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Purpose: This paper aims to outline the initial pilot use of the client complexity matrix (CCM), an outcome measure developed for an NHS Adult Intellectual Disabilities Intensive Support Team (IST) in the West Midlands of England. Design/methodology/approach: A mixed method approach was used to report the results and evaluate the use of the CCM within this IST. The CCM was trialled for six months between January 2022 and June 2022. CCM scores pre and post IST intervention were analysed via t-test, and qualitative feedback from clinicians is detailed. Findings: Analysis suggests the CCM captures service success showing a significant decrease in complexity and risk post-intervention. Qualitative comments from clinicians were generally positive; however, there were requested changes regarding specific presentations, use of labels/language and for a digital version. Research limitations/implications: The tool is not co-constructed with the client. Because of this IST's caseload, the sample size was small. Only one clinician was asked to complete the CCM pre and post intervention. Future use of the measure will encourage two clinicians to complete the measure to evidence its inter-rater reliability. Each client's specific presentation was not explicitly analysed here. Practical implications: The CCM will be updated using the feedback from clinicians and from the peer review process. Research that examines the generalisability of this measure to other IST services would be beneficial. Originality/value: The CCM appears to fill a gap in outcome measurements for this IST service which looks at breadth and depth of client complexity and risk. [ABSTRACT FROM AUTHOR]

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

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

Purpose: This study aims to critically examine the effects of COVID-19 social discourses and policy decisions specifically on older adult volunteers in the UK, comparing the responses and their effects in England, Scotland, Wales and Northern Ireland, providing perspectives on effects of policy changes designed to reduce risk of infection as a result of COVID-19, specifically on volunteer involvement of and for older adults, and understand, from the perspectives of volunteer managers, how COVID-19 restrictions had impacted older people's volunteering and situating this within statutory public health policies. Design/methodology/approach: The study uses a critical discourse approach to explore, compare and contrast accounts of volunteering of and for older people in policy, and then compare the discourses within policy documents with the discourses in personal accounts of volunteering in health and social care settings in the four nations of the UK. This paper is co-produced in collaboration with co-authors who have direct experience with volunteer involvement responses and their impact on older people. Findings: The prevailing overall policy approach during the pandemic was that risk of morbidity and mortality to older people was too high to permit them to participate in volunteering activities. Disenfranchising of older people, as exemplified in volunteer involvement, was remarkably uniform across the four nations of the UK. However, the authors find that despite, rather than because of policy changes, older volunteers, as part of, or with the help of, volunteer involving organisations, are taking time to think and to reconsider their involvement and are renewing their volunteer involvement with associated health benefits. Research limitations/implications: Working with participants as co-authors helps to ensure the credibility of results in that there was agreement in the themes identified and the conclusions. A limitation of this study lies in the sampling method, as a convenience sample was used and there is only representation from one organisation in each of the four nations. Originality/value: The paper combines existing knowledge about volunteer involvement of and for older adults. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: Nurses work in mental health services around the world, constituting the largest professional group.Nurses have been identified as being potentially able to carry out a much wider range of functions than are typically allowed in practice, when provided with suitable training.There are long‐term concerns regarding shortages of mental health nurses in England and many other countries.Workforce data is rarely subject to analysis in peer‐reviewed journals. What the paper adds to existing knowledge?: This paper provides a case study of the workforce patterns of a national mental health nurse (MHN) workforce overtime allowing comparison with other countries and specialities.MHN numbers reduced from 2011 to 2017, then increased to near the 2011 level by 2021, not meeting ambitious national plans for increasing numbers.The mental health nursing proportion of the total NHS nursing workforce decreased through this period.Advanced practice roles and skills are widely, but unevenly, distributed and are provided by a small proportion of nurses.The proportion of nurses working in community settings has increased to constitute more than half of all nurses for the first time.The ratio of support workers to nurses increased in inpatient settings and will continue to change. What are the implications for practice?: Historical challenges in recruiting MHNs suggest that future plans to expand the profession are overly optimistic.To support the development of advanced practice roles and new skill sets, clearer research evidence of impact is required and clearer national guidance regarding best practice models.Good workforce data are essential to inform good workforce planning. Introduction: Data regarding changes in characteristics of the MHN workforce is commonly cited in governmental publications, but is rarely analysed in peer‐reviewed journals, despite ongoing concerns regarding high vacancy rates within mental health services. Aim: The aim of the study was to characterize changes in the MHN workforce, implementation of new nursing roles/skills and alignment with national policy. Method: Analysis of nationally published workforce data, peer‐reviewed publications and governmental policy/planning documents. Results: Nurse numbers declined from 2011 to 2017, subsequently returning to near 2011 levels, but remaining below national targets. Nurses in community settings increased to constitute more than half of all nurses, whilst inpatient numbers declined, although more slowly than bed numbers. The ratio between nurses and support workers changed due to more support workers in inpatient settings. New advanced skills and roles for nurses have increased, but are unevenly distributed, constituting a small proportion of the total workforce. Implications for Practice: This paper provides a case study against which comparisons may be made with the nursing workforce in other countries and specialities. Even clear policy commitment to nursing growth may not deliver planned changes in numbers and introducing new roles may have uneven impact, especially in the absence of a robust evidence base. [ABSTRACT FROM AUTHOR]

Background: Early language delay is exacerbated by social disadvantage. Factors such as parents' low levels of literacy, confidence and self‐perception can affect the capacity to act on advice received, critical to empowerment. Methods used to achieve successful health outcomes in socially disadvantaged clinical populations may need enhancing. Aims: To compare the impact of standard parent‐based intervention (PBI) to enhanced PBI for young children with speech, language and communication needs (SCLN) and their families living in more socially disadvantaged populations. Methods and Procedures: A multicentre clustered blind randomised controlled trial was used to compare the effect of parent‐based group interventions to improve early language development with children (mean age 27.5 months) from more socially disadvantaged populations with an expressive vocabulary of 40 or less single words. Intervention sessions were delivered by a speech and language therapist, over a 20‐week period. Participants received one of two interventions: (1) Standard Care – indirect group PBI – (PBI) (2) Enhanced Care: indirect group enhanced PBI – (EPBI). Both standardised and non‐standardised measures were used as outcomes. Parent engagement in the intervention was captured through analysis of attendance and the Parent Activation Measure – Speech & Language Therapy (PAM‐SLT) (Insignia Health, 2014). The PAM measures a person's knowledge, skills and confidence to manage their own health and well‐being (NHS England, 2018). In this study, activation referred to parents' knowledge, skills and confidence to manage their child's language development. Outcomes and Results: One hundred fifty‐five participants were randomised at baseline. Children in both groups made significant improvements in the outcome on MacArthur‐Bates Communicative Development Inventories Sentence Length, from pre‐intervention to post‐intervention and 6 months post‐intervention (p < 0.05). Changes in vocabulary and expressive language skills were more equivocal, showing wide variation in confidence intervals for both groups. Where parents attended at least one intervention session almost all effect sizes were in favour of the EPBI intervention. Parents' activation levels significantly increased for both groups (EPBI p < 0.001, PBI p = 0.003), with a moderate effect size in favour of EPBI (Hedges' G 0.37, confidence interval –0.02 to 0.76), although wide variation was found. Conclusions and Implications: This trial provides some evidence of facilitating the language development of children with SLCN from more socially disadvantaged areas through supporting caregivers. However, we found variation in outcomes; some children made excellent progress, whilst others did not. Further exploration of parent engagement and its relationship to child language outcomes will be valuable to understanding more about mechanisms of change in interventions that involve parents. WHAT THIS PAPER ADDS: What is already known on the subject: Speech, language and communication needs (SLCN) have a knock‐on effect on emotional well‐being, school readiness, literacy and school attainment, putting children at increased risk of long‐term consequences such as poor literacy, mental health problems and unemployment. In disadvantaged areas, the prevalence of language difficulties is higher than elsewhere. Factors such as parents' low levels of literacy, confidence and self‐perception can affect the capacity to act on advice received, critical to empowerment. What this paper adds to existing knowledge: Children with SLCN from more socially disadvantaged areas can make improvements in their language development through parent intervention, although wide individual variation was found. There was some evidence that children achieve better outcomes with EPBI, which employed an interagency collaborative approach. Parent's engagement (activation levels) increased significantly over time with intervention, with the increase twice as big for EPBI. What are the potential or actual clinical implications of this work?: This trial provides some evidence that it is possible to facilitate the language development of children from more socially disadvantaged areas through supporting their caregivers. Further research would be useful to determine whether increases in parent engagement are related to adherence to intervention and change in child outcomes. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To understand the complexity of the needs of people with delirium superimposed on dementia • To enhance your knowledge of second-generation activity theory • To recognise the consequences of the separation of physical health and mental healthcare. Background: Delirium superimposed on dementia (DSD) affects the physical, mental and cognitive well-being of the person. The separation of physical health and mental health means that the care of people with DSD is at odds with the multifaceted aetiology and presentation of the condition. There is a lack of research on DSD from a mental health perspective. Aim: To explore UK mental health nurses’ experiences of providing care for people with DSD. Method: Individual semi-structured interviews were conducted with seven mental health nurses from one NHS trust in England. Participants’ experiences were considered through the lens of second-generation activity theory. Data were analysed using framework analysis. Findings: Six themes were identified: awareness of guidance and tools; guidance or tools as ‘paper exercises’; knowing the patient; the multidisciplinary team; care burden; and mental health versus physical health. Conclusion: When providing care for people with DSD, mental health nurses use their skills in knowing patients as individuals. However, this aspect of ‘knowing’ cannot be readily translated into the use of a numerical scoring tool. An integrated approach is required to support the care of people with DSD. [ABSTRACT FROM AUTHOR]

Purpose: Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances? Design/methodology/approach: Development of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013). Findings: The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system. Research limitations/implications: Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context. Originality/value: This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems. [ABSTRACT FROM AUTHOR]

Purpose: It is over 20 years since the publication of the Wanless Report, "Securing our Future Health: Taking a Long-Term View". The Wanless Report argued that the National Health Service (NHS) would survive in its current form only if the population became "fully engaged" with it. Design/methodology/approach: In this discussion paper, the authors explored what "fully engaged" meant to Wanless, what it might mean now (allowing for the impact of the anti-vaxxer movement) and what policymakers could do to enhance public engagement. Findings: Although the Wanless Report neatly fitted into other long-term thinking about the NHS, it was unique in that it built economic models to predict the costs and impact of different patterns of NHS performance. Wanless predicted that people's poor levels of health would put considerable pressure on the NHS. This pressure could swamp efforts to meet healthcare targets and improve health outcomes, despite its sizeable investment of money. Wanless set out three possible scenarios for public engagement with the NHS: solid progress, slow uptake and fully engaged. Practical implications: The authors pose questions for policymakers and practitioners. Would a reboot of the Wanless approach be worth the effort for policymakers? If yes, how would it differ from the original? The NHS faces the whole of society; could it be the vehicle for engaging the anti-vaxxer public with the truthfulness of medical science, and will it be this, that is, Wanless' enduring legacy? Originality/value: The exploration of the Wanless Report is complicated (at least for the time being) by the rise of the anti-vaxxer movement's resistance to health promotion and mistrust of part of the NHS. [ABSTRACT FROM AUTHOR]

People with intellectual disabilities face health disparities, including in high‐income countries such as the United Kingdom, despite publicly funded healthcare. This paper describes the healthcare system in England (a nation of the United Kingdom) for the general population, and more specifically for people with intellectual disabilities. Key legislation that impacts the lives of people with intellectual disabilities, such as the UK Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15/contents), the Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9/contents), and the UN Convention on the Rights of Persons with Disabilities, and its implementation in the United Kingdom, is discussed. The role of deinstitutionalization and the shift to living in the community for people with intellectual disabilities is also discussed. Programmes that have been implemented to address the health disparities experienced by people with intellectual disabilities are reviewed. Finally, the recent changes to healthcare organization in the UK, the COVID‐19 pandemic, and the implementation of the Valuing People white paper are discussed. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic impacted on the provision of care and routine activity of all National Health Service (NHS) services. While General Practitioner referrals to memory services in England have returned to pre‐pandemic levels, the estimated dementia diagnosis rate (DDR) fell by 5.4% between March 2020 and February 2023. Methods: In this paper we explore whether this reduction is accurate or is an artefact of the way the NHS collects data. Results: We explore the processes that may have affected national dementia diagnosis rates during and following the COVID‐19 pandemic. Conclusions: We discuss what action could be taken to improve the DDR in the future. Key points: Despite General Practitioner (GP) referrals to memory services in England returning to levels seen before the pandemic, there was a decline of 5.4% in the estimated dementia diagnosis rate (DDR) from March 2020 to February 2023.This paper explores the factors which may have affected the national DDR reduction. These include a backlog in dementia referrals, a reduction in coding of diagnoses, or a decrease in true dementia prevalence secondary to excess COVID‐19 deaths which has yet to be reflected in the DDR denominator.Further work is suggested to accurately capture dementia prevalence in the United Kingdom (UK). These include an up‐to‐date multicentre population‐based cohort study and adjusting the DDR denominator for factors known to affect dementia susceptibility such as deprivation, rurality, and ethnicity. [ABSTRACT FROM AUTHOR]

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

Purpose: The purpose of this paper is to report on the use and content of written guidance produced by mental health services in England and Wales describing hospital leave for informally admitted patients. Design/methodology/approach: Guidance on leave was requested from National Health Service (NHS) mental health trusts in England and health boards in Wales (n = 61) using a Freedom of Information submission. Data were analysed using content analysis. Findings: In total, 32 organisations had a leave policy for informal patients. Policies varied considerably in content and quality. The content of policies was not supported by research evidence. Organisations appeared to have developed their policies by either adapting or copying the guidance on section 17 leave outlined in the Mental Health Act Codes of Practice for England and Wales (Department of Health, 2016; Welsh Government, 2016). Definitions of important terms, for example, leave and hospital premises, were either absent or poorly defined. Finally, some organisations appeared to be operating pseudo-legal coercive contracts to prevent informal patients from leaving hospital wards. Research limitations/implications: Research should be undertaken to explore the impact of local policies on the informal patient's right to life and liberty. Practical implications: All NHS organisations need to develop an evidence-based policy to facilitate the informal patient's right to take leave. A set of national standards that organisations are required to comply with would help to standardise the content of leave policies. Originality/value: To the best of the author's knowledge, this is the first study to examine the use and content of local policies describing how informal patients can take leave from hospital. [ABSTRACT FROM AUTHOR]

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

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

In April 2013 the local public health function in England was returned from the National Health Service (NHS) to local government, reversing the transfer to the NHS made in 1974 with the abolition of the medical officer of health. Although many in the field had long felt that local government was the appropriate home for public health given its wide-ranging responsibilities for the social determinants of health, the timing was poor. Local government was in the third year of what continued to be an unprecedented ten-year period of austerity imposed by central government with cumulative cuts of the order of 40% for many local authorities. And despite an initial commitment to a ring-fenced public health grant, this grant has been cut each year since 2015–2016 in addition to the wider local authority funding cuts which have had inevitable knock-on effects on the public health function. Crucial public health services such as early years, smoking cessation and sexual health services have all been cut. Despite these cuts the UK government continues to claim a commitment to improving public health and tackling inequalities in health. This study examines the government's discourse on funding local public health services, and the ways in which it has responded to critics through a detailed documentary analysis of key government white papers, ministerial statements and its responses to criticisms, particularly from parliamentary select committees and professional bodies. The paper concludes by considering the implications for effective local public health action in a national regime of austerity. [ABSTRACT FROM AUTHOR]

Purpose: Policies on integrated care have waxed and waned over time in the English health and care sectors, culminating in the creation of 42 integrated care systems (ICSs) which were confirmed in law in July 2022. One of the four fundamental purposes of ICSs is to tackle health inequalities. This paper reports on the content of the overarching ICS plans in order to explore how they focus on health inequalities and the strategies they intend to employ to make progress. It explores how the integrated approach of ICSs may help to facilitate progress on equity. Design/methodology/approach: The analysis is based on a sample of 23 ICS strategic plans using a framework to extract relevant information on health inequalities. Findings: The place-based nature of ICSs and the focus on working across traditional health and care boundaries with non-health partners gives the potential for them to tackle not only the inequalities in access to healthcare services, but also to address health behaviours and the wider social determinants of health inequalities. The plans reveal a commitment to addressing all three of these issues, although there is variation in their approach to tackling the wider social determinants of health and inequalities. Originality/value: This study adds to our knowledge of the strategic importance assigned by the new ICSs to tackling health inequalities and illustrates the ways in which features of integrated care can facilitate progress in an area of prime importance to society. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to explore the influence of a talent management scheme in an English National Health Service (NHS) Trust on registered nurses' retention intentions. Background: The retention of nurses is a global challenge, and talent management initiatives can play a role in improving retention. Talent management in its broadest sense is a way in which an organization recruits and retains the workforce that it needs to optimize the services it delivers. Methods: In this qualitative study, eight in‐depth semi‐structured interviews were conducted with registered nurses who had participated in a talent management initiative, at an English acute NHS Trust. Data were collected in July 2019. Results: The talent management initiative influenced positive retention intentions. Retention of nurses was facilitated by the creation of networks and networking. Conclusion: Networks and networking can be viewed as a form of social capital, which was a facilitating factor for positive retention intentions for nurses. Implications for Nursing Management: Talent management initiatives for nurses should be developed and directed to include the building of networks and networking to enable development of social capital. Although this talent management scheme is within the NHS, the issue of nursing retention is global. Application of learning from this paper to other health care systems is possible. [ABSTRACT FROM AUTHOR]

This paper explores public sentiment towards strike action among healthcare workers, as a result of their perceived inadequate pay. By analysing survey data collected in England between 2022 and 2023, the study focuses on NHS nurses and junior doctors, due to their critical role in delivering essential public services. Results indicate higher public support for strikes by nurses and junior doctors compared to other professions such as postal workers, teachers, rail workers, airport workers, civil servants and university lecturers. However, variation in support for strikes by healthcare workers is observed across societal segments. Significant disparities in support are linked to individual political affiliations, left–right ideological positions and trust in the NHS. In short, nonconservative voters, individuals leaning towards left‐wing politics and those with greater trust in the NHS demonstrate higher likelihoods of supporting strikes by health workers. These findings carry implications for future strike decisions and highlight specific target groups for enhanced communication efforts to garner increased public support. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: 'Leave' is a common occurrence for patients detained in mental health settings. The term covers multiple scenarios, for example short periods to get off the ward through to extended periods at home prior to discharge.Despite the frequency and importance of leave, there is very little research about how it is implemented and whether, and in what circumstances, it is effective.While there is legislation about leave in the Mental Health Act (1983) mental health services are free to implement their own policies or not to implement one at all. What the paper adds to existing knowledge?: The leave policies of NHS mental health services in England and Wales are highly inconsistent.The extent to which policies are consistent with guidance differs depending on which service is providing care. What are the implications for practice?: It is very likely that, because of inconsistencies between services and policies, practice also differs.Clinicians need to understand their responsibilities in the leave process to ensure that patients are supported in their recovery journey.Policymakers need to revisit leave policies in light of evidence from this study. Introduction: Considerable guidance is available about the implementation of leave for detained patients, but individual mental health services are free to determine their own policies. Aim: To determine how consistent leave policies of NHS mental health services in England and Wales are with relevant guidance and legislation. Method: A national audit of NHS mental health services leave policies. Data were obtained through web searching and Freedom of Information requests. Policies were assessed against 65 criteria across four domains (administrative, Responsible Clinician, types of leave and nursing). Definitions of leave‐related terms were extracted and analysed. Results: Fifty‐seven (91.9%) policies were obtained. There were considerable inconsistencies in how policies were informed by relevant guidance: Domain‐level consistency was 72.3% (administrative), 64.0% (Responsible Clinician), 44.7% (types of leave) and 41.9% (nursing). Definitions varied widely and commonly differed from those in relevant guidance. Discussion: Mental health professionals are inconsistently supported by the policy in their leave‐related practice. This could potentially contribute to inconsistent practice and leave‐related patient outcomes. Implications for Practice: To ensure patients are treated fairly clinicians need to be aware of their responsibilities around leave. In some services, they will need to go beyond their organization's stated policy to ensure this occurs. [ABSTRACT FROM AUTHOR]

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

Despite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework. [ABSTRACT FROM AUTHOR]

Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded. [ABSTRACT FROM AUTHOR]

England's National Health Service (NHS) is in the process of major reform as old institutional structures based around an internal "market" are being replaced with integrated care systems. The changes represent a significant shift in ethos away from commercialisation to collaboration between health providers. But the way that these policies unfold will depend on the context within which they are implemented, and three decades of neoliberal reforms have left their mark on the structure of the health system. This paper shows how a powerful, politically-connected financialised private sector has evolved alongside a weakened public system, depleted further by the pandemic. While the share of overall public health spending reaching the private sector has not increased greatly over the past decade, private financial investors are strongly embedded in some segments of health delivery, particularly mental health services where shareholder returns are boosted by financial engineering. The boundaries between private and public are increasingly blurred with the NHS treating private patients and self-payment for health services is increasingly normalised. Rather than traditional privatisation, the health system is facing a more subtle and pernicious erosion of public services across different dimensions which seems likely to continue despite the new reforms. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To recognise some of the factors that can make it challenging for nurses to access training and maintain competence in using medical devices • To learn about development of an electronic medical device training passport that aims to better identify nurses' training needs • To understand the benefits of an electronic medical device training passport for nurses, nurse managers and clinical leaders Background: All nurses, particularly those working in critical care settings, are required to use medical devices when providing patient care. However, inconsistent practice and variations in documentation can make it challenging for nurses and nurse managers to identify what medical device training is required and when. Aim: To develop and evaluate the use of an electronic medical device training passport to identify the training needs of nurses in intensive care units (ICUs). Method: A pilot study was conducted in a multi-unit critical care department in London, England, to determine if the passport could make it easier to identify ICU nurses' medical device training needs compared with existing practice. Nine participants were first asked to identify their needs using existing spreadsheets or paper records, then asked to identify them using the passport. The participants were also interviewed to identify their training requirements before and after using the passport. The data were analysed quantitatively and qualitatively. Findings: The electronic passport significantly improved identification of medical device training needs compared with paperwork or spreadsheets for all device groups, except for medical devices used on high dependency units (P≤0.005). However, there may be issues related to nurses' behaviours and expectations, particularly that staff do not always recognise their need for training. Conclusion: The findings of this pilot study suggest that the use of an electronic medical device training passport has many benefits and could make it easier to identify ICU nurses' training needs in clinical practice. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known about the subject?: The practices of mental health nurses in the administration of repetitive transcranial magnetic stimulation (rTMS) treatments for depression in outpatient clinic are crucial for patient outcomesTo date, most research has focused directly on procedural aspects of treatment delivery with limited focus on the delivery of holistic care and treatment.There is a lack of best practice guidance based on the experiences of those involved in clinical delivery to inform and improve rTMS practices What this paper adds to existing knowledge?: This study provides unique insights into service and personalized non‐treatment factors associated with rTMS delivery that may reduce stress and improve the experiences of rTMS patientsIt reviews and updates understanding of the factors that contribute to the delivery of effective rTMS. What are the implications for practice?: The need to apply findings for the development of best practice guidanceFactors to improve practice include (a) rTMS machine demonstrations; (b) constructive, individualized, friendly, and therapeutic conversations; (c) a relaxing, comfortable, 'homely' physical environment; (d) long term supportive management; and (e) careful engagement of nursing and support staff. [ABSTRACT FROM AUTHOR]

Clinical academic career pathways for nurses, midwives and allied health professionals are a strategic priority for NHS England, and there has been significant investment in the National Institute of Health Research integrated clinical academic programme for non-medical healthcare professionals. Nurses, midwives and allied health professionals face numerous barriers to successfully building a clinical academic career. For those outside the integrated clinical academic programme, clinical academic career approaches are varied and often driven by individual practitioners rather than robust organisational processes or strategy. The vision of 'future midwife' is that midwives maximise opportunities in research and scholarship. However, there is little clarity about how these academic aspirations may be supported. This reflective lived experience discussion paper explores key issues around clinical academic midwifery careers, including how space for clinical academic midwives can be assured and the steps midwives can take to start to develop this rewarding and important career. [ABSTRACT FROM AUTHOR]

The aim of this paper was to explore the experiences of perceived prejudices faced in England by Black African mental health nurses. Purposive sampling was used to identify five nurses from sub‐Saharan Africa. They were interviewed using face‐to‐face semi‐structured interviews. Data were analysed using interpretative phenomenological analysis (IPA). The findings were reported under two superordinate themes: Judging a book by its cover and opportunities. The findings showed that Black African nurses experience deep‐rooted discrimination and marginalisation. Aside from that, because of their ethnicity and the fact that they speak English as a second language, they face discrimination and have difficulty achieving leadership roles. These findings provide key stakeholders, such as nursing trade unions and professional associations, as well as NHS employers, with the opportunity to act to counter hegemony in the NHS and recognise that discriminatory and racially related barriers hinder Black African nurses from reaching their full professional potential. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has impacted healthcare education and delivery, including both theory and practice learning. Academic staff responded rapidly to move teaching online during the first lockdown, with many returning to practice to deliver care or upskill practice staff to work in critical care. Many pre-registration students responded by becoming paid NHS employees, contributing to care delivery while remaining on their programme of study. Practice learning partners, despite the challenges of the pandemic, continued to support students to achieve their registration status. This occurred within the context of the Emergency and Recovery Standards, published by the Nursing and Midwifery Council between March 2020 and September 2021. This paper sets out the response of students, practice learning partners and higher education institutions involved in pre-registration nursing and midwifery programmes. [ABSTRACT FROM AUTHOR]

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency – specifically their commitment to patient care – in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs. • Managers can show strong faith in uncertain evidence for healthcare service change. • The moral background explains this in a way which considers power and moral agency. • Confidence in evidence depends on background assumption of future as predictable. • Confidence also depends on premise that finances are not open to moral evaluation. • Service change regulations carry out epistemic work on background assumptions. [ABSTRACT FROM AUTHOR]

The NHS England Radiotherapy Service Specification calls for routine use of patient-reported outcome measures (PROMs). However, barriers exist at patient, healthcare professional and service levels. The aim of the present study was to determine the current use of PROMs within radiotherapy services in England. The current attitudes, barriers and enablers to the implementation of PROMs in radiotherapy practice were evaluated and practical recommendations to inform future implementation were developed. A mixed-methods approach was adopted to obtain quantitative and qualitative data. An online questionnaire was developed and disseminated to all radiotherapy operational delivery network managers across England. The questionnaire consisted of 12 open and closed questions relating to PROMs use, with the option to provide free-text responses. Inductive thematic analysis was conducted on free-text comments, whereas descriptive statistics were used to analyse quantitative data. In total, 182 responses were received from 40 of the 50 radiotherapy providers, resulting in a response rate of 84%. The current use of PROMs was analysed, including rationale for use, tools used, format of PROMs collection and timing within the radiotherapy pathway. Most respondents indicated that PROMs were used in the context of clinical trials only. Through thematic analysis, four identical key themes were identified relating to both barriers and enablers to PROMs use; these included IT infrastructure, time, human/financial resources and training/education. A fifth theme, standardisation, was identified as a key enabler to PROMs use. Our findings show that outside of clinical trials, PROMs are not routinely used in radiotherapy services due to barriers identified at professional and service levels. Here we provide recommendations to mitigate the barriers identified and implement PROMs in radiotherapy, including training for healthcare professionals and standardisation of PROMs tools and storage. This study provides a key first step in driving PROMs implementation within radiotherapy services across England. • Outside of clinical trials, PROMs were not widely used within radiotherapy services. • Common PROMs used included QOL, anxiety/depression and urinary/bowel function tools. • PROMs are completed using either paper or electronic forms, by staff or patients. • Barriers include IT infrastructure, time, resources (staff/finances) and training. • Enablers included IT, time, resources, training and standardisation. [ABSTRACT FROM AUTHOR]

The research goals were to obtain an understanding of who the users of e‐books in the NHS are, what they are using e‐books for, and when and how they use them. This article presents the methodology used and the findings from the research. It also explores the outputs and next steps from the research, both for the individual countries and collectively. The Five Nations group, (library leads in England, Northern Ireland, Ireland, Scotland and Wales) commissioned research into healthcare staff use and non‐use of e‐books to understand the behaviours, needs and expectations of healthcare staff and to identify shared challenges around e‐books to inform policy and practice. [ABSTRACT FROM AUTHOR]

Objective: This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018. Method: All clinical negligence claims held by National Health Service Resolution relating to rhinology in England between 1 April 2013 and 1 April 2018 were reviewed. Results: There were 171 rhinology related claims with a total estimated potential cost of £13.6 million. There were 119 closed claims (70 per cent) with a total cost of £2.3 million, of which 55 claims resulted in payment of damages. Over three quarters of all rhinology claims were associated with surgery (n = 132). Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172 978). Unnecessary pain (33.9 per cent) and unnecessary operation (28.1 per cent) were the most commonly cited patient injuries. Conclusion: Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology. [ABSTRACT FROM AUTHOR]

BACKGROUND: Advance care treatment escalation plans (TEPs) are often lost between healthcare settings, leading to duplication of work and loss of patient autonomy. OBJECTIVE: This quality improvement project reviewed the usage of TEP forms and aimed to improve completeness of documentation and visibility between admissions. METHODS: Over four months we monitored TEP form documentation using a standardised data extraction form. This examined section completion, seniority of documenting clinician and transfer of forms to our hospital electronic patient record (EPRO). We added reminders to computer monitors on wards to improve EPRO upload. RESULTS: Initial data demonstrated that 95% of patients (n = 230) had a TEP, with 99% of TEPs recording resuscitation status. However, other sections were not well documented (patient capacity 57% completion and personal priorities 45% completion, respectively). Only 11.9% of TEPs documented consultant involvement. Furthermore, only 44% of TEPs with a do not attempt resuscitation (DNACPR) decision were uploaded. Following this, we added reminders to computer monitors explaining how to upload TEP decisions to EPRO, which increased EPRO uploads to 74%. CONCLUSION: Communication of TEPs needs improving across healthcare settings. This project showed that the use of a physical reminder can greatly improve communication of treatment escalation decisions. Furthermore, this intervention has inspired future projects aiming at making communication more sustainable through the use of discharge summaries. [ABSTRACT FROM AUTHOR]

Pressure ulcers (PUs) represent a burden to the health economy and patients alike. Despite national and international guidelines regarding the management of risk, the incidence and prevalence across England remains high. Detecting early the risk of PUs is paramount, and requires using a valid risk assessment tool alongside clinical judgement and management of associated risk factors. There is a need to implement prevention strategies. Introducing care bundles for pressure ulcers, for example SKIN, SSKIN and most recently aSSKINg, is designed to guide clinicians and reduce variations in care. This article presents a review of the evidence on compliance with guidelines, frameworks, pathways or care bundles within primary and secondary care settings. This article focuses on the literature review that was conducted to inform a subsequent clinical audit of compliance with the aSSKINg framework in a Community NHS Foundation Trust in the South East of England. [ABSTRACT FROM AUTHOR]

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

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

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

The British National Health Service (NHS) relies for the great bulk of its funding on direct taxation, but the contribution of charitable sources of income to the NHS is not well-understood. The few studies of charitable giving to the NHS to date have concentrated on aggregate levels of income and expenditure. However, to date there has been limited collective understanding about the extent to which different kinds of NHS Trusts benefit from charitable funding and about the persistence of inequalities between trusts in their access to these resources. This paper presents novel analyses of the distribution of NHS Trusts in terms of the proportion of their income that comes from charitable sources. We build a unique linked longitudinal dataset which follows through time the population of NHS Trusts, and the population of associated NHS charities, in England since 2000. The analysis illustrates intermediate levels of charitable support for acute hospital trusts compared with the much lower levels of charitable support for ambulance, community and mental health Trusts and, conversely, much higher levels of charitable support for Trusts providing specialist care. These results represent rare quantitative evidence relevant to theoretical discussions about the uneven nature of the voluntary sector's response to healthcare need. They provide important evidence for a key feature (and arguably weakness) of voluntary initiative, namely philanthropic particularism - the tendency for charitable support to focus on a restricted range of causes. We also show that this 'philanthropic particularism' – reflected in the very sizeable differences in charitable income between different sectors of NHS trusts - is becoming more marked over time, while spatial disparities, notably between elite institutions in London and other locations, are also substantial. The paper reflects on the implications of these inequalities for policy and planning within a public health care system. • Novel analyses of pattern of charitable resources supporting NHS Trusts in England. • Trust – level comparisons of the ratio of charitable income to total Trust income. • Lower levels of fundraising for ambulance, community and mental health Trusts. • Higher levels of charitable support for larger Trusts and Trusts in London. • Charitable income of specialist Trusts has grown; other Trusts have seen decline. [ABSTRACT FROM AUTHOR]

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots – so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation. • Innovation intermediaries mobilize evidence from pilot studies to spread innovation. • Pilot-based evidence can link early adoption to wider spread and sustainability. • Mobilizing involves co-creating multiple forms of evidence with different groups. • Intermediary roles allow transitioning of pilot-based evidence into wider adoption. • Pilotitis involves a failure to transition evidence along the innovation journey. [ABSTRACT FROM AUTHOR]

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

Experience feedback data is increasingly recognised as being helpful in improving healthcare services, and in meeting patient and family needs. This end-of-life care project, based on the principles of appreciative inquiry, sought to learn from the experiences of bereaved people whose relative had died in an acute hospital setting. Informal feedback, offered during a routine telephone call, was thematically analysed and interpreted in an appreciative manner. Confirmatory representations of caring practices and behaviours were identified, categorised and disseminated in a way that enabled staff to come to know and understand end-of-life care at its best, rather than as a set of problematised events. The findings served as a benchmark for individuals and teams to assess and progress their practice reflectively. The authors conclude that staff receptiveness to informal bereaved family feedback may be enhanced by focusing on the positive qualities of end-of-life care within existing practices. [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]

The National Health Service (NHS) cardiac rehabilitation patient care pathway has remained largely unchanged for many years despite, on average, half of all eligible patients declining to engage. To investigate reasons for non-engagement, we explored the experiences of ten cardiac patients who participated in cardiac rehabilitation, dropped out, or declined, as well as experiences of seven people deemed significant others by participants. Our ethnographic study involved participant observations, repeat in-depth semi-structured interviews, and reflexive journaling. Reflexive thematic analysis was conducted, focusing on participants' lived experiences. Utilising Bourdieusian concepts of habitus, capital, and field, this article highlights how personal biography, material conditions, and dispositional inclinations combine to make cardiac health care decision-making individual and complex. Despite this, health professionals were not always attuned to specific circumstances arising from differences in patients' experiences and lifeworlds. By considering service improvement recommendations that acknowledge socio-cultural influences, cardiac rehabilitation can work towards providing patients and their significant others with more appropriate, personalised, and person-centred support. [ABSTRACT FROM AUTHOR]

Objectives: There is limited literature on the experiences of internationally educated nurses (IENs) who have joined NHS trusts in England in the past 20 years. The objectives of this integrative review included exploring and analysing the experiences of IENs in the NHS in England and identifying the cultural, pastoral and training needs of IENs during their first 2 years working in England and providing research-informed recommendations to better support IENs. Design: An integrative review of primary research studies using quantitative, qualitative, and mixed methods of data collection. Data source: CINAHL, British Nursing Index and Google Scholar. Results: Nine articles met the inclusion criteria for this integrative review. All articles contributed to the findings of three main analytical themes: expectations, challenges and belongingness. Conclusion: Limited research fully met the search criteria. This was concerning since IENs have been working in the NHS for decades, yet so few primary studies have been conducted into their experiences. The findings were in line with previous studies, which found that IENs faced challenges both in the workplace and in settling into an English way of life, and often reported feeling that they were not treated equally to their English counterparts. This integrative review raises issues and increases awareness of how the NHS in England can better support IENs transitioning into their new life and ways of working, to further aid recruitment and retention of the international nursing workforce. [ABSTRACT FROM AUTHOR]

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