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Background The use of locum doctors in the National Health Service is widely believed to have increased, and there have been widespread and sustained concerns among policy-makers, healthcare providers, professional associations and professional regulators about the quality/safety, cost and effective use of locum doctors. Objectives To provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English National Health Service, to support policy and practice. Design Four interlinked work packages involving surveys of National Health Service trusts and of general practices in England; semistructured interviews and focus groups across 11 healthcare organisations in England; analysis of existing routine data sets on the medical workforce in primary care and in National Health Service trusts in England from National Health Service Digital and National Health Service Improvement; and analysis of data from the Clinical Practice Research Datalink in primary care and of electronic patient record data from two National Health Service hospitals in secondary care. Results In primary care, about 6% of general practice medical consultations were undertaken by locums in 2010 and this had risen slightly to about 7.1% in 2021. In National Health Service trusts (mostly secondary care and mental health), about 4.4% of medical staff full-time equivalent was provided by locum doctors. But those overall national rates of locum use hide a great deal of variation. In primary care, we found the National Health Service Digital workforce returns showed the rate of locum use by Clinical Commissioning Group varied from 1% to almost 31%. Among National Health Service trusts, the reported rate of locum use varied from < 1% to almost 16%. We found that there was poor awareness of and adherence to national guidance on locum working arrangements produced by National Health Service England. Our research showed that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. Limitations Our research was hampered in some respects by the COVID pandemic which both resulted in some delays and other challenges. Our efforts to use electronic patient record data in secondary care to explore locum doctor working were stymied by the problems of data access and quality. Conclusions Locum doctors are a key component of the medical workforce in the National Health Service, and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found that patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information. Plain language summary Doctors who work in the National Health Service in temporary positions are generally known as ‘locum doctors’. They may be working for a hospital or a general practice just for a single shift or a few days, or may work there for several weeks or even months. Often, locum doctors are used to cover staff sickness or absence, or to provide for longer-term cover for staff vacancies. While some doctors just work as locums, others will have a permanent job but do some extra shifts as a locum as well. The number of doctors working as locums and the costs of this to the National Health Service have caused some concerns nationally. It has also been suggested that locum doctors may not provide as good a quality of care as permanent doctors. So we set out to find out more, through two large surveys of National Health Service trusts and general practices in England; interviews and focus group discussions across 11 National Health Service organisations; and by analysing data that had already been collected about the National Health Service workforce and about clinical care. We found that about 6% of medical care in general practices is provided by locum doctors, and about 4.4% of the medical workforce in National Health Service trusts are locums, but this varies a great deal and can be much higher in some organisations. The high and continuing use of locums in some services or areas should be a cause for concern. We found locum working could cause problems with the quality and safety of care, but that this was often because of the way organisations used locums without sufficient support. When concerns about the practice of a locum doctor arose, they were often not dealt with properly. We found that patients were generally more interested in being able to see a good doctor promptly than with whether or not they were a locum. This research has important implications for how the National Health Service uses locum doctors in future, and our recommendations are designed to help the National Health Service use locums safely and appropriately. Scientific summary Background The numbers of doctors working as locums in the NHS in England are thought to have grown substantially over the last decade, although there have been surprisingly little empirical data published on the NHS medical workforce to substantiate this trend. There have been concerns about the costs of locum working, and about the quality and safety of locum doctors’ practice. Our earlier qualitative research on the experiences of and attitudes towards locum doctors, involving interviews with locum doctors, locum agency staff and representatives of healthcare organisations who use locums, showed that locums were often perceived to be inferior to permanently employed doctors in terms of quality, competency and safety. Our findings suggested that the treatment and use of locums could have important potential negative implications for team functioning and patient safety. Objectives The overall aim of our research was to provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English NHS. Our three main research questions were: What is the nature, scale and scope of locum doctor working in the NHS in England? Why are locum doctors needed, what kinds of work do they undertake and how is locum working organised? How may locum doctor working arrangements affect patient safety and the quality of care? What are the mechanisms or factors which may lead to variations in safety/quality between locum and permanent doctors? What strategies or systems do organisations use to assure and improve safety and quality in locum practice? How do locum doctors themselves seek to assure and improve the quality and safety of their practice? How do the clinical practice and performance of locum and permanent doctors compare? What differences in practice and performance exist and what consequences may they have for patient safety and quality of care? Methods This was a mixed-methods study, consisting of four main work packages: Work package 1 (addressing research questions 1 and 2) involved a survey of medical directors/medical staffing leads in NHS trusts in England and a survey of general practices in England. The two surveys examined the nature, scale and scope of locum doctor working, why locums were needed, what work they undertook and how their work was organised, and sought views on the performance of locum doctors and a range of issues concerning governance and oversight of practice. Work package 2 (addressing research questions 1, 2 and 3) involved a combination of semistructured interviews and focus groups conducted across 11 healthcare organisations in both primary and secondary care in the NHS in England. We developed and used three interview schedules (for interviews with locum doctors; people who worked with locums in healthcare organisations; and patients and members of the public). Work package 3 (addressing research question 1) involved the collection and analysis of existing routine quantitative data sets on locum doctors working in the NHS in England. We used quarterly workforce returns from all general practices in England to NHS Digital to examine locum working in primary care. We used weekly locum usage returns from all NHS trusts in England to NHS Improvement to examine locum working in secondary and community services. Work package 4 (addressing research question 3) involved the collection and analysis of existing, routine quantitative data sets on doctors’ practice/performance which identify whether doctors are locum or permanent staff and so allow us to compare the practice/performance of locums and permanent doctors. We used the Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics to examine these issues in primary care. We sought to undertake a similar analysis in secondary care, using electronic patient record (EPR) data from two NHS hospitals: Salford Royal Hospital and the Bradford Royal Infirmary. However, we encountered a number of problems both in securing data extraction from the two hospitals' EPR systems and in identifying locum and permanent staff activity in the data sets, which severely limited our ability to examine these issues in secondary care. Results We report our results from the four work packages grouped around our three main research questions. The nature, scale and scope of locum doctor working in the NHS in England In primary care, we found from our analysis of NHS Digital workforce returns that just over 3% of medical staffing was provided by locums and that it had not changed much over the time period 2017–20. However, our analysis of CPRD data for the longer time period of 2010–21 suggested that about 6% of general practice medical consultations were undertaken by locums in 2010 and that this had risen slightly to about 7.1% in 2021. We think there are two main explanations for this discrepancy. First, locums generally only undertake consultations while permanent general practitioners do a lot of other non-consultation clinical and administrative tasks – the NHS Digital workforce returns measure staff numbers in full-time equivalent (FTE), while the CPRD data measure numbers of consultations. Second, the NHS Digital workforce returns from general practices may under-report the numbers of locum doctors, and there have been concerns about the quality and completeness of the data. But both data sources suggest a relatively low – and stable – rate of locum use in primary care. In NHS trusts (mostly secondary care and mental health), our analysis of NHS Improvement returns from NHS trusts indicated that about 4.4% of medical staff FTE was provided by locum doctors. With a much shorter time series from 2019 to 2021, it is rather more difficult to draw any conclusions about the secular trend, although in that time period the rate of locum use was fairly stable – dropping as expected in the first phase of the COVID pandemic in early to mid-2020, and then recovering. We found NHS trusts making more use of bank (rather than agency) locums over the time period, and some an increase in the reported numbers of unfilled shifts which would indicate increasing unmet need. However, those overall national rates of locum use hide a great deal of variation between organisations which it is important to consider. In primary care, we found the NHS Digital workforce returns showed the rate of locum use by Clinical Commissioning Group (CCG) varied from 1% to almost 31%. Among NHS trusts, the reported rate of locum use varied from < 1% to almost 16%. Our qualitative work suggested that there were some particularly problematic specialties in which workforce shortages were acute, such as psychiatry. Our multivariate quantitative analyses suggested that there was some variation by region/geography which might reflect workforce capacity or shortage in some parts of England. But they also showed that both smaller general practices and smaller NHS trusts made more use of locums, which might plausibly suggest that larger organisations are more able to cope with workforce gaps without having to resort to locums. In both primary care and NHS trusts, there was an association between Care Quality Commission (CQC) ratings and locum use, with organisations with lower CQC ratings making more use of locums. Our surveys of general practices and of NHS trusts showed both some similarities in their reasons for needing locums and ways of using them, as well as some notable differences. Both gave as common reasons for using locums the need to cover either planned or unplanned absences or gaps in staffing – mainly leave and sickness absence – and both reported using them to provide additional workforce capacity when it was needed. But NHS trusts were much more likely to report needing locums because of difficulties recruiting doctors. We also found some interesting differences in where general practices and NHS trusts sourced locum doctors from. Practices said they made much less use of locum agencies and tended to use trusted locums who were familiar to the practice, while NHS trusts made much more use of locum agencies and staff banks, and within that there was a lot of variation in that some NHS trusts made much more use of locum agencies rather than staff banks. Overall, NHS trusts sourced about a third of their locums from staff banks according to our analysis of NHS Improvement returns. Our qualitative research found that respondents thought an over-reliance on locums (however that might be defined) could be a ‘red flag’. Respondents suggested that the consistent use of high levels of locums was both a concern in itself, because of the implications for quality and safety (which we turn to later in this discussion) and a potential indicator of wider organisational problems in the general practice or NHS trust. How locum doctor working arrangements affect patient safety and the quality of care Our surveys of NHS trusts and general practices suggested that awareness of the national NHS England guidance on locum working was very mixed – and particularly poor among respondents from general practice. Those who were aware of it in NHS trusts generally viewed it quite favourably, but some commented that it set out an ideal model which was hard to follow in practice. Among general practices, it was often seen as less relevant to their needs and to the setting of an individual general practice. Self-reported compliance with the guidance was generally high in areas like pre-employment checks and induction, but much less good in areas like end-of-placement reporting and supporting the locum with appraisal and revalidation. Our qualitative research confirmed and extended the survey findings. For example, we found that giving locums a proper induction was viewed by locums as really important to their subsequent ability to perform in their role, and that issues not covered properly in their induction hampered them and could add to the workload of other members of the clinical team. But in our qualitative interviews with respondents who work with locums, we often found an unrealistic expectation that locums should come into the organisation and be able to start work immediately – to ‘hit the ground running’ – and that they should devote all their time to clinical work as that was what they were being paid – and paid well – to do. Locums themselves reported taking steps – like working in fewer organisations and avoiding some organisations, working at a lower level/grade and limiting their scope of practice – to deal with the problems of being inadequately inducted and supported. This was part of a wider negative and stigmatising narrative which often cast locums as less professional, less committed, less competent, less reliable and more financially motivated than permanent medical staff. By ‘othering’ locum doctors in this way, it was easier both to justify treating them differently (and less well) than other staff and to explain problems or difficulties with quality and safety as being attributable to locums and locum working. In short, it was easy to blame locums when things went wrong, and they were often either not there to defend themselves or not able to do so. The position of locum doctors was, by definition, precarious – they could be removed or have a placement ended easily. We would contrast this with the attitudes of patients to locum doctors, which were generally more accepting of locum working, and which valued access to seeing a doctor in a timely fashion over whether the doctor was a locum or not. Patients thought that traditional notions of relational continuity were not consistent with their own experiences of care, and some valued the fresh perspectives on their condition which came from seeing a different doctor. It is clear from our research that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. It is also clear that there is great variation in the characteristics both of organisations which use locums and of locums themselves. One of the concerning findings from our research was that when problems related to locum doctors’ practice arose, they were not dealt with well. How the clinical practice and performance of locum and permanent doctors compare From our surveys of NHS trusts and general practices, respondents generally reported that on a range of areas of clinical practice, they thought locum doctors performed about the same as or worse than permanent doctors. It is notable that the areas where they tended to think locums performed worse were things like continuity of care, and adherence to guidelines and protocols, which are, as we have already discussed, more influenced by the organisational setting and arrangements like induction than by the locum doctor’s own clinical expertise and fitness to practice. We were able to explore differences in practice in primary care directly through our quantitative analysis of the CPRD data set, and this provided some very interesting but quite mixed findings which should be interpreted with great caution. For example, our multivariate analysis found that patients who saw a locum doctor were less likely to make a return visit to the general practice within 7 days than those who had seen a permanent doctor. We found that locum doctors and permanent doctors had some differences in prescribing behaviour, but they were mixed (locums prescribed antibiotics and opioids more frequently but hypnotics less frequently than permanent doctors). Locum doctors were less likely to make referrals and to order tests. In terms of hospital events following a consultation with a locum, patients were more likely to visit accident and emergency within 7 days but there was no difference for hospital admission. Conclusions Locum doctors are a key component of the medical workforce in the NHS and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects, and there were particular problems with the way any concerns about locum doctors were managed. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information.

Introduction Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention.Objectives To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions.Design We performed a scoping review as defined by the Joanna Briggs Institute.Setting The focus was on primary care settings.Data sources Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024.Eligibility criteria We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded.Extraction and analysis We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions.Results In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention.Conclusions Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

Introduction Paediatric otorrhoea (PO) refers to the leakage of fluid through a perforation in the ear drum, resulting from an infection of the middle ear of a child or young person (CYP). PO frequently results in hearing loss which may lead to developmental delay, restricted communication and reduced educational attainment.Epidemiological information for PO is largely derived from low-income countries. The aim of this study will be to establish the incidence of PO within the UK and to understand the impact of PO on CYP and their families’ everyday lives. It will build the foundations for a randomised controlled trial investigating the best antibiotic treatment for PO.Methods and analysis The study will consist of two work packages. (1) Data from the Clinical Practice Research Datalink (CPRD), January 2005 to July 2021, will be used to determine the incidence of patient presentations with PO to primary care in the UK. It will also explore the current antimicrobial prescribing practice for PO in primary care. (2) Thirty semi-structured interviews will be conducted from 13 July to 31 October 2023 with CYP and their parents/carers to help identify the impact of PO on everyday life, the patient journey and how service users define treatment success. Three medical professional focus groups will be used to understand the current management practice, how treatment success is measured and acceptability to randomise patients. Thematic analysis will be used.Ethics and dissemination The Health Research Authority, The Health and Social Care Research Ethics Committee (23/NI/0082) and the CPRD’s research data governance panel (22_002508) reviewed this study. Results will be disseminated at medical conferences, in peer-reviewed journals and via social media. The study will cocreate a webpage on healthtalk.org, with the Dipex Charity, about PO to ensure members of the public can learn more about the condition.Trial registration number ISRCTN46071200.

Introduction This project applies a Learning Healthcare System (LHS) approach to antibiotic prescribing for common infections in primary care. The approach involves iterations of data analysis, feedback to clinicians and implementation of quality improvement activities by the clinicians. The main research question is, can a knowledge support system (KSS) intervention within an LHS implementation improve antibiotic prescribing without increasing the risk of complications?Methods and analysis A pragmatic cluster randomised controlled trial will be conducted, with randomisation of at least 112 general practices in North-West England. General practices participating in the trial will be randomised to the following interventions: periodic practice-level and individual prescriber feedback using dashboards; or the same dashboards plus a KSS. Data from large databases of healthcare records are used to characterise heterogeneity in antibiotic uses, and to calculate risk scores for clinical outcomes and for the effectiveness of different treatment strategies. The results provide the baseline content for the dashboards and KSS. The KSS comprises a display within the electronic health record used during the consultation; the prescriber (general practitioner or allied health professional) will answer standard questions about the patient’s presentation and will then be presented with information (eg, patient’s risk of complications from the infection) to guide decision making. The KSS can generate information sheets for patients, conveyed by the clinicians during consultations. The primary outcome is the practice-level rate of antibiotic prescribing (per 1000 patients) with secondary safety outcomes. The data from practices participating in the trial and the dashboard infrastructure will be held within regional shared care record systems of the National Health Service in the UK.Ethics and dissemination Approved by National Health Service Ethics Committee IRAS 290050. The research results will be published in peer-reviewed journals and also disseminated to participating clinical staff and policy and guideline developers.Trial registration number ISRCTN16230629.

Objectives Temporary doctors, known as locum doctors, play an important role in the delivery of care in the National Health Service (NHS); however, little is known about the extent of locum use in NHS trusts. This study aimed to quantify and describe locum use for all NHS trusts in England in 2019–2021.Setting Descriptive analyses of data on locum shifts from all NHS trusts in England in 2019–2021. Weekly data were available for the number of shifts filled by agency and bank staff and the number of shifts requested by each trust. Negative binomial models were used to investigate the association between the proportion of medical staffing provided by locums and NHS trust characteristics.Results In 2019, on average 4.4% of total medical staffing was provided by locums, but this varied substantially across trusts (25th–75th centile=2.2%–6.2%). Over time, on average two-thirds of locum shifts were filled by locum agencies and a third by trusts’ staff banks. On average, 11.3% of shifts requested were left unfilled. In 2019–2021, the mean number of weekly shifts per trust increased by 19% (175.2–208.6) and the mean number of weekly unfilled shifts per trust increased by 54% (32.7 to 50.4). Trusts rated by the Care Quality Commission (CQC) as inadequate or requiring improvement (incidence rate ratio=1.495; 95% CI 1.191 to 1.877), and smaller trusts had a higher use of locums. Large variability was observed across regions for use of locums, proportion of shifts filled by locum agencies and unfilled shifts.Conclusions There were large variations in the demand for and use of locum doctors in NHS trusts. Trusts with poor CQC ratings and smaller trusts appear to use locum doctors more intensively compared with other trust types. Unfilled shifts were at a 3-year high at the end of 2021 suggesting increased demand which may result from growing workforce shortages in NHS trusts.

Abstract Background The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.8 million. People can be visually impaired from birth, childhood, early adulthood or later in life. Those with visual impairment are subject to health inequities and increased risk for patient safety incidents in comparison to the general population. They are also known to be at an increased risk of experiencing medication errors compared to those without visual impairment. In view of this, this review aims to understand the issues of medication safety for VI people. Methods/design Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. Our search strategy will include search combinations of two key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies. They will include studies that relate to both medication safety and visual impairment. Two reviewers (SG and LR) will screen all the titles and abstracts. SG, LR, RM, SCS and PL will perform study selection and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected will include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), medication safety incident type and characteristics. Discussion The review will summarise the literature relating to medication safety and visual impairment.

Abstract Background Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes. Methods An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored. Discussion It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Background: Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable. Objectives: To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis. Design: Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies. Setting: Primary care, secondary care and online surveys. Participants: People with psoriasis and health-care professionals who manage patients with psoriasis. Results: Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness. Limitations: The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended. Conclusions: Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored. Future work: Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Abstract Background Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

Abstract Evidence suggests that the prescription of bladder anticholinergics is increasing. Recent studies have accentuated concerns about whether certain prescribed medications could increase risk of dementia, including anticholinergic drugs, and specifically anticholinergics used for bladder symptoms. Nevertheless, it can be difficult to draw together the evidence to review the case for possible causation. Recognising this issue in 1965, Bradford‐Hill set out nine criteria to help assess whether evidence of a causal relationship could be inferred between a presumed cause and an observed effect. In this commentary, we explore the extent to which associations between anticholinergics and dementia satisfy the Bradford‐Hill criteria and examine the potential implications. First, we look at studies that have examined the relationship between anticholinergic drugs with urological properties (bladder drugs) and the onset of dementia, and then present those studies which specifically focus on the cognitive effects of bladder drugs that affect muscarinic receptors in the brain versus the bladder on older people along with suggestions for future research. We also discuss the risks and benefits of these drugs for treating overactive bladder. If it can be shown that certain medications carry a specific risk of dementia, it is possible that initiatives to change prescribing could become a key tool in reducing the risk of dementia and may be easier to implement than some lifestyle changes.

Abstract Objective  To explore pharmacists’ perceptions on the use of economic evaluations in decision-making within Medicine Management Committees (MMCs), identify factors that influence the uptake of economic evidence and examine the usefulness of different presentations of economic evidence. Method  This two-stage qualitative study was carried out in July and August 2004 in two hospitals in northwest England. First, a researcher observed the decision-making process at two MMCs. Handwritten notes were made during observation, which were later transcribed. Subsequently, in-depth semi-structured interviews were conducted with a purposive sample of pharmacists involved in the MMCs. The interviews explored pharmacists’ views on the usefulness of economic evaluations in decision-making, the factors influencing the uptake of economic evidence by the MMCs, and the optimal presentation of economic results. The interviews were audiotaped and transcribed verbatim. All the transcribed data were thematically analysed using the constant comparison approach. Results  In all, six new drug applications were observed and ten pharmacists were interviewed. Pharmacists were observed to play an important role in decisions about drug formularies in hospitals. Although interviewees considered that timely economic evaluations would be useful in reviewing new medicines, the actual use of economic evidence in decision-making within MMCs was limited. The barriers to using economic evaluations included pharmacists’ lack of initiative to search for and difficulty in understanding economic evaluations, and the perceived availability, credibility and transferability of economic studies. However, the main barrier to implementing economic evidence was the decision makers’ concern about the impact of the medicines on the hospitals’ drug budgets. Interviewees felt that they understood and trusted disaggregated economic results better than aggregated ones. Conclusion  This study found the use of economic evidence in decision-making at both MMCs was limited. To improve the usefulness of economic evaluations in MMCs, members of MMCs will need more training in accessing, understanding and appraising economic evidence; researchers need to improve the credibility and transferability of economic studies, and present the results in clear and understandable ways. However, due to the restricted focus of local, short-term drug budgets, evidence-based decision-making remains a challenge for local MMCs. [ABSTRACT FROM AUTHOR]