National Health Service Boards Research Articles

Reduction in hip fracture admissions over a 10 year period in a Scottish health board with a well established falls and fracture liaison service

BackgroundGuidelines on reducing falls/fractures 1–4 have been published with the aim of reducing the burden both to health services/individuals. Data on hip fractures are collected centrally and through National Hip...

Management of medication use in Scotland

Scotland is one of the four countries that form the United Kingdom and is home to approximately 5.1 million people.1 It has a system of devolved government, whereby global issues such as foreign affairs and national security come under the United Kingdom parliament and issues such as health, social care, education, and the judiciary are devolved to the Scottish government.2 The National Health Service (NHS) is the publicly funded health care system within the United Kingdom. In common with many health systems, NHS faces increasing cost pressures from an aging population and the need to make available innovative treatments, particularly new medications. This article describes programs of work within NHS Scotland that manage the introduction of new medications and monitor and encourage evidence-based and cost-efficient medication use. NHS Scotland has an annual budget of approximately 12.6 billion U.S. dollars (USD, based on current conversion)3 and employs more than 165,000 staff providing a full range of clinical and administrative functions.4 Although the government develops health policy and strategic direction, responsibility for health care delivery lies with 14 regional NHS boards that follow geographic boundaries within the country. The largest, NHS Greater Glasgow and Clyde, covers 25% of the Scottish population in a dense urban area, whereas NHS Shetland covers less than 1% of the population spread over several remote islands. Smaller boards commission specialist services from larger boards. In addition, there are eight special boards providing national specialized services to NHS boards (Table 1).

Scotland's national approach to improving mental health services: integrated care pathways as tools for redesign and continuous quality improvement

National Health Service (NHS) Scotland is taking a national approach to improving the quality and safety of mental health services. This programme relies on implementing integrated care pathways (ICPs) for people with mental health conditions across the whole journey of care. This long-term improvement programme has started with the publication of national standards by NHS Quality Improvement Scotland (NHS QIS), setting out the framework of what needs to be developed in each local area. The emphasis of development and implementation of the ICPs lies with local NHS Boards to ensure they are developed with local ownership and to meet the needs of the local population. However, to ensure accreditation by NHS QIS, the local ICPs must incorporate the national standards and evidence improvement to the quality of care provided. A concerted effort has been made to ensure good involvement of service users, social work colleagues and NHS staff in order to get buy-in from all stakeholders. NHS QIS is also supporting local boards and their partner agencies in their implementation of ICPs through a team of National ICP Coordinators and has developed a web-based toolkit to act as an electronic resource: www.icptoolkit.org . This supportive and facilitative approach helped to ensure that person-centred care was driving service redesign. This is the beginning of a long-term improvement programme that has been carefully staged and is being facilitated in order to give it the best chance for success. In Scotland, ICPs for mental health are being used as a tool for service redesign and continuous quality improvement and a way to focus on meeting service user needs.

Exploring assessment for learning during dietetic practice placements

Practice placement, which contributes to the development of professional skills and competencies, is an important component of dietetic pre-registration education in the UK. The assessment of practice placement impacts on students' experience and progression; however, currently, limited evidence-based information about assessment methods and practice in dietetic placements exists. The present study aimed to investigate the assessment methods and practices utilised when providing pre-registration dietetic practice placements. Using an online questionnaire survey of dietitians within Scottish National Health Service (NHS) dietetic departments, and a follow-on telephone interview with Lead Trainers, the present study explored the assessment methods utilised by dietitians as well as areas of variability within NHS Boards. Data were analysed using descriptive statistics and relationships were assessed using the chi-square test, Kruskall-Wallis test and Spearmans' correlation. One hundred and eleven fully-completed questionnaires were analysed and fourteen departments participated in the follow-on telephone interview. Over 80% respondents had greater than 2 years of involvement in student training. To assess student performance, departments used between 5-16 and 6-16 assessment tools for placements B and C, respectively. Significant correlations between staff training and knowledge of how to apply assessment tools support a need for robust staff training in assessment matters. The majority (87%) of respondents positively favour standardisation of assessment via the development of national assessment tools. The findings obtained in the present study confirm that there is a wide variation in assessment practices by dietitians. The development of standardised assessments and tools within dietetic practice placements, in terms of parity in numbers and methods of assessment, would ensure equity and fairness for students.

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians. Aim To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations. Design Prospective, multicentred national study, data collection and improvement phase. Setting All NHS boards in Scotland ( n = 14) plus two private provider sites. Participants One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain. Method A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008–2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting. Results Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle. Conclusion It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.

Homelessness as an independent risk factor for mortality: results from a retrospective cohort study

Homelessness is associated with increased risks of mortality but it has not previously been possible to distinguish whether this is typical of other socio-economically deprived populations, the result of a higher prevalence of morbidity or an independent risk of homelessness itself. The aim of this study was to describe mortality among a cohort of homeless adults and adjust for the effects of morbidity and socio-economic deprivation. Retrospective 5-year study of two fixed cohorts, homeless adults and an age- and sex-matched random sample of the local non-homeless population in Greater Glasgow National Health Service Board area for comparison. Over 5 years of observation, 1.7% (209/12 451) of the general population and 7.2% (457/6323) of the homeless cohort died. The hazard ratio of all-cause mortality in homeless compared with non-homeless cohorts was 4.4 (95% CI: 3.8-5.2). After adjustment for age, sex and previous hospitalization, homelessness was associated with an all-cause mortality hazard ratio of 1.6 (95% CI: 1.3-1.9). Homelessness had differential effects on cause-specific mortality. Among patients who had been hospitalized for drug-related conditions, the homeless cohort experienced a 7-fold increase in risk of death from drugs compared with the general population. Homelessness is an independent risk factor for deaths from specific causes. Preventive programmes might be most effectively targeted at the homeless with these conditions.

Implementing a national quality assurance system for diabetes care: the Scottish Diabetes Survey 2001–2006

To create a standardized systematic quality assurance system for diabetes care throughout Scotland. Each of 15 National Health Service (NHS) boards have submitted core diabetes data for a nationally agreed data specification on an annual basis since 2001. These data are collated to produce an annual national report. We describe the iterative progress of the work in obtaining and analysing this information. The setting was Scotland, with a population of 5 million. In Scotland in 2006, 196,801 people (3.9% of the population) were reported as having diabetes compared with 105,777 in 2001. In 2006 the prevalence of reported diabetes varied from 3.5 to 4.4% in different NHS board areas, reflecting variation in completeness of local registers as well as different demographic patterns. The completeness of recording of many clinical parameters has also increased. (2002 data n = 103,755: diagnosis date 77%, HbA(1c), blood pressure and cholesterol within 15 months 71, 67 and 60%, respectively, increasing to 98, 87, 89 and 85% by 2006, n = 196,801.) A national information management and technology solution (Scottish Collaborative Information-Diabetes Care), involving automatic daily collection of data from routinely used systems both in primary and secondary care, is now used to co-ordinate the collection of data in all NHS board areas. We have used routine data to estimate the prevalence of reported diabetes in Scotland, UK. This iterative approach to quality improvement has taken 6 years to achieve a baseline measure of care. There is potential to analyse these data further for a better understanding of the epidemiology of diabetes in Scotland. The national diabetes information technology system will contribute to this process.

Policy and practice in the management of postnatal depression in Scotland

To investigate current policy and practice in postnatal depression in Scotland and to consider how effectively guidelines were addressed. A questionnaire survey of all National Health Service Boards in Scotland between September 2003 and February 2004 to determine what written policies for postnatal depression were in place as at September 2003. This was followed by a questionnaire survey of a representative sample of general practices in Scotland to determine the routine procedures in use for managing postnatal depression in general practice primary care teams. NHS Boards and general practices in Scotland, UK. Forty-seven per cent of policies and 68% of General Practices had implemented the majority of the Scottish Intercollegiate Guidelines Network 60 evidence based recommendations. Practices were more likely than NHS Boards to have addressed a higher percentage of the recommendations (p < 0.05). Practices were more likely to implement antenatal screening for a history of puerperal psychosis if they were within NHS Boards that recommend this as routine practice. Practices within NHS Boards that had in-patient facilities for mother and baby admissions were more likely to identify these services as a treatment option than in the areas where the NHS Boards indicated the facilities were unavailable. Board guidance did not relate significantly to the likelihood of practices following the other evidence-based recommendations. Minimum standards represented by the SIGN 60 evidence-based recommendations were mostly followed in both policy and practice. If Board policy followed guidelines, the guidelines were more likely to be implemented at primary care level.

The NHS is dead…long live the UK's health system

The Chief Medical Officer (CMO) of England's most recent update to doctors was entitled A new vision for the NHS. 1 CMO update. London: Department of Health, Winter 2007, issue 46. Google Scholar A new vision for Britain's health service is the last thing those working on the frontlines of patient care will want today. The history of the National Health Service (NHS) is nothing less than a cemetery of new visions, all born and slaughtered on the altar of party political expediency. But this present sense of transition, partly triggered by reflection over the 60th anniversary of the NHS, has propelled two ideas to the foreground of policy debate: an NHS board and an NHS constitution. Both proposals have been reviewed by the King's Fund. 2 Dixon A Alvarez-Rosete A Governing the NHS: alternatives to an independent board. http://www.kingsfund.org.uk/publications/kings_fund_publications/governing_the.htmlDate: 2008 Google Scholar

Chlamydia trachomatis testing among 13–25-year-olds in non-genitourinary medicine settings

ObjectivesIn this paper we examine Chlamydia trachomatis testing in settings other than genitourinary medicine (GUM) clinics, focusing on the factors associated with chlamydial infection and with postal testing.MethodsAnalysis of tests...

The impact of educational interventions on primary health care workers' knowledge of occupational exposure to blood or body fluids

To assess the impact of educational interventions on primary health care workers' knowledge of management of occupational exposure to blood or body fluids. Cluster-randomized trial of educational interventions in two National Health Service board areas in Scotland. Medical and dental practices were randomized to four groups; Group A, a control group of practices where staff received no intervention, Group B practices where staff received a flow chart regarding the management of blood and body fluid exposures, Group C received an e-mail alert containing the flow chart and Group D practices received an oral presentation of information in the flow chart. Staff knowledge was assessed on one occasion, following the educational intervention, using an anonymous postal questionnaire. Two hundred and fifteen medical and dental practices were approached and 114 practices participated (response rate 53%). A total of 1120 individual questionnaires were returned. Face to face training was the most effective intervention with four of five outcome measures showing better than expected knowledge. Seventy-seven percent of staff identified themselves as at risk of exposure to blood and body fluids. Twenty-one percent of staff believed they were not at risk of exposure to blood-borne viruses although potentially exposed and 16% of exposed staff had not been immunized against hepatitis B. Of the 856 'at risk' staff, 48% had not received training regarding blood-borne viruses. We found greater knowledge regarding management of exposures to blood and body fluids following face to face training than other educational interventions. There is a need for education of at risk primary health care workers.

Community nurses’ health promotion work with older people

This paper reports a study describing community nurses' health promotion work with older people aged 50 years and above, and exploring particular health promotion initiatives for older people that would have transferability potential. With the ageing of populations worldwide, community nurses in primary healthcare settings have a key contribution to make to the health improvement agenda for older people, yet little is known of the extent of this aspect of their work. Questionnaires were sent to 1062 community nurses in six Scottish National Health Service Boards - public health nurses/health visitors, district nurses, general practice nurses, community psychiatric and learning disability nurses and combined duty nurses; 373 (35%) responded, 30 of whom were interviewed by telephone. The data were collected in 2003-2004. Findings confirmed the wide scope of health promotion, much of which may be embedded and unrecognized. Creative group work showed promise in achieving heath gain for older people, and a range of partnership approaches - interdisciplinary, multidisciplinary and interagency - was evident. Theoretical input and project opportunities within educational programmes had been a catalyst for health promotion initiatives in practice. However, evidence of audit, evaluation, and active involvement of older people in planning health promotion was limited. Funding of health promotion initiatives was vital to sustainability. There is merit in making the health promotion work of community nurses more visible through audit and systematic evaluation; promoting the active involvement of older people; strengthening partnership working; and further raising the profile of health in later life within undergraduate and postgraduate community nursing programmes.

The role of digital photography and electronic referral in the triage of patients with suspected skin cancer

Conflicts of interest: none declared. Sir, Most patients with suspected skin cancer, fast‐tracked to dermatology departments, eventually turn out to have benign lesions.1, 2 To improve the skin cancer capture rate, we redesigned our service to use digital images taken by a medical photographer, in conjunction with an electronic referral letter, in order to triage patients. Patients suspected of having skin cancer by their general practitioner (GP) were referred using a structured electronic letter. The referral was sent to Monklands Hospital via the Scottish Care Initiative referral pathway. This is a secure Scotland‐wide web‐based electronic referral system (Electronic Clinical Communications Implementation, ECCI) open to all GPs linked to the National Health Service boards' intranet systems. The referral letter was received and vetted by the dermatologist (C.D.E., G.G) on‐line with the help of digital images. The GP arranged an appointment for photography at the Department of Medical Illustration in Monklands Hospital by telephone, at a time to suit the patient. Images showing the location and a close‐up shot of the lesion were taken. In addition, a digital dermoscopy image was included for pigmented lesions.

Survey of zoonoses recorded in Scotland between 1993 and 2002

All the human and animal laboratory reports of zoonoses sent to Health Protection Scotland between 1993 and 2002 were identified. There were 24,946 reports from veterinary laboratories, and 94,718 (20...

Women's and doctors' accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients' and doctors' decisions

Little is known about how general practitioners (GPs) manage depression within everyday clinical practice, particularly in relation to the issue of 'problem definition'. In addition, there has been relatively little research on the patients' perspective of depression and its management in primary care. Qualitative interviews explored women's and GPs' experiences of recognizing depression and their experiences of the management of depression. Thirty-seven women and 20 GPs were recruited from practices in four National Health Service Board areas of Scotland. Each participant was interviewed at the start of the study, and 30 women and 19 GPs were revisited approximately 9-12 months later so that the process of care could be reviewed. The findings demonstrate the social and moral reasoning that lies behind women's decisions to seek help and to subsequently accept their GPs' explanation and advice, and that the acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes. The implication is that, for the majority of women, a chronic-disease model for the management for depression in primary care would be likely to increase rather than reduce the moral dilemma. In addition, the management of depression is not solely based on clinical decisions, so the applicability of a chronic-disease model to primary care requires further consideration.

Patient notification exercise following a dentist's admission of the periodic use of unsterilized equipment

During 2001, Greater Glasgow National Health Service (NHS) Board undertook a patient notification exercise in a Glasgow dental practice following the admission, by the dentist, of the use of unsterilized dental equipment on patients. Four thousand and eighty-nine exposed patients were identified; of these, 1696 contacted the NHS helpline and 1005 were counselled and screened for hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus. One patient showed evidence of previous HBV infection and 13 had antibodies to HCV. Molecular investigation of the HCV isolates indicated no significant associations. The investigation found no evidence of patient-to-patient transmission of HCV among patients attending the practice of a dentist who admitted periodically using unsterilized equipment.