English NHS Research Articles

Range and Frequency of Congenital Malformations Among Children With Cleft Lip and/or Palate.

To assess the range and frequency of additional congenital malformations identified among children born alive with CL/P. Analysis of patient-level data from a national registry of cleft births linked to national administrative data of hospital admissions. National Health Service, England. Children born between 2000 and 2012 receiving cleft care in English NHS hospitals. The proportion of children with ICD-10 codes for additional congenital malformations, according to cleft type. The study included 9403 children. Of these 2114 (22.5%) had CL±A, 4509 (48.0%) had CP, 1896 (20.2%) had UCLP, and 884 (9.4%) had BCLP. A total of 3653 (38.8%) children had additional congenital malformations documented in their hospital admission records. The prevalence of additional congenital malformations was greatest among children with CP (53.0%), followed by those with BCLP (33.5%), UCLP (26.3%), and then CL±A (22.2%) ( P < .001). Among those with UCLP, children with right-sided clefts were more likely to have additional malformations than those with left-sided clefts (31.6% vs 23.0%, P < .001). Malformations of the skeletal system and circulatory system were most common, affecting 10.5% and 10.2% of the included children, respectively. A total of 16.8% of children had additional congenital malformations affecting 2 or more structural systems. Congenital malformations are common among children born alive with a cleft, affecting over half of some cleft subgroups. Given the frequency of certain structural malformations, clinicians should consider standardized screening for these children. Establishing good links with pediatric and genetic services is recommended.

Exploring elderly patients’ perspectives on deprescribing: a qualitative study interim analysis

Abstract Introduction The ageing population has caused an increase in polypharmacy, multimorbidities and complexity of patients (1). Polypharmacy increases the likelihood of Adverse Drug Reactions, particularly in elderly patients due to functional/cognitive changes (1). Current research investigating views on deprescribing has shown that patients are often willing to undertake deprescribing, however qualitative research in elderly populations is sparse (1). Aim This study aimed to explore elderly patients’ perspectives on deprescribing and pharmaceutical input into their care. Methods Semi-structured interviews were undertaken with a purposive sample of elderly (>65 years) inpatients with multiple morbidities and/or frailty and were taking at least one regular medicine, at two English NHS hospital Trusts. The interview guide was developed with public contributions, aligned with the study aim and informed by the Theoretical Framework of Acceptability (TFA)(2). The TFA was used because it was developed for assessing the acceptability of healthcare interventions (2). The interview guide included a distress protocol because the patient cohort was vulnerable. Interviews were conducted face-to-face, audio-recorded, transcribed verbatim and analysed using the Framework Analysis approach, with a priori categories informed by the TFA. Results Interviews were conducted with 8 participants (2 male,6 female), aged 67-89 and taking 3-9 pre-admission medicines. Most participants seemed to understand that deprescribing may become appropriate and trusted their doctor to initiate discussion when deprescribing is appropriate. However, participants reported wanting to know the rationale for deprescribing (TFA domain: affective attitude): “…why was I taking it in the first place if I don’t need it now?”. Most participants wanted deprescribing discussions to start with the rationale and some said medicines should be stopped gradually with regular reviews (TFA domain: affective attitude, ethicality). Most participants referred to pharmacists having a small role in their healthcare and none mentioned pharmacists stopping medicines (TFA domain: affective attitude): “… they sort all the drugs out don’t they, that they’re ordered…”. Access to GPs was commonly reported as a burden (TFA domain: burden). Some participants reported not feeling confident to ask their GP questions and some said they had not established trust due to not seeing a regular doctor (TFA domain: burden and opportunity costs): “I’ve gotta get my confidence in them…”. Several participants reported having taken medicines for years and said that they thought the medicines were beneficial, whilst other participants said that if they could take fewer medicines they would (TFA domain: ethicality and perceived effectiveness). Some participants understood that deprescribing required weighing up risks and benefits (TFA domain: intervention coherence): “…consider the benefits and the possibility of side effects”. Conclusion This study adds insights from qualitative research, but these may not be widely transferrable. Whilst these are interim analysis findings that may be further refined, they suggest that deprescribing is likely to be acceptable to patients when conducted by healthcare professionals they trust and who provides the rationale for deprescribing. Patients’ awareness of who can deprescribe would benefit from being increased, since participants did not cite pharmacists as experts who can deprescribe. Future research could explore how to do so. References (1) Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014 Oct;78(4):738-47. (2) Sekhon M, Cartwright M, Francis J. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res, 2017; 17: 88.

Corporatising compassion? A contemporary history study of English NHS Trusts' nursing strategy documents.

The purpose of this contemporary history study is to analyse nursing strategy documents produced by NHS Trusts in England in the period 2009-2013, through a process of discourse analysis. In 2013 the Francis Report on the Mid-Staffordshire NHS Foundation Trust was published. The Report highlighted the full range of organisational failures in a Trust that valued financial efficiency over patient care. The analysis that followed, however, dwelt heavily on the failings of the nurses. Nursing strategy documents at that time served to set the future direction for NHS Trusts, prescribing specific value frameworks for each nursing workforce. However, the values chosen frequently conflicted with each other pitting nursing values against a managerial trope. It is argued that documents provided a response to wider NHS concerns and high-profile failures in care, particularly the Francis Report, paying lip service to staff engagement whilst maintaining a corporate focus. Nursing values were placed firmly within a managerialist discourse, one that has needed to be re-evaluated in the current Covid-19 pandemic. Wider implications of the research suggest discussion of value conflict may be beneficial within nursing education and a truly local approach to strategy creation would potentially promote staff buy-in to strategy documents.

The diffusion of robotic surgery: Examining technology use in the English NHS

This paper examines the adoption and diffusion of medical technology as associated with the dramatic recent increase in the surgical use of robots. We consider specifically the sequential adoption and diffusion patterns of three interrelated surgical technologies within a single healthcare system (the English NHS): robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar patient benefits, but the newer robotic technique requires a high initial investment cost to purchase the robot and carries high maintenance costs over time. Using data from a large UK administrative database, Hospital Episodes Statistics, for the period 2000–2018, we analyse 173 hospitals performing radical prostatectomy, the most prevalent and earliest surgical area of adoption of robotic surgery. Our empirical analysis first identifies substitution effects, with robotic surgery replacing the incumbent technology, including the recently diffused laparoscopic technology. We then quantify the spillover of robotic surgery as it diffuses to other surgical specialties. Finally, we perform time-to-event analysis at the hospital level to quantitatively examine the adoption. Results show that a higher number of urologists and a wealthier referral area favor robot adoption.

The impact of management practices on relative patient mortality: Evidence from public hospitals.

A small, but growing, body of empirical evidence shows that the material and persistent variation in many aspects of the performance of healthcare organisations can be related to variation in their management practices. This study uses public data on hospital patient mortality outcomes, the Summary Hospital-level Mortality Indicator (SHMI) to extend this programme of research. We assemble a five-year dataset combining SHMI with potential confounding variables for all English NHS non-specialist acute hospital trusts. The large number of providers working within a common system provides a powerful environment for such investigations. We find considerable variation in SHMI between trusts and a high degree of persistence of high- or low performance. This variation is associated with a composite metric for management practices based on the NHS National Staff Survey. We then use a machine learning technique to suggest potential clusters of individual management practices related to patient mortality performance and test some of these using traditional multivariate regression. The results support the hypothesis that such clusters do matter for patient mortality, and so we conclude that any systematic effort at improving patient mortality should consider adopting an optimal cluster of management practices.

Abstract P1-22-06: A longitudinal cohort study of outcomes in 311 women with unresected ductal carcinoma in situ detected through the English breast screening programme

Abstract Background The variable natural history of ductal carcinoma in situ (DCIS) is poorly understood. The aim of this retrospective cohort study was to determine the outcomes of women who were diagnosed through the English National Health Service Breast Screening Programme (NHS BSP) and had no surgery for screen-detected DCIS. Method English NHS BSP databases were searched for women diagnosed with DCIS without invasive cancer on needle biopsy between 1 April 2001 and 31 March 2018 inclusive, who had no record of surgery within 6 months of diagnosis. These were cross-referenced with cancer registry data for further treatment, event information and mortality records. Details of potentially eligible women were sent to the relevant breast screening units for verification and for completion of data forms detailing clinical, radiological and pathological findings, non-surgical treatment, subsequent clinical course and outcomes. Results Data for 311 eligible women (median age 62 years) were included, with median follow-up (primary DCIS diagnosis to either surgery, development of invasive disease, death or last known to be alive) of 4.1 years (range 0.5 to 17.4 years). The median age at diagnosis was 64 years (range 47 to 90 years). Sixty (19%) women developed invasive breast cancer, 56 ipsilateral and 4 contralateral. Twenty-two women (7%) underwent surgery for DCIS (>6 months after diagnosis) and 86 (28%) died of other causes. Women with high or intermediate grade DCIS were significantly more likely to develop ipsilateral invasive breast cancer (iIBC) than those with low grade DCIS. 28/123 (23%) with high grade DCIS, 21/105 (20%) with intermediate grade DCIS, 5/76 (7%) with low grade DCIS and 2/7 (29%) with an unknown grade of DCIS developed iIBC. Ipsilateral invasion risk increased approximately linearly with time for at least 10 years. Women who developed iIBC were significantly younger than those who did not. This was driven primarily by a strong association among those with high grade DCIS. There was no significant difference in age between those with intermediate and low grade DCIS respectively who did or did not develop iIBC. The median baseline size of DCIS in women who developed iIBC was higher than in women who did not develop iIBC, both overall and in each of the three grade categories (median sizes - high grade 38 mm vs 29 mm, p=0.19; intermediate grade 35 mm vs 18 mm, p=0.31; low grade 18 mm vs 15 mm, p=0.38). This reached statistical significance for all grades combined: 37 mm (range 3-95) v 20 mm (range 3-200), p=0.02. Of the 262 women with a known microinvasion status, 8/25 (32%) with definite or possible microinvasion were subsequently diagnosed with ipsilateral invasive cancer compared to 38/237 (16%) without microinvasion (p=0.027). There was no significant association on univariable analysis between risk of iIBC and microcalcification as the predominant radiological feature (iIBC and microcalcification 47/258 vs iIBC and other radiological feature 7/46; p=0.83), the presence of histological necrosis (iIBC and necrosis, 14/89 vs iIBC and no necrosis, 31/157; p=0.49) or the use of ET (iIBC and ET 11/67 vs iIBC and no ET 45/244; p=0.86). Of the 51 invasive cancers that developed with a known grade, 46 (90%) were grade 2 or 3. Conclusion The findings suggest that women diagnosed with high or intermediate grade DCIS and those with microinvasion should continue to be offered surgery. For those with low grade DCIS there is a need for shared decision-making in the choice of surgery or active surveillance based on a discussion of the risks and benefits of the options as currently understood, and in the light of the low reproducibility of DCIS grading. Citation Format: Karen Clements, Anthony Maxwell, Bridget Hilton, Matthew Wallis, Cliona Kirwan, Hilary Stobart, Elena Provenzano, Nisha Sharma, Janet Litherland, Abeer Shaaban, David Dodwell, Joanne Dulson-Cox, Elinor Sawyer, Senthurun Mylvaganam, Olive Kearins, Samantha Brace-McDonnell, Sarah Pinder, Alastair Thompson. A longitudinal cohort study of outcomes in 311 women with unresected ductal carcinoma in situ detected through the English breast screening programme [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-22-06.

Transferable learning about patient and public involvement and engagement in gambling support services from health and social care: findings from a narrative review and workshop with people with lived experience

PurposeThe involvement of patients or members of the public within public health, health and social care and addictions services is growing in the UK and internationally but is less common in gambling support services. The purpose of this study was to explore Patient and Public Involvement (PPI) infrastructures and engagement channels used in health and care services and debate their transferability to the gambling support sector (including research, education and treatment).Design/methodology/approachA narrative review examined data from six English language electronic databases, NHS evidence and grey literature covering the period 2007–2019. We identified 130 relevant items from UK literature. A workshop was held in London, England, with people with lived experience of gambling harm to seek their views on and applicability of the review findings to gambling services.FindingsSynthesis of literature and workshop data was undertaken. Main themes addressed “What works” in relation to: building infrastructures and organising involvement of people with lived experience; what people want to be involved in; widening participation and sustaining involvement and respecting people with lived experience.Practical implicationsExamination of the literature about involvement and engagement of patients, service users and the public in public health, health and social care and addiction services provides potentially useful examples of good practice which may be adopted by gambling services.Originality/valueThe involvement of people with lived experience of gambling harms in gambling support services is under-explored, with little published evidence of what constitutes good practice amongst self-organising groups/networks/grassroots organisations or rights-based/empowerment-based approaches.

Investigation of the critical factors required to improve the disclosure and discussion of harm with affected women and families: a study protocol for a qualitative, realist study in NHS maternity services (the DISCERN study)

Patients and families are entitled to an open disclosure and discussion of healthcare incidents affecting them. This reduces distress and contributes to learning for safety improvement. Complex barriers prevent effective...

Does the presence of general practitioners in emergency departments affect quality and safety in English NHS hospitals? A retrospective observational study

ObjectivesEmergency departments (EDs) in NHS hospitals in England have faced considerable increases in demand over recent years. Most hospitals have developed general practitioner services in emergency departments (GPEDs) to treat...

Outcome of Femoral Angioplasty/Stenting Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics and Review of Literature

Purpose Various studies, mainly from North America, report worse outcomes in ethnic minority populations submitted to revascularization for peripheral arterial disease (PAD). Limited nationwide data in relation to ethnicity are available from Europe. Objective The objective of the study is to compare the outcomes of femoral angioplasty/stenting procedures among different ethnic groups in England during the 10-year period from 2006 to 2015. Materials and Methods The “Hospital Episode Statistics” database has been searched using International Classification of Diseases, Tenth Revision (ICD-10) codes to identify all cases of femoral angioplasty or stenting from English NHS Hospitals between January 1, 2006, and December 31, 2015. Subsequent mortality, second open or endovascular infrainguinal procedures, and major amputations on the same side within 2 years after the first procedure have been recorded. Patients were broadly categorized according to ethnicity as whites, Asians, and blacks. Chi-square test was used to demonstrate significant differences among ethnic groups and odds ratios (ORs) were calculated using white ethnic group as reference. Results A total number of 70 887 femoral endovascular procedures were recorded in patients from the 3 ethnic groups. Two-year mortality in whites, Asians, and blacks was 18.3%, 22.1%, and 19.5% (p<0.001); rates of second endovascular procedure were 12.1%, 13.1%, and 13.5% (p=0.24); rates of open infrainguinal procedure were 5.6%, 4.5%, and 8.0% (p<0.001); and rates of major amputation were 4.8%, 4.1%, and 7.0% (p<0.001), respectively. Mortality was higher in Asians (OR=1.26, 95% confidence interval [CI]=1.10-1.45, p<0.01) compared with whites. On the contrary, blacks underwent more open arterial operations (OR=1.48, 95% CI=1.19-1.83, p<0.01) and more amputations (OR=1.49, 95% CI=1.18-1.87, p<0.01). There were no significant differences in the rates of second endovascular procedures. Conclusion Two-year mortality after femoral angioplasty/stenting is higher in Asians, whereas risk of limb loss is higher in blacks compared with whites. Reasons of these ethnic differences in outcomes following femoral endovascular procedures for PAD merit further study.

Do Non-Monetary Interventions Improve Staff Retention? Evidence from English NHS Hospitals

Do Non-Monetary Interventions Improve Staff Retention? Evidence from English NHS Hospitals

Staff Engagement, Job Complementarity and Labour Supply: Evidence from the English NHS Hospital Workforce

Staff Engagement, Job Complementarity and Labour Supply: Evidence from the English NHS Hospital Workforce

The Vascular PAD-QIF CQUIN: what is it, why is it important, what does it mean for vascular units?

The Commissioning for Quality and Innovation (CQUIN) indicators for 2022/23 were recently published by NHS England and for the first time include a vascular indicator, the “Achievement of revascularisation standards for lower limb ischaemia”.1 This is great news and will drive quality improvement for patients with chronic limb-threatening ischaemia (CLTI). In this editorial we describe what this means for English NHS organisations providing vascular services, vascular clinicians and patients.

Staff Engagement, Coworkers' Complementarity and Employee Retention: Evidence from English NHS Hospitals

Staff Engagement, Coworkers' Complementarity and Employee Retention: Evidence from English NHS Hospitals

Personalising the risk of conversion from laparoscopic to open hysterectomy in benign conditions: Development and external validation of risk prediction models.

To develop and validate novel prediction models to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions. Retrospective cohort study. English NHS Hospitals between 2011 and 2018. 68752 women undergoing laparoscopic hysterectomy for benign conditions. We developed two multivariable logistic models using readily available clinical information, one for the pre-operative setting and another for operative decision-making using additional surgical information, using 2011-2016 data in five regions (24806 women). We validated them (a) temporally in the same regions using 2017-2018 data (12438 women); (b) geographically in the same time-period using data from three different regions (22024 women); and (c) temporally and geographically using 2017-2018 data in three different regions (9484 women). Conversion from laparoscopic to open hysterectomy. Conversions occurred in 6.8% (1687/24806) of hysterectomies in the development group, and in 5.5% (681/12438) in the temporal, 5.9% (1297/22204) in the geographical and 5.2% (488/9484) in the temporal and geographical validation groups. In the development cohort, the area under the receiver operating characteristic curve values for the pre-operative and operative models were 0.65 and 0.67, respectively. In the validation cohorts the corresponding values were 0.65 and 0.66 (temporal), 0.66 and 0.68 (geographical) and 0.65 and 0.68 (temporal and geographical), respectively. Factors predictive of conversion included age, Asian ethnicity, obesity, fibroids, adenomyosis, endometriosis and adhesions. Adhesions were the most predictive (odds ratio 2.54, 95% confidence interval 2.22-2.90). The models for predicting conversions showed acceptable performance and transferability. Novel tool to personalise the risk of conversion from laparoscopic to open hysterectomy in benign conditions.

Death after surgery among patients with chronic disease: prospective study of routinely collected data in the English NHS

BackgroundFive million surgeries take place in the NHS each year. Little is known about the prevalence of chronic diseases among these patients, and the association with postoperative outcomes. MethodsAnalysis of routine data from all NHS hospitals in England including patients aged ≥18 yr undergoing non-obstetric surgery between January 1, 2010 and December 31, 2015. The primary outcome was death within 90 days after surgery. For each chronic disease, we adjusted for age, sex, presence of other diseases, emergency surgery, and year using logistic regression models. We defined high-risk diseases as those with an adjusted odds ratio (OR) for death ≥2 and report associated 2-yr survival. ResultsWe included 8 624 611 patients (median age, 53 [36–68] yr), of whom 6 913 451 (80.2%) underwent elective surgery and 1 711 160 (19.8%) emergency surgery. Overall, 2 311 600 (26.8%) patients had a chronic disease, of whom 109 686 (4.7%) died within 90 days compared with 24 136 (0.4%) of 6 313 011 without chronic disease. Respiratory disease (1 002 281 [11.6%]), diabetes mellitus (662 706 [7.7%]), and cancer (310 363; 3.6%) were the most common. Four chronic diseases accounted for 7.7% of patients but 59.0% of deaths: cancer (37 693 deaths [12.1%]; OR=8.3 [8.2–8.5]), liver disease (8638 deaths [10.3%]; OR=4.5 [4.4–4.7]), cardiac failure (26 604 deaths [12.6%]; OR=2.4 [2.4–2.5]), and dementia (19 912 deaths [17.9%]; OR=2.0 [1.9–2.0]). Two-year survival was 67.7% among patients with high-risk chronic disease, compared with 97.1% without. ConclusionOne in four surgical patients has a chronic disease with an associated 10-fold increase in risk of postoperative death. Two-thirds of all deaths after surgery occur among patients with high-risk diseases (cancer, cardiac failure, liver disease, dementia).

Procurement and commissioning during COVID-19: reflections and (early) lessons

This commentary reflects on some common themes that are starting to emerge in the early analysis of the healthcare procurement and commissioning response to the COVID-19 pandemic. Although it largely results from the observation of the situation in the English NHS, the most salient issues are common to procurement in other EU healthcare systems, as well as more broadly across areas of the public sector that have strongly relied on the extremely urgent procurement exception in the aftermath of the first wave of the pandemic. Given the disfunction and abuse of ‘unregulated procurement’ in the context of COVID-19, the commentary reflects on the longer term need for suitable procurement rules to face impending challenges, such as Brexit and, more importantly, climate change.

Caring for hospital patients with COVID-19: Quality of care in England examined by case record review

The Royal College of Physicians' COVID-19 study was conducted in 2020 as a collaboration of 19 English NHS trusts, the Association of Professional Healthcare Analysts and a data team in the Institute of Global Health Innovation at Imperial College London. The participating trusts had a combined catchment population of 10.46 million and looked after over 26,000 patients with SARS-CoV-2. The study involved 510 patient cases the majority of which were mortality reviews. The data were analysed both quantitatively and qualitatively and employed novel natural language processing methods. The quantitative data established that 96.5% of the care delivered was adequate, good or excellent. Poor care was uncommon. Qualitative data generated 24 common themes that were articulated by the creation of nine vignettes (four explored here). Six recommendations were created, and further analysis of specific recommendations is advised.

Integrated Care in England - what can we Learn from a Decade of National Pilot Programmes?

Introduction:For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care.Description:The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration.The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots’ objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy.Discussion:There was little stable or shared understanding of what ‘integrated care’ meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors.Conclusion:Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

To mesh or not to mesh-the known unknowns of preventing parastomal hernias.

Despite recent technical advances in rectal cancer treatment, the proportion of patients with rectal cancer who ultimately have a permanent stoma remains high. English NHS data (National Bowel Cancer Audit) demonstrates that approximately 50 per cent of rectal cancer patients who undergo surgery of any sort have a permanent stoma (either an end-colostomy or diverting loop ileostomy) and consequently, the sequelae of living with a stoma continues to have an impact1. The most significant long-term complication of a stoma remains the development of parastomal hernia (PSH) with a reported incidence of 40–50 per cent at 2 years2. Few patients with a PSH are truly asymptomatic and it is sufficiently troublesome that one-fifth of patients will have a repair within 5 years and one-third of those who have undergone repair will have multiple recurrent PSH repairs3. The high incidence of PSH development and the potential...