Current Service Provision Research Articles

P07 Improving patient care in psoriatic arthritis through quality improvement and audit against the National Institute for Health and Care Excellence NG65 guidelines

Abstract Background NICE guidelines (NG65) for diagnosis and management of spondyloarthritis (SpA) in over 16s provide evidence-based recommendations for provision of care and services for patients, with an aim to improving quality of care. There often appears to be misdiagnosis/under diagnosis of psoriatic arthritis (PsA), as well as unmet needs of achieving treatment to target and low disease activity. Our objective was to audit our PsA service against the guidelines to benchmark current service provision compared to the National recommendations, highlighting potential key areas to improve quality of SpA and PsA patient care and enable service development including our new electronic patient pathway. Methods The NICE baseline assessment tool was used to audit 100 patients diagnosed with PsA, attending the outpatient rheumatology clinic between 2017-2019. The mean age was 54, with a 3:2 female to male ratio. 30% of patients included were on a biologic disease modifying anti-rheumatic drug (bDMARD). Data was collected from clinic letters/medical/physiotherapy records. Data was collated to identify areas of compliance of our service against the guidelines, with the key outcomes scrutinised being assessment and diagnosis, imaging, information and support, pharmacological management and long-term condition management. Results 78% of patients with PsA had documentation of meeting the CASPAR or peripheral ASAS Criteria. 83% of patients who had symptomatic hands/feet obtained X-rays, and 82% had imaging of other peripheral or axial sites. 58% of patients with PsA had documented evidence of having received information on PsA. Out of 100% of patients that were started on a conventional synthetic DMARD (csDMARD), 83% that were on monotherapy were escalated to either an additional csDMARD or a bDMARD. Largely by month 3 the csDMARD was switched or the patient started combination therapy, in comparison to those that started a bDMARD which occurred largely around month 6. 100% of patients had access to flare management advice and flare clinic, but only 30% had documented discussions about cardiovascular (CV) and skin cancer risks on anti-TNF therapy. Subsequent action plans for service improvement included: a best practice pathway developed on the electronic patient records (EPR), including the CASPAR and ASAS criteria, the Group for Research and Assessment of Psoriasis (GRAPPA) 6 domains of PsA, CV and skin cancer risk. All patients are seen in the Nurse/therapist led education sessions for information on the disease. Conclusion Performing an audit of patients against the NG65 guidelines ensured that we were using real-world data to benchmark our service, enabling robust action plans to be developed to address low compliance areas. Consequently, the audit allowed us to justify changing and developing the service for improved patient care. Disclosures E.J. Papadopoulos: Other; Paid work with Novartis Pharmaceuticals. A. Chan: Member of speakers’ bureau; Novartis, Celgene, Janssen, Sanofi. Other; Advisory Board for: Novartis, Celgene, Lilly. K. Rigler: Other; aid work for Novartis Pharmaceuticals. A. Kachwaha: None. J. Gunn: None. N. Zabbey: None. E. Walsh: None.

An antenatal alcohol service evaluation of the north-east of England and north Cumbria

NHS England's 'Better Births' strategy aims to improve maternal and infant health outcomes. A strategic priority identified in the north-east local maternity system is to reduce alcohol consumption in pregnancy due to the documented diverse risks of harm to mother and baby, including foetal alcohol spectrum disorder. To evaluate current alcohol prevention, screening and treatment service provision in maternity care across the region, and inform future recommendations. A service evaluation survey was developed to systematically consult strategic stakeholders across all nine maternity trusts in the region over a 2-month period in 2018. Content analysis was employed to identify fundamental themes and inform recommendations for practice. High variation was reported throughout regional clinical practices, service provision and staff training. For example, a number of alcohol screening tools were identified, each with diverse thresholds for referral; reported data collection and documentation practices were multifarious, incomparable and unquantifiable; audit was rare and guidelines were primarily influenced by local commissioning agreements. Standardized patient pathways involving alcohol screening and management practices are required, and sharing best practices will facilitate referrals and support regardless of location. The implementation of these recommendations requires appropriate leadership, commissioning and training strategies.

Access to health-care policies for refugees and asylum-seekers

Purpose The influx of refugees and asylum-seekers over the past decade into the European Union creates challenges to the health systems of receiving countries in the preparedness and requisite adjustments to policy addressing the new needs of the migrant population. This study aims to examine and compare policies for access to health care and the related health outcomes for refugees and asylum-seekers settling both in the UK and Germany as host countries. Design/methodology/approach The paper conducted a scoping review of academic databases and grey literature for studies within the period 2010-2017, seeking to identify evidence from current policies and service provision for refugees and asylum-seekers in Germany and the UK, distilling the best practice and clarifying gaps in knowledge, to determine implications for policy. Findings Analysis reveals that legal entitlements for refugees and asylum-seekers allow access to primary and secondary health care free of charge in the UK versus a more restrictive policy of access limited to acute and emergency care during the first 15 months of resettlements in Germany. In both countries, many factors hinder the access of this group to normal health care from legal status, procedural hurdles and lingual and cultural barriers. Refugees and asylum-seeker populations were reported with poor general health condition, lower rates of utilization of health services and noticeable reliance on non-governmental organizations. Originality/value This paper helps to fulfill the need for an extensive research required to help decision makers in host countries to adjust health systems towards reducing health disparities and inequalities among refugees and asylum-seekers.

Development of a Resource Impact Model for Clinics Treating Pre-Operative Iron Deficiency Anemia in Ireland.

IntroductionIntravenous (IV) iron is typically the preferred treatment for patients with iron deficiency anemia (IDA) who cannot tolerate or absorb oral iron, or who require fast replenishment of iron stores pre-operatively. Several IV iron formulations are available with different dosing characteristics affecting infusion speed and maximum dose. The aim was to develop a resource impact model to calculate the cost of establishing an IV iron clinic and model resource impact of different IV irons to inform clinicians and service providers implementing innovative pre-operative IV iron services in Ireland.MethodsA resource impact tool was developed to model resource utilization and IDA treatment costs. Two fast-administration, high-dose formulations of IV iron are available in Ireland: iron isomaltoside 1000/ferric derisomaltose (IIM) and ferric carboxymaltose (FCM). The tool modeled clinic throughput based on their different dosing characteristics in a specific IDA population, capturing fixed overheads, variable costs, clinic income from private and publicly-funded patients, and savings associated with IV iron.ResultsBased on a 70:30 split between public and private patients in a new pre-operative service with capacity for 12 infusion slots weekly, IIM would facilitate correction of iron deficits in 474 patients annually, resulting in a net annual clinic balance of €42,736 on income of €159,887 and net costs of €117,151. FCM would facilitate treatment of 353 patients, resulting in a net annual clinic balance of €36,327 on income of €116,050 and costs of €79,722, a difference of €6408 and 121 patients treated in favor of using IIM over FCM.ConclusionBased on this provider-perspective analysis, IIM would maximize clinic throughput relative to other IV iron formulations, allowing clinicians in Ireland to optimize their current service provision and expenditure, and model the impact of introducing IV iron clinics for pre-operative patients with IDA.

Dietitians' experiences and perspectives regarding access to and delivery of dietetic services for people with type 2 diabetes mellitus

AimsDietetic intervention improves glycaemic control of type 2 diabetes mellitus (T2DM). The aim of this study was to explore the views of Australian dietitians with respect to the nutritional management of people with T2DM, patient access to dietitians and any suggested improvements for access to and delivery of dietetic services. MethodsSemi-structured interviews were conducted via telephone with 31 dietitians counselling people with T2DM and consulting a minimum of two sessions per week in private and/or non-private practice. ResultsParticipants came from urban and rural areas, public and private practice and with a range of years of practice. Themes that emerged from the interviews included the importance of dietetic services for people with T2DM; the referral pathways and beliefs about lack of referrals to dietitians; the perceptions on adequacy of the current dietetic services available for people with T2DM; and the recommendations on services available for people with T2DM. ConclusionConsidering the evidence that diet is key in the prevention and management of T2DM, it is suggested current funding and service provision be reviewed with a focus on treating the aetiology of diabetes.

Healthcare Professionals’ Perspectives on The Provision of Sexual and Reproductive Health to Young People in Malaysia

Objective: In Malaysia, sexual health issues among young people encompassing premarital sex, the incidence of STI including HIV/AIDS, unintended pregnancy, unsafe abortion and the practice of baby abandonment. Little is known about the provision of sexual health care for young people since it has not been examined in-depth in a Malaysian context. This study aimed to explore the perspectives of healthcare professionals who deliver sexual health services provision to young people within primary healthcare settings which included schools as part of an outreach programme. Methods: This qualitative study used a self-developed topic guide for in-depth interview with twenty-four healthcare professionals of several government health clinics in Malaysia. The aim was to understand healthcare professionals’ experiences of dealing with young people and their views on current sexual health services provision. The interview data were entered into Nvivo and analysed using thematic analysis. Results: The findings show that healthcare professionals regarded the use of the Adolescent Health Screening Form as a cornerstone for all initial interactions between and young people in health clinics. The findings also highlight the problem with an appointment system that includes lack of consultation times, privacy issues and the requirement of parental consent when dealing with unmarried young people. Conclusion: This study had recognized several facility-based obstacles that restricted sexual health services to young people in Malaysia. Their access to and the utilization of sexual health services are dependent on health care system improvement.

Could maternal ethnicity be a determinant of healthcare costs for birth assistance? Insights from a retrospective hospital-based study for the implementation of a woman-centered approach in obstetrics

Background Current policy and service provision recommend a woman-centered approach to maternity care and the development of personalized models for clinical assistance. Ethnicity has been recognized as a determinant in the risk calculation of selected obstetric complications. Based on these assumptions, our aims were to describe the linkage between baseline characteristics and maternal ethnicity and to analyze the cost for the local healthcare system, distinguishing mode of delivery, absence or presence of complications at birth, and maternal stay duration for all ethnic groups. Methods In a 5-year period (2012–16), all women admitted for delivery at the Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario “A Gemelli” IRCCS, Rome, Italy, were included in the analysis. Maternal demographics, adverse outcomes, and costs were evaluated. Economic calculations were performed by using the “diagnosis-related group” (DRG) approach. Results A total of 18,093 patients were included in the analysis. An overall care expense of €42,663,481 was calculated. Caucasian was the main ethnicity (90.7%), with 9.3% minority groups. Vaginal delivery (VD) was the most common mode of delivery in all ethnic groups, with a global rate of 59.6%. The highest cesarean section (CS) rates were observed among Maghreb (51.5%) and Afro-Caribbean (47.8%) women. Minority groups had a doubled rate of complicated VD, primarily Afro-Caribbean women (69.9%), followed by Asian (64.1%), Maghreb (63.2%), and Latin American (62.7%) women. Afro-Caribbean women had the highest rate of complicated CS compared to the overall study population (37.6 versus 28.5%, p < .005). Conclusions Minority groups have increased healthcare costs for birth assistance, mainly due to the higher rates of complications. In a prospective view, two strategies could be planned: first, calculating individualized risk to mitigate the clinical care charge, based on the ad hoc combination of ethnicity, mode of delivery, and obstetric complications; and second, endorsing the current financial return-on-investment opportunity tied to mitigating ethnic disparities in birth outcomes.

General practitioners’ preferences towards incentive measures linked with cancer screening

General practitioners (GPs) play a key role in the delivery of preventive and screening services for breast, cervical, and colorectal cancers. Yet, their current provision of screening services remains low and varies considerably across screening contexts and GPs. This study investigates the determinants of GPs' involvement in cancer screening activities using discrete choice experiment (DCE) methodology. A representative sample of 402GPs was recruited in France between March and April 2014. The participants completed 12choice tasks designed to elicit their preferences for 5cancer screening attributes aimed at increasing their supply of cancer screening services. GPs are sensitive to both financial and non-financial incentives, such as a compensated training and systematic transmission of information about screened patients, aimed to facilitate communication between doctors and patients. There is also evidence that the preferences differ across screening contexts: GPs appear to be relatively more sensitive to financial incentives for being involved in colorectal cancer screening, whereas they have higher preference for non-financial incentives in breast and cervical cancers. Our study provides new findings for policymakers interested in prioritizing levers to increase the supply of cancer screening services in general practice.

Experiences of physiotherapy in mental health: an interpretative phenomenological analysis of barriers and facilitators to care

BackgroundService users with severe mental illness (SMI) are at increased risk of physical health co-morbidity such as musculoskeletal pain, neurological impairment, obesity and COPD; many of which require input from physiotherapists. Physiotherapists play a pivotal role in treatment of those with SMI but are reported to lack skills and confidence with this patient group. Furthermore, disparities in accessing healthcare are evidenced for those with SMI. PurposeThis study explored experiences of physiotherapeutic care for those with co-morbid physical and mental health complaints to identify barriers and facilitators to care. MethodsA qualitative study using Interpretive Phenomenological Analysis was undertaken. Semi-structured interviews were completed with service users (n=8) with longstanding physiotherapeutic and psychiatric complaints. Focus groups were completed with physiotherapists working in mental health. Verbatim transcripts of interviews were analysed using Interpretive Phenomenological Analysis to obtain in depth insight into participant experiences. Study quality was enhanced through use of methodological and investigator triangulation, negative case analysis, reflexivity and secondary coding. AnalysisData was analysed systematically following the structure: individual case analysis, emergence of themes, cross case analysis, validation of themes and ideas. ResultsThis analysis produced five master themes: Communication [1], holistic care [2], benefit of physiotherapy [3], healthcare politics and service interaction [4], patient activation [5].Results identified current service provision did not always meet the complexities of service user needs. Conclusion and ImplicationsImproved physiotherapist awareness of mental health and how to communicate and treat this population was identified. The importance of better integration between services was also highlighted. A positive experience of physiotherapy is vital for patient activation and engagement with physiotherapy.

Are we meeting the support needs of LGBT cancer patients and carers in radiotherapy and oncology? A service improvement report

Keywords: LGBT, Psychological, supportive care, healthcare, radiotherapy, oncology. Introduction: 3.6 million people in the UK identify as LGBT [1,2]. LGBT cancer patients are not represented as often as heterosexual patients in research or in provision of resources. Many services can exclude LGBT people and have a heterosexist environment. Mental health issues have been found to be more prevalent in the LGBT community [3, 4], and may indicate a higher incidence of psychological distress after a cancer diagnosis. This research sets out to investigate what current service provision is available within the author’s organisation in terms of psychological support, and how this relates to current guidance within the literature. Method: The methodology employed for this research was in the form of a service improvement proposal that evaluates the services and resources provided for by the author’s organisation for LGBT cancer patients and carers. This includes a literature search of three databases to evaluate current guidance for support needs. Results: Twelve studies were reviewed. The main themes included: health care professional (HCP) knowledge and training, inclusive support groups and resources, prevalence of heterosexism, and any increase in mental health issues. Discussion and Conclusion: Within this particular organisation it was found that inclusive support groups and resources were limited. It is suggested that psychological distress is higher in LGBT cancer patients than in heterosexual patients meaning psychological support and resources are needed for this group. HCPs should provide an inclusive environment where LGBT people can feel safe. Sufficient sexual orientation and gender identity monitoring should be standard to be able to collect data for research and health outcomes. Education of LGBT specific health issues is important in meeting the needs of patients. Recommendations have been made to improve the services to be inclusive within the radiotherapy and oncology department, as well as the need to develop support services for LGBT cancer patients and carers. Education and training must be improved to ensure all HCP’s and support services have sufficient knowledge of LGBT cancer specific issues in order to better support all patients. Numerical

Past intensification trajectories of livestock led to mixed social and environmental services

Recent studies highlighted the multiple positive and negative contributions of livestock to society. Livestock production, through its direct and indirect impacts on land use, is an important driver of services provision. Although a few studies provide an account on the multiple services in different livestock systems, there is still an important knowledge gap on the drivers that contribute to the differentiation of services provisioning across areas. We investigated the hypothesis that the current level of services has derived from past intensification trajectories of livestock. The objective of this study was to understand the influences of past changes in livestock, land-use and socio-economic variables on the current provision of social, environmental and cultural services by the livestock sector in France. We combined a long-term country-wide database on livestock intensification between 1938 and 2010 and a database on services provisioning in 2010. We used a set of multivariate methods to simultaneously analyse the changes in livestock intensification from 1938 to 2010 and the current level of services provisioning. Our analysis focused on a set of 60 French departments where livestock play a significant economic role in agricultural production. Our study revealed that the provision of services was spatially structured and based on three groups of departments, characterised by different rates of change in intensification variables. In the first group, ‘Intensive livestock areas’, the high level of employment in the livestock sector was mainly associated with high rates of change in monogastric stocking rates (+1045%) and milk productivity (+451%). In the second group, ‘Extensive livestock areas’, the high levels of environmental and cultural services were mainly associated with moderate rates of change in herbivores stocking rate (+95%) and the stability of grassland area (+13%). In the third group, ‘Transition areas’, the low provision of all services was associated with the decline in livestock due to crop expansion. This study provides knowledge to understand how past changes determined the current contribution of livestock areas in providing differentiated bundles of services, which might help steer the development of the current livestock sector towards more sustainable trajectories.

Should A.I. Be Your Therapist?

Recent advances in Artificial Intelligence (A.I.) and their application within the field of mental health provision raise issues that cross social, economic, and philosophical boundaries. While Therapeutic A.I. promises to disrupt the current provision of mental health services to reach populations without access to adequate mental health care there are risks. This paper addresses the philosophical problems posed by Therapeutic A.I. I suggest that in the absence of legal guidelines there is a need for philosophical guidance that prioritizes the dignity of clients/consumers. To that end, I advance Rosen’s (2012) concept of dignity-as-respectfulness as the most appropriate philosophical principle to guide the application of Therapeutic A.I.

Mapping non-malignant respiratory palliative care services in Australia and New Zealand.

Objective Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic? People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add? This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners? Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.

Provision of home medicines reviews in Australia: linking population need with service provision and available pharmacist workforce.

Objective Identifying and quantifying the health needs of a population are the basis of evidence-based health policy and workforce planning. The motivation for undertaking the present study was to evaluate whether the current level of medication review services corresponds to population need, as proxied by the rate of polypharmacy, and to undertake a preliminary analysis of the sufficiency of the current workforce. This paper: (1) estimates the age- and sex-standardised rates of polypharmacy as a proxy for population need for home medicines review; (2) compares the rate of polypharmacy with current service provision of home medicines reviews; and (3) links the estimated need for services with the current number and location of pharmacist providers. Methods Age- and sex-adjusted polypharmacy rates, by state, were estimated from the National Health Survey of Australia (2017-18), service levels were estimated from national-level administrative claims data (2017-18) and the current workforce was estimated from the Australian Association of Consultant Pharmacists (2018). The current level of service provision was compared to the estimated population need for services, alongside the size of the pharmacy workforce required if need was met. Results The adjusted rate of polypharmacy in Australia, using the strictest definition of ≥10 medications and ≥3 current chronic illnesses, was 1389 per 100000 population. The illustrative needs-based analysis suggests that there may be a disconnect between the current level of service provision and population health needs. Conclusion Given that polypharmacy is a risk factor for medication-related problems, and that medication review is one of the few targeted strategies currently available to address medication-related problems in the population, service provision may be inadequate. Policy options to improve service provision could include interventions to increase workforce productivity and relaxing the current eligibility criteria for review, especially in rural and remote areas. What is known about the topic? Polypharmacy is a risk factor for medication-related problems, which can cause increased morbidity and mortality in the population. What does this paper add? This paper provides representative, population-based rates of polypharmacy in Australia and uses these rates in a needs-based analysis of service provision and workforce adequacy to provide home medicines review services. What are the implications for practitioners? Several policy options are available for consideration, including interventions to increase workforce productivity and relaxation of the current eligibility criteria for medicines review, especially in rural and remote areas.

Outcomes of aortic aneurysm surgery in England: a nationwide cohort study using hospital admissions data from 2002 to 2015

BackgroundThe United Kingdom aortic aneurysms (AA) services have undergone reconfiguration to improve outcomes. The National Health Service collects data on all hospital admissions in England. The complex administrative datasets generated have the potential to be used to monitor activity and outcomes, however, there are challenges in using these data as they are primarily collected for administrative purposes. The aim of this study was to develop standardised algorithms with the support of a clinical consensus group to identify all AA activity, classify the AA management into clinically meaningful case mix groups and define outcome measures that could be used to compare outcomes among AA service providers.MethodsIn-patient data about aortic aneurysm (AA) admissions from the 2002/03 to 2014/15 were acquired. A stepwise approach, with input from a clinical consensus group, was used to identify relevant cases. The data is primarily coded into episodes, these were amalgamated to identify admissions; admissions were linked to understand patient pathways and index admissions. Cases were then divided into case-mix groups based upon examination of individually sampled and aggregate data. Consistent measures of outcome were developed, including length of stay, complications within the index admission, post-operative mortality and re-admission.ResultsSeveral issues were identified in the dataset including potential conflict in identifying emergency and elective cases and potential confusion if an inappropriate admission definition is used. Ninety six thousand seven hundred thirty-five patients were identified using the algorithms developed in this study to extract AA cases from Hospital episode statistics. From 2002 to 2015, 83,968 patients (87% of all cases identified) underwent repair for AA and 12,767 patients (13% of all cases identified) died in hospital without any AA repair. Six thousand three hundred twenty-nine patients (7.5%) had repair for complex AA and 77,639 (92.5%) had repair for infra-renal AA.ConclusionThe proposed methods define homogeneous clinical groups and outcomes by combining administrative codes in the data. These methodologically robust methods can help examine outcomes associated with previous and current service provisions and aid future reconfiguration of aortic aneurysm surgery services.

InFORM: Improving care for people who Frequently call 999: co-production of guidance through an Observational study using Routine linked data and Mixed methods

BackgroundPeople who frequently call the 999 ambulance service present an operational challenge to providers and their needs are inadequately met by current service provision.&#x0D; Aim of researchTo understand patterns and health outcomes of frequent calling and to work with stakeholders to co-produce guidance for formal testing in a future evaluation.&#x0D; MethodsThis mixed methods study will include a scoping review of national and international literature followed by an epidemiological study of callers at the all Wales level exploring health outcomes through anonymised linked data. We will also explore the views of patients using qualitative Bio-photographic interview method with a follow up interview at six months and use focus groups with care providers from across primary and emergency care and the third sector. We will use generalised linear model to analyse quantitative data and qualitative data will be analysed thematically.&#x0D; ResultsFindings will include follow up of eligible patients; successful data matching and data linkage; retrieval of outcomes within 12 months. Outcomes will include: adverse events, deaths, emergency admissions; 999 attendances. Qualitative results will include Bio-photographic interviews with completed scrap books and interviews based on the books (n=34). Care provider focus groups (n= 22).&#x0D; Output Co-produced guidance developed with stakeholders.&#x0D; ConclusionHigh users of the 999-ambulance represent a significant policy challenge to emergency ambulance services and often present with complex needs. This study will inform on the characteristics of callers and how to address their care supported with a co-produced guidance for care providers.

Social Work Assessment: What Are We Meant To Assess?

ABSTRACTThe social work assessment, which takes account of a range of factors, contrasts starkly with health assessment tools which focus individually on one small part of a patient’s functioning. The social work assessment may be viewed with suspicion, or even outright hostility, by hospital professionals particularly if the outcome is different to the prevailing opinion of the multi-disciplinary team. Increasingly, obtaining a global, holistic assessment is becoming difficult as hospitals develop a range of strategies to ‘speed up’ the discharge process. These strategies impact patients’ physical and mental health. Older patients with a cognitive impairment are disproportionately affected – the very group whose hospital admissions are rising fastest. As hospital stays shorten, the assessment is done earlier. Social work managers allocate dwindling resources on a basis of need. The social work assessment is increasingly driven by indicators of ‘critical’ and ‘substantial’. Lower levels of need or need that cannot be met by current service provision is simply not recorded. Thus, the social worker bases the assessment on less information, on a patient subjected to additional factors, using indicators designed to control budgets. However, social work resources are charged so patients themselves may pay the price for an inaccurate assessment.

The influence of cemetery governance on tree management in urban cemeteries: A case study of Halifax, Canada and Malmö, Sweden

Urban cemeteries represent an unusual type of greenspace that can provide a wide range of ecosystem benefits and services if they have mature tree populations. However, the extent to which tree management is prioritized in cemeteries alongside tasks associated with the burial and commemoration of the deceased is unknown. Given the large differences that exist amongst burial traditions and cemetery management around the world, it seems likely that cemetery tree management will not be uniform across countries. To investigate this, we compared cemetery governance and management in Halifax (Canada) and Malmö (Sweden) to determine which factors influence their cemetery tree populations, with a specific focus on tree planting.An inventory of places in which trees could be planted in cemeteries indicated that a large number of trees could theoretically be planted in both cities’ cemeteries. However, manager interviews and a review of cemetery legislation indicated multiple dimensions of governance that result in the very real prospect that precious few of these plantable spots will actually become occupied by a tree. These dimensions differed between the two cities, with financial constraints and limited knowledge about trees playing a large role in Halifax, while in Malmö, legislation and public opinion influence the extent to which tree planting occurs. As such, the cities require different solutions to promote tree planting in their cemeteries to avoid future canopy loss and ensure the long-term continued provision of current ecosystem benefits and services.

Understanding differences of sexual differentiation (DSD) MDT services across the UK; current service provision and sharing best practice

Understanding differences of sexual differentiation (DSD) MDT services across the UK; current service provision and sharing best practice

Assessing service and treatment needs of young people who use illicit and non-medical prescription drugs living in Northern Ontario, Canada.

Background: The use of illicit and prescription drugs for non-medical purposes among youth and young adults living in Northern Ontario communities is a major public health concern. This problem is amplified in that there is insufficient knowledge on the types of services and treatment centers available for and utilized by young people with substance use issues in Northern Ontario. This needs assessment study aims to examine the service and treatment needs of youth and young adults who use drugs in Northern Ontario communities. Methods/Design: A mixed-methods study design will be used to assess the service and treatment needs of youth and young adults (aged 14-25) who have used one or more illicit drug (excluding cannabis) and/or psychoactive prescription drug for non-medical purposes for at least 3 months and on at least 10 days in the last month. Participants will be recruited from approximately ten Northern, remote and rural communities across Northern Ontario using a mobile research lab. Eligible study candidates from each community will be asked to partake in a focus group and questionnaire exploring service and treatment utilization and needs. We will additionally collect basic socio-demographic information as well as examine patterns of problematic drug use. Interviews with service providers and community organizers will also be conducted in each community. Discussion: Findings from our study will highlight the availability, accessibility and utilization of existing services; identify the gaps and barriers in current service provision; and provide insight into the service and treatment needs of youth and young adults who use drugs in Northern Ontario communities. Assessing the needs of young people who use drugs will allow service providers, community organizers and health policymakers to improve addiction-related services and treatment centers in Northern Ontario.