published in the United Kingdom every three years, have consistently raised concerns about maternal observations in maternity care. The reports identify that observations are not being done, not being completed fully, are not recorded on Early Warning Score systems, and/or are not escalated appropriately. This has resulted in delays in referral, intervention and increases the risk of maternal morbidity or mortality. However there has been little exploration of the possible reasons for non-completion of maternal observations.Methods: The aim of this study was to explore midwives' experiences of performing maternal observations and escalating concerns in rural and urban maternity settings in the West Midlands of England. A qualitative design involving a series of six focus groups with midwives and Supervisors of Midwives was employed to investigate the facilitators of, and barriers to the completion of maternal observations.Results: Eighteen Midwives and 8 Supervisors of Midwives participated in a total of 6 focus groups. Three key themes emerged from the data: (1) Organisation of Maternal Observations (including delegation of tasks to Midwifery Support Workers, variation in their training, the care model used e.g. one to one care, and staffing issues); (2) Prioritisation of Maternal Observations (including the role of professional judgement and concerns expressed by midwives that they did not feel equipped to care for women with complex clinical needs; and (3) Negotiated Escalation (including the inappropriate response from senior staff to use of Modified Early Warning Score systems, and the emotional impact of escalation).Conclusions: A number of organisational and cultural barriers exist to the completion of maternal observations and the escalation of concerns. In order to address these the following actions are recommended: standardised training for Midwifery Support Workers, review of training of midwives to ensure it addresses the increasing complexity of the maternal population, identification and agreement regarding the organisation of maternal observations among staff, an emphasis on increasing the priority placed on maternal observations in all clinical settings, and clarification and reinforcement of escalation procedures for both midwives and senior clinicians. [ABSTRACT FROM AUTHOR]

Health care in England is predominantly provided free at the point of service through the publicly-funded National Health Service (NHS). Total NHS expenditure, which has risen in real terms by an average of 3.7 per cent per annum since the inception of the NHS in 1948, constituted 7.9 per cent of GDP in 2012. This paper presents a summary of the trends in medical expenditure in England together with, using detailed administrative data, an analysis of the growth over 15 years of expenditure and activity in hospital inpatient health care, which represents around 20-25 per cent of all NHS expenditure. We document the coincidence of observed trends in expenditure with reported activity, morbidity and the proximity of individuals to death. We find that: (i) expenditure for both elective and emergency inpatient care broadly follows activity, so that expenditure is mostly driven by activity rather than unit costs; (ii) expenditure is concentrated in individuals with multiple diseases, so that the prevalence and identification of complex medical conditions are important drivers of expenditure; and (iii) health care activity rises substantially for individuals in the period before death, so that expenditure is driven substantially by mortality in the population. Taken together, these findings indicate that this element of health care expenditure in England has been substantially driven by the underlying morbidity and age of the population in conjunction with improving health care technology. [ABSTRACT FROM AUTHOR]

Background: Biomedical Research Centres (BRCs) are partnerships between healthcare organisations and universities in England. Their mission is to generate novel treatments, technologies, diagnostics and other interventions that increase the country's international competitiveness, to rapidly translate these innovations into benefits for patients, and to improve efficiency and reduce waste in healthcare. As NIHR Oxford BRC (Oxford BRC) enters its third 5-year funding period, we seek to (1) apply the evidence base on how best to support the various partnerships in this large, multi-stakeholder research system and (2) research how these partnerships play out in a new, ambitious programme of translational research.Methods: Organisational case study, informed by the principles of action research. A cross-cutting theme, 'Partnerships for Health, Wealth and Innovation' has been established with multiple sub-themes (drug development, device development, business support and commercialisation, research methodology and statistics, health economics, bioethics, patient and public involvement and engagement, knowledge translation, and education and training) to support individual BRC research themes and generate cross-theme learning. The 'Partnerships' theme will support the BRC's goals by facilitating six types of partnership (with patients and citizens, clinical services, industry, across the NIHR infrastructure, across academic disciplines, and with policymakers and payers) through a range of engagement platforms and activities. We will develop a longitudinal progress narrative centred around exemplar case studies, and apply theoretical models from innovation studies (Triple Helix), sociology of science (Mode 2 knowledge production) and business studies (Value Co-creation). Data sources will be the empirical research studies within individual BRC research themes (who will apply separately for NHS ethics approval), plus documentary analysis and interviews and ethnography with research stakeholders. This study has received ethics clearance through the University of Oxford Central University Research Ethics Committee.Discussion: We anticipate that this work will add significant value to Oxford BRC. We predict accelerated knowledge translation; closer alignment of the innovation process with patient priorities and the principles of responsible, ethical research; reduction in research waste; new knowledge about the governance and activities of multi-stakeholder research partnerships and the contexts in which they operate; and capacity-building that reflects the future needs of a rapidly-evolving health research system. [ABSTRACT FROM AUTHOR]

Background: NHS specialist chronic fatigue syndrome (CFS/ME) services in England treat approximately 8000 adult patients each year. Variation in therapy programmes and treatment outcomes across services has not been described.Methods: We described treatments provided by 11 CFS/ME specialist services and we measured changes in patient-reported fatigue (Chalder, Checklist Individual Strength), function (SF-36 physical subscale, Work & Social Adjustment Scale), anxiety and depression (Hospital Anxiety & Depression Scale), pain (visual analogue rating), sleep (Epworth, Jenkins), and overall health (Clinical Global Impression) 1 year after the start of treatment, plus questions about impact of CFS/ME on employment, education/training and domestic tasks/unpaid work. A subset of these outcome measures was collected from former patients 2-5 years after assessment at 7 of the 11 specialist services.Results: Baseline data at clinical assessment were available for 952 patients, of whom 440 (46.2%) provided 1-year follow-up data. Treatment data were available for 435/440 (98.9%) of these patients, of whom 175 (40.2%) had been discharged at time of follow-up. Therapy programmes varied substantially in mode of delivery (individual or group) and number of sessions. Overall change in health 1 year after first attending specialist services was 'very much' or 'much better' for 27.5% (115/418) of patients, 'a little better' for 36.6% (153/418), 'no change' for 15.8% (66/418), 'a little worse' for 12.2% (51/418), and 'worse' or 'very much worse' for 7.9% (33/418). Among former patients who provided 2- to 5-year follow-up (30.4% (385/1265)), these proportions were 30.4% (117/385), 27.5% (106/385), 11.4% (44/385), 13.5% (52/385), and 17.1% (66/385), respectively. 85.4% (327/383) of former patients responded "Yes" to "Do you think that you are still suffering from CFS/ME?" 8.9% (34/383) were "Uncertain", and 5.7% (22/383) responded "No".Conclusions: This multi-centre NHS study has shown that, although one third of patients reported substantial overall improvement in their health, CFS/ME is a long term condition that persists for the majority of adult patients even after receiving specialist treatment. [ABSTRACT FROM AUTHOR]

The Transforming Cancer Services Team (TCST) in London has produced comprehensive commissioning guidance for commissioners to improve the commissioning of lymphoedema services for people living with and beyond cancer. The guidance identifies how services are commissioned in London, sets out what good looks like and recommends how it can be achieved. The guidance was developed with the support of a task and finish group and was informed by telephone interviews with seven GP commissioners. A comprehensive mapping of specialist services was undertaken and has shown shortfalls in commissioning processes and significant gaps in provision across London. There is considerable opportunity to make cost-savings through investment in lymphoedema services and education and training of the workforce is a clear priority moving forward. TCST is now supporting commissioners to examine their lymphoedema services, benchmark themselves against best practice, and work with others to deliver the best possible care for their communities. [ABSTRACT FROM AUTHOR]

Background: Around 1 million primary care consultations happen in England every day. Despite this, much of what happens in these visits remains a 'black box'.Aim: To create an archive of videotaped consultations and linked data based on a large sample of routine face-to-face doctor-patient consultations with consent for use in future research and training.Design and Setting: Cross-sectional study in 12 general practices in the west of England, UK.Method: Up to two GPs from each practice took part in the study. Over 1 to 2 days, consecutive patients were approached until up to 20 eligible patients for each GP consented to be videotaped. Eligible patients were aged ≥18 years, consulting on their own behalf, fluent in English, and with capacity to consent. GP questionnaires were self-administered. Patient questionnaires were self-administered immediately pre-consultation and post-consultation, and GPs filled in a checklist after each recording. A follow-up questionnaire was sent to patients after 10 days, and data about subsequent related consultations were collected from medical records 3 months later.Results: Of the 485 patients approached, 421 (86.8%) were eligible. Of the eligible patients, 334 (79.3%) consented to participate and 327 consultations with 23 GPs were successfully taped (307 video, 20 audio-only). Most patients (n = 300, 89.8%) consented to use by other researchers, subject to specific ethical approval.Conclusion: Most patients were willing to allow their consultations to be videotaped, and, with very few exceptions, to allow recordings and linked data to be stored in a data repository for future use for research and training. [ABSTRACT FROM AUTHOR]

The article reports developments in the operation of the National Health Service (NHS) in Great Britain as of April 2017. Also cited are the funding shortage facing the NHS, the crisis in social care across the country based on a study by The King's Fund, and the sustainability and transformation plans (STP) developed by NHS England to improve health services.