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Objective: To assess the representativeness of National Cancer Patient Experience Survey (CPES) responders compared with the English cancer registry population in term of age, sex, socioeconomic deprivation, ethnicity, disease stage and median survival., Design: Population-based case-control study., Setting: England., Population: We identified 103 186 colorectal, lung, breast and prostate cancer patients responding to at least one survey during 2010-2014 and randomly selected one non-responder from the cancer registry matched on cancer type and yearly quarter of diagnosis., Main Outcome Measure: We compared age, sex, socioeconomic deprivation, ethnicity and disease stage between the two groups using logistic regression. We also compared survival (in years) using the Mann-Whitney test., Results: Across all cancer types survey responders were younger, more likely to have a White ethnic background, to be resident in less deprived areas and diagnosed with earlier stage disease although they varied between cancers. Median survival for responders was also higher than for the cancer registry population (colorectal: 4.8 vs 3.2; lung: 2.0 vs 0.3; breast: 5.7 vs 5.4; and prostate: 5.7 vs 5.2 years; all p-values<0.001)., Conclusion: CPES responders with the four most common cancers do not necessarily represent all patients with these cancers in terms of demographic characteristics and tumour stage at diagnosis. These limitations should be considered when interpreting findings. To capture the experiences of patients currently underrepresented in CPES, different approaches may need to be taken., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In England, the NHS111 service provides assessment and triage by telephone for urgent health problems. A digital version of this service has recently been introduced. We aimed to systematically review the evidence on digital and online symptom checkers and similar services., Design: Systematic review., Data Sources: We searched Medline, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium, Web of Science and ACM Digital Library up to April 2018, supplemented by phrase searches for known symptom checkers and citation searching of key studies., Eligibility Criteria: Studies of any design that evaluated a digital or online symptom checker or health assessment service for people seeking advice about an urgent health problem., Data Extraction and Synthesis: Data extraction and quality assessment (using the Cochrane Collaboration version of QUADAS for diagnostic accuracy studies and the National Heart, Lung and Blood Institute tool for observational studies) were done by one reviewer with a sample checked for accuracy and consistency. We performed a narrative synthesis of the included studies structured around pre-defined research questions and key outcomes., Results: We included 29 publications (27 studies). Evidence on patient safety was weak. Diagnostic accuracy varied between different systems but was generally low. Algorithm-based triage tended to be more risk averse than that of health professionals. There was very limited evidence on patients' compliance with online triage advice. Study participants generally expressed high levels of satisfaction, although in mainly uncontrolled studies. Younger and more highly educated people were more likely to use these services., Conclusions: The English 'digital 111' service has been implemented against a background of uncertainty around the likely impact on important outcomes. The health system may need to respond to short-term changes and/or shifts in demand. The popularity of online and digital services with younger and more educated people has implications for health equity., Prospero Registration Number: CRD42018093564., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives : Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7-93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods : Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results : The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care ( N  = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5-10.5% of patients were admitted to hospital and 0.06-0.24% of patient died within 3 days of the call. Conclusions : Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.

Background: Obesity is twice as common in people with schizophrenia as in the general population. The National Institute for Health and Care Excellence guidance recommends that people with psychosis or schizophrenia, especially those taking antipsychotics, be offered a healthy eating and physical activity programme by their mental health care provider. There is insufficient evidence to inform how these lifestyle services should be commissioned., Objectives: To develop a lifestyle intervention for people with first episode psychosis or schizophrenia and to evaluate its clinical effectiveness, cost-effectiveness, delivery and acceptability., Design: A two-arm, analyst-blind, parallel-group, randomised controlled trial, with a 1 : 1 allocation ratio, using web-based randomisation; a mixed-methods process evaluation, including qualitative case study methods and logic modelling; and a cost-utility analysis., Setting: Ten community mental health trusts in England., Participants: People with first episode psychosis, schizophrenia or schizoaffective disorder., Interventions: Intervention group: (1) four 2.5-hour group-based structured lifestyle self-management education sessions, 1 week apart; (2) multimodal fortnightly support contacts; (3) three 2.5-hour group booster sessions at 3-monthly intervals, post core sessions. Control group: usual care assessed through a longitudinal survey. All participants received standard written lifestyle information., Main Outcome Measures: The primary outcome was change in weight (kg) at 12 months post randomisation. The key secondary outcomes measured at 3 and 12 months included self-reported nutrition (measured with the Dietary Instrument for Nutrition Education questionnaire), objectively measured physical activity measured by accelerometry [GENEActiv (Activinsights, Kimbolton, UK)], biomedical measures, adverse events, patient-reported outcome measures and a health economic assessment., Results: The trial recruited 414 participants (intervention arm: 208 participants; usual care: 206 participants) between 10 March 2015 and 31 March 2016. A total of 341 participants (81.6%) completed the trial. A total of 412 participants were analysed. After 12 months, weight change did not differ between the groups (mean difference 0.0 kg, 95% confidence interval -1.59 to 1.67 kg; p  = 0.964); physical activity, dietary intake and biochemical measures were unchanged. Glycated haemoglobin, fasting glucose and lipid profile were unchanged by the intervention. Quality of life, psychiatric symptoms and illness perception did not change during the trial. There were three deaths, but none was related to the intervention. Most adverse events were expected and related to the psychiatric illness. The process evaluation showed that the intervention was acceptable, with participants valuing the opportunity to interact with others facing similar challenges. Session feedback indicated that 87.2% of participants agreed that the sessions had met their needs. Some indicated the desire for more ongoing support. Professionals felt that the intervention was under-resourced and questioned the long-term sustainability within current NHS settings. Professionals would have preferred greater access to participants' behaviour data to tailor the intervention better. The incremental cost-effectiveness ratio from the health-care perspective is £246,921 per quality-adjusted life-year (QALY) gained and the incremental cost-effectiveness ratio from the societal perspective is £367,543 per QALY gained., Conclusions: Despite the challenges of undertaking clinical research in this population, the trial successfully recruited and retained participants, indicating a high level of interest in weight management interventions; however, the STEPWISE intervention was neither clinically effective nor cost-effective. Further research will be required to define how overweight and obesity in people with schizophrenia should be managed. The trial results suggest that lifestyle programmes for people with schizophrenia may need greater resourcing than for other populations, and interventions that have been shown to be effective in other populations, such as people with diabetes mellitus, are not necessarily effective in people with schizophrenia., Trial Registration: Current Controlled Trials ISRCTN19447796., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 65. See the NIHR Journals Library website for further project information., Competing Interests: Richard IG Holt received fees for lecturing, consultancy work and attendance at conferences from the following companies: Boehringer Ingelheim (Ingelheim am Rhein, Germany), Eli Lilly and Company (Indianapolis, IN, USA), Janssen Pharmaceutica (Beerse, Belgium), Lundbeck (Copenhagen, Denmark), Novo Nordisk (Bagsværd, Denmark), Novartis (Basel, Switzerland), Otsuka Pharmaceutical Co., Ltd (Tokyo, Japan), Sanofi-Aventis (Paris, France) and Sunovion Pharmaceuticals, Inc. (Marlborough, MA, USA). Paul French is a member of the National Institute for Health Research (NIHR) Health Technology Assessment Mental, Psychological and Occupational Health funding panel. Melanie J Davies and Kamlesh Khunti are members of a NIHR Clinical Trials Unit. Melanie J Davies reports personal fees from Novo Nordisk, Sanofi-Aventis, Eli Lilly and Company, Merck Sharp & Dohme (Kenilworth, NJ, USA), Boehringer Ingelheim, AstraZeneca (Cambridge, UK), Janssen Pharmaceutica, Servier Laboratories (Neuilly-sur-Seine, France), Mitsubishi Tanabe Pharma Corporation (Tokyo, Japan) and Takeda Pharmaceuticals International Inc. (Canton of Zürich, Switzerland) and grants from Novo Nordisk, Sanofi-Aventis, Eli Lilly and Company, Boehringer Ingelheim and Janssen Pharmaceutica. Kamlesh Khunti has received fees for consultancy and being a speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Eli Lilly and Company, Servier Laboratories and Merck Sharp & Dohme. He has received grants in support of investigator and investigator-initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Eli Lilly and Company, Pfizer (New York, NY, USA), Boehringer Ingelheim and Merck Sharp & Dohme. Kamlesh Khunti has also received funds for research and honoraria for speaking at meetings, and has served on advisory boards for Eli Lilly and Company, Sanofi-Aventis, Merck Sharp & Dohme and Novo Nordisk. David Shiers is an expert advisor to the National Institute for Health and Care Excellence (NICE) centre for guidelines, a board member of the National Collaborating Centre for Mental Health (NCCMH) and a clinical advisor (on a paid consultancy basis) to the National Clinical Audit of Psychosis (NCAP); any views given in this report are personal and not those of NICE, NCCMH or NCAP. David Shiers reports personal fees from the Wiley-Blackwell publication Promoting Recovery in Early Psychosis, 2010 (ISBN 978-1-4051-4894-8), as he is a joint editor in receipt of royalties. John Pendelbury received personal fees for involvement in the study from a NIHR grant; he reports personal fees from the Greater Manchester Mental Health NHS foundation trust outside the submitted work and has published papers in the area of weight management and physical health related to mental health. Marian E Carey and Yvonne Doherty report being employed by the Leicester Diabetes Centre, an organisation (employer) jointly hosted by a NHS hospital trust and the University of Leicester and which is the holder (through the University of Leicester) of the copyright of the STEPWISE programme and of the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) suite of programmes, training and intervention fidelity framework that were used in this study. Fiona Gaughran reports personal fees from Otsuka and Lundbeck and personal fees and non-financial support from Sunovion, outside the submitted work, and has a family member with professional links to Eli Lilly and Company and GlaxoSmithKline (Brentford, UK), including shares.

Background: Some patients calling ambulance services (known as Emergency Medical Services internationally) are not transported to hospital. In England, national ambulance quality indicators show considerable variation in non-transport rates between the ten large regional ambulance services. The aim of this study was to explain variation between ambulance services in two types of non-transport: discharge at scene and telephone advice., Methods: Mixed model logistic regressions using one month of data (November 2014) from the Computer Aided Despatch systems of the ten large regional ambulance services in England., Results: 41% (251 677/615 815) of patients calling ambulance services were not transported to hospital. Most were discharged at scene after attendance by an ambulance (29% n = 182 479) and a small percentage were given telephone advice (7% n = 40 679). Discharge at scene rates varied by patient-level factors e.g. they were higher for elderly patients, where the reason for calling was falls, and for patients attended by paramedics with extended skills. These patient-level factors did not explain variation between ambulance services. After adjustment for patient-level factors, the following ambulance service level factors explained variation in discharge at scene rates: proportion of patients attended by paramedics with extended skills (odds ratio 1.05 (95% CI 1.04, 1.07)), the perception of ambulance service staff that paramedics with extended skills were established and valued within the workforce (odds ratio 1.84 (1.45, 2.33), and the perception of ambulance service staff that senior management viewed non-transport as risky (odds ratio 0.78 (0.63, 0.98)). Variation in telephone advice rates could not be explained., Conclusions: Variation in discharge at scene rates was explained by differences in workforce configuration and managerial motivation, factors that are largely modifiable by ambulance services., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Despite the focus during the last decade on introducing interventions such as senior doctor initial assessment or senior doctor triage (SDT) to reduce emergency department (ED) crowding, there has been little attempt to identify the views of emergency healthcare professionals on such interventions. The aim of this study was to gain an understanding of SDT from the perspective of emergency hospital staff. A secondary aim of this study was to develop a definition of SDT based on the interview findings and the available literature on this process., Methods: Qualitative semi-structured telephone interviews were conducted with participants of different backgrounds including senior doctors, nurses, paramedics and ED managers. Textual data were analysed using a template analysis approach., Results: 27 participants from 13 EDs across England were interviewed. SDT was viewed as a safety mechanism and a measure to control patient flow. The most prominent positive aspect was the ability to initiate early investigations and treatment. Various shortcomings of SDT were described such as the lack of standardisation of the process and its cost implications. Participants identified a number of barriers to this process including insufficient resources and exit block, and called for solutions focused on these issues. A proposed definition of an 'ideal' SDT was developed where it is described as a systematic brief assessment of patients arriving at the ED by a senior doctor-led team, which takes place in a dedicated unit. The aim of this assessment is to facilitate early investigation and management of patients, early patient disposition and guide junior staff to deliver safe and high-quality clinical care., Conclusion: This is the first national study to explore the opinions of various emergency and managerial staff on the SDT model. It revealed variable interpretations of this model and what it can and cannot offer. This has led to a standard definition of the SDT process, which can be useful for clinicians and researchers in emergency care., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To gain an understanding of womens' views surrounding decisions on the timing of childbearing., Study Design: This study was based on interviews with 18 childless women, from North-West England, in three age groups: Six women aged between 18 and 24; Six women aged between 25 and 34; and six women aged 35 or more. Data were analysed using a hermeneutic phenomenological approach with thematic analysis., Results: Three main themes were identified. Women perceived themselves as living within boundaries, defined internally and externally; they aspired to being a great mother or no mother; and had a desire to contribute to family and society, at multiple levels. Risks associated with delaying childbearing had little or no influence on decision-making. The overarching phenomenon was social comparability; decisions were made in the context of women's knowledge and perceptions of others and a high degree of critical self-evaluation., Conclusion: We conclude that social reality dominates womens' reproductive decisions. Whilst the biological reality is that fertility reduces and medical complications increase with maternal age, social discourses deter women from acknowledging this. Medical risks associated with advanced maternal age are undermined by the notion that women can choose when to start a family., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: In 2010, a new telephone service, NHS 111, was piloted to improve access to urgent care in England. A unique feature is the use of non-clinical call takers who triage calls with computerized decision support and have access to clinical advisors when necessary. Aim. To explore users' acceptability of NHS 111., Design: Cross-sectional postal survey., Setting: Four pilot sites in England., Method: A postal survey of recent users of NHS 111., Results: The response rate was 41% (1769/4265), with 49% offering written comments (872/1769). Sixty-five percent indicated the advice given had been very helpful and 28% quite helpful. The majority of respondents (86%) indicated that they fully complied with advice. Seventy-three percent was very satisfied and 19% quite satisfied with the service overall. Users were less satisfied with the relevance of questions asked, and the accuracy and appropriateness of advice given, than with other aspects of the service. Users who were autorouted to NHS 111 from services such as GP out-of-hours services were less satisfied than direct callers., Conclusion: In pilot services in the first year of operation, NHS 111 appeared to be acceptable to the majority of users. Acceptability could be improved by reassessing the necessity of triage questions used and auditing the accuracy and appropriateness of advice given. User acceptability should be viewed in the context of findings from the wider evaluation, which identified that the NHS 111 pilot services did not improve access to urgent care and indeed increased the use of emergency ambulance services.

It is essential for neuroscience nurses everywhere to have reliable and valid instruments with which to measure functional ability, but reliability and validity have yet to be reported on the adult Alpha Functional Independence Measure (AlphaFIM) in England. The aim of this study was to determine the reliability and validity of the adult AlphaFIM instrument. Reliability was estimated using Cronbach's alpha. Validity was examined by comparing adult AlphaFIM instrument scores with Barthel Index scores and by factor analysis in a group of 551 patients admitted to acute medical units. Cronbach's alpha for the 6-item adult AlphaFIM instrument was .90. The correlation between the adult AlphaFIM instrument and the Barthel Index was .68 (p < .001). The factor analysis supported a one-factor solution for the 6-item adult AlphaFIM instrument. This is the first report of reliability and validity on this instrument. The adult AlphaFIM instrument appears to be a reliable and valid tool with which to measure functional ability in an acute medical geriatric population in England.

Purpose: To report on two population screening programs designed to detect significant refractive errors in 8308 8- to 9-month-old infants, examine the sequelae of infant hyperopia, and test whether early partial spectacle correction improved visual outcome (strabismus and acuity). The second program also examined whether infant hyperopia was associated with developmental differences across various domains such as language, cognition, attention, and visuomotor competences up to age 7 years. Linked programs in six European countries assessed costs of infant refractive screening., Method: In the first program, screening included an orthoptic examination and isotropic photorefraction, with cycloplegia. In the second program we carried out the same screening procedure without cycloplegia. Hyperopic infants (> or = +4 D) were followed up alongside an emmetropic control group, with visual and developmental measures up to age 7 years, and entered a controlled trial of partial spectacle correction., Results: The second program showed that accommodative lag during photorefraction with a target at 75 cm (focus > or = +1.5 D) was a marker for significant hyperopia. In each program, prevalence of significant hyperopia at 9 to 11 months was around 5%; manifest strabismus was 0.3% at 9 months and 1.5 to 2.0% by school age. Infant hyperopia was associated with increased strabismus and poor acuity at 4 years. Spectacle wear by infant hyperopes produced better visual outcome than in uncorrected infants, although an improvement in strabismus was found in the first program only. The corrections did not affect emmetropization to 3.5 years; however, both corrected and uncorrected groups remained more hyperopic than controls in the preschool years. The hyperopic group showed poorer overall performance than controls between 1 and 7 years on visuoperceptual, cognitive, motor, and attention tests, but showed no consistent differences in early language or phonological awareness. Relative cost estimates suggest that refractive screening programs can detect visual problems in infancy at lower overall cost than surveillance in primary care., Conclusions: Photo/videorefraction can successfully screen infants for refractive errors, with visual outcomes improved through early refractive correction. Infant hyperopia is associated with mild delays across many aspects of visuocognitive and visuomotor development. These studies raise the possibility that infant refractive screening can identify not only visual problems, but also potential developmental and learning difficulties.

Background: Antipsychotic drugs have been linked to sudden death among psychiatric patients, with a suggestion that prolongation of the QT-interval detectable on a standard electrocardiogram may be linked to fatal cardiac arrhythmias in these circumstances. Patients in secure forensic psychiatric facilities may be particularly likely to be on high-dose antipsychotic medication, and yet, as far as the authors are aware, no study of QT-intervals among such patients has been reported., Aim: To investigate the prevalence of QT-interval abnormalities and associated known risk factors for fatal cardiac arrhythmias in a sample of forensic patients., Method: Participants had a 12-lead electrocardiogram taken at 50 mm/s. Information was collected on their age, gender, psychiatric diagnosis, history of cardiovascular, liver and kidney diseases, and smoking, on all medications and on history of seclusion over the previous 12 months. Analysis was carried out using binary logistic regression., Results: Lower rates of QT-interval abnormalities than might be expected for this population were found. It was also found that a high dose of antipsychotics was associated with QTc prolongation (Adjusted OR = 9.5, 95% CI 2.6-34.2), a result consistent with previous literature., Conclusion: Forensic patients need not be at increased risk of QTc abnormality provided risk factors are properly managed. A high dose of antipsychotic medication increases the risk of QTc prolongation.

Background: The management of epilepsy incurs significant costs to the United Kingdom (UK) National Health Service (NHS). Making a diagnosis of epilepsy can, however, be difficult and misdiagnosis frequently occurs when patients are seen by non-specialists. This study estimates the financial costs of epilepsy misdiagnosis in the NHS in England and Wales., Methods: Standard costing methods were applied to estimate the costs attributable to epilepsy misdiagnosis. The primary data were published in UK studies on the prevalence of epilepsy, epilepsy misdiagnosis and costs identified from Medline, Cinahl and Embase (1996-May 2006)., Results: An estimated total of 92,000 people were misdiagnosed with epilepsy in England and Wales in 2002. The average medical cost per patient per year of misdiagnosis was 316 pounds sterling, with the chief economic burdens being inpatient admissions (45%), inappropriate prescribing of antiepileptic drugs (AEDs) (26%), outpatient attendances (16%) and general practitioner (GP) care (8%). The estimated annual medical costs in England and Wales were 29,000,000 pounds sterling, while total costs could reach up to 138,000,000 pounds sterling a year., Conclusions: Allowing for uncertainty, and considering the analysis exclusively from the NHS/CBS (community based services) perspective the opportunity costs of misdiagnosis are substantial. There is a need for health care commissioners to ensure that misdiagnosis is kept to a minimum by ensuring that individuals with a recent onset suspected seizure are seen as soon as possible by a specialist medical practitioner with training and expertise in epilepsy.

Consultative occupational therapy services are becoming widely used in the school environment. However, few studies have evaluated the utility of and the process by which these services are delivered. This study examined whether the written communication and fine motor skills of 23 children with fine motor difficulties improved after receiving school-based occupational therapy from a program whose mandate was to deliver services according to a consultation model of service delivery. In addition, the study assessed the process of service delivery, including treatment fidelity, or the extent to which consultation services were implemented as intended. Statistically significant and practically meaningful improvement was found in written communication on the Vineland Adaptive Behavior Scales-Classroom Edition (VABS-C) and School Functional Assessment-Version 3.0 (SFA), and in fine motor skills on the SFA, but not on the VABS-C. An examination of the service delivery process revealed that therapists deviated from a purely consultative model, with 86% providing some direct therapy to children. Parents were mostly satisfied with services received, whereas teachers were indifferent or somewhat dissatisfied. Treatment fidelity is taken into consideration when discussing study findings. Recommendations to enhance school-based occupational therapy services delivered according to a primarily consultative model, and suggestions for future research, are provided.