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The introduction of the Initial Education and Training Standards for Pharmacists reforms outlined that trainee pharmacists will be able to qualify as independent prescribers (IPs) on registration from 2026. To enable this transformation, sufficient numbers of designated prescribing practitioners (DPPs) are required to supervise the IP element of their training. A regional survey identified 12 DPPs, which highlights a potential workforce challenge. This study expanded on the findings of the survey, aiming to explore the experiences of DPPs to understand how to increase capacity and inform the next steps towards implementing the reforms. In a descriptive, qualitative study, a series of two focus groups were conducted with DPPs and a chief pharmacist. Training and funding of DPPs was reported as the key enabler to increasing capacity whilst time constraints was the most significant barrier. Cross-sector supervision was considered possible provided there was time and funding. NHS England Workforce, Transformation and Education Directorate (NHSE WT&E) are a national organisation leading on this work stream and should consider targeting some of the immediate enablers (training and funding) and barriers (time) as identified from this study to increase DPP capacity in preparation for 2026. NHSE WT&E should consider developing plans to address other important themes identified such as whether DPPs can provide supervision cross-sector supervision as well as funding showing that the themes identified do not exist in isolation but intricately linked to one another. [ABSTRACT FROM AUTHOR]

Summary: This study uses NHS waiting times and osteoporosis medication community prescription datasets to assess the impact of COVID-19 on DXA waits and osteoporosis medication patterns in England. Results show significant increases in DXA waiting list times and variation in prescription rates. Investment is needed to improve waiting list times. Purpose: This study investigates the impact of COVID-19 on DXA scan waiting lists, service recovery and osteoporosis medication prescriptions in the NHS following the March 2020 national lockdowns and staff redeployment. Methods: Data from March 2019 to June 2023, including NHS digital diagnostics waiting times (DM01) and osteoporosis medication prescriptions from the English Prescribing Dataset (EPD), were analysed. This encompassed total waiting list data across England's seven regions and prescribing patterns for various osteoporosis medications. Analyses included total activity figures and regression analysis to estimate expected activity without COVID-19, using R for all data analysis. Results: In England, DXA waiting lists have grown significantly, with the yearly mean waiting list length increasing from 31,851 in 2019 to 65,757 in 2023. The percentage of patients waiting over 6 weeks for DXA scans rose from 0.9% in 2019 to 40% in 2020, and those waiting over 13 weeks increased from 0.1% in 2019 to 16.7% in 2020. Prescription trends varied, with increases in denosumab, ibandronic acid and risedronate sodium and decreases in alendronic acid, raloxifene hydrochloride and teriparatide. A notable overall prescription decrease occurred in the second quarter of 2020. Conclusion: COVID-19 has significantly increased DXA scan waiting lists with ongoing recovery challenges. There is a noticeable disparity in DXA service access across England. Osteoporosis care, indicated by medication prescriptions, also declined during the pandemic. Addressing these issues requires focused investment and effort to improve DXA scan waiting times and overall access to osteoporosis care in England. [ABSTRACT FROM AUTHOR]

Unchecked antimicrobial resistance is lethal and carries a high economic burden on the global economy. Primary care is central to the success of health service antibiotic stewardship programmes, as most of these infections are managed in the community. This article examines a pioneering programme that aims to reduce resistance to antibiotics commonly used to treat lower urinary tract infections. [ABSTRACT FROM AUTHOR]

Background: Depression is the second most common chronic condition affecting women of reproductive age; 23.4% of women enter pregnancy with depression and use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy is often necessary for maternal wellbeing. However, SSRI use during pregnancy can cause congenital malformations, postpartum haemorrhage (PPH), and persistent pulmonary hypertension of the newborn (PPHN). In UK primary care, prescribing formularies are one medium by which prescribers are provided with local medicines advice. Aim: To review all local prescribing formularies with respect to prescribing SSRIs in women of reproductive age, during pregnancy, and during breastfeeding. Design & setting: A systematic review of prescribing formularies in England and Wales. Method: A systematic keyword search of all clinical commissioning group and Integrated Care Board websites in England and Local Health Board websites in Wales was undertaken between December 2021–22 to identify prescribing formularies. Data were extracted on prescribing guidance for SSRIs. Results: Seventy-four prescribing formularies were reviewed. Of these, 14.9% (n = 11/74) provided links to the Medicines and Healthcare products Regulatory Agency guidance on congenital abnormalities associated with SSRIs, 28.4% (n = 21/74) provided links to guidance on PPH risk, and 1.4% (n = 1/74) provided links to guidance on PPHN. Specific local guidance was given on SSRI prescribing for women of reproductive age, during pregnancy, and during breastfeeding in 12.2% (n = 9/74), 23.0% (n = 17/74), and 21.6% (n = 16/74) of formularies, respectively. Conclusion: Our results suggest that prescribers may be poorly informed by local formularies about the risks of SSRI use around pregnancy. This could place babies at increased risk of unintentional SSRI exposure. [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]

Background: Overprescribing of potentially harmful medication in UK general practice has a complex association with socioeconomic deprivation. Aim: To assess trends in general practice prescribing of five high-risk medications and their relationship with deprivation. Design & setting: An observational study was conducted using general practice data from three English regions with varied sociodemographic factors: West Yorkshire and Harrogate (WY), Black Country and West Birmingham (BC), and Surrey and East Sussex (SE). Method: Practice-level prescribing data were obtained from 2016–2021 for five drug classes: opioids, hypnotics, gabapentinoids, non-steroidal anti-inflammatory drugs (NSAIDs), and antibacterials. Prescribing trends were demonstrated using a linear model. Results: Reduction in NSAID, opioid, hypnotic and antibacterial prescriptions, and the increase in gabapentinoid prescriptions, were significant at each financial year time period. Index of Multiple Deprivation (IMD) was positively associated with all drug classes except antibacterials, which showed a positive association when incorporating the interaction term between IMD and age. When adjusting for IMD and population, region was independently associated with prescribing rate. Compared with WY, IMD had a smaller association with prescribing in BC for NSAIDs (coefficient = −0.01578, P = 0.004) and antibacterials (coefficient = −0.02769, P = 0.007), whereas IMD had a greater association with prescribing in SE for NSAIDs (coefficient = 0.02443, P<0.001), opioids (coefficient = 0.08919, P<0.001), hypnotics (coefficient = 0.09038, P<0.001), gabapentinoids (coefficient = 0.1095, P<0.001), and antibacterials (coefficient = 0.01601, P = 0.19). Conclusion: The association of socioeconomic deprivation with overprescribing of high-risk medication in general practice varies by region and drug type. Geographical location is associated with overprescribing, independent of socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: Following government calls for General Practices in England to work at scale, some practices have grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience. Methods: We linked five practice-level datasets in England to obtain a single dataset of practice workforce, list size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance. Results: A total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as 'Small GP-reliant practices', 1400 (23.2%) were labelled 'Medium-size GP-led practices with a multidisciplinary team (MDT) input' and 131 (2.2%) practices were named 'Large multidisciplinary practices'. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than small GP-reliant practices. Conclusion: Small GP-reliant practices were found to provide better patient reported access, continuity of care, experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection rates but had no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve good patient experience. [ABSTRACT FROM AUTHOR]

Objectives Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this. Methods From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models. Results Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids). Conclusion IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing. [ABSTRACT FROM AUTHOR]

Background The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety. Methods Qualitative semi- structured interviews and focus groups were conducted with 130 participants, including locums, patients, permanently employed doctors, nurses and other healthcare professionals with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS. Data were collected between March 2021 and April 2022. Data were analysed using reflexive thematic analysis and abductive analysis. Results Participants described the implications of locum working for quality and safety across five themes: (1) 'familiarity' with an organisation and its patients and staff was essential to delivering safe care; (2) 'balance and stability' of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) 'discrimination and exclusion' experienced by locums had negative implications for morale, retention and patient outcomes; (4) 'defensive practice' by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors. Conclusion Locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention. [ABSTRACT FROM AUTHOR]

Objectives: Despite significant investment in social prescribing in England over the last decade, we still do not know if it works, or how models of social prescribing fit within wider health and care policy and practice. This study explores current service delivery structures and assesses the feasibility of a national evaluation of the link worker model. Methods: Semi-structured interviews were conducted between May and September 2020, with 25 key informants from across social prescribing services in England. Participants included link workers, voluntary, community and social enterprise staff, and those involved in policy and decision-making for social prescribing services. Interview and workshop transcripts were analysed thematically, adopting a framework approach. Results: We found differences in how services are provided, including by individual link workers, and between organisations and regions. Standards, referral pathways, reporting, and monitoring structures differ or are lacking in voluntary services as compared to clinical services. People can self-refer to a link worker or be referred by a third party, but the lack of standardised processes generated confusion in both public and professional perceptions of the link worker model. We identified challenges in determining the appropriate outcomes and outcome measures needed to assess the impact of the link worker model. Conclusions: The current varied service delivery structures in England poses major challenges for a national impact evaluation. Any future rigorous evaluation needs to be underpinned with national standardised outcomes and process measures which promote uniform data collection. [ABSTRACT FROM AUTHOR]

Summary: In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically‐led, data‐driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero. [ABSTRACT FROM AUTHOR]

Background: Changes to prescribing policies in England have restricted or stopped access to gluten‐free food on prescription for people with coeliac disease in some geographical areas. The present study aimed to explore the impact of these changes on the affordability and obtainability of gluten‐free foods for adults with coeliac disease. Methods: Semi‐structured qualitative interviews (n = 24) were conducted with people with coeliac disease living in areas where prescriptions for gluten‐free foods were no longer available, were restricted or followed national guidelines. Interviews explored the impact of gluten‐free prescribing changes on the affordability and obtainability of gluten‐free food, as well as dietary adherence. Results: All participants considered gluten‐free substitute foods to be expensive. Participants felt the availability of gluten‐free foods has improved over time, also acknowledging some challenges remain, such as limited local availability. For most, the withdrawal of prescriptions had minimal impact requiring small adjustments such as reducing the quantity of foods obtained. However, greater challenges were faced by those less mobile, permanently sick or disabled and/or on lower incomes. Conclusions: The majority of participants affected by the withdrawal of prescriptions were able to adapt to cope with these changes. However, participants with mobility issues, who are permanently sick or disabled and/or on lower incomes were struggling to afford and obtain gluten‐free substitute foods from elsewhere. The withdrawal of prescriptions may further widen health inequalities. Further research should focus on the long‐term impacts of prescription withdrawal for the vulnerable groups identified. Key points: Prescriptions for gluten‐free substitute foods have been restricted or withdrawn in some areas of England, but the impact of these changes on people with coeliac disease is unknown.The present study found that the majority of people with coeliac disease were able to adapt to cope with prescribing changes, but certain groups (people with mobility issues, who are permanently sick or disabled and/or on lower incomes) were struggling to afford and obtain gluten‐free foods.Future research should focus on the longer‐term impacts of no access or restricted access to gluten‐free substitute foods on prescription, with specific focus on the groups identified above. [ABSTRACT FROM AUTHOR]

Background: Identification in UK general practice of women affected by domestic violence and abuse (DVA) is increasing, but men and children/young people (CYP) are rarely identified and referred for specialist support. To address this gap, we collaborated with IRISi (UK social enterprise) to strengthen elements of the IRIS + intervention which included the identification of men, direct engagement with CYP, and improved guidance on responding to information received from other agencies. IRIS + was an adaptation of the national IRIS (Identification and Referral to Improve Safety) model focused on the needs of women victim-survivors of DVA. Without diminishing the responses to women, IRIS + also responded to the needs of men experiencing or perpetrating DVA, and CYP living with DVA and/or experiencing it in their own relationships. Our study tested the feasibility of the adapted IRIS + intervention in England and Wales between 2019–21. Methods: We used mixed method analysis to triangulate data from various sources (pre/post intervention questionnaires with primary care clinicians; data extracted from medical records and DVA agencies; semi-structured interviews with clinicians, service providers and referred adults and children) to assess the feasibility and acceptability of the IRIS + intervention. Results: The rate of referral for women doubled (21.6/year/practice) from the rate (9.29/year/practice) in the original IRIS trial. The intervention also enabled identification and direct referral of CYP (15% of total referrals) and men (mostly survivors, 10% of total referrals). Despite an increase in self-reported clinician preparedness to respond to all patient groups, the intervention generated a low number of men perpetrator referrals (2% of all referrals). GPs were the principal patient referrers. Over two-thirds of referred women and CYP and almost half of all referred men were directly supported by the service. Many CYP also received IRIS + support indirectly, via the referred parents. Men and CYP supported by IRIS + reported improved physical and mental health, wellbeing, and confidence. Conclusions: Although the study showed acceptability and feasibility, there remains uncertainty about the effectiveness, cost-effectiveness, and scalability of IRIS +. Building on the success of this feasibility study, the next step should be trialling the effectiveness of IRIS + implementation to inform service implementation decisions. [ABSTRACT FROM AUTHOR]

Background and Aims: An apparently protective effect of opioid agonist treatment (OAT) on all‐cause and cause‐specific mortality risk has been widely reported. Non‐fatal overdose (NFO) often precedes subsequent drug‐poisoning deaths. We hypothesized that benzodiazepines, gabapentinoids, antipsychotics, antidepressants, Z‐drugs or opioids increase the NFO risk when co‐prescribed with OAT. Design: We conducted a cohort study using the Clinical Practice Research Datalink GOLD and Aurum databases. The cohort was linked to Hospital Episode Statistics admitted patient care data (HES‐APC), neighbourhood‐ and practice‐level Index of Multiple Deprivation quintiles and mortality records from the Office for National Statistics. Setting: Primary care in England. Participants: We studied patients with opioid use disorder, aged 18–64 years, who were prescribed OAT (15155 methadone and 5743 buprenorphine recipients) between Jan 1, 1998, and Dec 31, 2017. Measurements: The main outcome examined was NFO risk during co‐prescription of OAT with benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z‐drugs or opioids. Overdose was defined according to International Classification of Diseases codes from the HES‐APC data set. Negative binomial regression models were used to estimate weighted rate ratios (wRR) for NFO during co‐prescription of OAT and benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z‐drugs or opioids with periods of exclusive OAT usage. Findings Among 20 898 patients observed over 83 856 person‐years, we found an elevated overdose risk that resulted in hospital admission during co‐prescription of OAT with benzodiazepines [wRR: 1.45; 95% confidence interval (CI) = 1.26–1.67], gabapentinoids (wRR = 2.22; 95% CI = 1.77–2.79), Z‐drugs (wRR = 1.60; 95% CI = 1.31–1.96), antipsychotics (wRR = 1.85; 95% CI = 1.53–2.25) and opioids (wRR = 1.28; 95% CI = 1.02–1.60). The risk ratio for antidepressant co‐prescriptions was below unity (wRR = 0.90; 95% CI = 0.79–1.02) but this result was not statistically significant. Conclusion: Elevated risk of non‐fatal overdose among opioid agonist treatment recipients is associated with concurrent use of medication prescribed for other reasons. [ABSTRACT FROM AUTHOR]

Background: Performing an episiotomy where clinically indicated is a key intervention in the Obstetric Anal Sphincter Injury Care Bundle (OASI‐CB) implemented across England and Wales to reduce the risk and increase the detection of severe perineal trauma after birth. Standards of consent provided to people in maternity care generally and for episiotomy specifically have been reported as suboptimal. Compromising birthing people's personal autonomy or sense of control has been linked to a dissatisfying birth experience, negative psychological sequelae, and litigation. Methods: This study explored experienced midwives' practice of informed consent for episiotomy during a midwife‐led birth. We sampled 43 midwives across eight NHS Trusts in England and Wales using online focus groups and telephone interviews about their experience of consent in episiotomy. Using qualitative content analysis and art‐based co‐analysis methods with eight midwives from across the research sites, we co‐analyzed and co‐constructed three themes and four practice recommendations from the data. Results: Three themes were constructed from the data: Assent rather than consent, Change in culture to support best practice, and Standardized information. These themes informed the shaping of four recommendations for best practice in episiotomy informed consent. Conclusion: This study has shown how variations in midwifery practice and culture may impact birthing people's experience of informed consent in episiotomy. Midwives may not have the knowledge or skills to conduct a detailed consent conversation, leading to variation in practice and messages for birthing people. The use of antenatal discussion aids can offer women the opportunity to become informed and fully participate in the decision‐making process. [ABSTRACT FROM AUTHOR]

This article explores the experiences and perspectives of designated safeguarding leads (DSL) in fee‐paying schools to better understand how they engage affluent parents when there are safeguarding and child protection concerns. The research employed a roundtable data gathering methodology, with 33 DSLs from a range of fee‐paying schools in southern England participating in the study. A primary objective of the research was to understand the factors that influence how DSLs in fee‐paying schools engage parents from affluent backgrounds. The findings showed that a major concern is that affluent parents are adept at using their power and privilege to avoid statutory interventions, which meant that the DSLs' safeguarding role was often fraught with difficulties. This article addresses factors that enable or hinder DSLs' conversations with affluent parents and offers some critical reflections on the challenges posed for their duty to safeguard the children in their care. For the purpose of this article, three key themes will be addressed: the interpretation of harm thresholds; communication issues; and mental health issues. Overall, the analysis contributes to a greater understanding of how DSLs in fee‐paying schools navigate their engagement with parents when familial risks are identified. [ABSTRACT FROM AUTHOR]

Background: Paramedic prescribing has been permitted in legislation from 2018. In 2019 one of the first cohorts of paramedic prescribers in the country was invited to share their experiences, thoughts and perceptions around the new and evolving role of paramedic prescribing practice. Aim: To explore the opinions of student and newly qualified paramedic prescribers regarding the impact and effectiveness of paramedic independent prescribing on their clinical practice. Design and setting: A qualitative study was undertaken within the North East of England with a group of experienced paramedics undertaking non-medical prescribing education. Methods: A focus group and dyad interview were undertaken with a purposive sample of paramedics recruited from a higher education institution providing V300 independent and supplementary prescribing education. The focus group was undertaken with paramedics on the non-medical prescribing (NMP) programme of study. The dyad interview was undertaken with participants once qualified as prescribers, and actively prescribing. The focus group and interview were audio recorded, transcribed verbatim and subjected to thematic analysis to identify key themes. Results: A total of n = 7 and n = 2 paramedics undertook the focus group and dyad interview, respectively. Paramedics in this sample represented a range of paramedic practice areas. Paramedic NMP students noted four key themes around role, expectations, governance and opportunities and challenges in relation to prescribing practice. The returning sample of paramedics, now practising as prescribers, noted themes of organisational and infrastructure challenges, monitoring of prescribing practice and the evolution of paramedic roles. Conclusion: Paramedic prescribing is rapidly expanding and evolving into new clinical areas. As such, careful consideration should be given to not only the resourcing of prescribers as individuals, but also the wider organisational and technological support and structures needed to be in place to allow paramedic prescribers to fulfil their roles and utilise their advanced practice skills. [ABSTRACT FROM AUTHOR]

BACKGROUND: The prescription opioid epidemic in the United States (US) is well documented, and recent measures have reduced prescribing rates in that country. Evidence suggests opioid prescriptions have been rising recently in other countries too. OBJECTIVE: The current paper aimed to compare trends in opioid prescribing in England and the US. METHODS: Trends in rates of prescriptions per 100 members of the population were calculated for England and the US using publicly available government data on prescriptions and population statistics. RESULTS: Rates of prescribing are converging. At the peak of the US epidemic in 2012, there were 81.3 prescriptions per 100 people, but this had fallen to 43.3 by 2020. Prescribing peaked in England in 2016 at 43.2 prescriptions per 100 people, but has fallen only slightly, so that in 2020 there were 40.9 prescriptions per 100 people. CONCLUSION: The data indicate that levels of opioid prescribing in England are now similar to those in the US. They remain high in both countries, despite recent falls. This suggests the need for further measures to prevent over-prescribing and to support people who would benefit from withdrawing from these drugs. [ABSTRACT FROM AUTHOR]

Introduction: Anemia is common in chronic kidney disease (CKD) and is associated with increased cardiovascular risk and reduced quality of life, but is often sub-optimally managed. Most patients are managed in primary care alongside other comorbidities. Interventions to improve the management of anemia in CKD in this setting are needed. Methods: We conducted a qualitative study to evaluate how an audit-based education (ABE) intervention might improve the management of anemia in CKD. We explored outcomes that would be relevant to practitioners and patients, that exposed variation of practice from National Institute for Health and Care Excellence (NICE) guidelines, and whether the intervention was feasible and acceptable. Results: Practitioners (n = 5 groups) and patients (n = 7) from 4 London general practices participated in discussions. Practitioners welcomed the evidence-based step-wise intervention. However, prescribing erythropoiesis-stimulating agents (ESAs) was felt to be outside of their scope of practice. There was a gap between NICE guidance and clinical practice in primary care. Iron studies were not well understood and anemia management was often conservative or delayed. Patients were often unaware of having CKD, and were more concerned about their other comorbidities, but largely trusted their GPs to manage them appropriately. Conclusions: The first steps of the intervention were welcomed by practitioners, but they expressed concerns about independently prescribing ESAs. Renal physicians and GPs could develop shared care protocols for ESA use in primary care. There is scope to improve awareness of renal anemia, and enhance knowledge of guideline recommendations; and our intervention should be modified accordingly. [ABSTRACT FROM AUTHOR]

Background: This article is part two of a series presenting the findings of stakeholder surveys with ostomates and stoma care nurses (SCNs) for stoma services in England. Part one explored the experiences of ostomates. This article focuses on the views and experiences of 108 SCNs in England. Aim: To understand the experience of SCNs in England in relation to current services provided. This includes the scope of the SCN role, the service they provide, and SCN experience and views on areas for improvement. Method: SCNs were invited to share their experiences and views in a national online survey. Questions considered the experience of the nurse, where the care they provide is delivered, how their post is funded and their views on current issues such as responsibility for managing waste of stoma product. Two free-text questions asked what areas of stoma care services worked well and what areas could be improved, results of which were coded and thematically analysed. Findings: Themes included patient care, industry involvement and prescribing process. Conclusion: Overall, survey respondents felt that they provided a good standard of care. Nurses reported complex industry relationships. Awareness of the Nursing and Midwifery Council Code, Bribery Act 2010 and NHS England guidance on managing conflicts of interest is advocated, as is promoting transparency in funding arrangements. It was noted that there appears to be variation in the care provided to ostomates. [ABSTRACT FROM AUTHOR]

Background: Patients with both atrial fibrillation (AF) and cardiovascular disease (CVD) may receive dual antithrombotic therapy (DAT) with both an anticoagulant and ≥1 antiplatelet agents. Avoiding prolonged duration of DAT and use of gastroprotective therapies reduces bleeding risk. Aim: To describe the extent and duration of DAT and use of gastroprotection in a primary care cohort of patients with AF. Design & setting: Observational study in 1.2 million people registered with GPs across four east London clinical commissioning groups (CCGs), covering prescribing from January 2020--June 2021. Method: In patients with AF, factors associated with DAT prescription, prolonged DAT prescription (>12 months), and gastroprotective prescription were characterised using logistic regression. Results: There were 8881 patients with AF, of whom 4.7% (n = 416) were on DAT. Of these, 65.9% (n = 274) were prescribed DAT for >12 months and 84.4% (n = 351) were prescribed concomitant gastroprotection. Independent of all other factors, females with AF were less likely to receive DAT than males (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.49 to 0.77). Similarly, older (aged ≥75 years) individuals (OR 0.79, 95% CI = 0.63 to 0.98) were less likely to receive DAT than younger patients. Among those with AF on DAT, pre-existing CVD (OR 3.33, 95% CI = 1.71 to 6.47) and South Asian ethnicity (OR 2.70, 95% CI = 1.15 to 6.32) were associated with increased gastroprotection prescriptions. Gastroprotection prescription (OR 1.80, 95% CI = 1.01 to 3.22) was associated with prolonged DAT prescription. Conclusion: Almost two-thirds of patients with AF on DAT were prescribed prolonged durations of therapy. Prescription of gastroprotection therapies was suboptimal in one in six patients. Treatment decisions varied by sex, age, ethnic group, and comorbidity. Duration of DAT and gastroprotection in patients with AF requires improvement. [ABSTRACT FROM AUTHOR]

Synopses of a selection of recently published research articles of relevance to palliative care [ABSTRACT FROM AUTHOR]

Background: Part one of this study identified that prescribing behaviours during 2020 differed significantly from 2016-2021. Part 2, presented here, covers a more detailed analysis of the impact of the early part of the COVID-19 pandemic is presented here. Aims: To describe patterns in community prescribed and dispensed antibiotic volumes attributable to non-medical prescribers during 2020 compared to the previous 4 years and identify any changes of behaviour during this period and their impact on antimicrobial stewardship. Methods: An analysis of retrospective non-medical prescribers' prescribing data was performed to determine the numbers of independent non-medical prescribers and the patterns of prescribed community dispensed antibiotic volumes between 2016-2021. The 2020 data were then compared to the data from previous years. Findings: The total amount of dispensed non-medical prescribers antibiotic prescription items per 100000 population dropped by 12% in 2020 compared to 2019, driven predominantly by reductions in nurse prescribing. However, high-risk antibiotic prescribing rose from 5.3% of antibiotics prescribed in 2019 to 6.4% in 2020. Seasonal patterns of antibiotic prescribing differed in 2020, with significant reductions in prescribing of antibiotics normally associated with treating LRTI from the first lockdown in March 2020. Conclusions: The COVID-19 pandemic forced rapid changes in practice, including increased remote working, which created a challenging prescribing environment that adversely affected the high-risk antibiotic prescribing behaviour of non-medical prescribers more than it affected their medical colleagues. There were unusually low levels of prescribing for respiratory tract infections over the last quarter of 2020 which, although likely multifactorial, may indicate over-prescribing for self-limiting viral infections in previous years. More research is needed to establish ongoing prescribing trends and patient outcomes, and how antimicrobial stewardship programmes and training can be better targeted to support prescribers to address quality and safety issues arising from changing modes of practice. [ABSTRACT FROM AUTHOR]

Background: Non-medical prescriber numbers have increased rapidly over the last 10 years, with increasingly diverse roles and backgrounds. Previous evaluations of their antibiotic prescribing demonstrated it was generally of a high quality and guideline-driven, but recent evidence is lacking and the data are not easily accessible. Aims: To describe changes in the non-medical prescriber population and patterns in dispensed antibiotic volumes between 2016–2021, highlighting evidence of good antimicrobial stewardship and where further interventions may be required. Methods: An analysis of retrospective non-medical prescriber prescribing data was performed, to determine the numbers of independent non-medical prescribers and the patterns of prescribed community-dispensed antibiotics in England between 2016–2021. Findings: Between 2016–2021, it was found that independent non-medical prescriber numbers in England rose by 54%. Whilst they remain predominantly nurses (76%), the numbers of pharmacists and allied health professionals have increased. Non-medical prescribers were responsible for 10.6% of all dispensed antibiotic items prescribed in primary care in England. However, the proportion of dispensed antibiotic items prescribed by these non-medical prescribers reduced by over 50%. Prescribing in 2020 differed from previous years, with increased high-risk antibiotic prescribing. Conclusion: The quality of prescribing generally appears good and in accordance with national guidelines and principles of good antimicrobial stewardship. The 2020 COVID-19 pandemic prompted changes in antibiotic prescribing behaviour. [ABSTRACT FROM AUTHOR]

Aim: The Chief Medical Officer of England writes an annual social-norms-feedback letter to the highest antibiotic-prescribing GP practices. We investigated whether sending a social-norms-feedback letter to practices whose prescribing was increasing would reduce prescribing. Subject and methods: We conducted a two-armed randomised controlled trial amongst practices whose STAR-PU-adjusted prescribing was in the 20th–95th percentiles and had increased by > 4% year-on-year in the 2 previous financial years. Intervention practices received a letter on 1st March 2018 stating 'The great majority (80%) of practices in England reduced or stabilised their antibiotic prescribing rates in 2016/17. However, your practice is in the minority that have increased their prescribing by more than 4%.'. Control practices received no letter. The primary outcome was the STAR-PU-adjusted rate of antibiotic prescribing in the months from March to September 2018. Results: We randomly assigned 930 practices; ten closed or merged pre-trial, leaving 920 practices — 448 in the intervention and 472 in the control. An autoregressive and moving average model of first order ARMA(1,1) correlation structure showed no effect of the intervention (β < −0.01, z = −0.50, p = 0.565). Prescribing reduced over time in both arms (β < −0.01, z = −36.36, p < 0.001). Conclusions: A social-norms-feedback letter to practices whose prescribing was increasing did not decrease prescribing compared to no letter. Trial registration: NCT03582072. [ABSTRACT FROM AUTHOR]

The article addresses challenges of accessing medical compression garments in the United Kingdom (UK). Topics discussed include factors that can influence access to medical compression garments, aim of the economic evaluation published by Lymphoedema Wales Clinical Network in collaboration with medicine management personnel of the local health board pharmacy department, and four key processes of the standard prescription service in England.

Aims: To measure registered nurses', registered midwives', and nursing and midwifery students' current levels of knowledge, attitude and practices related to intimate partner violence. Background: Nurses and midwives whether registered or students need to be confident and competent in identifying and responding to intimate partner violence. Design A cross‐sectional survey. Methods: Data were collected through online surveys using the Physician Readiness to Manage Intimate Partner Violence Survey. Descriptive and inferential statistics were used to analyse the data. Results: Nursing and midwifery students were less knowledgeable and prepared than nurses and midwives. Midwives had more positive attitudes compared with nurses towards women experiencing intimate partner violence. Conclusions: Heath care institutions and regulatory bodies should provide resources and support to nursing and midwifery professionals. Personal experiences of domestic abuse and professional experience of supporting victims of domestic abuse/intimate partner violence affected practitioner's abilities to identify and manage intimate partner violence. Implications for Nursing Management: Nurse and midwifery managers can ensure that clinical and organisational policies and protocols are revisited and updated regularly and that interdisciplinary collaboration is promoted and emphasized for prompt identification and management of intimate partner violence. [ABSTRACT FROM AUTHOR]

Background: Acute appendicitis is a common surgical emergency with an estimated lifetime prevalence of 8.6% for males and 6.7% for females. Despite the frequency of presentation, considerable variation in clinical practice exists. Our study aimed to explore temporal trends in the investigation, treatment and outcomes for patients with appendicitis between 2002 and 2016. Methods: Data collected included all patients aged ≥16 years across the NHS trusts in Northern England between 01/01/2002 and 31/12/2016 diagnosed with appendicitis. Patient demographics, co-morbidity and management strategies were included. Outcomes of interest were length of stay and inpatient mortality. Results: Over a 15 years period, 22,137 patients were admitted with acute appendicitis. A consistent male preponderance (n = 11,952, 54%) was observed, and median age increased over time (2002–2006: 36.4 vs. 2012–2016: 39.5, p < 0.001). Comorbidity of patients also increased (p < 0.001) in recent years. Computed tomography (CT) use increased from 0.8 to 21.9% (p < 0.001) over the study period. Following CT scanning, there was a longer time to theatre (1.22 vs. 0.70 days, p < 0.001), and patients were more frequently managed non-operatively (23.8% vs. 5.7%, p < 0.001). The utilisation of laparoscopic approaches significantly increased from 4.1 to 70.4% (p < 0.001). Laparoscopic patients had a shorter median length of stay (2.97 days) when compared with open surgery (4.44 days) or non-operative (6.19 days) patients. The 30-day mortality rate was 0.33% overall and decreased with time (p = 0.004). Conclusions: CT and laparoscopic surgery are increasingly utilised in the management of appendicitis. Along with other advances in clinical practice, they have led to reduced lengths of stay and mortality. [ABSTRACT FROM AUTHOR]

Background: Prescribing errors can cause significant morbidity and occur in about 5% of prescriptions in English general practices. Aim: To describe the frequency and nature of prescribing problems in a cohort of GPs- i n-training to determine whether they need additional prescribing support. Design & setting: A primary care pharmacist undertook a retrospective review of prescriptions issued between 9 October 2014 and 11 March 2015 by 10 GPs in their final year of training from 10 practices in England. Method: Pre-existing standards and expert panel discussion were used to classify the appropriateness of prescribing. Data were imported into Stata (version 13) to perform descriptive analysis. An individualised report highlighting prescribing errors, suboptimal prescribing, and areas of good practice identified during the review was shared with the GPs-in-training and their trainers. This report was used to guide discussions during the GP-in-training's feedback session. Results: A total of 1028 prescription items were reviewed from 643 consultations performed by 10 GPs-in-training. There were 92 prescribing errors (8.9%) and 360 episodes of suboptimal prescribing (35.0%). The most common types of error concerned medication dosages (n = 30, 32.6% of errors). Conclusion: Personalised review of prescribing revealed an error rate higher than recorded in a previous similar study mainly comprising GPs who had completed postgraduate training, and a substantially higher rate of suboptimal prescribing. A larger intervention study is now required to evaluate the effectiveness of receiving a personalised review of prescribing, and to assess its impact on patient safety. [ABSTRACT FROM AUTHOR]

Organisations funded by Sport England or UK Sport must work towards achieving standards for safeguarding and protecting children in sport as set by the National Society for the Prevention of Cruelty to Children's Child Protection in Sport Unit (CPSU) and encourage a culture of listening to children. The present research was commissioned by the NSPCC CPSU to understand the practices of UK sports clubs regarding this objective. An electronic questionnaire was distributed through the national governing bodies of sport working with the CPSU. Some 64 clubs/squads representing 6,000+ juniors (under 18 years) responded. Quantitative data were analysed using simple statistics and qualitative data were themed utilising Foucault's theory of power and following Braun and Clark's six‐phase guide. Discourse, hierarchical judgement and docility were considered with reference to formal management and cultural environments. Semantic and latent themes were explored. The themes identified were: expectation awareness, reframing voice and preserving discourse. Clubs recognise the value of listening to children. However, existing power relations valorise adult knowledge fields over the experiences of juniors. Technology could provide an effective solution as it is remote, potentially anonymous and culturally accessible. As power is a productive force, problematisation of organisational culture could centralise children's voices and limit/prevent abuse. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to present findings from a mixed-methods study on the impact that COVID-19 has had on adult safeguarding. The research sought to explore the challenges and opportunities presented by COVID-19 to both frontline and non-frontline professionals working in adult safeguarding. Design/methodology/approach: A mixed-methods project was undertaken comprising a literature review, survey, semi-structured interviews and a small number of freedom of information requests. This paper presents the findings predominantly from the survey and interviews. Findings: Unsurprisingly, COVID-19 has presented a variety of challenges for professionals working in adult safeguarding. The themes that occurred most often were the day-to-day changes and challenges, relationships across sectors, information and navigating the ethical questions in safeguarding. Originality/value: To the best of the authors' knowledge, the findings represent the first focused qualitative mixed-method study aimed at understanding more about the impact the pandemic has had on adult safeguarding through the eyes of those professionals working in that field. [ABSTRACT FROM AUTHOR]

The article describes a service audit at a National Health Service (NHS) trust in England investigating the practice regarding the use of cyclin-dependent kinase 4 and 6 (CDK 4/6) inhibitors in the treatment of metastatic breast cancer patients.

Purpose: To describe drug utilisation patterns in neonatal units. Methods: Retrospective observational cohort study using data held in the National Neonatal Research Database (NNRD) for neonatal units in England and Wales including infants born at 23 to 44 weeks' gestational age (GA) from 01 January 2010 to 31 December 2017. Results: The cohort included 17,501 (3%) extremely preterm infants; 40,607 (7%) very preterm infants; 193,536 (31%) moderate-to-late preterm infants; and 371,606 (59%) term infants. The number of unique drugs received by an infant (median (IQR)) increased with decreasing GA: 17 (11–24) in extremely preterm, 7 (5–11) in very preterm, 3 (0–4) in moderate-to-late preterm, and 3 (0–3) in term infants. The two most frequently prescribed drugs were benzylpenicillin and gentamicin in all GA groups, and caffeine in extremely preterm. Other frequently used drugs among preterm infants were electrolytes, diuretics and anti-reflux medications. Among infants <32 weeks' GA, the largest increase in use was for surfactant (given on the neonatal unit), caffeine and probiotics, while domperidone and ranitidine had the largest decline. Conclusion: Antibiotics, for all GAs and caffeine, among preterm infants, are the most frequently used drugs in neonatal medicine. Preterm infants are exposed to a high burden of drugs, particularly antibiotics. Changing patterns in use reflect the emergence of evidence in some areas but several non-evidence-based drugs continue to be used widely. Improvements are needed to ensure rational drug use on neonatal units. Registration: ClinicalTrials.gov (NCT03773289). Date of registration 21 Dec 2018. [ABSTRACT FROM AUTHOR]

In the first of a two‐part series on the non‐medical use of prescription‐only and over‐the‐counter (OTC) medicines, Graham Parsons discusses the prevalence of the problem, the medicines most likely to be misused and the patient groups at highest risk. [ABSTRACT FROM AUTHOR]

Background: National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes. Aims: The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey. Methods & Procedures: An online survey was created with 26 multiple‐choice questions across seven sub‐sections, with options for free‐text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes. Outcomes & Results: Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27 h per week input to the unit compared to 80 h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload. Conclusions & Implications: Speech and language therapy services delivering post‐acute and long‐term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services. What this paper adds: What is already known on this subject: In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds: This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study: Speech and language therapy services in spinal injury units are often available part‐time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long‐term consequences for integrating back into community. [ABSTRACT FROM AUTHOR]

Aims: To determine the pattern and extent of prescribing of medications for alcohol relapse prevention (ARP) in England. Design Cross‐sectional. Setting: Specialist drug and alcohol treatment providers in England reporting to the National Drug Treatment Monitoring System. Participants: Service users aged 18+, with alcohol the primary substance of dependence, completing a treatment journey between April 2013 and March 2016 (n = 188 152). Measurements Prescription of medications for ARP during a treatment journey. Data on service users' demographics, treatment and clinical characteristics were extracted. Findings The rate of prescribing medications for ARP was 2.1% in 2013/14, 6.8% in 2014/15 and 7.8% in 2015/16. A greater likelihood of prescription was associated with treatment journey year [2014/15; adjusted odds ratio (aOR) = 3.269, 95% confidence intervals (CI) = 3.044–3.510, 2015/16; aOR = 3.823, CI = 3.560–4.106], age (25–34; aOR = 1.622, CI = 1.380–1.907, 35–54; aOR = 1.901, CI = 1.628–2.220 or 55+; aOR = 1.700, CI = 1.446–1.999), female gender (aOR = 1.129, CI = 1.077–1.184), white ethnicity (aOR = 1.219, CI = 1.077–1.380), regional prevalence of alcohol dependence (middle rate; aOR = 1.121, CI = 1.024–1.228), severity of alcohol dependence (moderate dependence without complex needs; aOR = 1.329, CI = 1.244–1.419, severe dependence without complex needs; aOR = 1.308, CI = 1.188–1.441, moderate/severe dependence with complex needs; aOR = 1.131, CI = 1.020–1.255), treatment setting (inpatient; aOR = 10.512, CI = 9.950–11.104, primary care; aOR = 2.264, CI = 2.050–2.500, residential; aOR = 3.216, CI = 2.807–3.685), prior treatment for alcohol dependence (aOR = 1.242, CI = 1.183–1.304), longer treatment journey (aOR = 1.002, CI = 1.002–1.002), more drinking days in the prior 28 days (aOR = 1.021, CI = 1.018–1.024) and drinking a higher number of alcohol units in the prior 28 days (aOR = 1.002 CI = 1.001–1.004). Living in a region of England with the lowest alcohol prevalence was associated with a lower likelihood of prescription of medication for aRP (AOR = 0.491, CI = 0.436–0.552). Conclusions: In England, medications for alcohol relapse prevention are rarely prescribed (e.g. 7.8% in 2015/16) and those prescriptions appear to be associated with specific service user demographics, treatment and clinical characteristics. [ABSTRACT FROM AUTHOR]

Inhaled corticosteroids (ICS), prednisolone and antibiotics all play a crucial role in the management of respiratory diseases. The aim of this study was to analyse whether the declaration of the COVID-19 pandemic affected prescribing rates, as public health measures were implemented to reduce transmission of SARS-CoV-2. Monthly practise-level prescribing data published by NHS Digital were analysed. At the point, the COVID-19 outbreak was declared a pandemic, ICS prescriptions rose significantly. This was followed by a decrease in ICS and prednisolone prescribing in the following months. There was no difference in the antibiotic prescribing trend. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial usage and stewardship programmes during COVID-19 have been poorly studied. Prescribing practice varies despite national guidelines, and there is concern that stewardship principles have suffered. Aim: To analyse antibiotic prescriptions during the COVID-19 pandemic at a teaching hospital and to propose improved approaches to stewardship. Methods: We reviewed COVID-19 admissions to medical wards and intensive care units (ICUs) in a London teaching hospital to assess initial antibiotic usage and evidence of bacterial co-infection, and to determine if our current antibiotic guidelines were adhered to. Findings: Data from 130 inpatients (76% medical and 24% ICU) were obtained. On admission, 90% were treated with antibiotics. No microbiological samples taken on admission provided definitive evidence of respiratory co-infection. In 13% of cases, antibiotics were escalated, usually without supporting clinical, radiological or laboratory evidence. In 16% of cases, antibiotics were stopped or de-escalated within 72 h. Blood results and chest radiographs were characteristic of COVID-19 in 20% of ward patients and 42% of ICU patients. Overall mortality was 25% at 14 days – similar to rates described for the UK as a whole. Conclusion: The majority of patients received antibiotics despite limited evidence of co-infection. Most patients received narrower spectrum antibiotics than recommended by NICE. As understanding of the natural history of COVID-19 infections progresses, stewardship programmes will need to evolve; however, at this point, we feel that a more restrictive antibiotic prescribing approach is warranted. We propose strategies for effective stewardship and estimate the effect this may have on antibiotic consumption. [ABSTRACT FROM AUTHOR]

There is a sustained increase in demand for emergency and urgent care services in England. The NHS Long Term Plan aims to reduce the burden on emergency hospital services through changing how pre‐hospital care operates, including increased delivery of urgent care. Given the recognised potential of social prescribing to address wider determinants of health and reduce costs in other settings, this study aimed to understand the role that social prescribing can play in pre‐hospital emergency and urgent care from the perspectives of staff. Semi‐structured interviews (n = 15) and a focus group (n = 3) were conducted with clinical staff (n = 14) and non‐clinical health advisors (n = 4) from an English Ambulance Service covering emergency (999) and non‐emergency (111) calls. Data were analysed using a pre‐defined framework: awareness of social prescribing; potential cohorts suitable for social prescribing; and determinants of social prescribing. Awareness and knowledge of social prescribing was limited, though when social prescribing was explained to participants they almost universally recognised its benefits for their role. Social prescribing was considered to be most beneficial to those calling for reasons relating to mental health, loneliness or social isolation, in particular older people and frequent users of 999 and 111 services. Determinants of social prescribing were identified across the micro (patient and staff acceptability of social prescribing), meso (triage and referral pathways) and macro (commissioning and funding) levels of analysis. This is the first empirical study to explore social prescribing in pre‐hospital emergency and urgent care services, which suggests that it has potential to improve quality of care at the point of people accessing these services. There is a pressing need to address the micro, macro and meso level determinants identified within this study, in order to support staff within pre‐hospital emergency and urgent care services to socially prescribe. [ABSTRACT FROM AUTHOR]

Overuse of antibiotics and inappropriate prescribing has resulted in rapid development of antimicrobial resistance. Most antibiotics in the United Kingdom (71.4%) are prescribed in primary care by general practitioners, with about half prescribed for viral rather than bacterial illnesses. To explore antibiotic prescribing and factors which may influence maternal decision making to seek antibiotics for their young children. Data for children under five years were gathered using a mixed-methods case study approach. Quantitative general practice antibiotic prescribing data (n = 697 children) was statistically analysed and these results were further explored in six focus groups with mothers (n = 19) of children under five. The qualitative data was thematically analysed. Quantitative data identified nearly half of children received antibiotics. Children under one were prescribed the fewest antibiotics. Qualitative focus group data showed mothers trusted their general practitioner to provide expert care for their child and often wanted convenient and timely access to advice and reassurance rather than treatment. Antibiotics are frequently prescribed for young children in primary care. Healthcare professionals need to understand the maternal influences contributing to antibiotic use in children and consider strategies and interventions to reduce unnecessary antibiotic prescriptions. Nurses and health visitors should have a greater role in supporting maternal decision making for managing their children's illnesses. [ABSTRACT FROM AUTHOR]

Background: Social Prescribing is increasingly popular, and several evaluations have shown positive results. However, Social Prescribing is an umbrella term that covers many different interventions. We aimed to test, develop and refine a programme theory explaining the underlying mechanisms operating in Social Prescribing to better enhance its effectiveness by allowing it to be targeted to those who will benefit most, when they will benefit most. Methods: We conducted a realist evaluation of a large Social Prescribing organisation in the North of England. Thirty-five interviews were conducted with stakeholders (clients attending Social Prescribing, Social Prescribing staff and general practice staff). Through an iterative process of analysis, a series of context-mechanism-outcome configurations were developed, refined and retested at a workshop of 15 stakeholders. The initial programme theory was refined, retested and 'applied' to wider theory. Results: Social Prescribing in this organisation was found to be only superficially similar to collaborative care. A complex web of contexts, mechanisms and outcomes for its clients are described. Key elements influencing outcomes described by stakeholders included social isolation and wider determinants of health; poor interagency communication for people with multiple needs. Successful Social Prescribing requires a non-stigmatising environment and person-centred care, and shares many features described by the asset-based theory of Salutogenesis. Conclusions: The Social Prescribing model studied is holistic and person-centred and as such enables those with a weak sense of coherence to strengthen this, access resistance resources, and move in a health promoting or salutogenic direction. [ABSTRACT FROM AUTHOR]

The social restrictions amid coronavirus disease 2019 (COVID-19) pandemic have posed a serious threat to mental health and have implications in the use of medications for mental health including antidepressants (ADs). This study investigated the trends in prescriptions and costs of various ADs in England during COVID-19 pandemic. National prescribing rates and net ingredient costs (NIC) of all ADs prescriptions during 2016 to 2020 were analyed. The total number of ADs prescriptions dispensed during COVID-19 pandemic (January to December 2020) were 78 million, 4 million more than in 2019 that costed NHS England £ 139 million more than in 2019. Sertraline, an SSRI antidepressant drug, alone accounted for an extra £113 million during 2020 than in 2019. The peak dispensing for ADs was observed in March 2020 while the total costs for AD drugs peaked in April 2020. The rising prescription costs for ADs during COVID-19 pandemic is a potential cause of concern, in particular the increasing use in adolescents and younger adults needs attention, who are at a higher risk of life-threatening adverse drug reactions. [ABSTRACT FROM AUTHOR]

Objectives To provide national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England. Methods We used UK-based prevalence of medication errors (in prescribing, dispensing, administration and monitoring) in primary care, secondary care and care home settings, and associated healthcare resource use, to estimate annual number and burden of errors to the NHS. Burden (healthcare resource use and deaths) was estimated from harm associated with avoidable adverse drug events (ADEs). Results We estimated that 237 million medication errors occur at some point in the medication process in England annually, 38.4% occurring in primary care; 72% have little/no potential for harm and 66 million are potentially clinically significant. Prescribing in primary care accounts for 34% of all potentially clinically significant errors. Definitely avoidable ADEs are estimated to cost the NHS £98 462 582 per year, consuming 181 626 bed-days, and causing/contributing to 1708 deaths. This comprises primary care ADEs leading to hospital admission (£83.7 million; causing 627 deaths), and secondary care ADEs leading to longer hospital stay (£14.8 million; causing or contributing to 1081 deaths). Conclusions Ubiquitous medicines use in health care leads unsurprisingly to high numbers of medication errors, although most are not clinically important. There is significant uncertainty around estimates due to the assumption that avoidable ADEs correspond to medication errors, data quality, and lack of data around longer-term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area. [ABSTRACT FROM AUTHOR]

Background: Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. Methods: This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. Results: Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies. Conclusions: High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation. [ABSTRACT FROM AUTHOR]