NHS Digital Research Articles

What is the relationship between the volume and type of appointments in general practice and patient experience? An observational study of general practice in England.

Background Patient satisfaction is a significant dimension of quality in general practice and has notably declined post-COVID. Understanding the dynamics between practice activities, practice characteristics and patient experience is vital for improving care quality. Aim This study investigates the relationship between the volume, modality (telephone or face-to-face) and practitioner type of general practice appointments and patient experience. Design and Setting An observational study of general practices in England. Method Data from the General Practice Patient Survey (GPPS) were merged with NHS Digital's practice level appointment data, covering August 2022 to March 2023. We estimate ordinary least squares regressions of patient satisfaction with access, general satisfaction, preference for a specific GP, and support for managing long-term conditions (dependent variables) against appointment volume, modality (telephone or face-to-face), and practitioner type. Results Analysis of 5,278 practices showed that a higher volume of appointments, especially face-to-face with GPs, was significantly (p<0.001) associated with increased patient satisfaction. Practices having a greater proportion of same-day appointments was significantly correlated with lower patient satisfaction. Conclusion Patient satisfaction and ability to have health needs met is associated with face-to-face access to GPs as well as the total volume of appointments available. The results suggest that patients' perceptions of access involve more than immediate availability of appointments or that patients may struggle to get appointments at practices offering more same day appointments. Initiatives to improve access to and satisfaction with general practice should prioritise expanding face-to-face GP appointments.

#1248 Sex specific associations between fat free mass and weight with mortality: sequences of regressions analyses from the UK Biobank cohort

Abstract Background and Aims There is growing evidence that muscle mass (MM) loss, observed in long term conditions (LTCs), including chronic kidney disease (CKD), is associated with mortality. This study aimed to explore the direct association between MM and mortality, having controlled for the combined influence of ageing, long term conditions (LTCs), inflammation, renal function and body weight. Furthermore, we sought to explore whether this association differed between the biological sexes. Method An observational study was conducted using the UK Biobank cohort. Adults were recruited between 2007-2010 at 22 UK centres. MM was estimated using bioimpedance defined whole body fat-free mass (BI-FFM: Tanita BC418). Primary outcome was all-cause mortality (ACM), with the cause / date of death being obtained from the NHS Information Centre (England and Wales) and NHS Central Registry (Scotland). Follow up was defined as the period between the first visit date to either date of death / the latest date for central registry downloads (December 2021). Estimated glomerular filtration rate using creatinine (eGFRCreat) or cystatin-C (eGFRcystatin-C) were calculated (CKD-EPI 2009 equation without ethnicity correction). Participants were excluded if they were on dialysis, died from SARS-CoV-2 infection or withdrew consent. Sequences of regressions analyses (SoRA), a graphical Markov modelling technique which assesses the complexity of direct and indirect pathways of association between blocks of variables which are ordered a-priori to reflect postulated directions of association, were fitted for both sexes. Results There were 500,589 participants eligible for analysis (272,623 females / 227,966 males). There were 33,755 deaths over a median follow up period of 12.58 (IQR 11.85-13.30) yrs. The male model revealed per 5 kg-higher BI-FFM (holding weight constant) was associated with lower odds of ACM in the eGFRCreat (OR 0.827, 95% CI 0.781-0.875) and eGFRCystatin-C (OR 0.425, 95% CI 0.301-0.599) sub-models, whereas a 5 kg-higher weight (holding BI-FFM constant) was associated with higher odds of ACM in the eGFRCreat (OR 1.070, 95% CI 1.027-1.115) and eGFRCystatin-C (OR 1.395, 95% CI 1.170-1.663) sub-models. In contrast, the female model revealed a 5 kg-higher BI-FFM (holding weight constant) was associated with higher odds of ACM in the eGFRCreat (OR 2.016, 95% CI 1.650-2.463) and eGFRCystatin-C (OR 1.729, 95% CI 1.391-2.151: Fig. 1) sub-models, whereas a 5 kg-higher body weight (holding BI-FFM constant) was associated with lower odds of ACM in the eGFRCystatin-C (OR 0.935, 95% CI 0.918-0.952) but not the eGFRCreat (OR 1.020, 0.970-1.072) sub-model. Conclusion Our analysis demonstrates sex-divergent associations between BI-FFM and/or body weight with ACM when estimated kidney function is accounted for. These associations suggest sex-specific explanations as to why MM loss leads to adverse outcomes in multimorbid populations and further characterises the sex-stratified nature of the “obesity paradox” in LTCs.

#2796 Divergent associations between mortality and different measures of renal function after adjustment for body composition: results from the UK Biobank

Abstract Background and Aims There is data suggesting estimated glomerular filtration rate using Cystatin-C (eGFRCystatin-C) is superior to the creatinine-based (eGFRCreat) method when assessing associations between renal function and mortality (Lees et al. 2019). Given cystatin-C is derived from all nucleated cells and creatinine from skeletal muscle, there remains a need to understand how controlling for multimorbidity, inflammation and estimates of muscle mass will affect the association between mortality and these different measures of renal function. Method An observational study was conducted using the UK Biobank cohort. Adults were recruited between 2007-2010 at 22 UK centres. MM was estimated using bioimpedance defined whole body fat-free mass (BI-FFM: Tanita BC418). The primary outcome was all-cause mortality (ACM—data from NHS Information Centre [England / Wales] and NHS Central Registry [Scotland]). Follow up was defined as the period between the first visit date to either date of death / the latest date for central registry downloads (December 2021). Estimated GFRCreat or eGFRCystatin-C were calculated using the CKD-EPI 2009 equation without ethnicity correction. Albuminuria was defined as a urine albumin / creatinine ratio of &amp;gt;3 mg/mmol. Participants were excluded if they were on dialysis, died from SARS-CoV-2 infection or withdrew consent. Sequences of regressions analyses (SoRA), a graphical Markov modelling technique which assesses complex direct and indirect pathways of association between blocks of variables which are ordered a-priori to reflect postulated directions of association, were constructed for both eGFRCreat and eGFRCystatin-C. Results There were 500,589 participants eligible for analysis (272,623 females / 227,966 males). There were 10,299 and 21,319 participants with eGFRCreat and eGFRCystatin-C &amp;lt; 60 ml/min/1.73 m2 respectively, and 25,308 with a urine albumin/creatinine ratio &amp;gt; 3 mg/mmol. There were 33,755 deaths over a median follow up period of 12.58 (IQR 11.85-13.30) yrs. Higher eGFRCreat was associated with higher odds of ACM in men (OR 1.012, 95% CI 1.004-1.020) and women (OR 1.010, 95% CI 1.001-1.018) in the presence of an interaction with weight in both sexes. Higher eGFRCystatin-C was associated with lower odds of ACM in men (OR 0.978, 95% CI 0.968-0.988) and women (Fig. 1: OR 0.986, 95% CI 0.984-0.987). In men there was an interaction between eGFRCystatin-C and weight observed but no such interaction was observed in women. Interaction plots showed that weight had less influence on the association between ACM and renal function in the eGFRCystatin-C compared to the eGFRCreat sub-models. Conclusion Higher eGFRCreat is associated with higher odds of ACM when controlling for FFM and weight, whereas higher eGFRCystatin-C is associated with lower odds of ACM. This suggests eGFRCystatin-C is more resilient to the effects of variable body composition when compared with eGFRCreat, providing a potential explanation for the stronger association between eGFRCystatin-C and mortality in patients with long term conditions including in chronic kidney disease (CKD). In this model, eGFRCreat should be viewed as a FFM surrogate.

Diagnosis, treatment, and survival from kidney cancer: real-world National Health Service England data between 2013 and 2019.

To report the NHS Digital (NHSD) data for patients diagnosed with kidney cancer (KC) in England. We explore the incidence, route to diagnosis (RTD), treatment, and survival patterns from 2013 to 2019. Data was extracted from the Cancer Data NHSD portal for International Classification of Diseases, 10th edition coded KC; this included Cancer Registry data, Hospital Episode Statistics, and cancer waiting times data. Registrations included 66 696 individuals with KC. Incidence of new KC diagnoses increased (8998 in 2013, to 10 232 in 2019), but the age-standardised rates were stable (18.7-19.4/100 000 population). Almost half of patients (30 340 [45.5%]) were aged 0-70 years and the cohort were most frequently diagnosed with Stage 1-2 KC (n = 26 297 [39.4%]). Most patients were diagnosed through non-urgent general practitioner referrals (n = 16 814 [30.4%]), followed by 2-week-wait (n = 15 472 [28.0%]) and emergency routes (n = 11 796 [21.3%]), with older patients (aged ≥70 years), Stage 4 KCs, and patients with non-specified renal cell carcinoma being significantly more likely to present through the emergency route (all P < 0.001). Invasive treatment (surgery or ablation), radiotherapy, or systemic anti-cancer therapy use varied with disease stage, patient factors, and treatment network (Cancer Alliance). Survival outcomes differed by Stage, histological subtype, and social deprivation class (P < 0.001). Age-standardised mortality rates did not change over the study duration, although immunotherapy usage is likely not captured in this study timeline. The NHSD resource provides useful insight about the incidence, diagnostic pathways, treatment, and survival of patients with KC in England and a useful benchmark for the upcoming commissioned National Kidney Cancer Audit. The RTD data may be limited by incidental diagnoses, which could confound the high proportion of 'emergency' diagnoses. Importantly, survival outcomes remained relatively unchanged.

Tortoise or Hare? The Associations between Physical Activity Volume and Intensity Distribution and the Risk of All-Cause Mortality: A Large Prospective Analysis of the UK Biobank.

Analysis methods to determine the optimal combination of volume and intensity of objectively measured physical activity (PA) with prospective outcomes are limited. Participants in UK Biobank were recruited in the UK between 2006 and 2010. We linked the questionnaire and accelerometer with all-cause mortality data from the NHS Information Centre and NHS Central Register up to April 2021. We developed a novel method, extending the penalized spline model of Augustin et al. to a smooth additive Cox model for survival data, and estimated the prospective relationship between intensity distribution and all-cause mortality, adjusting for the overall volume of PA. We followed 84,166 men and women (aged 40-69) for an average of 6.4 years (range 5.3-7.9), with an observed mortality rate of 22.2 deaths per 1000. Survival rates differed by PA volume quartile, with poorer outcomes for the lowest PA volumes. Participants with more sedentary to light intensity PA (<100 milligravities (mg)) and/or less vigorous intensity PA (>250 mg) than average for a given volume of PA, had higher mortality rates than vice versa. Approximate hazard ratios were 0.83 (95% credible interval [CI]: 0.79, 0.88) for an average-risk profile compared to a high-risk profile and 0.80 (95% CI: 0.74, 0.87) for a low-risk profile compared to an average-risk profile. A high- versus low-risk profile has the equivalent of 15 min more slow walking, but 10 min less moderate walking. At low PA volumes, increasing overall volume suggests the most benefit in reducing all-cause mortality risk. However, at higher overall volumes, substituting lighter with more vigorous intensity activity suggests greater benefit.

Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016

IntroductionSuicide and mental health disorders are a recognized increasing public concern. Most suicide prevention rely on evidence from mortality data, although suicide attempts are a better predictor for completed suicides. Understanding spatio-temporal patterns and demographic profiles of people at risk can improve suicide prevention schemes, including for carbon monoxide (CO) poisoning, a common method for gas-related suicides. ObjectiveDescribe spatio-temporal patterns of intentional CO poisoning hospitalization rates in England between 2002 and 2016, and identify population sub-groups at risk. MethodsWe used NHS Digital's Hospital Episode Statistics (HES) routinely collected data on hospital admissions for intentional CO poisoning. We estimated age-standardised rates (ASR) by year, gender and residential small-area characteristics, including rural/urban, deprivation and ethnic composition. Temporal trends were assessed through linear regression and joinpoint regression analysis. Regional differences were explored. ResultsOn average, we identified 178 hospital admissions for intentional CO poisoning per year. The ASR decreased substantially over the study period, particularly among males (average annual percent change of −7.8 % (95 % CI: −11.0; −4.6)), in comparison to 3.9 % (95%CI, −6.4; −1.4) among females. Most admissions (81 %) occurred in males. White men aged 35–44 years were particularly at risk. The ASR in London (0.08/100,000) was almost six times lower than in the South-West (0.47/100,000). ConclusionsThis study provides novel insights into attempted suicides by intentional CO poisoning. Further prevention interventions, targeting sub-groups at risk (i.e. white men in their 30s/40s), need to be developed and implemented to reduce the burden of suicides and of CO poisoning.

Application of a machine learning contouring tool for the evaluation of left ventricular strain in clinical practice

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AK has been funded by the Egyptian cultural centre and educational bureau of the Egyptian embassy in London and the Ministry of higher education in Egypt. SEP acknowledges support from the “SmartHeart” EPSRC programme grant (www.nihr.ac.uk; EP/P001009/1) and the London Medical Imaging and AI Centre for Value-Based Healthcare. This new centre is one of the UK Centres supported by a £50m investment from the Data to Early Diagnosis and Precision Medicine strand of the government’s Industrial Strategy Challenge Fund, managed and delivered by UK Research and Innovation (UKRI). SEP acknowledges support from the CAP-AI programme, London’s first AI enabling programme focused on stimulating growth in the capital’s AI Sector. CAP-AI is led by Capital Enterprise in partnership with Barts Health NHS Trust and Digital Catapult and is funded by the European Regional Development Fund and Barts Charity. SEP also acts as a paid consultant to Circle Cardiovascular Imaging Inc., Calgary, Canada and Servier onbehalf Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London, UK Background Manual contouring of cardiovascular magnetic resonance (CMR) cine images remains common practice and the reference standard for left ventricular (LV) volumes and mass evaluation. However, it is time-consuming and machine learning (ML) may significantly reduce the time required for contouring. Accurate LV contours are the basis for reliable LV strain analysis using tissue tracking. Purpose To assess the impact of a ML contouring tool alone versus expert adjusted contours on LV strain. Methods We retrospectively selected 402 CMR studies with diagnoses of myocardial infarction (n = 108), myocarditis (n = 130) and healthy controls (n = 164) from the Barts BioResource between January 2015 to June 2018. CMR examinations were obtained using 1.5T and 3T scanners (Siemens Healthineers, Germany). We excluded 32 cases due to phase inconsistency between short (SAX) and long axes (LAX) cine images or suboptimal cine image quality. For the remaining 370 cases, steady state free precession cine images for LAX and SAX were analysed by the ML contouring tool (using CVI42 research prototype software 5.11). Manual expert adjustment for the contours was done for each case if considered suboptimal for strain analysis in the reference end-diastolic phase. Strain results from ML and expert adjusted ML methods were compared for strain agreement. Times taken by these methods were recorded and compared against the time taken for standard manual contouring. Results SAX and LAX derived strains by ML and expert adjusted ML methods showed good agreement by Bland-Altman analysis (Figure 1) with excellent coefficient of concordance using Kendall W which is 0.98 for global SAX, radial and circumferential strains (mean difference(MD) = -1.7% (lower and upper limits of agreement (UL,LL) -6.6,3.2), MD = 0.5% (-1.0,2.1)) and is 0.95 for global LAX derived strain (radial and longitudinal, MD = 0.7% (UL,LL -8.7 ,7.4),MD= 0.2% (-1.9,2.5), respectively). Time taken for adjustment of ML contours was significantly shorter than manual contouring (1.35 minutes vs 8.0 minutes, around 590% time saving in ML adjusted method). Conclusions ML contouring compared to expert manual adjustment has a clinically reasonable agreement when used for measuring LV strain. Also, using the ML tool with expert adjustment shows significant time saving for analysis and reporting time compared to entirely manual analysis, favouring its application in routine clinical practice. Abstract Figure.

The influence of personal communities in understanding avoidable emergency department attendance: qualitative study

BackgroundUse of emergency department (ED) care globally seems to be increasing at a faster rate than population growth (Baker, House of Commons Library. Accident and Emergency Statistics, Demand, Performance, 2017). In the UK there has been a reported 16% rise in emergency admissions over the past 5 years. Estimates that between 11 and 40% of ED attendances are non-urgent, with 11% of patients being discharged from the ED without treatment (NHS Digital 2017), and a further 44% require no follow-up treatment (NHS Digital, Hospital Accident and Emergency Activity 2016-17, 2019) is cited as evidence that these patients did not require this level of care. The solution to not using the most appropriate point in the system has traditionally been seen as a knowledge problem, requiring, improved sign-posting and information to enable people to self-manage or use health care management for minor ailments. However research about help-seeking behaviour suggests that the problem may not be an informational one. A considerable literature points to help seeking as a social process influenced by a range of contingencies and contextual factors including the way in which lay people influence health care utilisation (Giebel et al. BMJ Open 9:1, 2019). Personal communities comprise a variety of active and significant social ties which have potential to influence individual capacity to seek help. Here we extend and unpack further influencing decisions about seeking formal health care with reference to how they are shaped and informed by and within personal social networks.MethodsWe undertook a personal network mapping and qualitative interview-based study to look at, problematize and understand attendance for non-urgent problems. We used network analysis and methods to map and characterise the personal communities of people seeking help from ED for minor ailments and semi-structured interviews with 40 people attending a single ED and associated GP hub providing equivalent care. Interviews were built around an ego network mapping activity and a topic guide structured to explore attender’s narratives about why they had visited the ED. This ego network activity uses a diagram consisting of three concentric circles (Fiori et al. J Gerontol B-Psychol 62: 322-30, 2007), representing closest social network members (in the centre) and those at further distance. Participants were initially presented with one of these diagrams and asked to write names of people or resources that had played a role in their attendance and the interviewer probed the interviewee to discuss the actions, input and value of the people and services that supported the visit to the ED.ResultsWe analysed number and type of network connections and undertook a thematic analysis to identify how imagined and actual network members and influences were implicated in ED attendance. The network maps created during the interviews were examined and a typology of networks was developed and used to distinguish different types of networks informed by our reading of the data, and a Network Typology Scoring Tool, a measure of frequency of contact and relationship type in networks.ConclusionsOur study suggests that faced with acute minor illness or injury people’s networks narrow: they do not (and perhaps cannot) mobilise their imagined care network because the resources or connections may not be there or are difficult to engage. In addition we identified important system drivers of behaviour, notably that these patients are often directed to the ED by ‘professional influencers’ including health services staff.

Safeguarding the elderly

The Health and Social Care Information Centre (HSCIC) has shown a 4% rise in the number of alleged cases of abuse against elderly people. Priya Sharma investigates your role in protecting them

Pharmacists granted iPad access to patient records in NHS Digital trial

Pharmacists granted iPad access to patient records in NHS Digital trial

Using Free Text From Medical Notes To Enrich a Longitudinal Cohort Study

IntroductionThe Cleft Collective Cohort study is the world's largest multidisciplinary cleft lip/palate research programme. Despite being one of the most common birth anomalies, the causes of clefting are unknown. Treatment involves a considerable burden of care from birth onwards, together with a variety of social and psychological challenges.&#x0D; Objectives and ApproachOur aim is to create the infrastructure and resources necessary to gain important new knowledge that will advance our understanding of the causes of cleft lip/palate, inform treatment and improve the lives of people born with cleft; data linkage is a key aspect of this. There are challenges associated with linking to multiple data sources (NHS Digital, Cleft National Registry). However, using the consent obtained, we are also able to link directly to the participant’s medical notes held by their NHS cleft team; enabling us to access a variety of data, including free text.&#x0D; ResultsThe study already collects social and demographic data via questionnaires and genetic data from biological samples. Data linkage enriches this but also enables us to validate and address missing data problems. However, linkage to external sources brings many challenges, including, governance, costs, access issues. By gaining direct access to cleft team medical notes these issues are significantly reduced and provide us with rich phenotype data that cannot be obtained elsewhere, for example, via ‘read codes’ within electronic medical records. By tailoring our own data collection tool we can collect specific cleft data to enhance the resource and allow for subtype analyses. This process can be repeated throughout the duration of this longitudinal study for subsequent data.&#x0D; Conclusion/ImplicationsData linkage is a valuable resource but comes with many challenges. One route to overcome many of these issues is by accessing free text data directly from participants medical notes. The richness of these data allows for more in depth phenotypic analyses.

The healthcare assistant and bowel care

In February this year, an inquest into the premature death of a 33-year-old man concluded that gross failures in care had led to his death. Mr Richard Hanley had learning disabilities, some mental health problems and had lifelong constipation. This was managed effectively when he lived in residential care; however, when he moved to supported living he became constipated. His family reported that his abdomen resembled that of a woman about to give birth. Mr Handley was admitted to hospital and 10kg of faeces was surgically removed from his body two days before his death. The coroner determined that the causes of death were inhalation of gastric contents, large bowel obstruction and faecal impaction ( BBC News, 2018 ; Hill, 2018 ; Inquest, 2018 ). Constipation is often considered a minor problem; however, it can have serious and even life-threatening consequences. Each year, 66 287 people are admitted to hospital because of constipation ( Department of Health (DH), 2015 ). The NHS spends around £250 million pounds annually treating constipation. Hospital admissions cost £145 million and primary care spends around £92 million in laxative prescriptions ( DH, 2015 ; Shafe et al, 2011 : NHS Information Centre, 2016 ). This article aims to enable readers to be aware of how normal bowel function varies in individuals, how ageing, frailty, long-term conditions and medication affect bowel function, how to promote normal bowel function and to manage constipation.

Understanding and managing constipation in older adults

Constipation is a common problem in older adults. Linda Nazarko provides an overview of the causes and how to manage this distressing condition in primary care Constipation is often considered a trivial complaint; however, the NHS spends around £250 million a year treating this symptom. It leads to 66 287 hospital admissions costing £145 million and primary care spends around £92 million on laxative prescriptions ( Shafe et al, 2011 ; Department of Health, 2014; NHS Information Centre, 2016 ). Older people are more likely to experience constipation than younger people. The prevention and treatment of constipation is more complex in older people; however, we currently lack specific national guidance on this subject. This article outlines the causes of this common symptom, explores normal bowel function and explains what factors can lead to constipation and how these can be identified and treated.

An estimated carbon footprint of NHS primary dental care within England. How can dentistry be more environmentally sustainable?

Introduction National Health Service (NHS) England dental teams need to consider from a professional perspective how they can, along with their NHS colleagues, play their part in reducing their carbon emissions and improve the sustainability of the care they deliver. In order to help understand carbon emissions from dental services, Public Health England (PHE) commissioned a calculation and analysis of the carbon footprint of key dental procedures.Methods Secondary data analysis from Business Services Authority (BSA), Health and Social Care Information Centre (HSCIC) (now called NHS Digital, Information Services Division [ISD]), National Association of Specialist Dental Accountants (NASDA) and recent Scottish papers was undertaken using a process-based and environmental input-output analysis using industry established conversion factors.Results The carbon footprint of the NHS dental service is 675 kilotonnes carbon dioxide equivalents (CO2e). Examinations contributed the highest proportion to this footprint (27.1%) followed by scale and polish (13.4%) and amalgam/composite restorations (19.3%). From an emissions perspective, nearly 2/3 (64.5%) of emissions related to travel (staff and patient travel), 19% procurement (the products and services dental clinics buy) and 15.3% related to energy use.Discussion The results are estimates of carbon emissions based on a number of broad assumptions. More research, education and awareness is needed to help dentistry develop low carbon patient pathways.

Differences in clinician versus patient recording of comorbidities in PROMs

A data request was made from the Health and Social Care Information Centre (HSCIC) regarding patients who had undergone a primary total knee replacement (TKR) at the Norfolk and Norwich Hospital in 2014. In total, 576 patients had received post-operative PROMs questionnaires in 2014. Complete information was available for 195 patients, which forms the basis of this analysis. The patient letters and the pre-operative assessment documentation on our electronic system (Bluespier) were then reviewed. The comorbidities that the clinician felt would apply to that patient were recorded from the list provided in the Oxford Knee Score (OKS) and were then compared with what the patients had recorded. In total, there were 189 additional comorbidities identified from our notes review. Of these, 95 would alter the predicted OKS score in 77 patients. There was a significant change in average predicted OKS score from 33.7 ± 3.9 to 32.3 ± 4.0 (p = 0.02) in the 77 patients who had additional OKS-altering comorbidities. When looking at the case-mix adjustment, the original mean adjustment was -0.83 (± 1.1). After adjusting for clinician-reported comorbidities, there was a significant change in the mean to -1.40 (± 1.4) (p < 0.0001). After the relevant recalculations were carried out, the adjusted average health gain went from 15.254 to 15.907. This is an improvement of 0.653. The small change of ensuring accurate comorbidity recording can have an impact on the adjusted average health gain for a hospital. This is important information: patients report comorbidities differently to clinicians, and often overrate their health. Despite the limitation of this comorbidity data, hospital performance data, which are publically available, are based on this case-mix and comorbidity adjustment. Care clearly needs to be taken in the interpretation of these case mix-adjusted scores. The PROMs (Patient-Reported Outcome Measures) programme, embedded within the NJR, …

The Care Programme Approach, sexual violence and clinical practice in mental health

IntroductionResearch in Sexual Assault Referral Centres has shown that 40% of those attending are known to mental health services. The question we posed in this study was to what extent do mental health services know about this group? This was a pertinent question to ask as in 2008 the Department of Health (DH) amended the Care Programme Approach (CPA) to include a question on sexual abuse/violence as part of the overall assessment. AimsTo assess the extent to which Mental health Trusts were implementing DH guidance on the CPA in relation to assessment of sexual violence and abuse. Method1. Freedom of Information (FOI) requests were sent to all Mental Health Trusts. 2. The Information base at the Health and Social Care Information Centre (HSCIC) was interrogated as Trusts can make returns on this CPA question, however it is not mandatory. Results1. The FOI requests revealed that: only 66% of staff were trained to 'ask the question' (range 35–100%) and only five out of 53 Trusts audited whether the question was asked. 2. The HSCIC data revealed that in 2014/15 there were 335,727 people in the CPA in England and there was a record in only 17% of cases of the question being asked. Over half (57%) of the 69 providers who did not submit any information on the indicator in 2014/15 as well as, for those 30 providers who did submit information, the data field was only 41% complete. ConclusionsThe impetus for ‘asking the question’ first established in 2008 with the establishment of eight pilot training programmes, has been lost. It is clear that Trusts are not training adequate number of staff nor are they returning useable data to HSCIC. If 40% of people attending SARCs are known to mental health services we suspect that few staff in mental health trusts known much about such a referral. Research shows convincingly that sexual violence and abuse plays a clear role in the aetiology of mental health disorders. A history of such violence/abuse should be always established (or otherwise).

Diagnosis and management of angina for the cardiac nurse

The burden of treating stable angina is vast, as it is estimated that almost 2 million people currently have or have had angina in the UK ( Health and Social Care Information Centre (HSCIC), 2006 ). Angina is the main symptom of myocardial ischaemia, usually caused by atherosclerotic obstructive coronary artery disease, restricting bloodflow and therefore oxygen delivery to the heart muscle ( National Institute for Health and Care Excellence (NICE), 2011 ). Characteristic features of stable angina include tightness or heaviness across the chest, which can radiate to the left arm, neck, jaw and back. However, it is important to be aware that some people present with atypical symptoms. A diagnosis of stable angina can be based on clinical assessment alone or with the addition of diagnostic testing. Diagnosic tests used in this instance can include: exercise testing, computerised tomography (CT), myocardial perfusion scanning and stress echocardiography, in addition to blood tests and electrocardiogram which all patients will undergo. Management of angina includes medical therapy, the aim of which is to help reduce symptoms and prevent cardiovascular events such as myocardial infarction and stroke ( Montalescot et al, 2013 ). Guidelines on stable angina by NICE (2011) and the European Society of Cardiology (ESC) ( Montalescot et al, 2013 ) provide us with recommendations on which medications should be prescribed. Lifestyle changes are a key aspect of angina management: namely in the areas of diet, exercise, smoking, diabetes, hypertension and psychological issues.

Tackling obesity, physical activity levels and dietary intake: the extent of the problem

Tackling obesity, physical activity levels and dietary intake: the extent of the problem

The feasibility of introducing an adult safeguarding measure for inclusion in the Adult Social Care Outcomes Framework (ASCOF): findings from a pilot study.

BackgroundThere are currently no national measures in England reporting the experiences of people who have been involved with adult safeguarding services following concerns that they may be at risk of abuse or neglect. The Health and Social Care Information Centre (HSCIC) aimed to develop a new adult safeguarding outcome measure (survey) for local authorities (LAs) that could be added to the Adult Social Care Outcomes Framework (ASCOF). The ASCOF is a national collection of social care outcomes performance indicators collected from the perspective of people receiving partial or total funding from a LA for care services.MethodsAn outcome measure (a face-to-face interview based survey consisting of 7 questions) was piloted in 40 LAs with 382 adults at risk (or their representative) who had been the subject of a safeguarding investigation. The aim was to investigate the feasibility of the survey in three domains: i) if a statistically representative sample of adults at risk (or their family, friend, carer or advocate) could be recruited; ii) analysis of survey responses and its acceptability to participants iii) feedback from LAs about the survey’s administration.Results and discussionOverall the survey results met statistical confidence; however the individual results for adults at risk did not, due to the high proportion of representatives who responded because adults at risk were unable. Responses to the survey were generally positive; 72 % of participants felt that the help received during the safeguarding investigation had made them or the adult at risk (if reporting as a proxy) feel ‘quite a bit’ or ‘a lot safer’. These results are the most robust data collected in England on the perspectives of adults at risk and their representatives on safeguarding services. Participants reported they appreciated being asked for feedback. LAs suggested survey administration improvements.ConclusionsThis survey is one way LAs can meet their new legal requirement under the Care Act 2014 to ‘seek feedback’ from adults at risk about adult safeguarding services. The survey findings provide the first robust evidence that safeguarding services in the main meet their goals of promoting feelings of safety among adults at risk.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1464-9) contains supplementary material, which is available to authorized users.

Clinicians in the classroom: The consultant anaesthetist

In 2013–14, 166 081 babies born in England—accounting for 26.2% of all births in the country—were born by caesarean section ( Health and Social Care Information Centre (HSCIC), 2015 ). Epidural or caudal anaesthesia was required in 16.4% of births, while spinal anaesthetics were used in 15.1% of births ( HSCIC, 2015 ). Support from obstetric anaesthesia services is also required in obstetric emergencies such as postpartum haemorrhage and eclampsia. Modern maternity services require a multi-professional approach to providing high-quality care, and it is therefore important that pre-registration midwifery education prepares student midwives to work in such an environment. This is the fourth in a series of articles exploring the value of expert clinicians' participation in teaching pre-registration midwifery students in the classroom setting. This article will consider sessions at the University of Northampton facilitated by Dr Kalpna Gupta, consultant anaesthetist at Northampton General Hospital NHS Trust.