NHS Health Research Articles

Involving the public in mental health and learning disability research: Can we, should we, do we?

Introduction Patient and public involvement (PPI) is integral to UK health research guidance; however, implementation is inconsistent. There is little research into the attitudes of NHS health researchers towards PPI. Aim This study explored the attitude of researchers working in mental health and learning disability services in the UK towards PPI in health research. Method Using a qualitative methodology, semi-structured interviews were conducted with a purposive sample of eight researchers. A framework approach was used in the analysis to generate themes and core concepts. Results Participants valued the perspective PPI could bring to research, but frustration with tokenistic approaches to involvement work was also evident. Some cultural and attitudinal barriers to integrating PPI across the whole research process were identified. Discussion Despite clear guidelines and established service user involvement, challenges still exist in the integration of PPI in mental health and learning disability research in the UK. Implications for practice Guidelines on PPI may not be enough to prompt changes in research practice. Leaders and researchers need to support attitudinal and cultural changes where required, to ensure the full potential of PPI in mental health and learning disability services research is realized. Relevance statement Findings suggest that despite clear guidelines and a history of service user involvement, there are still challenges to the integration of PPI in mental health and learning disability research in the UK. For countries where PPI guidelines are being developed, attention needs to be paid to cultural factors in the research community to win "hearts and minds" and support the effective integration of PPI across the whole research process.

DEVELOPMENT AND EVALUATION OF MOBILE APPLICATION FOR PEOPLE WITH YOUNG-ONSET DEMENTIA AND THEIR CARERS

Young Onset Dementia (YOD) defined as the onset of dementia before the age of 65 years is increasingly recognized as an important clinical and social problem with devastating consequences for the patients and those who care for them. YOD is less common than late onset dementia and accessing age appropriate information and services for young people with YOD is limited. Post-diagnostic support for patient and carers to help adjust to the reality of what this may mean in terms of the future is important. We aimed to develop a YOD app which would provide information and support for YOD patients and their carers; and to obtain feedback via focus groups with patient and carers. YOD app was developed, collaboration between Memory Services, National Health Service Trust, NHS Health informatics Service and Common Point. Focus groups with different patient and carers were conducted for feedback on the app which was used to improvise the app before its publication. After undergoing styling, content checking and video-editing the app was published on Apple Store and Google Play Store (for android devices) for free download with search term- YOD dementia (please download to view the app). YOD app developed is used by people with dementia and their carers to access information and provide guidance for self –management with appropriate knowledge and more importantly signposts them to an array of services and organisations that provide specialised support locally, regionally and Nationally. The app enables them to access information from a wide range of sources, in one place, in a timely fashion, at the point when they are ready to this information. It also has fact sheets and links to various websites with more information. The app has been downloaded locally and globally (analytics will be presented).

A cross-sectional study using freedom of information requests to evaluate variation in local authority commissioning of community pharmacy public health services in England

ObjectivesThis study aims to provide a national picture of the extent and nature of public health services commissioned by local authorities (LAs) from community pharmacies across England in financial year...

Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiences.

ObjectiveTo explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic.DesignQualitative interview study.SettingOne National Health Service health board (administrative) area in Scotland.Population or SampleWomen in Scotland who had undergone medical TOP ≤63 days, and self‐managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014.MethodsIn‐depth, semi‐structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method.Main outcome measuresWomen's experiences of self‐management of TOP ≤63 days of gestation.ResultsKey themes emerging from the analysis related to self‐administration of misoprostol in clinic; reasons for choosing home self‐management; facilitation of self‐management and expectation‐setting; experiences of getting home; self‐managing and monitoring treatment progress; support for self‐management (in person and remotely); and pregnancy self‐testing to confirm completion.ConclusionsParticipants primarily found self‐administration of misoprostol and home self‐management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self‐management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol.Tweetable abstractWomen undergoing medical TOP 63 days found home self‐management to be acceptable and/or preferable.

CPD needs of opioid nurse prescribers: A survey

Background: The Misuse of Drugs Act non-medical prescribing legislation permits nurse independent prescribers (NIPs) to prescribe any controlled drug that is within their scope of professional practice. Continuing professional development (CPD) is essential for safe effective prescribing and is required for professional revalidation. This study was conducted to explore the educational requirements of non-medical opioid prescribers. Methods: Informed by a critical realism position, an electronic survey was distributed to 147 NIPs working in a Scottish NHS Health Board. The aim was to identify how many NIPs were prescribing opioids and to explore their CPD requirements regardless of whether they prescribed opioids or not, including preferred method of delivery of education and to explore whether the single competency framework was sufficient to facilitate safe and effective prescribing. Results: The response rate was 46% (n=68). The majority of respondents (69%, n=37) prescribed opioids. Ninety-four percent of respondents (n=64) stated they felt that ongoing education was necessary to ensure safe opioid prescribing practice. Face-to-face methods of learning in small group discussions were the preferred option. Two thirds of the respondents (66%, n=45) felt that there should be protected time for prescribing CPD and 64% (n=27) felt the single competency framework provided a good standard for prescribing CPD. Conclusions: The results from this study suggest that nurses are prescribing opioids in acute and community hospitals. Group opioid education is recommended and using a structured competency framework to inform clinical practice may ensure safe, effective prescribing practice.

O07 National response to an outbreak of hepatitis a associated with men who have sex with men in england, 2016/2017

IntroductionHepatitis A virus (HAV) is a vaccine-preventable infection, mainly travel-associated in the UK. Since July 2016 Public Health England has detected an increase in hepatitis A laboratory notifications in men who have sex with men (MSM). We described the outbreak characteristics to inform implementation of nation-wide control measures.MethodsA confirmed case was defined as a HAV infection with one of three outbreak strains and symptom onset after 31//6/16. Demographics, travel history and sexual behaviours were collected using a questionnaire.ResultsBy February 2017, 73 confirmed cases were detected across England. Of these 58 identified as MSM (median age 36 years) and 28 reported travel within the incubation period, primarily to Spain. 25% reported >1 casual partner in the previous 8 weeks. In addition to supporting the local public health response, PHE collaborated with national STI, HIV and liver associations to refine immunisation recommendations for at-risk MSM and alert front-line clinicians, and worked with the NHS and sexual health charities to raise awareness and promote personal hygiene and immunisation among MSM via social media, posters and leaflets.DiscussionThe outbreak is likely associated with other MSM outbreaks with the same strains in other UK and European countries. The investigation suggests initial multiple importations from abroad followed by secondary sexual transmission within the MSM population in England. This outbreak highlights the need for MSM and healthcare professionals to consider the potential of HAV as a sexually transmitted infection, and the need to consider immunisation of MSMs where recommended.

Geographic distribution of vestibular schwannomas in West Scotland between 2000-2015.

BackgroundAlthough the natural history of vestibular schwannomas (VS) has been previously studied, few studies have investigated associated epidemiological factors, primarily because of the lack of large available cohorts.ObjectiveThe objective of this study was to perform a multi-scale geographical analysis of the period prevalence of VS in West Scotland from 2000 to 2015.MethodsAdults diagnosed with sporadic VS were identified through the National Health Services of West Scotland database and geocoded to the unit postcode. To assess whether the cohort of VS cases could be pooled into a period prevalence measure, the locations of VS cases were analyzed by sex using Cross-L and Difference-K functions. VS period prevalence was examined at two aggregate spatial scales: the postcode district and a coarser scale of NHS Health Boards. The spatial structure of period prevalence within each level of spatial aggregation was measured using univariate global and local Moran’s I. Bivariate local Moran’s I was used to examine the between-scale variability in period prevalence from the postcode district level to the NHS Health Boards levels. Prior to spatial autocorrelation analyses, the period prevalence at the postcode district was tested for stratified spatial heterogeneity within the NHS Health Boards using Wang’s q-Statistic.ResultsA total of 512 sporadic VS were identified in a population of over 3.1 million. Between 2000 and 2015, VS period prevalence was highest within the NHS Health Boards of Greater Glasgow and Clyde, Ayrshire and Arran and the Western Isles. However, at the NHS scale, period prevalence exhibited no spatial autocorrelation globally or locally. At the district scale, Highland exhibited the most unusual local spatial autocorrelation. Bivariate local Moran’s I results indicated general stability of period prevalence across the postcode district to Health Boards scales. However, locally, some postcode districts in Greater Glasgow and Clyde, Ayrshire and Arran exhibited unusually low district to zone spatial autocorrelation in period prevalence, as did the southern parts of the Western Isles. Some unusually high period prevalence values between the postcode district to Health Board scale were found in Tayside, Forth Valley and Dumfries and Galloway.ConclusionGeographic variability in VS in West Scotland was identified in this patient population, showing that there are areas, even remote, with unusually high or low period prevalence. This can be partially attributed to links between primary and tertiary care. Potential genetic or environmental risk factors that may contribute to geographic variation in this disease within Scotland are also a possibility but require further investigation.

Deriving literature-based benchmarks for surgical complications in high-income countries: a protocol for a systematic review and meta-analysis

IntroductionTo improve surgical safety, health systems must identify preventable adverse outcomes and measure changes in these outcomes in response to quality improvement initiatives. This requires understanding of the scope and...

Screening for valve disease in patients with hyperprolactinaemia disorders prescribed cabergoline: a service evaluation and literature review.

The indication for screening for valvular heart disease in patients taking cabergoline is based on evidence from patients with Parkinson's disease on high-dose medication. However, current patients take much lower doses for indications such as hyperprolactinaemia disorders. Contemporary guidelines for echocardiogram monitoring in patients taking cabergoline are conflicting. This study aimed to review current clinical practice in our area regarding echocardiographic screening and to review the literature examining the evidence of valvular heart disease in patients taking lower dose cabergoline. This was a retrospective study of all patients with hyperprolactinaemia disorders prescribed cabergoline in a single UK NHS health board between January 2014 and July 2015. The proportion of patients receiving baseline and follow-up echocardiograms was recorded. A review of the published literature was carried out using the databases EMBASE and Medline to examine the current evidence for the effect cabergoline has on cardiac valves in patients treated for hyperprolactinaemia disorders. The mean age was 51.7 ± 16.5 years with a 64.4% female predominance. The mean duration of therapy was 5.9 years ± 4.1 years. Of the total cohort (n = 45), two (4.4%) patients had an initial baseline echocardiogram and five (13.2%) had follow-up echocardiograms every 24 months. Of the 25 articles identified, 12 showed no clinically significant evidence of valvular dysfunction in the cabergoline group groups. Of the remaining 13 articles, evidence for valvular changes was confined to high cumulative dose cabergoline patients and there was only one confirmed case of 'cabergoline associated valvulopathy' described. Clinically significant valvular dysfunction is uncommon and generally only reported in high cumulative dose treatment groups. We propose that clearer national guidelines are required and that echocardiogram screening be reserved for patients who are high risk, are taking a high weekly dose (≥2 mg cabergoline weekly) or high cumulative dose.

The cost-effectiveness of population Health Checks: have the NHS Health Checks been unfairly maligned?

AimThe English NHS currently has a policy of providing Health Checks to all 40–74 year olds. Administered in primary care, they aim to identify patients at risk of a range of diseases, including diabetes and heart disease, and facilitate care. This study is the first to use observed data on the effectiveness of the Checks to consider whether they represent a cost-effective use of limited NHS resources.Subject and methodsUsing a publicly available evaluation tool we conducted an analysis of the Checks to establish the long-term cost and health-related outcomes of a cohort of patients. The primary focus of the analysis was to establish whether the impact of the Checks on BMI was sufficient to justify their cost.ResultsThe Checks were associated with a reduction in mean BMI of 0.27 (95% CI 0.20 to 0.34) compared to no Check. When applied to the evaluative tool, a small but positive QALY gain of 0.05 per participant was observed, coupled with a reduction in disease-related care costs of £170 ($210 USD). When the estimated cost per Check (£179, $220 USD) is taken into account, we estimate an incremental cost-effectiveness ratio of £900/QALY ($1109 USD/QALY).ConclusionsMuch of the criticism of the Health Checks has focussed on the relatively small average change in risk factors such as BMI. However, this analysis suggests that the significant health and cost-saving benefits from even a modest reduction in mean BMI, coupled with the low costs of the Checks, combine to result in a potentially highly cost-effective policy.

Data linkage of routinely collected electronic health records to characterise risk factors associated with antibiotic resistance in urinary isolates: an exemplar of NHS Scotland’s Infection Intelligence Platform

ABSTRACT
 ObjectivesUrinary tract infections (UTIs) are amongst the most common infections treated in community and hospital settings. Initial antibiotic treatment of UTI is usually empirical, that is, where the prescriber has no definitive information on the organism or its antibiotic sensitivity.. Overall the prevalence of antimicrobial resistance is increasing, and specifically so for antibiotics commonly used for UTI.
 By linking NHS surveillance data to routinely collected administrative health data this study aims to investigate risk factors for antibiotic resistance in urine samples
 ApproachAll positive urine samples included in the “Surveillance of Antimicrobial Resistance in Urinary Isolates in Scotland” dataset in the period from January 2012 to June 2015 (all NHS Health Boards in Scotland submit susceptibility data for up to eleven antibiotics on 400 positive urinary samples per quarter) were analysed. Cases were assigned a resistance status of Sensitive, Resistant or Multi-drug resistant based on the antibiotic susceptibility data recorded.
 Using the NHS Scotland Infection Intelligence Platform all cases were linked to national coverage data: (i) hospital discharge data to create the Charlson score for comorbidity and (ii) patient-level community prescribing data to measure cumulative antibiotic exposure (number of defined daily doses) in the 3 months prior to infection. Risk factors associated with the infection susceptibility to antibiotics were assessed using multivariable multinomial logistic regression.
 Results40,984 positive urine samples were examined. Overall 29.0% were sensitive, 48.1% resistant and 22.9% multi drug resistant. Around a third of the cases (33.9%) had no antibiotic prescribing in the 3 months prior to infection. Age, care home residence and increasing comorbidity were both found to be associated with resistance and multidrug resistance. Cumulative antibiotic exposure had a clear dose-response effect. Those with 1-7DDDs were 1.2 times (95% CI: 1.11-1.29) more likely to have a multidrug resistant infection (compared to a sensitive infection) rising to 7.45 times (95% CI: 95% CI 6.45-8.6) for 29+ DDDs. Similar dose response held for resistant infection but at a lesser scale (1-7DDDs OR=1.36 (95% CI: 1.2-1.5) rising to OR=3.04 (95% CI: 2.38-3.89).
 ConclusionA clear effect of cumulative antibiotic exposure in the community and multidrug resistance in UTI cases has been demonstrated. Such quantification is key to ensuring and supporting robust antimicrobial stewardship policy and will form the evidence base for development of prescribing decision support tools for more patient centred treatment of UTI.

Outcomes in Paediatric Intensive Care Units for Children with Life-Limiting Conditions: A national data linkage study

ABSTRACT
 ObjectiveTo identify children with a Life-Limiting Condition (LLC) who have had an admission to a Paediatric Intensive Care Unit (PICU) in England and their outcomes.
 ApproachData for all children who had had a PICU admission in the UK between 1st Jan 2004 and 31st March 2015 were identified from the PICANet dataset.
 Linkage to inpatient Hospital Episode Statistics (HES) data was undertaken by the NHS Health and Social Care Information Centre for all children who had been resident in England. Their standard algorithm using NHS number, date of birth, sex and postcode was used. All inpatient HES episodes from the financial years 1997/98-2014/15 were received.
 Although the data quality is high in the PICANet dataset, comorbidities are variably coded therefore identifying whether a child has a LLC or not is not possible. A previously developed ICD10 coding framework was used to identify individuals with one or more of these LLC codes in the inpatient HES dataset.
 ResultsA total of 199,548 PICU admissions in the UK for 135,759 individuals occurred during the time period of the study. Data for 43,565 admissions (32,025 individuals) were excluded due to not having been resident in England or poor quality demographic data.
 Data on 103,734 individuals (155,983 admissions) were sent for linkage. Successful linkage occurred in 102,722 individuals (99.4%). Individuals who could not be linked were excluded from the analysis.51.0% of these children had a LLC and these children accounted for 62.7% of the PICU admissions.
 The crude PICU death rate in the children with a LLC was 5.0% (n=4826) compared to 3.1% (n=1786) in those without a LLC. The OR of death in a model adjusted for diagnostic group, sex, age, and expected risk of mortality for children with a LLC was 2.11 (95%CI 1.97-2.27).
 ConclusionsChildren with a LLC account for a large proportion of all PICU admissions in England. Although only one in twenty of these children die in PICU, as death may be expected in this population of children more integration of specialist palliative care with PICU services may allow more choice for children and families.

A framework for public involvement at the design stage of NHS health and social care research: time to develop ethically conscious standards

Plain English summaryResearchers who conduct studies in health and social care are encouraged to involve the public as early as possible in the process of designing their studies. Before their studies are allowed to start researchers must seek approval from a Research Ethics Committee, which will assess whether the study is going to be safe and ethical for patients or healthy volunteers to take part in. The process of ethical review does not consider how researchers work with patients and the public early on to design their studies. Furthermore, there is no requirement for researchers to seek ethical approval for public involvement. However, in our work advising researchers about public involvement we have found that the ways in which researchers involve the public in the design of their studies are sometimes unintentionally unethical, and this is the focus of our paper. We have observed ten areas where ethical issues may arise because of the actions researchers may or may not take and which might consequently have a negative impact. Therefore, we have used these observations to develop a “framework” to help researchers and the public work together at the early design stage in ways that are ethical. Our intention for the framework is to help researchers be mindful of these ten areas and how easily ethical issues can arise. The framework suggests some ways to overcome the potential issues in each of the ten areas. The ten areas are: 1) Allocating sufficient time for public involvement; 2) Avoiding tokenism; 3) Registering research design stage public involvement work with NHS Research & Development Trust Office at earliest opportunity; 4) Communicating clearly from the outset; 5) Entitling public contributors to stop their involvement for any unstated reasons; 6) Operating fairness of opportunity; 7) Differentiating qualitative research methods and public involvement activities; 8) Working sensitively; 9) Being conscious of confidentiality and 10) Valuing, acknowledging and rewarding public involvement.We looked to see whether any other similar approaches to helping researchers address potential ethical issues when working with the public on designing studies have been published and to our knowledge none exist. Our framework is presented as a draft and believe that it would now benefit from input from researchers and the public to gauge how useful it is and whether there are any other possible situations that it might need to cover.The current paper highlights real life examples of how ethical issues can arise during public involvement activities at the research design stage. We refer to “the research design stage” as the time between the generation of the research ideas and when formal permissions to start the work including ethical approval are granted. We argue that although most researchers work ethically at this early stage, some may still benefit from being informed about ethically conscious approaches to involving the public.The paper highlights 10 ethical issues that we have observed with involving the public at the research design stage. We provide examples of these observed scenarios to illustrate the issues and make suggestions for how they can be avoided to help researchers become more ethically conscious when involving the public at the research design stage. Currently the draft framework comprises: 1) Allocating sufficient time for public involvement; 2) Avoiding tokenism; 3) Registering research design stage public involvement work with NHS Research & Development Trust Office at earliest opportunity; 4) Communicating clearly from the outset; 5) Entitling public contributors to stop their involvement for any unstated reasons; 6) Operating fairness of opportunity; 7) Differentiating qualitative research methods and public involvement activities; 8) Working sensitively; 9) Being conscious of confidentiality and 10) Valuing, acknowledging and rewarding public involvement.The draft framework will help researchers to recognise the ethical issues when involving the public and is intended to be used voluntarily in a self-regulatory way. We believe that the draft framework requires further consultation and input from the wider research community and the public before endorsement by national UK bodies such as INVOLVE and the Health Research Authority (HRA).

Improving pregnancy outcome in obese women: the UK Pregnancies Better Eating and Activity randomised controlled Trial

BackgroundObesity in pregnancy is associated with insulin resistance, which underpins many common complications including gestational diabetes mellitus (GDM) and fetal macrosomia.ObjectivesTo assess the effect of a complex behavioural intervention based on diet and physical activity (PA) on the risk of GDM and delivery of a large-for-gestational age (LGA) infant.DesignThree phases: (1) the development phase, (2) the pilot study and (3) a multicentre randomised controlled trial (RCT) comparing a behavioural intervention to improve glycaemic control with standard antenatal care in obese pregnant women. A cost–utility analysis was undertaken to estimate the cost-effectiveness of the health training (intervention) over and above standard care (control).SettingPilot study: antenatal clinics in four inner-city UK hospitals. RCT: eight antenatal clinics in eight UK inner-city hospitals.ParticipantsWomen were eligible for inclusion if they had a body mass index of ≥ 30 kg/m2, were pregnant with a single fetus and at 15+0to 18+6weeks’ gestation, were able to give written informed consent and were without predefined disorders.InterventionThe intervention comprised an initial session with a health trainer, followed by eight weekly sessions. Dietary advice recommended foods with a low dietary glycaemic index, avoidance of sugar-sweetened beverages and reduced saturated fats. Women were encouraged to increase daily PA.Main outcome measuresDevelopment phase: intervention development, acceptability and optimal approach for delivery. Pilot study: change in dietary and PA behaviours at 28 weeks’ gestation. RCT: the primary outcome of the RCT was, for the mother, GDM [as measured by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)’s diagnostic criteria] and, for the infant, LGA delivery (i.e. customised birthweight ≥ 90th centile for gestational age).ResultsDevelopment phase: following a literature meta-analysis, a study of dietary intention questionnaires and semistructured interviews, an intervention based on behavioural science was developed that incorporated optimal and acceptable methods for delivery. Pilot study: the pilot study demonstrated improvement in dietary behaviours in the intervention compared with the standard care arm but no increase in objectively measured PA. Process evaluation demonstrated feasibility and general acceptability. RCT: the RCT showed no effect of the intervention on GDM in obese pregnant women or the number of deliveries of LGA infants. There was a reduction in dietary glycaemic load (GL) and reduced saturated fat intake, an increase in PA and a modest reduction in gestational weight gain, all secondary outcomes. Lower than expected was the number of LGA infant deliveries in all women, which suggested that universal screening for GDM with IADPSG’s diagnostic criteria, and subsequent treatment, may reduce the number of deliveries of LGA infants. According to the cost–utility analysis, the estimated probability that the UK Pregnancies Better Eating and Activity Trial (UPBEAT) behavioural intervention is cost-effective at the £30,000/quality-adjusted life-year willingness-to-pay threshold was 1%.LimitationsIncluded the high refusal rate for participation and self-reported assessment of diet and PA.ConclusionsThe UPBEAT intervention, an intense theoretically based intervention in obese pregnant women, did not reduce the risk of GDM in women or the number of LGA infant deliveries, despite successfully reducing the dietary GL. Based on total cost to the NHS provider and health gains, the UPBEAT intervention provided no supporting evidence to suggest that the intervention represents value for money based on the National Institute for Health and Care Excellence benchmarks for cost-effectiveness.Future workAlternative strategies for reducing the risk of GDM in obese pregnant women and the number of LGA infant deliveries should be considered, including development of clinically effective interventions to prevent obesity in women of reproductive age, of clinically effective interventions to reduce weight retention following pregnancy and of risk stratification tools in early pregnancy.Trial registrationCurrent Controlled Trials ISRCTN89971375 and UK Clinical Research Network Portfolio 5035.FundingThis project was funded by the NIHR Programme Grant for Applied Research programme and will be published in full inProgramme Grants for Applied Research, Vol. 5, No. 10. See the NIHR journals library website for further project information. Contributions to funding were also provided by the Chief Scientist Office CZB/4/680, Scottish Government Health Directorates, Edinburgh; Guys and St Thomas’ Charity, Tommy’s Charity (Lucilla Poston, Annette L Briley, Paul T Seed) and the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK and the Academy of Finland, Finland. Keith M Godfrey was supported by the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre. Lucilla Poston and Keith M Godfrey were supported by the European Union’s Seventh Framework Programme (FP7/2007-2013), project EarlyNutrition under grant agreement number 289346.

General practice: the heart of the NHS

General practice is often hailed as the jewel in the crown of the NHS.1 However, a decade of underfunding, increasing patient complexity, issues with recruitment, and rising bureaucracy have led to a loss of its lustre. Amid a drive to move care into the community we continue to have the most stressed GPs in the Western world.2 This is doubtless impacting on junior doctors and medical students contemplating a career in general practice, as highlighted by Professor Wass’s recent report By Choice — Not by Chance .3 It is general practice that makes the NHS one of the world’s most cost-effective health services, yet spend on general practice continues to be outstripped by that on hospital outpatient clinics alone. Never before has the need for an optimised version of general practice felt more critical to the long-term sustainability of the NHS. As Roland and Everington write, ‘If general practice fails, the whole NHS fails.’ 4 The General Practice Forward View (GPFV) was launched in April 2016 by NHS England and Health Education England, with the support of the RCGP. It is a complex plan for a complex set of issues that have besieged primary care for too long.5 NHS England is backing this plan with a 14% real-terms increase in funding to support general practice services over 5 years. This is almost double the investment going into other parts of the NHS, and a notable change from a system that has historically prioritised the acute sector. At a time of austerity, this remarkable shift seeks to both stabilise …

Change for the better?

Jackie Stephen-Haynes, Professor in Tissue Viability, Professional Development Unit, Birmingham City University and Consultant Nurse, Worcestershire Health and Care NHS Trust.

A Markov model assessing the impact on primary care practice revenues and patient's health when using mid-level providers, lesson learned from the United Kingdom.

To evaluate the cost-effectiveness of using mid-level providers for dental "check-up" examinations and the treatment of caries in different NHS settings in the United Kingdom. Mid-level providers are a broad category that describes non-dentist members of dental teams. This study focused on the potential use of Dental Hygiene Therapists undertaking dental "check-up" examinations and simple restorative treatment, instead of dentists. A Markov model was used to construct the natural history of caries development in adults that visit a dental practice every six months over a five-year period. Three cost perspectives are taken: those borne to dental healthcare providers in England and Wales, Northern Ireland and Scotland. These represent three separate forms of retrospective payment system that are currently in use in the United Kingdom. The cost outcome was the average amount of retained practice earnings required to provide healthcare per patient visit. The health outcome was the average length of time in a cavity-free state and the cost-effectiveness outcome was incremental cost for six months in a cavity-free state. No statistical difference was found between dentists and mid-level providers in the length of time in a cavity-free state but the use of the latter saved money in all three NHS health system jurisdictions. This ranged from £7.85 (England and Wales) to £9.16 (Northern Ireland) per patient visit ($10.20 to $11.90, respectively) meaning the incremental cost for six month in a cavity-free state ranged from £261.67 ($339.93) in England and Wales to £305.33 ($369.68) in Northern Ireland. Further, changes in baseline assumptions and parameter values did not change mid-level providers being the dominant service intervention. In a time of limited funds for dental services, these results suggest that resources in public funded systems could be saved using mid-level providers in dental practices, without any health risk to patients or capital investment.

Research roundup: February 2017

In brief Non-medical prescribers are as effective as medical prescribers, but further studies are needed to fully quantify the benefits Infant rotavirus vaccine reduces episodes of acute gastroenteritis by up to 50%, saving £12.5 million a year Listerine reduces Neisseria gonorrhoeae in the pharynx of men who have sex with men The NHS Health Check programme in England prevents up to 8400 heart attacks, strokes or deaths over 5 years Vascular-targeted photodynamic therapy is effective for some prostate cancers

Patient safety.

E-learning sessions to support the Freedom to Speak Up review of education and training in patient safety have been produced by NHS Health Education England.

Value for money: an evaluation of health spending in Canada.

The long-term increase in international health spending sparked concerns about sustainability of health care systems but also the impact of such spending and the value for money from health spending. The period since 1975 has witnessed an increase in per capita health spending in Canada along with improvements in health outcomes. This paper is an economic evaluation of health spending in Canada-an analysis of the cost-effectiveness of aggregate health spending. Estimates of the cost per quality-adjusted life-year (QALY) are made for the whole 1980-2012 period and for four sub-periods of time-1980-1989; 1989-1998; 1998-2007 and 2007-2012. This is done for both the general population as well as Canadian seniors. Under a medium contribution of health spending to life expectancy scenario for the 1980-2012 period, the costs per QALY gained averaged $16,977 and $14,968, respectively for the general population and the seniors. This suggests that the Canadian health system produces relatively good value for money, especially for the seniors. After applying separate adjustments to match total health spending in the US and NHS health spending in the UK, we found that costs per QALY gained in Canada were generally lower than those found for the US, but not for the UK.