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This study aimed to compare appraisal decisions about anticancer drugs between the health technology assessment (HTA) agencies in Korea and England, and investigate whether the decisions and supporting evidence are comparable.This study identified 49 anticancer drugs listed by the Korean Ministry of Health and Welfare between January 2014 and December 2019. Of those, 46 anticancer drugs for 58 indications were included for analysis. Official appraisal documents from both countries for 58 drug-indication pairs were compared and assessed in terms of clinical and economic evidence. Evidence items and their groups for analysis were predefined.Three-quarters of cases were recommended with managed entry agreements (MEAs) in England and three-fifths in Korea. Finance-based MEA types were most common in both countries. Korean and English authorities made consistent decisions in 48 cases (83%) when classifying decisions as 'recommended' and 'not recommended', while the degree of agreement lowered to 16 cases (28%) when subdividing decisions according to MEA types. When the evidence base was identical, their decisions were more likely to be consistent. Regarding clinical evidence, while the majority of cases referred to the same pivotal studies, differences between the committees' recognized comparators and the appraisal date caused discrepancies in decisions. Economic evidence, including incremental cost-effectiveness ratio (ICER) estimates, was identical in only 12 cases (21%), which contributed to discrepancies.England relies on economic evaluation, with increasing use of data collection agreements, in contrast with Korea's new procedure exempting companies from providing economic evaluation. While there is possibility for international cooperation in the assessment of clinical evidence, transferability issues exist, particularly with regard to economic evidence.

ObjectivesTo examine the effect of general practitioners (GPs) working in or alongside the emergency department (GPED) on patient outcomes and experience, and the associated impacts of implementation on the workforce.DesignMixed-methods study: interviews with service leaders and NHS managers; in-depth case studies (n=10) and retrospective observational analysis of routinely collected national data. We used normalisation process theory to map our findings to the theory’s four main constructs of coherence, cognitive participation, collective action and reflexive monitoring.Setting and participantsData were collected from 64 EDs in England. Case site data included: non-participant observation of 142 clinical encounters; 467 semistructured interviews with policy-makers, service leaders, clinical staff, patients and carers. Retrospective observational analysis used routinely collected Hospital Episode Statistics alongside information on GPED service hours from 40 hospitals for which complete data were available.ResultsThere was disagreement at individual, stakeholder and organisational levels regarding the purpose and potential impact of GPED (coherence). Participants criticised policy development and implementation, and staff engagement was hindered by tensions between ED and GP staff (cognitive participation). Patient ‘streaming’ processes, staffing and resource constraints influenced whether GPED became embedded in routine practice. Concerns that GPED may increase ED attendance influenced staff views. Our quantitative analysis showed no detectable impact on attendance (collective action). Stakeholders disagreed whether GPED was successful, due to variations in GPED model, site-specific patient mix and governance arrangements. Following statistical adjustment for multiple testing, we found no impact on: ED reattendances within 7 days, patients discharged within 4 hours of arrival, patients leaving the ED without being seen; inpatient admissions; non-urgent ED attendances and 30-day mortality (reflexive monitoring).ConclusionsWe found a high degree of variability between hospital sites, but no overall evidence that GPED increases the efficient operation of EDs or improves clinical outcomes, patient or staff experience.Trial registration numberISCRTN5178022.

It is difficult to engage busy healthcare professionals in research. Yet during the COVID-19 pandemic, gaining their perspectives has never been more important.To explore social media data for insights into the wellbeing of UK General Practitioners (GPs) during the Covid-19 pandemic.We used a combination of search approaches to identify 381 practising UK NHS GPs on Twitter. Using a two stage social media analysis, we firstly searched for key themes from 91,034 retrieved tweets (before and during the pandemic). Following this we used qualitative content analysis to provide in-depth insights from 7145 tweets related to wellbeing.Social media proved a useful tool to identify a cohort of UK GPs; following their tweets longitudinally to explore key themes and trends in issues related to GP wellbeing during the pandemic. These predominately related to support, resources and public perceptions and fluctuations were identified at key timepoints during the pandemic, all achieved without burdening busy GPs.Social media data can be searched to identify a cohort of GPs to explore their wellbeing and changes over time.

Background The impact of consumption of sugar-sweetened beverages (SSB) on health outcomes such as obesity have been studied extensively, but oral health has been relatively neglected. This study aims to assess the association between SSB consumption and dental caries and erosion. Methods Systematic review of observational studies. Search strategy applied to Medline, Embase, Cochrane Library, SciELO, LILACS, OpenGrey and HMIC. The risk of bias was assessed using the NIH Quality Assessment Tool for Observational Cross-Sectional Studies and evidence certainty using Grading of Recommendation Assessment Development and Evaluation. Relationships between SSB consumption and caries and erosion were estimated using random-effects model meta- and dose–response analyses. Results A total of 38 cross-sectional studies were included, of which 26 were rated as high quality. Comparing moderate-to-low consumption, there was significantly increased risk of both caries [OR = 1.57, 95% CI: 1.28–1.92; decayed, missing and filled teeth weighted mean differences (DMFT WMD) = 0.82, 95% CI: 0.38–1.26] and erosion (OR = 1.43, 95% CI: 1.01–2.03). Comparing high-to-moderate consumption, there was further increased risk of caries (OR = 1.53, 95% CI: 1.17–1.99; DMFT WMD = 1.16, 95% CI: −0.59–2.91) and erosion (OR = 3.09, 95% CI: 1.37–6.97). A dose–response gradient and high certainty of evidence was observed for caries. Conclusions Increasing SSB consumption is associated with increased risk of dental caries and erosion. Studies were cross-sectional, hence temporality could not be established, but the positive dose–response suggests this relationship is likely to be causal. These findings illustrate the potential benefits to oral health of policies that reduce SSB consumption, including sugar taxation.

Background: The unadjusted gender pay gap in general practice is reported to be 33.5%. This reflects partly the differential rate at which women become partners, but evidence exploing gender differences in GPs’ career progression is sparse. Aim: To explore factors affecting uptake of partnership roles, focusing particularly on gender differences. Design and Setting: Convergent mixed methods research design using data from UK GPs. Method: Secondary analysis of qualitative interviews and social media analysis of UK GPs’ Twitter commentaries, which informed the conduct of asynchronous online focus groups. We combined findings using methodological triangulation. Results: Our sample comprised 40 GP interviews, 232 GPs tweeting about GP partnership roles and seven focus groups with 50 GPs. Factors at individual, organisational and national levels influence partnership uptake and career decisions of both men and women GPs. Desire for work-family balance (particularly childcare responsibilities) presented the greatest barrier, for both men and women, as well as workload, responsibility, financial investment and risk. Greater challenges were, however, reported by women, particularly regarding balancing work/family lives and prohibitive working conditions (including maternity and sickness pay) and discriminatory practices perceived to favour men and full time GPs. Conclusion: There are some longstanding gendered barriers which continue to affect the career decisions of women GPs. The relative attractiveness of salaried, locum or private roles in general practice appears to discourage both men and women from partnerships presently. Promoting positive workplace cultures through strong role models, improved flexibility in roles and skills training could potentially encourage greater uptake.

BackgroundWorkload pressures and poor job satisfaction have been reported by UK general practitioners (GPs) for some time. The COVID-19 pandemic presented new challenges, with growing international evidence of its negative impact on GPs’ mental health and wellbeing. While there has been wide commentary on this topic, UK research evidence is lacking. Developing greater understanding of these lived experiences and subgroup differences is important as doctor wellbeing may affect the sustainability of health care systems and quality of patient care.ObjectivesTo explore the lived experience of UK GPs during COVID-19, and the pandemic’s impact on their psychological wellbeing.Design and SettingIn-depth qualitative interviews, conducted remotely by telephone or video call, with NHS GPs.ParticipantsGPs were sampled purposively across three career stages (early career, established and late career or retired GPs) with variation in other key demographics. A comprehensive recruitment strategy used multiple channels. Data were analysed thematically using Framework Analysis.ResultsWe interviewed 40 GPs; most described generally negative sentiment and many displayed signs of psychological distress and burnout. Causes of stress and anxiety related to personal risk, workload, practice changes, public perceptions and leadership, teamworking and wider collaboration and personal challenges. GPs described facilitators of their wellbeing, including sources of support and plans to reduce clinical hours or change career path.ConclusionsA range of factors detrimentally affected the wellbeing of GPs during the pandemic and we highlight the potential impact of this on workforce retention and quality of care. As the pandemic progresses and general practice faces continued challenges, urgent policy measures are now needed.Strengths and limitations of this studyWhile there is growing international evidence base demonstrating the impact of the COVID-19 pandemic on GPs’ wellbeing and much UK media coverage, this qualitative interview study provides much-needed research evidence of UK GPs’ lived experiences and wellbeing during COVID-19.40 GPs were sampled purposively to include GPs with different demographic and practice characteristics.While there are no easy solutions to the problems highlighted, this research provides increased contextualised understanding of how these experiences may impact future workforce retention and the sustainability of health systems longer-term.Sub-group differences by gender and age are reported; highlighting a potential need for further research and support targeted at specific groups.Findings are necessarily limited to the time of data collection (Spring/Summer 2021); further tensions in general practice have since arisen, particularly regarding negative and misleading media portrayal.

BackgroundAfter discharge from an intensive care unit(ICU), over 50% of patients face significant physical, mental and cognitive problems. The COVID-19 pandemic has resulted in a large cohort of these patients who will need follow-up services that can address their support needs.ObjectivesTo identify follow-up services planned for COVID-19 patients discharged from ICU, and to explore the views of ICU staff and General Practitioners(GPs) regarding these patients’ future needs and care coordination.DesignSequential mixed-methods UK study. We explored usual follow-up practice after ICU discharge and changes in follow-up during the pandemic through a survey of ICU staff, and GP awareness of follow-up and support needs of patients discharged from ICU through a survey of GPs. Through these surveys, we identified participants for semi-structured interviews with both groups.ResultsWe obtained 170 survey responses and conducted 23 interviews. Over 60% of GPs were unaware of the follow-up services generally provided by their local hospitals, and whether or not these were functioning during the pandemic. Eighty percent of ICUs reported some form of follow-up services, with 25% of these suspending provision during the peak of the pandemic, and over half modifying their provision (usually to provide the service remotely). Complex funding streams, poor communication between primary and secondary care, and lack of clarity about who was responsible for referrals and follow-up were the most common problems identified. Discharge documentation was described as poor and lacking key information. Both groups mentioned difficulties accessing services in the community.ConclusionsThe pandemic has highlighted long-standing issues of continuity of care and complex funding streams for post-ICU follow-up care. The large cohort of ICU patients admitted due to COVID-19 highlights the need for improved follow-up services and communication between specialists and GPs, not only for COVID-19 patients, but for all those discharged from ICU.Article SummaryStrengths and limitations of this studyThis is the first study exploring NHS staff views of post-ICU follow-up services to support patients recovering from severe COVID-19.Responses to our survey had good geographic spread but were limited in number and relied on volunteers.GP interviews were small in number, but our findings align with those of larger studies conducted before the pandemic.

Objectives\ud \ud This is a protocol for a Cochrane Review (intervention). The objectives are as follows:\ud \ud \ud \ud Main objective: to assess the effects of computerised clinical decision support systems (CDSS) use on nurses' and allied health professionals’ performance and patient outcomes, by comparing those who use CDSS and those who do not use CDSS.\ud \ud \ud \ud Secondary objective: to assess the resource use associated with CDSS used by nurses and allied health professionals.

BackgroundExpanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years.MethodsWe reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status.Findings8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies).InterpretationIncreased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.

Objectives Evidence suggests that maternal psychological distress is an under-diagnosed condition that can have lasting impacts on child outcomes. Models based solely on maternal outcomes have not found screening to be cost-effective. This research explores the effects of self-reported maternal psychological distress on children’s language and behavioural development up to the age of 7. Methods Using longitudinal survey data from 10,893 families in the UK Millennium Cohort Study, multilevel models are used to explore the differential effects of maternal diagnosed and treated depression versus untreated maternal psychological distress during the postnatal year on longer-term child outcomes. Results Both diagnosed and treated depression and self-reported maternal psychological distress have detrimental effects on child behavioural development. Behavioural outcomes up to age 5 were better for children of women who received treatment for depression, compared with children those whose mothers’ psychological distress was untreated, but this was not maintained to age 7. Little or no evidence of a difference was found between maternal psychological distress and child language development. Conclusions for Practice This research highlights the lack of effectiveness of existing treatment for maternal psychological distress both to benefit child development and to provide long-term symptom remediation for women. Future research could aim to identify more effective treatments for both women and children.

Objectives To evaluate the effect of Care Quality Commission external inspections of acute trusts on adverse event rates in the English National Health Service. Methods Interrupted time-series analysis including all acute NHS trusts in England ( n = 155) using two control groups (new versus historical inspection regime and trusts not inspected). Multilevel random-coefficient modelling of (1) rates of falls with harm and (2) pressure ulcers, from April 2012 to June 2016, was undertaken using the new, resource-intensive regime of Care Quality Commission inspections as an intervention. Data used in the model included dates and type of inspection, patient safety indicators, demographic characteristics and financial risk of hospitals. Results In one year, Care Quality Commission inspected 66 acute trusts (42% of all English trusts) using their new regime and 46 (30%) using their previous one. Prior to inspections being announced, rates of falls with harm and pressure ulcers were improving in both intervention and control hospitals. The announcement of an inspection did not affect either indicator. After inspections, rates of falls with harm improved more slowly, and pressure ulcer rates no longer improved for trusts inspected using both regimes. Conclusions Neither form of external inspection was associated with positive, clinically significant effects on adverse event rates. Any improvement happening before the announced Care Quality Commission inspections slowed after the inspection.

Objectives This study is the first rigorous evaluation of the impact of Jaminan Kesehatan Nasional (JKN) on improving access to outpatient and inpatient care, utilising longitudinal data from the Indonesian Family Life Survey. Methods Two treatment groups were identified: a contributory group (N = 982), who paid the premium voluntarily, and a subsidised group (N = 2503), paid by government. Each group was compared with the uninsured group (N = 8576). Propensity score matching combined with difference-in-difference approaches was used to estimate the causal effect of the JKN programme. Results The results found that JKN increased the probability of inpatient admission for the contributory and subsidised groups by 8.2% (95% CI 5.9–10.5%) and 1.8% (95% CI 0.7–2.82%), respectively. The contributory group had an increase in probability of an outpatient visit of 7.9% (95% CI 4.3–11.4%). Conclusions The JKN programme has increased the utilisation of outpatient and inpatient care in the contributory group. Those with subsidised insurance have an increase in access to inpatient facilities only, and this is of a smaller magnitude. Hence, while JKN has improved average utilisation, inequity in access to both outpatient and inpatient care may remain. Electronic supplementary material The online version of this article (10.1007/s00038-019-01215-2) contains supplementary material, which is available to authorized users.

IntroductionPressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.Methods and analysisThe study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination.Ethics and disseminationThe study has been approved by the National Health Service East Midlands—Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation.Trial registration numberISRCTN51780222.

Highlights • Performance management initiatives are increasingly targeting individual doctors as well as hospitals. • Less than 25% of variation in clinical outcomes is attributable to providers. • More variation in clinical outcomes is associated with doctors than with hospitals. • Performance estimates for individual doctors are unreliable due to small samples., Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably. This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations. Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.

The Income Deprivation Affecting Children Index (IDACI) uses administrative data to count children living in households in receipt of both in-work and out-of-work means-tested benefits and provides small area ranking as an indicator of child poverty in neighbourhoods. Benefit take-up rates within an area will affect its reliability. We aimed to examine benefit take-up rates and compare area ranking by the IDACI with ranking using individually reported data across areas of varying ethnic composition. Mothers living in areas with high minority ethnic density were less likely to report claiming a benefit than those in majority White or mixed areas, despite reporting lower incomes. The correlation between self-reported material difficulties and worsening IDACI rank was much lower in areas characterised by minority ethnic populations. Further investigation into the performance of area-based deprivation measures in areas with high minority ethnic density is needed.

Introduction Women now outnumber men in British medical schools. This paper charts the history of women in medicine and provides current demographic trends. Sources of data A historical literature review and routinely collected data from Department of Health and the Health and Social Care Information Centre. Areas of agreement Clear gender differences are apparent in working practices, including greater likelihood of working part time and specializing in certain areas of medicine. Areas of controversy The increasing need to increase activity among the existing medical workforce is timely amidst a changing workforce demographic. Growing points Workforce planners, policymakers and Royal Colleges should continue to develop interventions that may reduce disparities in career choices, as well as considering ways to increase participation and activity. Areas timely for developing research Further research is needed to explore the cost-effectiveness of existing and future interventions in this field.

Objective: To assess the feasibility, strengths and weaknesses of using administrative data to compare hospital performance across countries, using mortality after coronary artery bypass graft (CABG) surgery as an illustrative example. Methods: Country specific and pooled models using individual-level data and logistic regression methods assess individual hospital performance using funnel plots accounting for multiple testing. Outcomes are adjusted for age, sex, comorbidities and indicators of patient severity. Data includes patients from all publicly funded hospitals delivering CABG surgery in England and Spain. Inpatient hospital-level standardized mortality rates within 30 days of CABG surgery are calculated for 83 999 CABG patients between 2007 and 2009. Results: Unadjusted national mortality rates are 5% in Spain and 2.3% in England. Country-specific models identified similar patterns of excess mortality ‘alerts’ and ‘alarms’ in hospitals in Spain or England. Pooling data from both countries identifies larger numbers of alerts and alarms in Spanish hospitals, and risk-adjustment increased the already large national mortality difference. This was reduced but not eliminated by accounting for lower volume in Spanish hospitals. Conclusion: Cross-national comparisons potentially add value by providing international performance benchmarks. Hospital-level analysis across countries can illuminate differences in hospital performance, which might not be identified using country-specific data or incomplete registry data, and can test hypotheses that may explain national differences. Difficulties of making data comparable between countries, however, compound the usual within-country measurement problems.

Background: The Charlson and Elixhauser comorbidity measures are commonly used methods to account for patient comorbidities in hospital-level comparisons of clinical quality using administrative data. Both have been validated in North America, but there is less evidence of their performance in Europe and in pooled cross-country data, which are features of the European Collaboration for Healthcare Optimization (ECHO) project. This study compares the performance of the Charlson/Deyo and Elixhauser comorbidity measures in predicting in-hospital mortality using data from five European countries in three inpatient groups. Methods: Administrative data is used from five countries in 2008-2009 for three indicators commonly used in hospital quality comparisons: mortality rates following acute myocardial infarction, coronary artery bypass graft surgery and stroke. Logistic regression models are constructed to predict mortality controlling for age, gender and the relevant comorbidity measure. Model discrimination is evaluated using c-statistics. Model calibration is evaluated using calibration slopes. Overall goodness-of-fit is evaluated using Nagelkerke's R 2 and the Akaike information criterion. All models are validated internally by using bootstrapping and externally by using the 2009 model parameters to predict mortality in 2008. Results: The Elixhauser measure has better overall predictive ability in terms of discrimination and goodness-of-fit than the Charlson/Deyo measure or the age-sex only model. There is no clear difference in model calibration. These findings are robust to the choice of country, to pooling all five countries and to internal and external validation. Conclusions: The Elixhauser list contains more comorbidities, which may enable it to achieve better discrimination than the Charlson measure. Both measures achieve similar calibration, so for the purpose of ECHO we judged the Elixhauser measure to be preferable.

Introduction: Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries. Methods: Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated. Results: Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10 000 inhabitants in Denmark to 34.8 cases per 10 000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions. Conclusion: The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care.

Objectives To investigate the effect of physician gender on consultation length in UK hospital outpatient clinics and compare this, through meta-analysis, with previous studies outside the UK. Design Observational data on clinic times were analysed and findings were combined in a meta-analysis with existing studies investigating the effect of physician gender on consultation length. Setting UK hospital practice. Participants A total of 174 observations of outpatient consultations with 10 hospital specialists (consultants) from different specialties in two UK hospital trusts. Main outcome measures Clinic times were recorded and analysis of consultation length was undertaken with physician gender as a covariate. Data were then synthesised through meta-analysis with 10 existing studies in this field. Results No statistically significant difference was found in the length of consultations for male and female doctors in these UK hospital settings. When pooled with existing studies, consultations with women doctors were found to be approximately two minutes longer than with men ( p = 0.01). Conclusions Findings from this analysis of clinic consultations in the UK National Health Service do not support previous studies, which were undertaken predominantly in North America and primary care settings. Overall, meta-analysis suggests doctors’ gender may influence consultation length. Gender differences in communication should be considered in training clinicians and in overall clinical practice.

For over 30 years, researchers have questioned the standard practice of planning the health workforce, with relatively little effect on policy. The authors of this commentary find it extremely refreshing and thoroughly heartening to see their Canadian colleagues making new attempts to change the way that the health workforce is planned and structured. In this commentary, the authors discuss what is meant by healthcare "needs" and the traditionally poor use of data in healthcare planning, and they support Tomblin Murphy and MacKenzie's call for proper evaluation of healthcare resources interventions.

BackgroundCommunity nursing (and health) services are faced with the growing challenge of caring for increasingly dependent patients with chronic conditions and complex care needs. Over the past decade there have been changes in the composition of the community nursing workforce with increasing numbers of assistants yet there is a lack of published literature on the roles, contribution and impacts of community nursing assistants to the delivery of care and services.DesignWe adopted a three-stage approach for the scoping study using mixed quantitative and qualitative methods. First, we established contact with senior managers in provider organisations where we had research governance approval (n = 76; 75% of total provider organisations) to determine whether or not (a) they employ assistants within community nursing teams and (b) they would be interested in participating in the study. Second, we carried out a short telephone interview with all senior managers who indicated a willingness to participate (census approach). We also analysed secondary data (using the NHS iView data source, from the Electronic Staff Record Data Warehouse) to scope the national use of community nursing assistant roles. Finally, we conducted telephone interviews with a purposive sample of managers from 10 organisations that participated in stage two to gain an in-depth understanding of assistant roles in community nursing teamsSettingCommunity nursing provider organisations in England, UK.ParticipantsThirty-seven senior managers were interviewed for stage two (49% of all contacted). Thirty managers (20 service-level managers and 10 senior managers) were interviewed for stage three.ResultsAssistants promote flexibility in the community nursing workforce so as to respond to the changing demands on these services. However, the lack of consensus in defining the role of community nursing assistants has created inconsistency in the national deployment and development of these roles. These roles have tended to develop ad hoc, creating variations in numbers of assistants, the roles that they play and preparation for practice across different provider organisations and nursing teams. There is general enthusiasm among managers about the contribution of assistants. Their employment is regarded as fundamental to the ability of community nursing teams to deliver acceptable and appropriate services. However, the role may not always support career progression and development for those assistants who require this. The maturity and life experience of assistants is greatly valued in the nursing team to support care delivery and to offer stability and support to other members of the nursing team. Line management, responsibility and accountability in managing the work of assistants were highlighted as important for managing risk associated with an unregulated role. These have to be balanced with promoting flexibility in use and innovation.ConclusionsOur scoping study highlights the opportunities and challenges associated with the use of assistants to deliver care by the community nursing team. Further attention at national and local levels is required to support and mediate the development of these roles in the future so as to promote the delivery of quality, safe and acceptable care. As provider organisations plan for delivering an ambitious community services agenda in the future, the role of the assistant is likely to have increasing importance.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Objective To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery. Data Source Hospital data on all publicly funded CABG in five European countries, 2007–2009 (106,149 patients). Design Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold. Findings The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0–6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8–2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year. Conclusions There is a clear relationship between hospital CABG volume and mortality in Europe, implying a “safe” threshold volume of 415 cases per year.

Objectives This study examined the effect of new Korean pricing and copayment schemes for pharmaceuticals (1) on per patient drug expenditure, utilisation and unit prices of overall pharmaceuticals; (2) on the utilisation of essential medications and (3) on the utilisation of less costly alternatives to the study medication. Methods Interrupted time series analysis using retrospective observational data. Results The increasing trend of per patient drug expenditure fell gradually after the introduction of a new copayment scheme. The segmented regression model suggested that per patient drug expenditure might decrease by about 12% 1 year after the copayment increase, compared with the absence of such a policy, with few changes in overall utilisation and unit prices. The level of savings was much smaller when the new price scheme was included, while the effects of a price cut were inconclusive due to the short time period before an additional policy change. Based on the segmented regression models, we estimate that the number of patients filling their antihyperlipidemics prescriptions decreased by 18% in the corresponding period. Those prescribed generic and brand-named antihyperlipidemics declined by around 16 and 19%, respectively, indicating little evidence of generic substitution resulting from the copayment increase. Few changes were found in the use of antihypertensives. Conclusions The policies under consideration appear to contain costs not by the intended mechanisms, such as substituting generics for brand name products, but by reducing patients’ access to costly therapies regardless of clinical necessity. Thus, concerns were raised about potentially compromising overall health and loss of equity in pharmaceutical utilisation.

We aimed to examine associations between factors readily obtainable in health care settings and post-partum smoking relapse in women of differing marital status. We analysed data on 1,829 mothers in the Millennium Cohort Study who reported quitting smoking during their pregnancy using multivariate logistic regression. We analysed single, married and cohabiting women separately. Fifty-seven percent of mothers who quit during pregnancy had relapsed at 9 months. The risk of relapse was highest for single women, followed by cohabiting, then married women. Higher parity and not managing financially were associated with relapse for single women. For married women the greatest risk of relapse was associated with having a partner who also relapsed. Women whose husbands continued to smoke had an increased risk of relapse but those whose husbands had sustained a quit were protected. Other significant risk factors were not breastfeeding, having other children and drinking at moderate frequencies. A similar pattern was seen for cohabiting women, except that having a partner who quit but then relapsed did not appear to confer an additional risk. Drinking at moderate intervals (only) was associated with relapse but breastfeeding and parity were not. The association between married couple relapse was not evident when only the husband's smoking status during the pregnancy was considered, indicating that partner follow-up is important post-partum. Risk factors for relapse appear to differ according to marital status. A 'one size fits all' package of post-partum relapse prevention is unlikely to be an appropriate intervention strategy.

Objectives To understand the challenges and opportunities associated with the introduction of assistant practitioner (AP) roles supporting the work of ward-based registered nurses (RNs) in National Health Service (NHS) acute hospital trusts in England. Methods Three case studies of NHS acute hospital trusts. This paper presents qualitative findings, drawing on documentary data sources and data generated through interviews and focus group discussions. Results Introduction of APs into ward-based nursing teams has been variable, and often driven by external pressures rather than perceived organizational need. This, along with little national guidance, has created some confusion about the role, but at the same time has permitted flexible role development through ‘negotiated compromise’ at local level. While there are various areas of potential improvement in policy and practice, APs are generally perceived to have the potential to make a valuable contribution to patient care. Conclusions Findings from this study will help policy-makers, organizations and practitioners understand factors that enable and/or inhibit the integration of new assistant roles within existing occupational structures to develop innovative services and enhance patient care. These factors are important when considering how care will be delivered to maximize the skills of the entire nursing workforce.

Assistant practitioners (APs) are ‘higher-level’ support workers who complement the work of registered professionals. This article discusses the first national survey of APs in acute hospital wards in England, forming part of a national study surrounding the introduction and development of AP roles in acute settings. Survey findings and their implications are reported, as well as AP responsibilities, characteristics, career progression and integration with nurses.

Although taxation is arguably the most efficient funding mechanism, NHS expenditure is a political choice, say Anita Charlesworth and Karen Bloor

Objective To explore whether or not gender predicts consultant activity rates. Design Using data from the Hospital Episode Statistics for England 2004/2005, we explored inpatient activity rates of male and female hospital consultants, with and without adjustment for case-mix differences. As a sensitivity analysis we also explored outpatient attendances for male and female hospital consultants. Setting Data from the Hospital Episode Statistics for England. Main outcome measures Finished consultant episodes per year, with and without adjustment for case-mix differences, age and gender of consultant, contract held, hospital trust, specialty of practice, and clinical excellence awards, discretionary points and distinction awards. Results Including only consultants on full-time or maximum part-time contracts, men have significantly higher activity rates than women, after accounting for age, specialty and hospital trust. Conclusions The reasons for the different activity rates of male and female consultatns are unclear, but the implications of these results for the planning of the medical workforce are important.

Universities in England have recently been invited to bid for additional medical student numbers from 2006, and consider increasing numbers further from 2008.1 Do we need more doctors, or are there alternatives to expansion of medical education?