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Background: Melatonin is commonly used to treat sleep disturbance in children and adolescents, although uncertainties about its optimal use remain., Objective: To determine to what extent prescribing of melatonin complies with evidence-based clinical practice standards., Methods: As part of a quality improvement programme, the Prescribing Observatory for Mental Health conducted a retrospective clinical audit in UK services for children and adolescents., Findings: Data were submitted for 4151 children and adolescents up to 18 years of age, treated with melatonin: 3053 (74%) had a diagnosis of neurodevelopmental disorder. In 2655 (73%) of the 3651 patients prescribed melatonin to be taken regularly, the main reason was to reduce sleep latency (time taken to fall asleep). In 409 patients recently starting melatonin, a non-pharmacological intervention had already been tried in 279 (68%). The therapeutic response of patients early in treatment (n=899) and on long-term treatment (n=2353) had been assessed and quantified in 36% and 31%, respectively, while for review of side effects, the respective proportions were 46% and 43%. Planned treatment breaks were documented in 317 (13%) of those on long-term treatment., Conclusions: Melatonin was predominantly prescribed for evidence-based clinical indications, but the clinical review and monitoring of this treatment fell short of best practice., Clinical Implications: With limited methodical review of melatonin use in their patients, clinicians will fail to garner reliable information on its risks and benefits for individual patients. The lack of such practice-based evidence may increase the risk of melatonin being inappropriately targeted or continued despite being ineffective or no longer indicated., Competing Interests: Competing interests: CP, OR, AR, GB and TREB have no interests to declare. PG was CI on the NIHR investigator-led Mends RCT melatonin trial and the Neurim industry-led international RCT for Slenyto melatonin; reports participation in advisory panels for AGB, Flynn Pharma and Alturix; but reports no shares or ongoing work with any of the above. AL reports speaking and travel honoraria from Takeda and Flynn Pharma., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

This Perspective argues that the NHS in the UK is facing a critical 'tipping point' which means that its very survival is at stake. The article considers the political responses to this crisis-(briefly) from the Conservative government; (briefly) from the 'anti-NHS' Right in politics; (briefly) from the 'centre' in politics in the form of the Tony Blair Institute for Global Change; and (in depth) from the left-of-centre, the Labour Party. Labour is likely to form the next government, which is why its approach (in terms of both political strategy and the substance of health policy) is considered in depth. It is argued that Labour's approach, derived from an understandable desire by leader Sir Keir Starmer to disown its 'unelectable' recent past, is currently inadequate for the task of putting the NHS on a secure footing for the future., (© 2023 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Introduction: The Prescribing Observatory for Mental Health initiated a quality improvement (QI) programme on clozapine use in UK mental health services., Methods: Clinical audits conducted in 2019 and 2021., Results: Sixty-three participating NHS Trusts/healthcare organisations in 2019, and 61 in 2021, submitted treatment data for 6948 and 8155 patients, respectively. In both audits, high-dose and/or combined antipsychotic medications had been prescribed immediately before initiating clozapine in over a quarter of patients recently started on clozapine. In patients who were tobacco smokers and recently discharged from a smoke-free ward, the impact of the potential change in smoking status had been considered in the care plans of just under one-third in 2019 and just over a half in 2021. For community patients, their Summary Care Records (SCRs) included their clozapine prescriptions in 58% of cases in 2019 and 72% in 2021., Conclusions: Three QI issues were identified. (1) Antipsychotic regimens with limited evidence for efficacy in treatment-resistant schizophrenia were prescribed for over a quarter of cases before starting clozapine. Use of such strategies may delay clozapine treatment, potentially reducing the likelihood of a therapeutic response. (2) While anticipation of the consequences of a change in smoking status on plasma clozapine concentration following discharge from hospital showed improvement over time, even in 2021 it was not evident for nearly a half of relevant cases. (3) While inclusion of clozapine in the SCR also improved over time, even in 2021 it was missing for more than a quarter of community patients.

The UK, and England in particular, has suffered egregiously poor outcomes in managing the Covid-19 pandemic. This short perspective points to the explanation in terms of both current British politics and the public health policy inheritance. Boris Johnson's Premiership was born in an opportunistic assertion of British exceptionalism, and Johnson's initial, fate-tempting reaction to the novel Coronavirus set the UK on the wrong path. Furthermore, the gradual erosion of professionalism in (especially health) policy-making over almost four decades, and the hollowing-out of the health protection infrastructure, both facilitated and accentuated a toxic approach to managing Covid-19.

The new White Paper, Integration and Innovation, prefiguring a Health and Social Care Bill for England, means that the NHS structure in England will have come full circle in the last 32 years, since the Thatcher government began in 1989 to implement the reforms announced that year in the White Paper, Working for Patients (incidentally without waiting for parliamentary approval, which came in 1990). This will be denied by some, who will depict the 'new' integration as only being possible as a result of learning during the various phases of reform over the last 30 years. This is a fallacious teleology. It is argued here that, while the 'old' NHS of the 1980s (of course) required improvement, the persistent 'reforms' of the last 30 years or so have been based on political fads which have been both hugely expensive and, in the end, transitory and self-defeating., (© 2021 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

This article gives key reasons for the UK's tardy and confused attempts to react to the COVID-19 pandemic. It explains very poor outcomes in the UK (in terms of the spread of the virus and high mortality, already striking at the time of writing), in terms of an initial lack of political will to prioritise public health, itself a product of a strong Prime Minister who made the "wrong call". It also highlights a failure to "follow the science", except in so far as the "science" had already accepted some dubious political judgements and the lack of capacity to test as the starting-point., (© 2020 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Background: A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health., Method: This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts., Results: Fifty-eight mental health services submitted data on 2172 episodes of acutely disturbed behaviour. A benzodiazepine alone was administered in 60% of the 1091 episodes where oral medication only was used and in 39% of the 1081 episodes where parenteral medication (rapid tranquillisation) was used. Haloperidol was combined with lorazepam in 22% of rapid tranquillisation episodes and with promethazine in 3%. Physical violence towards others was strongly associated with receiving rapid tranquillisation in men (odds ratio 1.74, 1.25-2.44; p<0.001) as was actual or attempted self-harm in women (odds ratio 1.87, 1.19-2.94; p=0.007). Where physical violence towards others was exhibited, a benzodiazepine and antipsychotic was more likely to be prescribed than a benzodiazepine alone (odds ratio 1.39, 1.00-1.92; p=0.05). The data suggested that 25% of patients were at least 'extremely or continuously active' in the hour after rapid tranquillisation was administered., Conclusion: The current management of acutely disturbed behaviour with parenteral medication may fail to achieve a calming effect in up to a quarter of episodes. The most common rapid tranquillisation combination used was lorazepam and haloperidol, for which the randomised controlled trial evidence is very limited. Rapid tranquillisation prescribing practice was not wholly consistent with the relevant National Institute for Health and Care Excellence guideline, which recommends intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine. Clinical factors prompting the use of rapid tranquillisation rather than oral medication may differ between the genders.