Health Authorities In England Research Articles

A Scaling Law for PCR Positivity in the COVID Second Wave

In this preliminary report, PCR positivity data in the second wave of theCOVID pandemic (September-January 2020) are shown to obey a scalinglaw given by: where and are the y- and x-intwhere and are the y- and x-intercepts of a plot of positivity, ,against the number of tests, . The law holds across international, regionaland local boundaries, as demonstrated for Great Britain, Austria,Germany and Sweden, the nine English regions, London - Yorkshire &Humber, and various Local Health Authorities in England. One possibleexplanation for scaling might be Dorfman pooling.The scaling law can be used to remove a systematic or false positive (FP)component from the daily number of positive tests, or cases, to yield thereal number of cases. The results correlate strongly with the ZOE surveyfor London ( = 0.787) and Excess Deaths for England ( =0.833). Thecumulative total of FPs can be estimated as 1.4M by the beginning of2021, in line with other estimates.

A Scaling Law for PCR Positivity in the COVID Second Wave

In this preliminary report, PCR positivity data in the second wave of theCOVID pandemic (September-January 2020) are shown to obey a scalinglaw given by: where and are the y- and x-intwhere and are the y- and x-intercepts of a plot of positivity, ,against the number of tests, . The law holds across international, regionaland local boundaries, as demonstrated for Great Britain, Austria,Germany and Sweden, the nine English regions, London - Yorkshire &Humber, and various Local Health Authorities in England. One possibleexplanation for scaling might be Dorfman pooling.The scaling law can be used to remove a systematic or false positive (FP)component from the daily number of positive tests, or cases, to yield thereal number of cases. The results correlate strongly with the ZOE surveyfor London ( = 0.787) and Excess Deaths for England ( =0.833). Thecumulative total of FPs can be estimated as 1.4M by the beginning of2021, in line with other estimates.

An investigation into the content validity of the Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT v15a) using cognitive interviews with antimicrobial pharmacists.

The Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT) was developed to evaluate the organizational strategies used to implement hospital-based antimicrobial stewardship programmes. An iterative approach was used to develop ASAT v15a, which has been previously investigated for face validity; however, further investigation into other types of validity was required. Therefore, the aim of this study was to investigate the content validity of ASAT v15a and hence modify and improve the content validity of the toolkit. A purposive sample of eight antimicrobial pharmacists was interviewed using cognitive interviewing techniques from within the former North-west Strategic Health Authority in England. Respondents were asked to 'think aloud' and to verbally express their thought processes as they generated responses to each question with the ASAT. There were no cognitive difficulties reported by respondents in response to 26/83 (31·3%) questions within the ASAT. However, cognitive difficulties were reported by respondents at each stage of the cognitive processing pathway in response to 57/83 (68·7%) questions. These difficulties were comprehension/interpretation in 27/83 (32·5%) questions, information retrieval in 10/83 (12%) questions, judgment/decision in 6/83 (7·2%) questions and response generation/formatting in 13/83 (15·7%) questions. Other findings included disagreement with the weightings applied to 13/83 (15·7%) questions. Respondents recommended that these questions should be modified to reflect their impact on hospital-based antimicrobial stewardship programmes (ASPs). Based on these findings, modifications were made to ASAT v15a to produce the next iteration (ASAT v16). Furthermore, respondents indicated that the role of clinical microbiologists was underrepresented in the current version of the toolkit; therefore, seven proposed questions were drafted, based on a literature review. Cognitive interviews were effectively able to detect problems encountered by respondents along the cognitive processing pathway by identifying words and/or phrases that required further modifications. Also, this method highlighted that there was a disparity between the respondents' interpretation and the ASAT developers' intent within some questions. Although respondents indicated that the toolkit evaluated the most pertinent components of ASPs, further modifications and testing would be required to improve its validity. These results highlight the importance of the inclusion of end-users in the development of reporting and/or evaluation tools or questionnaires.

Apprenticeship and progression in the healthcare sector: can labour market theory illuminate barriers and opportunities in contrasting occupations?

There is growing research and policy interest in the extent to which government supported Apprenticeship in England provides a platform for educational and career progression in different occupational sectors. This paper makes a contribution to this debate by presenting research on the healthcare sector undertaken in a regional health authority in England, and by suggesting that ideas associated with labour market theory can shed light on some of the key differences in Apprenticeship frameworks and the progression opportunities available in different kinds of healthcare occupations. The research included policy and documentary review as well as qualitative interviews with employers in NHS Trusts. More specifically, our analysis applies key characteristics of occupational and internal labour markets to show how Apprenticeship frameworks fit and reinforce variations in employment, training and career opportunities in two contrasting Advanced Apprenticeship frameworks; Clinical Healthcare Support and Pharmacy Services. We conclude that the labour market lens is useful in focusing attention on the structures and key stakeholder relationships which determine the development of vocational training and the barriers or opportunities for educational or career progression in diverse sectoral contexts and occupations across the economy.

A retrospective study of the impact of the doctors’ strike in England on 21 June 2012

To examine the effect of the 24-h doctors' strike on 21 June 2012 on hospital activity in English NHS hospitals. Retrospective descriptive study of inpatient, outpatient and Accident and Emergency (A&E) activity in NHS hospitals over the strike period. All English NHS hospitals. Patients admitted to hospital, patients with outpatient appointments and A&E attendances over a three-week period (from 11 to 29 June 2012), excluding weekends and spanning the strike day. Numbers and percentage change of inpatient admissions (elective and emergency), day surgery cases, outpatient appointments cancellations, A&E attendances and in-hospital deaths on the day of the strike compared with patient activity on the Thursday before and the Thursday after the strike week. There were a total of 795,267 admissions, 5,602,971 outpatient appointments, 356,645 outpatient cancellations (by NHS provider), 4,470,208 outpatients seen by medical staff, 986,322 A&E attendances and 13,857 in-hospital deaths over the three-week period. Compared with the non-strike period, on the day of the strike, emergency admissions fell by 2.4% while the elective admissions decreased by 12.8%. There was a 7.8% drop in the number of outpatients seen by medical staff on the day of the strike and a 45.5% increase in the number of cancelled appointments by NHS hospitals, while A&E attendances dropped by 4.7%. The impact of the strike across regional Health Authorities in England was varied. The North West Health Authority was affected the most while the least affected Health Authorities were the South West, East of England and South Central. The 24-h doctors' strike in England on 21 June 2012 significantly affected the provision of healthcare by NHS hospitals. We observed regional variations on NHS service levels on the day of the strike.

The perceived impact of advanced practice nurses (APNs) on promoting evidence-based practice amongst frontline nurses: findings from a collective case study

The aim of this study was to explore the perceived impact of advanced practice nurses in promoting evidence-based practice amongst frontline nurses. A collective instrumental case study was undertaken involving five extended case studies and eighteen short case studies in a range of hospital and primary care settings across seven Strategic Health Authorities in England. The study participants were a purposive sample of 23 advanced practice nurses selected to represent a range of settings, clinical specialities, organisational responsibilities and ways of working. In-depth interviews were undertaken with the advanced practice nurse and up to 10 interviews with health care professionals with whom they worked. For the extended case studies, non-participant observation and follow-up interviews were also undertaken. Data analysis drew on the principles of the Framework approach. From the perspectives of the participants, these advanced practice nurses enhanced the ability of frontline nurses to provide evidence-based care. They improved the competence, knowledge and skills of frontline nurses and empowered them to deliver care which they considered to be safer, holistic, more timely and of a higher standard. This is likely to have a positive effect on patient outcomes and on patient experience. However, this impact is inherently hard to capture.

Investigating Official Records of Suicides for Research Purposes

In many countries worldwide the circumstances of unnatural deaths, including suicides, are subject to official investigations, usually by medical examiners or coroners. In England and Wales, where our experience is based, investigations into sudden or unexplained deaths are conducted by a coroner, an independent officer appointed by the local government authority, who usually has a legal or medical professional background. Findings from the investigation are presented at a public inquest at which the coroner reaches a verdict about the likely cause of death. The paper records of the investigation (the “inquest record”) are usually then filed at the coroner’s offices or local authority archive. The content of inquest records varies, but they generally include police reports, witness statements, postmortem autopsy and toxicological reports, and, where judged appropriate, information on health service contact from general practitioners and psychiatrists. There may also be photographs of the scene of death and copies (or originals) of suicide notes. The files from these investigations are a valuable source of information to further our understanding of suicide, whether from a historical or sociological perspective (e.g., Atkinson, 1978; Bailey, 1998) or, in a public health context, by providing data relevant to suicide prevention strategies (Bennewith, Hawton et al., 2005). Suicide case files have been used for sociological autopsy studies (Langer, Scourfield, & Fincham, 2008), qualitative thematic analysis (Valle, Gosney, & Sinclair, 2008), and as part of psychological autopsy studies (Hawton et al., 1998). In addition, the health authorities in England and Wales are required to carry out local suicide audits, including an analysis of inquest records, though the value of this has been questioned (Caley & Fowler, 2008). Outside the United Kingdom, researchers have used inquest records to investigate various aspects of suicide, including social and environmental factors (Almasi et al., 2009), gender differences (Walsh, Clayton, Liu, & Hodges, 2009), and associations with specific problems (Wong, Cheung, Conner, Conwell, & Yip, 2010). In the United States, researchers use the reports compiled by the police, medical examiners, and coroners to extract data for the National Violent Death Reporting System (Ward, Shields, & Cramer, 2011). Yet working with such material can be challenging, both practically and emotionally, and there is relatively little published guidance on the use and limitations of these records (Bennewith, Hawton et al., 2005). To our knowledge, only one study has addressed the impact of such work on the researchers themselves (Fincham, Scourfield, & Langer, 2008). We have been involved in extracting information from coroners’ records for a number of research projects (e.g., Appleby, Cooper, & Amos, 1999; Bennewith, Gunnell et al., 2005; Hawton et al., 2005). This editorial draws on our experiences to highlight some of the issues that need to be considered when planning research into suicide based on records such as those produced by coroners in England and Wales.

What does the future hold for the role of the Local Supervising Authority?

The Local Supervising Authority (LSA) is the statutory body responsible for the supervision of all midwives practising within its boundaries and LSAs must ensure midwifery practice is safe and effective wherever it is provided. The LSA produces standards and guidance for the supervisors of midwives within its boundaries in relation to their practice, based on the requirements of the Midwives' Rules and Standards of the Nursing and Midwifery Council (NMC). Effective use of the supervisory framework leads to improvements in the standard of midwifery care and better outcomes for women. Proactive and effective statutory supervision is evident, but there are variations across the UK. While LSAs continue to face many challenges in delivering their statutory function, annual reports from all 16 LSAs received by the NMC in 2010 described examples of good practice and referred to the value of supervision for both midwives and women. Over the years, the LSA role and function have developed and strengthened significantly. While most recently, LSAs have been the responsibility of the Strategic Health Authorities in England, it is crucial that this development continues in the new NHS. The specific challenges to LSA Midwifery Officers will be to provide leadership and support in the face of the challenges to come and to be pivotal and at the centre of addressing them.

Primary care for tinnitus: practice and opinion among GPs in England

Rationale, aim and objectiveEffective tinnitus management starts with appropriate general practitioner (GP) triage, which in England can be guided by the Department of Health's Good Practice Guide (GPG). Despite the prevalence of the condition, there has never been a systematic survey of its management in primary care in England. We aimed to evaluate how people with tinnitus are assessed and managed in general practice, noting variation in practice across GPs and health authorities, and evaluating how closely typical practice aligns to the GPG for tinnitus.MethodsA nine-item postal questionnaire was sent to 2000 GPs randomly selected to proportionally represent the number of primary care trusts and strategic health authorities in England.ResultsWe received 368 responses. Responses indicated a mix of frequent and infrequent practices, for example, 90% of GPs assessed the impact of tinnitus on quality of life, but fewer examined cranial nerves (38%) or assessed for a carotid bruit (26%) during a tinnitus consultation. In the management of tinnitus, 83% routinely removed earwax, and 87% provided information-based advice. In contrast, only 4% of responders would offer antidepressant drugs or psychological therapies. Thematic analysis revealed a desire for concise training on tinnitus management.ConclusionsGP assessment and management of tinnitus represents potential inequity of service for tinnitus patients. While the GPG aims to promote equity of care, it is only referred to by a minority of clinicians and so its utility for guiding service delivery is questionable. Although some GPs highlighted little demand for tinnitus management within their practice, many others expressed an unmet need for specific and concise GP training on tinnitus management. Further work should therefore evaluate current informational resources and propose effective modes of delivering educational updates.

The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses

To identify approaches used by advanced practice nurses to promote evidence-based practice among clinical nurses. Barriers encountered at individual and organizational levels hinder clinical nurses in their ability to deliver evidence-based practice. Advanced practice nurses are well placed to promote evidence-based practice through interactions with clinical nurses. However, little is understood about how advanced practice nurses might realize this potential. A multiple instrumental case study of 23 advanced practice nurses from hospital and primary care settings across seven Strategic Health Authorities in England was undertaken in 2006. Data collection comprised interviews and observation of advanced practice nurses and interviews with clinical nurses and other healthcare professionals. Data were analysed using the Framework approach. Advanced practice nurses acted as knowledge brokers in promoting evidence-based practice among clinical nurses. Knowledge management and promoting the uptake of knowledge were key components of knowledge brokering. Knowledge management involved generating different types of evidence, accumulating evidence to act as a repository for clinical nurses, synthesizing different forms of evidence, translating evidence by evaluating, interpreting and distilling it for different audiences and disseminating evidence by formal and informal means. Advanced practice nurses promoted the uptake of evidence by developing the knowledge and skills of clinical nurses through role modelling, teaching, clinical problem-solving and facilitating change. The role of advanced practice nurses in knowledge brokering is complex and multi-faceted. It extends beyond the knowledge management, linkage and capacity building identified in the literature to include active processes of problem-solving and facilitating change.

Qualitative insights into general practitioners' views on the appropriateness of their long-term prescribing

Abstract Objective To explore factors which may contribute to inappropriate long-term prescribing in United Kingdom general practice. Methods Nine previously validated indicators of the appropriateness of long-term prescribing were applied to a sample of patients, each under the care of one of 22 general practitioners from 10 practices. The GPs were then interviewed, using as the basis for the discussion specific examples of their prescribing that had been identified as potentially inappropriate. The interview transcripts were studied repeatedly to identify key themes in the reasons or explanations for apparently inappropriate prescribing. Setting General practices in three health authorities in England and one health board in Scotland. Key findings In total, 227 instances of potentially inappropriate prescribing, relating to 101 patients, were discussed with the 22 GPs. Four key themes emerged from the interview data. One common theme was that of perceived patient preference to continue with long-term therapy. A second theme was cases where the prescribing was “historical,” ie, the drug had been started a long time before, or by another doctor. Within this context, many doctors expressed great reluctance to change a drug when there was no obvious clinical need to do so, even though they would not initiate the drug regimen within their current practice. A third theme was that “hospital-led” prescribing was perceived to pose frequent and sometimes potentially difficult problems. Fourth, many GPs expressed their unease with the process of repeat prescribing which is operated in many UK practices. Conclusions This study has reinforced the fact that there are a number of internal and external factors which can impact on a GP's decision to continue apparently inappropriate long-term prescribing.

Reviewing Repeat Prescribing — General Practitioners and Community Pharmacists Working Together

Abstract In the United Kingdom, patients receiving medication to treat chronic conditions frequently obtain treatment via repeat prescriptions. This reduces the workload of general practitioners (GPs) but increases the potential for patients to receive inappropriate and unnecessary medication over long periods of time. The aim of this project was to determine the potential role that community pharmacists could fulfil in reviewing and rationalising medication received on repeat prescriptions. Volunteer pharmacists and general practitioners in two health authorities in England formed 47 GP-pharmacist partnerships. Each GP identified up to 50 patients receiving six or more “repeat” medicines. Pharmacists reviewed GP notes and record systems to identify potential problems. Discussions addressing the identified problems and possible solutions were held between the GP-pharmacist partners. Three months later the pharmacists revisited the surgeries to review GP notes to determine whether changes had occurred. On completion of the project, focus groups were held with participating GPs and pharmacists to ascertain their views on the project. In total, repeat prescriptions for 1,564 patients were investigated which resulted in 13,194 medicines being reviewed. The pharmacists identified 9,762 potential “problems” of which the most common were: drugs no longer required, inappropriate quantity ordered, and unsatisfactory directions. The GPs agreed with 58 per cent of identified problems and acted upon 56 per cent of these (32 per cent of the original total). In general, the involvement of pharmacists was beneficial in terms of rationalising prescribing and reducing possible drug interactions and adverse drug reactions resulting from multiple supplies of potentially inappropriate and unnecessary medication. Furthermore, pharmacists were able to rationalise patients' supplies to help improve the actual management of medication in terms of ordering and collecting supplies and coping with complex daily regimens.

Results of a Quantitative Survey to Explore Both Perceptions of the Purposes of Follow-up and Preferences for Methods of Follow-up Delivery Among Service Users, Primary Care Practitioners and Specialist Clinicians after Cancer Treatment

Aims To ascertain perceptions of reasons for follow-up after cancer treatment among service users (patients and carers), primary care practitioners and specialist clinicians (doctors and specialist nurses) and to identify levels of preference for different models of follow-up and the effect of an individual’s experience on preferred models. Materials and methods A national survey designed to meet the needs of each key respondent group was carried out after a structured literature review, an extensive consultation process and a pilot scheme. Respondents were asked to assess their degree of preference for 10 pre-selected indications for follow-up. Eight models of follow-up were also identified and respondents were asked to state their experience and preference for each type. The questionnaire was distributed nationally via the 34 cancer networks in England and was available both online and in hard copy (postal). The uptake for the electronic format was in the main by primary care practitioners and specialist clinicians. Service users preferred the paper (postal) format. The survey was also publicised through the primary care and patient partnership forums at a Cancer Network Development event. Results In total, 2928 responses were received, comprising service users (21% of the sample), primary care practitioners (32%) and specialist clinicians (47%). Eighty-six per cent of responses were received from the 10 strategic health authorities in England, with the remaining 14% from Scotland, Wales and The Isle of Man. The responses from Scotland, Wales and the Isle of Man generally occurred where they interfaced with English cancer networks or had been engaged through word of mouth by colleagues. Among all respondents the main aims of cancer follow-up were considered to be: (1) to monitor for early complications after treatment; (2) to detect recurrences early; (3) to detect late effects of treatment. The most commonly experienced method of follow-up among all respondent groups was outpatient review with a doctor. This was considered to be the most preferred follow-up option among service users (86%). The least preferred option among service users was postal follow-up (32%). Primary care practitioners and specialist clinicians were more likely than service users to have experienced alternative methods of follow-up, such as telephone follow-up, self-triggered referral and non-specialist follow-up. These models were highly rated by those who had experience of them. Conclusions There was a reasonable level of consensus between service users, primary care practitioners and specialist clinicians as to the reasons for follow-up. Service users seemed to have higher expectations of follow-up, particularly in relation to detecting recurrences early. As respondents were more likely to prefer a method of follow-up delivery that they had experienced than one they had not; there could be resistance to change from established methods to new methods without adequate explanation. This suggests that the communication of new methods could be critical to their successful introduction.

It seems that the defining role of caring is no longer our domain.

NHS boards in Wales are to cut a number of staff at bands 5 and above (news February 17) and replace them with healthcare support workers (HCSWs). Strategic health authorities in England are cutting commissions for nursing students and receptionists are being trained by doctors in their surgeries to adopt nurse roles (news February 15).

A library-based ecological study to investigate the contribution of ethnicity to the incidence of oral cancer within health authorities in England and Wales

Our aim was to investigate the incidence of oral cancer in three ethnic groups, Indian, Pakistani, and Bangladeshi residents of the UK, to try to establish a link between ethnic background and the incidence of oral cancer. We used data from the 1991 and 2001 censuses to calculate approximate percentages of the number of Indian, Pakistani, and Bangladeshi residents in each Health Authority (HA) region and correlated these with rates of oral cancer from the Office of National Statistics (ONS) cancer atlas for the same period. Data about lung cancer and oesophageal cancer were used as proxies for the confounding variables of smoking and alcohol, respectively, in a multiple regression analysis. There was a strong significant correlation between figures for lung cancer and variations in oral cancer rates among HAs ( p < 0.001). Ethnicity contributed weakly and insignificantly to variations in rates of oral cancer among HAs. In summary, we found only a weak correlation between ethnicity and oral cancer in the UK population, unlike previously published studies, while simultaneously showing a stronger relation with the proxy for smoking trends. There are various drawbacks inherent in library-based ecological studies in general, and in this study in particular, that may have been responsible for this.

A national survey of general practitioners understanding and awareness of malnutrition

It is estimated that more than 3 million people in the UK are either malnourished or at risk of malnutrition, most of whom live in the community (93 %) (1) and are under the care of their general practitioner (GP) (2) . Although NICE nutrition support guidelines (CG32) (3) are relevant in GP surgeries, there is little published information about the detection and management of malnutrition in general practice. This survey aimed at understanding GP awareness and the use of relevant nutrition support guidelines, including their approaches to the identification and management and malnutrition. A national cross-sectional online survey, comprising seven questions about the prevalence of malnutrition, methods for the detection and management of malnutrition including the perceived benefits of ready-made oral nutritional supplements (ONS). and awareness of relevant nutrition guidelines, was conducted on 201 GP (121 male; 80 female, mean age 46 years) in June 2010. GP were representative of all ten Strategic Health Authorities in England (82%) plus Scotland (9%), Northern Ireland (4%) and Wales (5 %). Two-thirds of GP (67 %) were unaware of the NICE Nutrition Support guidelines (CG32), and 70 % of those who were aware had not implemented them into clinical practice. To identify malnutrition, GP reported using clinical judgement (48 %), BMI (30 %) or a screening tool (10 %), of which 90 % used the ‘Malnutrition Universal Screening Tool’ (‘MUST’). Eight percent reported not actively identifying patients. GP estimated the prevalence of malnourished people attending their practice to be 4.8% on average (0–50%). Less than a third of GP reported having a local policy for malnutrition management (31 %) but in most practices these were not implemented routinely (73%). Of those without a local policy for the management of malnutrition (69 %), 34 % felt one would be useful. Strategies that GP reported using for the management of malnutrition included: none (9 %), referral to another health-care professional (42 %) (most of which (95 %) were dietetic referrals), providing a dietary advice sheet (6%); or prescribing supplements including ready-made ONS (41 %). When asked to rank the clinical benefits of ONS, the GP main perceived benefits were: reductions in complications (18%); improvements in quality of life (17 %) and reductions in mortality (15 %). Other benefits were ranked to a lesser extent and included improvements in intake and weight (11 and 10 %, respectively), and reductions in health-care use (readmissions 9 % and length of stay 4 %). Similar results were obtained irrespective of the age, sex or location of GP. Despite malnutrition being a common and costly problem in the community, this survey suggests that there appears to be limited awareness and application of NICE guidelines for nutrition support with a lack of routine screening and local policies for the management of malnutrition in general practice. Further research is needed to understand the prevalence of malnutrition and the potential benefits of appropriate management in this setting.

Regional risk factors for health inequalities in Scotland and England and the “Scottish effect”

This paper uses data from the Scottish Health Survey 2003 and the comparable Health Survey for England 2003 to look at whether Scotland's poor health image and mortality profile is reflected in regional inequalities in prevalence of four risk factors for cardiovascular disease: fruit and vegetable consumption, smoking, obesity and diabetes. It also looks at the "Scottish effect" - how much of any difference between and within Scotland and England remains once socio-demographic factors have been taken in to account. The paper then uses regional analyses to determine the extent to which areas within England and Scotland contribute to their national health advantage and disadvantage. All 2003 strategic health authorities in England and Scottish health boards were compared with Greater Glasgow health board as the reference category. The results showed that significant geographic variation in the risk factors remained once individual economic status was taken into account, but the relationship was complex and varied in strength and direction depending upon risk factor involved and gender of respondent. A small number of areas had significantly lower odds of fruit and vegetable consumption of five portions or more a day in men, compared with Greater Glasgow. In contrast some areas had significantly higher odds of fruit and vegetable consumption for women compared with Greater Glasgow. There was greater geographic variation in the odds of smoking in women than in men. Respondents in the south west and southeast of England (areas which usually show health advantage) did not show significantly lower odds of smoking compared with Greater Glasgow once socio-economic variation, age and urban residence was taken into account. It was respondents from central England that had lower odds of smoking than might be expected. Obesity stood out as the single risk factor that had demonstrated a "Scottish effect" in women only.

Risk of cervical abnormality after age 50 in women with previously negative smears

There is discussion over the benefit of continuing cervical screening in women over the age of 50 with a history of negative cytology. We aimed to determine the risk of abnormal cytology in such women. Screening history data from 1985 to 2003 were obtained for a cohort of 2 million women from the NHS cervical screening programme from four Health Authorities in England. The 57 651 women in the cohort who reached age 40 between 1 January 1985 and 31 December 1990 and had at least one routine or opportunistic smear between ages 50 and 54 were included in the analysis. Exposure groups (negative cytology history, negative but including inadequate smears, and positive history) were defined on the basis of screening histories from ages 40 to 49. Sixty-four percent (134/206) (95% CI: 57–71%) of the moderate dyskaryosis or worse lesions at ages over 50 were detected from women in the negative smear history group. After allowance for time since last negative smear, the relative risk for the first primary smear over the age of 50 having moderate dyskaryosis or worse decreased from 0.60 (95% CI: 0.41–0.84) for two negative smear episodes to 0.25 (95% CI: 0.10–0.56) for four negative smear episodes, compared with the positive history group. If screening were discontinued for all women over 50 with a negative history, the majority of cytological abnormalities now being detected at these ages that lead directly to referral to colposcopy would be missed.

Stratification of COPD patients by previous admission for targeting of preventative care

Hospital admissions for exacerbations of chronic obstructive pulmonary disease (COPD) impact considerably on disease evolution and healthcare provision. Building on previous studies, this study postulated that COPD patients could be stratified by risk of admission to determine which groups provide the greatest burden on resources, and how interventions should be targeted to prevent admissions. COPD admissions during 1997-2003 in three Strategic Health Authorities in England were analysed (n=80,291). Patients admitted during winter (1 November-31 March) were stratified into three groups according to the number of admissions during the previous year: 0 (NIL), 1-2 (MOD) or >or=3 (FRQ). Winter weeks were classified as "average", "above average", "high", or "very high" risk, compared with the long-term mean. The risk of admission during winter for FRQ and MOD patients was 40% and 12% respectively. NIL patients contributed to 70% of winter admissions, and 90% of the variation between "average" and "very high" weeks, versus 9% and 1% for MOD and FRQ. Patients with no previous admissions have lower individual risk, but contribute to a high overall utilisation of health care resources and should be targeted to prevent admissions. Focusing upon high-risk patients (frequent attenders or more severe) may only reduce a small proportion of admissions, and therefore clinicians should ensure that all COPD patients receive appropriate therapy to reduce risk of exacerbations.

The potential for measles transmission in England

BackgroundSince the schools vaccination campaign in 1994, measles has been eliminated from England. Maintaining elimination requires low susceptibility levels to keep the effective reproduction number R below 1. Since 1995, however, MMR coverage in two year old children has decreased by more than 10%.MethodsQuarterly MMR coverage data for children aged two and five years resident in each district health authority in England were used to estimate susceptibility to measles by age. The effective reproduction numbers for each district and strategic health authority were calculated and possible outbreak sizes estimated.ResultsIn 2004/05, about 1.9 million school children and 300,000 pre-school children were recorded as incompletely vaccinated against measles in England, including more than 800,000 children completely unvaccinated. Based on this, approximately 1.3 million children aged 2–17 years were susceptible to measles. In 14 of the 99 districts, the level of susceptibility is sufficiently high for R to exceed 1, indicating the potential for sustained measles transmission. Eleven of these districts are in London. Our model suggests that the potential exists for an outbreak of up to 100,000 cases. These results are sensitive to the accuracy of reported vaccination coverage data.ConclusionOur analysis identified several districts with the potential for sustaining measles transmission. Many London areas remain at high risk even allowing for considerable under-reporting of coverage. Primary care trusts should ensure that accurate systems are in place to identify unimmunised children and to offer catch-up immunisation for those not up to date for MMR.