Search

To establish whether there are geographic differences in treatments and outcomes for patients with kidney cancer (KC) in England which could potentially be improved by the creation of national guidelines. A multidisciplinary group convened by the charity Kidney Cancer UK developed Quality Performance Indicators (QPIs) for the treatment of KC. Adherence to these QPIs was reported for all patients with a histological diagnosis of KC diagnosed in England between 2017 and 2018. Utilising data extracted from national datasets, logistic and linear probability models were used to estimate geographic variation in the delivery of surgery and systemic anti-cancer therapy at Cancer Alliance and NHS trust levels. Results were adjusted for a priori confounders, including age at diagnosis, area deprivation of residence, and Charlson Comorbidity Index. Differences in overall survival are reported. The cohort comprised 18,640 tumours in 18,421 patients. Of tumours diagnosed, median patient age was 68 (interquartile range 58–77) years and 63.4% were in males. When stratified by Cancer Alliance, the proportions of T1a/T1b/N0/M0 KC that had radical nephrectomy (RN), nephron sparing surgery or ablation ranged from 53.3% (95% CI [48.7, 57.8]) to 80.3% (95% CI [73.0, 86.0]). For stage T1b-3 cancers, the proportion that received RN ranged from 65.6% (95% CI [60.3, 70.5]) to 77.3% (95% CI [72.1, 81.7]). Patients with M0 (n = 12,365) and M1 KC (n = 3312) at diagnosis had 24-month survival of 87.5% and 25.1%, respectively. Of patients diagnosed with M1 KC, 50.3% received systemic anti-cancer therapy, ranging from 39.7% (95% CI [33.7, 46.1]) to 70.7% (95% CI [59.6, 79.8]) between Cancer Alliances. The six-month survival of these patients was 77.4% compared to 27.6% for those that did not receive SACT. These major geographical differences in surgical and systemic therapy practice have led to national guideline development. • Analysis of 18,421 patients with Kidney Cancer presenting in England 2017–18. • Marked variations between Cancer Alliances in rates of surgery for primary kidney cancer. • Systemic anti-cancer therapy improves outcomes in metastatic kidney cancer patients. • Significant variations between Cancer Alliances in systemic anti-cancer therapy use. • Low rates of clinical trial recruitment. [ABSTRACT FROM AUTHOR]

Background PTH assays are not standardized; therefore, method-specific PTH reference intervals are required for interpretation of results. PTH increases with age in adults but age-related reference intervals for the Abbott intact PTH (iPTH) assay are not available. Methods Deidentified serum PTH results from September 2015 to November 2022 were retrieved from the laboratory information system of a laboratory serving a cosmopolitan population in central-west England for individuals aged 18 years and older if the estimated glomerular filtration rate was ≥60 mL/min, serum 25-hydroxyvitamin D was >50 nmol/L, and serum albumin-adjusted calcium and serum phosphate were within reference intervals. Age-specific reference intervals for Abbott iPTH were derived by an indirect method using the refineR algorithm. Results PTH increased with age and correlated with age when controlled for 25-hydroxyvitamin D, estimated glomerular filtration rate, and adjusted calcium (r = 0.093, P <.001). The iPTH age-specific reference intervals for 4 age partitions of 18 to 45 years, 46 to 60 years, 61 to 80 years, and 81 to 95 years were 1.6 to 8.6 pmol/L, 1.8 to 9.5 pmol/L, 2.0 to 11.3 pmol/L, and 2.3 to 12.3 pmol/L, respectively. PTH was higher in women compared with men (P <.001). Sex-specific age-related reference intervals could not be derived because of the limited sample size. Conclusion Age-specific Abbott iPTH reference intervals were derived. Application of age-specific reference intervals will impact the diagnosis and management of normocalcemic hyperparathyroidism, based on current definitions, and secondary hyperparathyroidism. Additional studies are required to clarify the effect of sex and ethnicity on PTH. [ABSTRACT FROM AUTHOR]

Background: The purpose of this 6-month intervention pilot feasibility randomised trial was to test sending brief messages using mobile phones to promote self-management through taking medication as prescribed to people with type 2 diabetes. This was to inform the design and conduct of a future large-scale United Kingdom-based clinical trial and establish the feasibility of recruitment, the technology used, follow-up, and data collection. Methods: A multicentre individually randomised, controlled parallel group trial in primary care, recruiting adults (≥ 35 years) with type 2 diabetes in England. Consenting participants were randomly allocated to receive short message system text messages up to four times a week, or usual care, for a period of 6 months; messages contained behavioural change techniques targeting medication use. The primary outcome was the rate of recruitment to randomisation of participants to the trial with a planned rate of 22 participants randomised per month. The study also aimed to establish the feasibility of follow-up at 6 months, with an aim of retaining more than 80% of participants. Data, including patient-reported measures, were collected at baseline and the end of the 6-month follow-up period, and a notes review was completed at 24 months. Results: The trial took place between 26 November 2018 and 30 September 2019. In total 209 participants were randomly allocated to intervention (n = 103) or usual care (n = 106). The maximum rate of monthly recruitment to the trial was 60–80 participants per month. In total, 12,734 messages were sent to participants. Of these messages, 47 were identified as having failed to be sent by the service provider. Participants sent 2,864 messages to the automated messaging system. Baseline data from medical records were available for > 90% of participants with the exception of cholesterol (78.9%). At 6 months, a further HbA1c measurement was reported for 67% of participants. In total medical record data were available at 6 months for 207 (99.0%) of participants and completed self-report data were available for 177 (84.7%) of participants. Conclusion: The feasibility of a large-scale randomised evaluation of brief message intervention for people with type 2 diabetes appears to be high using this efficient design. Failure rate of sending messages is low, rapid recruitment was achieved among people with type 2 diabetes, clinical data is available on participants from routine medical records and self-report of economic measures was acceptable. Trial registration: ISCTRN ISRCTN13404264. Registered on 10 October 2018. [ABSTRACT FROM AUTHOR]

Objective GCA is the commonest primary systemic vasculitis in adults, with significant health economic costs and societal burden. There is wide variation in access to secondary care GCA services, with 34% of hospitals in England not having any formal clinical pathway. Quality standards provide levers for change to improve services. Methods The multidisciplinary steering committee were asked to anonymously put forward up to five aspects of service essential for best practice. Responses were qualitatively analysed to identify common themes, subsequently condensed into domain headings, and ranked in order of importance. Quality standards and metrics for each domain were drafted, requiring a minimum 75% agreement. Results 13 themes were identified from the initial suggestions. Nine quality standards with auditable metrics were developed from the top 10 themes. Patient Access, glucocorticoid use, pathways, ultrasonography, temporal artery biopsy, PET scan access, rheumatology/ophthalmology expertise, education, multidisciplinary working have all been covered in these quality standards. Access to care is a strand that has run through each of the developed standards. An audit tool was developed as part of this exercise. Conclusion These are the first consensus auditable quality standards developed by clinicians from rheumatology and ophthalmology, nursing representatives and involvement of a patient charity. We hope that these standards will be adopted by commissioning bodies to provide levers for change from the improvement of patient care of individuals with GCA. [ABSTRACT FROM AUTHOR]

Health information exchange (HIE) is seen as a key component of effective care but remains poorly evidenced at a health system level. In the UK National Health Service (NHS), the ability to share primary care data with secondary care clinicians is a focus of continued digital investment. In this study, we report the evolution of interoperable technology across a period of rapid digital transformation in NHS England from 2015 to 2019, and test association of primary to secondary care data-sharing capabilities with clinical care quality indicators across all acute secondary care providers (n = 135 NHS Trusts). In multivariable analyses, data-sharing capabilities are associated with reduction in patients breaching an Accident & Emergency (A&E) 4-h decision time threshold, and better patient-reported experience of acute hospital care quality. Using synthetic control analyses, we estimate mean 2.271% (STD+/−3.371) absolute reduction in A&E 4-h decision time breach, 12 months following introduction of data-sharing capabilities. Our findings support current digital transformation programmes for developing regional HIE networks but highlight the need to focus on implementation factors in addition to technological procurement. [ABSTRACT FROM AUTHOR]

Introduction: There has been global investment of new ways of working to support workforce pressures, including investment in clinical pharmacists working in primary care by the NHS in the England. Clinical pharmacists are well suited to support older adults who have multiple long-term conditions and are on multiple medications. It is important to establish an evidence base for the role of clinical pharmacists in supporting older adults in primary care, to inform strategic and research priorities. The aim of this scoping review is to identify, map and describe existing research and policy/guidance on the role of clinical pharmacists in primary care supporting older adults, and the models of care they provide. Methods and analysis: A scoping review guided by the Joanne Briggs Institute methodology for scoping reviews, using a three-step strategy. We will search Medline, CINAHL, Scopus, EMBASE, Web of Science, PSYCHInfo, and Cochrane for English language articles, from 2015 –present day. Grey literature will be searched using Grey Matters guidelines, the Index of Grey Literature and Alternative Sources and Resources, and Google keyword searching. References of all included sources will be hand searched to identify further resources. Using the Population, Concept and Context framework for inclusion and exclusion criteria, articles will be independently screened by two reviewers. The inclusion and exclusion criteria will be refined after we become familiar with the search results, following the iterative nature of a scoping review. Data will be extracted using a data extraction tool using Microsoft Excel and presented using a narrative synthesis approach. Ethics and dissemination: Ethical approval is not required for this review. Review findings will be disseminated in academic conferences and used to inform subsequent qualitative research. Findings will be published and shared with relevant local and national organisations. [ABSTRACT FROM AUTHOR]

An ecological study from England examines the relationship between primary care and life expectancy. The study confirms three hypotheses: higher life expectancy is associated with more practice staff, better access and continuity of care, as well as better clinical care in practices. The results show that life expectancy is most strongly related to population characteristics and the deprivation index. Higher patient-related payment to the practice and the number of specialist doctors per 1000 patients are also associated with higher life expectancy. The study emphasizes the importance of investing in primary care to improve life expectancy. [Extracted from the article]

Aim: To identify and describe the impact areas of a newly developed leadership development programme focussed on positioning leaders to improve the student experience of the clinical learning environment. Background: There is a need to consider extending traditional ways of developing leaders within the clinical learning in order to accommodate an increased number of students and ensure their learning experience is fulfilling and developmental. The Florence Nightingale Foundation implemented a bespoke leadership development programme within the clinical learning environment. Identifying the areas of impact will help to inform organisational decision making regarding the benefits of encouraging and supporting emerging leaders to undertake this type of programme. Method: For this qualitative descriptive study, eight health care professionals who took part in a bespoke leadership development programme were interviewed individually and then collectively. The Florence Nightingale Foundation fellowship/scholarship programme is examined to determine impact. Results: Two key themes were described in relation to impact of the programme. These were 'Personal Development' and 'Professional Impact'. The two key themes comprised several subthemes. The notion of time and space to think was subsumed within each theme. Conclusion: Data highlights that the Florence Nightingale Foundation programme had a distinct impact on participants by transforming thinking and increasing self‐confidence to enable changes to make improvements both within their organisations and at national level. Implications for Nursing Management: Health care managers must continue to invest in building leadership capacity and capability through programmes that can help position individuals to realize their potential to positively influence health outcomes and wider society. [ABSTRACT FROM AUTHOR]

In England, not all cancer drugs are routinely funded; new medicines are first appraised by the National Institute for Health and Care Excellence. Funding can be temporarily given through the Cancer Drugs Fund while further information is collected. The Systemic Anti-Cancer Therapy (SACT) dataset collects information on all patients receiving chemotherapy in England. To date, little has been published, despite concerns that real-world effectiveness of medicines may be inferior to that seen in clinical trials. The aim of the present study was to establish the feasibility of using our local copy of routinely collected SACT data for the evaluation of outcomes, using the data within the context of gastrointestinal cancers. We used our local SACT dataset submissions from three National Health Service trusts, with a reproducible method of data linkage, to undertake a cohort analysis of treatment duration and overall survival for cetuximab, panitumumab, trifluridine/tipiracil (all three in colorectal cancer), sorafenib (in hepatocellular cancer) and nab-paclitaxel (nanoparticle albumin-bound paclitaxel) with gemcitabine (in pancreatic cancer) for all patients treated from May 2016 to March 2021. In our population, epidermal growth factor receptor inhibitors and trifluridine/tipiracil and sorafenib performed similarly to expected but nab-paclitaxel with gemcitabine in pancreatic cancer seemed to be no better than gemcitabine alone, when given within the current funding arrangements in England. Our results support the publication of national outcome data. If these results are confirmed on a larger cohort, it would support the reappraisal of certain drugs and provide further evidence to clinicians and patients when deciding the best treatment. • This study used local data and a simple IT system to analyse real-world outcomes. • Cetuxumab, panitumumab, sorafenib and trifluridine/tipiracil outcomes matched trials. • nab-paclitaxel in pancreatic cancer had poorer outcomes than expected. [ABSTRACT FROM AUTHOR]

Trauma in older people leads to substantial morbidity and mortality. The National Hip Fracture Database (NHFD) has driven improved practice with units compared to identify outliers. In 2013, our unit was an outlier for mortality post hip fracture (30-day mortality 12.2% vs. 8.3% nationally). This triggered external review. In 2019 the unit was highlighted as an exemplar in the UK. We describe the process that moved us from outlier to outstanding. After the initial review process, we made changes to our healthcare system, with regular reassessment of progress and care quality. Examples include a dedicated hip fracture unit, strong leadership (Nursing, Orthopaedic, Geriatrician, Anaesthetic), consultant-led in-depth monthly mortality reviews, changes to admission pathways and delirium prevention. Improvements were seen in all aspects of hip fracture care in 2019 compared with 2012. Thirty-day case-mixed adjusted mortality halved (12.2–6.1%), with substantial reductions in reoperations and pressure sores. Length of stay reduced by 5.9 days. In 2019 our unit's performance was significantly above the national average for all six indicators assessed by NHFD: prompt orthogeriatric review (97% vs. 91% national average), prompt surgery (85% vs. 68%); NICE compliant surgery (85% vs. 74%); prompt mobilisation (93% vs. 81%); not delirious postoperatively (77% vs. 69%); return to original residence (78% vs. 71%). The NHFD highlighted our Unit as one of nine (from 175 total) highly performing UK trusts. We summarise our service development and improvement work undertaken to achieve 'outstanding' status, which provides a valuable template to units managing trauma in older people. [ABSTRACT FROM AUTHOR]

Point-of-care tests (POCTs) to diagnose sexually transmitted infections (STIs) have potential to positively impact patient management and patient perceptions of clinical services. Yet there remains a disconnect between development of new technologies and their implementation into clinical care. With the advent of new STI POCTs arriving to the global market, guidance for their successful adoption and implementation into clinical services is urgently needed. We conducted qualitative in-depth interviews with professionals prior to and post-implementation of a Chlamydia trachomatis/Neisseria gonorrhoeae POCT into clinical services in England to define key stakeholder roles and explore the process of POCT integration. Participants self-identified themselves as key stakeholders in the STI POCT adoption and/or implementation processes. Data consisted of interview transcripts, which were analysed thematically using NVIVO 11. Six sexual health services were included in the study; three of which have implemented POCTs. We conducted 40 total interviews: 31 prior to POCT implementation and 9 follow-up post-implementation. Post-implementation data showed that implementation plans required little or no change during service evaluation. Lead clinicians and managers self-identified as key stakeholders for the decision to purchase, while nurses self-identified as "change champions" for implementation. Many identified senior clinical staff as those most likely to introduce and drive change. However, participants stressed the importance of engaging all clinical staff in implementation. While the accuracy of the POCT, its positive impact on patient management and the ease of its integration within existing pathways were considered essential, costs of purchasing and utilising the technology were identified as central to the decision to purchase. Our study shows that key decision-makers for adoption and implementation require STI POCTs to have laboratory-comparable accuracy and be affordable for purchase and ongoing use. Further, successful integration of POCTs into sexual health services relies on supportive interpersonal relationships between all levels of staff. [ABSTRACT FROM AUTHOR]

Infants' experience of the early caregiving environment is fundamental to the development of positive social and emotional functioning. The Leeds Infant Mental Health Service was established to provide early intervention to infantsunder two and their caregivers, where there are concerns about the attachment relationship. This paper describes preliminary data to evaluate its effectiveness. Improved parent-infant relationships and parental well-beingare achieved by asmall multidisciplinary workforce through direct therapeutic work with infants and their caregivers and by up-skilling other professionals who are in contact with infants, through specialist training and consultation. Launched in 2012, the service has trained over 2500 professionals.Over 500 reflective case discussions and 200 case consultations have been delivered to practitioners, many of whom work with vulnerable infants. Ascreening tool has been developed to enable health visitors to identify infants at risk of developing poor attachment relationships with their caregivers. Direct therapeutic work has been completed with over 531 families, the majority (71%) before the infant was 6 months old. Caregivers and professionals are positive about the service. The model represents a clinically and cost-effective way to deliver city-wide infant mental health provision. Future research is needed on effectivess, particularly long-term outcomes. [ABSTRACT FROM AUTHOR]

Background and objective The impact of the COVID-19 pandemic on the quality of care for patients with acute myocardial infarction (AMI) is uncertain. We aimed to compare quality of AMI care in England and Wales during and before the COVID-19 pandemic using the 2020 European Society of Cardiology Association for Acute Cardiovascular Care quality indicators (QIs) for AMI. Methods Cohort study of linked data from the AMI and the percutaneous coronary intervention registries in England and Wales between 1 January 2017 and 27 May 2020 (representing 236 743 patients from 186 hospitals). At the patient level, the likelihood of attainment for each QI compared with pre COVID-19 was calculated using logistic regression. The date of the first national lockdown in England and Wales (23 March 2020) was chosen for time series comparisons. Results There were 10 749 admissions with AMI after 23 March 2020. Compared with before the lockdown, patients admitted with AMI during the first wave had similar age (mean 68.0 vs 69.0 years), with no major differences in baseline characteristics (history of diabetes (25% vs 26%), renal failure (6.4% vs 6.9%), heart failure (5.8% vs 6.4%) and previous myocardial infarction (22.9% vs 23.7%)), and less frequently had high Global Registry of Acute Coronary Events risk scores (43.6% vs 48.6%). There was an improvement in attainment for 10 (62.5%) of the 16 measured QIs including a composite QI (43.8% to 45.2%, OR 1.06, 95% CI 1.02 to 1.10) during, compared with before, the lockdown. Conclusion During the first wave of the COVID-19 pandemic in England and Wales, quality of care for AMI as measured against international standards did not worsen, but improved modestly. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has disrupted healthcare activity. The NHS stopped non-urgent work in March 2020, later recommending services be restored to near-normal levels before winter where possible.Aim: To describe the volume and variation of coded clinical activity in general practice, taking respiratory disease and laboratory procedures as examples.Design and Setting: Working on behalf of NHS England, a cohort study was conducted of 23.8 million patient records in general practice, in situ using OpenSAFELY.Method: Activity using Clinical Terms Version 3 codes and keyword searches from January 2019 to September 2020 are described.Results: Activity recorded in general practice declined during the pandemic, but largely recovered by September. There was a large drop in coded activity for laboratory tests, with broad recovery to pre-pandemic levels by September. One exception was the international normalised ratio test, with a smaller reduction (median tests per 1000 patients in 2020: February 8.0; April 6.2; September 6.9). The pattern of recording for respiratory symptoms was less affected, following an expected seasonal pattern and classified as 'no change'. Respiratory infections exhibited a sustained drop, not returning to pre-pandemic levels by September. Asthma reviews experienced a small drop but recovered, whereas chronic obstructive pulmonary disease reviews remained below baseline.Conclusion: An open-source software framework was delivered to describe trends and variation in clinical activity across an unprecedented scale of primary care data. The COVD-19 pandemic led to a substantial change in healthcare activity. Most laboratory tests showed substantial reduction, largely recovering to near-normal levels by September, with some important tests less affected and recording of respiratory disease codes was mixed. [ABSTRACT FROM AUTHOR]

Liaison neurology (consulting with inpatient ward referrals) is the main way that most patients admitted with neurological disease will access neurology services. Most liaison neurology services are responsive, seeing referrals on request, but they also can be proactive, with a regular neurology presence in the acute medical unit. Fewer than half of hospitals in England have electronic systems, yet these can facilitate the process--allowing electronic responses to advise on investigations before seeing the patient, and arranging follow-up after--as well as prioritising referrals and documenting the process. In this time of COVID-19, there are additional benefits in providing prompt remote advice. Improving the way liaison neurology is delivered can improve patient outcomes and save money by shortening admissions. This hidden work of the neurologists needs to be recorded and recognised. [ABSTRACT FROM AUTHOR]

Introduction: General practice (GP) antidepressants (ADs) prescribing in England has almost doubled in the past decade: how does location, GP characteristics, and prescribing selection influence antidepressant prescribing rate (ADPR) and growth. Methods: Stepwise multivariate regression analysis was applied to national public relevant data for each general practice to establish associations between these factors and ADPR. The regression coefficient was applied to the actual change in the number of different ADs and costs/dose to extrapolate the impact of these on growth. Results: In 2017–2018, 2.1 billion doses of antidepressant were prescribed into a population of 52 million people in 6,146 larger practices. In the model, location demographics accounted for 62% of the variation in ADPR: including practice size and health raised this to 71%, and local prescribing behaviour to 80%. Practices using more different drugs and lower‐cost/dose had higher ADPR. Extrapolation showed that 40% of growth in ADPR could be attributed to the historic changes in these factors. Conclusions: While practice location factors do impact on AD prescription rates, local long‐term physical health condition prevalence and prescribing behaviours are almost as important. We hope that our findings can provide insights that are helpful to local clinical behaviour and medicines management. [ABSTRACT FROM AUTHOR]

Background: Molecular point-of-care testing (POCT) for influenza in primary care could influence clinical care and patient outcomes.Aim: To assess the feasibility of incorporating influenza POCT into general practice in England.Design and Setting: A mixed-methods study conducted in six general practices that had not previously participated in respiratory virology sampling, which are part of the Royal College of General Practitioners Research and Surveillance Centre English sentinel surveillance network, from February 2019 to May 2019.Method: A sociotechnical perspective was adopted using the Public Health England POCT implementation toolkit and business process modelling notation to inform qualitative analysis. Quantitative data were collected about the number of samples taken, their representativeness, and the virology results obtained, comparing them with the rest of the sentinel system over the same weeks.Results: A total of 312 POCTs were performed; 276 were used for quantitative analysis, of which 60 were positive for influenza and 216 were negative. The average swabbing rate was 0.4 per 1000 population and swab positivity was between 16.7% (n = 14/84) and 41.4% (n = 12/29). Given a positive influenza POCT result, the odds ratio of receiving an antiviral was 14.1 (95% confidence intervals [CI] = 2.9 to 70.0, P<0.001) and of receiving an antibiotic was 0.4 (95% CI = 0.2 to 0.8, P = 0.01), compared with patients with a negative result. Qualitative analysis showed that it was feasible for practices to implement POCT, but there is considerable variation in the processes used.Conclusion: Testing for influenza using POCT is feasible in primary care and may improve antimicrobial use. However, further evidence from randomised trials of influenza POCT in general practice is needed. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to explore whether performance indicators in children's services can be used to predict the outcome of Ofsted inspections. Every local authority in England is inspected by Ofsted (the Office for Standards in Education, children's services and skills) and given a single, overall rating – outstanding, good, requirements improvement or inadequate. These ratings carry immense significance. Persistently inadequate authorities are liable to have legal responsibility for providing services outsourced to another organisation. Ofsted have been criticised in the past for focusing too much on procedure, and previous research has highlighted the importance of deprivation and spending levels. In this paper, we describe a new study using more recent Ofsted and local authority data to see what patterns there might be now between performance indicators and inspection results. Design/methodology/approach: We report an analysis of 45 variables in relation to children in need, children in care and young adults with care experience. Using statistical analysis, we consider to what extent performance measured by these variables differs between authorities based on their Ofsted ratings and which of the variables can be used to predict Ofsted inspection outcomes. Findings: We identified no consistent patterns of difference between local authorities in relation to Ofsted ratings. Deprivation was the best single predictor of Ofsted inspection outcomes. Originality/value: This study uses relatively recent Ofsted and local authority data and builds on previous research findings which are increasingly highlighting the significance of deprivation as a factor to help explain variable performance between different authorities. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether mortality alerts, triggered by sustained higher than expected hospital mortality, are associated with other potential indicators of hospital quality relating to factors of hospital structure, clinical process and patient outcomes. Methods: Cross-sectional study of National Health Service hospital trusts in England (2011–2013) using publicly available hospital measures reflecting organizational structure (mean acute bed occupancy, nurse/bed ratio, training satisfaction and proportion of trusts with low National Health Service Litigation Authority risk assessment or in financial deficit); process (mean proportion of eligible patients who receive percutaneous coronary intervention within 90 minutes) and outcomes (mean patient satisfaction scores, summary measures of hospital mortality and proportion of patients harmed). Mortality alerts were based on hospital administrative data. Results: Mortality alerts were associated with structural indicators and outcome indicators of quality. There was insufficient data to detect an association between mortality alerts and the process indicator. Conclusions: Mortality alerts appear to reflect aspects of quality within an English hospital setting, suggesting that there may be value in a mortality alerting system in highlighting poor hospital quality. [ABSTRACT FROM AUTHOR]

Background: The Care Quality Commission regulates, inspects, and rates general practice providers in England. Inspections are costly and infrequent, and are supplemented by a system of routine quality indicators, measuring patient satisfaction and the management of chronic conditions. These indicators can be used to prioritise or target inspections.Aim: To determine whether this set of indicators can be used to predict the ratings awarded in subsequent inspections.Design and Setting: This cross-sectional study was conducted using a dataset of 6860 general practice providers in England.Method: The indicators and first-inspection ratings were used to build ordered logistic regression models to predict inspection outcomes on the four-level rating system ('outstanding', 'good', 'requires improvement', and 'inadequate') for domain ratings and the 'overall' rating. Predictive accuracy was assessed using the percentage of correct predictions and a measure of agreement (weighted κ).Results: The model correctly predicted 79.7% of the 'overall' practice ratings. However, 78.8% of all practices were rated 'good' on 'overall', and the weighted κ measure of agreement was very low (0.097); as such, predictions were little more than chance. This lack of predictive power was also found for each of the individual domain ratings.Conclusion: The poor power of performance of these indicators to predict subsequent inspection ratings may call into question the validity and reliability of the indicators, inspection ratings, or both. A number of changes to the way data relating to performance indicators are collected and used are suggested to improve the predictive value of indicators. It is also recommended that assessments of predictive power be undertaken prospectively when sets of indicators are being designed and selected by regulators. [ABSTRACT FROM AUTHOR]

Clinical pharmacists are important members of the multidisciplinary team within primary care networks (PCNs), which were established across England in July 2019. This article discusses the roles that will be expected of clinical pharmacists within PCNs and how these roles are likely to develop in the future. [ABSTRACT FROM AUTHOR]

Introduction: Increasing the capacity of Primary Care to meet the challenge of providing future complex and multi-disciplinary care in England has led to the increasing establishment of 'Training Hubs' [TH]. Other terms are used interchangeably to refer to TH activity: Advanced Training Practices, Enhanced Training Practices and Community Education Providers. The aim of this study was to gather the perceptions of TH Leads in North West England on how they established their TH and lessons learned. Methods: Five semi-structured telephone interviews were undertaken with TH Leads. Thematic analysis of the transcripts was undertaken. Findings: Four themes were identified: Motivation and Expectations of Establishing THs; Benefits to Learners and Practice Staff; Implementation Challenges and Barriers to Scale-Up; Sustainability and Wider Implementation. Discussion: TH Leads highlighted that the establishment of THs enhanced the multi-disciplinary learning experience. However, several barriers for sustaining the quality of the TH learning environments were identified. Difficulties recruiting 'Spoke Practices' were greater than expected. Findings identified the following factors for consideration for wider implementation: the maintenance of TH Lead support networks; appropriateness of funding to encourage practices who may be reluctant to take on this additional responsibility; the importance of communication channels between THs and HEIs; careful management of students numbers. [ABSTRACT FROM AUTHOR]

Aim: To investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.Methods: Nationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.Results: There were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3-84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9-77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%-13.1%) vs 2.3% (IQR 0.8%-7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.Conclusion: According to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap. [ABSTRACT FROM AUTHOR]

Trifluridine (FTD) and tipiracil (TPI) hydrochloride tablets (TAS-102) were used for the treatment of patients with metastatic rectal cancer that was resistant to conventional chemotherapy drugs. In this study, a rapid and sensitive liquid chromatography-tandem mass spectrometry method was developed and fully validated for the simultaneous determination of TPI, FTD, and the metabolite 5-trifluoromethyluracil (FTY) of FTD in human plasma. The plasma samples were prepared by protein precipitation. The chromatography separation was performed using ACE Excel 3 AQ (100 × 2.1 mm i.d., 1.7 µm, ACE, England) column protected by a security guard cartridge (4.0 × 2.0 mm i.d., 5 µm, Phenomenex, USA) with a gradient elution of 0.05% acetic acid in water and methanol at a flow rate of 0.35 mL/min. The MS/MS analysis was performed by using multiple reaction monitoring with the segmented polarity (positive for TPI: m/z 243.1→183.0, and negative for FTD: m/z 295.1→252.0 and FTY: m/z 178.9→158.9) electrospray ionization mode. The segmented polarity mode was designed to achieve two advantages: better sensitivity and simultaneous determination of the analytes with different ion polarities. The calibration ranges were as follows: 1.00–250 ng/ for TPI, 8.00–8000 ng/mL for FTD and 5.00–1250 ng/mL for FTY. The selectivity, accuracy, precision, matrix effect, recovery, carryover, dilution integrity and stability test results meet ICH acceptance criteria. The method was evaluated using the RGB model and successfully applied to a clinical study in patients with solid tumors. For TPI, FTD and FTY, the maximum plasma concentration was 137–147 ng/mL, 6160–6240 ng/mL and 724–725 ng/mL, respectively; the plasma elimination half-life was 1.69–1.78 h, 1.70 h, and 3.09–3.14 h, respectively, after an oral administration of 60 mg TAS-102. [Display omitted] • A sensitive LC-MS/MS method was established for pharmacokinetics of nucleoside drugs. • Simultaneous determination of tipiracil, trifluridine and 5-trifluoromethyluracil. • MS response of analytes can be improved by using segmented polarity. • The PK parameters were obtained in Chinese patients after the administration. [ABSTRACT FROM AUTHOR]

Quality clinical placements for pre-registration nursing students are particularly important at a time when there is a recruitment crisis within nursing. A study was conducted to identify what impact clinical placements have on pre-registration adult nursing students' choice of clinical specialty as a newly qualified nurse (NQN). Data were collected from students on their final day of a BSc (Hons) programme at two campus sites at a university in the east of England. Participants judged the desirability of a clinical placement on the basis of the quality of the learning, working and clinical environment and the nature of the specialty. The influence of clinical placements on the choice of first destination of NQNs more than doubles within the final year of study. Clinical placements generate vivid experiences, which exert a strong influence on the first employment destination decisions of NQNs. [ABSTRACT FROM AUTHOR]

Purpose: Delay in histologically confirming rectal cancer may lead to late treatment as histological confirmation is required prior to chemo-radiotherapy or surgical intervention. Multidisciplinary colorectal meetings indicate that there are patients who require multiple tissue biopsy episodes prior to histologically confirming rectal cancer. The purpose of this paper is to examine a quality improvement (QI) measure's impact on tissue biopsy process diagnostic yield.Design/methodology/approach: The authors performed the study in two phases (pre- and post-QI), between February 2012 and April 2014 in a district general hospital. The QI measures were derived from process mapping a rectal cancer diagnostic pathway. The primary outcome was to assess the tissue biopsy process diagnostic yield. The secondary outcome included total breaches for a 62-day target in the pre- and post-QI study phases.Findings: There was no significant difference in demographics or referral mode in both study phases. There were 81 patients in the pre-QI phase compared to 38 in the post-QI phase, 68 per cent and 74 per cent were referred via the two-week wait urgent pathway, respectively. Diagnostic tissue biopsy process yield improved from 58.1 to 77.6 per cent after implementing the QI measure ( p=0.02). The 62-day target breach was reduced from 14.8 to 3.5 per cent ( p=0.42).Practical Implications: Simple QI measures can achieve significant improvements in rectal cancer diagnostic tissue biopsy process yields. A multidisciplinary approach, involving process mapping and cause and effect modelling, proved useful tools.Originality/value: A process mapping exercise and QI measures resulted in significant improvements in diagnostic yield, reducing the episodes per patient before histological diagnosis was confirmed. [ABSTRACT FROM AUTHOR]

Abstract In the United Kingdom student nurses spend approximately half of their education programme in a practical setting commonly referred to as the Clinical Learning Environment (CLE). The significant amount of time student nurses spend in CLEs, combined with reports of negative experiences, indicate that it is important to consider the challenges of learning within this environment. Nurse Link Lecturers spend up to 20% of their teaching time supporting student nurses in CLEs. Link lecturers' proximity to the CLE means that they are well-placed to articulate the challenges facing student nurses in this context. This paper reports on a study that used interviews and focus groups to collect experienced adult field Link Lecturers' views on the challenges facing student nurses in CLEs. Link Lecturers reported that students often find themselves in polarised positions of either 'fitting in' with the pressures of the environment and thereby potentially gaining 'access to learning' opportunities or 'falling out' and merely 'learning to get through' their placement. Mentors were thought to have a significant influence on student nurses' negotiation of learning. This insight is timely due to the changes in supervisory and assessment arrangements required by the new Nursing and Midwifery Council Standards (NMC, 2018). Highlights • The Clinical Learning Environment may be a challenging environment to learn in (for students) and to teach in (for mentors). • Mentors are responsible for delivering patient care in addition to supporting student learning. • Students may 'fit in' and potentially gain 'access to learning' opportunities or 'fall out' and merely 'learn to get through'. • It is timely to reconsider supervisory and assessment arrangements in practice. [ABSTRACT FROM AUTHOR]

Background: Paliperidone palmitate is one of the most widely prescribed long-acting injectable (LAI) antipsychotics in the UK. However, it is relatively expensive and there are few data comparing its effectiveness to that of other LAI antipsychotics. We sought to address this issue by analyzing a large anonymized electronic health record (EHR) dataset from patients treated with LAI antipsychotics. Methods: EHR data were obtained from 1281 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who started treatment with a LAI antipsychotic between 1 April 2011 and 31 January 2015. The number of days spent as a psychiatric inpatient and the number of admissions to a psychiatric hospital were analyzed in each of the 3 years before and after LAI prescription. Results: Patients treated with paliperidone palmitate (n = 430; 33.6%) had a greater number of inpatient days and a greater number of admissions in the year prior to treatment than those treated with other LAI antipsychotics. Nevertheless, in the 3 years after initiation there were no significant differences between paliperidone and the other LAI antipsychotics in the number of days as an inpatient (B coefficient 5.4 days, 95% confidence interval (CI) −57.3 to 68.2, p = 0.86) or number of hospital admissions (Incidence rate ratio 1.07, 95% CI 0.62 to 1.83, p = 0.82). Conclusion: Paliperidone palmitate was more likely to be prescribed in patients with more frequent and lengthy hospital admissions prior to initiation. However, the absence of differences in outcomes after initiation indicates that paliperidone palmitate was not more effective than other cheaper LAI antipsychotics. [ABSTRACT FROM AUTHOR]

General practice continues to increase in use as a placement area for nursing students in England. Introducing new general practice placements requires intensive preparation to ensure there is a quality learning environment and the placement is successful. A qualitative study used interviews and focus groups to understand nine nursing students' perspectives of factors that affected their clinical learning experiences in general practice placements. Students identified factors aiding their learning that were congruent with the characteristics of a good clinical learning environment proposed by the Willis Commission (2012). These included nurse mentorship qualities, interdisciplinary practices, opportunities to share learning, being given a new focus and motivation for learning. The findings suggest GP placements can provide a high-quality learning environment, the factors identified enabling the development of analytical decision-making and professional autonomy, which students regarded as being important components of their successful learning in practice. Further investment and support to increase mentor development in general practice will ensure a wider exposure and positive experience in this clinical practice area for nursing students. This may lead to fewer difficulties in recruiting practice nurses in future. [ABSTRACT FROM AUTHOR]

This study represents an effectiveness study and service evaluation of a cognitive behavioral, couple‐based treatment for depression (BCT‐D) provided in London services that are part of the “Improving Access to Psychological Therapies” (IAPT) program in England. Twenty‐three therapists in community clinics were trained in BCT‐D during a 5‐day workshop, followed by monthly group supervision for 1 year. The BCT‐D treatment outcome findings are based on 63 couples in which at least one partner was depressed and elected to receive BCT‐D. Eighty‐five percent of couples also demonstrated relationship distress, and 49% of the nonclient partners also met caseness for depression or anxiety. Findings demonstrated a recovery rate of 57% with BCT‐D, compared to 41% for all IAPT treatments for depression in London. Nonclient partners who met caseness demonstrated a 48% recovery rate with BCT‐D, although they were not the focus of treatment. BCT‐D was equally effective for clients regardless of the clinical status of the nonclient partner, suggesting its effectiveness in assisting both members of the couple simultaneously. Likewise, treatment was equally effective whether or not both partners reported relationship distress. The findings are promising regarding the successful application of BCT‐D in routine clinical settings. [ABSTRACT FROM AUTHOR]

Background: Emergency presentations (EP) represent over a third of all lung cancer admissions in England. Such presentations usually reflect late stage disease and are associated with poor survival. General practitioners (GPs) act as gate-keepers to secondary care and so we sought to understand the association between GP practice characteristics and lung cancer EP.Methods: Data on general practice characteristics were extracted for all practices in England from the Quality Outcomes Framework, the Health and Social Care Information Centre, the GP Patient Survey, the Cancer Commissioning Toolkit and the area deprivation score for each practice. After linking these data to lung cancer patient registrations in 2006-2013, we explored trends in three types of EP, patient-led, GP-led and 'other', by general practice characteristics and by socio-demographic characteristics of patients.Results: Overall proportions of lung cancer EP decreased from 37.9% in 2006 to 34.3% in 2013. Proportions of GP-led EP nearly halved during this period, from 28.3 to 16.3%, whilst patient-led emergency presentations rose from 62.1 to 66.7%. When focusing on practice-specific levels of EP, 14% of general practices had higher than expected proportions of EP at least once in 2006-13, but there was no evidence of clustering of patients within practice, meaning that none of the practice characteristics examined explained differing proportions of EP by practice.Conclusion: We found that the high proportion of lung cancer EP is not the result of a few practices with very abnormal patterns of EP, but of a large number of practices susceptible to reaching high proportions of EP. This suggests a system-wide issue, rather than problems with specific practices. High proportions of lung cancer EP are mainly the result of patient-initiated attendances in A&E. Our results demonstrate that interventions to encourage patients not to bypass primary care must be system wide rather than targeted at specific practices. [ABSTRACT FROM AUTHOR]

We investigated the relationship between primary care supply and quality of care in England. We analysed 35 process measures of quality of care covering 13 medical conditions using English Longitudinal Study of Aging data linked to area of residence indicators. Greater GP density had a statistically significant and positive association with quality of care, and distance to GP practice had a statistically significant and negative association. The effects were concentrated in indicators of care related to cardiovascular diseases and arthritis, and on specific indicators for diabetes, incontinence and hearing problems. The results suggest that better primary care supply can improve quality of care. [ABSTRACT FROM AUTHOR]

Objective: To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making.Data Sources: A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012.Study Design: Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care ("quality assurance," "education and training," "medicine management," "access," "clinical management," and "patient-centered care"), health outcomes ("intermediate outcomes" and "patient-reported health status"), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling.Principal Findings: The model supported two independent paths. In the first path, "access" was associated with "patient-centered care" (β = 0.63), which in turn was strongly associated with "patient satisfaction" (β = 0.88). In the second path, "education and training" was associated with "clinical management" (β = 0.32), which in turn was associated with "intermediate outcomes" (β = 0.69). "Patient-reported health status" was weakly associated with "patient-centered care" (β = -0.05) and "patient satisfaction" (β = 0.09), and not associated with "clinical management" or "intermediate outcomes."Conclusions: This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Objectives Recent public reporting initiatives in England highlight general practice variation in indicators of diagnostic activity related to cancer. We aimed to quantify the size and sources of variation and the reliability of practice-level estimates of such indicators, to better inform how this information is interpreted and used for quality improvement purposes. Design Ecological cross-sectional study. Setting English primary care. Participants All general practices in England with at least 1000 patients. Main outcome measures Sixteen diagnostic activity indicators from the Cancer Services Public Health Profiles. Results Mixed-effects logistic and Poisson regression showed that substantial proportions of the observed variance in practice scores reflected chance, variably so for different indicators (between 7% and 85%). However, after accounting for the role of chance, there remained substantial variation between practices (typically up to twofold variation between the 75th and 25th centiles of practice scores, and up to fourfold variation between the 90th and 10th centiles). The age and sex profile of practice populations explained some of this variation, by different amounts across indicators. Generally, the reliability of diagnostic process indicators relating to broader populations of patients most of whom do not have cancer (eg, rate of endoscopic investigations, or urgent referrals for suspected cancer (also known as 'two week wait referrals')) was high (>0.80) or very high (>0.90). In contrast, the reliability of diagnostic outcome indicators relating to incident cancer cases (eg, per cent of all cancer cases detected after an emergency presentation) ranged from 0.24 to 0.54, which is well below recommended thresholds (>0.70). Conclusions Use of indicators of diagnostic activity in individual general practices should principally focus on process indicators which have adequate or high reliability and not outcome indicators which are unreliable at practice level. [ABSTRACT FROM AUTHOR]

Purpose Each year approximately 3,200 women have a stillbirth in the UK. Although national evidence-based guidance has existed since 2010, case reviews continue to identify suboptimal clinical care and communication with parents. Inconsistencies in management include induction and management of labour and the frequency of investigation after stillbirth. The paper aims to discuss these issues.Design/methodology/approach An audit of stillbirths was performed in 2014 in 13 maternity units in the North West of England, this confirmed variation in practice described nationally. An integrated care pathway (ICP) was developed from national guidelines to enable optimal care for the management of stillbirth, reduce variation, standardise investigations and coordinate patient-focussed care. This was launched in 2015 and updated in 2016 to resolve the issues that were apparent after implementation.Findings Each participating unit had commenced using the ICP by May 2015. Following implementation there were changes in care, most notably from diverse methods for the induction of labour to guideline-directed induction of labour. There were trends towards better care in terms of information given, choices offered, more appropriate analgesia in labour and improved post-delivery investigation for cause. Staff feedback about the ICP was positive.Practical implications The use of this ICP improved care for women who had a stillbirth and their families. Issues with implementing a changed care pathway meant that further iterations were required, ongoing improvement is expected following the refinement of the ICP.Originality/value ICPs have been used for various clinical conditions. However, this is the first example of their use in women who had a stillbirth. [ABSTRACT FROM AUTHOR]

This overview provides insight into changes in clinical practice and the implications for nursing staff and clinicians who are involved in the management of patients undergoing primary total hip arthroplasty. The review highlights commonly used surgical approaches, their advantages, their associated risks and how to manage complications if they occur. [ABSTRACT FROM AUTHOR]

Improvement of wound outcomes is a priority for the NHS if the cost of wound management is to be reduced. Failure to undertake a full holistic wound assessment can result in inappropriate and ineffective treatment, resulting in delayed healing, which can have a negative effect on patient quality of life and healthcare resources. NHS England has commissioned a CQUIN scheme for 2017-19. This comprises 13 indicators which seek to improve quality and outcomes of care for NHS patients, while supporting local areas in delivering their sustainability and transformation partnerships (STPs). The tenth national indicator focuses on 'improving the assessment of wounds'. This article provides a practical guide to systematic wound assessment for community nurses so that CQUIN targets can be met, and also introduces a new tool from BSN medical, an Essity company, to help nurses in this area. [ABSTRACT FROM AUTHOR]

Objectives: To assess clinical service value of STI point-of-care test (POCT) use in a 'sample first' clinical pathway (patients providing samples on arrival at clinic, before clinician consultation). Specific outcomes were: patient acceptability; whether a rapid nucleic acid amplification test (NAAT) for Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) could be used as a POCT in practice; feasibility of non-NAAT POCT implementation for Trichomonas vaginalis (TV) and bacterial vaginosis (BV); impact on patient diagnosis and treatment.Methods: Service evaluation in a south London sexual health clinic. Symptomatic female and male patients and sexual contacts of CT/NG-positive individuals provided samples for diagnostic testing on clinic arrival, prior to clinical consultation. Tests included routine culture and microscopy; CT/NG (GeneXpert) NAAT; non-NAAT POCTs for TV and BV.Results: All 70 (35 males, 35 females) patients approached participated. The 'sample first' pathway was acceptable, with >90% reporting they were happy to give samples on arrival and receive results in the same visit. Non-NAAT POCT results were available for all patients prior to leaving clinic; rapid CT/NG results were available for only 21.4% (15/70; 5 males, 10 females) of patients prior to leaving clinic. Known negative CT/NG results led to two females avoiding presumptive treatment, and one male receiving treatment directed at possible Mycoplasma genitalium infection causing non-gonococcal urethritis. Non-NAAT POCTs detected more positives than routine microscopy (TV 3 vs 2; BV 24 vs 7), resulting in more patients receiving treatment.Conclusions: A 'sample first' clinical pathway to enable multiple POCT use was acceptable to patients and feasible in a busy sexual health clinic, but rapid CT/NG processing time was too long to enable POCT use. There is need for further development to improve test processing times to enable POC use of rapid NAATs. [ABSTRACT FROM AUTHOR]

Accessible Summary What is known on the subject? Primary care and, in particular, general practice ( GP) are often first point of access to health care. International evidence suggests that healthcare systems oriented towards primary care may produce better outcomes, at lower costs and with higher user satisfaction. Despite this, there are noted deficiencies and variations in the quality of care in primary care for patients with mental health problems., What this paper adds to existing knowledge? Emerging models of providing mental health services in primary care are poorly understood. This paper evaluates a mental health nurse-led Primary Care Liaison Service ( PCLS), developed in 2011 in inner London., The findings suggest that this type of service can improve the quality of care for people presenting with mental health problems within primary care, specifically due to improved integration, clinical effectiveness, patient-centred care, access and efficiency. The study also highlighted challenges such as staff retention within this new role and setting appropriate referral criteria., What are the implications for practice? This is a relatively new service, and the cost-effectiveness is not yet fully understood; however, commissioners may want to consider the potential benefits of a similar service in their area. The extent to which the findings are transferable will depend on service configuration and local demographics which can vary., Further research within this area could give more detail on the impact of such teams on health outcomes, recovery rates, secondary care referrals and accident and emergency attendances, and its cost-effectiveness., Abstract Aims/Question General practice is typically the first point of access to healthcare. This study explores what value a Primary Care Liaison Nurse ( PCLN) service, established in 2011, can bring to people with mental health problems in primary care. Method Semi-structured interviews were used to elicit participants' experiences and perspectives on the value of a PCLN service. Participants included ten interviews with seven general practitioners and three senior practitioners working in primary care mental health services. Thematic analysis, based on a 6-phase approach, was used to describe and explore the data collected. Results Five main themes were derived from the thematic analysis of the interviews relating to: integration; clinical effectiveness; patient centred care; access; and efficiency. Discussion The study suggests that the PCLN service can improve the quality of care and is generally highly valued by its stakeholders. The study identifies particularly valued elements of the service, including having a duty worker, as well as aspects which could be improved, such as patient criteria. Implications for practice This is a relatively new service and the cost-effectiveness is not yet fully understood; however, commissioners may want to consider the potential benefits of a similar service in their area. [ABSTRACT FROM AUTHOR]

Aim The Back Rehabilitation Programme (BRP) is a group exercise programme for patients with non-specific low back pain (NSLBP) that combines cognitive behavioural therapy principles and therapeutic exercise to empower patients to self-manage their condition. Poor attendance and high attrition rates resulted in changes to the format of the programme from a standard sequential approach to a continual rolling approach. The aim of this study was to evaluate the effectiveness of this new approach on patient outcomes and its impact on attendance rates. Method A service evaluation, using a retrospective, observational cohort design, of all patients with NSLBP who attended the BRP during a 12-month period was undertaken. Outcome measures used were as follows: Bournemouth Questionnaire (BQ); fitness tests: sit to stand test, step test and walk test (taken at baseline and post programme); and attendance (taken post programme). Results Of the patients, 56% had an improved BQ score > 47%, indicating a clinically significant change. Inferential testing showed statistically significant improvements in the BQ and all three fitness tests post programme (P< 0.0001). In total, 62 patients attended the rolling BRP, and 41 patients (66%) completed. Thus, the percentage of patients completing the new programme had doubled compared with the original standard programme. Conclusion Patients with NSLBP who attended the continual rolling BRP show clinical and statistical improvements. The rolling format also appeared to enhance patient attendance. As such, the rolling BRP should be considered by practitioners as an effective management strategy when treating patients with NSLBP. [ABSTRACT FROM AUTHOR]

Policy Points:Similarities and disparities between countries and initiatives are identified. Measuring, reporting, and rewarding quality is heavily focused on process measures. Hospital‐level benchmarking is not always available publicly. Quality‐related payment schemes vary widely, with several countries only piloting small‐scale initiatives.To increase quality accountability, the government has to set standards and incentives. The right balance between system centralization and decentralization has to be struck. Accountability needs to be based on outcomes, not process measures, and focus should be on hospital and medical condition levels. Providers have a central role as quality accountability advocates. Context: Studies have documented wide quality variation among hospitals within and across countries. Increasing quality‐of‐care accountability for hospitals, especially for patients and the general public, is an important policy objective, but no study has yet systematically and comprehensively compared leading countries’ initiatives in this regard. Methods: Based on expert interviews and an extensive literature review, we investigate hospital quality accountability in England, Germany, the Netherlands, Sweden, and the United States. The underlying framework includes 3 elements: measuring quality, reporting quality, and rewarding quality. Each element is subdivided into 2 dimensions, with measuring composed of indicator type and data source, reporting composed of degree of reporting centralization and data accessibility, and rewarding composed of extent of application and type of quality‐related payments. Findings: The results show a wide spectrum of approaches and progress levels. Measuring strategies are more similar across countries, while quality reporting and financial rewards are more dissimilar. Reporting of process indicators is more prevalent than reporting of outcomes. Most countries have introduced some quality‐related payment schemes, with the United States having the most comprehensive approach. Based on the cross‐country assessment, 5 policy levers to enhance quality transparency are identified and illustrated through country‐specific examples: (1) the government should take a central role in establishing standards and incentives for quality transparency and health IT system integration; (2) system centralization and decentralization need to be balanced to ensure both national comparability and local innovation; (3) health systems need to focus more on outcome transparency and less on process measures; (4) health systems need to engage providers as proponents of quality transparency; and (5) reporting should focus on hospital and condition levels to ensure comparability and enable meaningful patient choice. Conclusions: The findings facilitate cross‐country learning and best‐practice adoption by assessing hospital quality accountability strategies in 5 countries in a structured and comparative manner. The identified policy levers are relevant for enhancing breadth, depth, and value of quality accountability. [ABSTRACT FROM AUTHOR]

Purpose Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care. Design/methodology/approach Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management. Findings There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Originality/value The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors. [ABSTRACT FROM AUTHOR]

Objective: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes.Methods: We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007-2013). We investigated hospital adherence to three recommended key performance measures (KPMs) for inhospital care (ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on discharge, β-blockers on discharge and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation.Results: Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (95% CI 7% to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%) with 26% of this being attributable to hospital-level differences (CI 22% to 31%).Conclusion: Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs. [ABSTRACT FROM AUTHOR]

This paper draws on research into the role of Independent Reviewing Officers (IROs) in England, exploring the dimensions and challenges of their ‘independence’. IROs are specialist social workers whose function is to review the cases of children in public care and ensure that they have appropriate plans and that these plans are being implemented in a timely manner. IROs are ‘independent’ in the sense that they are not the social worker to whom a child's case is allocated, and do not have line management responsibility for the case, however they are employed by the same local authority. There are detailed regulations and government guidelines on their role, and high expectations, but what does independence mean in this context? The paper draws on a mixed methods study conducted by the authors in 2012–14, which included a survey of 122 files of children in care from four local authorities; interviews with 54 social workers, 54 IROs, 15 parents, and 15 young people; six focus groups; and nationally-distributed questionnaires for IROs (65), social work managers (46) and children's guardians (39). The study found five dimensions of independence: professional, operational, perceived, institutional and effective. The IROs and social workers generally took more nuanced and pragmatic approaches to their inter-professional working than prescribed in the policy guidance or the pronouncements of politicians and judges, seeing this as more likely to be effective. IROs are not, and cannot be, the solution to all the problems that exist in services for children in care, and the other professionals involved should not be seen as necessarily any less capable or committed to the best interests of the children. Rather, the IRO is part of an interactive system of checks and balances which, together, may increase the likelihood that professional judgement will be exercised effectively on the child's behalf. [ABSTRACT FROM AUTHOR]