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Background: The MODEM project (A comprehensive approach to MODelling outcome and costs impacts of interventions for DEMentia) explores how changes in arrangements for the future treatment and care of people living with dementia, and support for family and other unpaid carers, could result in better outcomes and more efficient use of resources.Methods: MODEM starts with a systematic mapping of the literature on effective and (potentially) cost-effective interventions in dementia care. Those findings, as well as data from a cohort, will then be used to model the quality of life and cost impacts of making these evidence-based interventions more widely available in England over the period from now to 2040. Modelling will use a suite of models, combining microsimulation and macrosimulation methods, modelling the costs and outcomes of care, both for an individual over the life-course from the point of dementia diagnosis, and for individuals and England as a whole in a particular year. Project outputs will include an online Dementia Evidence Toolkit, making evidence summaries and a literature database available free to anyone, papers in academic journals and other written outputs, and a MODEM Legacy Model, which will enable local commissioners of services to apply the model to their own populations.Discussion: Modelling the effects of evidence-based cost-effective interventions and making this information widely available has the potential to improve the health and quality of life both of people with dementia and their carers, while ensuring that resources are used efficiently. [ABSTRACT FROM AUTHOR]

Background: Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution. Methods: Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively. Results: Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained. Discussion: There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to report the findings of a horizontal integration programme in the South West of England. The programme was unusual insofar as it included the full range of public services being provided in a single town. It was a place-based system framed by the concept that a person’s wellbeing includes their health, economic status and living environment and that they are inextricably linked. As well as aiming for broader system integration, the programme utilised a person-centred approach using service-user perceptions to influence design. It was implemented through a local governance structure using a set of collaborative principles.Design/methodology/approach The paper presents personal reflections of the programme manager about the efficacy of the model, its sustainability and the problems encountered. It sets out the principles defining the model and the extent to which the principles were followed in practice.Findings Creating a holistic public service based on integration to tackle deep seated problems within a population requires reducing complexity at the interface between citizens and services. A local system model that includes all public services allows for collective responsibility for meeting the service needs of the population augmenting the connections and bridging the gaps between services. There was a recognition amongst participants that service redesign does not require wholesale organisational restructuring but does require creating shared aims and objectives and the participation of leaders with the ability to implement change within their services. A user-led, bottom-up approach provides deeper understanding and traction on the ground but should be combined with top-down strategic support to provide structural sustainability and the ability to scale out.Originality/value The paper demonstrates that horizontal service integration based on the concept of wellbeing is possible but faces significant challenges. The benefits and complexities of inter-agency collaboration multiply when enhancing the outcome focus from improving population health to general wellbeing. New theories of implementation and transformation are needed that relate to this important emerging service theme. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on the subject?: Internationally, systematic reviews have identified evidence of equal or improved clinical outcomes comparing advanced practitioner treatment with medical treatment as usual, across a range of specialities.Studies of nurse consultants in the United Kingdom have largely been non‐empirical. Most studies specifically related to nurse consultant roles in mental health services are case studies or reports of views on this role. What this paper adds to existing knowledge?: The study demonstrates that nurse consultant numbers vary over time and by clinical specialty. This is influenced by the value invested in the role by local nursing leadership and by national policy change.A lack of role clarity affects the uptake and sustainability of advanced practice roles internationally and is also an issue for the nurse consultant role in England's mental health services. What are the implications for practice?: Successfully introducing advanced practice nursing roles in mental health services requires role clarity and support from local nurse directors.The continued absence of robust evidence as to the clinical/cost‐effectiveness of nurse consultant roles in mental health settings places an onus on individual posts to generate data to justify the role at a time of financial constraint.Detailed post holder characteristics reported in this paper provide a basis for future comparison with other advanced practice roles in mental health services and other specialties nationally and internationally. Introduction: The nurse consultant is an advanced practice role providing expert clinical practice, consultancy and professional leadership. To date, few studies have examined this role within mental health services and none have described the professional characteristics of post holders. Aims: The main aims of the study were to identify changes in nurse consultant numbers in mental health services, identify post holder characteristics and factors influencing number of posts. Method: We used a triangulated mixed methods approach comprised of a longitudinal examination of national workforce data, a national cross‐sectional survey of post holder characteristics and semi‐structured interviews with directors of nursing. Results: Of 58 mental health organizations, 51 (88%) responded, identifying 123 nurse consultant posts, and a range of 0–12 posts per organization. One in 229 mental health nurses and 1 in 186 learning disability nurses were nurse consultant. An average of 40% of nurse consultants' work time was reported as being in clinical practice. Themes identified as important in relation to role sustainability were cost and value, contribution of individual post holders, role clarity and domains of work. Discussion: Nurse consultants are represented to a greater extent in the mental health service workforce than in nursing generally, but their roles often lack clarity. Attitudes of local professional leaders and national policies are likely to affect post numbers. Implications for practice: Developing and sustaining nurse consultant roles requires role clarity and active support from nurse leaders. Roles need to demonstrate their value to the clinical systems in which they work. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: Literature on staffing levels and outcomes in psychiatric wards is limited and shows mixed associationsLack of economic evidence on conflicts and containment in psychiatric careData from the City‐128 study showed that regular qualified nurse staffing levels in the preceding shifts were associated with raised conflict and containment levels What this paper adds to existing knowledge?: This is the first economic analysis using the City‐128 data, with costs and outcomes data have been combined.Cost‐effectiveness of different staffing levels in relation to conflicts and containments in England, using data from the City‐128 studyBoth day and night shifts appeared to show that the low staff scenario was cost‐effective in terms of conflicts and containment averted, even after attempts were made to adjust for patient severity What are the implications for practice?: This paper could be an indication towards further investigation into how mental health inpatient care, specially nursing is organized in England. Introduction: Evidence from City‐128 study shows a positive association between staffing levels and conflicts/containment. Economic evidence on this topic is scarce, with no economic analyses combining costs and outcomes. Aim/Question: To assess the cost‐effectiveness of different staffing levels in relation to conflicts and containments in England, using City‐128 study data. Methods: Shifts were grouped into three groups based on staff‐to‐bed ratio. Cost information was combined with total conflicts and containment measures to assess cost‐effectiveness. Results: The cost‐effectiveness analysis of the three staffing scenarios for both day and night shifts appeared to show that the low staff scenario was cost‐effective in terms of conflicts and containment averted, even adjusting for patient severity. A production function analysis also revealed that increased staff numbers were associated with higher numbers of events. Discussion: Causation cannot be attributed and neither can recommendations be made on optimal staffing levels. The impact on other outcomes such as symptoms, functioning and length of stay, and other factors should be explored, and these may all benefit from increased staff numbers. Implications for practice: These results indicate that increasing staff numbers may not necessarily improve conflict and containment outcomes. They may produce positive outcomes in other domains. [ABSTRACT FROM AUTHOR]

Health care interventions are increasingly being delivered through digital technologies, offering major opportunities for delivering more health gains from scarce health care resources. Digital health interventions (DHIs) raise distinct challenges for economic evaluations compared with drugs and medical devices, not least due to their interacting, evolving features. The implications of the distinctive nature of DHIs for the methodological choices underpinning their economic evaluation is not well understood. This paper provides an in-depth discussion of distinct features of DHIs and how they might impact the design, measurement, analysis and reporting of cost-effectiveness analysis conducted alongside both randomised and non-randomised studies. These include aspects related to choice of comparator, costs and benefits assessment, study perspective and type of economic analysis. We argue that typical methodological standpoints, such as taking a health service perspective, focusing on health-related benefits and adopting cost-utility analyses, as typically adopted in the economic evaluation of non-digital technologies (pharmaceutical drugs and medical devices), are unlikely to be appropriate for DHIs. We illustrate how these methodological aspects can be appropriately addressed in an evaluation of a digitally supported, remote rehabilitation programme for patients with Long Covid in England. We highlight several methodological considerations for improving practice and areas where further methodological work is required. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to evaluate the Supported Discharge Service as a case study of integrated care. The paper will critically evaluate integrated care with regard to patient outcomes, patient satisfaction and cost and productivity.Design/methodology/approach A retrospective mixed methods case study design was adopted utilising patient satisfaction questionnaires, therapy outcome measure and a performance dashboard to measure improvements in patient satisfaction, patient outcomes and cost and productivity.Findings Measured improvements were observed in the integrated discharge process and analysis of the findings demonstrated a statistically significant improvement in patient outcomes, high levels of patient satisfaction and improved productivity subsequently leading to financial savings.Research limitations/implications Due to convenience sampling, the small sample size and a short time frame when analysing patient outcomes, the generalisability of results is limited. Despite this, with integrated care being polymorphous the findings can be utilised to develop theoretical principles to make assertions about integration (Wikfeldt, 1993).Originality/value This paper draws on the importance of integration as the principal driver of reform within the healthcare system. Even though on a small scale, the case study provides evidence to support the use of integration to improve patient outcomes, patient satisfaction and financial savings. [ABSTRACT FROM AUTHOR]

Background: Telephone therapist delivered CBT (TCBT) and web-based CBT (WCBT) have been shown to be significantly more clinically effective than treatment as usual (TAU) at reducing IBS symptom severity and impact at 12 months in adults with refractory IBS. In this paper we assess the cost-effectiveness of the interventions.Methods: Participants were recruited from 74 general practices and three gastroenterology centres in England. Interventions costs were calculated, and other service use and lost employment measured and costed for one-year post randomisation. Quality-adjusted life years (QALYs) were combined with costs to determine cost-effectiveness of TCBT and WCBT compared to TAU.Results: TCBT cost £956 more than TAU (95% CI, £601-£1435) and generated 0.0429 more QALYs. WCBT cost £224 more than TAU (95% CI, - £11 to £448) and produced 0.029 more QALYs. Compared to TAU, TCBT had an incremental cost per QALY of £22,284 while the figure for WCBT was £7724. After multiple imputation these ratios increased to £27,436 and £17,388 respectively. Including lost employment and informal care, TCBT had costs that were on average £866 lower than TAU (95% CI, - £1133 to £2957), and WCBT had costs that were £1028 lower than TAU (95% CI, - £448 to £2580).Conclusions: TCBT and WCBT resulted in more QALYs and higher costs than TAU. Complete case analysis suggests both therapies are cost-effective from a healthcare perspective. Imputation for missing data reduces cost-effectiveness but WCTB remained cost-effective. If the reduced societal costs are included both interventions are likely to be more cost-effective. Trial registration ISRCTN44427879 (registered 18.11.13). [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to examine trends over time and geographical variation in rates of paid employment amongst working age adults with learning disabilities receiving long-term social care in England.Design/methodology/approach Data were drawn from NHS Digital adult social care statistics examining paid/self-employment for working age (18-64 years) adults with learning disabilities known to social care (2008/2009 to 2013/2014) or receiving long-term social care (2014/2015 to 2016/2017).Findings In 2016/2017, councils reported that 5.7 per cent of working age adults (7,422 people) with learning disabilities receiving long-term social care were in paid/self-employment, with higher employment rates for men than women and most people working less than 16 hours per week. Paid employment rates seem to be slightly declining over time, and there is wide variation across councils in reported paid/self-employment rates.Social implications Despite good evidence for the cost effectiveness of supported employment support, employment rates for adults with learning disabilities receiving long-term social care remain extremely low.Originality/value This paper presents in one place statistics concerning the paid employment of working age adults with learning disabilities in England. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to detail the research and findings from a piece of work commissioned by the Local Government Association in England, in May 2013 into the current implementation of integrated care Design/methodology/approach - The field research was carried out by Integrating Care, a collaborative drawn from leading academics, health and social care executives, analysts and clinicians working in the field of integrated care; along with consultancy support from public sector consultancies PPL and GE Healthcare Finnamore. It comprised a series of local interviews, workshops, modelling and analysis and ongoing engagement. Findings - The paper describes the outputs that were delivered to support the development of "whole-system" integrated health and social care drawing on national and international best-practice, and knowledge gained from experiences of implementation. Social implications - The paper concludes by drawing together the key lessons from the overarching analysis of whole-system integration. This includes the opportunities and the complexities of redesigning and re-implementing better co-ordinated health and social care provision at scale, as experienced in England currently. Originality/value - The paper describes the specific challenges posed through the fieldwork and ongoing development process of integration in England, and the paper reflects upon some of the deeper questions that this has led to. The paper then draws together the research and analysis with emerging, strategic questions around the concept of value in health provision; and begins to question whether this has yet been demonstrated; and, if not, what a demonstration and evidencing of "value" in this context might look like [ABSTRACT FROM AUTHOR]

Background: This paper describes the design and development of a complex multifactorial falls prevention (MFFP) intervention for implementation and testing within the framework of a large UK-based falls prevention randomised controlled trial (RCT).Methods: A complex intervention was developed for inclusion within the Prevention of Falls Injury Trial (PreFIT), a multicentre pragmatic RCT. PreFIT aims to compare the clinical and cost-effectiveness of three alternative primary care falls prevention interventions (advice, exercise and MFFP), on outcomes of fractures and falls. Community-dwelling adults, aged 70 years and older, were recruited from primary care in the National Health Service (NHS), England.Results: Development of the PreFIT MFFP intervention was informed by the existing evidence base and clinical guidelines for the assessment and management of falls in older adults. After piloting and modification, the final MFFP intervention includes seven falls risk factors: a detailed falls history interview with consideration of 'red flags'; assessment of balance and gait; vision; medication screen; cardiac screen; feet and footwear screen and home environment assessment. This complex intervention has been fully manualised with clear, documented assessment and treatment pathways for each risk factor. Each risk factor is assessed in every trial participant referred for MFFP. Referral for assessment is based upon a screening survey to identify those with a history of falling or balance problems. Intervention delivery can be adapted to the local setting.Conclusion: This complex falls prevention intervention is currently being tested within the framework of a large clinical trial. This paper adheres to TIDieR and CONSORT recommendations for the comprehensive and explicit reporting of trial interventions. Results from the PreFIT study will be published in due course. The effectiveness and cost-effectiveness of the PreFIT MFFP intervention, compared to advice and exercise, on the prevention of falls and fractures, will be reported at the conclusion of the trial. [ABSTRACT FROM AUTHOR]

We examine the cost-effectiveness of treating epilepsy with anti-epileptic medicines in autistic children, looking at impacts on healthcare providers (in England, Ireland, Italy and Spain) and children's families (in Ireland). We find carbamazepine to be the most cost-effective drug to try first in children with newly diagnosed focal seizures. For England and Spain, oxcarbazepine is the most cost-effective treatment when taken as additional treatment for those children whose response to monotherapy is suboptimal. In Ireland and Italy, gabapentin is the most cost-effective option. Our additional scenario analysis presents the aggregate cost to families with autistic children who are being treated for epilepsy: this cost is considerably higher than healthcare provider expenditure. [ABSTRACT FROM AUTHOR]

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

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care. [ABSTRACT FROM PUBLISHER]

Background: The National Institute for Health and Care Excellence (NICE) recommends evidence-based parenting programmes as a first-line intervention for conduct disorders (CD) in children aged 5-11 years. As these are not effective in 25-33% of cases, NICE has requested research into second-line interventions. Child and Adolescent Psychotherapists (CAPTs) address highly complex problems where first-line treatments have failed and there have been small-scale studies of Psychoanalytic Child Psychotherapy (PCP) for CD. A feasibility trial is needed to determine whether a confirmatory trial of manualised PCP (mPCP) versus Treatment as Usual (TaU) for CD is practicable or needs refinement. The aim of this paper is to publish the abridged protocol of this feasibility trial.Methods and Design: TIGA-CUB (Trial on improving Inter-Generational Attachment for Children Undergoing Behaviour problems) is a two-arm, pragmatic, parallel-group, multicentre, individually randomised (1:1) controlled feasibility trial (target n = 60) with blinded outcome assessment (at 4 and 8 months), which aims to develop an optimum practicable protocol for a confirmatory, pragmatic, randomised controlled trial (RCT) (primary outcome: child's behaviour; secondary outcomes: parental reflective functioning and mental health, child and parent quality of life), comparing mPCP and TaU as second-line treatments for children aged 5-11 years with treatment-resistant CD and inter-generational attachment difficulties, and for their primary carers. Child-primary carer dyads will be recruited following a referral to, or re-referral within, National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) after an unsuccessful first-line parenting intervention. PCP will be delivered by qualified CAPTs working in routine NHS clinical practice, using a trial-specific PCP manual (a brief version of established PCP clinical practice). Outcomes are: (1) feasibility of recruitment methods, (2) uptake and follow-up rates, (3) therapeutic delivery, treatment retention and attendance, intervention adherence rates, (4) follow-up data collection, and (5) statistical, health economics, process evaluation, and qualitative outcomes.Discussion: TIGA-CUB will provide important information on the feasibility and potential challenges of undertaking a confirmatory RCT to evaluate the effectiveness and cost-effectiveness of mPCP.Trial Registration: Current Controlled Trials, ID: ISRCTN86725795 . Registered on 31 May 2016. [ABSTRACT FROM AUTHOR]

Background: Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people's homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness. Methods: ACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners' experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is 'successful rehabilitation' defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months. Discussion: The ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services. Trial registration: ISRCTN17381762 retrospectively registered. [ABSTRACT FROM AUTHOR]

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

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

Background: In contrast to evidence for interventions supporting victim/survivors of domestic violence and abuse (DVA), the effectiveness of perpetrator programmes for reduction of abuse is uncertain. This study aims to estimate the effectiveness and cost-effectiveness of a perpetrator programme for men. Methods: Pragmatic two-group individually randomised controlled trial (RCT) with embedded process and economic evaluation. Five centres in southwest England and South Wales aim to recruit 316 (reduced from original target of 366) male domestic abuse perpetrators. These will be randomised 2:1 to a community-based domestic abuse perpetrator programme (DAPP) or usual care comparator with 12-month follow-up. Female partners/ex-partners will be invited to join the study. The intervention for men comprises 23 weekly sessions of a group programme delivered in voluntary sector domestic abuse services. The intervention for female partners/ex-partners is one-to-one support from a safety worker. Men allocated to usual care receive no intervention; however, they are free to access other services. Their partners/ex-partners will be signposted to support services. Data is collected at baseline, and 4, 8 and 12 months' follow-up. The primary outcome is men's self-reported abusive behaviour measured by the Abusive Behaviour Inventory (ABI-29) at 12 months. Secondary measures include physical and mental health status and resource use alongside the abuse measure ABI (ABI-R) for partners/ex-partners and criminal justice contact for men. A mixed methods process evaluation and qualitative study will explore mechanisms of effectiveness, judge fidelity to the intervention model using interviews and group observations. The economic evaluation, over a 1-year time horizon from three perspectives (health and social care, public sector and society), will employ a cost-consequences framework reporting costs alongside economic outcomes (Quality-Adjusted Life Years derived from EQ-5D-5L, SF-12 and CHU-9D, and ICECAP-A) as well as the primary and other secondary outcomes. Discussion: This trial will provide evidence of the (cost)effectiveness of a DAPP. The embedded process evaluation will further insights in the experiences and contexts of participants and their journey through a perpetrator programme, and the study will seek to address the omission in other studies of economic evaluations. Trial registration: ISRCTN15804282, April 1, 2019 [ABSTRACT FROM AUTHOR]

Background: Systematic reviews suggest that multi-component interventions are effective in reducing bullying victimisation and perpetration. We are undertaking a phase III randomised trial of the INCLUSIVE multi-component intervention. This trial aims to assess the effectiveness and cost-effectiveness of the INCLUSIVE intervention in reducing aggression and bullying victimisation in English secondary schools. This paper updates the original trial protocol published in 2014 (Trials 15:381, 2014) and presents the changes in the process evaluation protocol and the secondary outcome data collection.Methods: The methods are summarised as follows.Design: cluster randomised trial.Participants: 40 state secondary schools. Outcomes assessed among the cohort of students at the end of year 7 (n = 6667) at baseline.Intervention: INCLUSIVE is a multi-component school intervention including a social and emotional learning curriculum, changes to school environment (an action group comprising staff and students reviews local data on needs to review rules and policies and determine other local actions) and staff training in restorative practice. The intervention will be delivered by schools supported in the first two years by educational facilitators independent of the research team, with a third intervention year involving no external facilitation but all other elements. Comparator: normal practice.Outcomes: Primary: Two primary outcomes at student level assessed at baseline and at 36 months: 1. Aggressive behaviours in school: Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale (ESYTC) 2. Bullying and victimisation: Gatehouse Bullying Scale (GBS) Secondary outcomes assessed at baseline, 24 and 36 months will include measures relating to the economic evaluation, psychosocial outcomes in students and staff and school-level truancy and exclusion rates.Sample Size: 20 schools per arm will provide 90% power to identify an effect size of 0.25 SD with a 5% significance level. Randomisation: eligible consenting schools were randomised stratified for single-sex versus mixed-sex schools, school-level deprivation and measures of school attainment.Discussion: The trial involves independent research and intervention teams and is supervised by a Trial Steering Committee and a Data Monitoring Committee.Trial Registration: Current Controlled Trials, ISRCTN10751359 . Registered on 11 March 2014. [ABSTRACT FROM AUTHOR]

A case study was conducted in 2016 to evaluate the effectiveness of an innovation to enable people with "complex" care requirements to be discharged from hospital to an appropriate service for their care, without using the NHS England Continuing Health Care (CHC) assessment. The setting was a rural district general hospital in England, where the quality outcomes and cost‐effectiveness of the CHC assessment being conducted in hospital were giving cause for concern. The NHS CHC Framework advocates conducting these assessments in the community where a more accurate indication of long‐term care can be determined. The "5Q Care Test" was collaboratively developed with health and social care partners, care providers, and CHC interest groups, including users of the services. It was implemented as a tool to support moving the CHC assessment into the community, as it enabled practitioners to swiftly determine patients' appropriate initial care pathway out of hospital. A full economic impact analysis was conducted 7 months after the tool was introduced. The results showed significant improvement in the quality and cost‐effectiveness of the "5Q Care Test," with a reduction in the hospital length of stay, which is known to be associated with improved outcomes for patients and financial savings. [ABSTRACT FROM AUTHOR]

Abstract In recent decades, many authors have claimed that, compared to traditional appraisal techniques such as cost-benefit analysis (CBA), participatory multi-criteria analysis (MCA) methodologies represent a more effective approach to appraising transport projects, largely due to the range of criteria able to be used and the ability to reflect multiple viewpoints. This paper applies a participatory MCA process to appraise potential rail investments in North West England. The results of this analysis show that, while promising, participatory MCA processes also have several limitations, and successful application is subject to several issues which require careful consideration, including selection of participants, identification of appraisal criteria, and the process of assessing impacts. Highlights • While promising, participatory MCA methodologies should not be regarded as a panacea for better decisions. • The application of such methods is subject to several issues which require careful consideration. • Participatory processes do not always produce comprehensive and sound assessments. • Some people may experience difficulties in understanding the basic principle of MCA. • There is also an undeniable potential for arbitrariness in such processes. • There is a clear need for further empirical research in this area, testing different approaches to participatory MCA. [ABSTRACT FROM AUTHOR]

Aims: To evaluate whether adding financial incentives to usual care is cost‐effective in encouraging pregnant women to quit tobacco smoking, compared with usual care alone. Design: Cost‐effectiveness analysis (CEA) and cost–utility analysis (CUA) from a health‐care provider's perspective, embedded in the Smoking Cessation in Pregnancy Incentives Trial (CPIT III). Long‐term analyses were conducted from the same perspective, using an existing Markov model over a life‐time horizon. Setting: Seven maternity smoking cessation sites in Scotland, England and Northern Ireland in the United Kingdom. Participants: In the short‐term analysis, CPIT III participants were assessed: women 16 years or older, self‐reporting as smokers, fewer than 24 weeks pregnant and English‐speaking (n = 944). The same population was used for the life‐time analysis, plus their infants. Measurements Costs included financial incentive vouchers and postage, cessation support and nicotine replacement therapy and neonatal stays. The outcome measure was a biochemically verified quit rate for the CEA and quality‐adjusted life‐years (QALYs) for CUA. Costs are presented in 2020 GBP sterling (£). Data for the life‐time analysis came from the trial and were combined with data from published literature embedded in the model, reporting incremental cost per quitter and QALY. A 3.5% discount rate was applied. Findings The short‐term incremental cost per quitter was £4400 and cost per QALY was £150 000. Results of sensitivity analyses confirmed these results. The long‐term analysis combined costs and outcomes for mother and infants; results showed a cost saving of £37 [95% confidence interval (CI]) = £35–106] and increase in QALYs of 0.171 (95% CI = 0.124–0.229). These findings indicate that, over a life‐time, financial incentives are cost‐saving and improve health outcomes. Conclusions: In the United Kingdom, offering up to £400 financial incentives, in addition to usual care, to support pregnant women to stop smoking appears to be highly cost‐effective over a life‐time for mother and infants. [ABSTRACT FROM AUTHOR]

Background: Child maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population.Methods: A multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20-24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses.Results: Between August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI - 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group - 0 · 68 (95% CI - 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%.Conclusions: The trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention.Trial Registration: ISRCTN78814904 . Registered on 17 May 2013. [ABSTRACT FROM AUTHOR]

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not sufficient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most effective and cost-effective policies to reduce alcohol-related harm. [ABSTRACT FROM AUTHOR]

The care home staff influenza vaccination rate in England is significantly lower than the 75% World Health Organisation recommendation. This represents a substantial potential for resident harm. Barriers to staff vaccination stem from individual and organisational levels. Existing interventions address some but not all barriers and are not underpinned by behavioural science theory. This study aims to estimate the effectiveness and cost-effectiveness of a theory-informed intervention to improve care home staff vaccination rates compared to routine practice. Set in care homes with both nursing and residential focus, and a range of ownership status, only homes providing long stay care to older people with a staff vaccination rate below 40% are eligible to participate. Participation expressions of interest will be sought using a variety of approaches prior to seeking consent. The primary outcome measure is the proportion of staff vaccinated at 6 months, with secondary outcome measures being proportion vaccinated at 3 months, numbers of staff sick days, general practitioner and nurse visits to care home, care home resident hospitalisations and mortality. Based on the assumptions that the mean cluster (care home) size is 54 staff, a coefficient of variation of 0.48, control vaccination rate is 55%, intervention 75%, intra-cluster correlation coefficient of 0.2 and with 90% power, and 20% attrition, we require 39 care homes per arm. Blocked randomisation will be at the level of care home, stratified by the proportion of non-white care home staff, and implemented by Norwich Clinical Trials Unit. The intervention comprises co-designed information videos and posters, provision of in-house staff vaccination clinics, and incentive scheme and monthly data collection on trial outcomes. Beyond usual practice, the control arm will additionally contribute monthly data. Data will be collected at the start, monthly and at 6 months, and analysis will be blind to allocation. Statistical analysis will use the intention-to-treat principle with the difference in vaccination rates between groups compared using a random effect logistic regression model at the staff-level. This will be the first study to use a theory-informed intervention designed to comprehensively address identified barriers to care home staff influenza vaccination. Trial registration: ISRCTN ISRCTN22729870. Registered on 24 August 22. Secondary identifiers: R209939, IRAS 316820, CPMS 53812. [ABSTRACT FROM AUTHOR]

Background: Acne vulgaris is a common skin condition that may cause psychosocial distress. There is evidence that topical treatment combinations, chemical peels and photochemical therapy (combined blue/red light) are effective for mild‐to‐moderate acne, while topical treatment combinations, oral antibiotics combined with topical treatments, oral isotretinoin and photodynamic therapy are most effective for moderate‐to‐severe acne. Effective treatments have varying costs. The National Institute for Health and Care Excellence (NICE) in England considers cost‐effectiveness when producing national clinical, public health and social care guidance. Aim: To assess the cost‐effectiveness of treatments for mild‐to‐moderate and moderate‐to‐severe acne to inform relevant NICE guidance. Methods: A decision–analytical model compared costs and quality‐adjusted life‐years (QALYs) of effective topical pharmacological, oral pharmacological, physical and combined treatments for mild‐to‐moderate and moderate‐to‐severe acne, from the perspective of the National Health Service in England. Effectiveness data were derived from a network meta‐analysis. Other model input parameters were based on published sources, supplemented by expert opinion. Results: All of the assessed treatments were more cost‐effective than treatment with placebo (general practitioner visits without active treatment). For mild‐to‐moderate acne, topical treatment combinations and photochemical therapy (combined blue/red light) were most cost‐effective. For moderate‐to‐severe acne, topical treatment combinations, oral antibiotics combined with topical treatments, and oral isotretinoin were the most cost‐effective. Results showed uncertainty, as reflected in the wide confidence intervals around mean treatment rankings. Conclusion: A range of treatments are cost‐effective for the management of acne. Well‐conducted studies are needed to examine the long‐term clinical efficacy and cost‐effectiveness of the full range of acne treatments. [ABSTRACT FROM AUTHOR]

There are long‐standing concerns that people experiencing homelessness may not recover well if left unsupported after a hospital stay. This study reports on a study investigating the cost‐effectiveness of three different 'in patient care coordination and discharge planning' configurations for adults experiencing homelessness who are discharged from hospitals in England. The first configuration provided a clinical and housing in‐reach service during acute care and discharge coordination but with no 'step‐down' care. The second configuration provided clinical and housing in‐reach, discharge coordination and 'step‐down' intermediate care. The third configuration consisted of housing support workers providing in‐reach and discharge coordination as well as step‐down care. These three configurations were each compared with 'standard care' (control, defined as one visit by the homelessness health nurse before discharge during which patients received an information leaflet on local services). Multiple sources of data and multi‐outcome measures were adopted to assess the cost utility of hospital discharge service delivery for the NHS and broader public perspective. Details of 354 participants were collated on service delivery costs (salary, on‐costs, capital, overheads and 'hotel' costs, advertising and other indirect costs), the economic consequences for different public services (e.g. NHS, social care, criminal justice, housing, etc.) and health utilities (quality‐adjusted‐life‐years, QALYs). Findings were complex across the configurations, but, on the whole, there was promising evidence suggesting that, with delivery costs similar to those reported for bed‐based intermediate care, step‐down care secured better health outcomes and improved cost‐effectiveness (compared with usual care) within NICE cost‐effectiveness recommendations. [ABSTRACT FROM AUTHOR]

Background: Empirical estimates of health system opportunity costs have been suggested as a basis for the cost-effectiveness threshold to use in Health Technology Assessment. Econometric methods have been used to estimate these in several countries based on data on spending and mortality. This study examines empirical evidence on four issues: non-linearity of the relationship between spending and mortality; the inclusion of outcomes other than mortality; variation in the efficiency with which expenditures generate health outcomes; and the relationship among efficiency, mortality rates and outcome elasticities. Methods: Quantile Regression is used to examine non-linearities in the relationship between mortality and health expenditures along the mortality distribution. Data Envelopment Analysis extends the approach, using multiple measures of health outcomes to measure efficiency. These are applied to health expenditure data from 151 geographical units (Primary Care Trusts) of the National Health Service in England, across eight different clinical areas (Programme Budget Categories), for 3 fiscal years from 2010/11 to 2012/13. Results: The results suggest differences in efficiency levels across geographical units and clinical areas as to how health resources generate outcomes, which indicates the capacity to adjust to a decrease in health expenditure without affecting health outcomes. Moreover, efficient units have lower absolute levels of mortality elasticity to health expenditure than inefficient ones. Conclusions: The policy of adopting thresholds based on estimates of a single system-wide cost-effectiveness threshold assumes a relationship between expenditure and health outcomes that generates an opportunity cost estimate which applies to the whole system. Our evidence of variations in that relationship and therefore in opportunity costs suggests that adopting a single threshold may exacerbate the efficiency and equity concerns that such thresholds are designed to counter. In most health care systems, many decisions about provision are not made centrally. Our analytical approach to understanding variability in opportunity cost can help policy makers target efficiency improvements and set realistic targets for local and clinical area health improvements from increased expenditure. [ABSTRACT FROM AUTHOR]

Background: Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.Aims: We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).Method: Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother-infant interaction quality and safeguarding outcome.Results: Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86-1.04, P = 0.29; an absolute difference of -5%, 95% CI -14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.Conclusions: We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To assess the cost‐effectiveness of the WISDOM self‐management intervention for type 2 diabetes compared with care as usual. Design: We performed a difference‐in‐differences analysis to estimate differences in risk factors for diabetes complications between people in the WISDOM group (n = 25, 276) and a control group (n = 15, 272) using GP records. A decision analytic model was then used to extrapolate differences in risk factors into costs and outcomes in the long term. Setting: Participating GP practices in West Hampshire and Southampton, UK. Participants: All people diagnosed with type 2 diabetes between January 1990 and March 2020 (n = 40,548). Outcomes Diabetes‐related complications, quality‐adjusted life years (QALYs) and costs to the English National Health Service at 5 years and lifetime. Interventions: The WISDOM intervention included risk stratification, self‐management education programme to professionals and people with type 2 diabetes, and monitoring of key treatment targets. Results: WISDOM was associated with less atrial fibrillation [p = 0.001], albuminuria [p = 0.002] and blood pressure [p = 0.098]. Among all people in the intervention group, WISDOM led to 51 [95%CI: 25; 76] QALYs gained and saved £278,036 [95%CI: −631,900; 176,392] in the first 5 years after its implementation compared with care as usual. During those people' lifetime, WISDOM led to 253 [95%CI: 75; 404] QALYs gained and cost saving of £126,380 [95%CI: −1,466,008; 1,339,628]. The gains in QALYs were a result of reduced diabetes‐related complications through improved management of the associated risk factors. Conclusions: The WISDOM risk‐stratification and education intervention for type 2 diabetes appear to be cost‐effective compared to usual care by reducing diabetes complications. [ABSTRACT FROM AUTHOR]

Background In countries where there are large disparities in smoking with persistent high rates among disadvantaged groups, there is a need to ensure that stop smoking services (SSS) reach such smokers. The primary aim of this study was to evaluate the effectiveness of a mobile, drop-in, community-based SSS in reaching more disadvantaged smokers, particularly those from routine and manual (RM) occupation groups, than standard services; secondary aims were to evaluate effectiveness in reaching those who had not previously accessed SSS, triggering unplanned quit behaviour, helping people quit and cost-effectiveness. Methods Following a 4-week pilot period, a mobile drop-in SSS was delivered across various public locations in Nottingham City, UK for 6 months, offering behavioural and pharmacological support via one-to-one consultations with trained cessation advisors. Detailed demographic and smoking behaviour data were collected from all clients accessing the mobile SSS, and Nottingham's standard SSS for comparison. Results Compared with smokers accessing the standard SSS (n=1856), mobile SSS smokers (n=811) were significantly more likely to be from the RM group (33.3% vs 27.2%, p=0.002), and to be first-time SSS users (67.8% vs 59.3%, p<0.001). Nearly 1 in 10 smokers setting a quit date through the mobile SSS had no prior quit intentions. The cost per smoker setting a quit date for the mobile SSS was only slightly higher than the standard SSS (£224 vs £202). Conclusions A mobile drop-in SSS is an effective way of reaching more disadvantaged smokers from RM occupations, as well as those who have not previously accessed standard SSS and those without prior quit intentions. [ABSTRACT FROM AUTHOR]

Single-sided deafness presents communication challenges for adults. There are a range of care options, including CROS hearing aids, available but little is known about patient preferences for these interventions. The objective of this study was to understand the viewpoints of patients making decisions about audiological interventions they use. A constructivist worldview using thematic analysis to undertake a constant comparative analysis of 8 semi-structured interviews. Participants were recruited from Portsmouth Hospitals University NHS Trust audiology service in England. The results of the study describe ongoing iterative judgements being made by participants, informed by their access to information, effectiveness of audiological interventions, stigma, barriers to accessing care, and constant cost-benefit analyses being made. The key factors involved in decision-making by individuals with Single-sided deafness (SSD) are discussed. This study represents the first in-depth exploration of the individual's lifeworld related to which factors influence use of different audiological interventions by individuals with SSD. It highlights the complex and ongoing nature of how decisions are made by these individuals and identifies the need for greater information provision by clinicians, such as through use of a decision aid tool. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore what women aged below the national screening age in the UK know and think about cervical cancer and cervical screening. Background: The efficacy of cervical cancer screening is well established. However, cervical screening attendance in the United Kingdom has decreased, with especially low rates at the first screening opportunity at age 25. Research has not yet explored knowledge and beliefs underpinning young women's intention to screen before first screening invitation. Design: Qualitative exploratory study. Methods: Qualitative email interviews were undertaken with 16 participants, using questions derived from the Health Belief Model. Data were analysed using template analysis. The COREQ were followed. Results: Analysis generated three themes; (1) Learning about cervical cancer and cervical screening: sources of information and (missed) opportunities; (2) Young women know screening is important – but they don't always know why; (3) Screening intentions: a cost/benefit analysis of the available information. Conclusions: Young women had varied knowledge and beliefs about cervical cancer and screening which were underpinned by several sources of information available to them. Most women expressed an intention to attend screening when invited; however, some participants were unsure, with low screening‐based knowledge and low perceived susceptibility of cervical cancer identified as key barriers. Social media, familial interactions and interventions within education were highlighted as being suited to interventions aimed at increasing cervical cancer‐ and screening‐based knowledge in young women. Relevance to clinical practice: Findings suggest that women below screening age could be better informed about cervical cancer and screening. Tailored interventions addressing common concerns and misconceptions around screening may be acceptable to young women and could help to promote screening attendance at first invitation. [ABSTRACT FROM AUTHOR]

Objectives: To explore the feasibility of a full economic evaluation of usual care plus peer-befriending versus usual care control, and potential cost-effectiveness of peer-befriending for people with aphasia. To report initial costs, ease of instruments' completion and overall data completeness. Design: Pilot economic evaluation within a feasibility randomised controlled trial Setting: Community, England Participants: People with post-stroke aphasia and low levels of psychological distress Intervention: All participants received usual care; intervention participants received six peer-befriending visits between randomisation and four months Main measures: Costs were collected on the stroke-adapted Client Service Receipt Inventory (CSRI) for health, social care and personal out-of-pocket expenditure arising from care for participants and carers at 4- and 10-months post-randomisation. Health gains and costs were reported using the General Health Questionnaire-12 and the EQ-5D-5L. Mean (CI) differences for costs and health gains were reported and uncertainty represented using non-parametric bootstrapping and cost-effectiveness acceptability curves. Results: 56 participants were randomised. Mean age was 70.1 (SD 13.4). Most (n = 37, 66%) had mild and many (n = 14; 25%) severe aphasia. There was ≥94% completion of CSRI questions. Peer-befriending was higher in intervention arm (p < 0.01) but there were no significant differences in total costs between trial arms. Peer-befriending visits costed on average £57.24 (including training and supervision costs). The probability of peer-befriending being cost-effective ranged 39% to 66%. Conclusions: Economic data can be collected from participants with post-stroke aphasia, indicating a full economic evaluation within a definitive trial is feasible. A larger study is needed to demonstrate further cost-effectiveness of peer-befriending. [ABSTRACT FROM AUTHOR]

Background and Aims: Communication of personalised disease risk can motivate smoking cessation. We assessed whether routine implementation of this intervention by general practitioners (GPs) in England is cost‐effective or whether we need further research to better establish its effectiveness. Design Cost‐effectiveness analysis (CEA) with value of information (VoI) analysis from the UK National Health Service perspective, using GP communication of personalised disease risk on smoking cessation versus usual care. Setting: GP practices in England. Study population: Healthy smokers aged 35–60 years attending the GP practice. Measurements Effectiveness of GP communication of personalised disease risk on smoking cessation was estimated through systematic review and meta‐analysis. A Bayesian CEA was then performed using a lifetime Markov model on smokers aged 35–60 years that measured lifetime costs and quality‐adjusted life‐years (QALYs) assigned to the four diseases contributing the most to smoking‐related morbidity, mortality and costs: chronic obstructive pulmonary disease, lung cancer, myocardial infarction and stroke. Costs and QALYs for each disease state were obtained from the literature. VoI analysis identified sources of uncertainty in the CEA and assessed how much would be worth investing in further research to reduce this uncertainty. Findings The meta‐analysis odds ratio for the effectiveness estimate of GP communication of personalised disease risk was 1.48 (95% credibility interval, 0.91–2.26), an absolute increase in smoking cessation rates of 3.84%. The probability of cost‐effectiveness ranged 89–94% depending on sex and age. VoI analysis indicated that: (i) uncertainty in the effectiveness of the intervention was the driver of the overall uncertainty in the CEA; and (ii) a research investment to reduce this uncertainty is justified if lower than £27.6 million (£7 per smoker). Conclusions: Evidence to date shows that, in England, incorporating disease risk communication into general practitioners' practices to motivate smoking cessation is likely to be cost‐effective compared with usual care. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Chief Medical Officer for England recommending that young people remaining alcohol free until 18 years of age. Topics include highest levels of drinking among adolescents and the North East England being one of the highest levels of adolescent alcohol consumption in the UK; and exploring the relationship between alcohol use during adolescence and negative consequences in adulthood.

Background: Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.Methods: The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.Discussion: The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.Trial Registration: ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021. [ABSTRACT FROM AUTHOR]

The real-time control of water distribution networks for firefighting is an important but little-studied problem. Water utilities in England and Wales reduce hydraulic pressure to a minimum regulatory threshold in order to reduce leakage and avoid financial penalties. However, utilities are not legally bound to guarantee specific flow rates from fire hydrants, which poses a risk for firefighting. This study presents an adaptive nonlinear model predictive control scheme for water distribution networks integrating two modes of control: (1) normal control, when a network operates under normal conditions and the objective is to minimize energy costs and average zonal pressure, and (2) fire control, when fire flows need to be delivered from hydrants without exceeding maximum pressure and customer demand is maintained to the best extent possible. The proposed scheme is applied to an operational network. It demonstrates the combined benefits of reducing costs and leakage with increased fire flows. [ABSTRACT FROM AUTHOR]

Background: The novel coronavirus disease in 2019 (COVID-19) has placed unprecedented strain on healthcare providers, in particular, primary care services. General practitioners (GP) have to effectively manage patients remotely preserving social distancing. We aim to assess an app-based remote patient monitoring solution in reducing the workload of a clinician and reflect this as time-saved in an economic context. Primary care COVID patients in West London deemed medium risk were recruited into the virtual ward. Patients were monitored for 14 days by telephone or by both the Huma app and telephone. Information on number of phone calls, duration of phone calls and duration of time spent reviewing the app data was recorded. Results: The amount of time spent reviewing one patient in the telephone only arm of the study was 490 min, compared with 280 min spent reviewing one patient who was monitored via both the Huma app and telephone. Based on employed clinicians monitoring patients, this equates to a 0.04 reduction of full-time equivalent staffing I.e. for every 100 patients, it would require 4 less personnel to remotely monitor them. There was no difference in mortality or adverse events between the two groups. Conclusion: App-based remote patient monitoring potentially holds large economic benefit to COVID-19 patients. In wake of further waves or future pandemics, and even in routine care, app-based remote monitoring patients could free up vital resources in terms of clinical team's time, allowing a better reallocation of services. [ABSTRACT FROM AUTHOR]

Two studies examined whether rapport-based interviewing with child sexual abuse (CSA) suspects provides greater interview yield that could result in overall cost-savings to the investigation. First, multi-level modelling was applied to 35 naturalistic CSA suspect interviews to establish whether rapport-based interviewing techniques increase "yield" – defined as information of investigative value. The Observing Rapport Based Interviewing Technique (ORBIT coding manual was used to code interviews; it includes an assessment of both interpersonal adaptive and maladaptive rapport-based interviewer engagement as well as motivational interviewing (MI) strategies. The impact of these two strands (interpersonal and MI) on extracting information of investigative value (including strengthening a case for court and safeguarding) were examined. Adaptive interpersonal strategies increased case strengthening and safeguarding yield, with motivational interviewing having the largest impact on safeguarding yield. Both strategies increase the likelihood of gaining additional types of economic yield. Maladaptive interviewer strategies reduced case strengthening and different types of economic yield. In study two, literature-based economic estimates were applied to establish the potential cost benefits from following national ORBIT rapport training. Further training in adaptive and motivational interviewing could contribute cost savings between £19 and £78 million (annual unit costs) increasing to £238–£972 million (lifetime costs) for online CSA across England and Wales; and £157–£639 million (annual unit costs) increasing to £2–£8 billion (lifetime costs) for all CSA. Failure to commit training resource to this, or an alternative strategy, could mean the cost burden attributable to maladaptive interviewing (between £1 and £6 million for online CSA and £12 and £48 million for all CSA) is not successfully averted. [ABSTRACT FROM AUTHOR]

Summary: Local Area Coordination is an approach that emerged during the 1980s and 1990s to support individuals with learning disabilities in rural and metropolitan Western Australia. Offering direct family support, signposting and networking it aimed to improve access to services and promote social inclusion. It leveraged community resources and sought broader transformation through local collaborations and service redesign, as underpinned by a strengths-based philosophy. Scotland introduced a similar model of delivery from the early 2000s for learning disability support. Since 2010, a number of English and Welsh Local Authorities have introduced Local Area Coordination, and in doing so have expanded its support eligibility criteria to include those considered 'vulnerable' due to age, frailty, disability, mental health issues and housing precariousness. Findings: This article provides the first review of developments in England and Wales. Drawing upon published evaluation studies it reflects on Local Area Coordination implementation; reviews the existing evidence base and challenges surrounding data collection; and discusses the competing logic of Local Area Coordination in its aim of supporting individual and community improvement of health outcomes and well-being, and of furthering local government civic engagement and participation. Applications: This article points to the challenges and opportunities of implementing such a strength-, assets- and placed-based initiatives within Local Authority social service settings. Embedding Local Area Coordination within Local Authority settings requires skilled political and policy leadership. It balances emerging individual outcomes – health and well-being – with the civic mission (values, control and coproduction), and avoids one being subverted to the other. [ABSTRACT FROM AUTHOR]

River infrastructure can cause adverse impacts on fish populations, which, in turn, compromises the ability of river ecosystems to provide a range of ecosystem services. In this paper, we present a methodological approach to assess the potential economics costs and benefits of river connectivity enhancement achieved through removal and mitigation of fish dispersal barriers. Our approach combines the results of a stated preference study for nonuse values of rivers and statistical models of fish population responses to barrier mitigation actions within an integrated bioeconomic optimization framework. We demonstrate the utility of our methodology using a case study of the River Wey catchment in southeast England, which contains over 650 artificial barriers. Our results reveal the presence of benefit-cost trade-offs which can form the basis for river barrier mitigation policy development. In particular, we find that benefits exceed costs in the River Wey for all levels of investment in barrier mitigation considered (£2.5 to 53.4 M). Furthermore, from an economic efficiency standpoint, a total budget of approximately £22.5M allocated to barrier mitigation would maximize net societal benefits derived from anticipated increases fish species richness and abundance. • We present an integrated approach to examine costs & benefits of river restoration. • We develop and employ a novel mixed integer linear program to integrate all data. • We derive optimal economic solutions for river barrier mitigation actions. • Our integrated framework enables practical application of cost benefit analysis. [ABSTRACT FROM AUTHOR]

Objective: To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. Design: A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. Results: The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18–1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07–1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21–1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32–1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Conclusions: Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. Trial registration: The study was registered on (NCT03231007); www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies–Practical Obstetric Multi-Professional Training (PROMPT)–with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs). Design: A model-based cost-utility analysis. Setting: Maternity units in England. Population: Simulated cohorts of individuals affected by permanent OBPIs. Methods: A decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters. Main outcome measures: Outcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained. Results: Nationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings. Conclusion: In this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs. [ABSTRACT FROM AUTHOR]

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a recent report by the Royal College of Nursing calling for the Government to change the system of funding for nurse education [ABSTRACT FROM AUTHOR]

Aims: To evaluate the cost‐effectiveness of a specialist smoking cessation package for people with severe mental illness Design Incremental cost‐effectiveness analysis was undertaken from the UK National Health Service and Personal Social Services perspective over a 12‐month time horizon. Total costs, including smoking cessation, health‐care and social services costs and quality‐adjusted life years (QALYs), derived from the five‐level EuroQol 5‐dimension (EQ‐5D‐5 L), collected from a randomized controlled trial, were used as outcome measures. The bootstrap technique was employed to assess the uncertainty. Setting: Sixteen primary care and 21 secondary care mental health sites in England. Participants: Adult smokers with bipolar affective disorder, schizoaffective disorder or schizophrenia and related illnesses (n = 526). Intervention and comparator: A bespoke smoking cessation (BSC) package for people with severe mental illness offered up to 12 individual sessions with a mental health smoking cessation practitioner versus usual care (UC). Of the participants who were randomized, 261 were in UC group and 265 were in BSC group. Measurements BSC intervention cost was estimated from the treatment log. Costs of UC, health‐care and social services and EQ‐5D‐5 L were collected at baseline, 6‐ and 12‐month follow‐ups. Incremental costs and incremental QLAYs were estimated using regression adjusting for respective baseline values and other baseline covariates. Findings The mean total cost in the BSC group was £270 [95% confidence interval (CI) = –£1690 to £1424] lower than in the UC group, while the mean QALYs were 0.013 (95% CI = –0.008 to 0.045) higher, leading to BSC dominating UC (76% probability of cost‐effective at £20 000/QALY). Conclusions: A bespoke smoking cessation package for people with severe mental illness is likely to be cost‐effective over 12 months compared with usual care provided by the UK's National Health Service and personal social services. [ABSTRACT FROM AUTHOR]

Objectives: The FiCTION trial compared co‐primary outcomes (dental pain and/or infection) and secondary outcomes (child oral health‐related quality of life [COHRQOL], child dental anxiety, cost‐effectiveness, caries development/progression and acceptability) across three treatment strategies (Conventional with Prevention [C + P]; Biological with Prevention [B + P]; Prevention Alone [PA]) for managing caries in children in primary care. COHRQOL and child dental anxiety experiences are reported upon here. Methods: A multi‐centre, 3‐arm, parallel‐group, unblinded patient‐randomized controlled trial of 3‐ to 7‐year‐olds treated under NHS contracts was conducted in 72 general dental practices in England, Wales and Scotland. Child participants (with at least one primary molar with dentinal caries) were randomized (1:1:1) to one of three treatment arms with the intention of being managed according to allocated arm for 3 years (minimum 23 months). Randomization was via a centrally administered system using random permuted blocks of variable length. At baseline and final visit, accompanying parents/caregivers completed a parental questionnaire including COHRQOL (16 item P‐CPQ‐16), and at every visit, child‐ and parental‐questionnaire‐based data were collected for child‐based dental trait and state anxiety. Statistical analyses were conducted on complete cases from the modified intention‐to‐treat (mITT) analysis set. Results: A total of 1144 children were randomized (C + P: 386; B + P: 381; PA: 377). The mITT analysis set included the 1058 children who attended at least one study visit (C + P: 352; B + P: 352; PA: 354). Median follow‐up was 33.8 months (IQR: 23.8, 36.7). The P‐CPQ‐16 overall score could be calculated after simple imputation at both baseline and final visit for 560 children (C + P: 189; B + P: 189; PA: 182). There was no evidence of a difference in the estimated adjusted mean P‐CPQ‐16 at the final visit which was, on average, 0.3 points higher (97.5% CI: −1.1 to 1.6) in B + P than C + P and 0.2 points higher, on average, (97.5% CI: −1.2 to 1.5) in PA than for C + P. Child dental trait anxiety and child dental state anxiety, measured at every treatment visit, showed no evidence of any statistically or clinically significant difference between arms in adjusted mean scores averaged over all follow‐up visits. Conclusions: The differences noted in COHRQOL and child‐based dental trait and dental state anxiety measures across three treatment strategies for managing dental caries in primary teeth were small, and not considered to be clinically meaningful. The findings highlight the importance of including all three strategies in a clinician's armamentarium, to manage childhood caries throughout the young child's life and achieve positive experiences of dental care. [ABSTRACT FROM AUTHOR]

Objectives: Transvenous lead extraction (TLE) poses a significant economic and resource burden on healthcare systems; however, limited data exist on its true cost. We therefore estimate real-world healthcare reimbursement costs of TLE to the UK healthcare system at a single extraction centre.Methods: Consecutive admissions entailing TLE at a high-volume UK centre between April 2013 and March 2018 were prospectively recorded in a computer registry. In the hospital's National Health Service (NHS) clinical coding/reimbursement database, 447 cases were identified. Mean reimbursement cost (n=445) and length of stay (n=447) were calculated. Ordinary least squares regressions estimated the relationship between cost (bed days) and clinical factors.Results: Mean reimbursement cost per admission was £17 399.09±£13 966.49. Total reimbursement for all TLE admissions was £7 777 393.51. Mean length of stay was 16.3±15.16 days with a total of 7199 bed days. Implantable cardioverter-defibrillator and cardiac resynchronisation therapy defibrillator devices incurred higher reimbursement costs (70.5% and 68.7% higher, respectively, both p<0.001). Heart failure and prior valve surgery also incurred significantly higher reimbursement costs. Prior valve surgery and heart failure were associated with 8.3 (p=0.017) and 5.5 (p=0.021) additional days in hospital, respectively.Conclusions: Financial costs to the NHS from TLE are substantial. Consideration should therefore be given to cost/resource-sparing potential of leadless/extravascular cardiac devices that negate the need for TLE particularly in patients with prior valve surgery and/or heart failure. Additionally, use of antibiotic envelopes and other interventions that reduce infection risk in patients receiving transvenous leads should be considered. [ABSTRACT FROM AUTHOR]