NHS England Research Articles

BN SO40 - Increasing incidence of medicolegal claims in the NHS for bile duct injury in spite of 30 years of experience and training

Abstract Background Bile duct injury (BDI) in cholecystectomy is the most commonly recognised complication occurring in 0.5-1.4% of cases and is associated with significant morbidity and mortality. Despite the increasing number of cholecystectomies and falling number of bile duct injuries due to both surgical experience and recognition of the issue, there appears to be increasing number of payouts by NHS England. We investigated the trend in claims, their underlying cause, stage in procedure where they occurred in the past 20 years to identify areas where improvements could be made, for better patient outcomes and to reduce the medicolegal burden to the NHS. Method Data was obtained following a freedom of information request from NHS Resolution UK for cases of bile duct injury. Data analysis was performed on years 2001-2021 to examine the number of claims, their underlying cause and stage in procedure where they occurred as well as average damages awarded and cost to the NHS. Results In 2001 there were 11 claims made (costing £644,000) which rose to 28 in 2021 (costing £7,424,000). 400 claims were successful out if 508. The commonest being intraoperative error (49%) followed by operator error (11%) and delay in treatment (8%). The most expensive type of claim arose from intraoperative complications costing a total of £42,836,000 over the period. Pre-operative delays and inadequate patient consent cost the NHS £7,236,000, whilst delays in recognition of BDI cost £8,000,000 between 2001 and 2021. Conclusion Although settled cases of BDI have risen in the last 20 years despite improvement in training and techniques of cholecystectomy, they remain significantly below the anticipated numbers. Prompt recognition of anatomy and intraoperative complication as well as effective post-op management are essential for better patient outcomes and maintaining this low claim rate. Surgeon training within the NHS is crucial but appropriate case selection is the key to patient safety. Laparoscopic cholecystectomy can be a complex operation, worsened by delays in treatment , requires an experienced UGI surgeon or supervision by a consultant and never considered simple or routine operation.

MS O02 - OGC An audit of waiting times of the oesophagogastric cancer diagnostic pathway at a high-volume, tertiary centre

Abstract Background The oesophagogastric cancer (OGC) staging pathway is extensive, contributing to prolonged waiting times from referral to treatment. NHS England guidance details the ideal timeframe from referral to finalisation of the patient’s treatment plan and stipulates a time of 21 days from OGD to communication of the treatment plan to the patient. This audit aims to compare pathway times at a tertiary cancer centre, which accepts referrals from seven different hospitals, to the current NHS target and further stratify pathway times according to patient characteristics and referring hospitals. Method Data was collected using a prospectively collected database of OGC patients who underwent staging investigations at the tertiary centre between October 2022 and October 2023. The primary outcome was OGD to communication of the treatment plan. Secondary outcomes included time from OGD to first staging investigation and the proportion of patients that had a next-day computed tomography (CT) scan. Outcomes were stratified to investigate inter-hospital variation and the effect of curative status and tumour location. Data was expressed as median and interquartile range (IQR) for continuous data or n (%) if categorical. Results 263 patients were included in this audit with a median age of 69.0 (IQR 61.5-77.0). 13.8% of patients satisfied the target time of 21 days from OGD to communication of treatment plan. Curative patients had a longer median pathway time than palliative patients (49.0 vs 35.0 days), whereas oesophageal and gastric cancer patients had similar pathway times (44.0 vs 44.5 days). Patients diagnosed at the tertiary centre had a faster time from OGD to first staging investigation than patients diagnosed at non-specialist centres. Only 13.3% of patients had a next-day CT scan following their OGD (median time 5.0 days). Conclusion The OGC staging pathway is considerably slower than the target. Faster pathway times in palliative patients can be attributed to many of these patients not requiring further staging post-CT. Potentially, targets should be re-evaluated to distinguish between palliative and curative patients. The faster staging process at the central hospital may be explained by more regular clinics run by specialist clinicians and the prompt requesting of staging investigations without awaiting MDT discussions. Alongside increasing the proportion of next-day CT scans, these factors must be addressed to streamline the entire pathway.

EDI&S SO05 Barriers to delivering a net zero NHS: An evaluation of Sustainability in Surgery across the Midlands

Abstract Background The healthcare sector is under increasing scrutiny for contributing approximately 4.6% of the UK’s total carbon footprint and 25% of the public sector’s carbon footprint. With support from the UK Health Alliance on Climate Change, the NHS aims to reach a net zero carbon target by 2045 through its Greener NHS campaign. This study aimed to identify key barriers to implementing sustainable practices in the surgical environment. It involved reviewing Green Plans published by Integrated Care Systems (ICSs) in the Midlands, conducting a thematic analysis of relevant literature, and surveying key stakeholders within NHS Trusts in the Midlands. Method Between June and September 2023, Green Plans from 11 ICSs across the Midlands were evaluated by two reviewers for the inclusion of the "key areas of focus" outlined by the NHS Green Plan Guidance. Additionally, three computerised searches were conducted using Ovid MEDLINE and Embase to retrieve abstracts published before May 2023 on reusable surgical gowns, re-sterilisation of surgical energy devices, and operating theatre waste management. Three reviewers screened the abstracts to identify barriers to implementing change. Based on these findings, a framework was developed for the “Supporting a Greener NHS Survey” and disseminated to key stakeholders in the Midlands. Results A heat map was created to assess compliance of each Green Plan with NHS England guidance (Figure 1). The literature search yielded 82 abstracts and key barriers to sustainability were identified as infection control, cost implications, instrument damage, and waste management practices. The survey received 89 responses; 45% did not use reusable drapes at their Trust, 35% did not use reusable gowns, 46% did not use reusable laparoscopic ports, and 59% didn’t know whether their energy devices were recyclable. Key barriers to implementing sustainable change included surgeon preference, financial constraints, and infection control concerns. Conclusion The literature analysis and survey of stakeholders in the Midlands identified several barriers to implementing sustainable changes. With national, regional and local organisational impetus coupled with clinical leadership commitment to sustainability, these barriers can be overcome with multi-disciplinary involvement. By investing in comprehensive training programmes and implementing rigorous quality control measures with input from infection prevention and control teams, clinical leaders and clinicians are best placed to help overcome these barriers and promote sustainability in the surgical environment.

EDI&S SO08 A novel approach to environmentally sustainable surgical theatre by rationalising surgical instrument set – a qualitative analysis

Abstract Background The surgical theatres are a major source of hospital waste generation. The NHS has set a net zero supply chain target by 2045. This aim is supported by the RCS intercollegiate green theatre checklist to reduce the environmental impact of operating theatres. One key area identified in this process, that will support the net-zero target is surgical instrument tray rationalisation. Laparoscopic cholecystectomy was identified as one of the most common surgical procedures performed in England. The purpose of this study was to demonstrate the impact of rationalising the number of surgical instruments, enabling surgeons to drive towards net zero surgery. Method Our Trust participated in this study, in collaboration with NHS England sustainable procurement team and the innovation agency. Total 58 cholecystectomies performed across two sites, Pinderfields and Dewsbury were included in this prospective audit undertaken from January – March 2023. The surgical tray checklists were used to record the actual instrument usage and noted the redundant and supplementary instruments. This data presented to a surgical advisory group, who agreed on routine instruments and proposed removal of redundant. A green pilot tray was approved and used for cholecystectomy. Qualitative questionnaire feedback was collected from surgeons and operation theatre staff from both sites. Results The instrument use matrix revealed almost 50% instruments from the previously used major tray were never used in any of the 58 cholecystectomy surgeries performed. Subsequently, based on the use matrix data, we switched from using major tray containing 84 instruments, to a reduced size tray containing 46 instruments including re-usable metal ports. Survey results revealed tray rationalisation led to easier and faster surgery preparation, improved efficiency and a reduction in waste, thereby reducing the cost to the Trust. It was also noted that having a smaller tray means less time to count instruments during the surgical pause. Conclusion The results of tray rationalisation are very positive and have demonstrated cost savings, carbon reduction and time saved preparing for surgery and the post-operative instrument count. This pilot study has shown that by making the surgical set smaller, savings have been achieved from a reduction of slots required per machine cycle for decontamination. Tray rationalisation goes some way towards the net goal of zero carbon surgery and delivering a sustainable future.

Long-Term outcomes after stress echocardiography in real world practice: five-year follow-up of the UK Evarest study.

Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real world practice across a healthcare system has not been previously reported. 5503 patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios. Median follow-up was 829 days (IQR 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction (HR 2.71, 95% CI 1.73-4.24, P<0.001), and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P<0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least five years in patients with no prior history of coronary artery disease, and four years for those with disease. In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorises risk of future events over the next five years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Creating an inclusive workforce in 2024: Are pharmacy teams across England committed to embedding equality, diversity, and inclusion?

Abstract Introduction The Pharmacy Workforce Race Equality Standard (PWRES) published in 2023 provided evidence of the varied experiences that registered pharmacy professionals in NHS trusts face, particularly in relation to gender and ethnicity.1 Following this, the Inclusive Pharmacy Practice delivery group at NHS England set out to raise awareness of the data and to support regions in developing action plans to drive improvements in equality, diversity and inclusion (EDI) within pharmacy teams. Aim The aim of this study was to identify current initiatives within NHS providers that promote EDI within the pharmacy workforce with a view to enabling the sharing of good practice, and identifying implementation barriers. Methods A questionnaire was created by the Chief Pharmaceutical Officer’s Clinical Fellows and distributed by the 6 regional chief pharmacists within NHS England to their networks. The questionnaire was also promoted in regional pharmacy leadership meetings. Responses were collected between 1st February and 31st May 2024. Data was collected on an Excel spreadsheet. London was excluded from data collection as a similar questionnaire was distributed in 2023. No ethical approval was needed for non-sensitive anonymised data. Results There were 77 responses: 75% (n = 58) from hospital trusts, 13% (n = 10) from integrated care boards and the remaining 9 responses included the Local Pharmaceutical Committee, Hospice and Mental Health Trust. 86% of respondents (n = 66) indicated that their organisation has EDI initiatives in place. These have been summarised into six key themes: 1) EDI network/steering group (n = 44), 2) action plan (n = 14), 3) EDI training/accreditation (n =14), 4) reverse/reciprocal mentoring (n = 11), 5) awareness days (n = 10) and 6) inclusive recruitment practices (n = 10). In contrast, only half of respondents indicated that their team had EDI initiatives. The impact of any initiatives was measured by feedback from staff (e.g. Internal staff survey, NHS staff survey, focus groups, open staff forums) and regular staff demographic data collection. 55% of respondents (n = 36) indicated that recruitment panel members received compulsory EDI training for interviews and 54% of respondents (n = 35) received mandatory recruitment training. Barriers and challenges identified with implementing EDI initiatives included organisational change, workforce capacity, competing priorities and staff apathy. Discussion The survey results highlight a strong commitment to EDI initiatives at an organisational level, with most organisations having established EDI frameworks. However, the lower prevalence of EDI initiatives within individual pharmacy teams suggests a gap in implementation. This discrepancy indicates a need for better dissemination and integration of EDI practices within pharmacy team settings. There is evidence of varied practice in terms of EDI training requirements of interview panellists, and these variations are opportunities where improvements can be made in terms of IPP. The survey was only sent to the managed NHS sector and is not reflective of primary care or community pharmacy. One of the next steps is for regions to use the results of the questionnaire in combination with the PWRES data to develop and implement local action plans to address these issues. Reference 1. NHS England. Pharmacy Workforce Race Equality Standard Report 2023. [Accessed 4th June 2024]. Available from https://www.england.nhs.uk/long-read/pharmacy-workforce-race-equality-standard-report/

Exploring the career aspirations of pre-registration trainee and qualified pharmacy technicians in NHS Birmingham and Solihull using a self-administered questionnaire

Abstract Introduction The NHS Long-Term Workforce Plan (LTWP) recommends expanding the number of pharmacy technicians to support transformation across the pharmacy workforce.1 Birmingham and Solihull Pharmacy Faculty (BSPF) undertook workforce planning, identifying challenges around recruitment and retention. Aim To identify the career aspirations of pre-registration trainee pharmacy technicians (PTPTs) and pharmacy technicians (PTs) to improve recruitment and retention and inform the BSol pharmacy workforce strategy. Method A self-administered online questionnaire (Microsoft Forms) was developed and piloted before emailing to PTPTs and PTs via the BSPF members to all sectors during November to December 2023. Themes included career aspirations (and support required to achieve these), views on career progression and pathways (and skill utilisation), training received, opinions on cross-sector working, retention and concerns post qualification. An excel spreadsheet of downloaded responses were analysed using descriptive statistics. Ethical approval was not required. Results PTPTs: Responses received were 29 (45%) out of 64 ICS PTPTs from all sectors. The majority, 20 (69%) were from secondary care, two (7%) worked cross-sector. Twenty (69%) were women, with seventeen (27%) aged 25 years and above on entering training. Post qualification, 21 (72%) preferred secondary care; role expectations included medication histories, accuracy checking and patient facing work. Post qualification concerns were autonomy, responsibility, utilising skills and changing sector. PTs: Responses received were 62 (13%) out of 477 ICS PTs from all sectors. The majority, 21 (34%) were from secondary care, six (10%) worked cross-sector. Fifty (81%) were women, length of experience varied with 16 (26%) working for 25 years or more. Common themes PTs identified limited career progression (clinical and leadership), feeling undervalued, work-related stress and salary as factors for leaving the profession. PTPTs and PTs identified location, continuity, familiarity, and progression as reasons for retention. Seventeen (27%) PTs said their skills were underutilised, 25 (40%) stated lack of opportunities affected progression. Only 17 (27%) said their organisation had a career pathway. Twenty (69%) PTPTs expected post-qualification training, but 17 (27%) PTs had received no training in the last three years (or gave no reply). Educational, clinical and leadership roles were common career aspirations for both PTPTs and PTs, facilitators being training opportunities, encouragement from seniors, cross-sector experience and creation of career pathways. Nineteen (66%) PTPTs and 46 (74%) PTs desired cross-sector working. All PTPTs were unfamiliar with other pharmacy sectors, 12 (41%) wanted shadowing opportunities. Discussion / Conclusion The study informs the BSol pharmacy workforce strategy to include: cross/multi-sector working, increase novel ‘top-of-license’ roles and develop career pathways for PTs, to support the NHS LTWP. PTPTs results suggest systems should recruit from an audience wider than schools and colleges, to explore this, the BSPF have funded a BSol PT fellowship. The BSPF are providing shadowing opportunities and the promotion of different pharmacy sectors in colleges. This study provides an insight into career aspirations to improve recruitment and retention of BSol pharmacy technicians. Study limitations include; participants are from BSol and/or the Midlands only, self-selected and small numbers (few from community pharmacy), with PTPTs at colleges only, thus results are not generalisable and risk bias. Reference 1. NHS England (2019). The NHS Long Term Plan. Available at: www.longtermplan.nhs.uk/publications/nhs-long-term-plan (accessed 31st May 2024). NHS Improvement (2019).

Barriers and facilitators to implementation of a national antimicrobial stewardship toolkit for inpatient settings

Abstract Introduction Antimicrobial stewardship (AMS) is vital for combating antimicrobial resistance (AMR). The updated 2023 "Start Smart Then Focus" (SSTF) national antimicrobial stewardship (AMS) toolkit1, designed for inpatient settings, supports optimising prescribing of antimicrobials. Aim This project was designed to identify the barriers and facilitators to implementing the national toolkit to improve patient outcomes and reduce AMR. Method An online training workshop was conducted for healthcare professionals across England, focusing on the SSTF toolkit. Before the workshop, participants completed a survey that included consent and gathered information on their roles, familiarity with AMS principles, current practices, and perceived barriers and facilitators to AMS implementation. This information in this survey was used to form basis for the workshop and it was helpful in developing content appropriate for the target audience, which will be delivered during the session. The workshop included discussions on knowledge mobilisation, behavioural science using the COM-B model, and SSTF implementation case studies. Participants engaged in breakout sessions to identify implementation challenges at their organisations. Post-workshop surveys collected feedback on learning outcomes. Collaboration with NHS England AMS leads and UKHSA behavioural scientists was integral. The NHS Health Research Authority tool confirmed the project did not require ethical approval as the surveys were service evaluation. Data were analysed using descriptive statistics for quantitative responses and thematic analysis for qualitative feedback, tailoring workshop content to address specific needs. Results The workshop attracted 57 out of 71 (80%) registered healthcare professionals, including pharmacists (n=45), doctors(n=3), and nurses(n=4). Post-workshop surveys received a 28%(n=16) response rate. Feedback was positive, with 14 out of 16 (88%) of participants expressing high satisfaction. Highlights included SSTF development, e-prescribing implementation, and sessions on barriers and facilitators.Key barriers identified were lack of time, competing priorities, data complexity, insufficient organisational support, and limited resources3. Facilitators included engaging microbiology consultants and the ePMA team, raising awareness through AMS ward rounds, and embedding the SSTF toolkit into guidelines and education. Participants suggested further support from UKHSA and NHSE, including more teaching sessions, workshops, educational materials, and e-learning resources. Practical tools like posters, lanyard cards, infographics, and virtual sessions were recommended to reinforce implementation. The survey responses were analysed using descriptive statistics for quantitative data, such as satisfaction ratings, and thematic analysis for qualitative feedback. This analysis evaluated the workshop's impact on participants' understanding and readiness to implement the toolkit and provided insights for enhancing future training activities. Discussion/Conclusion The workshop identified key facilitators and barriers to SSTF implementation. While the toolkit offers a comprehensive framework for AMS, overcoming barriers requires a multifaceted approach involving education, stakeholder engagement, and continuous support. Clearer role definitions and improved support structures are essential. Limitations include limited participant representation and reliance on self-reported data, which may introduce bias. The study lacks long-term follow-up data to assess sustained impact, and feedback might be influenced by personal experiences or organisational culture, affecting generalisability. Future studies could expand participant diversity, incorporate longitudinal assessments, and explore additional AMS aspects.

Stakeholder-led proactive risk assessment of medication safety in the pharmaceutical supply chain

Abstract Introduction In 2022/23, 1.08 billion medications were dispensed to patients using NHS England, at a cost of £19.04 billion1 . However, Elliot et al (2019)2 estimate every year there are 237 million medication errors at some point of the medication process, with a high associated cost. Increasingly, media is reporting medication shortages of critical medicines3 that can contribute to errors of omission. Medication errors suggests system, tasks and processes should be explored to understand if they have been poorly designed. This paper is a pre-Brexit study that examines the pharmaceutical supply chain with stakeholders. Aim To explore risk to medication safety in the pharmaceutical supply chain using qualitative interviews of stakeholders across the supply chain and proactive risk assessment method SHERPA (Systematic Human Error Reduction and Prediction Approach). Method 1. Qualitative interviews with process models System process models were developed (by literature, field observations and interviewees) and employed to elicit stakeholder perceptions about risk to medication safety in 31 qualitative interviews. Participants included pharmacists, wholesalers, pharmaceutical industry representatives, regulators and policymakers. Ethical approval was granted by Cambridge LREC to include healthcare professionals and 6 patients. Interviews were audio-recorded, transcribed and thematically analysed using N-Vivo. 2. Focus group for SHERPA Six stakeholders participated in the SHERPA focus group4 , including pharmacists and representatives from pharmaceutical manufacturing and wholesale industries. Interview participants were invited and those that agreed, attended. The SHERPA template was completed by the group. The session was audio-recorded, transcribed and thematically analysed using N-Vivo. Results The system models led to a greater understanding of the current system ‘as-is’ and created an overview of the supply chain. SHERPA is a validated method and provided the rigour to risk assess the supply chain process and identify sources of risk. However, the error mode terminology required adjustment to healthcare. Across all supply routes, the main source of risk was failure to supply medicines that caused errors of omission and the risk of counterfeit medicines. Failure to supply resulted from shortages that take place from trading activities that result in stockpiling or exporting of medicines. A lack of robust regulation and parallel imports increased the risk of counterfeit medicines. Stakeholders highlighted deficiencies in the supply chain and poor performance of stakeholders, as medication safety concerns. In order of frequency, the deficiencies include fragmented supply chain; complacency by stakeholders; poor communication and integration across supply chain; and end-user often regarded as the pharmacist, rather than the patient. Discussion and conclusion From the findings, strategies emerged as possible solutions. These included communication of shortages in each component of supply chain; robust counterfeit strategies; use of technology (automation/digital tools); and re-design tasks and processes in dispensaries and wards. Staff training, education, and revalidation of stakeholders is vital. Key limitations in this study include biases that can occur from recruitment strategy and small sample size. The SHERPA method posed terminology problems. In conclusion, this multi-method approach reveals risk and possible solutions to improve safety and reduce cost in the NHS. It is clear this study needs to be repeated to understand the impact of Brexit and current reconfiguration of NHS.

Working across boundaries

Abstract We are delighted to publish the abstracts presented at the Royal Pharmaceutical Society (RPS) Annual Conference 2024 in this International Journal of Pharmacy Practice Issue Supplement. The conference entitled ‘Working across boundaries: Embracing new opportunities and empowering excellence’ included the themes of: Enhancing patient care; Advancing the workforce; Science &amp; Research; and Your RPS. It was held both online and in person at Convene, 133 Houndsditch, London on 8 November 2024. As the flagship event for the RPS, the conference hosted a full day of discussions centred on the topic of cross-boundary working, from dealing with medicines shortages, to prescribing and clinical supervision, to the strategic work of the RPS, and finally to innovations and research that will be shaping practice. The morning’s keynote presentation was delivered by Dr Liz O'Riordan, a breast oncology surgeon who herself has had breast cancer three times, speaking on the topic of high-quality care from the perspectives of being both a medical doctor and a patient. The conference also included a keynote panel discussion in the afternoon with the four of the United Kingdom’s Chief Pharmaceutical Officers, namely David Webb (NHS England), Andrew Evans (Welsh Government), Cathy Harrison (Northern Ireland), and Alison Strath (Scotland). The event included a multitude of research and innovation presentations, as posters and orals, many published as abstracts herewith. We were particularly pleased to see the return of five oral research presentations selected from the submitted abstracts, covering a breadth of methodologies. We would like to acknowledge all those who have contributed to making this event happen, in particular members of the conference steering committee co-chaired by Helen Chang and Anna Pielach at the RPS; Leah Burton and Lauren Ross from the RPS Science and Research team who managed the abstract processes; Dr Christopher Martin and Dr Diane Ashiru-Oredope, also from the RPS Science and Research team, who joined the Conference Abstract Review Panel; Science and Research Committee members who joined us on the Conference Abstract Review Panel, namely Dr Mar Estupiñan Fdez. de Mesa, Dr Andy Fox, Prof. Amira Guirguis, Dr Gillian Hawksworth, Prof. Delyth James, Dr Rachel Palmer, and Dr Ka-Wai Wan, as well as additional members of the Conference Abstract Review Panel, including Dr Paul Forsyth, Ola Howell, Dr Louise Hughes, Dr Matthew Ivory, Prof. Catriona Mathieson, Prof. Hamde Nazar, Prof. Philip Rogers, Dr Julian Smith, and Dr Sara Visram. In common with previous years, this Supplement has been prepared ahead of the conference, so that it is ready in time. Simon White, Cathrine McKenzie, Christine Bond, Amira Guirguis, and Parastou Donyai Simon White, Deputy Chair of the RPS Science and Research Committee and co-Chair of the Conference Abstract Review Panel Keele University Cathrine A McKenzie, member of the RPS Science and Research Committee and co-Chair of the Conference Abstract Review Panel University of Southampton Christine Bond, Editor-in-Chief of the International Journal of Pharmacy Practice, member of the RPS Science and Research Committee and co-Chair of the Conference Abstract Review Panel University of Aberdeen Amira Guirguis, Chair of the RPS Science and Research Committee Swansea University Parastou Donyai, RPS Chief Scientist The Royal Pharmaceutical Society

Evaluation of the current use and impact of the United Kingdom Clinical Pharmacy Association (UKCPA) handbook of perioperative medicines

Abstract Introduction Originally a paper-based resource, the UKCPA Handbook of Perioperative Medicines1 moved online in 2019 and the website was updated in March 2024, with improved functionality. The resource aims to standardise management of medication during the perioperative period by providing evidence-based advice and guidance for healthcare professionals, removing the need for local Trust guidelines. Aim To evaluate current use of, and opinions of users of, the UKCPA Handbook of Perioperative Medicines. Methods Usage data, including engagement rate and time and frequently accessed monographs, was obtained for 4th-March-2024 to 29th-May-2024 from Google Analytics and the website dashboard. Further usage information and user opinion was collected using a 9-question survey hosted on Survey Monkey and disseminated via UKCPA’s ‘X’ account and Surgery and Theatres Committee, plus NHS England non-medical pre-operative association network. Ethical approval was not required as this was a service evaluation.2 Results Analytics Most (79%, 23158) users are from the United Kingdom where the engagement rate is 64%. Outside the UK most users are from Australia (1858), Ireland (785) and the United States (575). The average engagement time is 3-minutes and 42-seconds. Frequently accessed monographs include antiplatelets (aspirin, clopidogrel), direct oral anticoagulants (apixaban, edoxaban) and diabetic medication (sodium glucose co-transporter 2 inhibitors, insulin). Survey Of the 237 responses received, individual question completion rates varied. 72% (170) of respondents were aware of the Handbook of which 89% (151) use it, with 22% (34) having it as their sole resource. Respondents were predominantly from NHS secondary care sector and comprised of pharmacists (24%, 58), pre-assessment nurses (21%, 49) and anaesthetists (19%, 44). Most (84%, 133) users access it via desktop. 85% (132) of respondents either “strongly agreed” or “agreed” that it has a professional appearance, 82% (128) that it has good search functionality and 80% (126) that they could find the required information. Discussion and conclusion The Handbook is mostly accessed within the United Kingdom, where it has a good engagement rate.3 However, there is usage on a global scale from countries including Australia, Ireland, USA, NZ, Canada, and Germany. Monographs for medicines considered ‘high-risk’ or where there is potential controversy about their perioperative management are the most accessed. There is good awareness of the Handbook from respondents, with the majority of those familiar with it using it in their area of work. It is expected that those who are aware of the Handbook would be more likely to respond to the survey. The Handbook is mainly used within the NHS secondary care setting, where most surgical procedures take place. However, it is likely that due to how the survey was disseminated, this influenced the healthcare professional groups that responded. In general, the Handbook is deemed to have a professional appearance, good search functionality and includes information that healthcare professionals require. The aim of the Handbook is to provide a standardised, evidence-based resource for healthcare professionals for perioperative medicines management. The survey results indicate that there is still variation in practice with centres choosing to use it in conjunction with other guidelines as opposed to their sole resource.

Assessing the impact of a leadership development programme on self-reported confidence of Community Pharmacy Neighbourhood Leads in South East London

Abstract Introduction Community Pharmacy (CP) integration is a key NHS England strategy, including for South East London (SEL) Integrated Care Board (ICB). To drive forward this strategy in SEL, the ICB medicines team created and funded community pharmacy neighbourhood lead (CPNL) roles. The CPNLs provide local leadership to strengthen CP-GP relationships and increase uptake of CP services (now badged Pharmacy First). To support implementation, a leadership programme was developed with system partners and delivered by Kaleidoscope,1 building on previous work.2 Core themes were building trust, driving collaboration and embedding innovation. Aim To measure the confidence level of CPNLs in SEL throughout the development programme, and associated outcomes. Methods There were five leadership sessions delivered to invited CPNLs and ICB colleagues between November 2023 and March 2024. The first and last sessions were face-to-face with the others virtual. Sessions covered both theory and implementation. At the end of each session all participants were asked to complete an online Microsoft forms survey compiled by Kaleidoscope, asking about their confidence in the CPNL role (where 1 is not at all confident and 5 is extremely confident), current relationships locally and actions planned and completed to date, using tick box, Likert scale and free text responses. Data was analysed in Microsoft Excel and through content analysis, with analysis completed for all attendees per session and separately for those attending 4 or 5 sessions. This study received ethics approval from Kingston University Ethics Committee (3396). Results A total of 37 individuals attended one or more sessions, with 16 attending 4 or 5 sessions. For all attendees, mean confidence score increased from 3.7 in session one to 4.14 in session five (out of 5) (session two:3.77; session three:4.05; session 4:4.17). Those who attended four or five sessions finished with a mean confidence score of 4.33, starting at 4.00 (session two:3.86; session three:4.19; session four:4.27). Comments showed participants initially reporting that there was room to improve relationships with key stakeholders, such as clinical directors, GPs, ICB and CP colleagues. By session five confidence had increased with comments noting that there was confidence to meet new people, network appropriately, and fulfil the required role. ‘Through the network we have created through this programme, confidence has grown with shared learning and new relationships.’ Comments were also received relating to improved joint working supporting the rollout of community pharmacy initiatives such as the Pharmacy First scheme. ‘Our confidence has grown, and we are arranging training sessions with the clinical directors with the local surgeries for some of the newer services like Pharmacy First.’ Discussion / Conclusion Our programme has increased CPNL confidence and engagement with local stakeholders, with greater confidence seen in those engaging most with the leadership programme. Limitations include not having consistent attendance at sessions. The launch of the national ‘Pharmacy First’ service halfway through the programme had a significant impact on the community pharmacy sector,3 with CPNLs being pivotal in building success in partnership. Further evaluation should assess impact of CPNLs on community pharmacy service provision and referrals by GPs.

Identifying barriers and opportunities to facilitate the uptake of whole genome sequencing in paediatric haematology and oncology practice

BackgroundThe clinical utility of whole genome sequencing (WGS) in paediatric cancer has been demonstrated in recent years. WGS has been routinely available in the National Health Service (NHS) England for all children with cancer in England since 2021, but its uptake has been variable geographically. To explore the underlying barriers to routine use of WGS in this population across England and more widely in the United Kingdom (UK) and the Republic of Ireland (ROI), a one-day workshop was held in Cambridge, United Kingdom in October 2022.MethodsFollowing a series of talks, delegates participated in open, round-table discussions to outline local and broader challenges limiting routine WGS for diagnostic work-up for children with cancer in their Principal Treatment Centres (PTCs) and Genomic Laboratory Hubs (GLHs). Within smaller groups, delegates answered structured questions regarding clinical capability, education and training needs, and workforce competence and requirements. Data was recorded, centrally collated, and analysed following the event using thematic analysis.ResultsSixty participants attended the workshop with broad representation from the 20 PTCs across the UK and ROI and the seven GLHs in England. All healthcare professionals involved in the WGS pathway were represented, including paediatric oncologists, clinical geneticists, clinical scientists, and histopathologists. The main themes highlighted by the group in ensuring equitable access to WGS identified were: lack of knowledge equity between NHS trusts, with a perception of WGS being for research only; and perception of lack of financial support for the clinical process surrounding WGS, including lack of time to take informed consent from patients. The latter also included limited trained staff available for data interpretation, affecting the turnaround time for reporting. Finally, the need for an integrated digital pathway to order, track, and return data to clinicians was highlighted.ConclusionAt the workshop, the general motivation for including WGS in the diagnostic work up for children with cancer was high throughout the UK, however a perceived lack of resources and education opportunities limit the widespread use of this commissioned assay. This workshop has led to some recommendations to increase access to WGS in this population in England and more widely in the devolved national of the UK and the ROI.

Qualitative service evaluation of a multimodal pilot service for early detection of liver disease in high-risk groups: ‘Alright My Liver?’

ObjectiveLiver disease is a growing cause of premature death in the UK. The National Health Service in England (NHS England) has funded regional early detection programmes through Community Liver Health...

Variation in surgery postponement rates in the NHS in England.

Postponement of surgery at preoperative assessment in the days or weeks before the patient is admitted for surgery, as distinct from cancellation on the planned day of surgery, can be devastating for patients and an inefficient use of finite resources. However, postponements are often poorly recorded. The primary aim of this pilot study was to investigate elective surgical postponement rates during or after preoperative assessment across England, and the reasons for postponement for patients on an elective surgical pathway. A retrospective analysis of clinical audit data from 16 National Health Service (NHS) trusts in England was undertaken. Data were collected during a two-week period in March 2024 on all postponements within a service. The primary outcome of interest was the postponement rate. Some 8000 case notes were reviewed. There were 583 (7.3%) postponements. Postponement rates across trusts varied from 31.9% to 1.0%. Significantly shorter time from referral to preoperative assessment was observed for day-case patients, urgent patients, patients without early screening and patients without a 'to come in' date in place. Of the 342 routine patients, 293 (85.7%) had postponements for medical rather than pathways or process reasons. Half of all routine patients waited over 94 days and a quarter of patients waited 198 days from being added to a patient tracking list to preoperative assessment. Minimizing postponements and improving preoperative assessment efficiency should be part of wider initiatives to streamline perioperative pathways.

Implementing a pathway for patients diagnosed with cancer in the emergency department.

Patients diagnosed with cancer or suspected cancer during an emergency department (ED) presentation are often signposted back to their GP for urgent referral to cancer services. However, this can result in delays in patients receiving specialist support, confirmation of diagnosis and, vitally, starting treatment. A quality improvement initiative that aimed to address these issues through the introduction of an ED suspected cancer diagnosis pathway was implemented by the acute oncology service in two EDs in Oxford University Hospitals NHS Foundation Trust in April 2023. Data collected during the first year of implementation of the pathway show there has been a significant increase in the numbers of patients meeting the NHS England 62-day referral to treatment standard and in the numbers of patients receiving support from an acute oncology named cancer clinical nurse specialist from the point of discharge from the ED. This article details the initiative, which is ongoing, and shares some of the results from the first year of data collection.

Modern epidemiology of heart failure with reduced and preserved ejection fraction in population-wide linked electronic health records: a study of 208815 heart failure patients in England

Abstract Background The modern epidemiology of heart failure (HF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) is yet to be studied on a population-wide scale in the United Kingdom, particularly in the post-COVID-19 era. Purpose To explore the post-pandemic epidemiology and outcomes of HFrEF and HFpEF in population-wide electronic health records (EHRs). Methods We accessed data in the National Health Service England’s Secure Data Environment for England via the British Heart Foundation Data Science Centre CVD-COVID-UK/COVID-IMPACT Consortium. We used EHRs for 57 million individuals to identify patients aged ≥18 years, of known sex, who were diagnosed with HF as the primary condition in any inpatient hospital stay from 01 Jan 2020 to 27 Feb 2023. By linking HF admissions with the National Heart Failure Audit, six other National Institute for Cardiovascular Outcomes Research audits, and the General Practice Extraction Service Data for Pandemic Planning and Research, we classified HF into HFrEF and HFpEF based on recorded left ventricular ejection fraction (LVEF; ≤40% and &amp;gt;40% respectively) or documented diagnosis. We compared characteristics of these groups and used Cox proportional hazards models, adjusted for key confounders, to examine differences in cause-specific mortality and hospitalisation outcomes. Results Over 3.2 years, we identified 208815 patients with a HF hospitalisation. 86110 (41%) patients had HFrEF, 65735 (31%) had HFpEF, and 56970 (27%) could not be categorised. Compared to patients with HFrEF, patients with HFpEF were older (mean [SD], 80.5 [10.9] vs 75.6 [13.6] years), more often female (n [%], 35990 [54.8] vs 30835 [35.8]), and less deprived (n [%] in the least-deprived Index of Multiple Deprivation 2019 quintile, 12275 [18.7] vs 15055 [17.5]; Table). Over a median follow-up of 11 months among patients with HFrEF and HFpEF, 99740 patients were re-hospitalised (66%) and 71075 (47%) died. Risks of all-cause, cardiovascular, non-cardiovascular, and heart-failure re-hospitalisations were all higher in patients with HFpEF compared with patients with HFrEF (Figure). The risk of all-cause mortality was modestly higher in patients with HFpEF (HR 1.04, 95% CI 1.02–1.06; Figure). Risks of death due to cardiovascular disease overall, fatal myocardial infarction, and fatal HF were higher among patients with HFrEF. In contrast, risks of death due to non-cardiovascular causes were higher in patients with HFpEF. There were no differences in risk of death due to COVID-19. Conclusions Unlike previous epidemiological surveys of HF, patients with HFpEF appear to face worse prognosis and risk-adjusted disease trajectories compared with those with HFrEF after hospitalisation in this population-wide study. Excess mortality in HFpEF appears driven by higher risk of non-cardiovascular mortality. However, post-discharge survival is poor regardless of LVEF and represents an ongoing target for quality improvement efforts.

Real-world evaluation of a lipid transformation project in primary care settings

Abstract Background The National Health Service England Long-Term Plan (2019) highlights the need to optimise lipid management to reduce cardiovascular disease (CVD) risk. A collaborative project was funded between a local health service and an industry partner to review current practice and improve outcomes in a UK region through introduction of lipid management pathways, primary care education and patient-focused reviews to optimise lipid-lowering therapies among high-risk patient groups. Purpose The project aimed to increase prescribing of CVD risk reduction therapies such as high-intensity statins (HIST), escalation of therapy to achieve lipid-lowering treatment targets, to improve clinician knowledge and confidence in lipid management and provide benefits for local populations in reducing CVD risk. Methods Systematic patient searches across six Primary Care Networks (PCNs) prioritised high-risk patients for review. Community of Practice sessions were held to facilitate shared learning and problem-solving. A pragmatic, real-world evaluation was conducted to explore the impact of the new pathways and tools on prescribing outcomes and optimisation of lipid-lowering therapies. To examine the changes in HIST prescriptions, a statistical analysis of open-source prescribing data was undertaken between baseline (December 2021) and follow-up (December 2022) on over 39,000 eligible patient records. Qualitative interviews with clinicians from all participating PCNs and a thematic analysis of emerging themes was conducted in 2023. Results A paired sample t-test demonstrated a significant increase in the percentage of HIST prescribed, of the total number of statins prescribed, across the six PCNs between baseline and follow-up t(5) = -3.38, p = 0.01. Table 1 illustrates the changes at individual PCN level. Four of the six PCNs reached the National Institute for Health and Care Excellence minimum threshold of 65% target for HIST prescribing in statin prescriptions and three of these PCNs exceeded the optimal target of 75% HIST. An additional 600 patients were prescribed Ezetimibe (as therapy escalation or for statin intolerance). Through qualitative data, clinicians reported development of new skills and knowledge, leading to increased confidence in optimising lipid management with medication and lifestyle interventions. Conclusion The lipid transformation project demonstrated significant improvements in prescribing of lipid-lowering therapies and improved clinician competence in lipid management pathways and guidance. This has enabled sustainable improvements in lipid management and cardiovascular disease reduction in local populations.

Association of COVID-19 and influenza vaccinations and cardiovascular drugs with hospitalisation and mortality in COVID-19 and Long COVID: 2-year follow-up of 17 million individuals in England

Abstract Introduction For COVID-19 and Long COVID, determining the highest-risk subgroups, particularly in the context of compound pressures such as influenza and cardiovascular disease (CVD), may identify effective interventions to prevent adverse health outcomes, and inform public health and policy decisions. Methods Using national, linked electronic health records for England (NHS England Secure Data Environment: via CVD-COVID-UK/COVID-IMPACT Consortium), we studied individuals with COVID-19 and Long COVID from January 2020 to February 2023. We compared all-cause hospitalisation and mortality in unmatched and matched cohort analyses, by prior CVD, high CVD risk (by QRISK2), COVID-19 and influenza vaccination status, and prescription of CVD preventive therapies. We investigated potential impact of targeted vaccination and CVD prevention strategies on mortality and hospitalisations by calculating population preventable fractions. Results We identified 17,373,850 individuals with COVID-19 [54.4% female; mean age 38.8 years; COVID-19 vaccination ≥2 doses:50.0%, influenza vaccination (≥1 dose):27.8%; mean follow-up 1.28 years] and 301,115 with Long Covid [61.8% female; mean age 46.0 years; COVID-19 vaccination ≥2 doses:66.4%, influenza vaccination:33.1%; mean follow-up 1.1 years]. Hospitalisation and mortality rates were 15.3% and 2.0% in COVID-19 (Long COVID rate 1.3%) and 16.8% and 1.4% in Long COVID, respectively. Adjusted risk of mortality and hospitalisation were reduced with COVID-19 vaccination ≥2 doses (COVID-19:HR 0.36, 95% CI 0.34-0.38 and 0.69, 0.68-0.69; Long COVID:0.44, 0.42-0.47 and 0.90, 0.89-0.91). With influenza vaccination, mortality was reduced, but not hospitalisation (COVID-19: 0.86, 0.85-0.86 and HR 1.01, 1.01-1.01, and Long COVID: 0.72, 0.67-0.76, and 1.05, 1.03-1.07), with greatest effect in those with prior CVD and high CVD risk. Mortality and hospitalisation were also reduced by CVD prevention in those with CVD, e.g. anticoagulants- COVID-19: 0.69, 0.69-0.70 and 0.92, 0.91-0.93; Long Covid: 0.59, 0.54-0.64, and 0.88, 0.84-0.92. COVID-19 vaccination, influenza vaccination and CVD drugs (Anticoagulants) averted 101117 of 193598, 2138 of 4017 and 16573 of 36847 preventable deaths among individuals after COVID-19, and 875 of 1189, 65 of 127 and 507 of 1007 preventable deaths among those with Long COVID, particularly in people with CVD. Conclusions Prior CVD and high CVD risk are associated with increased hospitalisation and mortality risk in people with COVID-19 and Long COVID. Targeted improvement in COVID-19 vaccination and CVD prevention, especially in those with CVD are priority interventions in pandemics to avoid excess hospitalisation and mortality.Baseline Characteristics and OutcomesHospitalisation/mortality by COVID vaccn

Inequalities in preterm birth by deprivation and ethnicity: A national cohort study in England

Abstract Background Preterm birth has decreased in the UK; however, the extent of inequalities remains unclear. This study aimed to quantify socioeconomic and ethnic inequalities in preterm birth rates using routinely collected maternity data in England. Methods Retrospective analysis of cohort data from the NHS England Hospital Episode Statistics (HES). All women aged 13-55 with a singleton livebirth (April 2018 to March 2021) at 24-42 weeks were included. Multivariate Poisson regression was used to estimate the rate of preterm birth (livebirth between 24 + 0 and 36 + 6 weeks’) for each ethnic and deprivation postcode group, these were compared to white women from the least deprived 20% of areas. We iteratively developed the model, adjusting for covariates associated with preterm birth. A post-hoc calculation identified the rate of preterm birth for each ethnic group at each level of deprivation. Results We identified 1,111,045 livebirths between April 2018 and March 2021. The rate of preterm birth increased with socioeconomic deprivation and was highest at 7.1% per 100 livebirths (95%CI:7.00-7.20) in women living in the 20% most deprived areas, compared to 5.6% (95%CI:5.50-5.74) in women in the 20% least deprived areas. White women had the lowest preterm birth rate at 6.5% (95%CI:6.47-6.58) and South Asian women had the highest rate at 6.9% (95%CI:6.76-7.04) (Table 2). The rate of preterm birth increased according to increased area-level deprivation across all ethnic groups. In areas of high deprivation, the preterm birth rate was similar across ethnic groups. Whereas in less deprived areas, there were marked inequalities between ethnic groups. Conclusions Inequalities in preterm birth remain, despite overall decreases in preterm birth. We found area deprivation and individual ethnicity interact to increase the risk of preterm birth in marginalized communities. Interventions need to holistically consider the structural and socioenvironmental determinants of preterm birth. Key messages • Area deprivation and ethnicity remain key drivers of inequalities in preterm birth, despite overall decreases in preterm birth. • To reduce inequalities tailored prevention strategies are needed to address socioenvironmental and structural determinants of preterm birth in high deprivation areas and minoritized ethnicity groups.