NHS Care Research Articles

Enhanced Care Units: Guidance on development and implementation within Acute Medicine.

The Society for Acute Medicine (SAM) and Intensive Care Society (ICS) have produced joint guidance on the standards of care and infrastructure required to deliver enhanced care within Acute Medicine. The cohort of patients this relates to are in the most part already being looked after on the AMU, but co-location and providing enhanced monitoring and nursing input will ensure safe, high-quality care can be delivered to them. We strongly support the development of enhanced care units, whilst clearly acknowledging that they are not a replacement for critical care where that is indicated. Enhanced care and critical care complement each other and will help foster the close working between the two specialties that modern acute care requires. This guidance draws on expertise and existing relevant guidance from the two societies, alongside that from the Faculty of Intensive Care Medicine (FICM), British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and NHS England / Improvement (NHSE/I). We recognise this is an area with limited evidence and so will aim to review it regularly as the knowledge and experience in this area increases.

Language matters: The importance of person‐first language and an introduction to the People First Charter

Language matters: The importance of person‐first language and an introduction to the People First Charter

British-Bangladeshi Muslim men: removing barriers to mental health support and effectively supporting our community

Abstract In England, Bangladeshi men are amongst the lowest number of people referred to primary care NHS Talking Therapies services and amongst the most likely to have deteriorated (NHS Digital, 2020). Factors related to culture, religion and gender influence stigma and help-seeking (Robinson et al., 2011). Furthermore, a lack of knowledge from services and professionals on cultural understandings of mental distress facilitate a failure to fully understand the needs of individual populations (Faheem, 2023). The aim of this research study was to qualitatively explore stigma and help-seeking for mental health difficulties, within British-Bangladeshi Muslim men in London. Recruitment consisted of men aged 22–59 years, experiencing symptoms of anxiety and/or depression but not accessing formal support. Ethical approval was obtained from Royal Holloway, University of London. After an online screening questionnaire, individual semi-structured video interviews were completed between May and October 2020. Reflexive thematic analysis presented six over-arching themes: ‘different understanding of mental health’, ‘traditional cultural expectations’, ‘fear and loss’, ‘coping resources’, ‘barriers to access’ and ‘community outreach and collaboration’. Many factors were highlighted as barriers accessing support, such as stigma and trust in services. Key practice implications are highlighted for services and practitioners. Professionals must understand the factors which impact the wellbeing of Bangladeshi men, how to better meet the needs of the community, and remove barriers to help. Participants also suggested initiatives to raise mental health awareness and reduce stigma, as an inclusive approach is needed with greater listening to communities and partnerships with local authorities. Key learning aims (1) To better understand the needs of the population and factors which impact wellbeing. (2) To consider the muti-faceted barriers to access mental health support, such as CBT, and how to address these. (3) To unpack what stigma means (internally and externally) for men in the population. (4) How to support low- and high-intensity CBT practitioners to better work therapeutically to support Bangladeshi men.

REFRAME, REFORM, AND TRANSFORM: POLICY APPROACHES TO IMPROVE NURSING HOME QUALITY IN THE UNITED STATES

Abstract Nursing homes (NHs) are one of the most heavily regulated industries in the United States. However, concerns about quality of care remain, especially for more vulnerable residents, including those with dementia. Concerns only increased during recent natural disasters and the COVID-19 pandemic. Community and industry advocates have suggested diverse reforms that prompted new federal policies. This study poses the following research questions: (1) How do federal policies compare with proposals by community (staff and patient advocates) and industry (NH) advocates to improve quality of care in NHs before and during the pandemic; and (2) How do federal policies address micro, mezzo, and macro level issues? To address these questions, this study employs a multi-level comparison case study design. Primary data includes systematically collected and analyzed federal bills, CMS regulations, and community and industry reports, press releases, and website data from 2018 through 2022. Findings revealed that policy proposals fell into three categories: reframe, reform, and transform. Reframe approaches included minimal transformation at the micro-level. Reform approaches involved more mezzo and macro-level changes. Transform approaches proposed significant structural changes at the macro-level. Community advocates presented far more transformative changes than industry advocates and federal policymakers. Federal policies focused on reframe and reform solutions at the micro level and rarely proposed transforming macro-level structures (e.g., workforce structural inequities). This study has important implications for research, policy, and practice by exposing limitations and strengths of proposed solutions for addressing resident care and concludes with suggestions for better aligning with community advocates.

OP76 “Thunderbirds Are Go!” Rapid Response HTA Outputs For COVID-19

IntroductionThe COVID-19 pandemic has highlighted the need for rapid assessment of potential health technologies that can improve health outcomes in COVID-19 patients, as well as helping pressurized health service provision. Medical technologies play a key role in the COVID-19 pandemic, especially diagnostic tests and respiratory technologies. This study evaluates the rapid response work that the medical technology evaluation programme (MTEP) at the National Institute for Health and Care Excellence (NICE) has done in response to the COVID-19 pandemic.MethodsCompanies routinely submit medical technologies for evaluation by NICE through HealthTech Connect, which is an online portal for devices, diagnostics and digital technologies intended for use in the NHS or wider United Kingdom health and care system. During the COVID-19 pandemic, companies were able to use a designated email address if they perceived their technology may benefit the healthcare system regarding the COVID-19 pandemic. This new system bypassed the usual full registration and data submission. All technologies were reviewed that were submitted via HealthTech connect and email between March 2020 and June 2021.ResultsDuring this period, 20 technologies were submitted to MTEP. Most of these technologies were submitted via email. These technologies consisted of a mix of digital, diagnostic, and respiratory technologies. Seven technologies were selected for a rapid COVID-19 MedTech innovation briefing (MIB), with one specifically addressing issues around waiting lists because of knock-on effects of COVID-19 restricting normal clinical work. A further six technologies were not selected because of limited evidence, while one was not selected because it was not perceived as innovative. The other five technologies were progressed as normal MIBs as there was not enough evidence of potential benefits related to COVID-19 to expedite to a rapid COVID-19 MIB. In total, two technologies were selected for medical technology guidance (myCOPD and Anaconda) and are currently in development.ConclusionsMTEP has responded to the COVID-19 pandemic by prioritising and producing rapid COVID-19 MIBs on technologies to improve health and social care.

Designing person-centred technologies to support patients undergoing cancer surgery: a pharmacist-led, qualitative study

Abstract Introduction Lifestyle changes made during the pre-operative period can positively influence post-operative outcomes and the overall success of cancer surgeries.1 Digital technologies (including smartphone apps and fitness trackers) which support patients with physical activity and rehabilitation advice present an opportunity to support surgical patients remotely.2 However, little is known about the best way to design or provide these digital technologies in a person-centred manner. In order to develop effective digital strategies for this unique patient cohort, it is important to first understand in what way(s) do cardiothoracic cancer surgery patients want to be supported with technology.3 Aim To understand how digital technologies could be designed and delivered to better support patients undergoing cancer surgery, specifically: 1) what support do patients want from technologies, 2) how do they want to use them, and 3) when should they be implemented pre- and/or post-operatively? Methods The EQUATOR guidelines and COREQ checklist were followed. Pre- and post-operative patients attending cardiothoracic cancer surgery clinics within one large teaching hospital in the North of England were invited to take part. Purposive sampling was employed to recruit a representative sample of patients. Semi-structured interviews took place between September 2020-February 2021, during the coronavirus pandemic; interviews were conducted over the telephone or via video call-based software, and were audio-recorded and transcribed verbatim. Interviews included questions on participant surgical experience, behaviour change and perspectives on digital technologies. Reflexive thematic analysis enabled the development of themes from the data. QSR NVivo software (Version 12) facilitated data analysis. The Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualisation. Ethical approval was obtained from the NHS Health Research Authority (HRA) and Care Research Wales (reference: 19/NE/0318). Results Sixteen participants were recruited; these included 9 females, with 6 interviews being ran via Zoom®, and an average age for all participants of 65-years (SD 8.29). Four themes were developed from the data that related to the design and delivery of person-centred technologies in order to best meet the needs of patients undergoing cardiothoracic cancer surgery; these centred on: (i) “getting the technology to tell me, guide me and encourage me”; (ii) “tracking me and supporting me to reach my goals”; (iii) “feeling comfort in knowing I’m not alone”; and (iv) “getting the timing right for me”. Discussion/Conclusion This study is one of the first in this patient cohort to involve pre- and post-operative participants. It provides key insights to address knowledge gaps relating to the design and optimisation of person-centred digital technologies for patients undergoing surgery for cardiothoracic cancer. We acknowledge some limitations with our work; whilst we did not sample participants by socioeconomic status, it is possible that different socioeconomic classes may have varied experiences with technologies. Our focus was solely cardiothoracic cancer surgery and thus findings may not be generalisable to other surgical procedures. These findings have the potential to shape and influence future work on the co-design and optimisation of person-centred digital health technologies in modern healthcare settings.

Avon Community-Acquired Pneumonia (AvonCAP) Surveillance Study: A Pan-pandemic Acute Lower Respiratory Tract Disease Surveillance Study, and the linked records of the participants in the Avon Longitudinal Study of Parents and Children (ALSPAC)

This data note describes the linking of records of the Avon Community-Acquired Pneumonia (AvonCAP) Surveillance Study – A Pan-pandemic Acute Lower Respiratory Tract Disease Surveillance Study (ISRCTN: 17354061), with the participants of the Avon Longitudinal Study of Parents and Children (ALSPAC – also known as ‘Children of the 90s’). These records were obtained from a database created specifically by AvonCAP operating within the two acute care NHS Trusts in Bristol, which is the centre of the ALSPAC study catchment area. These two trusts are the (a) North Bristol NHS Trust (NBT) based at Southmead Hospital (SMH) and (b) the University Hospitals Bristol and Weston NHS Foundation Trust (UHBWT) based at Bristol Royal Infirmary (BRI). The AvonCAP database was updated by staff using a combination of clinical records and self-reporting by the participant, which was unable to be independently verified. Data was collected using the REDCap (Research Electronic Data Capture) software program. Software code was created to transform the original files into a single data base which was reviewed for data-completeness and for its potential value as a research resource. The AvonCAP records provide a contemporaneous record of a subset of the ALSPAC cohort who experienced Lower Respiratory Tract Disease. It is available for research and may be used in conjunction with other ALSPAC data.

Recurrent posterior fossa group A (PFA) ependymoma in a young child with constitutional mismatch repair deficiency (CMMRD).

Recurrent posterior fossa group A (PFA) ependymoma in a young child with constitutional mismatch repair deficiency (CMMRD).

No stability without health: time to give back to NHS and social care staff

No stability without health: time to give back to NHS and social care staff

Teeth and gums in diabetes

Teeth and gums in diabetes

The Interactive Effects of Post-Traumatic Stress Symptoms and Breathlessness on Fatigue Severity in Post-COVID-19 Syndrome.

Background: Post-traumatic stress symptoms (PTSS) and breathlessness have been well documented in the acute phase of COVID-19 as well as in Post-COVID-19 Syndrome (PCS), commonly known as Long-COVID. The present study aimed to explore whether PTSS and breathlessness interact to exacerbate fatigue among individuals recovering from PCS, similar to the effects evidenced in other health conditions that feature respiratory distress.. Methods: Outcome measures were collected from 154 participants reporting persistent fatigue following acute COVID-19 infection who were enrolled in a 7-week rehabilitation course provided by the Primary Care Wellbeing Service (PCWBS) in Bradford District Care NHS Foundation Trust (BDCFT). Results: Hierarchical multiple linear regression revealed that fatigue severity was associated with a significant interaction between PTSS and breathlessness, even when controlling for pre-COVID health related quality of life (HRQoL), age, symptom duration and hospital admittance during the acute phase. Furthermore, improvements in fatigue following rehabilitation were significantly associated with improvements in PTSS. Conclusions: PTSS may be an important therapeutic target in multidisciplinary rehabilitation for reducing fatigue in the recovery from PCS. It is therefore important that treatment for PCS takes a biopsychosocial approach to recovery, putting emphasis on direct and indirect psychological factors which may facilitate or disrupt physical recovery. This highlights the need for all PCS clinics to screen for PTSD and if present, target as a priority in treatment to maximise the potential for successful rehabilitation.

The voice of the child in dental care plans: a service evaluation.

Introduction The voice of the child (VOC) is vitally important in the dental setting as 'patient participation' is a key clinical governance pillar. A recent Care Quality Commission review of Bradford District Care NHS Foundation Trust identified 'the voice of the patient was not always clear in the care plans stored on the electronic system'.Aims To determine if Bradford District Care NHS Foundation Trust's Community Dental Service was recording and acting upon the voice of children and young people (CYP) regarding their dental care.Methods Retrospective case note analysis of CYP who had completed a course of treatment between January and March 2019. Patient notes were reviewed to determine if key indicators of the VOC were included. Verbal communication, communication barriers and evidence treatment options were discussed with CYP wherever feasible and whether comments by CYP were used to tailor their care.Results Review of 200 patients aged 4-16 years old found that no CYP notes recorded all key VOC indicators. In total, 36% of dentists recorded if the CYP had verbal communication or otherwise; 26% of notes evidenced treatment options had been discussed; and 11% of notes evidenced that CYP comments were used to tailor their care.Discussion Presentation of results to clinicians locally highlighted the importance of the VOC and the need to improve documentation. Subsequently, implementation of a modified clinical note pro forma has taken place which includes VOC indicators, thus providing evidence that CYP are being listened to and, where feasible, their opinions used to tailor care.Conclusion The VOC was not routinely being documented in clinical notes, thus it was difficult to prove/disprove if the VOC was being listened to.

Mental health and wellbeing

The Zero Suicide Alliance (ZSA) is a charity hosted by Mersey Care NHS Foundation Trust, a mental health and community trust with a zero suicide ambition. ZSA works in collaboration with NHS trusts, non-profit organizations, local authorities, businesses, and individuals to raise awareness of suicide and its contributing factors. The aim is to break the stigma that surrounds suicide and enable leaders to drive meaningful action to help prevent suicide in the UK and beyond.

Severe COVID-19 anxiety among adults in the UK: protocol for a cohort study and nested feasibility trial of modified cognitive–behavioural therapy for health anxiety

IntroductionSome people are so anxious about COVID-19 that it impairs their functioning. However, little is known about the course of severe COVID-19 anxiety or what can be done to help...

The psychological therapy preferences of patients who hear voices

ABSTRACT Background Voice-hearing is a common, phenomenologically diverse, experience across different mental health diagnoses. Patient preferences for psychological therapies are helpful in informing treatment commissioning and provision, especially in the context of complex and variable experiences like voice-hearing. There is, however, very limited evidence as to the psychological therapy preferences of transdiagnostic voice-hearers. Methods Three-hundred and thirty-five voice hearers were recruited from secondary care NHS mental health services across England, between 2020 and 2022. Participants completed a questionnaire battery, involving a psychological therapy preference survey. Participants ranked their preferences across categories of practical, technical and relational therapy elements. Therapy preferences were examined using non-parametric ANOVAs and the significance of pairwise comparisons between different therapy elements. Results There were significant differences in all categories of preference elements. Clear hierarchies of preference were observed in therapy location, timing, delivery, and therapy approach. Preferences were evident, albeit with less clear vertical hierarchies, for number of sessions, mode, therapist qualities, and therapy focus, tasks and outcomes. Discussion Overall, participants expressed a preference for individual, face-to-face intervention of at least nine sessions, with a highly experienced therapist and a core focus on enhancing coping strategies for voice-hearing experiences.

315 The Impact of COVID-19 on Training Opportunities and Long-Term Career Aspirations of UK Based Doctors

Abstract Background The onset of the COVID-19 pandemic in November 2019 has witnessed a reactive ‘covidisation’ of NHS care services. Training opportunities for junior doctors have suffered and psycho-social impacts are anticipated. This study will seek to assess these factors and their impact on doctors’ career aspirations. Method A five question survey was disseminated to 350 junior doctors in the Yorkshire and Humber deanery. 115 responses were gained; 78 Foundation doctors (FY1–2), 24 Core/Early specialist trainees (CT 1–2/ST1–2) and 13 Specialist Registrars. Results Negative impacts on training include teaching commitments (61.7%) and work-based assessments (48%). A change in treatment protocols (67%) and acute referrals (58%) were also identified. Concerns regarding personal wellbeing were highlighted by 65%, with a greater willingness to consider taking time out of training (32%) or leave UK medical practice altogether (22%). Discussion The number of doctors immediately progressing into specialist training has almost halved. COVID era practice has impacted on training opportunities, clinical experience, and the ability to meet ARCP requirements. It has also led to high levels of personal concern amongst junior doctors surveyed. These factors may stimulate a greater willingness to take time out of training (1/3) or leave UK based medical practice (1/4). Conclusions It is evident that new and existing concerns amongst junior doctors have been heightened by COVID-19. This data provides a useful snapshot and may be utilised in ensuring the continued health and robustness of the UK's junior doctor workforce and its ability to meet the evolving challenges of global healthcare.

How do general hospitals respond to people diagnosed with a personality disorder who are distressed: A qualitative study of clinicians in mental health liaison.

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with a personality disorder might be more likely to have physical health problems and be admitted to the hospital. Treatment in hospitals might be complicated by mental health crises or self-injury, and barriers to NHS care may increase the risk of developing further illness with serious consequences. Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Thirteen clinicians working in mental health liaison in the general hospital were interviewed as part of a sequence of research studies. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: This study identified unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in general hospitals. People with a "personality disorder" diagnosis were discriminated against and over- and under-medicated. Mental health liaison clinicians reported limited understanding and skills among general hospital clinicians. People working in general hospitals were fearful of the "personality disorder" diagnosis. Poor care was accepted because general hospital clinicians did not consider themselves to be "mental health trained." WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Clinicians working in mental health liaison need credible knowledge of mental and physical health and medicines. Capability, influence, and high-level interpersonal skills are needed to successfully work across mental health services and the general hospital. More advanced and consultant-level nursing roles in more mental health liaison teams are needed to strengthen this specialist workforce. ABSTRACT: Introduction Literature on "personality disorder" and the general hospital has to date primarily focused on emergency departments. Research on how general hospital inpatient wards respond to people diagnosed with a "personality disorder" has been long overdue. Aim Qualitative telephone interviews were undertaken to explore the views and perspectives of clinicians working in mental health liaison in this final strand of a mixed methods explanatory sequential study. Method Participants were recruited via social media and professional networks by snowball sampling. Data were analysed using a framework approach. Results Four themes were identified: knowledge, understanding, skills, and discriminatory practice; alliances, diplomacy, care, and treatment of people diagnosed with a "personality disorder"; achieving parity of esteem in a disparate healthcare system; and organizational stress, mismatched expectations, and service led decision-making. Discussion There were unjust and avoidable differences in the care and treatment received by people diagnosed with a "personality disorder" in the general hospital. People were discriminated against and routinely over- and under-medicated. Implications for practice Clinicians working in mental health liaison need capacity for partnership working, clinical capability spanning mental and physical health, credibility and influence and high-level interpersonal skills to address the entrenched discrimination of people diagnosed with a "personality disorder."

The health, cost and equity impacts of restrictions on the advertisement of high fat, salt and sugar products across the transport for London network: a health economic modelling study

BackgroundPolicies aimed at restricting the marketing of high fat, salt and sugar products have been proposed as one way of improving population diet and reducing obesity. In 2019, Transport for London implemented advertising restrictions on high fat, salt and sugar products. A controlled interrupted time-series analysis comparing London with a north of England control, suggested that the advertising restrictions had resulted in a reduction in household energy purchases. The aim of the study presented here was to estimate the health benefits, cost savings and equity impacts of the Transport for London policy using a health economic modelling approach, from an English National Health Service and personal social services perspective.MethodsA diabetes prevention microsimulation model was modified to incorporate the London population and Transport for London advertising intervention. Conversion of calorie to body mass index reduction was mediated through an approximation of a mathematical model estimating weight loss. Outcomes gathered included incremental obesity, long-term diabetes and cardiovascular disease events, quality-adjusted life years, healthcare costs saved and net monetary benefit. Slope index of inequality was calculated for proportion of people with obesity across socioeconomic groups to assess equity impacts.ResultsThe results show that the Transport for London policy was estimated to have resulted in 94,867 (4.8%) fewer individuals with obesity, and to reduce incidence of diabetes and cardiovascular disease by 2,857 and 1,915 cases respectively within three years post intervention. The policy would produce an estimated 16,394 additional quality-adjusted life-years and save £218 m in NHS and social care costs over the lifetime of the current population. Greater benefits (e.g. a 37% higher gain in quality-adjusted life-years) were expected to accrue to individuals from the most socioeconomically deprived groups compared to the least deprived.ConclusionsThis analysis suggests that there are considerable potential health and economic gains from restricting the advertisement of high fat, salt and sugar products. The population health and economic impacts of the Transport for London advertising restrictions are likely to have reduced health inequalities in London.

Audit Cycle on Medical Reviews of Seclusion in Medium and Low Secure Learning Disability Units

AimsSeclusion is defined as “the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others”. Patients in seclusion require reviews at the frequency set out in the Mersey Care NHS Foundation Trust policy, “The use of seclusion and long-term segregation” (SD28). This is based on the requirements set out in the Chapter 26 of the Mental Health Act 1983 Code of Practice (2015).This audit will look at whether medical reviews for secluded patients in the secure learning disability wards meet with the expectations set out in the Trust Policy. In doing so, the audit will establish whether medical reviews of seclusion meet and uphold the guiding principles of the Mental Health Act Code of Practice as highlighted in Chapter 26.110.MethodsRetrospective audit that collected data from inpatients on secure learning disability wards in Mersey Care. After reviewing data, we actioned plans which involved educating colleagues working in secure services. This was re audited after three months. One month of seclusion reviews was audited in each cycle, which equated to 39 reviews in the first cycle and 100 reviews in the second.ResultsThe re-audit data showed an improvement in most parameters.Re-audit showed that 66% (34%) of the seclusion reviews had an initial medical review within the first hour. The on call consultant was informed in 60% (50%) of the situations and 4 hourly reviews took place in 66% (50%) of scenarios. All MDT reviews took place within 24 hours, Responsible Clinician was present in 100% (67%) of reviews.34% (33%) of MDT reviews had only 2 MDT members.There was 100% compliance with reviewing physical health in both audits. 100% (90%) of the reviews commented on mental health, 72% (20%) commented on medications used, 51% (39%) of reviews commented on level of observations and 89% (48%) included risk assessment. 95% (92%) of reviews assessed need for continuing seclusion. 84% (59%) of reviews commented on reducing restriction in seclusion.ConclusionThis audit cycle has focused on the quality of medical reviews and not just the frequency. The improvement in practice will strengthen the safeguard provided by these reviews.

An Evaluation of the Prescribing of High Dose Antipsychotic Therapy and Combination Antipsychotic Therapy to Inpatients on the General Adult Wards of Mersey Care NHS Foundation Trust

AimsHigh dose antipsychotic therapy (HDAT) is defined as “a total daily dose of a single antipsychotic which exceeds the upper limit stated in the SPC or BNF or a total daily dose of two or more antipsychotics exceeding the SPC or BNF maximum using the percentage method. Previous audits have looked at HDAT on both a national level (the Prescribing Observatory for Mental Health) and within Mersey Care NHS Foundation Trust. This audit aimed to identify the proportion of patients subject to HDAT and review combination antipsychotic strategies and consideration of Clozapine in patients subject to HDAT.MethodsIn August 2021, data were collected from the eight inpatient wards in Mersey Care NHS Foundation Trust. This involved using the Electronic Prescription and Administration system to identify those prescribed antipsychotics. Following this, the patient's electronic record was scrutinised for documentation of the rationale for HDAT, combination antipsychotics and consideration of Clozapine.Results129 inpatients were identified as being prescribed antipsychotic medication. 21 (16.3%) patients were prescribed combination antipsychotic therapy, with four of these patients (3.1%) being prescribed HDAT. For these four HDAT patients, there was no recorded documentation of discussion of the option of Clozapine. The most common antipsychotic combination was Paliperidone depot with oral Risperidone. 38 out of 129 (29.5%) patients had been considered for Clozapine. Reasons for Clozapine being refused included the patient declining, concerns about non-concordance with oral medication, patients having had a neutropenia on an FBC, the patient being reluctant to have regular blood tests and a patient's comorbidities.ConclusionWhen comparing the proportion of patients subject to HDAT (3.1%) to the previous Trust audit in December 2020 (9.1%), there is a recurrent theme that antipsychotic prescribing practice in Mersey Care is safe, with minimal HDAT. Of note, the figure is significantly lower than the proportion of HDAT patients identified in the 2012 national study (28%). In this audit, none of the patients on HDAT had documented consideration of Clozapine. Three of the four patients were soon to be no longer subject to HDAT which may explain this result. Compared to the Trust's HDAT audit in 2020, the percentage of patients on combination antipsychotic therapy has stayed largely the same - 16.3% compared to 17.4%. The Trust needs to strive to continue minimal HDAT prescriptions and ensure that, in those patients subject to HDAT, there is consideration of and documentation of Clozapine being considered.