National Health Service Services Research Articles

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.

Improving Patient Flow in the Surgical Assessment Unit by Facilitating Access to Computer Tomography Scanning.

Introduction Patient flow is "the ability of healthcare systems to manage patients effectively and with minimal delays as they move through stages of care". National Health Service (NHS) England has highlighted the importance of improving patient flow, and the many benefits to both staff and patients, including: "improved clinical outcome and experience of patients"; "eliminating waits and delays"; "saving time and effort by avoiding duplication of work"; "saving money"; and "improving the reputation of the NHS". Limited access to computerised tomography (CT) imaging for surgical patients can disrupt patient flow through delayed diagnosis, management, and discharge.The aims of this quality improvement project were to assess the effect of a dedicated Surgical Assessment Unit (SAU) radiologist on access to CT scanning and its impact on patient flow. The measured outcomes were time from admission to CT scanning, and length of admission. Method In June 2020, a radiology registrar was allocated to the SAU to vet and report CT imaging. CT requests from the SAU were identified from Picture Archiving and Communication System (PACS) in the first two weeks of June 2019 and 2020 during normal working hours (Monday to Friday, between 0900 and 1700). We performed a retrospective audit and compared data from 2019 and 2020. The measured primary outcome was time from admission to imaging. The secondary outcome was the length of admission. Results In the two-week period in June 2019, 25 patients requiring a CT scan presented to SAU during normal working hours. In 2020, this number increased to 40 patients. In 2019, 5 patients had a CT scan performed within four hours of admission (20%). In 2020, following the allocation of a radiologist to the SAU, 33 patients (82.5%) had their CT performed within four hours of admission.In 2019, one patient (4%) was discharged within six hours of admission. A further 16% had a length of admission between six and 12 hours. The majority of patients (80%) remained in the hospital for more than 12 hours. In 2020, 45% of patients were discharged within four hours following a CT scan. More than half of the patients (57.5%) were discharged within 12 hours. Conclusion The allocation of a radiologist in the SAU led to both areduction in time to perform CT scans and an increased number of patients being discharged within 12 hours. These results suggest that early access to imaging improves patient flow. Further research will help to establish whether the allocation of a radiologist in the SAU is a beneficial and cost-effective method of improving patient flow, and whether this may help reduce the current pressure on NHS services.

An integrated discrete event simulation and particle swarm optimisation model for optimising efficiency of cancer diagnosis pathways

The National Health Service (NHS) constitution sets out minimum standards for rights of access of patients to NHS services. The ‘Faster Diagnosis Standard’ (FDS) states that 75% of patients should be told whether they have a diagnosis of cancer or not within 28 days of an urgent GP referral. Timely diagnosis and treatment lead to improved outcomes for cancer patients, however, compliance with these standards has recently been challenged, particularly in the context of operational pressures and resource constraints relating to the COVID-19 pandemic. In order to minimise diagnostic delays, the National Physical Laboratory in collaboration with the Royal Free London (RFL) NHS Foundation Trust address this problem by treating it as a formal resource optimisation, aiming to minimise the number of patients who breach the FDS. We use discrete event simulation and particle swarm optimisation to identify areas for improving the efficiency of cancer diagnosis at the RFL. We highlight capacity-demand mismatches in the current cancer diagnosis pathways at the RFL, including imaging and endoscopy investigations. This is due to the volume of patients requiring these investigations to meet the 28-day FDS target. We find that increasing resources in one area alone does not fully solve the problem. By looking at the system as a whole we identify areas for improvement which will have system-wide impact even though individually they do not necessarily seem significant. The outcomes and impact of this project have the potential to make a valuable impact on shaping future hospital activity.

Encouraging openness in health care: Policy and practice implications of a mixed-methods study in the English National Health Service.

The National Health Service (NHS) in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. We draw on the findings of an evaluation of the implementation of these policies in NHS organisations, with the aim of identifying key implications for policy and practice. We undertook a mixed-methods policy evaluation, comprising four substudies: a longitudinal analysis of data from surveys of NHS staff and service users; interviews with senior stakeholders in NHS provider organisations and the wider system; a survey of board members of NHS provider organisations and organisational case studies across acute, community and mental health, and ambulance services. Our findings indicate a mixed picture of progress towards improving openness in NHS organisations, influenced by organisational history and memories of past efforts, and complicated by organisational heterogeneity. We identify four features that appear to be necessary conditions for sustained progress in improving openness: (1) authentic integration into organisational mission is crucial in making openness a day-to-day concern; (2) functional and effective administrative systems are vital; (3) these systems must be leavened by flexibility and sensitivity in implementation and (4) a spirit of continuous inquiry, learning and improvement is required to avoid the fallacy that advancing openness can be reduced to a time-limited project. We also identify four persistent challenges in consolidating and sustaining improvement: (1) a reliance on goodwill and discretionary effort; (2) caring for staff, patients and relatives who seek openness; (3) the limits of values-driven approaches on their own and (4) the continued marginality of patients, carers and families. Variation in policy implementation offers important lessons on how organisations can better deliver openness, transparency and candour. These lessons highlight practical actions for policymakers, managers and senior clinicians.

Black swan theory: legal policy of the Indonesian national healthcare

The Indonesian National Health Service (NHS) is part of Indonesia’s national social security system. Its implementation is full of problems, such as the rejection of patients, the NHS payment which is lower than the real health cost, sanctions, fines, etc. The Indonesian National Social Security System, especially the NHS services, was established by the state to give social protection to its citizens. The Black Swan Theory is based on the presumption that all swans are white, thus in this case, the Indonesian NHS is truly a program aimed to give social security in the health sector, just as the general conditions of social securities applied in other countries. This research studies this theory to explore the paradoxes which happen in the Indonesian NHS to find the black swan. In this case, the black swan is a paradoxical symbol regarding the regulations and the problems of the Indonesian NHS. This research uses the juridical-doctrinal or the normative method and is descriptive research with a qualitative approach. Based on the Black Swan theory, this research tries to find paradoxical, extreme, and unpredictable discrepancies in the Indonesian NHS. It is found that the Indonesian NHS is a black swan or unpredicted according to black swan theory. The objectives, practices, and regulations of this NHS are truly different from the NHS which is supposed to be given to the Indonesians. It transfers the government’s burden in establishing the health service and the rights of the citizens to the citizens, coupled with the threat of sanctions which is unknown in NHS. The applied Indonesian NHS has an extensive impact on hundreds of millions of Indonesian citizens.

Barriers and facilitators for implementation of a national recommended specialty core-curriculum across UK medical schools: a cross-sectional study using an online questionnaire

ObjectivesThe National Health Service (NHS) Long-Term plan published in 2019 set out healthcare reforms to meet the healthcare demands of UK. Undergraduate specialty core-curricula like dermatology aligns well to the...

Pregnancy-related lumbopelvic pain: Exploring the use of digital media for condition-related information provision

Background: Online health information-seeking is thought to be common among pregnant women, and the use of digital media has been widely adopted. Women with pregnancy-related lumbopelvic pain (PLPP) are often disappointed with the volume and content of condition-related information offered by their healthcare providers and alternative modes of information provision therefore need to be explored. The widespread adoption of digital media suggests that such platforms may provide a convenient alternative for information delivery. Aims of this study: To explore the PLPP-related information-seeking practices of women experiencing this condition and the attitudes of National Health Service (NHS) service users and healthcare professionals towards the use of digital media for PLPP-related information provision. Methods: Multi-method qualitative study: individual semi-structured interviews with seven NHS service users and two single-profession focus groups, one with six NHSbased midwives and one with four NHS-based physiotherapists. A framework method of thematic analysis was used. No member checking was undertaken. Results: All service users were aged 21-36 years, with gestational age 10 years post-qualification and had experience of an antenatal clinic setting. Two physiotherapists were 5-10 years post qualification, two were >10 years postqualification. All had relevant experience of treating women with PPLP. Searching online for condition-related information was reported by all service users and complex drivers for this behaviour were described. All stakeholder groups shared concerns about the quality and trustworthiness of PLPP-related information available online. The use of apps for condition-related information provision was viewed positively by all groups, but the majority of service users stated a lack of trust in health information obtained via social media. Conclusion: The development of an app-based intervention to facilitate the management of PLPP is supported by this study and is therefore worthy of further exploration.

The STAR care pathway for patients with pain at 3 months after total knee replacement: a multicentre, pragmatic, randomised, controlled trial

SummaryBackgroundApproximately 20% of people experience chronic pain after total knee replacement, but effective treatments are not available. We aimed to evaluate the clinical effectiveness and cost-effectiveness of a new care pathway for chronic pain after total knee replacement.MethodsWe did an unmasked, parallel group, pragmatic, superiority, randomised, controlled trial at eight UK National Health Service (NHS) hospitals. People with chronic pain at 3 months after total knee replacement surgery were randomly assigned (2:1) to the Support and Treatment After Replacement (STAR) care pathway plus usual care, or to usual care alone. The STAR intervention aimed to identify underlying causes of chronic pain and enable onward referrals for targeted treatment through a 3-month post-surgery assessment with an extended scope practitioner and telephone follow-up over 12 months. Co-primary outcomes were self-reported pain severity and pain interference in the replaced knee, assessed with the Brief Pain Inventory (BPI) pain severity and interference scales at 12 months (scored 0–10, best to worst) and analysed on an as-randomised basis. Resource use, collected from electronic hospital records and participants, was valued with UK reference costs. Quality-adjusted life-years (QALYs) were calculated from EQ-5D-5L responses. This trial is registered with ISRCTN, ISRCTN92545361.FindingsBetween Sept 6, 2016, and May 31, 2019, 363 participants were randomly assigned to receive the intervention plus usual care (n=242) or to receive usual care alone (n=121). Participants had a median age of 67 years (IQR 61 to 73), 217 (60%) of 363 were female, and 335 (92%) were White. 313 (86%) patients provided follow-up data at 12 months after randomisation (213 assigned to the intervention plus usual care and 100 assigned to usual care alone). At 12 months, the mean between-group difference in the BPI severity score was −0·65 (95% CI −1·17 to −0·13; p=0·014) and the mean between-group difference in the BPI interference score was −0·68 (−1·29 to −0·08; p=0·026), both favouring the intervention. From an NHS and personal social services perspective, the intervention was cost-effective (greater improvement with lower cost), with an incremental net monetary benefit of £1256 (95% CI 164 to 2348) at £20 000 per QALY threshold. One adverse reaction of participant distress was reported in the intervention group.InterpretationSTAR is a clinically effective and cost-effective intervention to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery.FundingNational Institute for Health Research.

Practitioner perspectives on best practice in non-treatment factors that support the delivery of repetitive transcranial magnetic stimulation (rTMS) for depression.

Accessible SummaryWhat is known about the subject? The practices of mental health nurses in the administration of repetitive transcranial magnetic stimulation (rTMS) treatments for depression in outpatient clinic are crucial for patient outcomesTo date, most research has focused directly on procedural aspects of treatment delivery with limited focus on the delivery of holistic care and treatment.There is a lack of best practice guidance based on the experiences of those involved in clinical delivery to inform and improve rTMS practices What this paper adds to existing knowledge? This study provides unique insights into service and personalized non‐treatment factors associated with rTMS delivery that may reduce stress and improve the experiences of rTMS patientsIt reviews and updates understanding of the factors that contribute to the delivery of effective rTMS. What are the implications for practice? The need to apply findings for the development of best practice guidanceFactors to improve practice include (a) rTMS machine demonstrations; (b) constructive, individualized, friendly, and therapeutic conversations; (c) a relaxing, comfortable, 'homely' physical environment; (d) long term supportive management; and (e) careful engagement of nursing and support staff.

Early medical abortion by telemedicine in the United Kingdom: a costing analysis.

To determine the potential cost savings resulting from the introduction of routine early medical abortion (EMA) at home by telemedicine in the UK. A costing study. The UK. Women in 2020 undergoing EMA provided by three independent abortion providers and two National Health Service (NHS) abortion clinics. Computation of the costs of each abortion procedure and of managing failed or incomplete abortion and haemorrhage requiring blood transfusion. Cost savings. Overall estimated cost savings are £15.80 per abortion undertaken by independent abortion providers, representing a saving to the NHS of over £3 million per year. Limited data from NHS services resulted in an estimated average saving of £188.84 per abortion. Were telemedicine EMA to become routine, an increase in the number of women eligible for medical rather than surgical abortion, and a reduction in adverse events resulting from earlier abortion, could result in significant cost savings. Early medical abortion at home using telemedicine could save the NHS £3 million per year.

Optimising the health-care experiences of babies, children, and young people

The views of children and young people are too often missing from discussions about their care. The 2021 National Institute for Health and Care Excellence (NICE) guideline on babies, children, and young people's experience of health care aims to optimise the health-care experiences of these populations and ultimately improve their health outcomes and wellbeing. 1 National Institute for Health and Care ExcellenceBabies, children and young people's experience of healthcare NICE guideline (NG204). https://www.nice.org.uk/guidance/ng204Date: Aug 25, 2021 Date accessed: August 31, 2021 Google Scholar Given that almost 10 years have passed since parallel guidelines were published on adults' experiences of health care, 2 National Institute for Health and Care ExcellencePatient experience in adult NHS services: improving the experience of care for people using adult NHS services: clinical guideline. https://www.nice.org.uk/guidance/cg138Date: February, 2012 Date accessed: August 31, 2021 Google Scholar this new guideline for babies, children, and young people in the UK who access the National Health Service (NHS) or local authority commissioned health-care services is welcome, if overdue. The guidance is particularly important because children and young people report less positively about their experiences of inpatient care than their parents, including feeling safe, pain relief, privacy, and involvement in decisions. 3 Hargreaves DS Sizmur S Pitchforth J et al. Children and young people's versus parents' responses in an English national inpatient survey. Arch Dis Childhood. 2018; 103: 486-491 Crossref PubMed Scopus (18) Google Scholar

Improvement in Renal Function in Participants in the First UK National Health Service (NHS) EndoBarrier Service for Uncontrolled Diabesity

Aims: EndoBarrier, a 60cm proximal intestinal liner, endoscopically implanted for up to one-year, reduces weight and HbA1c. As the risk of progressive chronic kidney disease (CKD) is increased by high BMI, we assessed the impact of EndoBarrier on renal function. Methods: Between October 2014 and November 2017 we implanted EndoBarriers in 62 patients with sub-optimally controlled diabesity in our NHS service; by November 2018 all were explanted. Clinical and laboratory outcomes, including routinely performed kidney function testing by serum creatinine and MDRD eGFR, were collected in a registry Results: In 61 patients (aged 51.4±7.2 years, 54.1% male, 57.4% europid, diabetes duration 12.0 (8.0-19.5) years, 57.4% insulin-treated, BMI 41.9±7.4 kg/m2) with implant and explant data, weight fell by 15.9±8.5 kg from 122.6±27.9 to 106.7±28.9 kg (p<0.001), BMI from 41.9±7.4 to 36.2±7.6 kg/m2 (p<0.001) and systolic blood pressure (BP) from 138.5±15.0 to 125.8±14.6 mmHg (p<0.001), mean±SD. HbA1c fell by 23.7±21.4 mmol/mol from 80.2±22.5 to 56.5±11.5 mmol/mol(p<0.001), cholesterol from 4.7±1.4 to 3.9±0.9 mmol/L (p<0.001) and alanine-aminotransferase (ALT – a marker of liver fat) from 33.2±19.8 to 19.5±11.4 U/L (p<0.001). In the 35 insulin-treated patients median (IQR) insulin dose reduced from 100 (54-140) to 40 (0-70) units (p<0.001) with 10/35 (28.6%) discontinuing insulin. With regard to renal function, mean±SD serum creatinine improved by 5.5±15.4 μmol/L from 91.7±47.7 to 86.2±45.7 μmol/L (p=0.007) and estimated-Glomerular-Filtration-Rate (abbreviated MDRD equation) improved by 5.8±10.7 ml/min/1.73m2 from 84.3±25.2 to 90.1±26.4 ml/min/1.73m2 (p<0.001). Five patients had raised serum creatinine (>133 μmol/L) prior to Endobarrier; after implantation in four of these creatinine reduced and in two normalised. The four patients with renal impairment who sustained improvement had large weight loss (19.3-34.4 kg), the patient without improvement had only 6.6 kg weight loss. Conclusion: As well as previously documented improvements in weight, HbA1c, BP, ALT and cholesterol, EndoBarrier was associated with improvements in renal function. These observational findings warrant further investigation through prospective study of the impact of such bariatric interventions on progressive CKD.

Breathing Synchronised Hypoglossal Nerve Stimulation with Inspire for Untreated Severe Obstructive Sleep Apnoea/Hypopnoea Syndrome: A Simulated Cost-Utility Analysis from a National Health Service Perspective.

BackgroundHypoglossal nerve stimulation (HNS) with Inspire is a novel treatment indicated for moderate or severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS), intolerant to or unable to be treated with continuous positive airway pressure (CPAP).ObjectiveThe aim of this study was to assess the cost effectiveness of treating moderate or severe OSAHS, in patients intolerant to CPAP, with HNS, compared with standard care, from a National Health Service (NHS) perspective.MethodsA cohort state transition model was developed to compare HNS with Inspire with no treatment in UK adult patients with moderate or severe OSAHS who have previously tried and have not responded to CPAP therapy. Published literature was applied in the model to estimate incremental cost-effectiveness ratios (ICERs; 2019 Great British pounds per quality-adjusted life-year [QALY] gained), from an NHS and personal social services (PSS) perspective, over a cohort’s lifetime.ResultsThe model base-case predicts that patients undergoing HNS will incur lifetime costs of £65,026 compared with £36,727 among untreated patients. The HNS cohort would gain 12.72 QALYs compared with 11.15 QALYs in the no-treatment arm. The ICER of treating severe OSAHS with HNS is therefore estimated to be £17,989 per QALYs gained. Probabilistic sensitivity analysis found that at a threshold of £30,000/QALY, HNS has a 69% probability of being cost effective. Limitations of the model include uncertainty around the utility data that were not sourced directly from HNS clinical trials. There is further uncertainty in the relationship between change in the Apnoea-Hypopnoea Index (AHI) and reduction in ischaemic heart disease and stroke because of difficulty capturing the reduction in risk over a long time horizon in studies.ConclusionsOver a patient’s lifetime, HNS with Inspire is expected to be cost effective when compared with no treatment in patients with severe OSAHS who have tried and have not responded to CPAP, from an NHS perspective.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-021-00266-7.

Waiting list eradication in secondary care psychology: Addressing a National Health Service blind spot

Waiting times for secondary care psychological therapy remain a 'blind spot' in serious mental illness (SMI) provision, and their reduction is a priority within the National Health Service (NHS) Five Year Forward View. The paper describes the eradication of waiting times within a community-based NHS service and the effectiveness of strategies whilst examining help-seeking behaviour, compliance and therapeutic need. Analyses are reported for treatment compliance and therapeutic outcomes for 208 waiting-list cohort individuals seen by the SMI psychology service over an 18-month period between October 2014 and March 2016. No significant clinical or demographic differentiation between individuals who successfully completed therapy compared to those who disengaged was observed. Despite an average 2.20-year waiting time, this alone did not significantly impact engagement with psychological treatment and all psychological therapies provided led to a significant clinical improvement and no individuals who completed therapy required re-referral at 12-month follow-up. If imposed appropriately over a suitable time frame evidence-based practice coupled with effective operationalization can result in efficient needs-led psychological provision within SMI and secondary care. Potentially debilitating waiting times for service users and other referring professionals can be avoided, whilst psychology provision retains a flexible, formulation-based and person-centred approach.

Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets

ObjectivesTo analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.DesignRetrospective cohort analysis of national datasets with application of...

What effect will the COVID-19 pandemic have on urogynecology services in the United Kingdom?

What effect will the COVID-19 pandemic have on urogynecology services in the United Kingdom?

Cognitive stimulation therapy for dementia: Provision in National Health Service settings in England, Scotland and Wales.

Objectives: Cognitive stimulation therapy (CST) is a brief, non-pharmacological intervention for people with dementia, with an established evidence base for improving cognition and quality of life. It is widely implemented in National Health Service (NHS) settings, but little is known about its naturalistic use. The aim of this survey was to identify and explore inclusion criteria, dose and quality of CST across services in Great Britain (England, Scotland and Wales).Methods: All NHS memory clinics and services for people with dementia were contacted and asked to complete a mixed methods online survey on CST delivery in their service. Questions were centred on who provided CST, who received CST, the dose of CST and any outcomes that were routinely measured.Results: A total of 57/186 services responded, giving a response rate of 30.7%. While the majority reported offering CST (87.7%), there was variability in how this was delivered. Differing inclusion criteria included the use of varying cognitive and behavioural outcome measures, and CST was reported as being offered once and twice weekly. Services also differed in how they evaluated the quality of CST and how this evidence was incorporated for future sessions.Conclusion: While there was a low response rate, this survey indicates that there is significant variability in how CST is used in clinical practice, with many trusts not adhering to the evidence base. To ensure that people with dementia are consistently offered evidence-based, high-quality CST across NHS settings, further standardisation of inclusion criteria, dose and outcomes is needed.

The cost-effectiveness of transurethral resection of the prostate vs thulium laser transurethral vaporesection of the prostate in the UNBLOCS randomised controlled trial for benign prostatic obstruction.

To determine the cost-effectiveness of the current 'gold standard' operation of transurethral resection of the prostate (TURP) compared to the new laser technique of thulium laser transurethral vaporesection of the prostate (ThuVARP) in men with benign prostatic obstruction (BPO) within the UK National Health Service (NHS). The trial was conducted across seven UK centres (four university teaching hospitals and three district general hospitals). A total of 410 men aged ≥18years presenting with either bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO, and suitable for surgery, were randomised (whilst under anaesthetic) 1:1 to receive the TURP or ThuVARP procedure. Resource use in relation to the operation, initial inpatient stay, and subsequent use of NHS services was collected for 12months from randomisation (equivalent to primary effectiveness outcome) using hospital records and patient questionnaires. Resources were valued using UK reference costs. Quality adjusted life years (QALYs) were calculated from the EuroQoL five Dimensions five Levels (EQ-5D-5L) questionnaire completed at baseline, 3- and 12-months. Total adjusted mean costs, QALYs and incremental Net Monetary Benefit statistics were calculated: cost-effectiveness acceptability curves and sensitivity analyses addressed uncertainty. The total adjusted mean secondary care cost over the 12months in the TURP arm (£4244) was £9 (95% CI -£376, £359) lower than the ThuVARP arm (£4253). The ThuVARP operation took on average 21min longer than TURP. The adjusted mean difference of QALYs (0.01 favouring TURP, 95% CI -0.01, 0.04) was similar between the arms. There is a 76% probability that TURP is the cost-effective option compared with ThuVARP at the £20000 per QALY willingness to pay threshold used by National Institute for Health and Care Excellence (NICE). One of the anticipated benefits of the laser surgery, reduced length of hospital stay with an associated reduction in cost, did not materialise within the study. The longer duration of the ThuVARP procedure is important to consider, both from a patient perspective in terms of increased time under anaesthetic, and from a service delivery perspective. TURP remains a highly cost-effective treatment for men with BPO.

COVID-19: digital equivalence of health care in English prisons

COVID-19: digital equivalence of health care in English prisons