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This paper builds on a previous article describing an innovative approach to enhance the service user and practitioner's experience of novel collaborative approach to service improvement. It aims to explore the impact of this through the voices of service users as collaborators and co-authors. The Recovery and Collaborative Care Planning Café (RCCPC) designed with World Café principles, created a safe space to foster inquiry and learning about recovery between service users, carers, and practitioners in an NHS Trust. An important part of the method was in changing conversations towards recovery and living well with conditions applying CHIME concepts (Connectedness, Hope, Identity, Meaning, and Empowerment). Story is a qualitative method known as a well-established effective means of engaging others in sharing experiences and perspectives. Through the stories of service users' experiences participating in the RCCP Cafe, it was clear that they felt that CHIME concepts had a positive impact on the way that their conversations evolved. Accounts of how these conversations had resulted in personal growth and increased connectedness emerged. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey. Methods: The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021–2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses. Results: Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor. Conclusions: This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access. [ABSTRACT FROM AUTHOR]

The rising prevalence of paediatric type 2 diabetes (T2D) is concerning, particularly with limited medical intervention despite evidence of accelerated disease progression. This study of a Barts Health NHS Trust cohort from 2008 to 2022 aims to elucidate the incidence, clinical outcomes, and complications associated with paediatric T2D. A retrospective analysis utilising electronic and paper records identified 40 patients with T2D. The incidence doubled from 2.6/year in 2008–2013 to 5.4/year in 2014–2018. Sixty-eight percent exhibited co-morbidities, notably learning disabilities. At diagnosis, the mean BMI was 32.4 ± 6.71 kg/m2, with no gender-based disparity and no significant change over a two-year follow-up. The initial HbA1c was 75.2 ± 21.0 mmol/mol, decreasing to 55.0 ± 17.4 mmol/mol after three months (p = 0.001) and then rising to 63.0 ± 25.5 mmol/mol at one year (p = 0.07). While 22/37 patients achieved HbA1c < 48 mmol/mol, only 9 maintained this for a year. Several metabolic and cardiovascular complications were observed at diagnosis and follow-up, with no significant change in frequency. In 2022, 15 patients transitioned to adult services. HbA1c at transition was 74.7 ± 27.6 mmol/mol, showing no change one year post-transition (71.9 ± 26.9 mmol/mol, p = 0.34). This study highlights substantial therapeutic failure, with current management falling short in achieving a sustained reduction in BMI or HbA1c. Novel treatment approaches are needed to improve clinical outcomes and address the high burden of co-morbidities and complications. [ABSTRACT FROM AUTHOR]

In 2016, England's National Institute for Health Research (NIHR) celebrated its tenth anniversary as an innovative national health research system with a focus on meeting patients' needs. This provides a good opportunity to reflect on how the creation of the NIHR has greatly enhanced important work, started in 1991, to develop a health research system in England that is embedded in the National Health Service.In 2004, WHO identified a range of functions that a national health research system should undertake to improve the health of populations. Health Research Policy and Systems (HRPS) has taken particular interest in the pioneering developments in the English health research system, where the comprehensive approach has covered most, if not all, of the functions identified by WHO. Furthermore, several significant recent developments in thinking about health research are relevant for the NIHR and have informed accounts of its achievements. These include recognition of the need to combat waste in health research, which had been identified as a global problem in successive papers in the Lancet, and an increasing emphasis on demonstrating impact. Here, pioneering evaluation of United Kingdom research, conducted through the impact case studies of the Research Excellence Framework, is particularly important. Analyses informed by these and other approaches identified many aspects of NIHR's progress in combating waste, building and sustaining research capacity, creating centres of research excellence linked to leading healthcare institutions, developing research networks, involving patients and others in identifying research needs, and producing and adopting research findings that are improving health outcomes.The NIHR's overall success, and an analysis of the remaining problems, might have lessons for other systems, notwithstanding important advances in many countries, as described in papers in HRPS and elsewhere. WHO's recently established Global Observatory for Health Research and Development provides an opportunity to promote some of these lessons. To inform its work, the Observatory is sponsoring a thematic series of papers in HRPS focusing on health research issues such as funding flows, priority setting, capacity building, utilisation and equity. While important papers on these have been published, this series is still open to new submissions. [ABSTRACT FROM AUTHOR]

Historically, information such as protocols and treatment pathways from specialist teams were shared with ward staff in paper format which proved cumbersome and difficult to update. Improvements were made with the addition of an intranet site, where protocols could be stored and accessed by clinical staff, however it was recognised that navigating the intranet site was not always straightforward and took up precious nursing time. The tissue viability team at the Royal United Hospitals NHS Foundation Trust (RUH) considered how such information might be made more readily available to clinicians. Inspired by widespread increased use of QR codes in public places during the COVID-19 pandemic, the team produced a poster containing multiple QR codes, enabling clinical staff to have instant access to wound care protocols as soon as the information was needed. [ABSTRACT FROM AUTHOR]

Background The term 'long COVID' describes ongoing symptoms and conditions experienced by people infected with SARS-CoV-2. This paper illustrates how a public health approach was used to influence and inform the development of post-COVID services across two Integrated Care Systems (ICSs). Methods A literature review was conducted between October and December 2020 to identify prevalence estimates for long COVID. The prevalence estimates were applied to locally available data on the susceptible population to estimate the number of people with long COVID. They were also used to develop a dashboard to predict fluctuations in the number of people experiencing persistent symptoms over time. Results A substantial number of people in each ICS may have experienced persistent symptoms or complications as a result of COVID-19. In Lancashire and South Cumbria, it is estimated that 33 000 people may have experienced post-COVID-19 syndrome since the beginning of the pandemic, which will include respiratory or cardiovascular complications. Conclusions The findings have been valuable in informing early service developments, engaging with managers and clinicians, and supporting applications for funding at a local level. Continued attention to emergent evidence on this topic will be vital in refining estimates and supporting service planning in the longer term. [ABSTRACT FROM AUTHOR]

The article discusses a review on the evaluations of ten initiatives specifically promoted in the National Health Service (NHS) white paper "Our Health, Our Care, Our Say," published in January 2006. An extensive mapping exercise was made to identify evaluations of the specified initiatives being conducted in England. It indicates that the rhetorical commitment to evaluation was compromised and the investment in evaluation at national and local levels was not as productive.

This paper examines the relationship between the prevalence of the urgent and emergency care vanguard (UEC) at the local authority level and their delayed transfers of care (DTOC) rates in England. We created a novel measure of exposure to UEC vanguards based on the residence of patients who used UEC partner hospitals, and we group it by the level of exposure (high, medium, low, none). We use this measure to estimate the effect of UEC vanguards on DTOC rates and then on DTOC rates by sector and a range of reasons associated with the delay. The analysis was run at the local authority level (LA) using quarterly data from NHS England for 150 English LAs from the years 2012–2017. We find a statistically significant UEC exposure effect of around 0.3% reduction in total DTOC to a 1% increase of UEC exposure (equivalent to 775 DTOC days per local authority per quarter in high UEC exposure areas), a result robust to various specification checks. Nonacute sector DTOC was found to be more responsive to UEC vanguards in comparison to acute sector DTOC (0.4% and 0.3% reductions, respectively, to every 1% of UEC exposure). DTOC due to social care was particularly responsive to UEC exposure (0.7% reduction to 1% exposure). DTOC reasons associated with the highest impact of UEC exposure were as follows: awaiting a care package at own home, waiting for further NHS nonacute care, and completion of assessment (reductions of 0.5%, 0.3%, and 0.3% to 1% exposure, respectively). All three reasons were originally associated with the largest number of DTOC days. These findings further advocate for UEC vanguards having been successful at alleviating the pressure on hospitals related to DTOC. [ABSTRACT FROM AUTHOR]

Background In April 2020, Covid-19 brought NHS elective procedures to a halt. The aim of this paper is to produce accurate forecasts on the building backlog, highlight the state of waiting lists currently and propose solutions required to prevent a public health crisis. Method Using data published by NHS digital and NHS England on previous years, we have analysed and used this to produce estimates of cancellations and missed cases. We also analyse government data on waiting lists and show compliance or lack of with these. Results We show that compliance with waiting list times pre pandemic was falling year on year (83.2% in 2020 down from 87% in 2019). Every month that passes we estimate that 400 000 cases are not being performed. This may include urgent cancer care work in some trusts. Conclusions Waiting lists have been governed by strict rules since 2004. Given falling compliance with 18-week intention to treat we believe the scale of the backlog combined with NHS capacity diminished due to Covid-19 precautions is a public health crisis waiting to occur. We identify difficulties in resuming elective work and suggest strategies that could be employed to avoid a public health crisis. [ABSTRACT FROM AUTHOR]

Background: Although policy discourses frame integrated Electronic Health Records (EHRs) as essential for contemporary healthcare systems, increased information sharing often raises concerns among patients and the public. This paper examines patient and public views about the security and privacy of EHRs used for health provision, research and policy in the UK.Methods: Sequential mixed methods study with a cross-sectional survey (in 2011) followed by focus group discussions (in 2012-2013). Survey participants (N = 5331) were recruited from primary and secondary care settings in West London (UK). Complete data for 2761 (51.8 %) participants were included in the final analysis for this paper. The survey results were discussed in 13 focus groups with people living with a range of different health conditions, and in 4 mixed focus groups with patients, health professionals and researchers (total N = 120). Qualitative data were analysed thematically.Results: In the survey, 79 % of participants reported that they would worry about the security of their record if this was part of a national EHR system and 71 % thought the National Health Service (NHS) was unable to guarantee EHR safety at the time this work was carried out. Almost half (47 %) responded that EHRs would be less secure compared with the way their health record was held at the time of the survey. Of those who reported being worried about EHR security, many would nevertheless support their development (55 %), while 12 % would not support national EHRs and a sizeable proportion (33 %) were undecided. There were also variations by age, ethnicity and education. In focus group discussions participants weighed up perceived benefits against potential security and privacy threats from wider sharing of information, as well as discussing other perceived risks: commercial exploitation, lack of accountability, data inaccuracies, prejudice and inequalities in health provision.Conclusions: Patient and public worries about the security risks associated with integrated EHRs highlight the need for intensive public awareness and engagement initiatives, together with the establishment of trustworthy security and privacy mechanisms for health information sharing. [ABSTRACT FROM AUTHOR]

Background: A new diagnosis of complex post‐traumatic stress disorder, CPTSD, has been agreed by the World Health Organization, WHO, and evidence is needed for what psychological treatment might be effective, particularly from those with experience of the disorder. We used a novel participatory approach to explore patient views and simultaneously studied the impact on the patient researchers of the research process itself. In this paper, we report on the latter section of the study how the involvement in research of patients with CPTSD affected their mental health. Symptoms of CPTSD may include emotional dysregulation, feelings of self‐worthlessness and difficulties in relationships. Objective: The aim of this study section was to explore whether patients' mental health could be promoted through empowering them to participate in research on CPTSD. Design: The study had a qualitative, participatory design. The clinician who led the research (first author) held group meetings with patient researchers to explore the impact of the research process. The clinician also kept notes on the process in a reflective log. Setting and participants: Six patient researchers participated in research with other patients with lived experience of CPTSD in an NHS outpatient unit in a London hospital. Intervention studied: The research process itself was analysed in group meetings with researchers which the clinician recorded and transcribed. Findings: Participation in research may promote increased self‐confidence and social inclusion for those with CPTSD. Conclusion: Involvement in research may be seen as an empowering intervention because patients felt it contributed to recovery. [ABSTRACT FROM AUTHOR]

Background Clinical commissioning groups (CCGs) were in early development when fieldwork took place. Public Health (PH) was moving into the local authority, and new ways of working were being established. Methods Three qualitative case studies in the North of England were undertaken using three different data collection methods: observations, interviews and the collection of documents that were related to the project. Comprehensive field notes were taken during observations, analysed alongside interview transcriptions and collected documentation using the software programme Atlas.ti. Results The relationship between the CCG and their local PH team was in development at the time of data collection. Three different PH roles could be discerned from the data: 'co-owner', 'service provider' and 'critical friend'. These roles impacted on the utilization of PH by CCGs and the wider relationship between the CCG and PH. Conclusions These models are 'ideal types', and in reality the CCG-PH relationship in most areas will contain elements of all three models. However, to think of them as set out in this paper is instructive for both CCGs and PH. It is important that CCGs and their PH colleagues to think clearly about what they are trying to achieve and how that can most effectively work together. [ABSTRACT FROM AUTHOR]

Background The evidence on public health interventions has traditionally focussed on a limited number of costs and benefits, adopted inconsistent methods and is not always relevant to the UK context. This paper develops a multi-criteria decision analysis (MCDA) approach to overcome these challenges. Methods A document review and stakeholder consultation was used to identify interventions and the criteria against which they should be assessed. The interventions were measured against these criteria using literature reviews and decision models. Criteria weights were generated using a discrete choice experiment. Results Fourteen interventions were included in the final ranking. Taxation was ranked as the highest priority. Mass-media campaigns and brief interventions ranked in the top half of interventions. School-based educational interventions, statins and interventions to address mental health problems ranked in the bottom half of interventions. Conclusions This paper demonstrates that it is possible to incorporate criteria other than cost-effectiveness in the prioritization of public health investment using an MCDA approach. There are numerous approaches available that adopt the MCDA framework. Further research is required to determine the most appropriate approach in different settings. [ABSTRACT FROM AUTHOR]

A national coordinated approach to workforce education and training in genomics is essential for the successful implementation of whole genome sequencing and, more broadly, genomic medicine within the National Health Service (NHS) in England. However, there have been no workforce wide assessments of genomics education and training needs that can be used to inform the strategic approach to be taken. In order to assess these needs the Genomics Education Programme (GEP) undertook a cross-professional training needs analysis. Responses from 2,814 individuals allowed the identification of four themes related to NHS staff's perceived education and training needs in genomics, those who: a) have a role in genomics and are competent; b) have a role in genomics but identified a specific learning need; c) could not identify whether genomics is relevant, but want to know more, and; d) do not see genomics as relevant to their role and do not believe they need to learn about it. Individuals are motivated to undertake training for their own continuing professional development and if they perceive training to have a direct impact on patient care. Overall, online learning is the preferred mode of delivery, but there are still many individuals who value face-to-face teaching. This paper demonstrates how the GEP has used these findings to provide an evidence base to inform the ongoing strategy for genomics education and training in the NHS, including the development of competency frameworks and a range of resources to address the diverse genomics learning needs of the healthcare workforce. [ABSTRACT FROM AUTHOR]

Background: Rapid evaluation was at the heart of National Health Service England's evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods.Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard.Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168.Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify "quick wins" and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources. [ABSTRACT FROM AUTHOR]

Introduction: Primary total elbow replacement (TER) services in England are being restructured with the goal of centralising care to specialised centres. It is important to monitor the impact of this service redesign. This protocol outlines an intended analysis to provide detailed descriptions of the patients who are receiving primary TER, where and by whom TER is being performed, and what the current surgical practices for TER are in England before the reconfiguration. Methods: This analysis will use the National Joint Registry (NJR) elbow dataset and link it with NHS England Hospital Episode Statistics-Admitted Patient Care (HES-APC). It will include eligible patients from the start of the NJR elbow dataset in April 2012 to December 2022. The main objective is to determine the incidence of TER in England. Age-sex standardised rates will be calculated for groups including different ethnicities, and socioeconomic backgrounds, using the mid-year population data provided by the Office for National Statistics. This planned analysis will summarise patient characteristics such as age, sex, body mass index (BMI), hand dominance, American Society of Anaesthesiologists (ASA) grade, indication for TER, socioeconomic status, and patient co-morbidities. It will also examine implant fixation type, classification, brand/type, and changes over time in implant types used in England. Additionally, it will explore the characteristics and volume of the surgeons and hospitals providing primary TER services, including the grade of the primary surgeons, funding source for surgery, and admission type. The analysis will cover the number of procedures performed by surgeons and hospitals annually in England and in each region of England. Finally, the planned analysis will summarise the elective wait time, postoperative length of stay, and any serious adverse events or re-admissions within 30 and 90 days after the TER. Discussion: This protocol describes the first deep dive analysis into the NJR elbow dataset to describe the incidence of TER surgery in England and the characteristics of patients who are receiving it. This analysis will summarise current primary TER practices in England before service reconfigurations. The impact of reconfiguration can be monitored by comparing future practice to the outcomes from this study. Trial registration ClinicalTrials.gov, NCT06355011. Registered 02 April 2024, https://clinicaltrials.gov/ct2/show/NCT06355011. [ABSTRACT FROM AUTHOR]

Background: Current research has identified how ethnic minority women experience poorer health outcomes during the perinatal period. In the United Kingdom, specialist perinatal mental health services provide mental health treatment for women throughout the perinatal period. Service users have previously highlighted that perinatal services are hard to access and lack cultural sensitivity, whereas healthcare professionals have described limited opportunities and resources for developing cultural competency. Objectives: We explored the experiences of ethnic minority women with National Health Service (NHS) specialist perinatal teams and identified what culturally sensitive perinatal mental health care means to this group. Design: Individual semi‐structured interviews were conducted, and an interpretative phenomenological analysis framework was used to analyse the interview transcripts. Setting and Participants: Participants were recruited from NHS specialist perinatal teams and online via social media. Results: Six women were interviewed. Four group experiential themes central to the experiences of participants emerged: (1) strengthening community networks and peer support; (2) valuing cultural curiosity; (3) making sense of how culture, ethnicity, race and racism impact mental health; and (4) tailoring interventions to ethnic minority women and their families. Discussion and Conclusions: The findings capture how ethnic minority women experience specialist perinatal teams and offer insights into practising culturally sensitive care. Perinatal mental health professionals can support ethnic minority women by strengthening their access to community resources and peer support; being curious about their culture; helping them to make sense of how culture, ethnicity, race and mental health interact; and applying cultural and practical adaptations to interventions. Patient or Public Contribution: A Lived Experience Advisory Group (LEAG) of women from ethnic minority groups contributed to the design and conduct of this study. The LEAG had lived experience of perinatal mental health conditions and accessing specialist perinatal teams. The LEAG chose to co‐produce specific aspects of the research they felt fit with their skills and available time throughout five group sessions. These aspects included developing the interview topic guide, a structure for debriefing participants and advising on the social media recruitment strategy. [ABSTRACT FROM AUTHOR]

Background: Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is ‘vertical integration’, where a provider of specialist care, such as a hospital, also runs general practices. Aim: To quantify the impact of vertical integration on hospital use in England. Design & setting: Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. Method: Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. Results: In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. Conclusion: Vertical integration is associated with modest reductions in use of some hospital services and no change in others. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic many patients were switched from warfarin to direct)acting oral anticoagulants (DOACs), which require the creatinine clearance (CrCl) calculated to ensure the correct dose is prescribed to avoid bleeding or reduced efficacy. Aim: To identify the study population proportion prescribed a DOAC. Of these, the proportion with recorded: weight, estimated glomerular filtration rate (eGFR), creatinine, CrCl and atrial fibrillation (AF). To analyse the proportion of patients with recorded AF and CrCl prescribed a recommended DOAC dose. Design & setting: A retrospective cohort study of 20.5 million adult NHS patients’ electronic health records (EHRs) in England in the OpenSAFELY-TPP platform (January 2018–February 2023). Method: Patients on DOACs were analysed for age, sex, recorded weight, eGFR, creatinine, CrCl and AF. Prescribed DOAC doses in patients with recorded AF were compared with recommended doses for recorded CrCl and determined as either recommended, higher than recommended (overdose), or lower than recommended (underdose). Results: In February 2023, weight, eGFR, creatinine, CrCl, and AF were recorded in 72.8%, 92.4%, 94.3%, 73.5%, and 73.9% of study population, respectively. Both AF and CrCl were recorded for 56.7% of patients. Of these, 86.2% received the recommended, and 13.8% non-recommended, DOAC doses. Conclusion: CrCl is not recorded for a substantial number of patients on DOACs. We recommend that national organisations tasked with safety, collectively update guidance on the appropriate weight to use in the Cockcroft–Gault equation, clarify that CrCl is not equivalent to eGFR, and work with GP clinical system suppliers to standardise the calculation of CrCl in the EHR. [ABSTRACT FROM AUTHOR]

Aim: To provide a template for developing a national mentoring scheme to enhance the contribution practitioner researchers can make to the quality of health care in England. Background: The authors describe the background to and organisation of a mentorship scheme to support those awarded National Institute for Health Research (NIHR) fellowships as part of the Clinical Academic Training (CAT) scheme for nurses, midwives and the allied health professionals in England. Data sources: The paper draws on relevant policy documents to explain the development of the NIHR mentorship scheme. It also reviews the literature regarding mentoring in nursing and the health professions. Review methods: The review was conducted systematically using keywords: mentorship, clinical academic careers, research, nursing research, clinical academic careers, evidence, health care. Databases included PubMed, CINAHL and Google Scholar. An integrated approach was adopted. Discussion: Kirkpatrick’s (2006) four-level evaluation model provided a framework to evaluate the scheme and explore the role of mentorship in supporting NIHR fellows. Preliminary findings from baseline and end-of-year evaluations revealed mentees’ expectations of mentorship and its effects on their professional development. Developing a career as a clinical academic can be a challenging journey for novice researchers. In addition, there is a vital need to integrate research with clinical practice. Conclusion: Mentoring appears valuable in enabling NIHR fellows to navigate the challenges of demanding clinical roles in England’s National Health Service while making a high-level contribution to research. The importance of preparing mentors for their role is well documented in the literature but mentees also need preparation and guidance to manage this important relationship. Implications for research/practice The evaluation has implications for embedding similar schemes across nursing, midwifery and the allied health professions to promote capacity and leadership in clinical academic careers. This study has uniquely identified the need to support mentees as well as mentors in such programmes to ensure the optimal benefit of the programme reaches all participants. [ABSTRACT FROM AUTHOR]

Background: Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design: Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting: National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants: Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison: Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures: Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources: National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome: Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of −0.173 invasive dental treatments (95% CI −0.185 to −0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes: Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of −0.212 decayed, missing and filled teeth (95% CI −0.229 to −0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI −0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010–20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010–20 were 5.5% lower per person, by £22.26 (95% CI −£23.09 to −£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations: Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work: National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information. Plain language summary: Fluoride is a natural mineral that prevents tooth decay. It is added to some drinking water and toothpastes to improve dental health. Water with fluoride added is known as 'optimally fluoridated'. Most research on water fluoridation was carried out before fluoride was added to toothpastes in the 1970s and only included children. We wanted to know if water fluoridation still produced large reductions in tooth decay, now that decay levels are much lower because of fluoride in toothpaste. We also wanted to look at its effect on adults and teenagers. Dental patients we spoke to told us they worried about needing treatment with the 'drill', or 'injection', losing their teeth and paying for their dental care. To see if water fluoridation helped with these concerns, we compared the National Health Service dental records of 6.4 million adults and teenagers who received optimally fluoridated or non-optimally fluoridated water in England between 2010 and 2020. We found water fluoridation made a very small difference to each person. Between 2010 and 2020, the number of NHS fillings and extractions was 3% lower per person for those who received optimally fluoridated water. We found no difference in the number of teeth lost per person and no strong sign that fluoridation reduced differences in dental health between rich and poor areas. Between 2010 and 2020, the cost of optimal water fluoridation was £10.30 per person (not including setup costs). National Health Service dental patients who received optimally fluoridated water cost the National Health Service £22.26 (5.5%) less and paid £7.64 (2%) less per person in National Health Service dental charges over the 10 years. The benefits we found are much smaller than in the past, when toothpastes did not contain fluoride. The cost to set up a new water fluoridation programme can be high. Communities may need to consider if these smaller benefits would still outweigh the costs. Scientific summary: Background: There is a lack of contemporary evidence on the effectiveness and cost effectiveness of water fluoridation in populations who are also using fluoride toothpastes and have significantly lower levels of decay than when most of the research on water fluoridation was carried out. In their 2002 review of water fluoridation, the UK Medical Research Council identified several priority areas for future research, in particular: the effect of water fluoridation on the dental health of adults the effects of fluoridation on health and well-being beyond the usual measures of decayed, missing or filled teeth the economic impacts of water fluoridation how the effects of water fluoridation vary with social class. Conducting research on the effects of water fluoridation in adults involves significant methodological challenges. This has resulted in a paucity of evidence and recommendations for research that have not been addressed in 20 years. The present study has been designed to contribute to the evidence base in a pragmatic and cost-efficient way, using routinely collected NHS dental claims data. During our initial public engagement work, patients and the public told us that preventing dental treatment, particularly 'the drill' or 'injection', was a key impact that they would hope water fluoridation would produce. Other impacts were not losing teeth to extraction and avoiding costly dental charges. This feedback is reflected in our choice of primary and secondary outcome measures. Aim: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health. Primary objective: Impact of water fluoridation on NHS invasive dental treatments (fillings, extractions). Secondary objectives: Impact on oral health [number of teeth and caries experience, missing and filled teeth (DMFT)]. Impact on social inequalities. Cost effectiveness and return on investment (ROI). Study inclusion criteria: Adults and adolescents aged 12 years and over who had attended an NHS dental practice in England within the last 10 years. Adolescents were included in the study cohort because they are likely to have all of their permanent, adult teeth. Patient confirmed as a unique individual using the combination of NHS Business Service Authority (BSA) identifier (initial, surname, gender, date of birth) and NHS number. Study exclusion criteria: Individuals who did not have at least two episodes of dental attendance within the 10-year observation period. The reason for this was to provide at least two data points on location of residence (to assign fluoridation exposure). Cohort setting: The study population data set was supplied by NHS BSA , which processes payment claims for NHS for dentists. The NHS BSA data retention period is 10 years. National Health Service primary dental care is delivered in a range of settings and types of services, including: general dental practices (high street practices) prison dental services community dental services (special care referral service, which treats patients with additional needs, including medical conditions, disabilities, homelessness or drug use) domiciliary settings (home visits for housebound patients) urgent/out-of-hours services for patients without a regular dentist specialised referral-only services such as sedation or oral surgery. Data on care delivered in all of the above services are collected by NHS BSA. Selection of the study population: Selection of the study population was carried out on 21 October 2020, by NHS BSA. Individual dental treatment claim entries for England and Wales were screened for linkage and selection by NHS BSA in the following order: Identifiable data: Withdrawn or 'no information' claims (FP17s) were dropped. Claims with no 1 : 1 match between NHS number and NHS BSA ID were dropped. Claims containing only orthodontic care were dropped. Patients whose NHS number was on 'NHS national data opt-out list' were dropped. Anonymised data: Patients who had attended only once were dropped. Patients aged under 12 years were dropped. Patients whose first recorded address was not in England were dropped. Patients whose first course of treatment was prior to 22 November 2010 were dropped. The study population data set, securely transferred to the University of Manchester, included anonymised data on 17,855,239 unique individuals. Exposure assignment: Water fluoride sample data (mg F/l) were obtained from water suppliers in England under the Environmental Information Regulations (2004) and converted from water supply zones to lower super output areas (LSOAs) using mapping in statistical software 'R'. This resulted in a record of annual mean water fluoride concentrations by LSOA for every year between 2010 and 2020. Individuals within the study population data set were then assigned an individual water fluoride exposure (mg F/l) by combining their residential history (recorded in the NHS BSA dental claims data set) with the annual concentration of fluoride in the drinking water of the LSOAs they lived in between 2010 and 2020. Individuals exposed to drinking water with a grand mean fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were assigned to the 'optimally fluoridated' group, and those with a grand mean of < 0.7 mg F/l were assigned to the 'sub/non-optimally fluoridated' group. Propensity score matching: Individuals in the optimally fluoridated group were matched to individuals in the sub/non-optimally fluoridated group using propensity scores. The baseline characteristics used to create the propensity scores were selected using subject matter knowledge and theory to include all hypothesised confounders and important outcome predictors. To inform the selection of these variables, causal assumptions were made explicit using directed acyclic graphs. Baseline characteristics for propensity score estimation and matching were based on data recorded at the patient's first course of treatment: sex age ethnicity deprivation decile NHS exemption status rural–urban classification number of units of dental activities (UDAs) commissioned per person with the patient's local authority of residence dental practice contract type dental practice deprivation decile. Propensity scores were estimated using logistic regression, and matching was carried out using three specifications of nearest neighbour matching (one-to-one, variable ratio and variable ratio with a 0.25 calliper). The resulting matched data set which best met our pre-specified criteria regarding overall sample size, balance on baseline characteristics and ability to estimate the average treatment effect in the treated group was taken forwards for further analysis. Analysis of health effects: The effect of optimal water fluoridation on primary and secondary clinical outcomes was estimated using negative binomial regression models, including matching weights and using cluster-robust standard errors. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated for the mean number of invasive dental treatments received, the mean number of DMFTs and the mean number of missing teeth by fluoridation group. To determine whether there was a differential effect of water fluoridation according to deprivation, we included patient deprivation decile [Index of Multiple Deprivation (IMD) 2015] as an interaction term. 'Clinical' relevance of primary outcome: We engaged with 54 public and professional stakeholders from across the UK through 3 online workshops to explore views on what might be considered a relevant/practically significant effect of optimal water fluoridation on our primary outcome. We identified a wide range of views and some suggestions that dentists felt smaller reductions were meaningful, compared to non-dentists, but most contributors felt a reduction of at least one invasive NHS dental treatment per person over 10 years would be needed to be considered meaningful (a 16% relative reduction in the workshop scenario). Health economic evaluation: The health economic evaluation involved a cost-effectiveness and a ROI analysis. The time horizon was 2010–20, and the perspective was public sector payors [NHS, Public Health England (PHE) and local authorities]. Operating and capital costs of water fluoridation for England were supplied by PHE for the financial years 2013–9, with mean annual costs used for 2010–2. All costs are reported in 2020 prices. National Health Service dental care utilisation and patient charges were contained within the study population data set provided by NHS BSA , and an average UDA price for England supplied by NHS BSA [under the Freedom of Information Act (2000)] was used to calculate NHS costs. Differences in costs between patients from optimally fluoridated and sub/non-optimally fluoridated groups were estimated using a generalised linear model (GLM) with a log-link and a gamma distribution to account for right-skewed cost data. Cost effectiveness was based on the primary study outcome, assessed as the additional cost per avoided episode of invasive dental treatment [incremental cost-effectiveness ratio (ICER)]. We also calculated total NHS dental charges paid by patients in the optimally fluoridated and sub/non-optimally fluoridated groups. Water fluoridation cannot be provided on an individual basis, therefore per-patient cost effectiveness and ROI estimates were extrapolated from our sample to the estimated population of regular users of NHS dental services using a range of scenarios. Results: The study population data set (the full cohort) supplied by NHS BSA included records relating to 17,855,239 unique individuals. After propensity score matching (using nearest neighbour, one-to-three variable ratio), the matched cohort contained data on 6,370,280 individuals: 4,777,710 in the sub/non-optimally fluoridated group and 1,592,570 in the optimally fluoridated group. Primary objective: The rate of invasive dental treatments in the optimally fluoridated group was 3% lower than that of the sub/non-optimally fluoridated group (IRR 0.969, 95% CI 0.967 to 0.971). There was a predicted mean difference of 0.173 fewer invasive dental treatments per person (95% CI 0.185 to 0.161) in the optimally fluoridated group compared to the sub/non-optimally fluoridated group. During our stakeholder engagement work, only 4 of 54 contributors considered this magnitude of reduction to be meaningful. Secondary objectives: Oral health: Mean DMFT in the optimally fluoridated group was 2% lower than in the sub/non-optimally fluoridated group (IRR 0.984, 95% CI 0.983 to 0.985). There was a predicted mean difference of 0.212 fewer DMFTs (95% CI 0.229 fewer to 0.194 fewer) in the optimally fluoridated group compared to the sub/non-optimally fluoridated group. We found no significant difference in the mean number of missing teeth between the optimally fluoridated group and the sub/non-optimally fluoridated group (IRR 1.001, 95% CI 0.999 to 1.003). The negative binomial model predicted a mean difference of 0.006 more missing teeth in the fluoridated group, but the 95% CI includes the possibility of no effect (95% CI 0.008 fewer to 0.021 more). Effect of water fluoridation on social inequalities: In all deciles, the predicted number of invasive treatments was lower in the optimally fluoridated group than the sub/non-optimally fluoridated group, but the size of the reductions was very small. The largest predicted reduction of 0.337 fewer invasive dental treatments per person (95% CI 0.371 fewer to 0.302 fewer) was in the most deprived decile (IMD 1), a relative reduction of 5.3%. The relationship between patient deprivation and DMFT was unclear and did not demonstrate a social inequality gradient in the expected direction. Therefore, we are unable to conclude whether water fluoridation reduced social inequalities in DMFT. Small differences were evident in each decile, but the direction of effect was not consistent. Small differences in the number of missing teeth per person in the optimally fluoridated and sub/non-optimally fluoridated groups were evident in each decile of deprivation, but the direction of effect was not consistent. Overall, we could find no compelling evidence that water fluoridation reduced socioeconomic disparities in oral health in adult and adolescent users of NHS dental services. Health economic results: Water fluoridation costs: Total expenditure on water fluoridation between 2010 and 2019 was estimated to be £46,791,388. The cost of optimal water fluoridation per person over 10 years was estimated to be £10.30. No new water fluoridation programmes were commissioned between 2010 and 2020; therefore, our cost estimates for water fluoridation do not include setup costs, which are highly site-specific and can be significant. National Health Service dental treatment and patient charges: In the GLM , the marginal effects estimate revealed a saving in NHS treatment costs for optimally fluoridated patients over the study period of £22.26 per person (95% CI £21.43 to £23.09). This represents a relative reduction in costs to the NHS of 5.5% per person between 2010 and 2020. Patients in the optimally fluoridated group paid £7.64 less (2%) in total NHS dental charges than patients in the non-optimally fluoridated group between 2010 and 2020. Population-level cost effectiveness and return on investment: Water fluoridation is a whole-population intervention, which cannot be implemented on a per-person basis. In terms of cost effectiveness and ROI, it is important to consider the potential size of the population to whom our within-sample (per person) findings may apply. In the scenario thought to be most likely by our steering committee (that 62.9% of the population aged 12 years can be expected to use NHS dental services at least twice in 10 years), we estimate that: The cost to avoid one invasive dental treatment (the ICER) was £94.55. The predicted ROI for water fluoridation in England between November 2010 and October 2020 was estimated to be £16,884,595 (a 36% return on the investment). Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects which may not be meaningful for individuals, and we could find no evidence that water fluoridation reduced social inequalities in dental health. Slightly lower dental service utilisation produced a positive ROI during the period of observation, but it must be remembered that the cost estimates for water fluoridation did not include the initial set-up of the programmes. Where new capital investment in water fluoridation is required, the estimated project costs should be evaluated against the estimated savings contained within this report and the projected lifespan of the infrastructure. Whether the case for water fluoridation programmes can be based solely on a predicted ROI rather than meaningful health improvements may need to be considered by stakeholders. Recommendations for research: NHS primary care dental data are a potentially valuable resource for research, surveillance and epidemiology. Consideration should be given as to how to develop this resource further. Suggestions include: commissioning enhanced data collection through a network of dental providers (similar to medical G.P. Clinical Practice Research Datalink network); mandatory use of NHS numbers, recording the reason for treatment (caries, periodontal disease, trauma, repair of old restoration); steps to increase the completeness of patient ethnicity data and validation of the DMFT data. Routinely collected water quality monitoring data should be made publicly available. A central, annually updated database of water fluoride concentrations (mg F/l) at a small area level is required to support future research and monitoring of water fluoridation. To broaden the evidence base for triangulation, the effect of water fluoridation on the dental health of adults should be investigated in any future national dental epidemiology surveys. To determine if the estimated cost to avoid one invasive dental treatment (the ICER) represents good value for money, further work is required to identify a threshold level for 'good value' for this outcome. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information. [ABSTRACT FROM AUTHOR]

Women with obesity during pregnancy are at increased risk of excessive gestational weight gain (GWG) and other maternal and infant adverse outcomes, which all potentially increase childhood obesity. This study explored infant weight outcomes for women with a body mass index (BMI) ≥ 35 kg/m² who were offered an antenatal healthy lifestyle service. A retrospective cohort study, including linking data from two separate health care Trusts, was undertaken. Data were collected from maternity records for women with a BMI ≥ 35 kg/m2 referred to an antenatal healthy lifestyle service from 2009 to 2015. The respective child's weight outcome data was additionally collected from health and National Child Measurement Programme records. Univariate logistic regression determined the odds of childhood overweight, obesity and severe obesity according to attendance at the antenatal healthy lifestyle service, GWG and sociodemographic characteristics. Factors significant (p < 0.05) within the univariate analysis were entered into multiple logistic regression models. Among women with a BMI ≥ 35 kg/m², 30.4% of their children were obese at school entry and 13.3% severely obese. Healthy lifestyle service attendance was not associated with childhood overweight or obesity at any point within the univariate analysis. At school age multiple regression analysis showed the odds of overweight and obesity increased with excessive GWG and the odds of obesity decreased with a parent in a professional occupation, additionally having a mother who smoked in pregnancy increased severe obesity. Women should be supported to optimise their BMI before pregnancy. Additionally, rather than exclusively focusing on changing an individual's behaviour, future interventions should consider external influences such as the woman's family, friends and sociodemographic background. Key messages: Among children born to women with a body mass index (BMI) ≥ 35 kg/m2 almost 50% were classified as overweight or obese at age 5. Of these, only 15.6% had been born large for gestational age.This brief antenatal healthy lifestyle intervention provided to mothers with obesity did not significantly reduce child's overweight or obesity.Demographic factors such as household occupation and maternal smoking during pregnancy were associated with long‐term childhood obesity.More emphasis is required on interventions that support women to optimise their BMI before pregnancy.Future interventions should consider external influences on the woman for example through a socioecological framework. [ABSTRACT FROM AUTHOR]

Objectives The NHS bowel screening programme offers people aged 60-69 screening by faecal occult blood (FOB) testing, with colonoscopy as the diagnostic test. This paper describes the calculation of targets for the purpose of monitoring screening performance in the programme. Methods Targets were calculated for the prevalent round of screening in people aged 60-69, and for the 'steady state' of the programme when people will be offered their first screen at age 60 and subsequent screens at ages 62-69. Targets for the cancer and adenoma detection rates per 1000 people screened and per 100 colonoscopies were calculated using information from the English bowel cancer screening pilot. Results For the prevalent round, prevalent screen and incident screens the calculated targets for the cancer detection rate are 2.3, 1.3 and 1.7 per 1000 people respectively. For the adenoma detection rate the targets are 6.7, 5.2 and 5.5 per 1000 respectively. Targets for the cancer detection rate per 100 colonoscopies are 11.3, 7.5 and 8.4 and those for the adenoma detection rate are 32.0, 30.4 and 32.5 respectively. Conclusions The purpose of these targets is to ensure that the national bowel cancer screening programme is effective with a high quality of screening. The cancer detection and adenoma detection rates per 1000 people are those estimated to be necessary to achieve the expected mortality reduction. Rates per 100 colonoscopies (equivalent to the positive predictive value of referral to colonoscopy) are designed to maintain a high quality of screening by minimizing the number of false-positive referrals. [ABSTRACT FROM AUTHOR]

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Background: The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.Methods: We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.Results: Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.Conclusions: Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system. [ABSTRACT FROM AUTHOR]

Adults accessing community mental health services are required to have a care plan, developed in collaboration with the person accessing the service. The variation in care plan templates in use in England and Wales, and their impact on care planning, is unknown. This study evaluates the community mental health care plan templates in use across England and Wales. Data were obtained from a Freedom of Information request to 50 NHS Mental Health Trusts. An evaluation tool was designed and used to extract data. Data were rated red, amber, or green against clinical and design standards. Forty-seven care plan templates were obtained. The clinical aspect of the care plan template had 60% adherence to the national standards, and the design aspects had 87% adherence. A 'high/low' typology is proposed against the design/clinical standards. The study identifies priority areas for improvement in the care plan templates as space to record the actions that service users and carers will take to contribute to their care plan, space to record the name and contact details for their care coordinator or lead professional, plus others involved in the person's care. This study was not registered. [ABSTRACT FROM AUTHOR]

Background: Older people account heavily for palliative care needs at the population level and are growing in number as the population ages. There is relatively little high-quality data on symptom burden and quality of life, since these data are not routinely collected, and this group are under-recruited in primary research. It is unclear which measurement tools are best suited to capture burdens and experience. Methods: We recruited a cohort of 221 patients aged 75 + years with poor prognosis who had an unplanned admission via the emergency department in a large urban hospital in England between 2019 and 2020. Risk of dying was assessed using the CriSTAL tool. We collected primary data and combined these with routine health records. Baseline clinical data and patient reported quality of life outcomes were collected on admission and reassessed within the first 72 h of presentation using two established tools: EQ-5D-5 L, EQ-VAS and the Integrated Palliative Outcomes Scale (IPOS). Results: Completion rate was 68% (n = 151) and 33.1% were known to have died during admission or within 6 months post-discharge. The vast majority (84.8%) reported severe difficulties with at least one dimension of EQ-5D-5 L at baseline and improvements in EQ-VAS observed at reassessment in 51.7%. The baseline IPOS revealed 78.2% of patients rating seven or more items as moderate, severe or overwhelming, but a significant reduction (-3.6, p < 0.001) in overall physical symptom severity and prevalence was also apparent. No significant differences were noted in emotional symptoms or changes in communication/practical issues. IPOS total score at follow up was positively associated with age, having comorbidities (Charlson index score > = 1) and negatively associated with baseline IPOS and CriSTAL scores. Conclusion: Older people with poor prognosis admitted to hospital have very high symptom burden compared to population norms, though some improvement following assessment was observed on all measures. These data provide valuable descriptive information on quality of life among a priority population in practice and policy and can be used in future research to identify suitable interventions and model their effects. [ABSTRACT FROM AUTHOR]

Background Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10–19 years) and examined intervention affordability and readiness. Methods Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. Results Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. Conclusion The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness. [ABSTRACT FROM AUTHOR]

Background: We evaluated the dose–response relationship between the level of attendance at the English National Health Service Diabetes Prevention Programme (DPP) and risk of progression to type 2 diabetes amongst individuals participating in the programme. Methods: We linked data on DPP attendance for 51,803 individuals that were referred to the programme between 1st June 2016 and 31st March 2018 and attended at least one programme session, with primary care records of type 2 diabetes diagnoses from the National Diabetes Audit up to 31st March 2020. Weibull survival regressions were used to estimate the association between the number of programme sessions attended and risk of progression to type 2 diabetes. Results: Risk of developing type 2 diabetes declined significantly for individuals attending seven of the 13 programme sessions and continued to decline further up to 12 sessions. Attending the full 13 sessions was associated with a 45.5% lower risk (HR: 0.545 95% CI: 0.455 to 0.652). Compared to individuals that only partially attended the programme, attendance at 60% or more of the sessions was associated with a 30.7% lower risk of type 2 diabetes (HR: 0.693 95% CI: 0.645 to 0.745). Conclusions: Reducing the risk of progression to type 2 diabetes through diabetes prevention programmes requires a minimum attendance level at seven of the 13 programme sessions (54%). Retaining participants beyond this minimum level yields further benefits in diabetes risk reduction. Commissioners may wish to consider altering provider payment schedules to incentivise higher retention levels beyond 60% of programme sessions. [ABSTRACT FROM AUTHOR]

Introduction: Ulceration of the foot is a common problem among diabetic patients. Infection is a major risk in diabetic foot ulcers (DFU) and many of these are caused by Staphylococcus aureus, in particular meticillin-resistant strains (MRSA). The control and management of MRSA remains a significant challenge and all healthcare organisations in England are required to meet Zero Tolerance Objectives for cases of MRSA bacteraemia (MRSAB). This paper describes a collaborative approach across the health economy to investigate factors contributing to the acquisition of MRSA and MRSAB among DFU patients and make improvements to care to reduce the risk of healthcare-associated infections. Methods: A collaborative approach between acute and community healthcare providers and commissioners was used to conduct Root Cause Analysis and drive improvement to prevent MRSA transmission in DFU patients. Results: Screening of all DFU patients was initiated after 6 MRSAB were found to be associated with in DFU. In total 15 patients with the same MRSA antibiogram were identified. Following the implementation of actions focused on isolation, wound management, screening and cleaning no further cases were identified. Conclusion: This outbreak has demonstrated the value of cross-sector collaboration in investigating HCAI in patients with DFU, improving patient care and reducing the risk of MRSA transmission in these vulnerable patents. [ABSTRACT FROM AUTHOR]

Background: Screening with the guaiac faecal occult blood test (gFOBt) is associated with improved colorectal cancer (CRC) survival, and is offered biennially to men and women aged 60-74 years in England's national Bowel Cancer Screening Programme (BCSP). Uptake of the gFOBt is low, with only 54 % of the eligible population completing the test. Text-message reminders could improve uptake of gFOBt.Methods/design: This paper describes the protocol for a randomised controlled trial, which will examine the effectiveness of a text-message reminder to promote uptake of gFOBt screening in the BCSP. Individual mobile telephone data from 180 general practices in London with existing mobile-health services will be linked to the national BCSP information system via a secure on-line network. All screening-eligible adults registered with a participating practice will be randomised, to receive either usual care (N = 1600) or usual care plus a text-message reminder to self-complete and return their kit eight weeks after their initial invitation (N = 1600). The primary outcome will be the proportion of individuals who return an adequately completed gFOBt kit within 18 weeks of the initial invitation. Differences in uptake between groups will be evaluated using a logistic regression analysis, adjusting for individual-level and area-level socio-demographic variables.Discussion: This will be the first large-scale randomised trial of a text-message reminder in a national screening programme for CRC. If effective, this study provides a cost-effective means to promote uptake of CRC screening in an organised programme.Trial Registration: Current Controlled Trials ISRCTN70904476 (18/09/2015). [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.Methods: This paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.Results: Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.Conclusions: Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes. [ABSTRACT FROM AUTHOR]

Background: National Health Service (NHS) trusts, which provide the majority of hospital and community health services to the English NHS, are increasingly adopting a 'public firm' model with a board consisting of executive directors who are trust employees and external non-executives chosen for their experience in a range of areas such as finance, health care and management. In this paper we compare the non-executive directors' roles and interests in, and contributions to, NHS trust boards' governance activities with those of executive directors; and examine non-executive directors' approach to their role in board meetings.Methods: Non-participant observations of three successive trust board meetings in eight NHS trusts (primary care trusts, foundation trusts and self-governing (non-foundation) trusts) in England in 2008-9. The observational data were analysed inductively to yield categories of behaviour reflecting the perlocutionary types of intervention which non-executive directors made in trust meetings.Results: The observational data revealed six main perlocutionary types of questioning tactic used by non-executive directors to executive directors: supportive; lesson-seeking; diagnostic; options assessment; strategy seeking; and requesting further work. Non-executive board members' behaviours in holding the executive team to account at board meetings were variable. Non-executive directors were likely to contribute to finance-related discussions which suggests that they did see financial challenge as a key component of their role.Conclusions: The pattern of behaviours was more indicative of an active, strategic approach to governance than of passive monitoring or 'rubber-stamping'. Nevertheless, additional means of maintaining public accountability of NHS trusts may also be required. [ABSTRACT FROM AUTHOR]

Context In 2004, the English Public Health White Paper Choosing Health introduced 'health trainers' as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage 'hard-to-reach' individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services. Methods During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data. Findings Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. Conclusions The health trainer services have become more 'medicalized' over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics. [ABSTRACT FROM AUTHOR]

Driving improvements in patient safety has been a core goal of the Academic Health Science Networks (AHSNs) in England since their inception in 2013. The National Patient Safety Collaborative Programme, nested within the 15 geographically located AHSNs, was established in 2014 in response to the Berwick review. In 2019, the new NHS national patient safety strategy was published, which placed the AHSNs as a key vehicle for delivering its ambitions. This paper explores the achievements of, and opportunities presented by, the collaborative in addressing some of the key patient safety challenges facing physicians and their wider teams. Case studies illustrate the AHSNs' contribution to support national ambitions, including the adoption of the National Early Warning Score (NEWS) 2, and the impact of regionally-led work on patient outcomes, such as reducing mortality from sepsis and acute kidney injury. We set out current activities, opportunities for physician engagement and plans for future work. [ABSTRACT FROM AUTHOR]

The United Kingdom health and care system is changing dramatically to meet the health challenges of the 21st century. People will increasingly have multiple morbidities. The focus of service delivery is changing from hospital to community, patient to population and curative to preventive. This paper describes the NHS and primary care and community pharmacy in England at the start of 2020, a time of great change. The 10-year vison for the NHS is that everyone gets the best start in life, world class care for major health problems supporting people to age well. It has over 40 mentions of pharmacists and pharmacy. The key aims of the plan are to improve 'out-of-hospital' care, and finally dissolve the historic divide between primary and community health service in England. All of England is covered by integrated care systems and the newly formed primary care networks which will form the foundation of these new systems. Pharmacy is involved at multiple levels. There are 11,569 community pharmacies and most of their total income comes from the NHS (range 68-85%). Around 60% pharmacies are part of multiple chains, with the remaining 40% independents or small chains of less than six outlets. The new five-year community pharmacy contract provides an opportunity to develop community pharmacy and move towards service delivery away from dispensing volume. The new services are described under medicines optimisation, prevention and urgent care. The pharmacy quality scheme is also described. The new deal will help many community pharmacies to plan their future, particularly for those pharmacies who are ready and able to change and work closely with pharmacists and other health professionals in collaboration with Primary Care Networks. There will be specific challenges around: dispensing efficiencies, freeing up pharmacists' time, wider use of clinical skills of community pharmacists, community pharmacy viability and consolidations. [ABSTRACT FROM AUTHOR]

Introduction: Barcode medication administration (BCMA) technology helps ensure correct medications are administered by nursing staff through scanning of patient and medication barcodes. In many hospitals scanning rates are low, limiting the potential safety benefits. We aimed to explore the barriers and facilitators to BCMA use in a London hospital. Methods: In this mixed methods study we used local quantitative data on BCMA scanning rates to identify clinically similar wards (in terms of patient acuity and workload) with different scanning rates for qualitative exploration. Interviews designed to elicit barriers to using BCMA technology were conducted with nursing staff, supported by observations of medication administration. Qualitative data were analysed inductively and a thematic framework constructed housing key themes, subsequently categorised into barriers and facilitators. To explore patient perspectives of BCMA scanning, a purposive sample of patients were also interviewed. These patient data were analysed deductively according to the thematic framework. Themes were mapped to behavioural science frameworks to further understand the behaviours involved. Results: BCMA was operational on 15 wards, with only six having medication scan rates of more than 10% of scannable doses. Of three wards selected for qualitative investigation, the lowest scan rate was 6.7%. Twenty-seven nurses and 15 patients were interviewed. Eleven key themes were identified, encompassing both barriers and facilitators to BCMA use. Barriers included poor trolley ergonomics and perceived time inefficiency. Facilitators included a streamlined process and thorough training. All nurses described BCMA as positive for patient safety. Patients described BCMA as making them "feel safer". Behavioural science frameworks highlighted the importance of professional role and an individual's belief in their capability. Conclusion: We present a novel exploration of facilitators and barriers to BCMA use from the viewpoint of both patients and nursing staff, highlighting a strong perception that BCMA enhances safety. Barriers were reported on both high and low usage wards, demonstrating the importance of behaviours and motivations. These findings provide a detailed understanding from which to design interventions to support behaviour change and increase BCMA use. [ABSTRACT FROM AUTHOR]

Background Flooding can cause long-term, significant impacts on mental health in affected populations. We explored help-seeking behaviour of households affected by flooding. Methods A cross-sectional analysis was conducted on National Study of Flooding and Health data on households flooded in England in winter 2013/14. Participants (Year 1: n  = 2006; Year 2: n  = 988; Year 3: n  = 819) were asked if they sought help from health services and other sources. Logistic regression was conducted to calculate odds ratios (ORs) of help-seeking in flooded and disrupted participants compared to unaffected, adjusted for a priori confounders. Results The odds of seeking help from any source 1 year after flooding were greater for flooded participants [adjusted OR (aOR): 1.71, 95% confidence interval (CI): 1.19–1.45] and those disrupted by flooding (aOR: 1.92, 95% CI: 1.37–2.68) compared to unaffected participants. This continued in the second year (flooded: aOR 6.24, 95% CI: 3.18–13.34; disrupted: aOR: 2.22, 95% CI: 1.14–4.68), and help-seeking remained greater in flooded than unaffected participants in the third year. Flooded and disrupted participants were particularly likely to seek help from informal sources. Help-seeking was more prevalent amongst participants with mental health outcomes, but a notable proportion of individuals with any mental health outcome did not seek help (Year 1: 15.0%; Year 2: 33.3%; Year 3: 40.3%). Conclusions Flooding is associated with increased demand for formal and informal support, persisting for at least 3 years, and an unmet need for help amongst affected individuals. Our findings should be considered in flood response planning to reduce the long-term adverse health impacts of flooding. [ABSTRACT FROM AUTHOR]

Background: concern over the sustainability of the National Health Service (NHS) is often focussed on rising numbers of hospital admissions, particularly among older people. Hospital admissions are enumerated routinely by the Hospital Episode Statistics (HES) Service, but published data do not allow individual-level service use to be explored. This study linked information on Hertfordshire Cohort Study (HCS) participants with HES inpatient data, with the objective of describing patterns and predictors of admissions among individuals.Methods: 2,997 community-dwelling men and women aged 59–73 years completed a baseline HCS assessment between 1998 and 2004; HES and mortality data to 31 March 2010 were linked with the HCS database. This paper describes patterns of hospital use among the cohort at both the admission and individual person level.Results: the cohort experienced 8,741 admissions; rates were 391 per 1,000 person-years among men (95% CI: 380, 402) and 327 among women (95% CI: 316, 338), P < 0.0001 for gender difference. A total of 1,187 men (75%) and 981 women (69%) were admitted to hospital at least once; among these, median numbers of admissions were 3 in men (inter-quartile range, (IQR): 1, 6) and 2 in women (IQR: 1, 5). Forty-eight percent of those ever admitted had experienced an emergency admission and 70% had been admitted overnight.Discussion: It is possible to link routinely collected HES data with detailed information from a cohort study. Hospital admission is common among community-dwelling ‘young-old’ men and women. These linked datasets will facilitate research into lifecourse determinants of hospital admission and inform strategies to manage demand on the NHS. [ABSTRACT FROM AUTHOR]

In this article, the author focuses on the impact of the British National Health Service (NHS) health care guidelines restraints on clinical commissioning groups (CCGs) in England. He informs that four CCGs have implemented the National Institute for Health and Care Excellence (NICE) guideline for in vitro fertilisation and the general practitioner (GP) referral service management guideline has restricted the flow of patients in CCGs. It states that a white paper released by the NHS in 2010 has revealed that NHS has planned to abolish primary health care trusts. It also mentions that the guidelines have impacted both the budget and responsibilities of CCGs. INSETS: BOX 1: CCGS FAIL TO IMPLEMENT NICE GUIDANCE ON IVF;BOX 2: CLOSING THE GATES¿NEW REFERRAL MANAGEMENT SYSTEMS;COMMISSIONING GROUPS ¿ HOW THEY CAME INTO BEING;BOX 3: FAMILY DOCTOR¿PATIENTS¿ ADVOCATE OR GUARDIAN OF THE PUBLIC

Background: In England, influenza and pertussis vaccination has been recommended for all pregnant women since 2010 and 2012 respectively. However, in some areas, vaccination uptake rates have been low. A qualitative study was conducted to gain a contextualised understanding of factors influencing vaccination acceptance during pregnancy in Hackney, a borough in north-east London, UK. This paper draws on in-depth insights gained from the above study, to provide recommendations for increasing long-term maternal vaccination acceptance.Methods: Hackney was chosen as the study site because it has one of the lowest vaccination coverage rates in pregnancy in the UK. A maximum variation sampling method was used to recruit 47 pregnant and recently pregnant women from a wide range of backgrounds, as well as ten healthcare professionals from three general practices; two community antenatal clinics; nine parent-toddler groups; and four community centres. In-depth interviews and a video-recording of a pregnant patient's consultation, explored experiences of care within the National Health Service during pregnancy, and women's views about maternal vaccination. In-depth interviews with healthcare professionals explored their views towards, and how they discuss and provide maternal vaccination. Study data were analysed both deductively, through drawing on insights from anthropological works that address diverse conceptualisations and practices around vaccination; and inductively, with a thematic analysis approach.Results: The findings of this study and the recommendations based on them were divided into five broad themes: access to maternal vaccination; healthcare institution rhetoric and its effect on maternal vaccination acceptance; community and family influences on maternal vaccination decisions; healthcare professionals' views towards maternal vaccination; and the influence of patient-healthcare professional relationships on maternal vaccination acceptance.Conclusions: The strategies to improve maternal vaccination acceptance recommended in this paper would engender a more open and democratised healthcare system. [ABSTRACT FROM AUTHOR]

Objectives In August 2008 the British reality TV star Jade Goody made public her diagnosis of cervical cancer. In February 2009 it was announced that she was terminally ill and she died a few weeks later. A surge in cervical screening attendances associated with these events was widely reported. This paper aims to quantify the size of that effect across England, its duration, and whether it affected some groups of women more than others. Setting The Cervical Screening Programme in England. Methods Routinely collected statistics for the months around Jade Goody's diagnosis and death were compared with those for other periods. Results About half a million extra cervical screening attendances occurred in England between mid-2008 and mid-2009, the period during which Jade Goody was diagnosed and died; among these were 370 attendances where the test result was suspected neoplasia. At its peak in March 2009, attendance was 70% higher than expected. Increases were seen in both initial and follow-up screening attendances and in colposcopy attendances, and at all ages, though the magnitude was greater for women aged under 50. A substantially greater proportion of the extra attendances of women aged 25-49 on routine recall occurred in women whose attendance was overdue (28% occurred at 60 months or more) and relatively little represented over-screening (8% had been screened within the last 30 months). Conclusions The pattern of increased attendance mirrored the pattern of media coverage of Jade Goody's diagnosis and death. It is likely that the increased screening resulted in a number of lives saved. [ABSTRACT FROM AUTHOR]

Background: The presence of a tongue-tie (ankyloglossia) in an infant may lead to breastfeeding difficulties, but debate continues about which babies should be treated with frenotomy. The Bristol Tongue Assessment Tool (BTAT), a clear and simple evaluation of the severity of tongue-tie, is being used worldwide and translated into different languages. We aimed to produce a simple picture version of the BTAT to aid and enhance consistent assessment of infants with tongue-tie. Methods: The Tongue-tie and Breastfed Babies (TABBY) assessment tool was developed from the BTAT by a graphic designer, with iterative discussion with four practicing NHS midwives. The TABBY tool consists of 12 images demonstrating appearance of the infant tongue, its attachment to the gum and the limits of tongue mobility. The TABBY tool is scored from 0 to a maximum of 8. Two initial audits of the TABBY were undertaken at a large maternity unit in a secondary care NHS Trust, in Bristol UK from 2017 to 2019. TABBY was evaluated by five midwives on 262 babies with tongue-ties and experiencing breastfeeding difficulties who were referred for assessment to a tongue-tie assessment clinic using both BTAT and TABBY. Each pair of scores was recorded by one midwife at a time. A further training audit with 37 babies involved different assessors using BTAT and TABBY on each baby. Results: All midwives found the TABBY easy to use, and both audits showed 97.7% agreement between the scores. We suggest that a score of 8 indicates normal tongue function; 6 or 7 is considered as borderline and 5 or below suggests an impairment of tongue function. Selection of infants for frenotomy required an additional breastfeeding assessment, but all infants with a score of 4 or less in the audits had a frenotomy, following parental consent. Conclusions: The TABBY Assessment Tool is a simple addition to the assessment of tongue-tie in infants and can provide an objective score of tongue-tie severity. Together with a structured breastfeeding assessment it can inform selection of infants for frenotomy. It can be used by clinical staff following a short training and will facilitate translation into other languages. [ABSTRACT FROM AUTHOR]

This paper aims to estimate the service and social costs of headache presenting in primary care and to identify predictors of headache costs. Patients were recruited from GP practices in England and service use and lost employment recorded. Predictors of cost were identified using regression models. Service and social costs were available on 288 and 282 patients, respectively. Average service costs over 3 months were £117 whilst total costs (including lost production) were £582. Patients referred to neurologists had service costs that were £82 higher than those not referred (90% CI £36-£128). Costs including lost employment were higher by £150, but this was not significant (90% CI -£139-£439). The annual mean service and social costs, weighted to represent population rates of referral, were £468 and £2328, respectively. Higher costs were significantly related to pain. Age was linked to higher service costs and lower social costs. The figures extrapolated to the whole of the UK suggest £956 million due to service use and £4.8 billion including lost employment. These are likely to be underestimates because many people experiencing headaches do not consult their GP. [ABSTRACT FROM AUTHOR]

Objectives To explore similarities and differences in policy content and the political context of the three main English government reports on health inequalities: the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010). Methods Thematic policy and context analysis of the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010) in terms of: (i) underpinningtheoretical principles; (ii) policy recommendations; (iii) the political contexts in which each was released; and (iv) their actual or potential influence on research and policy. Results There were great similarities and very few differences in terms of both the theoretical principles guiding the recommendations of these reports and the focus of the recommendations themselves. However, there were clear differences in terms of the political contexts of each report, as well as their subsequent impacts on research and policy. Conclusion The paper calls into question the progress of health inequalities research, the use of evidence and of the links between research, politics and policy. [ABSTRACT FROM AUTHOR]

Aim. We aimed to conceptualise how environmental, institutional, and organisational dynamics of the ED underpin and "moderate" nurses' emotional labour. Background. Around the globe, EDs are struggling to meet rising patient demand including both UK health systems and public services in the US. In spite of these challenges and the intense and distinctive nature of EDs, an exploration of emotional labour is largely missing from current understanding. This is important, in part because emotional labour is established as an indicator of wellbeing including intention to leave, burnout, and compassion fatigue. We understand little of how the environment moderates emotional labour, and our study addressed this problem in the ED. Understanding the moderators of emotional labour, organisational perspective also offers theoretical development. Methods. Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. This included 200 hours of observation at one District General Hospital and one Major Trauma Centre in the English NHS with 35 semistructured concurrent formal interviews. Results/Conclusions. The ED calls for an extensive spectrum of emotional labour from staff, influenced and moderated by the restrictions on resources, particularly time. We argue that, despite the often short nature of interactions undertaken in ED, the labour required is effortful and gruelling for staff. Understanding the relevance of environmental elements, namely, time, to the emotional labour offers tangible opportunities for improvement. These new understandings can underpin solutions to negative consequences of this work. Suggested measures and interventions to alleviate the impact of emotional labour should be prioritised by policy makers and those tasked with managing, designing, and leading the delivery of care in ED. Implications for Profession and/or Patient Care. The more "sped up" a service is required to be, the higher the likelihood of emotional labour is. In light of the challenges facing healthcare services around the world and the increased throughput through services, particularly in ED, this is important. This is also critical when considering that there are well-established relationships between emotional labour and wellbeing in nursing. Understanding the relevance of the healthcare environment to staff members' experiences of emotional labour is critical in designing solutions which counterbalance the potentially negative consequences of this work. [ABSTRACT FROM AUTHOR]

Aims: In 2017, two distinct interventions were implemented in Ireland and England to reduce prescribing of lidocaine medicated plasters. In Ireland, restrictions on reimbursement were introduced through implementation of an application system for reimbursement. In England, updated guidance on items which should not be routinely prescribed in primary care, including lidocaine plasters, was published. This study aims to compare how the interventions impacted prescribing of lidocaine plasters in these countries. Methods: We conducted an interrupted time‐series study using general practice data. For Ireland, monthly dispensing data (2015–2019) from the means‐tested General Medical Services (GMS) scheme was used. For England, data covered all patients. Outcomes were the rate of dispensings, quantity and costs of lidocaine plasters, and we modelled level and trend changes from the first full month of the policy/guidance change. Results: Ireland had higher rates of lidocaine dispensings compared to England throughout the study period; this was 15.22/1000 population immediately pre‐intervention, and there was equivalent to a 97.2% immediate reduction following the intervention. In England, the immediate pre‐intervention dispensing rate was 0.36/1000, with an immediate reduction of 0.0251/1000 (a 5.8% decrease), followed by a small but significant decrease in the monthly trend relative to the pre‐intervention trend of 0.0057 per month. Conclusions: Among two different interventions aiming to decrease low‐value lidocaine plaster prescribing, there was a substantially larger impact in Ireland of reimbursement restriction compared to issuing guidance in England. However, this is in the context of much higher baseline rates of use in Ireland compared to England. [ABSTRACT FROM AUTHOR]

Objective: To understand how materiality affects patient and public involvement (PPI) for commissioning and leading health and care services in the English National Health Service (NHS) context. Context: From April 2013 groups of general practitioners (GPs) became members of NHS clinical commissioning groups (CCGs) to assess needs and procure core health services for and with local communities. Since July 2022, integrated care systems (ICSs) have subsumed this responsibility. NHS reorganisations have been driven by the promise of more effective and efficient health care and have led to a long history of PPI on economic, political, and moral grounds. Few studies researching PPI in clinical commissioning exist and fewer still have explored a more agentic understanding of materiality and its impact on PPI. Study Design: A focused ethnography was used to examine PPI for clinical commissioning within two CCG case study sites in England. Three CCG Governing Body lay representatives, nine GP commissioners and seven service user representatives took part in focus groups and/or were interviewed. Fifteen nonparticipant observations were also carried out at CCG meetings and the associated materiality was examined. Findings: The materiality of activities involved in clinical commissioning influences and shapes the nature of PPI. These forms of materiality may dilute and subvert meaningful engagement and involvement that relies on trust, leadership, learning, and partnership working. Conclusion: System leaders in ICSs should consider the significance of materiality in centrally driven processes involved in PPI commissioning to reduce barriers and ensure meaningful partnerships within local communities. Patient and Public Contribution: The study design ensured PPI throughout the research process in keeping with contemporary research practice guidance. The project steering committee included service users with current or recent PPI clinical commissioning experience outside of the study sites. There was PPI involvement in the original study proposal and its development including the bid for doctoral funds on which this study is based. All were involved in assessing the rigour of the data collection, interpretation of the findings and ensuring the project remained true to the aims of the study. Two members have also participated in presentation of the study findings. [ABSTRACT FROM AUTHOR]

Tissue viability services have been reconfigured and developed as a result of increased pressure on the NHS to deliver more efficient services that maintain quality of care. There is a need for tissue viability clinicians to develop the skills to outline and effect positive changes in practice. For this, they need business development skills, one of the most important of which is presentation skills. This article describes how to put together a presentation that will successfully promote a business case for change in clinical practice. [ABSTRACT FROM AUTHOR]

This paper addresses ethical concerns emanating from the practice of using patients for health care education. It shows how some of the ways that patients are used in educational strategies to bridge theory-practice gaps can cause harm to patients and patient-practitioner relationships, thus failing to meet acceptable standards of professional practice. This will continue unless there is increased awareness of the need for protection of human rights in teaching situations. Unnecessary exposure of patients, failing to obtain explicit consent, causing harm to vulnerable or disadvantaged groups and inappropriate use of information, though normally regarded as unacceptable professional practices, may go unrecognised in meeting educational needs, widening rather than narrowing theory-practice gaps. [ABSTRACT FROM AUTHOR]