National Health Service Services Research Articles

Characteristics of patients seeking national health service (NHS) care for Achilles tendinopathy: A service evaluation of 573 patients

BackgroundAchilles tendinopathy is a common condition that is often still symptomatic 10 years after onset. Much of the available research has focussed on active populations, however our experience is patients seeking care in the UK's National Health Service (NHS) may be different. ObjectivesTo determine the characteristics of patients receiving NHS care for Achilles tendinopathy (AT).To describe the utilisation of resources and the effectiveness of AT management in the NHS. MethodsA data extraction tool was developed and used to retrospectively extract the characteristics of 573 patients diagnosed with Achilles tendinopathy. ResultsNHS Achilles tendinopathy patients averaged 57 years old, had a Body Mass Index of 31, and 69% had at least one other long-term health condition. These included musculoskeletal complaints (59%), hypertension (30%), Chronic Obstructive Pulmonary Disease or asthma (17%), cardiovascular disease (13%) and diabetes (13%). Subsequently medication usage was higher than the general population and included drugs that have been linked to the pathogenesis of tendinopathy. On average, healthcare providers conducted 3.8 therapy sessions and 26% of patients had radiological investigations. Outcome measures were commonly absent with Visual Analog Scale (VAS) scores documented in 51% of records, and patient-reported outcome measures like VISA-A only appearing in 3% of cases. Reports on psychosocial factors were seldom documented. ConclusionIndividuals diagnosed with Achilles tendinopathy through NHS services exhibit distinct characteristics that diverge considerably from those currently represented in the published research used to develop clinical guidelines. NHS Achilles tendinopathy patients have multiple long-term health conditions and higher medication usage.

Using NHS Data to Monitor Trends in the Occurrence of Severe, Food-Induced Allergic Reactions Work Package 2

People with food allergies may experience food allergic reactions due to accidental exposure. These reactions are commonly categorised as non-severe, fatal food anaphylaxis and near-fatal food anaphylaxis. Non-severe allergic reactions to food are more common with an incidence of up to 1,000 times greater than fatal food-related anaphylaxis. However, obtaining accurate data relating to the circumstances under which these reactions occurred is challenging under the current diagnosis coding system used in the National Health Service (NHS). This project addressed two key questions: 1. What are the trends in the occurrence of food hypersensitivity (FHS) reactions and their consequences in terms of healthcare encounters (both to hospital and primary care)? 2. What are the circumstances surrounding severe, life-threatening reactions to food? Approach • A UK arm of NORA was established using the same online platform as the existing European Registry. • Participation of healthcare professionals and/or patients to enter relevant information was co-ordinated by BSACI in conjunction with the Paediatric Emergency Research in the United Kingdom Ireland (PERUKI) network. • Different versions of the questionnaire were developed to increase response rates: (1) a comprehensive form mapped to existing NORA data fields for completion by Healthcare Professionals in the non-acute setting; (2) a shorter form with key data fields to increase data reporting in more pressured, acute healthcare settings; and (3) a form for completion by patients or their parent/guardian. Key Results The launch of the UK anaphylaxis registry faced delays and was impacted by significant pressures on NHS services due to the COVID-19 pandemic. This led to a lower than anticipated uptake of the Registry by clinics and Accident & Emergency departments. As a result, only a minority of accidental reactions (less than 5%) were captured in the registry, almost all in children and young people under age 18 years. Some indicative results of this analysis are the following: • 213 cases reported to be due to a food trigger and of these, 208 occurred in children/young people aged 18 years or under. • Common food triggers were peanut, tree nuts (especially cashew), cow’s milk/dairy and hen’s egg. • 47% of reactions occurred after consumption of prepacked food products and in at least 59% of these cases, the allergen was declared as an actual ingredient. Further work would be needed to understand how to optimise reporting of data, for example by reducing the time burden for completion by clinicians and patients.

A qualitative study exploring how vocational rehabilitation for people with multiple sclerosis can be integrated within existing healthcare services in the United Kingdom

BackgroundTo explore how a vocational rehabilitation (VR) intervention can be integrated within existing healthcare services for people with multiple sclerosis (MS) in the United Kingdom (UK) National Health Service (NHS).MethodsData from 37 semi-structured interviews with 22 people with MS, eight employers, and seven healthcare professionals were analysed using a framework method informed by the Consolidated Framework for Implementation Research and an intervention logic model.ResultsFour themes were identified relating to the structure of current NHS services, how to improve access to and awareness of VR services, the collaboration between internal and external networks, and the benefits of integrating VR within the NHS services. Participants identified several implementation barriers such as poor links with external organisations, staffing issues, and lack of funding. To overcome these barriers, participants suggested enablers such as technology (e.g., apps or online assessments) and collaboration with third-sector organisations to reduce the pressure on the NHS.ConclusionSignificant organisational changes are required to ensure a successful implementation of a VR intervention within current NHS services. Despite this, the NHS was seen as a trustworthy organisation to offer support that can optimise the health and professional lives of people with MS.

Effectiveness and cost-effectiveness of radiofrequency denervation versus placebo for chronic and moderate to severe low back pain: study protocol for the RADICAL randomised controlled trial

IntroductionLow back pain (LBP) is the leading global cause of disability. Patients with moderate to severe LBP who respond positively to a diagnostic medial nerve branch block can be offered...

Exploring the Cost-Effectiveness of Newborn Screening for Metachromatic Leukodystrophy (MLD) in the UK.

Metachromatic leukodystrophy (MLD) is a fatal inherited lysosomal storage disease that can be detected through newborn bloodspot screening. The feasibility of the screening assay and the clinical rationale for screening for MLD have been previously demonstrated, so the aim of this study is to determine whether the addition of screening for MLD to the routine newborn screening program in the UK is a cost-effective use of National Health Service (NHS) resources. A health economic analysis from the perspective of the NHS and Personal Social Services was developed based on a decision-tree framework for each MLD subtype using long-term outcomes derived from a previously presented partitioned survival and Markov economic model. Modelling inputs for parameters related to epidemiology, test characteristics, screening and treatment costs were based on data from three major UK specialist MLD hospitals, structured expert opinion and published literature. Lifetime costs and quality-adjusted life years (QALYs) were discounted at 1.5% to account for time preference. Uncertainty associated with the parameter inputs was explored using sensitivity analyses. This health economic analysis demonstrates that newborn screening for MLD is a cost-effective use of NHS resources using a willingness-to-pay threshold appropriate to the severity of the disease; and supports the inclusion of MLD into the routine newborn screening programme in the UK.

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial

After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy. This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants. Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%. An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing). National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

A national research survey of childhood autism assessment services in the UK: empirical evidence of diagnostic practice, challenges and improvement opportunities

BackgroundThe UK National Health Service (NHS) Long Term Plan aims to reduce waiting times for childhood autism diagnostic assessment and improve parent and child satisfaction. This empirical research investigated current...

Time to unshackle the medical treatment of obesity in the NHS

Obesity affects one in four people in the United Kingdom and costs the National Health Service (NHS) ∼£6.5 billion annually. The glucagon-like peptide-1 (GLP-1) receptor analogues, such as once-daily subcutaneous Liraglutide 3.0 mg (Saxenda®) and once-weekly subcutaneous Semaglutide 2.4 mg (Wegovy®), were approved by the National Institute of Health and Care Excellence (NICE) as a treatment for obesity and funded by the NHS for 2 years. Our local data shows that Saxenda is effective at reducing body weight and glycaemia in people with obesity and diabetes; however, the supply issues of GLP-1 receptor analogues have contributed to the unavailability of Saxenda and Wegovy in our service. Our patients are devastated that they cannot access NICE-approved GLP-1 receptor analogues for obesity. The 2-year GLP-1 receptor analogue treatment limit for obesity alongside a lack of funded NHS services and supply issues represent barriers to treatment for people living with obesity who have clear medical indications.

The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Lived experience of recurrent miscarriage: women and their partners’ experience of subsequent pregnancy and support within an NHS specialist clinic – a qualitative study

ObjectiveThis study aims to describe the lived experiences of couples with a history of recurrent miscarriage in subsequent pregnancies and their perception of clinic support and cytogenetic investigations.DesignA qualitative interview...

Perspectives on registration to primary care from inclusion health groups in England: a mixed-method study

BackgroundAlthough everyone living in the UK is entitled to access free primary care within the National Health Service (NHS), evidence shows that people in need of health care are wrongly being refused access. This study aimed to explore the perspectives of individuals from inclusion health groups on primary care registration and accessibility. MethodsThis was a mixed-methods study. From Oct 5, 2022, to Feb 20, 2023, we surveyed 49 people (36 [73%] men; 12 [24%] women) and interviewed 25 other (14 [56%] men; 11 [44%] women) who were service users of the University College London Hospital Find & Treat mobile service. This service included people with lived experience of homelessness, asylum seeking, addiction, selling sex, and irregular immigration. We recruited these participants through hostels for people with ongoing addiction and complex needs, initial asylum accommodation centres, and day shelters. Our research team included two peer researchers. FindingsOf those surveyed, 25 (51%) perceived their access to primary health-care services as good, and 17 (35%) reported obstacles to going to the general practitioner (GP). Participants described multiple barriers to registering for GP surgeries, including a lack of understanding and poor communication with NHS services, a fear of discrimination, and a lack of digital access that prevents information seeking and access to services. Respondents also reported using emergency services instead of primary care because they were more immediately accessible without previous registration. Facilitators to GP registration included one-on-one support and outreach work that helps people navigate into services and know their rights, and the use of specialist GP services, which are perceived as more accepting, especially for people experiencing homelessness. InterpretationThe barriers to registration identified are related to both individual and group level characteristics and produce both similar and divergent needs between different inclusion health groups. The need for additional support during registration was clear, and our work highlights the requirement for interventions to improve access to primary care for underserved groups, as well as coordinated policy action. One-on-one support in particular, either outreach or provided in services where inclusion health groups spend time, appears to be a key facilitator to ensuring comprehensive and fast access to GP services. FundingNational Institute for Health and Care Research (NIHR).

Count Me In: an inclusive approach towards patient recruitment for clinical research studies in the NHS

BackgroundParticipation in clinical research is associated with better patient outcomes and higher staff retention and satisfaction rates. Nevertheless, patient recruitment to mental health studies is challenging due to a reliance...

From commodification to entrepreneurialism: how commercial income is transforming the English NHS

IMPACT The authors explore the way in which National Health Service (NHS) organizations in England are becoming more entrepreneurial through seeking more commercial income. As a form of commodification, commercialization has become more salient because of tightened public spending and the relaxation of regulations governing the scale of commercial income that the NHS could earn (since 2012). In turn, a stronger entrepreneurial ethos and practice has developed. The purpose and impact of commercialization is examined using secondary data from six NHS organizations (narrating developments post-2012), demonstrating the extent of and their justifications for commercialization. Recent and planned changes are explained. These income-generation activities, which are often set up to support or maintain existing NHS services, may unwittingly accelerate further commercialization—particularly in post-pandemic recovery. The authors conclude that the NHS risks becoming predicated upon commercial logics, thereby undermining public service logics.

Setting a tariff for IVF and ICSI treatment: a cost analysis

In-vitro fertilisation (IVF) and intra-cytoplasmatic sperm injection (ICSI) are available in Scotland through the National Health Service (NHS) according to specific criteria. There is no standardised NHS tariff for these treatments in Scotland, and variation exists amongst different centres providing NHS services. The aim of this study was to calculate the mean cost of IVF and ICSI cycles for NHS-funded treatment in Scotland. A detailed cost analysis of fresh and frozen cycles was performed, and a breakdown of the various cost components was presented. A deterministic approach was applied using NHS-funded individual cycle data from 2015–2018 and aggregate data. All costs were calculated in UK pounds sterling (£- using 2018 prices). Resource use was assigned to individual cycles based on cycle-level data or expert-informed assumptions; whenever needed, average aggregate costs were assigned to cycles. A total of 9442 NHS-funded cycles were included in the analysis. The average cost of fresh IVF and ICSI cycles was £3247 [£1526–£4215] and £3473 [£1526–£4416], respectively. Frozen cycles averaged £938 [£272–£1085]. This data can be useful to decision-makers, especially where IVF/ICSI is publicly funded, as it delivers a detailed IVF/ICSI cost breakdown. It is an opportunity for other authorities to estimate IVF/ICSI costs, as the methods applied are clear and reproducible.

Managing comorbid cognitive impairment and hearing loss in older adults: a UK survey of audiology and memory services.

midlife hearing loss is a potentially modifiable risk factor for dementia. Addressing comorbid hearing loss and cognitive impairment in services for older adults may offer opportunities to reduce dementia risk. to explore current practice and views amongst UK professionals regarding hearing assessment and care in memory clinics and cognitive assessment and care in hearing aid clinics. national survey study. Between July 2021 and March 2022, we distributed the online survey link via email and via QR codes at conferences to professionals working in National Health Service (NHS) memory services and audiologists working in NHS and private adult audiology services. We present descriptive statistics. 135 professionals working in NHS memory services and 156 audiologists (68% NHS, 32% private sector) responded. Of those working in memory services, 79% estimate that >25% of their patients have significant hearing difficulties; 98% think it useful to ask about hearing difficulties and 91% do so; 56% think it useful to perform a hearing test in clinic but only 4% do so. Of audiologists, 36% estimate that >25% of their older adult patients have significant memory problems; 90% think it useful to perform cognitive assessments, but only 4% do so. Main barriers cited are lack of training, time and resources. although professionals working in memory and audiology services felt addressing this comorbidity would be useful, current practice varies and does not generally address it. These results inform future research into operational solutions to integrating memory and audiology services.

Description of the nationally implemented National Health Service digital diabetes prevention programme and rationale for its development: mixed methods study

BackgroundThe National Health Service (NHS) Digital Diabetes Prevention Programme (DDPP) is a behaviour change programme for adults in England who are at high risk of developing type 2 diabetes. Four independent providers deliver the NHS-DDPP following a competitive tendering process. Although providers work to a single service specification, there is potential for some variation in the service across providers. This study (1) assesses fidelity of the structural features of the design of the NHS-DDPP compared to the service specification, (2) describes the structural features of delivery of the NHS-DDPP as implemented (3) reports developers’ views on how the structural components of the NHS-DDPP were developed and why changes were made following implementation.MethodsUsing mixed methods, we conducted a document review of providers’ NHS-DDPP design and delivery documentation, and extracted information using the Template for Intervention Description and Replication checklist, which was adapted to capture features of digital delivery. Documentation was supplemented by content analysis of interviews with 12 health coaches involved in delivering the NHS-DDPP. Semi-structured interviews were also conducted with 6 programme developers employed by the digital providers.ResultsProvider plans for the NHS-DDPP show relatively high fidelity to the NHS service specification. Despite this, there was wide variation in structural features of delivery of the NHS-DDPP across providers, particularly for delivery of ‘support’ (e.g. use, dose and scheduling of health coaching and/or group support). Interviews with developers of the programmes showed that much of this variation is likely to be attributable to the origin of each provider’s programme, which was usually a pre-existing programme that was adapted to conform to the NHS-DDPP service specification. The NHS-DDPP is continually improved and developed based on user experience feedback and research conducted by the providers.ConclusionIndirect evidence suggests that variation in delivery of support could affect effectiveness of the NHS-DDPP. A priority for future research is ascertaining whether the variation in delivery of the NHS-DDPP across providers is related to any differences in health outcomes. It is recommended that future rounds of commissioning the NHS-DDPP pre-specify the type of support participants should receive, including expected dose and scheduling.

Challenges Encountered and Lessons Learned when Using a Novel Anonymised Linked Dataset of Health and Social Care Records for Public Health Intelligence: The Sussex Integrated Dataset

Background: In the United Kingdom National Health Service (NHS), digital transformation programmes have resulted in the creation of pseudonymised linked datasets of patient-level medical records across all NHS and social care services. In the Southeast England counties of East and West Sussex, public health intelligence analysts based in local authorities (LAs) aimed to use the newly created “Sussex Integrated Dataset” (SID) for identifying cohorts of patients who are at risk of early onset multiple long-term conditions (MLTCs). Analysts from the LAs were among the first to have access to this new dataset. Methods: Data access was assured as the analysts were employed within joint data controller organisations and logged into the data via virtual machines following approval of a data access request. Analysts examined the demographics and medical history of patients against multiple external sources, identifying data quality issues and developing methods to establish true values for cases with multiple conflicting entries. Service use was plotted over timelines for individual patients. Results: Early evaluation of the data revealed multiple conflicting within-patient values for age, sex, ethnicity and date of death. This was partially resolved by creating a “demographic milestones” table, capturing demographic details for each patient for each year of the data available in the SID. Older data (≥5 y) was found to be sparse in events and diagnoses. Open-source code lists for defining long-term conditions were poor at identifying the expected number of patients, and bespoke code lists were developed by hand and validated against other sources of data. At the start, the age and sex distributions of patients submitted by GP practices were substantially different from those published by NHS Digital, and errors in data processing were identified and rectified. Conclusions: While new NHS linked datasets appear a promising resource for tracking multi-service use, MLTCs and health inequalities, substantial investment in data analysis and data architect time is necessary to ensure high enough quality data for meaningful analysis. Our team made conceptual progress in identifying the skills needed for programming analyses and understanding the types of questions which can be asked and answered reliably in these datasets.

Mental health coverage for forced migrants: Managing failure as everyday governance in the public and NGO sectors in England.

High-income countries (HICs) which are said to have "reached" universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in "hypothetical access". In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015-2016 and 2019-2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of "managing failure". These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of "health coverage assemblage" is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform.

Duodenal-jejunal bypass liner for treatment of T2DM and obesity: 4-year outcomes in the first National Health Service (NHS) EndoBarrier service

Background and aims: EndoBarrier is a 60cm duodenal-jejunal bypass liner endoscopically implanted for up to one year and designed to mimic the bypass part of roux-en-Y bariatric surgery. There is uncertainty concerning the extent to which improvements associated with EndoBarrier treatment are sus-tained once the liner has been removed. We aimed therefore to establish an EndoBarrier service for refractory diabesity and to continue to monitor the people with diabetes after EndoBarrier removal. Methods: Between October 2014 and November 2017, we implanted 62 EndoBarriers in our NHS service. All had been removed by November 2018. Outcomes were monitored in a registry. Results: As of November 2021, all patients reached three years after EndoBarrier removal and of these 43/62 (69%) (mean±SD age 51.6 ± 7.6 years, 55.8% male, 55.8% white ethnicity, median [IQR] diabetes duration 14.6 [8 – 21] years, 62.8% insulin-treated, mean±SD BMI 41.7±7.3 kg/m2) attended follow-up. In those who attended, during EndoBarrier implantation mean±SD HbA1c fell by 20.6±19.6 mmol/mol from 76.3±19.2 to 55.7±11.1 mmol/mol (p<0.001) (by 1.9±1.8% from 9.1±1.8% to 7.2±1.0% [p<0.001]), weight fell by 17.4±9.1 kg from 123.3±30.0 kg to 105.9±30.8 kg (p<0.001), BMI fell from 41.7±7.3 to 35.6±7.7 kg/m2 (p<0.001), systolic blood pressure from 138.7±14.4 to 125.4±14.7 mmHg (p<0.001), cholesterol from 4.6±1.0 to 3.7±0.7mmol/L (p<0.001), and serum alanine aminotransferase from 30.8±17.2 to 19.3±11.2 U/L (p<0.001). In those taking insulin median (IQR) total daily insulin dose reduced from 114 (54–180) to 20 (0–65) units (n=27, p<0.001); 10/27 (37%) insulin-treated people were able to discontinue insulin. Three years after EndoBarrier removal 33/43 (77%) maintained most of the improvement achieved with EndoBarrier whilst 10/43(23%) reverted to baseline. Of those deteriorating 9/10(90%) had depression and/or bereavement and/or major health problems/disability. 10/62(16%) required early Endo-Barrier removal for adverse events or symptoms; all 10 fully recovered after removal and most derived significant benefit. Conclusions: Our data demonstrate that EndoBarrier is highly effective in people with refractory diabesity, with mainte-nance of significant improvement three years after removal in 77% of cases.