Area Of Northwest England Research Articles

Associate Psychological Practitioners (APPs) in primary care: modelling the impact.

The 'Associate Psychological Practitioner' (APP) is an innovative new role that expands the psychological workforce and addresses the rising demand for mental health services in England, yet the impact of this role on NHS workforce capacity has yet to be modelled. We modelled the impact of the APP role in Primary Care in terms of additional capacity to provide mental health care and the impact on General Practitioner (GP) capacity within the sector. Workforce experts of the NHS Workforce Repository and Planning Tool (WRaPT) team used a modelling tool to determine future state scenarios of APPs working across all Primary Care Networks (PCNs) within a region and the associated change on the baseline workforce. Modelling was based on Lancashire and South Cumbria, a large geographical area in North-West England that includes 41 PCNs. Assumptions used in the modelling included identifying the patient population and workforce in scope, documenting the activity undertaken by APPs, and considering the future state scenarios for modelling. With regard to generating additional capacity, having 1 APP in each of the 41 PCNs in Lancashire and South Cumbria could provide 53000 brief intervention appointments of 45min each, thereby diverting these appointments away from the GP, and up to 48 people could benefit from attending Group and Well-being sessions over a year with 1 APP working with another Primary Care colleague, that is, 384 group intervention sessions delivered. In relation to GP capacity, 1 APP (if placed across a PCN, or within multiple practices) could free up at least 1,665 GP appointments within one year, which could lead to potential cost savings. These findings can be used to underpin decision-making with respect to training future cohorts of APPs and contribute to wider workforce planning in primary care.

Understanding barriers and facilitators to palliative and end-of-life care research: a mixed method study of generalist and specialist health, social care, and research professionals

BackgroundPalliative care provision should be driven by high quality research evidence. However, there are barriers to conducting research. Most research attention focuses on potential patient barriers; staff and organisational issues that affect research involvement are underexplored. The aim of this research is to understand professional and organisational facilitators and barriers to conducting palliative care research.MethodsA mixed methods study, using an open cross-sectional online survey, followed by working groups using nominal group techniques. Participants were professionals interested in palliative care research, working as generalist/specialist palliative care providers, or palliative care research staff across areas of North West England. Recruitment was via local health organisations, personal networks, and social media in 2022. Data were examined using descriptive statistics and content analysis.ResultsParticipants (survey n = 293, working groups n = 20) were mainly from clinical settings (71%) with 45% nurses and 45% working more than 10 years in palliative care. 75% were not active in research but 73% indicated a desire to increase research involvement. Key barriers included lack of organisational research culture and capacity (including prioritisation and available time); research knowledge (including skills/expertise and funding opportunities); research infrastructure (including collaborative opportunities across multiple organisations and governance challenges); and patient and public perceptions of research (including vulnerabilities and burdens). Key facilitators included dedicated research staff, and active research groups, collaborations, and networking opportunities.ConclusionsProfessionals working in palliative care are keen to be research active, but lack time, skills, and support to build research capabilities and collaborations. A shift in organisational culture is needed to enhance palliative care research capacity and collaborative opportunities across clinical and research settings.

A paradox of problems in accessing general practice: a qualitative participatory case study.

Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity. To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access. A qualitative participatory case study in an area of northwest England. A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al's theory of access, allowed the team to identify complexities and relationships between interrelated problems. This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities. Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.

Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin – ROSHNI-D

BackgroundPostnatal depression (PND) is a global public health problem. There is a high prevalence of PND amongst ethnic minority women and major ethnic inequalities in mental health care in the U.K. Language and cultural barriers pose a significant challenge for access to timely treatment and interventions for British South Asian (BSA) women with PND. MethodsThe study, carried out in Manchester and Lancashire, England, was a two-arm single-blind exploratory randomised controlled trial. BSA women (N = 83) having a baby <12 months were randomised either to the group receiving the culturally adapted Positive Health Programme (PHP) (n = 42) or to the group receiving treatment as usual (TAU) (n = 41). Follow-up assessments were at 3 months (end of intervention) and 6 months after randomisation. ResultsUsing an intention to treat analysis, there was no significant difference between PHP intervention and TAU groups in depression measured using Hamilton Depression Rating Scale both at 3 and 6 months follow up. Using modified intention to treat analysis, women who attended four or more sessions showed significant reduction in depression in the PHP group compared to the TAU group and the greater number of sessions attended was associated with greater reductions in depression scores. LimitationsThe sample was relatively small and the study was conducted in one geographical area in Northwest England; hence, these results may not be generalizable to other regions and populations. ConclusionThe recruitment and trial retention figures highlighted the ability of the research team to engage with BSA women, having implications in planning services for this group. Trial registrationClinicaltrials.govNCT01838889.

Children of Smoking and Non-Smoking Households' Perceptions of Physical Activity, Cardiorespiratory Fitness, and Exercise.

Previous research has shown secondhand tobacco smoke to be detrimental to children’s health. This qualitative study aimed to explore children from low socioeconomic status (SES) families and their reasons for being physically active, attitudes towards physical activity (PA), fitness and exercise, perceived barriers and facilitators to PA, self-perceptions of fitness and physical ability, and how these differ for children from smoking and non-smoking households. A total of 38 children (9–11 years; 50% female; 42% smoking households) from the deprived areas of North West England participated in focus groups (n = 8), which were analysed by utilizing thematic analysis. The findings support hypothesised mediators of PA in children including self-efficacy, enjoyment, perceived benefit, and social support. Fewer than a quarter of all children were aware of the PA guidelines with varying explanations, while the majority of children perceived their own fitness to be high. Variances also emerged between important barriers (e.g., sedentary behaviour and environmental factors) and facilitators (e.g., psychological factors and PA opportunity) for children from smoking and non-smoking households. This unique study provided a voice to children from low SES and smoking households and these child perspectives could be used to create relevant and effective strategies for interventions to improve PA, fitness, and health.

Is toothbrushing behaviour habitual? Cues, context, motivators and patient narratives.

Toothbrushing is generally considered as a key self-care behaviour necessary for maintaining good oral health. Although twice-daily brushing is widely recommended as beneficial since this provides both biofilm removal and a regular application of fluoride, some people such as those with low socio-economic (SES) backgrounds often brush less regularly. Habit theory identifies that behaviours become habitual when they are undertaken repeatedly in response to a particular cue within a stable context. Once behaviour becomes automatic, long-term maintenance is more likely even if motivation wanes. Establishing toothbrushing as a habitual behaviour is therefore an intervention strategy which may help reduce health inequalities. Therefore, the objective was to more fully understand the nature of toothbrushing behaviour in adults and what prompts its instigation and execution in the morning and evening, in order to inform the design of interventions in this area. Twenty-nine semi-structured interviews were undertaken in an urgent dental care centre in a deprived area of North West England. Thematic analysis using a framework method was used to code the data into theoretically derived categories. Morning toothbrushing was found to be strongly integrated into cleansing routines and was identified as a behaviour predominantly initiated in response to visual cues. Some toothbrushing behaviour was prompted by internal cues, expressed as strong feelings or urges. These were more related to night-time toothbrushing habits. Common morning motivators were aesthetics and social acceptability. Evening motivators were relatively idiosyncratic. Cleaning of the mouth following a hard, manual working day emerged as a strong driver for low SES males. Understanding the nature of habitual morning and evening toothbrushing is important for the design of effective behavioural interventions, especially those aiming to achieve sustainable improvement in the frequency of night-time toothbrushing.

Skill Acquisition Methods Fostering Physical Literacy in Early-Physical Education (SAMPLE-PE): Rationale and Study Protocol for a Cluster Randomized Controlled Trial in 5-6-Year-Old Children From Deprived Areas of North West England.

BackgroundThere is a need for interdisciplinary research to better understand how pedagogical approaches in primary physical education (PE) can support the linked development of physical, cognitive and affective aspects of physical literacy and physical activity behaviors in young children living in deprived areas. The Skill Acquisition Methods fostering Physical Literacy in Early-Physical Education (SAMPLE-PE) study aims to examine the efficacy of two different pedagogies for PE, underpinned by theories of motor learning, to foster physical literacy.MethodsSAMPLE-PE will be evaluated through a cluster-randomized controlled trial targeting 5–6 year old children from schools located in areas of high deprivation in Merseyside, North-West England. Schools will be randomly allocated to one of three conditions: Linear Pedagogy, Non-linear Pedagogy, or Control. Non-linear and Linear Pedagogy intervention primary schools will receive a PE curriculum delivered by trained coaches over 15 weeks, while control schools will follow their usual practice. Data will be collected at baseline (T0), immediately post-intervention (T1), and 6 months after the intervention has finished (T2). Children’s movement competence is the primary outcome in this trial. Secondary outcomes include physical activity, perceived competence, motivation, executive functions, and self-regulation. An extensive process evaluation will also examine implementation factors such as intervention context, reach, dose, fidelity and acceptability.DiscussionThe SAMPLE-PE project will enable better understanding surrounding how to operationalise physical literacy through enrichment of PE practices in early PE. The study will provide robust scientific evidence regarding the efficacy of underpinning PE pedagogy with theories of motor learning to promote the development of physical literacy.Trial RegistrationRetrospectively registered on 5th September 2018 at ClinicalTrials.gov, a resource provided by the U.S. National Library of Medicine (Identifier: NCT03551366).

Using the behaviour change wheel to explore infant feeding peer support provision; insights from a North West UK evaluation

BackgroundBreastfeeding peer support is advocated in national and international guidelines, but the evidence base is mixed. In the UK, breastfeeding peer support was found to be ineffective in randomised controlled trials, while women report positive impacts on breastfeeding experiences in qualitative studies. A key criticism levied against breastfeeding peer support is the lack of theory underpinning intervention design. Here we use the Behaviour Change Wheel to structure the analysis of evaluation data from an infant feeding peer support service in one area in North West England. We aimed to provide theoretically informed insights into how peer support can be operationalised to influence women’s breastfeeding experiences.MethodsA 2 year mixed-methods evaluation (2014–2016) comprised surveys and interviews (individual or group) with peer supporters, health and community professionals, project leads and women, and routinely collected infant feeding data. We used the three layers (policies, intervention functions and behaviour-related components) of the Behaviour Change Wheel to structure and interpret the data.ResultsOverall data comprised 23 interviews (n = 14 - individual; n = 9 - group) and 409 completed surveys. The findings are presented in three sections. First, the ‘policies’ (outer) layer of the Behaviour Change Wheel provides insights into the existing context, infrastructure and resources that underpinned peer support delivery. Then the second (intervention functions) and inner (behaviour components) layers of the Behaviour Change Wheel are used to present three themes, ‘developing capabilities for infant feeding’, ‘motivating guidance and support’ and ‘opportunities for support’. These findings highlight that a peer support service delivered in a context of effective interdisciplinary partnerships, Baby Friendly Initiative accreditation, and flexible service planning, with peer support provided via different types of instrumental, social, practical and emotional support was perceived to be highly beneficial on women’s breastfeeding experiences. In the final section key challenges faced by the service are outlined. ConclusionWhile gaps and areas for development were highlighted, the service enhanced women’s capabilities, motivations and opportunities for breastfeeding. These theoretically informed insights into an organic and responsive peer support service help build the evidence base for breastfeeding peer support and to identify positive delivery features for future testing.

Engaging Young Carers With Science Through Textile-Based Crafts

Textile-based crafts were used to engage young carers (under 18s providing care for another person) and accompanying adults in learning about underlying chemistry concepts, in an economically deprived area of northwest England; the region of the United Kingdom with the highest number of young carers. This science-crafts collaboration was supported by the Royal Society of Chemistry Outreach Fund and a British Science Week Community Grant. Feedback from participants indicated strong positive impacts on interest in and understanding of chemistry and its relevance to everyday life, social benefits, and, for accompanying adults, increased confidence in engaging young people with learning about chemistry.

A longitudinal study of the relationship between dental caries and obesity in late childhood and adolescence.

To determine whether caries experience in late childhood (aged 7-9 years) was predictive of adolescent obesity (ages 12-16 years) to inform the use of a common risk factor approach (CRFA) for prevention. A cohort study was conducted in an area of North West England. Clinical assessment of caries took place using the same methodology at ages 7-9 years and 12-16 years. Body mass index (BMI) category was calculated from height and weight measurements using age and gender specific cut-offs at 12-16 years only. The association between dependent variable (BMI category dichotomized as underweight/normal and overweight/obese) and explanatory variables (baseline and follow-up dental caries and sociodemographic status) adjusted for age, was assessed. At baseline, 5,470 (96.8 percent) participants took part and information was available for 2,958 (54.1 percent) participants at follow-up. Univariate analysis indicated that BMI category in adolescence was not shown to be significantly associated with: the presence or absence of caries in late childhood (P = 0.61); in adolescence (P = 0.06); gender (P = 0.91); or deprivation (P = 0.35). Multivariate logistic regression indicated that BMI category in adolescence was not predicted by caries in late childhood or adolescence, after adjusting for sociodemographic variables. Caries and obesity were highly prevalent in this population. Caries in childhood was not shown to be associated with obesity in adolescence and there was no cross-sectional association between the two diseases in adolescence. A CRFA is not precluded, however, the results suggest that additional interventions, specific for each disease, are required to prevent obesity and caries.

Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning.

BackgroundMental health problems in older people are common and costly, posing multiple challenges for commissioners. Against this backdrop, a series of initiatives have sought to shift resources from institutional to community care in the belief that this will save money and concurs with user preferences. However, most of this work has focused on the use of care home beds and general hospital admissions, and relatively little attention has been given to reducing the use of mental health inpatient beds, despite their very high cost.MethodsThe study employed a ‘Balance of Care approach’ in three areas of North-West England. This long-standing strategic planning framework identifies people whose needs can be met in more than one setting, and compares the costs and consequences of the possible alternatives in a simulation modelling exercise. Information was collected about a six-month cohort of admissions in 2010/11 (n = 216). The sample was divided into groups of people with similar needs for care, and vignettes were formulated to represent the most prevalent groups. A range of key staff judged the appropriateness of these admissions and suggested alternative care for those considered least appropriate for hospital. A public sector costing approach was used to compare the estimated costs of the recommended care with that people currently receive.ResultsThe findings suggest that more than a sixth of old age psychiatry inpatient admissions could be more appropriately supported in other settings if enhanced community services were available. Such restructuring could involve the provision of intensive support from Care Home Outreach and Community Mental Health Teams, rather than the development of crisis intervention and home treatment teams as currently advocated. Estimated savings were considerable, suggesting local agencies might release up to £1,300,000 per annum. No obvious trade-off between health and social care costs was predicted.ConclusionsThere is considerable potential to change the mix of institutional and community services provided for older people with mental health problems. The conclusions would be strengthened by further studies and the incorporation of evidence about relative outcomes. However, the utility of the approach in challenging established patterns of resource allocation and building local ownership for change is apparent.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0913-1) contains supplementary material, which is available to authorized users.

L20 Huntington's Disease - Bad For Your Wealth As Well As Your Health?

<h3>Background</h3> The Enroll-HD project aims to recruit one third of the manifest HD patients living in areas served by study sites. We conducted an audit of REGISTRY study participants at two sites (Manchester and Liverpool) to assess the feasibility of this, and to investigate the effect of geographical and socioeconomic factors on equality of access to the service. <h3>Aims</h3> To determine the number of REGISTRY participants per 100,000 of the population in different areas of North West England, and the relationship of this to distance from study sites and indicators of economic deprivation. <h3>Methods</h3> The total number of living REGISTRY participants and the number of currently active study participants were calculated for each county and borough in north west England. Postcodes were used to assign subjects to census areas (Lower-layer Super Output Areas; LSOAs) and the distribution of LSOAs containing at least one REGISTRY participant was compared to the overall distribution using the Index of Multiple Deprivations (IMD) of the UK Office of National Statistics. <h3>Results</h3> Rates of current REGISTRY participation varied greatly from borough to borough, but was approximately 4/100,000 across most of the region, rising to 6/100,000 when inactive participants were included. The borough with the highest rate of participation was the one most geographically distant (about 3 h travel) from the study sites. LSOAs containing a REGISTRY participant were significantly more likely to have a higher IMD score (more deprived). <h3>Conclusion</h3> If the prevalence of HD is 12/100,000, our findings suggest that the goal of recruiting one third of the available subjects is achievable. Distance from the study site does not appear to be a barrier to access in our region. Given that the primary cause of HD is genetic, the significant relationship with indices of deprivation suggests that HD has a detrimental effect on the socioeconomic status of families, as well as the health of affected individuals.

A population study showing that the advent of second generation tyrosine kinase inhibitors has improved progression-free survival in chronic myeloid leukaemia

BackgroundPopulation based data suggest the proportion of patients failing imatinib in chronic myeloid leukaemia (CML) is higher than the reported one-third of patients in clinical trials. Clinical trials have demonstrated second generation tyrosine kinase inhibitors (TKI) dasatinib and nilotinib can restore complete cytogenetic remission (CCR) and major molecular response (MMR) to many patients failing imatinib, but their impact in the general population is not clear. Design and methodsWe report CML outcome in a population of 2.3 million people in a geographically contiguous area of North West England and North Wales. ResultsBetween 2003 and 2009, 192 new CML cases were diagnosed, of whom 184 were in chronic phase and 160 started on imatinib. The maximal CCR rate was 65% at 24 months and the maximal MMR rate was 50% at 36 months. Patients diagnosed since second generation TKI became available for imatinib failure had a more rapid cumulative CCR and MMR rate and a significantly improved progression free survival (p=0.022) than those diagnosed before this time. ConclusionThe study indicates that second generation TKI have improved CML outcome in the general population.

Cattle producers' perceptions of biosecurity.

BackgroundThe limited use of biosecurity practices by many in the farming community is likely to be due to a range of factors; further understanding of this issue is required. In this study, attitudes and behaviours of producers relating to selected biosecurity practices and the farming industry were studied by interviewing cattle farmers within a 100 km2 study area in north-west England using an interview-based questionnaire.ResultsMost producers appeared to be familiar with the broad concept of the term biosecurity, although risks due to indirect contacts, rather than direct (animal) contacts, were more frequently highlighted. Most producers felt the nominated biosecurity practices were in some way useful, however there was not always agreement between the usefulness of a practice and it being undertaken, and vice versa. In agreement with other studies conducted in the UK, farmers most preferred to obtain information and advice on biosecurity from private veterinarians, but also highlighted DEFRA as a source.ConclusionsThis study highlights the importance of understanding the motivators and barriers behind the uptake of biosecurity practices on farms, as perceptions are variable. Further understanding of these issues is needed in order to more effectively communicate information in regards to herd health and disease prevention. By identifying differences in producers’ attitudes, programs can be tailored specifically to individuals’ needs.

Work–life reconciliation: Including children in the conversation

This paper seeks to further understanding about children’s experiences and knowledges of home and employment reconciliation. The paper, which draws on empirical research with children living in socio-economically diverse areas of North West England, makes three contributions. Firstly, it argues that children must be included in studies of work-balance, as the strategies parents adopt affect the way children are socialised towards appropriate divisions of domestic, caring and labour force responsibilities. Secondly, it contributes to research which considers the temporal and spatial boundaries between home and paid work to add the verbal dimension; demonstrating that children have varying levels of conversational interaction with their parents about employment in the home sphere. Finally, the paper contends that these distinct approaches to the verbal and spatial boundaries of production and reproduction are influenced by class dispositions, localised parenting cultures and constructions of childhood. This results in some children being shielded from the realities of paid work, whilst others are socialised to cope with labour market instability.

Improving outcomes in asthma by Commissioning Quality and Innovation (CQUIN)

<h3>Background</h3> Our catchment population has had higher than national average of asthma attendances to primary care and emergency department in this area of Northwest England. CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of the healthcare providers income to the achievement of local quality improvement goals. <h3>Methodology</h3> BTS annual children9s asthma audit pre and post introduction of CQUIN (Commissioning Quality and Innovation) recommendations to reduce admission rates and maintain good control of their symptoms. Clinical Setting: 4 district general hospitals attached to Pennine Acute Trust with a catchment population of nearly 1 million. <h3>Results</h3> Initial audit results in November 2009 identified suboptimal performance in asthma education, discharge planning and the early use of oral steroids. Following the CQUIN recommendations, an intervention team was formed to address the issues raised and a robust strategy was developed and the outcomes were evaluated by a repeat BTS audit in November 2010. Strategies included developing clear guidelines, seamless integrated care pathway from admission to discharge, robust education programme for all frontline medical and nursing personnel and enrolling nurses for diploma in asthma management to take on a more specialist role. The distribution of cases in relation to age, gender and severity was similar to the national cohort. These interventions resulted in good outcomes for a number of CQUIN indicators including more than 50% improvement in discharge planning, 50% reduction in CXR9s and 3 fold reduction in the use of antibiotics for exacerbations. The results for oral steroids administration within an hour of diagnosis was well above national average. <h3>Conclusions</h3> Focussed education to patients, parents and clinical personnel improves clinical outcomes. Integrated care pathway standardises care and improves patient experience. CQUIN schemes reward excellence and improve clinical outcomes.

Knowledge gaps in bryophyte distribution and prediction of species-richness

Knowledge of the distribution of species is fundamental to their conservation. Hence, it is important to understand the completeness of distribution inventories and the location of the main gaps. In an attempt to do this within an area of north-west England, this study builds a model which predicts bryophyte species-richness in 1220 tetrads (2 × 2 km squares) based upon their environmental characteristics, then compares predictions with current knowledge. The number of raindays (≥1 mm rain) each year was clearly the most important predictor of species-richness, followed by total nitrogen deposition and percentage cover of broad-leaved woodland. The main gaps in the current inventories are located and an assessment is made of their overall completeness. Suggestions for improvements in predicting bryophyte species-richness at tetrad resolution are provided.

Direct and indirect contacts between cattle farms in north-west England

Little is known regarding the types and frequencies of contact that exist between farms and which of these may act as pathogen transmission routes; however it is likely that farms demonstrate considerable heterogeneity in such contacts. In this cross-sectional study, we explored the direct and indirect contact types and frequencies that exist between cattle farms within a region, focusing on potential routes of pathogen transmission. The owners/managers of 56 farms located in a 10 km by 10 km study area in north-west England were administered an interview-based questionnaire between June and September 2005. Information was obtained relating to contact types and frequencies, including those involving animal movements, equipment sharing between farms and any contractors or companies visiting the farms. The data was explored using hierarchical cluster analysis and network analysis. There was considerable variation between farms arising from different contact types. Some networks exhibited great connectivity, incorporating approximately 90% of the farms interviewed in a single component, whilst other networks were more fragmented, with multiple small components (sets of connected farms not linked with other farms). A range of factors influencing contact between farms were identified. For example, contiguous farms were more likely to be linked via other contacts, such as sharing of equipment and direct farm-to-farm animal movements ( p < 0.001 and p = 0.02, respectively). The frequency of contacts was also investigated; it is likely that the amount of contact a farm receives from a company or contractor and whether or not biosecurity is performed after contact would impact on disease transmission potential. We found considerable heterogeneity in contact frequency and that many company and contractor personnel undertook little biosecurity. These findings lead to greater understanding of inter-farm contact and may aid development of appropriate biosecurity practices and control procedures, and inform mathematical modelling of infectious diseases.

Prevalence and risk factors for Cryptosporidium spp. infection in young calves

A cross-sectional study was designed to investigate the prevalence and risk factors for Cryptosporidium infection in young calves. Forty-one farms in a discrete, densely farmed 100 km 2 area of North West England were visited over a 3-week period and 215 faecal samples were collected from young calves. Farms were not selected on the basis of existing scour problems. At the time of sampling, several investigator-observed variables were recorded at the pen, animal and stool levels. Samples were screened and 60/215 were confirmed as positive by PCR of the 18S rRNA gene. Risk factors for infection were explored using multilevel multivariable logistic regression with farm as a random effect. Age was significant in the final model, with a higher risk of infection in calves aged 8–21 days, when compared to those aged 0–7 days. The depth of the bedding was also significant in the final model, with calves housed in bedding 11–15 cm deep being at lower risk of infection than those on beds 0–5 cm deep. Consistency of the faeces was highly correlated with age and colour of the faeces and was not significantly associated with infection when these variables, and clustering at farm-level, were accounted for. This is interesting as Cryptosporidium is considered to be a primary enteropathogen. The results suggest that intervention strategies should be targeted at calves under 21 days old. These animals represent a significant reservoir of infection on the farm and may also pose a risk to public health, assuming that the species and genotypes shed are zoonotic pathogens.

Commissioning Services for Older People with Mental Health Problems: Is There a Shared Vision?

UK policy seeks to shift commissioning of services ‘closer to the people’ with a view to establishing shared visions of local care services grounded in the opinions and priorities of the public. The participation of older people with mental health problems and their carers in the strategic planning process has been patchy, however. This article compares practitioner and public perspectives of the services that should be provided for older people with mental health problems in an area of North West England. Significant differences were found in the services the various stakeholder groups prioritised for development, and in their views on how they should be organised. The implications for commissioning are discussed.