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Rationale, aims and objective: Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. Method: The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. Results: A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. Conclusions: Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design. [ABSTRACT FROM AUTHOR]

Horses in Great Britain are living into increasingly older age and are often regarded as friends or family members by their owner. The horse is reliant on their owner to meet their needs and this paper discusses how horse owners frame an issue that becomes a matter of veterinary concern within the context of the older horse. Qualitative methods were used to explore the experiences of owners and veterinarians. Data were collected and analysed using a grounded theory approach during the period 2019-2022. Analysis identified that owners undertook an ongoing and iterative process of assessment, monitoring and decision making in relation to the animal and any changes they observed. Matters that became a veterinary concern required the owner to formulate the issue as something that fell within the knowledge domain of the veterinarian. Veterinarians had a medicalised view of older horse health and their perspectives on socially acceptable care were shaped by their understanding of speciesspecific needs, and whether owners were providing appropriately for those needs. The formulation of a matter of veterinary concern was itself shaped by an owner's experiential knowledge of both veterinary matters and their horse. The extent to which owners felt like they and their individual horse mattered during interactions with veterinarians affected whether they adopted veterinary advice and the nature of future veterinary employment. Findings demonstrate how matters of health, disease, and the role of professionalised forms of medical knowledge, are not static but constantly changing and interacting over time. An issue that became a matter of veterinary concern was contextual, and rooted in individual relationships. The significance of veterinarian-owner interactions in shaping future consumption of veterinary health care may be underestimated. [ABSTRACT FROM AUTHOR]

Introduction: Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom. Methods: The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786). Results: Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances. Discussion: Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists. [ABSTRACT FROM AUTHOR]

Physical inactivity has been identified as a leading risk factor for premature mortality globally, and adolescents, in particular, have low physical activity levels. Schools have been identified as a setting to tackle physical inactivity. Economic evidence of school-based physical activity programmes is limited, and the costs of these programmes are not always collected in full. This paper describes a micro-costing and cost-consequence analysis of the ‘Girls Active’ secondary school-based programme as part of a cluster randomised controlled trial (RCT). Micro-costing and cost-consequence analyses were conducted using bespoke cost diaries and questionnaires to collect programme delivery information. Outcomes for the cost-consequence analysis included health-related quality of life measured by the Child Health Utility-9D (CHU-9D), primary care General Practitioner (GP) and school-based (school nurse and school counsellor) service use as part of a cluster RCT of the ‘Girls Active’ programme. Overall, 1,752 secondary pupils were recruited and a complete case sample of 997 participants (Intervention n = 570, Control n = 427) was used for the cost-consequence analysis. The micro-costing analysis demonstrated that, depending upon how the programme was delivered, ‘Girls Active’ costs ranged from £1,054 (£2 per pupil, per school year) to £3,489 (£7 per pupil, per school year). The least costly option was to absorb ‘Girls Active’ strictly within curriculum hours. The analysis demonstrated no effect for the programme for the three main outcomes of interest (health-related quality of life, physical activity and service use).Micro-costing analyses demonstrated the costs of delivering the ‘Girls Active’ programme, addressing a gap in the United Kingdom (UK) literature regarding economic evidence from school-based physical activity programmes. This paper provides recommendations for those gathering cost and service use data in school settings to supplement validated and objective measures, furthering economic research in this field. Trial registration: -ISRCTN, . [ABSTRACT FROM AUTHOR]

Introduction: Non-medical prescribing was introduced into the United Kingdom (UK) to improve patient care, through extending healthcare professionals’ roles. More recent government health service policy focuses on the increased demand and the need for efficiency. This systematic policy review aimed to describe any changes in government policy position and the role that non-medical prescribing plays in healthcare provision. Method: The systematic policy review included policy and consultation documents that describe independent non-medical prescribing. A pre-defined protocol was registered with PROSPERO (CRD42015019786). Professional body websites, other relevant websites and the following databases were searched to identify relevant documents: HMIC, Lexis Nexis, UK Government Web Archive, UKOP, UK Parliamentary Papers and Web of Science. Documents published between 2006 and February 2018 were included. Results and discussion: Following exclusions, 45 documents were selected for review; 23 relating to policy or strategy and 22 to consultations. Of the former, 13/23 were published 2006–2010 and the remainder since 2013. Two main themes were identified: chronological aspects and healthcare provision. In the former, a publication gap for policy documents resulted from a change in government and associated major healthcare service reorganisation. In the later, the role of non-medical prescribing was found to have evolved to support efficient service delivery, and cost reduction. For many professions, prescribing appears embedded into practice; however, the pharmacy profession continues to produce policy documents, suggesting that prescribing is not yet perceived as normal practice. Conclusion: Prescribing appears to be more easily adopted into practice where it can form part of the overall care of the patient. Where new roles are required to be established, then prescribing takes longer to be universally adopted. While this review concerns policy and practice in the UK, the aspect of role adoption has wider potential implications. [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods: We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results: We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion: Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI. [ABSTRACT FROM AUTHOR]

Background: The accessibility of services within community pharmacies provides an ideal opportunity to manage minor ailments, yet over £1.1 billion is spent by the National Health Service (NHS) in the United Kingdom (UK) in managing minor ailments in high cost settings. There is a need to review the evidence base around clinical effectiveness of pharmacy-based management of minor ailments since the absence of such may lead to under-utilisation of pharmacy services and non-implementation of available pharmacy service models. This study aimed to systematically review the methodological approaches used to assess clinical outcomes of pharmacy-based management of minor ailments in the research literature. Methods: A systematic review was conducted to identify relevant literature using the following databases: Medline, EMBASE, CINAHL, IPA, CRD, CDSR, and Google Scholar from publication year 2000 onwards. Studies were included if they evaluated clinical outcomes of pharmacy-based management of any minor ailments, with or without a comparator setting such as Emergency Departments (EDs) or general practices. Screening and selection of titles, abstracts and full texts followed by data extraction and quality assessment (QA) was conducted. Paired researchers, from the team, reviewed papers using a protocol based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). QA was undertaken using the Critical Appraisal Skills Programme (CASP). Reporting was conducted in accordance with PRISMA checklist and statements. Results: A total of 19 studies were included. The majority of studies were observational, conducted in community pharmacies, and did not use a comparator participant group nor a comparator setting. Interventions included counselling, medicines supply and provision of advice on the management of minor ailments. One study used the randomised controlled trial (RCT) design with majority of the study utilising observational design. A range of clinical outcomes including symptom severity, pattern, resolution, and quality of life were reported. Methods used for the assessment of clinical outcomes were, overall, poorly reported. This included a lack of information on the development and validation of the data collection tools and the timing of baseline and follow-up data collection. Adverse clinical outcomes data were collected by only seven studies. Conclusions: Currently, there are methodological limitations in the studies that have sought to assess clinical outcomes of pharmacy-based management of minor ailments. Such lack of high quality evidence may contribute to failings to shift care from high cost settings, such as EDs and general practices. Generation of high quality evidence is likely to influence public choices when seeking care for minor ailments. There is scope for development of a core outcomes set specific to minor ailments management and development of a validated methodology for measuring such outcomes in a research study. [ABSTRACT FROM AUTHOR]

Personhood discourses in dementia care have gained prominence and current care home standards mandate that care should be “person-centred”. However, it is unclear how the personhood of staff is construed within the care relationship. This paper aims to explore how the personhood of paid carers of people with dementia can be understood by focussing on the views and experiences of care home staff. We undertook a secondary qualitative analysis of interviews with 25 paid care staff in England, conducted as part of the MARQUE (Managing Agitation and Raising QUality of lifE) study. The authors inductively developed themes around the topic of personhood for staff, contrasting management and care staff perspectives. We found that many care staff are not identified as persons in their own right by their employing institutions, and that there is a general lack of acknowledgment of the moral work of caring that occurs within formal care work. This oversight can reduce the complex relationships of care work to a series of care tasks, challenges care workers’ self-worth and self-efficacy, and impede their efforts to deliver person-centred care. We conclude that care staff status as persons in their own right should be explicitly considered in quality standards and supported by employers’ policies and practices, not simply for their role in preserving the personhood of people with dementia but for their own sense of valued personhood. Enhancing staff personhood may also result in improved care. [ABSTRACT FROM AUTHOR]

Purpose – This paper aims to explore the introduction of teamwork in two health call centres, NHS Direct and NHS24, and intervenes in the emergent debate over teamwork in call centres. Although within the call centre work environment there is no obvious functional rationale for teamwork, teams can be "accounted for" with reference to other purposes, including performance management, normative control, governmentality and institutional isomorphism/management fads. This research provides additional explanations for the use of teamwork in such an adverse work environment. Design/methodology/approach – The paper is based on qualitative data (interviews and non-participant observations) from NHS Direct and NHS24, the English and Scottish tele-nursing organisations in the UK. Findings – In the two tele-nursing case studies analysed, teamwork was introduced as an expression of managers' aspirations to emulate private sector practices and to reinforce new public management ideals. However, informal teamwork, which cut across organisationally prescribed forms, provided both emotional support and spontaneous knowledge sharing among nurses. Originality/value – This is an innovative study because teamwork has not been thoroughly explored in a health call centre environment. [ABSTRACT FROM AUTHOR]

Within the context of the U.K. background (public expenditure is being severely curtailed, at a local level health services and social services arc controlled by separate organisations and there are many groups of the population for whom a number of acceptable treatments, or methods of caring, exist), the paper describes the development of a resource allocation model and its use in a local planning situation. Although based on the techniques of mathematical programming, the model does not purport to indicate a single optimum allocation of health and social services resources, but rather to calculate the resource consequences of possible alternative courses of action. As such, its use is seen as iterative, in that health and social services decision makers can review and update their assumptions in the light of the results from successive runs of model. [ABSTRACT FROM AUTHOR]

Background: Wound-edge protection devices (WEPDs) have been used in surgery for more than 40 years to reduce surgical site infection (SSI). No economic evaluation of WEPDs against any comparator has ever been conducted. The aim of the paper was to assess whether WEPDs are cost-effective in reducing SSI compared to standard care alone in the United Kingdom. Methods and Findings: An economic evaluation was conducted alongside the ROSSINI trial. The study perspective was that of the UK National Health Service and the time horizon was 30 days post-operatively. The study was conducted in 21 UK hospitals. 760 patients undergoing laparotomy were randomised to either WEPD or standard care and 735 were included in the primary analysis. The main economic outcome was cost-effectiveness based on incremental cost (£) per quality adjusted life year (QALY) gained. Patients in the WEPD arm accessed health care worth £5,420 on average and gained 0.02131 QALYs, compared to £5,130 and 0.02133 QALYs gained in the standard care arm. The WEPD strategy was more costly and equally effective compared to standard care, but there was significant uncertainty around incremental costs and QALYs. The findings were robust to a range of sensitivity analyses. Conclusions: There is no evidence to suggest that WEPDs can be considered a cost effective device to reduce SSI. Their continued use is a waste of limited health care resources. [ABSTRACT FROM AUTHOR]

Health services are rarely highly successful in meeting the needs of people with headache disorders, who everywhere are low in the priority queue. Taking the UK as an example within Europe, this paper briefly reviews the present organisation of headache services, and proposes change. The solution does not appear to lie in expanding specialist headache centres in secondary care to which most people with needs fail to gain access. A three-tier system with emphasis on primary care will, it is argued, deliver care more cost-effectively and more responsively to patients' needs. [ABSTRACT FROM AUTHOR]

The organization of the corporate marketing function has attracted increasing attention from marketers in the 1990s. This reflects both the significant conceptual developments in marketing theory and a questioning of the role of the centralized marketing department to organizations operating in post-industrial service economies. Drawing on data from a broader research project into marketing activity in the acute health care sector in the United Kingdom, the paper examines the organizational solutions adopted by self-governing hospitals in managing the marketing function. The core theme to emerge from the research is the imperative for such professional service organizations to facilitate the development of flexible, project focused marketing teams, effectively mirroring the notion of the buying centre, capable of integrating core technical professionals directly into the marketing process. Coupled to this is the notion of marketing professionals having to abdicate ownership, and even dominance, of the corporate marketing process. [ABSTRACT FROM AUTHOR]

In this paper long-run changes in infant mortality for 55 regions of Great Britain are examined. A diverse pattern of change, substantially different from the familiar aggregate trend of stability before 1900, followed by general decline, was revealed. In some regions, those with the lowest infant mortality rates, there was improvement from the 1860s, while elsewhere rates increased. Hence several measures of inequality indicated divergence between regional rates from the late nineteenth century to a peak inequality in 1921/31, followed by convergence towards equality. Econometric analysis of these variations in regional inequality suggests that density of housing occupancy, and industrialisation were important factors. Housing density was particularly important in the relatively slow decline in infant mortality in twentieth-century Scotland as compared to England and Wales. [ABSTRACT FROM AUTHOR]

The UK government has recently recognised the need to improve mental health services in the country. Electronic health records provide a rich source of patient data which could help policymakers to better understand needs of the service users. The main objective of this study is to unveil statistics of diagnoses recorded in the Case Register of the South London and Maudsley NHS Foundation Trust, one of the largest mental health providers in the UK and Europe serving a source population of over 1.2 million people residing in south London. Based on over 500,000 diagnoses recorded in ICD10 codes for a cohort of approximately 200,000 mental health patients, we established frequency rate of each diagnosis (the ratio of the number of patients for whom a diagnosis has ever been recorded to the number of patients in the entire population who have made contact with mental disorders). We also investigated differences in diagnoses prevalence between subgroups of patients stratified by gender and ethnicity. The most common diagnoses in the considered population were (recurrent) depression (ICD10 codes F32-33; 16.4% of patients), reaction to severe stress and adjustment disorders (F43; 7.1%), mental/behavioural disorders due to use of alcohol (F10; 6.9%), and schizophrenia (F20; 5.6%). We also found many diagnoses which were more likely to be recorded in patients of a certain gender or ethnicity. For example, mood (affective) disorders (F31-F39); neurotic, stress-related and somatoform disorders (F40-F48, except F42); and eating disorders (F50) were more likely to be found in records of female patients, while males were more likely to be diagnosed with mental/behavioural disorders due to psychoactive substance use (F10-F19). Furthermore, mental/behavioural disorders due to use of alcohol and opioids were more likely to be recorded in patients of white ethnicity, and disorders due to use of cannabinoids in those of black ethnicity. [ABSTRACT FROM AUTHOR]

Background: More people than ever receive care and support from health and social care services. Initiatives to integrate the work of health and social care staff have increased rapidly across the UK but relatively little has been done to chart and improve their impact on service users. Our aim was to develop a framework for gathering and using service user feedback to improve integrated health and social care in one locality in the North of England. Methods: We used published literature and interviews with health and social care managers to determine the expected service user experiences of local community-based integrated teams and the ways in which team members were expected to work together. We used the results to devise qualitative data collection and analysis tools for gathering and analyzing service user feedback. We used developmental evaluation and service improvement methodologies to devise a procedure for developing service improvement plans. Findings: We identified six expected service user experiences of integrated care and 15 activities that health and social care teams were expected to undertake. We used these to develop logic models and tools for collecting and analysing service user experiences. These include a narrative interview schedule, a plan for analyzing data, and a method for synthesizing the results into a composite ‘story’. We devised a structured service improvement procedure which involves teams of health and social care staff listening to a composite service user story, identifying how their actions as a team may have contributed to the story and developing a service improvement plan. Conclusions: This framework aims to put service user experiences at the heart of efforts to improve integration. It has been developed in collaboration with National Health Service (NHS) and Social Care managers. We expect it to be useful for evaluating and improving integrated care initiatives elsewhere. [ABSTRACT FROM AUTHOR]

This paper details models that determine the efficient allocation of resources on a medical assessment unit (MAU) of a general hospital belonging to the National Health Service (NHS) UK. The MAU was established to improve the quality of care given to acute medical patients on admission, and also provide the organizational means of rapid assessment and investigation in order to avoid unnecessary admissions. To analyse the performance of the MAU, doctors, nurses and beds are considered as the three main resources. Then a model is developed using the goal programming approach in multiobjective decision making and solved to deal with MAU performance. The developed model is solved under three different sets of patient admissions with the same resource levels using past data from the MAU. The results of the model are used to analyse the needed resource levels. Conclusions as to the appropriate staffing levels and functions of the MAU are drawn. [ABSTRACT FROM AUTHOR]

There has been much discussion about the changes introduced by the Government in 1989 in the hospital sector of the British National Health Service. In contrast, the changes in the primary health care sector have gone largely undebated. This paper's contention is that these may turn out to be equally if not more important. The changes mean that general practice doctors are now subject to greater accountability than ever before through new management and finance systems, while new pay structures have shifted the emphasis of the service itself towards preventive health interventions. The new fundholding scheme, which allows some practices to apply to hold their own budgets and buy services for their patients, could alter the balance of power between the hospitals and general practice. In all, the emphasis of Government policy has been placed squarely on better pay for more and better work from general practice doctors while at the same time enabling patients to choose more freely where to register for primary health care. The changes in general practice could therefore achieve radical and permanent changes in the structure of the National Health Service and in the relationship between the State and the profession. [ABSTRACT FROM AUTHOR]

This paper first examines the usefulness of the internal markets being proposed in NHS reforms. The impact of those reforms on hospitals and general practitioners (GPs) is then assessed. Finally, the long-term implications of replacing medical culture with competition are discussed. [ABSTRACT FROM AUTHOR]

This paper tries to set the current changes in the British National Health Service in historical perspective. The NHS was born in 1948 amid controversy, both political and professional; but in the 50s and 60s a consensus was reached which won it the support of patients and doctors. But in the 70s and 80s it has undergone the stress of successive reorganizations, in the attempt to meet the economic strains imposed by an ageing population and expensive medical advances. The present changes aim to bring about an "internal market," regulated by contract between "purchases" and "providers." Reasons are given for the view that this artificial arrangement will impair the coherence of the NHS, will add administrative expense and complexity, and will impair the important role of general practitioners as "gate-keepers." [ABSTRACT FROM AUTHOR]

Background: Oral health worldwide needs improving: untreated dental caries is the most common health condition affecting people globally. Mobile applications (apps) have potential to provide preventative oral health interventions. This study aimed to investigate the quality of available oral health promotion apps, assessing information provided and the barriers to oral health addressed using psychological frameworks.Methods: A content assessment of oral health promotion apps targeted at adults in the UK iTunes store was conducted. The quality of 22 apps was assessed against 3 objective indices derived from the Delivering Better Oral Health toolkit, Theoretical Domains Framework and Behaviour Change Technique Taxonomy. Index scores were calculated and descriptive analyses were completed.Results: On average, four Delivering Better Oral Health messages, seven Theoretical Domains Framework components and eight Behaviour Change Technique Taxonomy components were addressed per app. The most common components were: 'take at least two minutes to brush' for the Delivering Better Oral Health index, 'goals' and 'intentions' for the Theoretical Domains Framework index and 'goal setting (behaviour)' for the Behaviour Change Technique Taxonomy index.Conclusion: The quality of information available in oral health apps requires improvement with the majority addressing only a few barriers to oral health. Currently, there is no recognized scale for evaluating oral health apps: this study provides a suggested method for future app evaluation. There is opportunity for a new app to be created based on health behaviour change theory which includes all the Delivering Better Oral Health messages. [ABSTRACT FROM AUTHOR]

Objective: To explore, through face to face interviews with a selection of General Dental Practitioners (GDPs), their views and experiences of having used the International Caries Detection and Assessment System (ICDAS) within primary care research studies for recording caries. Methods: This qualitative study involved one on one interviews with eight GDP’s who had previously used ICDAS on patients in their dental practices as part of a research study. The participants were selected from among those who had taken part in two clinical studies in the UK using convenient, but purposive sampling. The interviews were tape-recorded and transcribed; the data analysis was conducted by thematic analysis. Results: GDP’s indicated their beliefs that ICDAS had an important role in caries prevention but reported four main barriers while using the full (6 caries stages) ICDAS coding system in their practices: lack of simplicity of coding, financial implications and time consumption (in both training and use of ICDAS) and inadequate undergraduate training. An overarching theme identified from the GDPS was the willingness to offer potential solutions to their barriers which might improve the utilisation of the system in primary care. Conclusion: The GDPs experienced common obstacles in using ICDAS in the primary care setting, many of which have relatively straight-forward solutions which they put forward themselves such as: incentivisation, undergraduate-level training in ICDAS for both dentists and nurses and computerized data entry. Further qualitative and quantitative research is needed on how to facilitate the utilisation of the system in dental practice. It is also recommended to explore the influences of wider agencies on influencing primary dental care professionals’ caries management, including appropriate recording of diagnosis and risk assessment. [ABSTRACT FROM AUTHOR]

Introduction: The NICE clinical guidelines on psychosocial interventions for the treatment of schizophrenia and psychosis in adults are based on the results of randomized controlled trials (RCTs), which may not be studies with a pragmatic design, leading to uncertainty on applicability or recommendations to everyday clinical practice. Aim: To assess the level of pragmatism of the evidence used to develop the NICE guideline for psychosocial interventions in psychoses. Material and methods: We conducted a systematic and critical appraisal of RCTs used to develop the ‘psychological therapy and psychosocial interventions’ section of the NICE guideline on the treatment and management of psychosis and schizophrenia in adults, published in 2014. For each study we assessed pragmatism using the pragmatic–explanatory continuum indicator summary-2 (PRECIS-2) and the Cochrane risk of bias tool. The mean score of PRECIS-2, averaging across nine domains, was calculated to describe the level of pragmatism of each individual study. Results: A total of 143 studies were included in the analysis. Based on the PRECIS-2 tool, 16.8% were explanatory, 33.6% pragmatic, and 49.7% were rated in an intermediate category. Compared to explanatory studies, pragmatic studies showed a lower risk of bias. Additionally, pragmatism did not significantly improve over time, and no associations were found between pragmatism and a number of trial characteristics. However, studies with a UK leading investigator had the highest mean score of pragmatism. Cognitive behavioural therapy (CBT), art therapy, family intervention, psychoeducation, and adherence therapy, showed the higher average pragmatism scores. Conclusions: Two third of studies used to produce NICE recommendations on psychosocial interventions for the treatment of schizophrenia and psychosis in adults are based on studies that did not employ a pragmatic design. [ABSTRACT FROM AUTHOR]

Background: The United Kingdom (UK) was the first European country to introduce a national immunisation program for shingles (2013–2014). That year, vaccination coverage ranged from 50 to 64% across the UK, but uptake has declined ever since. This study explored determinants of the acceptance of the shingles vaccine in the UK. Methods: Vaccinated and unvaccinated individuals, who were eligible for the last catch-up cohort of the 2014–2015 shingles vaccination campaign, were identified using the Clinical Practice Research Datalink (the National Health Service data research service) and invited to participate by their general practitioner (GP). An anonymised self-administered questionnaire was developed using the Health Belief Model as a theoretical framework, to collect data on demographic and socio-economic characteristics, health status, knowledge, influences, experiences and attitudes to shingles and the shingles vaccine. Multivariable logistic regression was used to identify the factors associated with vaccination. Physicians’ views concerning perceived barriers to vaccination were also assessed. Results: Of the 2,530 questionnaires distributed, 536 were returned (21.2%) from 69 general practices throughout the UK. The majority of responders were female (58%), lived in care homes (56%) and had completed secondary or higher education (88%). There were no differences between vaccinated and unvaccinated responders. Being offered the shingles vaccine by a GP/nurse (odds ratio (OR) = 2.3), and self-efficacy (OR = 1.2) were associated with being vaccinated (p<0.05). In contrast, previous shingles history (OR = 0.4), perceived barriers to vaccination (OR = 0.7) and perceived control of the disease (OR = 0.7) were associated with not being vaccinated against shingles (p<0.05). Less than half (44.0%) of GPs were aware of the local communication campaigns regarding shingles and the shingles vaccine. Conclusions: Socio-psychological factors largely influence shingles vaccination acceptance in this study. The results add to existing evidence that healthcare providers (HCPs) have a pivotal role against vaccine hesitancy. Campaigns focusing on GPs and accessible information offered to eligible members of the public can further enhance shingles vaccine uptake. [ABSTRACT FROM AUTHOR]

Background: Patients are increasingly recognized as playing important roles in improving health services. Little is known about the mechanisms by which patients develop and diffuse local innovations in a complex health‐care system. Objective: To ascertain how diffusion of an innovation, My Medication Passport, occurred and roles played by patients in it. Design: Case study: quantitative mapping of innovation's diffusion and analysis of the routes and occupations of those through whom the innovation spread; documentary analysis; reflective assessment of patient's roles. Setting and participants: NHS Trusts, third sector organizations, patients and health‐care professionals. Interventions studied: Co‐produced action to raise awareness and influence use of the innovation; order database which enabled ease of access to the innovation. Main outcome measures: Geographical spread of innovation; occupations of individuals; types of organizations using the innovation. Results: The innovation spread from initial development and use in Northwest London across the UK and beyond. Key roles played by patients were as follows: co‐producer; advocate; relationship builder; relationship broker; planner; presenter; awareness raiser; trainer; networker. Patients identified and introduced potential audiences and users to MMP, using social, organizational, sectoral, lay and professional networks to do so. They organized a range of awareness‐raising and communication activities, monitored feedback, evaluated the impact and responded to new interest. Discussion and conclusions: The roles of patients in diffusing innovations are under‐recognized. Collaborative working between patients, carers and health‐care professionals in planning and progressing the use and supporting diffusion of the innovation was important. Principles described in this study are relevant to progressing other patient‐led ideas for innovative changes relating to health service development. [ABSTRACT FROM AUTHOR]

Emplaced health promotion interventions, delivered by community health workers are increasingly being used internationally. However, the application of epidemiological risk knowledge to individuals within such communities is not straightforward and creates tensions for community health workers who are part of the communities that they are serving. Situated qualitative interview data were co-produced with community health workers employed in a superdiverse, deprived, post-industrial region of the United Kingdom, using photo-voice methods, to develop an account of how they made sense of the challenges of their work. The analysis draws on and develops theories of risk work and resilience work, which draw on practice theory. The key findings were that, first, being a critical insider enabled community health workers to make sense of the diverse constraints on health and lifestyles within their community. Second, they understood their own public health role as limited by operating within this context, so they articulated their occupational identity as focused on supporting clients to make small but sustainable changes to their own and their families’ lifestyles. Third, the uncertainties of translating population based risk information to individual clients were (at least partially) resolved at an embodied level, with the community health workers identifying as accessible and trusted role models for the value of changed lifestyles. The article is important for policy and practice as it provides a critique of a rapidly evolving new mode of delivery of public health services, and insights on the development of this new public health workforce. [ABSTRACT FROM AUTHOR]

We systematically reviewed the evidence on secular trends in main chronic conditions, disability and self-assessed general health among adults in the United Kingdom, as reported in primary/secondary care databases and population-based surveys. Searches were conducted separately for: (1) trends in age-standardised or age-specific prevalence of major non-communicable diseases, disability, and self-reported general health; (2) trends in health expectancy. The databases searched were MEDLINE, EMBASE/EMBASE Classic and Web of Science (all from 1946/7). The evidence was synthesised narratively. There were 39 studies reporting trends in prevalence of health conditions and 15 studies in health expectancy. We did not find evidence for improvement in the age-standardised or age-specific prevalence of any of the studied major chronic conditions over the last few decades, apart from Alzheimer's disease and other dementias. Both increasing or stable prevalence rates with simultaneous rising life expectancy support the expansion of morbidity theory, meaning that people are expected to spend a greater number of years with chronic condition(s). The evidence on disability—expressed as prevalence or health expectancy—was mixed, but also appeared to support the expansion of morbidity among those aged 65 or over. The evidence on trends in disability for younger age is lacking. Across the studied period (1946–2017), the UK population endured more years with chronic morbidity and disability, which may place a serious strain on the health care system, the economy and the society. [ABSTRACT FROM AUTHOR]

Background: Funding shortages and an ageing population have increased pressures on state or insurance funded end of life care for older people. Across the world, policy debate has arisen about the potential role volunteers can play, working alongside health and social care professionals in the community to support and care for the ageing and dying. Aims: The authors examined self-reported levels of care for the elderly by the public in England, and public opinions of community volunteering concepts to care for the elderly at the end of life. In particular, claimed willingness to help and to be helped by local people was surveyed. Methods: A sample of 3,590 adults in England aged 45 or more from an online access panel responded to a questionnaire in late 2017. The survey data was weighted to be representative of the population within this age band. Key literature and formative qualitative research informed the design of the survey questionnaire, which was further refined after piloting. Results: Preferences for different models of community volunteering were elicited. There was a preference for ‘formal’ models with increased wariness of ‘informal’ features. Whilst 32% of adults said they ‘might join’ depending on whom the group helped, unsurprisingly more personal and demanding types of help significantly reduced the claimed willingness to help. Finally, willingness to help (or be helped) by local community carers or volunteers was regarded as less attractive than care being provided by personal family, close friends or indeed health and care professionals. Conclusion: Findings suggest that if community volunteering to care for elderly people at the end of life in England is to expand it may require considerable attention to the model including training for volunteers and protections for patients and volunteers as well as public education and promotion. Currently, in England, there is a clear preference for non-medical care to be delivered by close family or social care professionals, with volunteer community care regarded only as a back-up option. [ABSTRACT FROM AUTHOR]

Background Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards. Aim To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it. Design An international survey. Methods Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis. Results A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to. Conclusion This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required. [ABSTRACT FROM AUTHOR]

Introduction: The rapid rise in trade and use of NPS and the lack of information concerning their potential toxicity pose serious challenges to public health authorities across the world. Policy measures towards NPS taken so far have a special focus on their legal status, while the implementation of a public health strategy seems to be still missing. The aim of this study is to perform a general assessment of NPS-related policy (including regulatory measures and public health strategies) implemented by six European countries: Portugal, the Netherlands, Czech Republic, Poland, the United Kingdom and Sweden. Methods: Six EU countries were included in this scoping review study. Drug policies (including legal responses and public health strategies) were analysed. UNODC drug policy classification system was used as a benchmark, while path dependency approach was used for data analysis; a net of inter-dependencies between international, EU and national policies was highlighted. Results and discussion: The countries included in this study can be placed in a wide spectrum according to their formulation of drug policy, from Portugal and the UK that have specific legal responses to NPS but have differently focused on harm reduction strategies at one end, to Sweden whose drug-free society goal is not translated into a specific regulation of NPS at the other end. Conclusion: The findings of the study reveal limited development towards harmonisation of national drug policies–particularly with regard to NPS. To tackle the challenge presented by NPS, EU Member states have formulated legislation and public health strategies independently. National approaches to NPS are therefore in line with their already existing drug policies, reflecting cultural values towards substance abuse and national political interests, while the homogenization at an international level has so far mostly been focused on law enforcement and drugs use preventive strategies. [ABSTRACT FROM AUTHOR]

The relationship between child health, wellbeing and education demonstrates that healthier and happier children achieve higher educational attainment. An engaging curriculum that facilitates children in achieving their academic potential has strong implications for educational outcomes, future employment prospects, and health and wellbeing during adulthood. Outdoor learning is a pedagogical approach used to enrich learning, enhance school engagement and improve pupil health and wellbeing. However, its non-traditional means of achieving curricular aims are not yet recognised beyond the early years by education inspectorates. This requires evidence into its acceptability from those at the forefront of delivery. This study aimed to explore headteachers’, teachers’ and pupils’ views and experiences of an outdoor learning programme within the key stage two curriculum (ages 9–11) in South Wales, United Kingdom. We examine the process of implementation to offer case study evidence through 1:1 interviews with headteachers (n = 3) and teachers (n = 10) and focus groups with pupils aged 9–11 (n = 10) from three primary schools. Interviews and focus groups were conducted at baseline and six months into implementation. Schools introduced regular outdoor learning within the curriculum. This study found a variety of perceived benefits for pupils and schools. Pupils and teachers noticed improvements in pupils’ engagement with learning, concentration and behaviour, as well as positive impacts on health and wellbeing and teachers’ job satisfaction. Curriculum demands including testing and evidencing work were barriers to implementation, in addition to safety concerns, resources and teacher confidence. Participants supported outdoor learning as a curriculum-based programme for older primary school pupils. However, embedding outdoor learning within the curriculum requires education inspectorates to place higher value on this approach in achieving curricular aims, alongside greater acknowledgment of the wider benefits to children which current measurements do not capture. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal symptoms in people living with HIV (PLWH) such as pain, joint stiffness, and fatigue are commonly reported. Prevalence rates of up to 45%, 79% and 88% respectively have been reported. However, very little is known about differences in prevalence and impact of musculoskeletal symptoms on physical functioning and quality of life of PLWH on effective combined antiretroviral treatment (cART) in high and low-resource settings. Methods: A cross-sectional study of PLWH on effective cART enrolled from two large urban clinics in the UK and Zambia was conducted in 2016. Eligible participants had no history of trauma to the joints within 4 weeks of recruitment, or documented evidence of previous rheumatic disease. Current musculoskeletal symptoms, functional ability, and health-related quality of life were evaluated using the health assessment (HAQ) and quality-of-life short form (SF-36) self-reported questionnaires. Results: 214 patients were enrolled (108:UK and 106:Zambia). Participants from Zambia were younger (47 vs 44 years) and had significantly lower CD4 counts (640 vs 439 cells/mL p = 0.018) compared to those from the UK, while the UK group had lived with HIV longer (11 vs 6 years; p<0.001) and reported more comorbidities than the Zambian group (66% vs 26%; p<0.001). Musculoskeletal pain was common in both groups (UK:69% vs Zambia:61% p = 0.263) but no significant differences in physical functional capacity between the groups were observed. However, the UK group had significantly worse quality of life measurements (general health, vitality, mental health, emotional, and social functioning) associated with musculoskeletal symptoms compared to the Zambian group (p<0.001). Conclusions: Musculoskeletal symptoms in PLWH from both the UK and Zambia were common. PLWH in the UK reported worse quality of life measures associated with musculoskeletal symptoms compared to those in Zambia, suggesting that factors such as mental health, patient expectations and multimorbidity might play a role in determining well-being and quality of life of PLWH with musculoskeletal symptoms. [ABSTRACT FROM AUTHOR]

Objective: To examine cross-sectional and prospective associations between perceived discrimination in daily life (based on a range of attributes), sexual orientation discrimination, and health and wellbeing in middle-aged and older lesbian, gay and bisexual (LGB) people. Methods: Data were from 304 LGB men and women aged 41–85 years participating in the English Longitudinal Study of Ageing. Perceived discrimination in daily life was reported in 2010/11. Participants could attribute their discrimination experience to characteristics including age, sex, race, physical disability, and sexual orientation. Self-rated health, limiting long-standing illness, depressive symptoms, quality of life, life satisfaction and loneliness were assessed in 2010/11 and 2016/17. Analyses adjusted for age, sex, ethnicity, partnership status and socioeconomic position. Results: Perceived discrimination in daily life was reported by 144 (47.4%) participants. Cross-sectionally, perceived discrimination in daily life was associated with increased odds of depressive symptoms (OR = 2.30, 95% CI 1.02 to 5.21), loneliness (OR = 3.37, 95% CI 1.60 to 7.10) and lower quality of life (B = -3.31, 95% CI -5.49 to -1.12). Prospectively, perceived discrimination in daily life was associated with increased odds of loneliness (OR = 3.12, 95% CI 1.08 to 8.99) and lower quality of life (B = -2.08, 95% CI -3.85 to -0.31) and life satisfaction (B = -1.92, 95% CI -3.44 to -0.39) over six-year follow-up. Effect sizes were consistently larger for participants who attributed experiences of discrimination to their sexual orientation compared with those who attributed experiences of discrimination to other reasons (e.g. age, sex, race). Conclusion: These results provide cross-sectional and prospective evidence of associations between perceived discrimination in daily life and health and wellbeing outcomes in middle-aged and older LGB adults in England. [ABSTRACT FROM AUTHOR]

Background: The prevalence of, and risk factors for, herpes simplex virus type-1 (HSV-1) infection and reactivation in older individuals are poorly understood. Methods: This is a prospective population-based study among community-dwelling individuals aged 40–79 years, followed from 1993, formed as a random subsample of the UK-based EPIC-Norfolk cohort. HSV-1 seropositivity was derived from immunoglobulin G measurements and frequent oro-labial HSV reactivation was self-reported. We carried out two cross-sectional studies using logistic regression to investigate childhood social and environmental conditions as risk factors for HSV-1 seropositivity and comorbidities as risk factors for apparent HSV oro-labial reactivation. Results: Of 9,929 participants, 6310 (63.6%) were HSV-1 IgG positive, and 870 (of 4,934 seropositive participants with reactivation data) experienced frequent oro-labial reactivation. Being born outside the UK/Ireland, contemporaneous urban living and having ≥4 siblings were risk factors for HSV-1 seropositivity. Ever diagnosed with kidney disease, but no other comorbidities, was associated with an increased risk of frequent HSV reactivation (adjOR 1.87, 95%CI: 1.02–3.40). Discussion: Apparent HSV-1 seropositivity and clinical reactivation are common within an ageing UK population. HSV-1 seropositivity is socially patterned while risk factors for oro-labial HSV reactivation are less clear. Further large studies of risk factors are needed to inform HSV-1 control strategies. [ABSTRACT FROM AUTHOR]

The number of cancer-related emergency presentations and admissions has been steadily increasing in the UK. Drivers of this phenomenon are complex, multifactorial and interlinked. The main objective of this study was to understand the complexity of emergency hospital use in cancer patients. We conducted semi-structured interviews with 42 senior clinicians (20 doctors, 22 nurses) with diverse expertise and experience in caring for acutely ill cancer patients in the secondary care setting. Data analysis included thematic analysis and purposive text analysis to develop Causal Loop Diagrams. Our Causal Loop Diagrams represent an integrated understanding of the complex factors (13) influencing emergency hospital use in cancer patients. Eight factors formed five reinforcing feedback loops and therefore were high-leverage influences: Ability of patients and carers to self-care and cope; Effective and timely management of ambulatory care sensitive conditions by primary and community care; Sufficient and effective social care for patients and carers; Avoidable emergency hospital use; Bed capacity; Patients accessing timely appropriate specialist inpatient or ambulatory care; Prompt and effective management and prevention of acute episode; Timely and safe discharge with appropriate support. The loops show that reduction of avoidable hospital use helps relieve hospital bed pressure; improved bed capacity then has a decisive, positive influence on patient pathway and thus outcome and experience in the hospital; in turn, better in-hospital care and discharge help patients and carers self-care and cope better back home with better support from community-based health and social care services, which then reduces their future emergency hospital use. To optimise acute and emergency cancer care, it is also essential that patients, carers and other clinicians caring for cancer patients have prompt access to senior cancer specialists for advice, assessment, clinical decision and other support. The findings provide a useful framework and focus for service planners aiming to optimise care. [ABSTRACT FROM AUTHOR]

Given the high prevalence of common mental disorders (CMDs) and individuals living alone in the United Kingdom, the goal of this study using English nationally representative data was to examine the association between living alone and CMDs, and to identify potential mediating factors of this association. The data were drawn from the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. CMDs were assessed using the Clinical Interview Schedule-Revised (CIS-R), a questionnaire focusing on past week neurotic symptoms. The presence of CMDs was defined as a CIS-R total score of 12 and above. Multivariable logistic regression and mediation analyses were conducted to analyze the association between living alone and CMDs, and to identify mediators in this association. The prevalence of CMDs was higher in individuals living alone than in those not living alone in all survey years. Multivariable analysis showed a positive association between living alone and CMDs in all survey years (1993: odds ratio [OR] = 1.69; 2000: OR = 1.63; and 2007: OR = 1.88). Overall, loneliness explained 84% of the living alone-CMD association. Living alone was positively associated with CMDs. Interventions addressing loneliness among individuals living alone may be particularly important for the mental wellbeing of this vulnerable population. [ABSTRACT FROM AUTHOR]

Quantifying the value of investment in medical research can inform decision-making on the prioritisation of research programmes. Existing methodologies to estimate the rate of return of medical research are inappropriate for early-phase translational research due to censoring of health benefits and time lags. A strategy to improve the process of translational research for patient benefit has been initiated as part of the UK National Institute for Health Research (NIHR) investment in Biomedical Research Centres (BRCs) in England. By providing a platform for partnership between universities, NHS trusts and industry, successful BRCs should reduce time lags within translational research whilst also providing an impetus for local economic growth through industry collaboration. We present a novel contribution in the assessment of early-phase biomedical research by estimating the impact of the Oxford Biomedical Research Centre (OxBRC) on income and job creation following the initial NIHR investment. We adopt a macroeconomic assessment approach using Input-Output Analysis to estimate the value of medical research in terms of income and job creation during the early pathway towards translational biomedical research. Inter-industry linkages are assessed by building a model economy for the South East England region to estimate the return on investment of the OxBRC. The results from the input-output model estimate that the return on investment in biomedical research within the OxBRC is 46%. Each £1 invested in the OxBRC generates an additional £0.46 through income and job creation alone. Multiplicative employment effects following a marginal investment in the OxBRC of £98m during the period 2007-2017 result in an estimated additional 196 full time equivalent positions being created within the local economy on top of direct employment within OxBRC. Results from input-output analyses can be used to inform the prioritisation of biomedical research programmes when compared against national minimum thresholds of investment. [ABSTRACT FROM AUTHOR]

England’s national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective. [ABSTRACT FROM AUTHOR]

Background: Men and women are increasingly likely to stay sexually active into later life, but research shows that sexual activity and satisfaction decrease with increasing age. Ill health and medical treatments may affect sexual activity but there is little research on why some older people with a health problem affecting their sexual activity are satisfied with their sex life, and others are not. Methods: A mixed method study integrating data and analyses from the third British National Survey of Sexual Attitudes and Lifestyles (n = 3343 aged 55–74 years) and from follow-up in-depth interviews with 23 survey participants who reported having a health condition or taking medication affecting their sex life. Results: Overall, 26.9% of men and 17.1% of women aged 55–74 reported having a health condition that affected their sex life. Among this group, women were less likely than men to be sexually active in the previous 6 months (54.3% vs 62.0%) but just as likely to be satisfied with their sex life (41.9% vs 42.1%). In follow-up interviews, participants sometimes struggled to tease out the effects of ill health from those of advancing age. Where effects of ill health were identified, they tended to operate through the inclination and capacity to be sexually active, the practical possibilities for doing so and the limits placed on forms of sexual expression. In close relationships partners worked to establish compensatory mechanisms, but in less close relationships ill health provided an excuse to stop sex or deterred attempts to resolve difficulties. Most fundamentally, ill health may influence whether individuals have a partner with whom to have sex. Conclusion: The data show complex interactions between health, lifestyle and relationship factors that affect sexual activity/satisfaction. When dealing with sexual problems in older people, practitioners need to take account of individual lifestyle, needs and preferences. [ABSTRACT FROM AUTHOR]

Background: The Healthy Living Pharmacy (HLP) project, launched in England, UK in 2009 was a novel approach of introducing public health services within community pharmacy to tackle local health inequalities. A national roll-out followed a reported successful pilot; subsequent local evaluations ensued. Objectives: To summarise reported outcomes and investigate contextual factors that indicate the presence, absence and maturity of implementation determinants, thus offering useful lessons to stakeholders in implementing future initiatives to achieve successful outcomes. Methods: A systematic review was conducted to identify all publications reporting on the HLP project. All HLP articles and conference abstracts were considered for inclusion and were assessed for methodological quality. The Consolidated Framework for Implementation Research (CFIR) was utilised to identify potential implementation determinants reported. Each article was then analysed to identify reported economic, humanistic or clinical outcomes. Results: The review included six peer-reviewed journal articles and 12 conference abstracts. Joanna Briggs Institute Qualitative Assessment and Review Instrument indicated deficiencies in methodological quality. Through adoption of the CFIR framework, the implementation determinants relevant to the implementation of HLP into community pharmacy were identified. A resonating issue emerged in that the absence of adopting an evidence-based implementation process limited the ability to capture meaningful outcome data. This resulted in a lack of evidence to support sustainability and the failure to address many of the well cited barriers, e.g. lack of awareness amongst patients, public and other healthcare professionals, and weak support for future investment in resource for training and dissemination. Conclusions: Healthcare systems are increasingly called on to adopt evidence-based interventions that improve quality, control costs, and maximize value, thus offering opportunity to accelerate the implementation of clinical pharmacy services and programs aimed at improving patient care. Interventions, such as the HLP project require focused efforts on implementation and evaluation of those implementation efforts to produce effective and lasting changes in complex health care systems. [ABSTRACT FROM AUTHOR]

Objective: To describe the opinions of British general practitioners regarding the potential of future technology to replace key tasks carried out in primary care. Design: Cross sectional online survey. Participants: 1,474 registered GPs in the United Kingdom. Main outcome measures: Investigators measured GPs’ opinions about the likelihood that future technology will be able to fully replace–not merely aid–the average GP in performing six primary care tasks; in addition, if GPs considered replacement for a particular task likely, the survey measured opinions about how many years from now this technological capacity might emerge. Results: A total of 720 (49%) responded to the survey. Most GPs believed it unlikely that technology will ever be able to fully replace physicians when it comes to diagnosing patients (489, 68%), referring patients to other specialists (444, 61%), formulating personalized treatment plans (441, 61%), and delivering empathic care (680, 94%). GPs were not in agreement about prognostics: one in two participants (380, 53%) considered it likely that technology will be fully capable of replacing physicians in performing this task, nearly half (187, 49%) of whom believed that the technological capacity will arise in the next ten years. Against these findings, the majority of GPs (578, 80%) believed it likely that future technology will be able to fully replace humans to undertake documentation; among them 261 (79%) estimated that the technological wherewithal would emerge during the next ten years. In general, age and gender were not correlated with opinions; nor was reported burnout and job satisfaction or whether GPs worked full time or part time. Conclusions: The majority of UK GPs in this survey were skeptical about the potential for future technology to perform most primary care tasks as well as or better than humans. However, respondents were optimistic that in the near future technology would have the capacity to fully replace GPs’ in undertaking administrative duties related to patient documentation. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to ‘DIY PrEP’, purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club. [ABSTRACT FROM AUTHOR]

Objective: Despite poor clinic communication and staff treatment being reported by donors, high rates of overall satisfaction are still reported in surveys. This study will evaluate the importance of communication and interaction between donors and fertility clinic staff in gamete donor care. Methods: We report on 120 egg and sperm donors’ responses to a UK-wide online satisfaction survey. The survey focused on donors’ interactions with fertility clinic staff pre-, during, and post- donation. Basic cross-tabulation was performed on the data using online survey software. Textual data was read and extracts identified, which illustrated and expanded on the findings from the numerical data. Diagrammatic modeling was also utilised to analyse the textual data, with particular focus to relationships between the donors and clinic staff, the main activities within the gamete donation process, and how these activities may affect donor satisfaction with the gamete donation process. Results: Donors expressed concern for the infertile couple and the resulting child; conveyed frustration at not receiving information on the expenses they could claim; felt lost in the system regarding the ease of making clinic appointments, and once made they were routinely not seen on time for these appointments. Donors also negatively commented on aftercare, the location and condition of the donation room, and information on contraception. In addition, Ovarian Hyperstimulation Syndrome was frequently reported, with these egg donors believing that clinic staff were not concerned with their physical or emotional well-being, but were instead disproportionately focused on extracting the eggs. Conclusions: The multifaceted notion of donors highlights the complexity inherent to the gamete donation process, which comprises various aspects of uncertainty in the donation system, and ambiguity in the donation process. Categorising donors as Altruist, Customer, and Patient, conveys the particular importance of staff communication and treatment in donor care. These categories are not mutually exclusive however, in that an individual donor may experience more than one of these perspectives during the course of their gamete donation journey. Finally, there were a number of exemplar cases, where donors reported high satisfaction throughout, and these correlated with them being given a single point of contact at the clinic. Subject to resource constraints, we suggest that this practice should be implemented throughout clinics in the UK, so that donors have access to dedicated clinic staff who not only support them emotionally and physically throughout the gamete donation process, but also ensure that communication is open, clear, timely, and consistent. [ABSTRACT FROM AUTHOR]

Background: Air pollution damages health by promoting the onset of some non-communicable diseases (NCDs), putting additional strain on the National Health Service (NHS) and social care. This study quantifies the total health and related NHS and social care cost burden due to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in England.Method and Findings: Air pollutant concentration surfaces from land use regression models and cost data from hospital admissions data and a literature review were fed into a microsimulation model, that was run from 2015 to 2035. Different scenarios were modelled: (1) baseline 'no change' scenario; (2) individuals' pollutant exposure is reduced to natural (non-anthropogenic) levels to compute the disease cases attributable to PM2.5 and NO2; (3) PM2.5 and NO2 concentrations reduced by 1 μg/m3; and (4) NO2 annual European Union limit values reached (40 μg/m3). For the 18 years after baseline, the total cumulative cost to the NHS and social care is estimated at £5.37 billion for PM2.5 and NO2 combined, rising to £18.57 billion when costs for diseases for which there is less robust evidence are included. These costs are due to the cumulative incidence of air-pollution-related NCDs, such as 348,878 coronary heart disease cases estimated to be attributable to PM2.5 and 573,363 diabetes cases estimated to be attributable to NO2 by 2035. Findings from modelling studies are limited by the conceptual model, assumptions, and the availability and quality of input data.Conclusions: Approximately 2.5 million cases of NCDs attributable to air pollution are predicted by 2035 if PM2.5 and NO2 stay at current levels, making air pollution an important public health priority. In future work, the modelling framework should be updated to include multi-pollutant exposure-response functions, as well as to disaggregate results by socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) Health Check programme was introduced in 2009 in England to systematically assess all adults in midlife for cardiovascular disease risk factors. However, its current benefit and impact on health inequalities are unknown. It is also unclear whether feasible changes in how it is delivered could result in increased benefits. It is one of the first such programmes in the world. We sought to estimate the health benefits and effect on inequalities of the current NHS Health Check programme and the impact of making feasible changes to its implementation.Methods and Findings: We developed a microsimulation model to estimate the health benefits (incident ischaemic heart disease, stroke, dementia, and lung cancer) of the NHS Health Check programme in England. We simulated a population of adults in England aged 40-45 years and followed until age 100 years, using data from the Health Survey of England (2009-2012) and the English Longitudinal Study of Aging (1998-2012), to simulate changes in risk factors for simulated individuals over time. We used recent programme data to describe uptake of NHS Health Checks and of 4 associated interventions (statin medication, antihypertensive medication, smoking cessation, and weight management). Estimates of treatment efficacy and adherence were based on trial data. We estimated the benefits of the current NHS Health Check programme compared to a healthcare system without systematic health checks. This counterfactual scenario models the detection and treatment of risk factors that occur within 'routine' primary care. We also explored the impact of making feasible changes to implementation of the programme concerning eligibility, uptake of NHS Health Checks, and uptake of treatments offered through the programme. We estimate that the NHS Health Check programme prevents 390 (95% credible interval 290 to 500) premature deaths before 80 years of age and results in an additional 1,370 (95% credible interval 1,100 to 1,690) people being free of disease (ischaemic heart disease, stroke, dementia, and lung cancer) at age 80 years per million people aged 40-45 years at baseline. Over the life of the cohort (i.e., followed from 40-45 years to 100 years), the changes result in an additional 10,000 (95% credible interval 8,200 to 13,000) quality-adjusted life years (QALYs) and an additional 9,000 (6,900 to 11,300) years of life. This equates to approximately 300 fewer premature deaths and 1,000 more people living free of these diseases each year in England. We estimate that the current programme is increasing QALYs by 3.8 days (95% credible interval 3.0-4.7) per head of population and increasing survival by 3.3 days (2.5-4.1) per head of population over the 60 years of follow-up. The current programme has a greater absolute impact on health for those living in the most deprived areas compared to those living in the least deprived areas (4.4 [2.7-6.5] days of additional quality-adjusted life per head of population versus 2.8 [1.7-4.0] days; 5.1 [3.4-7.1] additional days lived per head of population versus 3.3 [2.1-4.5] days). Making feasible changes to the delivery of the existing programme could result in a sizable increase in the benefit. For example, a strategy that combines extending eligibility to those with preexisting hypertension, extending the upper age of eligibility to 79 years, increasing uptake of health checks by 30%, and increasing treatment rates 2.5-fold amongst eligible patients (i.e., 'maximum potential' scenario) results in at least a 3-fold increase in benefits compared to the current programme (1,360 premature deaths versus 390; 5,100 people free of 1 of the 4 diseases versus 1,370; 37,000 additional QALYs versus 10,000; 33,000 additional years of life versus 9,000). Ensuring those who are assessed and eligible for statins receive statins is a particularly important strategy to increase benefits. Estimates of overall benefit are based on current incidence and management, and future declines in disease incidence or improvements in treatment could alter the actual benefits observed in the long run. We have focused on the cardiovascular element of the NHS Health Check programme. Some important noncardiovascular health outcomes (e.g., chronic obstructive pulmonary disease [COPD] prevention from smoking cessation and cancer prevention from weight loss) and other parts of the programme (e.g., brief interventions to reduce harmful alcohol consumption) have not been modelled.Conclusions: Our model indicates that the current NHS Health Check programme is contributing to improvements in health and reducing health inequalities. Feasible changes in the organisation of the programme could result in more than a 3-fold increase in health benefits. [ABSTRACT FROM AUTHOR]

Background: Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England’s National Health Service. This study aimed to explore the implementation of the tool into routine practice from users’ perspectives. Method: Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. Results: Secondary care staff understood that the Medication Safety Thermometer’s purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of “capacity”. However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. Conclusion: Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required. [ABSTRACT FROM AUTHOR]

Objective: To estimate clinical progression and resource utilisation together with the associated costs of managing children and adults with LAL Deficiency, at a tertiary referral centre in the UK. Methods: A retrospective chart review was undertaken of patients in the UK with a confirmed diagnosis of LAL Deficiency who were managed at a LAL Deficiency tertiary referral treatment centre. Patients’ pathways, treatment patterns, health outcomes and resource use were quantified over differing lengths of time for each patient enabling the NHS cost of patient management in tertiary care to be estimated. Results: The study population comprised 19 patients of whom 58% were male. Mean age at the time of initial presentation was 15.5 years and the mean age at diagnosis was 18.0 years. 63%, 53% and 42% of patients had hepatomegaly, abnormal lipid storage and splenomegaly at a mean age of presentation of 17.8, 17.1 and 20.9 years, respectively. Over a period of 50 years there were a mean of 48.5 clinician visits and 3.4 hospital admissions per patient. The mean NHS cost of patient management at a LAL Deficiency tertiary referral treatment centre, spanning a period of over 50 years was £61,454 per patient. Conclusion: This study provides important insights into a number of aspects of the disease that are difficult to ascertain from published case reports. Additionally, it provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions pertaining to managing this ultra-orphan disease. [ABSTRACT FROM AUTHOR]

Objectives: Socioeconomic status has been shown to be associated with sexual activity, contraceptive-use, pregnancy and abortion among young people. Less is known about whether the strength of the association differs for each outcome, between men and women, or cross-nationally. We investigate this using contemporaneous national probability survey data from Britain and France. Methods: Data were analysed for 17–29 year-olds in Britain’s third National Survey of Sexual Attitudes and Lifestyles (Natsal-3, n = 5959) undertaken 2010–2012, and the 2010 French Fertility, Contraception and Sexual Dysfunction survey (FECOND, n = 3027). For each country, we estimated the gender-specific prevalence of sex before-16, contraceptive-use, conception before-20, and abortion in the event of conception, and used logistic regression to examine associations between two measures of socioeconomic status–educational-level and parental socioeconomic-group–and each outcome. We tested for interactions between socioeconomic characteristics and country, and socioeconomic characteristics and gender, for each outcome. Results: For each outcome, Britain and France differed with regard to prevalence but associations with socioeconomic characteristics were similar. Respondents of higher educational level, and, less consistently, with parents from higher socioeconomic-groups, were less likely to report sex before-16 (Britain, men: adjusted OR (aOR) 0.5, women: aOR 0.5; France, men: aOR 0.5, women: aOR 0.5), no contraception at first sex (Britain, men: aOR 0.4, women: aOR 0.6; France, men: aOR 0.4, women: aOR 0.4), pregnancy before-20 (Britain: aOR 0.3; France: aOR 0.1), and in Britain, a birth rather than an abortion in the event of conception (Britain: aOR 3.1). We found no strong evidence of variation in the magnitude of the associations with socioeconomic characteristics by country or gender. Conclusions: Population level differences in conception and abortion rates between the two countries may partly be driven by the larger proportion of the population that is disadvantaged in Britain. This research highlights the role intra-country comparisons can play in understanding young people’s sexual and reproductive behaviours. [ABSTRACT FROM AUTHOR]

Background: A National Health Service (NHS) contingent liability for medical error claims of over £26 billion. Objectives: To evaluate the safety management and educational benefits of adapting aviation's Normal Operations Safety Audit (NOSA) to health care. Methods: In vivo research, a NOSA was performed by medical students at an English NHS Trust. After receiving training from the author, the students spent 6 days gathering data under his supervision. Results: The data revealed a threat-rich environment, where errors - some consequential - were made (359 threats and 86 errors were recorded over 2 weeks). The students claimed that the exercise improved their observational, investigative, communication, teamworking and other nontechnical skills. Conclusion: NOSA is potentially an effective safety management and educational tool for health care. It is suggested that 1) the UK General Medical Council mandates that all medical students perform a NOSA in fulfillment of their degree; 2) the participating NHS Trusts be encouraged to act on students' findings; and 3) the UK Department of Health adopts NOSA as a cornerstone risk assessment and management tool. [ABSTRACT FROM AUTHOR]

Background: Health care systems in OECD countries are increasingly facing economic challenges and funding pressures. These normally demand interventions (political, financial and organisational) aimed at improving the efficiency of the health system as a whole and its single components. In 2009, the English NHS Chief Executive, Sir David Nicholson, warned that a potential funding gap of £20 billion should be met by extensive efficiency savings by March 2015. Our study investigates possible drivers of differential Trust performance (productivity) for the financial years 2010/11-2012/13. Methods: Following accounting practice, we define Productivity as the ratio of Outputs over Inputs. We analyse variation in both Total Factor and Labour Productivity using ordinary least squares regressions. We explicitly included in our analysis factors of differential performance highlighted in the Nicholson challenge as the sources were the efficiency savings should come from. Explanatory variables include efficiency in resource use measures, Trust and patient characteristics, and quality of care. Results: We find that larger Trusts and Foundation Trusts are associated with lower productivity, as are those treating a greater proportion of both older and/or younger patients. Surprisingly treating more patients in their last year of life is associated with higher Labour Productivity. [ABSTRACT FROM AUTHOR]