Health Service Scotland Research Articles

Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK.

Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting. 26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey. 24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD. We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting.

Speech for Intelligent cognition change tracking and DEtection of AD (SIDE‐AD) Research Program: SIDE‐AD

AbstractBackgroundThere is emerging evidence that speech could be a potential indicator and manifestation of early Alzheimer’s disease (AD) pathology. Symptomatic AD may change an individual’s language, especially certain elements in speech such as elaboration and attribution. Therefore, the University of Edinburgh and Sony Group Corporation are collaborating within the Sony Research Award Program to create the SIDE‐AD study which aims to develop digital speech‐based biomarkers technology for AD. The study is designed to assess disease status in the pre‐dementia stages in a real‐world at‐risk population in Brain Health Services.MethodSIDE‐AD is an observational longitudinal study developing speech biomarkers for use in neurodegenerative disease. Participants are recruited from Brain Health Services in Scotland with data collection starting in spring 2023. In the context of the SIDE‐AD study, we have developed a secured online data collection infrastructure for collecting voice data by prompting individuals to record a voice sample talking about their brain health. Individuals are asked to rate their mood, anxiety and apathy. The baseline speech biomarkers will be compared to the follow‐up visit’s speech recordings as well as to other variables from routinely collected health care data. The SIDE‐AD study will employ signal processing and machine learning technologies to automate the assessment of the respondents’ speech.ResultThe objective of the SIDE‐AD study is to recruit participants (n = 150) across the AD spectrum. The developed infrastructure will be used to collect data of participants with an objective of analysing baseline speech markers in relation to self‐reported mood, anxiety and apathy as well as clinical outcomes from patients’ health care records.ConclusionThe SIDE‐AD study is carrying out research and development of a speech‐based application recording data on individuals’ self‐perceived brain health. A secured online data collection infrastructure is developed to collect speech data with an objective to analyse speech data in combination with routinely available clinical data in Brain Health Clinics, enabling real world validation of speech‐based digital biomarkers for the early detection of AD. We plan to use automatic speech recognition and acoustic patterns for the automatic assessment of brain health status relevant to emergent AD‐specific speech biomarkers.

Identifying and prioritising future interventions with stakeholders to improve paediatric urgent care pathways in Scotland, UK: a mixed-methods study

ObjectivesTo identify and prioritise interventions, from the perspectives of parents and health professionals, which may be alternatives to current unscheduled paediatric urgent care pathways.DesignFLAMINGO (FLow of AdMissions in chIldren and...

Stakeholder views on the design of National Health Service perinatal mental health services: 360-degree survey.

At the start of a new community perinatal mental health service in Scotland we sought the opinions and aspirations of professional and lay stakeholders. A student elective project supported the creation of an anonymous 360-degree online survey of a variety of staff and people with lived experience of suffering from or managing perinatal mental health problems. The survey was designed and piloted with trainees and volunteer patients. A rich variety of opinions was gathered from the 60 responses, which came from a reasonably representative sample. Respondents provided specific answers to key questions and wrote free-text recommendations and concerns to inform service development. There is clear demand for the new expanded service, with strong support for provision of a mother and baby unit in the North of Scotland. The digital survey method could be adapted to generate future surveys to review satisfaction with service development and generate ideas for further change.

The Impact of COVID-19 on Mental Health Services in Scotland, UK.

There is a global emergency in relation to mental health (MH) and healthcare. In the UK each year, 1 in 4 people will experience MH problems. Healthcare services are increasingly oversubscribed, and COVID-19 has deepened the healthcare gap. We investigated the effect of COVID-19 on waiting times for MH services in Scotland. We used national registers of MH services provided by Public Health Scotland. The results show that waiting times for adults and children increased drastically during the pandemic. This was seen nationally and across most of the administrative regions of Scotland. We find, however, that child and adolescent services were comparatively less impacted by the pandemic than adult services. This is potentially due to prioritisation of paediatric patients, or due to an increasing demand on adult services triggered by the pandemic itself.

Perceived impact of formulating, implementing and enacting national mental health policies recommendations in practice: An exploratory qualitative study within child and adolescent mental health services in Scotland.

Objective:To understand the process of formulating, implementing and enacting national recommendations into practice, by exploring the interactions between government policymakers and national and local organisations supporting and delivering policy implementation within a Child and Adolescent Mental Health Service (CAMHS) context in Scotland.Methods:Data collection involved 16 semi-structured individual and four focus group interviews with a purposeful sample of policymakers, national health and social care stakeholders and local outpatient and inpatient CAMHS teams representing three NHS health boards in Scotland. Results:Study participants highlighted the challenges of navigating through evolving and often conflicting policy agendas, seen to not acknowledging the current evidence base or experiential learning from services and prior evaluations. Accounts of transformation fatigue often emerged from increased expectations for staff to adopt new approaches to accommodate constantly changing recommendations. Participants also reported a lack of integration and implementation support from national health and social care organisations, leading to duplication of effort and gaps in provision or waste. Policy recommendations were perceived as sometimes vague, lacking clarity about how to deliver service transformation using a whole-system approach. The collective narratives reflected increased tension between the need for local autonomy to innovate and the limitations created vertically by the relative inflexibility of policy recommendations, and horizontally by the proliferation of national organisations delivering the same transformation aims using different approaches in a resource-constrained environment.Conclusion:The findings contribute to the wider literature by offering an exploration of importance of evaluation and evidence uptake in policy formulation; the roles and remits in supporting the implementation of policy recommendations; and how the dynamics of central control and local autonomy might impact on the local enactment of policy recommendations.

Real-time monitoring of COVID-19 in Scotland.

To manage the public health risk posed by COVID-19 and assess the impact of interventions, policymakers must be able to closely monitor the epidemic's trajectory. Here we present a simple methodology based on basic surveillance metrics for monitoring the spread of COVID-19 and its burden on health services in Scotland. We examine how the dynamics of the epidemic have changed over time and assess the similarities and differences between metrics. We illustrate how our method has been used throughout the epidemic in Scotland, explore potential biases and conclude that our method has proven to be an effective tool for monitoring the epidemic's trajectory.

Navigating different public health roles in alcohol premises licensing: a multi-stakeholder interview study

BackgroundIn England and Scotland, local governments regulate the sale of alcohol through premises licensing. In the past 10 years, some public health practitioner teams have become proactive in engaging with alcohol licensing to encourage actions regarded as likely to improve population health. These public health teams are largely based in the National Health Service in Scotland, and within local authorities in England. This research explored ways in which public health actors believe their activities make a difference to alcohol licensing decisions, policies, and systems, and the acceptability of their involvement from licensing stakeholder perspectives. MethodsAll public health practitioner teams were directly informed about this multicentre study. Scoping calls were conducted with interested teams to explore their level of activity in alcohol licensing in 2012–19 across several pre-defined categories. Recruited local authority areas purposively varied by region and rurality. 53 in-depth telephone interviews (28 with public health actors and 25 with licensing stakeholders) were done in 20 local authority areas in England (n=14) and Scotland (n=6). Interview transcripts were analysed thematically with NVivo 12 using inductive and deductive approaches. FindingsMost public health actors felt that they could make a difference by broadening licensing decision makers' understanding of alcohol-related health harms. For many, a key motivation was to reduce harms through containing alcohol availability at current levels and, ultimately, long-term culture change. Others adapted their approach to fit with the aims of licensing staff, focusing on promoting responsible sale of alcohol, so-called responsible drinking, or both. In both cases, public health actors and licensing stakeholders viewed partnership working as key to effectiveness. Although most licensing staff valued public health involvement, a minority were sceptical about public health involvement focused on containing availability, considering this approach as too narrow in focus. Some public health actors felt unable to secure public health improvements within the constraints of current licensing systems, which have potential to prevent increases in alcohol availability but are unable to reduce alcohol availability. InterpretationPublic health actors take different approaches to engagement with alcohol licensing, including disruptive or collaborative approaches. Collaborative approaches were seen as more acceptable by some licensing stakeholders, but focus mainly on short-term outcomes other than health (eg, crime). The effectiveness of public health involvement, including through these different approaches, merits quantitative evaluation. Sampling did not include lower activity areas wherein experiences might differ. FundingThe ExILEnS study was funded by the National Institute for Health Research (project number 15/129/11). The views expressed in this work are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, or the UK Government's Department of Health and Social Care.

Complex lower limb trauma and reconstructive surgery: understanding health service resource use

Complex lower limb trauma is a challenging problem. Achieving optimal long-term outcomes requires multi-disciplinary input, while patients are in hospital, and after discharge. The aim of this study was to evaluate the long-term health services resource use of patients with such injuries, in the context of a publicly funded health system. This is a population-based retrospective cohort study. Data were obtained from the Information Services Division (ISD) Scotland. We included patients with isolated lower extremity injuries, sustained between 1997 and 2015, with follow-up to 2017. Cases were identified defined by ICD-10 and OPCS-4 procedural codes and divided into two groups, complex and simple injuries and analysed for their subsequent contacts with the health service. There were 42,601 patients with isolated lower limb injuries. 2976 (7.0%) had suffered complex injuries. The in-hospital mortality of these patients was 1.9%. 538 (18.1%) of the patients who sustained complex injuries underwent reconstructive surgery. Just over half attended an orthopaedic outpatient clinic in the first year, and 31.7% attended a plastic surgery clinic. Very few patients attended pain management clinics, or other clinics that might provide pain services. Only a small proportion of patients who undergo reconstructive surgery are followed up by specialist services. The reasons for such low follow-up rates are not obvious. Our findings raise the question of whether the health service in Scotland has sufficient resources to optimise functional outcome in this patient group. Level of evidence: Level III, risk / prognostic study

Community pharmacies to provide women's health services in Scotland

Community pharmacies to provide women's health services in Scotland

Scottish Health Technologies Group: enhancing patient engagement.

The Scottish Health Technologies Group (SHTG) provides evidence support and advice to the National Health Service in Scotland on the use of new and existing health technologies, which, although not medicines, are likely to have significant implications for people's care. The purpose of this paper is to highlight the developments that have taken place in the SHTG's patient involvement processes in the years 2017 to 2019, focusing primarily on specific engagement with patient organizations and considering how the new approaches have been received by stakeholders. Feedback from patient organizations that participated in the SHTG submission process, alongside SHTG committee members' views on patient organizations contributions, was gathered primarily via online questionnaires. The number of times that patient organizations were invited and accepted the opportunity to peer-review SHTG advice statements prior to and after the employment of a Public Involvement Advisor (PIA) was analyzed. Completed questionnaires (n = 4) from three case study examples showed high patient organization satisfaction with their experience of the SHTG process. The feedback from SHTG committee members that was gathered indicated that patient organization participation was generally well received. The number of peer reviews from patient organizations for SHTG advice statements in 2018-2019 doubled to 86 percent of the total advice statements (n = 22), compared with 43 percent (n = 14) in 2016-2017. Significant progress has been made toward improving the SHTG's patient involvement processes. A dedicated PIA post within the SHTG has allowed for a more tailored support to patient organizations and has encouraged their increased participation in SHTG processes.

Cost burden of Clostridioides difficile infection to the health service: A retrospective cohort study in Scotland

Clostridioides difficile infection (CDI) is associated with high healthcare demands and related costs. To evaluate the healthcare and economic burden of CDI in hospitalized patients with community- (HOCA-CDI) or hospital-associated CDI (HOHA-CDI) in the National Health Service in Scotland. A retrospective cohort study was conducted, examining data between August 2010 and July 2013 from four patient-level Scottish datasets, linked to death data. Data examined included prior antimicrobial prescriptions in the community, hospitalizations, length of stay and mortality. Each CDI case was matched to three hospital-based controls on the basis of age, gender, hospital and date of admission. Descriptive economic evaluations were based on bed-day costs for different types of wards. Overall, 3304 CDI cases were included in the study. CDI was associated with additional median lengths of stay of 7.2 days for HOCA-CDI and 12.0 days for HOHA-CDI compared with their respective, matched controls. The 30-day mortality rate was 6.8% for HOCA-CDI and 12.4% for HOHA-CDI. Overall, recurrence within 90 days of the first CDI episode occurred in 373/2740 (13.6%) survivors. The median additional expenditure for each initial CDI case compared with matched controls was £1713. In the 6 months after the index hospitalization, the cost associated with a CDI case was £5126 higher than for controls. Using routinely collected national data, we demonstrated the substantial burden of CDI on healthcare services, including lengthy hospital stays and readmissions, which increased the costs of managing patients with CDI compared with matched controls.

Circumnavigating the world of quality and patient safety: a compendium of highlights and perspectives.

Background In the UK, estimates suggest that approximately 10% of hospital admissions and 1–2% of primary care consultations result in some sort of adverse event. Globally, medication errors cost approximately US$42 billion annually, and 15% of total health spending in Organisation for Economic Cooperation and Development countries is used to deal with adverse events. Method Stemming from the Glasgow 2019 British Medical Journal and Institute for Healthcare Improvement International Forum on Quality and Safety in Healthcare (‘People Make Change’), a review of workforce characteristics, the psychology of change and design thinking in healthcare is presented. The concept of personalised care is also discussed. Conclusion In the last decade, the National Health Service in Scotland has undergone major reform around the integration of health and social care. In tandem with this, there have been a range of national initiatives to support patient safety and quality improvement. Moving forward, there is an increasing realisation of how service design, digital technologies and a national digitised infrastructure can improve services. Implications highlight the role of workforce development and in embedding design thinking in service organisation. This review article therefore presents an anthology of highlights and perspectives in improving healthcare quality and patient safety.

Transition from child to adult health services: A qualitative study of the views and experiences of families of young adults with intellectual disabilities.

To explore the experiences of the families of young adults with intellectual disabilities at the point of transition from child to adult health services. The population of people with intellectual disabilities is changing rapidly, with young people with increasingly complex needs surviving into adulthood and requiring transition from child to adult health services. An interpretative qualitative design. Semi-structured interviews were held with ten family carers of young adults with intellectual disabilities and complex care needs, who were in the process of or had recently completed a transition from child to adult health services in Scotland. Data were analysed using thematic analysis. The COREQ checklist was used. Transition emerged as a highly emotional and challenging period for family carers. Their experiences were captured in five main themes: "a deep sense of loss," "an overwhelming process," "parents making transitions happen," "a shock to the adult healthcare system" and "the unbearable pressure." Nurses were often seen as instrumental to counteracting some of these challenges. There is an urgent need to respond to the challenges experienced by carers at the point of transition and beyond, by ensuring early and coordinated planning, effective information sharing and communication and clear transition processes and guidelines. A person-centred and family-centred approach is required to minimise negative impact on the health and well-being of the young adult with intellectual disabilities and their carers. Registered nurses have a key role in providing information and support, along with coordinating care at the time of transition from child to adult health services for young adults with complex intellectual disabilities. It is vital that their input is person-centred and responds effectively to the expert knowledge of family carers, while at the same time ensuring their needs for information and support are also addressed.

My Diabetes My Way: supporting online diabetes self-management: progress and analysis from 2016

BackgroundMy Diabetes My Way (MDMW) is the National Health Service (NHS) Scotland website for people with diabetes and their carers. It consists of an interactive information website and an electronic personal health record (ePHR) available to the 291,981 people with diabetes in Scotland. We aimed to analyse the demographic characteristics of current registrants and system usage and activity during 2016.MethodsWe analysed system audit trails to monitor user activity and page accesses on the information website, and logins and activity within the ePHR. The ePHR contains data from SCI-Diabetes, NHS Scotland’s flagship diabetes record, sourcing data from primary and secondary care, specialist screening services and laboratory systems. We reviewed patient registration characteristics to collate demographic data for the MWDH cohort, then compared this to aggregate data published in the 2016 Scottish Diabetes Survey. The Scottish Diabetes Survey is an annual population-based report detailing diabetes statistics for the whole diabetes population in NHS Scotland.ResultsThe MDMW information website received an average of 101,382 page accesses per month during 2016 (56.9% increase from 2015; n = 64,607). ePHR registrants were more likely to be younger (p < 0.001) and have an ethnicity of “white” (p < 0.001) than the background diabetes population. At the end of 2016, 11,840 people with diabetes had accessed their personal clinical information (58.6% increase since end 2015; n = 7464). During 2016, an average of 1907 people accessed their records each month (48.3% increase from 2015; n = 1286).ConclusionMy Diabetes My Way is a useful tool aid to diabetes self-management. The service is unique in offering records access to a national population, providing information from all relevant diabetes-related sources, rather than a single silo. MDMW supports the diabetes improvement, self-management, healthcare quality and eHealth strategies of the Scottish Government. The service also has potential to be adapted to work with other clinical systems and conditions.

The effect of dapagliflozin on glycaemic control and other cardiovascular disease risk factors in type 2 diabetes mellitus: a real-world observational study

Aims/hypothesisDapagliflozin, a sodium–glucose cotransporter 2 (SGLT2) inhibitor, is indicated for improving glycaemic control in type 2 diabetes mellitus. Whether its effects on HbA1c and other variables, including safety outcomes, in clinical trials are obtained in real-world practice needs to be established.MethodsWe used data from the comprehensive national diabetes register, the Scottish Care Information-Diabetes (SCI-Diabetes) collaboration database, available from 2004 to mid-2016. Data within this database were linked to mortality data from the General Registrar, available from the Information Services Division (ISD) of the National Health Service in Scotland. We calculated crude within-person differences between pre- and post-drug-initiation values of HbA1c, BMI, body weight, systolic blood pressure (SBP) and eGFR. We used mixed-effects regression models to adjust for within-person time trajectories in these measures. For completeness, we evaluated safety outcomes, cardiovascular disease events, lower-limb amputation and diabetic ketoacidosis, focusing on cumulative exposure effects, using Cox proportional hazard models, though power to detect such effects was limited.ResultsAmong 8566 people exposed to dapagliflozin over a median of 210 days the crude within-person change in HbA1c was −10.41 mmol/mol (−0.95%) after 3 months’ exposure. The crude change after 12 months was −12.99 mmol/mol (−1.19%) but considering the expected rise over time in HbA1c gave a dapagliflozin-exposure-effect estimate of −15.14 mmol/mol (95% CI −15.87, −14.41) (−1.39% [95% CI −1.45, −1.32]) at 12 months that was maintained thereafter. A drop in SBP of −4.32 mmHg (95% CI −4.84, −3.79) on exposure within the first 3 months was also maintained thereafter. Reductions in BMI and body weight stabilised by 6 months at −0.82 kg/m2 (95% CI −0.87, −0.77) and −2.20 kg (95% CI −2.34, −2.06) and were maintained thereafter. eGFR declined initially by −1.81 ml min−1 [1.73 m]−2 (95% CI −2.10, −1.52) at 3 months but varied thereafter. There were no significant effects of cumulative drug exposure on safety outcomes.Conclusions/interpretationDapagliflozin exposure was associated with reductions in HbA1c, SBP, body weight and BMI that were at least as large as in clinical trials. Dapagliflozin also prevented the expected rise in HbA1c and SBP over the period of study.

The prevalence of multimorbidity measured by linked healthcare data and its association with mortality in a large longitudinal cohort

IntroductionMultimorbidity, the co-existence of two or more health conditions, is a growing challenge. It may be measured using health service administrative data via the emerging consensus measure by Barnett. However, the original Barnett was developed using Scottish-specific primary care coding, which restricts its application in other health systems.&#x0D; Objectives and ApproachThe aim was to create and test International Classification of Disease (ICD) coding algorithms for all 40 Barnett conditions.&#x0D; We evaluated this new measure by:&#x0D; &#x0D; Assessing the prevalence of secondary care multimorbidity in 2001&#x0D; Assessing the association between multimorbidity and mortality rate over 15 years&#x0D; &#x0D; Participants of the Aberdeen Children of the 1950s cohort (ACONF) were linked to their secondary-care healthcare records and mortality records. Multimorbidity was defined as the presence of two or more of the 40 conditions. The association between multimorbidity and mortality was assessed using Cox proportional hazards regression with adjustment for key covariates.&#x0D; ResultsWe combined results of a review of the coding literature with codes used commonly by the National Health Service in Scotland, to apply ICD codes to each Barnett condition.&#x0D; The ACONF were aged 45 to 51 years in 2001. Of 8,094 members who were alive and linked to Scottish administrative data, 246 (3%) had multimorbidity. There were 629 deaths by 2016 with 83 occurring in the multimorbidity group.&#x0D; Relative to those without multimorbidity, those with multimorbidity in 2001 had a mortality hazard ratio (HR) of 5.9 (95% CI 4.6-7.4) over 15 years follow-up. This was unchanged when adjusted for age, gender, social class at birth, cognition at age 7, secondary school type and educational attainment (HR 6.2, 95% CI 4.4-8.5).&#x0D; Conclusion/ImplicationsWe have created a new version of the influential Barnett measure using ICD codes, which allows for its wider application across health systems. We found that this measure of multimorbidity was associated with greatly increased mortality, indicating it could help predict poor outcome using administrative records.

Emergency general surgery in the United Kingdom: A lot of general, not many emergencies, and not much surgery.

The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development. This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included. There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate. Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems. Epidemiologic study, level III.

On the Road to Recovery psychological therapy versus treatment as usual for forensic mental health patients: study protocol for a randomized controlled feasibility trial

BackgroundOn the Road to Recovery (OTRTR) is a brief low intensity group psychological therapy that aims to improve patients’ insight into their mental disorder and develop adaptive coping skills to help manage distress. OTRTR is currently delivered in forensic mental health services in Scotland. However, to date, this therapy has not been evaluated as to its effectiveness or safety for forensic patients.MethodsThis is a parallel-group feasibility randomized controlled trial with single-blind assessments comparing OTRTR therapy to treatment as usual (TAU) for forensic mental health patients. Fifty participants will be recruited from high, medium, and low secure forensic mental health services in Scotland. Participants will receive OTRTR for approximately 12 weeks or continue treatment as usual for 12 weeks. The trial’s primary aims relate to testing the acceptability and feasibility of key trial procedures that would be necessary for a definitive RCT of OTRTR. The secondary aims include estimating therapeutic effect sizes on clinical outcomes including insight and coping skills. The study design also features an adverse event monitoring plan to estimate the safety of OTRTR for participants, as well as use of intensive longitudinal methods to identify “key ingredients” to the OTRTR therapy protocol.DiscussionThis study will inform the design and sample size for a future full-scale randomized controlled trial (RCT), which will be conducted to determine the effectiveness of the On the Road to Recovery intervention in improving forensic mental health patients’ clinical insight and coping skills.Trial registrationISRCTN Registry, ISRCTN75126867 registered 27 July 2017

Service provision in Scotland for people with an intellectual disability who have, or are at risk of developing, dementia.

This research aimed to identify current national provision by health services in Scotland in relation to proactive screening and reactive assessment for people with an intellectual disability in Scotland who have, or are at risk of developing, dementia. Staff from 12 intellectual disability services, representing the 11 health board areas in Scotland, completed an online questionnaire which asked about proactive screening and reactive assessment for people with intellectual disability who had, or were at risk of developing, dementia as well as suggested areas for improvement. All of the areas provided services for people with intellectual disability who have, or are at risk of developing, dementia, but differed as to whether this was reactive, proactive or both. Nine services offered intervention following diagnosis. The most common elements used across both proactive screening and reactive assessment were conducting a health check, using a general dementia questionnaire designed for people with an intellectual disability and direct assessment with the person. Clinical psychology and community learning disability nurses were the professions most likely to be involved routinely in both proactive screening and reactive assessments. The psychometric properties of the most commonly used assessments of cognitive and behavioural functioning were mixed. The areas of improvement suggested by practitioners mainly related to ways of improving existing pathways. This research represents the first step in providing an overview of service provision in Scotland. There was some inconsistency in relation to the general and specific components which were involved in proactive screening and reactive assessment. Implications for service provision are discussed.