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Background The majority of psychopathology emerges in late adolescence and continues into adulthood. Continuity of care must be guaranteed in this life phase. The current service configuration, with a distinction between child/adolescent and adult mental health services (CAMHS and AMHS), impedes continuity of care.AIm To map professionals' experiences with and attitudes towards young people's transition from CAMHS to AMHS and the problems they encounter.Methods An online questionnaire distributed among professionals providing mental health care to young people (15-25 years old) with psychiatric disorders.Results Five hundred and eighteen professionals completed the questionnaire. Decision-making regarding transition is generally based on the professional's own deliberations. The preparation was limited to discussing changes with the adolescent and parents. Most transition-related problems are experienced in CAMHS, primarily with regard to collaboration with AMHS. Respondents report that the developmental age should be leading in the transition-decision making process and that developmentally appropriate services are important in bridging the gap.Conclusion Professionals in CAMHS and AMHS experience problems in the preparation of, and the collaboration during transition. The problems are related to coordination, communication and rules and regulations. Professionals attach importance to improvement through an increase in flexibility and more specialist services for youth.

Take home messages This article continues our ‘Controversies in’ series for the Frontline Gastroenterology Twitter debates. The focus of the debate was endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), in which training, service configuration and management of challenging cases were discussed. We aim to summarise the key points from the debate. ### Training and service delivery #### Is the current UK training system appropriately set up for training in ERCP? The discussion started with the current setup for ERCP training in the UK. ERCP, unlike oesophagogastroduodenoscopy (OGD) and colonoscopy, is optional for training in gastroenterology. Currently in the UK, gastroenterology training is combined with general internal medicine (GIM) and there are mandatory competencies in subspecialties like inflammatory bowel disease (IBD), hepatology and nutrition. Trainees often find it challenging to achieve competency in therapeutic OGD and level 2 colonoscopy, and it is anticipated that the situation may become even more difficult with the new internal medicine training system, which would leave less time for endoscopy training. Consequently, trainees with an interest in ERCP are unable to achieve competency in this domain of endoscopy during the completion of training (CCT) and are left with no other choice but to pursue further training in the form of a post-CCT fellowship. This, combined with service standards1 that require minimum numbers of procedures per annum, has led to a reduction in the number of consultants undertaking ERCP. With fewer people …

Any hospital doctor will inform you that length of stay is a far better indicator of patient acuity than diagnosis. So why do hospital doctors continue to be harassed over supposed changes in hospital mortality generated by models which largely rely on diagnosis?

Background Trainees are performing fewer bronchoscopies as a result of the increased use of endobronchial ultrasound-guided transbronchial needle aspiration. Workforce planning and changes in trainee working patterns may also have compounded this situation. We investigated current trends in endobronchial biopsy (EBB) and transbronchial biopsy (TBB) training and competency in respiratory trainees and consultants across the United Kingdom. Methods We performed a national survey and received 131 online responses from 58 consultants and 73 registrars across 13 United Kingdom deaneries. Results A significant proportion (31%) of consultants, more than half of which were new consultants, had performed

The United Kingdom is committed to eliminating hepatitis C virus (HCV) infection by 2025. The prison estate provides an opportunity to identify and treat HCV-positive individuals in a high-prevalence environment. We designed and implemented a pathway of care within a London prison to diagnose, stratify and link HCV-positive prisoners into care. This study was a two-phase case study of a HCV care pathway. New arrivals to the prison were offered blood-borne virus screening with dried blood spot testing at their secondary health check. Those with active infection completed disease stratification tests and were reviewed at a weekly hospital-based multidisciplinary team meeting to determine management. In Phase-2, the pathway was redesigned to improve testing and the referral of HCV-positive prisoners into treatment. Over the 30-month evaluation period, 12,946 people were received in the prison. During Phase-1, 19.6% of new arrivals completed blood-borne virus testing, with 7.3% identified as HCV-positive. Just 8.3% of HCV-positive individuals were treated or referred for treatment in Phase-1. During Phase-2, 30% of new receptions completed BBV testing and 3.9% were identified as HCV-positive. Linkage into care was improved, with 38.9% treated or referred during the second phase. Poor access to testing and referral to treatment limit the effectiveness of care provision for prisoners with HCV. Elimination of HCV in prisons requires local service configuration to ensure high uptake of testing, with all HCV-positive cases then offered treatment during custody or referral on to treatment after release.

The management of Crohn's disease (CD) is shifting from a stepwise, incremental approach based on symptom control to more aggressive early combined immunosuppression in an attempt to induce remission more rapidly and avoid long-term bowel damage. Accurately defining disease activity is a major challenge, as there is often a disconnect between symptomatology and underlying disease status. The role of imaging in CD has evolved such that it now plays a central role establishing the initial diagnosis, characterising disease phenotype, activity assessment, disease surveillance, and assessing response to therapy. Furthermore, the "treat-to-target" approach is being investigated in CD, with resolution of transmural inflammation on cross-sectional imaging being the treatment goal. In this review, we summarise the principal imaging techniques available to the radiologist, the key findings, and provide some guidance on the preferred imaging option in the diagnostic pathway. We consider the relative merits and drawbacks of each imaging technique before offering a brief discussion of some current developments and research avenues in CD imaging. We discuss how imaging may be useful in a "treat-to-target" approach. Finally, we highlight some practical considerations around service configuration and delivery to optimise imaging in CD in an accurate, cost-effective manner.

Purpose The purpose of this paper is to add to the understanding of context by shedding light on the relationship between context and organisational actors’ abilities to resolve ongoing challenges. Design/methodology/approach The authors used qualitative data collection (interviews and focus groups with staff and site visits to English forensic psychiatry hospitals) and the analysis was informed by Lefebvre’s writings on space. Findings Responses to ongoing challenges were both constrained and facilitated by the context, which was negotiated and co-produced by the actors involved. Various (i.e. societal and professional) dimensions of context interacted to create tensions, which resulted in changes in service configuration. These changes were reconciled, to some extent, via discourse. Despite some resolution, the co-production of context preserved contradictions which mean that ongoing challenges were modified, but not resolved entirely. Originality/value The paper highlights the importance of viewing context as co-produced in a continuous manner. This helps us to delineate and understand its dynamic nature and its relationship with the everyday actions and beliefs of the organisational actors concerned.

SummaryThe relationship between alcohol use and cognitive impairment has been notoriously difficult to disentangle. We present what is known about cognitive impairment associated with alcohol use/misuse, covering the spectrum from mild and subtle cognitive change through to severe alcohol-related brain damage, including Wernicke-Korsakoff syndrome. We highlight aids to the diagnosis and management of these conditions, and emphasise the benefits of prompt treatment on outcome. We also review progress in understanding their neurobiology. Suggestions for possible service configuration based on both our clinical practice and national guidelines are given.Learning Objectives•Gain an understanding of the spectrum of clinical presentations found in alcohol-related brain damage.•Understand that the aetiology of these conditions is complex and not solely due to the neurotoxic effects of alcohol.•Be better able to plan for the rehabilitation of individuals with established alcohol-related brain damage in your local service area.

Children are getting healthier year by year, yet there are increasing demands being put on services. More care is being delivered in the community and there are more children with chronic handicap for whom more can be done. Parental expectations are also higher than they have ever been. The whole of the provision of health care to children is at a crossroads. There is a need to strengthen the care of children in the community and as part of this there will be more subspecialization in disability, social paediatrics, child mental health, audiology and public health. The traditional distinction between hospital and community paediatrics needs to be changed. Children should be cared for by consultant paediatricians, most of whom will have a special interest. A comprehensive service for the future needs to be built around the needs of a population of children. Any individual paediatrician will not be able to provide for all of these needs but a team will. A model is suggested of a locality team of paediatricians linking into district and tertiary services via managed networks of care.

We enjoyed reading the report by Young et al. on their experience with acute laparoscopic cholecystectomy (ALC) in Leeds.1 We recently presented similar findings from our district general hospital at the 14th Annual Scientific Meeting of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (8–10 September 2010, Oxford). In 2005, a change in service configuration was developed to manage surgical emergencies. The emergency surgical take team consists of two upper gastrointestinal surgeons (UGI) and eight non-UGI (NUGI) surgeons.2 In 2000 and 2001, ALC was performed in 16% of all emergency biliary admissions (67 patients). Between November 2008 and November 2009, this figure rose to 55% (99 patients). Of the 99 patients, 30 (30%) had biliary colic, 34 (34%) had acute cholecystitis, 24 (24%) had pancreatitis and the remaining 11 patients had obstructive jaundice or cholangitis. Six patients (6%; two UGI and four NUGI) required conversion to open surgery. Reported difficult intraoperative haemostasis occurred in 10 cases, of which one involved a UGI surgeon and nine involved NUGI surgeons (P = 0.043), although UGI patients have a higher average grading for operative difficulty. There was no difference in overall rates of postoperative complications, which occurred in seven of 43 UGI patients (16%) vs. 11 of 56 NUGI patients (20%) (P = 0.611). There were two cases of common bile duct injury and three readmissions for pain in the NUGI group, compared with none for either in the UGI group, but these differences were not statistically significant. A reconfigured emergency service has increased the proportion of patients undergoing cholecystectomy during their index admission, although our experience has confirmed the reports of others that acute surgery may be more challenging.3–5 Our experience also suggests that outcomes are improved when surgery is performed by UGI surgeons.

Background Significant variation in length of inpatient stay (LOS) exists across hospitals in the UK. 1 It is not clear whether demographic, clinical and/or process factors, in particular socio-economic position (SEP) can explain this. Studies examining the association between LOS and SEP have been inconclusive, possibly due to differences in the definition of prolonged LOS. 2–7 Study design A retrospective audit of 2889 children aged less than 16 years admitted to two District General Hospitals in London from 1st April 2009 to 30 th March 2010, each with different models of paediatric accident and emergency (A&E) service delivery. Hospital A A&E was paediatric and Hospital B A&E led. Exposure measures Demographic, clinical characteristics and process factors were examined (Tables 1 & 2). SEP was measured by quartile of Income deprivation affecting children index (IDACI). Methods Prolonged LOS was defined as greater than or equal to the mean length of stay (1.8 days). Multivariable logistic and linear regression analyses were performed. Sensitivity analysis was carried out using two other definitions of length of stay. Results A fifth of children stayed less than 24 hours and almost two fifths more than the mean of 1.8 days. Adjusted for age, sex and admission hospital, being in the 3 rd most deprived IDACI quartile was associated with increased odds of prolonged LOS (Model 1: Odds Ratio (OR) 1.26, 95% Confidence interval (CI) 1.01, 1.56) (Table 3). This association was attenuated by additional adjustment for clinical and process factors (Table 3, Models 3 & 4). In contrast, adjusting for demographic, clinical and process factors strengthened the association between admission to Hospital B and prolonged LOS (Model 4: OR 1.41, 95% CI 1.16, 1.71). These associations were not consistent using different definitions of prolonged LOS. Conclusion The association between SEP and prolonged LOS is weak and inconsistent and depends on the definition used and the consideration of other potential confounding factors. These findings suggest that service configuration may account for some of the variation in LOS between hospitals in the UK; alternatively they could be due to residual confounding. Model 1: Adjusted for age (groups), gender admission hospital and quartile of IDACI; as defined in Tables 1 and 2 Model 2: additionally adjusted for ethnicity (group) – as defined in Tables 1 and 2. Model 3: Additionally adjusted for final diagnosis, medical or surgical specialty and number of hospital admissions during the study period Model 4: Additionally adjusted for source of admission, weekend or week day admission, season of admission and time of admission – as defined in Tables 1 and 2

Background Benign headache is a common neurological symptom in both primary care (5% of consultations) and secondary care (20-30% of neurology referrals). Question Does a simple patient information sheet improve headache severity, frequency and impact as measured by the HIT-6 score? Methods A randomised controlled trial (RCT) in an NHS setting. Results The trial terminated early due to incomplete recruitment over a two year period. The information sheet had strong face validity with patients and patient groups but no meaningful conclusions can be drawn because of recruitment problems. One hundred and sixty eight patients were randomised from a projected sample size of 220 and only 62 fully completed the trial. Conclusions We analysed the reasons for trial failure, and they fall into a number of distinct groups: (1) major service configuration/re-orientation occurred concurrently as the trial was run with 'Choose and Book' and the '18 week targets' being introduced; (2) our aim was a classical evidence-based superiority trial, whereas the PCT aim was demand management; (3) there was a funding and resource shortfall. Our experience generates discussion about appropriate level of evaluation required for service development.

Intravenous recombinant tissue plasminogen activator is a highly effective treatment for acute ischemic stroke, but routine provision is challenging. We compared the activity, safety and response times of five service configurations: local services, redirection of selected or all suspected stroke patients by emergency medical services (EMS) to stroke centers and the use of telemedicine with and without secondary transfer to a stroke center. In total, 59 relevant service descriptions were identified. Pooled treatment rates (mean +/- standard deviation [SD]) per 100 confirmed stroke patients were: local service design, 2.5 +/- 2.5 (n = 21417); EMS redirection of only patients potentially eligible for thrombolysis, 3.9 +/- 1.2 (n = 1872); EMS redirection of all suspected stroke patients, 3.8 +/- 1.1 (n = 5427); telemedicine with secondary transfer, 6.9 (no pooled SD; n = 749); and telemedicine without secondary transfer, 3.4 (no pooled SD; n = 6610). A comprehensive stroke patient register was completed for only five regional collaborations, resulting in pooled ischemic stroke treatment rates of 5.7 (95% confidence interval: 4.6-6.9; n = 7815) compared with 3.1 (95% confidence interval: 2.1-4.1; n = 31411) for local services. Pooled symptomatic hemorrhage rates were similar for all service designs (range: 3.9-5.1%). Average door-needle times exceeded 60 min in most studies. We conclude that regional collaborations achieve higher rates of thrombolysis than local services working in isolation. Stroke services should continue to publish thrombolysis activity and safety data in a recommended format in order to determine the most suitable configuration for different settings.

Objectives To describe key demographic and clinical characteristics of frequent attenders to two paediatric accident and emergency (A&E) departments. Design Retrospective case note review of all children attending the paediatric A&E departments from 31st March 2009 to 1st April 2010. Setting Two large District General Hospitals in London, UK with different models of AE Hospital A paediatric led, Hospital B A&E led with paediatric input for under 1 year olds and all potential admissions. Subjects 44,500 children aged 0 to 16 years Outcome measure Frequent attendance defined by four or more attendances per child per year. Exposure measures Demographic (age, sex, ethnicity, socioeconomic position (SEP) and distance lived from hospital) and clinical characteristics (presenting complaint and outcome) as assessed on first A&E attendance. Income deprivation affecting children index (IDACI) was derived from the postcode as a measure of SEP. Methods Multivariable logistic regression was used to assess potential independent associations in each hospital. Results 27% of children attending the A&E accounted for 50% of all attendance episodes. Three percent from hospital A (HA) (n=478) and four percent from hospital B (HB) (n=625) presented 4 or more times in the year. All results are presented fully adjusted for age, sex, ethnicity, IDACI, distance lived from hospital, presenting complaint and outcome at first attendance (table 1). Frequent attendance, was associated with greater odds for younger children (HA and HB), living close to the hospital (HA only) being male, living in an area of higher deprivation and admission on first presentation (HB only) Lower odds were found for frequent attendance for those presenting with injury (HA and B), reporting ethnicity as black, other or unstated (compared to white) (HB only) Certain first presenting complaints were associated with odds of frequent attendance, albeit numbers were small and confidence intervals wide. Conclusion Key demographic and clinical characteristics were associated with more frequent attendance to paediatric A&E, but these differed for the two populations. Analyses of these types of data facilitates evidence informed service configuration

Background In 2003, it became legal in the UK for syringe exchange programmes (SEPs) to provide citrate to injecting drug users to solubilise heroin. Little work has been undertaken on the effect of policy change on SEP function. Here, we examine whether the introduction of citrate in Cheshire and Merseyside SEPs has altered the number of heroin/crack injectors accessing SEPs, the frequency at which heroin/crack injectors visited SEPs and the number of syringes dispensed. Methods Eleven SEPs in Cheshire and Merseyside commenced citrate provision in 2003. SEP-specific data for the six months before and six months after citrate was introduced were extracted from routine monitoring systems relating to heroin and crack injectors. Analyses compared all individuals attending pre and post citrate and matched analyses only those individuals attending in both periods (defined as 'longitudinal attenders'). Non-parametric tests were used throughout. Results Neither new (first seen in either six months period) nor established clients visited SEPs more frequently post citrate. New clients collected significantly less syringes per visit post citrate, than pre citrate (14.5,10.0; z = 1.992, P < 0.05). Matched pair analysis showed that the median number of visits for 'longitudinal attenders' (i.e. those who attended in both pre and post citrate periods) increased from four pre citrate to five post citrate (z = 2.187, P < 0.05) but the number of syringes collected remained unchanged. These changes were not due to seasonal variation or other changes in service configuration. Conclusion The introduction of citrate did not negatively affect SEP attendance. 'Longitudinal attenders' visited SEPs more frequently post citrate, providing staff with greater opportunity for intervention and referral. As the number of syringes they collected each visit remained unchanged the total number of clean syringes made available to this group of injectors increased very slightly between the pre and post citrate periods. However, new clients collected significantly less syringes post citrate than pre citrate, possibly due to staff concerns regarding the amount of citrate (and thus syringes) to dispense safely to new clients. These concerns should not be allowed to negatively impact on the number of syringes dispensed.