Clinical Commissioning Groups Research Articles

Investigating the prescribing trajectory and geographical drug utilisation patterns of gabapentinoids in primary care in England: An ecological study.

This study aimed to investigate the prescribing trajectory, geographical variation and population factors, including socioeconomic status (SES), related to prescribing gabapentinoids in primary care in England. This ecological study applied practice-level dispensing data and statistics from the UK National Health Service Digital and Office for National Statistics from 2013 to 2019. The prescribing of gabapentinoids (in defined daily doses [DDDs]/1000 people) was measured annually and quarterly. General practices were categorised according to the quarterly prescribing in a group-based trajectory model. The one-year prescribing in 2018/19 was associated with practice-level covariates in a mixed-effects multilevel regression, adjusted for the cluster-effects of Clinical Commissioning Groups (CCGs) and mapped geographically. The annual national prescription rate increased by 70% from 2800 to 4773 DDDs/1000 people in the time period 2013/14 to 2018/19. General practices were stratified into six trajectory groups. Practices with the highest level and the greatest increase in prescribing (n = 789; 9.8%) are mainly located in the north of England and along the east and south coastline. Socioeconomic status, demographic characteristics and relevant disease conditions were significantly associated with the prescribing. For every decrease in the Index of Multiple Deprivation decile (becoming less affluent), prescribing of gabapentinoids increased significantly by 203 (95% CI: 183-222) DDDs/1000 registrants. Gabapentinoid prescribing trajectories varied across geographical regions and are associated with socioeconomic status, CCG locality (geography) and other population characteristics. These factors should be considered in future studies investigating the determinants of gabapentinoid prescribing and the risk of harms associated with gabapentinoids.

P092 NICE biologics pathways for inflammatory arthritis exhibit regional variability due to modification by CCG’s: results from a national survey of pathways in England

Abstract Background/Aims NICE publishes guidance underpinned by act of Parliament and legally enforceable, on the use of biological therapies in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) which should allow harmonisation of access independent of region. However, sufficient guidance is not provided on the use of sequential biologics nor is a numerical cap placed on the number of biologics a patient can attempt if they have had an inadequate response. We have previously reported that in a limited sample, Clinical Commissioning Groups (CCGs) interpret NICE guidance variably and restrict access to NICE approved treatments depending on geography, the so-called “postcode lottery”. We determined the variability of biologics pathways in all CCG’s in England to examine whether a potentially unfair postcode lottery exists for sequential biologics use. Methods All 135 England CCGs covering over 55 million people, were sent Freedom of Information requests, for their biologic pathways for RA, PsA and AS. Where CCGs did not have this information, the relevant acute trusts were contacted, with responses recorded under that CCG. For every CCG the local biologics pathways were examined for detail on the number and type of biologics commissioned before an Individual Funding Request was needed. “No Cap” was recorded if CCG’s responded with no restriction on the number of biologics. Results Responses were obtained from 124/135 CCG’s for RA, 122/135 for PsA and AS, all covering an estimated population in excess of 45 million people. For RA, 55% CCG’s had no cap on the number of commissioned RA biologics. 45% had a variable cap from 3 to 6 commissioned biologics. For PsA, the figures were 54% with no cap and 46% with variable capping between 2-5 biologics allowed, for AS the figures were 51% and 49% respectively. In total this represented 41 different local pathways for RA, 29 different pathways for PsA and in AS where fewer biologics choices exist, 25 different pathways depending on CCG and location. Conclusion There is wide regional variation in the interpretation of NICE guidance by CCG’s resulting in many different local pathways depending on geography. Approximately 50% of pathways restricted biologics prescribing by mandating the type and sequence of biologics used, potentially compromising patient care and delaying treatment by requiring an IFR for a NICE approved biologic. Moreover, pathways varied as to which biologics could be used at any point of management by region as well. As exemplars of good practice, approximately 50% of CCG’s had no cap, allowing clinical freedom to prescribe the most appropriate biologic. The results of this national study demonstrate the variability of biologics pathways in many areas of England ensuring a postcode lottery still exists in many regions. Disclosure J. Mistry: None. D. Hill: None. A. Bosworth: None. A. Kaul: None.

Evaluating the communication within fire and rescue services and the NHS on the fire risk of emollients in accordance of the MHRA safety update

SUMMARYThe Medicines and Healthcare products Regulatory Agency update in 2018 reported 50 fatal fires linked with emollient use. It detailed the fire risk and new advice aimed at fire service and health care professionals in reporting of such fire incidents and educating the public on safer use of emollients. This study investigates how this has been communicated internally and publicly, with 52 Fire and Rescue Services (FRSs) websites and, 191 Clinical Commissioning Groups (CCGs), and 21 Local Health Boards (LHBs) formularies accessed. A Freedom of Information Request (FOIR) was also made, giving further details of implementations. Our study revealed that 63% of FRSs, 32% of CCGs and, 72% of LHBs gave no safety advice within their website or formularies. Of the 37% of FRSs and 68% of CCGs that did, only 5% and 4% were sufficiently up to date. 27% of FRSs and 28% of CCGs/LHBs revealed that they had no warning/advice internally in their FOIR responses and 25% of FRSs and, 35% of CCG/LHBs had not disseminated advice on using emollient safely to the public. We suggest improvements in safety campaigns using a multiagency and national approach and recommend organizations to educate professionals to improve reporting and effective dissemination.

Modifications to the delivery of NHS face-to-face general practice consultations during the COVID-19 pandemic in England.

Background: To minimise transmission of SARS-CoV-2, the virus causing COVID-19, delivery of general practice consultations has been modified to enable the separation of diagnosed or suspected COVID-19 patients from others. Remote triage and consultations are currently the default model, with adapted face-to-face contact used when clinically necessary. This study aimed to identify the modified face-to-face delivery models used across England, and evidence for their effectiveness. Methods: In June 2020, a national survey was sent by email to the 135 Clinical Commissioning Groups (CCGs) in England to identify local organisation of face-to-face general practice consultations since March 2020. An email was sent to Public Health England (PHE) requesting information about COVID-19 outbreaks or clusters linked to general practice. Results: All CCGs responded. Separation of COVID-19 patients from others was achieved using combinations of the following models: zoned surgeries (used in 47% of CCGs), where COVID-19 and other patients are separated within their own practice;'hot' or 'cold' hubs (used in 90% of CCGs), separate sites where COVID-19 or other patients registered at one of several collaborating practices are seen;'hot' and 'cold' home visits (used in 70% of CCGs). One of seven model combinations was used across each CCG, with some flexibility according to changing need shown through hub availability. Concomitant PHE data showed less than 2% of COVID-19 outbreaks or clusters in England were linked to general practice. Conclusions: Varied, flexible ways of delivering face-to-face general practice consultations were identified. While COVID-19 outbreaks or clusters linked to general practice constituted a small proportion of totals, their investigation, together with evaluations of the modified delivery models in terms of management of COVID-19 and other conditions and impacts on staff and patients, may aid future management of the pandemic and identify aspects of adapted practice of benefit beyond this.

Understanding the implementation and medium-longer term sustainability of the primary care prescribing safety intervention, PINCER: preliminary results from a longitudinal process evaluation

Abstract Introduction Medication errors are an important cause of morbidity and mortality across primary care in England. In the National Health Service, approximately 71% of 237 million medication errors made annually are attributable to primary care(1). The complex pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention has been shown to significantly reduce medication errors when tested in a cluster randomised controlled trial and when implemented on a larger scale across one geographical region of England. However, with a national rollout of PINCER now underway across England, there remains a limited understanding of whether and how wider implementation, impact and medium-longer term sustainability across diverse regions is achieved, and what factors may influence these processes. Aim This study aimed to explore the contextual factors that influenced the nature and extent of translation, implementation and sustained use of PINCER in diverse settings over time. Methods Intervention developers and personnel involved in the PINCER rollout and staff members from Academic Health Science Networks (AHSNs), Clinical Commissioning Groups (CCGs) and general practices from four regions of England, UK, were purposively recruited via research team connections and Clinical Research Networks. Interviews aimed to capture short-term (≤6 months), medium-term (6 – 18 months) and long-term (≥ 18 months) use of PINCER. Interview guides were informed by Normalisation Process Theory (NPT). Semi-structured, face-to-face or telephone interviews were conducted and digitally recorded. A preliminary thematic analysis was performed on the data collected. Results Forty-eight participants from 30 establishments, including two intervention developers, three involved in the PINCER rollout and five AHSN, seven CCG and thirty-one general practice employees were interviewed between June 2018 – June 2020. Their engagement with PINCER had either been in the medium (n=13) or long-term (n=17), (range 8 months - 5 years plus). Emerging themes identified in the preliminary analysis were: development and spread which incorporated intervention and training improvements as well as uptake, perceptions of PINCER which included awareness of PINCER as well as opinions on it and factors influencing the use of PINCER and sustainability which were mainly contextual but also related to PINCER functionalities. Within the development and spread theme, and relating to perceptions of PINCER theme, clear communication and ensuring there was an understanding of what PINCER entailed was considered important in initiating interest and uptake. Overall, PINCER was perceived positively. Key challenges to the implementation of PINCER identified were initial IT issues and workload. Policies advocating the use of PINCER, evidencing impact in reductions in the number of patients identified as being ‘at risk’ of hazardous prescribing and being able to benchmark results against other CCGs and practices helped facilitate the implementation and sustainability. Some changes made to prescribing and monitoring processes as a result of the implementation and use of PINCER, appeared to have become embedded into routine practice giving an indication of sustainable use. Conclusion Further interviews will establish if and how PINCER has been more widely adopted and normalised within primary care, in order to generate important learning to support its optimal and sustainable impact.

Evaluating the Utilisation of a Service Designed to Enhance Care with Medicines Following Acute Hospital Discharge: A Retrospective Study

Abstract Introduction Medication safety challenges are common after hospital discharge and an important global health care improvement target [1,2]. ‘Transfers of Care Around Medicines’ (TCAM) services have been suggested as an intervention that may help address this problem, and are designed to enable the referral of patients on discharge from the hospital to a named community pharmacy in the surrounding Clinical Commissioning Group (CCG). A TCAM service was launched by a large NHS Trust in England in February 2019 to enhance medicines communication and optimisation between primary and secondary care following hospital discharge. The TCAM service is delivered through the PharmOutcomes™ platform, and the initial focus of the service was to support patients with new or existing Monitored Dosage Systems (MDS). Aim To evaluate the utilisation of the TCAM service in the host NHS Trust and surrounding CCG through the examination of the nature and outcome of referrals made to community pharmacy. Method Anonymised service delivery data of patients referred from the TCAM service via the PharmOutcomes™ platform between March 2019 – February 2020 were retrospectively examined. The data comprised important variables, including patient demographics, status and time of referrals, and referral outcomes including problems/errors identified with medications and services provided by the community pharmacy such as medicines reconciliation. Study approvals were obtained from the host NHS Trust and the Health Research Authority (HRA); the study was exempt from the University Research Ethics Committee (UREC) approval [2019-7048-10983]. Results A total of 3,033 TCAM referrals to 67 community pharmacies were analysed. Most referrals were for patients aged 70 and above (72%, n=2,195) and 56% (n=1,713/3,033) of the referrals were for female patients. The number of referrals varied between 215 and 310 per month (median 246, Inter quartile range [IQR] 234 - 268). Most referrals (67%, 2,038/3,033) were marked as ‘completed’ by the community pharmacies, with 32.8% (n=995) left uncompleted. The rate of referral completion varied between 59 and 80% per month (median 66.4, IQR 64.5 - 70). Five (0.2%) patients were identified by community pharmacies that had adverse drug reactions (ADRs) from the cohort of 2,038 patients with completed referrals, with 45 (2%, n=45/2,038) identified as having issues that necessitated referral to the general practitioner (GP). The most common reason for referral to GP was medication changes identified from hospital, incorrect repeat prescriptions following discharge, to request a new prescription or weekly MDS, and to inform the GP that the patient has stopped taking their medication. The most common services carried out in community pharmacies following referral were reported as medicines reconciliation (47%, n=954/2,038), followed by review of information (46.7%, n=952/2,038), home delivery of medication (39%, n=798/2,038), review MDS arrangements (23.6%, n=482/2,038), commence MDS (18.6%, n=380/2,038), and pharmacy managed repeat service (12%, n=254/2,038). The main strength of this study is the inclusion of referral data that occurred over a one-year period, while the data were limited in generalisability due to inclusion of one geographical region and only patients using MDS. Conclusion The findings of this study may inform the ongoing development of electronic pharmacy referral systems for use at hospital discharge.

Exploring commissioners' understandings of early primary care network development: qualitative interview study.

BackgroundPrimary care networks (PCNs) are financially incentivised groupings of general practices in the English NHS. Their purpose is to deliver a number of policy goals set out in The NHS Long Term Plan. Clinical commissioning groups (CCGs) have a role in their establishment, support, and oversight.AimTo explore commissioners’ perspectives on the early development of PCNs.Design and settingQualitative study of CCG staff using telephone interviews.MethodSemi-structured interviews were carried out with 37 CCG employees involved in PCN establishment. Interviewees were asked about local PCNs’ characteristics, factors shaping development and form, activities to date, challenges and benefits, and their CCGs’ relationship with PCNs. Interviewee responses were summarised within a matrix and analysed thematically.ResultsThree meta-themes were identified: the multifaceted role of the commissioner, tensions between PCN policy and locally commissioned services, and engaging the broader system. Interviewees reported that the policy potentially favours those PCNs working from a ‘blank slate’ and does not sufficiently account for the fact some GP practices and wider system organisations have been doing similar work already. The prescriptive, contractual nature of the policy has led to local challenges, trying to ensure that local good practices are not lost during implementation. Interviewees also considered an important part of their work to be protecting PCNs from the weight of expectations placed on them.ConclusionCCGs are well placed to understand the complexities of local systems and to facilitate PCNs and working practices between wider system partners. It is important that this local role is not lost as CCGs continue to merge and cover larger geographical populations.

Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting

Direct-acting oral anticoagulants (DOACs) are replacing conventional VKA (vitamin K antagonist, i.e., warfarin) for various indications where a therapeutic anticoagulant effect is desired. We evaluated the prescribing patterns of the DOACs and warfarin, cost implications of the increasing DOACs prescribing, and deduce the reporting of serious and fatal events, during 2009–2019 in primary care England. Prescriptions and fatal or serious adverse events reporting data, between 2009 and 2019 were analysed, using linear regression to examine the trends in prescriptions, costs, and serious and fatal events reporting. We also compared the prescribing trends of four direct-acting oral anticoagulants and warfarin, normalised to per 1000 clinical commissioning group (CCG) patient population for the year 2019 to better understand the regional differences in DOACs prescribing. The overall use of any DOACs (as a proportion of total anticoagulants) increased from 16% in 2015 to 62% in 2019 with an average increase of 87% (95% CI 83.1, 90.5) per year. The reporting of serious and fatal events associated with DOACs decreased by 6% (95% CI 12.5, − 0.1) per year. Apixaban is by far the most prescribed with an average drug cost increasing to 156% (95% CI 140, 172) per year. In England, the lowest anticoagulant prescribing region was Greater London whereas the highest prescribing regions were Yorkshire and Humber for DOACs and the East Midlands for warfarin. Interestingly, Lancashire, Merseyside, and Cheshire showed a higher usage for warfarin over DOACs. The differing prescription patterns could be a result of changes in national guidelines and increasing population. Nevertheless, DOACs appear to make an increasing contribution to total anticoagulant prescription items and costs.

Protocol for an ‘efficient design’ cluster randomised controlled trial to evaluate a complex intervention to improve antibiotic prescribing for CHIldren presenting to primary care with acute COugh and respiratory tract infection: the CHICO study

IntroductionRespiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance....

Improving the utility and sustainability of novel health technology to improve clinical outcomes for patients: an East Staffordshire experience of screening for atrial fibrillation with the AliveCor KardiaMobile.

Atrial fibrillation (AF) is the most common sustained arrythmia in the world.1 With a two-fold increased risk of mortality, a near five-fold increased risk of stroke, and a two- to three-fold increased risk of heart failure, the rising prevalence of AF is a major public health burden.2 Patients typically present with palpitations, chest pain, or breathlessness; however, up to a third of patients are asymptomatic. Identifying this subgroup and commencing them on anticoagulation therapy if justified is therefore a major obstacle and necessity in the secondary prevention of AF.3,4 The use of novel health technology in this regard is an option with much potential. Across East Staffordshire Clinical Commissioning Group (CCG), we embraced this potential and piloted an initiative to improve identification of patients with AF by distributing single-lead electrocardiogram (ECG) devices to 18 general practices between October 2019 and March 2020, following an initial workshop as part of a CCG Local Incentive Scheme. Screening data, as well as clinical feedback in the form of a questionnaire using the online platform Google forms, were then collected from the practices. Further, quality and outcomes framework (QOF) data from NHS Digital and Public Heath England were analysed for trends in the CCG and region.5,6 We present five insights from our experiences and highlight how single lead ECG devices were used to improve clinical outcomes for patients across East Staffordshire. ### Insight 1: Choose a suitable product/novel technology Identifying a suitable solution for the need being addressed is vital to the successful implementation of novel technology. In the diagnosis of AF, 12-lead ECG is the gold-standard choice …

Valproate use in women aged 15-44 years: an observational study in general practice.

BackgroundValproate is a known teratogen. In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) restricted its use in women and banned use in pregnancy, except for epilepsy with no other effective treatment. To date, there is limited information on valproate prescribing within primary care.AimTo characterise valproate prescribing to women of childbearing age, recorded advice or GP prescribed contraception, and recorded pregnancies.Design & settingA cross-sectional study of patients from all 141 general practices across three clinical commissioning groups (CCGs) in East London.MethodWomen aged 15–44 years prescribed valproate between 1 October 2017 and 1 January 2020 were included. Exclusion criteria were early menopause, sterilisation procedures, or hysterectomy. Pseudonymised data on valproate indication, pregnancy, pre-conception, and contraception advice were retrospectively extracted from general practice consultation data. Data were analysed by quarter using univariate statistics.ResultsOf the total 1 042 463 registered patients, 344 women aged 15–44 years were prescribed valproate during the study period; 14 were excluded. There were 10 pregnancies during possible valproate exposure; one was terminated. During the study period, the number of women prescribed valproate significantly decreased (P = 0.003). The pregnancy rate decreased from 9.9/1000 on valproate before the MHRA April 2018 warning, to an average of 2.8/1000 afterwards. Recorded pre-conception and contraception advice increased by 79%, from 24% to 43%, of women prescribed valproate.ConclusionWith continued pregnancies in women aged 15–44 years prescribed valproate, patient education and foetal outcomes remain ongoing concerns. Further improvements are needed to ensure women make informed reproductive choices and safeguard future pregnancies from valproate exposure.

Disease activity and its predictors in early inflammatory arthritis: findings from a national cohort.

ObjectivesWe set out to characterize patient factors that predict disease activity during the first year of treatment for early inflammatory arthritis (EIA).MethodsWe used an observational cohort study design, extracting data from a national clinical audit. All NHS organizations providing secondary rheumatology care in England and Wales were eligible to take part, with recruitment from 215/218 (99%) clinical commissioning groups (CCGs)/Health Boards. Participants were >16 years old and newly diagnosed with RA pattern EIA between May 2018 and May 2019. Demographic details collected at baseline included age, gender, ethnicity, work status and postcode, which was converted to an area level measure of socioeconomic position (SEP). Disease activity scores (DAS28) were collected at baseline, three and 12 months follow-up.ResultsA total of 7455 participants were included in analyses. Significant levels of CCG/Health board variation could not be robustly identified from mixed effects modelling. Gender and SEP were predictors of low disease activity at baseline, three and 12 months follow-up. Mapping of margins identified a gradient for SEP, whereby those with higher degrees of deprivation had higher disease activity. Black, Asian and Minority Ethnic patients had lower odds of remission at three months follow-up.ConclusionPatient factors (gender, SEP, ethnicity) predict disease activity. The rheumatology community should galvanise to improve access to services for all members of society. More data are required to characterize area level variation in disease activity.

Evaluating equality in prescribing Novel Oral Anticoagulants (NOACs) in England: The protocol of a Bayesian small area analysis

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting about 1.6% of the population in England. Novel oral anticoagulants (NOACs) are approved AF treatments that reduce stroke risk. In this study, we estimate the equality in individual NOAC prescriptions with high spatial resolution in Clinical Commissioning Groups (CCGs) across England from 2014 to 2019. A Bayesian spatio-temporal model will be used to estimate and predict the individual NOAC prescription trend on 'prescription data' as an indicator of health services utilisation, using a small area analysis methodology. The main dataset in this study is the "Practice Level Prescribing in England," which contains four individual NOACs prescribed by all registered GP practices in England. We will use the defined daily dose (DDD) equivalent methodology, as recommended by the World Health Organization (WHO), to compare across space and time. Four licensed NOACs datasets will be summed per 1,000 patients at the CCG-level over time. We will also adjust for CCG-level covariates, such as demographic data, Multiple Deprivation Index, and rural-urban classification. We aim to employ the extended BYM2 model (space-time model) using the RStan package. This study suggests a new statistical modelling approach to link prescription and socioeconomic data to model pharmacoepidemiologic data. Quantifying space and time differences will allow for the evaluation of inequalities in the prescription of NOACs. The methodology will help develop geographically targeted public health interventions, campaigns, audits, or guidelines to improve areas of low prescription. This approach can be used for other medications, especially those used for chronic diseases that must be monitored over time.

Contractors can ‘proactively approach’ trusts to secure staff COVID-19 vaccinations, say pharmacy negotiators

Pharmacy contractors can “proactively approach” clinical commissioning groups (CCGs) and NHS Trusts to secure staff vaccinations, the Pharmaceutical Services Negotiating Committee (PSNC) has said. The PSNC previously confirmed that community pharmacy staff are included in the category of frontline health and social care staff, who are the second priority cohort eligible to receive COVID-19 vaccinations. In […]

Evaluating the use of a mobile device for detection of atrial fibrillation in primary care.

A trial fibrillation (AF) increases cardio-embolic stroke risk, yet AF diagnosis and subsequent prophylactic anticoagulant prescription rates are suboptimal globally. This project aimed to increase AF diagnosis and subsequent anticoagulation prescription rates in East Midlands Clinical Commissioning Groups (CCGs). This service improvement evaluation of the East Midlands AF Advance programme investigated the implementation of mobile AF detection devices (Kardia, AliveCor) into primary-care practices within East Midlands CCGs, along with audit tools and clinician upskilling workshops designed to increase AF diagnosis and anticoagulation prescription rates. AF prevalence and prescription data were collected quarterly from July to September (Q3) 2017/18 to April to June/July to September (Q2/3) 2018/19. AF prevalence increased from 1.9% (22,975 diagnoses) in Q3 2017/18 to 2.4% (24,246 diagnoses) in Q2 2018/19 (p=0.026), while the percentage of high-risk AF patients receiving anticoagulants increased from 80.5% in Q3 2017/18 to 86.9% in Q3 2018/19 (p=0.57), surpassing the Public Health England 2019 target of 85%. The East Midlands AF Advance programme increased AF diagnosis and anticoagulation rates, which is expected to be of significant clinical benefit. The mobile AF detection devices provide a more practical alternative to traditional 12-lead electrocardiograms (ECGs) and should be incorporated into routine clinical practice for opportunistic AF detection, in combination with medication reviews to increase anticoagulant prescription.

Evaluation of a community pharmacy service for uncomplicated urinary tract infection

Introduction: Urinary tract infections (UTIs) are one of the most common conditions seen in female patients in general practice. Community pharmacy can supply antibiotics under minor ailment service patient group directions (PGDs) for a variety of indications, including uncomplicated UTI in women. The NHS Kernow Clinical Commissioning Group (CCG) funds such a locally commissioned minor […]

Long-term nitrofurantoin: an analysis of complication awareness, monitoring, and pulmonary injury cases.

BackgroundLong-term nitrofurantoin (NF) treatment can result in pulmonary and hepatic injury. Current guidelines do not outline the type or frequency of monitoring required for detection of these injuries.AimTo assess 1) awareness of NF complications among prescribers; 2) monitoring practice; and 3) to describe the pulmonary sequelae of NF-related complications.Design & settingEvaluation of prescribing habits by questionnaires and review of GP databases, and case-note review in secondary care.MethodThe following study procedures were undertaken: 1) an electronic questionnaire was distributed to prescribers, interrogating prescribing and monitoring practices, and awareness of complications; 2) an analysis was undertaken (June–July 2020) of NF monitoring among GPs in the local clinical commissioning group (CCG); and 3) a case review was carried out of patients diagnosed with NF-induced interstitial lung disease (NFILD) at the interstitial lung disease (ILD) centre (2014–2020).ResultsA total of 125 prescribers of long-term NF responded to the questionnaire (82.4% GPs; 12.0% urologists). Many were unaware of the potential for liver (42.4%) and lung (28.0%) complications; 40.8% and 52.8% never monitored for these, respectively. Only 53.3% of urologists believed themselves responsible for arranging monitoring, while nearly all GPs believed this to be the prescriber’s responsibility (94.2%). One-third of all responders considered current British National Formulary (BNF) guidelines 'not at all sufficient/clear', with mean clarity scoring of 2.2/5. Among patients with NFILD (n = 46), NF had been prescribed most often (69.6%) for treatment of recurrent UTI and 58.6% (n = 27) were prescribed for >6 months. On withdrawal of the medication 61.4% displayed resolution (completely or minimal fibrosis), while 15.9% of patients had progressive lung fibrosis.ConclusionNF can cause marked or irreversible lung complications and there is currently a shortfall in awareness and monitoring. Existing monitoring guidelines should be augmented.

Were the hospital bed reductions proposed by English Clinical Commissioning Groups (CCGs) in the sustainability and transformation plans (STPs) achievable? Insights from a new model to compare international bed numbers.

A new model for hospital bed numbers which adjusts for end-of-life care and age structure is used to demonstrate that England has 20% fewer occupied beds than the other countries in the United Kingdom. It also shows that occupied beds in English Clinical Commissioning Groups (CCGs) lie parallel to a line of equivalence with New Zealand and Singapore. This is despite New Zealand and Singapore having invested many years into developing integrated care, while England has not. In addition, England has around half the number of nursing home beds per death available in these two countries. Large bed reductions proposed in the sustainability and transformation plans were likely to have been manipulated to meet financial cost-saving targets rather than a result of genuine modelling of demand. The ways in which bed demand models can be manipulated to give whatever answer is required are discussed. Trends in occupied acute medical beds in England over the past 20 years show no real reduction, despite a large reduction in available beds. This has resulted in daytime occupancy for adult beds being close to 100% and with resulting queues to admission. The ways to improve the small-area application of the model including the use of deprivation or social groups are discussed.

Guidance impact on primary care prescribing rates of simple analgesia: an interrupted time series analysis in England.

BackgroundIn March 2018, NHS England published guidance for clinical commissioning groups (CCGs) to encourage implementation of policy to reduce primary care prescriptions of over-the-counter medications, including simple analgesia.AimTo investigate the impact of guidance publication on prescribing rates of simple analgesia (oral paracetamol, oral ibuprofen, and topical non-steroidal anti-inflammatory drugs) in primary care; CCG guidance implementation intentions; and whether the guidance has created health inequality based on socioeconomic status.Design and settingInterrupted time series analysis of primary care prescribing data in England.MethodPractice-level prescribing data from January 2015 to March 2019 were obtained from NHS Digital. Interrupted time series analyses were used to assess the association of guidance publication with prescribing rates. The association between practice-level prescribing rates and Index of Multiple Deprivation scores before and after publication was quantified using multivariable Poisson regression. Freedom of information requests were submitted to all CCGs.ResultsThere was a statistically significant 4.4% reduction in prescribing of simple analgesia following guidance publication (adjusted incidence rate ratio 0.96, 95% CI = 0.92 to 0.99, P = 0.027), adjusting for underlying time trend and seasonality. There was considerable diversity across CCGs in whether or how they chose to implement the guidance. Practice-level prescribing rates were greater in more deprived areas.ConclusionGuidance publication was associated with a small reduction in the prescribing rates of simple analgesia across England, without evidence of creating additional health inequality. Careful implementation by CCGs would be required to optimise cost saving to the NHS.

Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals.

Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients’ social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., “struggling” with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., “high” or “appropriate” prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS.