NHS Organisations Research Articles

The complexities of integrating evidence-based preventative health into England’s NHS: lessons learnt from the case of PrEP

BackgroundThe integration of preventative health services into England’s National Health Service is one of the cornerstones of current health policy. This integration is primarily envisaged through the removal of legislation that blocks collaborations between NHS organisations, local government, and community groups.Aims and objectivesThis paper aims to illustrate why these actions are insufficient through the case study of the PrEP judicial review.MethodsThrough an interview study with 15 HIV experts (commissioners, activists, clinicians, and national health body representatives), we explore the means by which the HIV prevention agenda was actively blocked, when NHS England denied responsibility for funding the clinically effective HIV pre-exposure prophylaxis (PrEP) drug in 2016, a case that led to judicial review. We draw on Wu et al.’s (Policy Soc 34:165–171, 2016) conceptual framing of ‘policy capacity’ in undertaking this analysis.ResultsThe analyses highlight three main barriers to collaborating around evidence-based preventative health which indicate three main competence/capability issues in regard to policy capacity: latent stigma of ‘lifestyle conditions’ (individual-analytical capacity); the invisibility of prevention in the fragmented health and social care landscape related to issues of evidence generation and sharing, and public mobilisation (organizational-operational capacity); and institutional politics and distrust (systemic-political capacity).Discussion and conclusionWe suggest that the findings hold implications for other ‘lifestyle’ conditions that are tackled through interventions funded by multiple healthcare bodies. We extend the discussion beyond the ‘policy capacity and capabilities’ approach to connect with a wider range of insights from the policy sciences, aimed at considering the range of actions needed for limiting the potential of commissioners to ‘pass the buck’ in regard to evidence-based preventative health.

Developing a talent management support network for nurses and midwives.

Effective talent management is vital to retain skilled and experienced nurses and midwives in the NHS. In 2019, a group of NHS organisations in London set up a talent management support network (TMSN) aimed at helping specific groups of nurses and midwives facing challenges in fulfilling their professional potential. The network started by supporting nurses and midwives from minority ethnic backgrounds, later also offering the programme to dental nurses across England and to healthcare workers in Brazil. The network uses the power of action learning and networking in a framework that nurtures staff's talents. This article describes the London TMSN team's experience of setting up and running the network. It also explains how nursing and midwifery managers and leaders can create a business case for the development of a similar network in their setting.

O167 A decade of NHS never events – has formal reporting made a difference?

Abstract Introduction NHS England defines “Never Events” (NE) as 'patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers’. NHS Organisations were required to publish NE data from April 2012. This project aims to identify changes in NE patterns to help inform training. Methods Published data between April 2012 and March 2022 was collected from NHS England. Data processing and manipulation was carried out using Microsoft Excel. Results A total of n=4,055 NE and n=175,920,530 procedures were reported. During the 2020-2021 year there were significantly less (p=0.029) NE compared to 2019-2020, however the rate of NE per million procedures (25 vs 27) remained unchanged p=0.18. Overall, there appears to be an increasing trend in NE, p<0.001. The majority of NE related to wrong site surgery, n=1,628(40%), retained foreign objects, n=1,090(27%) and wrong implant/prosthesis, n=506(12%), p<0.001. Within wrong site surgery, the most common NE was wrong procedure, n=529(32%), followed by laterality errors, n=391(24%), p<0.001. Conclusion The results demonstrate that despite systemic protective barriers such as the WHO Checklist, overall rate of NE has not reduced. This is likely to be confounded by changes in reporting as well as definitions, for example from April 2021 wrong tooth extraction was not considered a NE. The importance of Human Factors must not be overlooked, and NHS Trusts should consider formal provision of such training for all those in clinical roles.

NHS staff awareness, attitudes and actions towards the change in organ donation law in England—results of the #options survey 2020

BackgroundIn Spring 2020 there was a change in organ donation legislation in England (UK). Much is known about public opinions to organ donation and the change in legislation, however, there is little evidence about the opinions of the NHS workforce. This study set out to understand the levels of awareness, support and action of NHS staff to this change and explore the impact of respondent demographics, place and type of work on awareness, support and action.MethodsAn online survey was offered to all NHS organisations in North Thames and the North East and North Cumbria through the NIHR Clinical Research Network between July and December 2020. Participating organisations were provided with an information package and promoted the survey via email and internal staff communications. Associations were compared univariately using chi-square tests and logistic regression was used for multivariable analysis to compare findings with NHS Blood and Transplant public Kantar survey data.ResultsA total of 5789 staff participated in the survey. They were more aware, more supportive, more likely to have discussed their organ donation choices with family and more likely to be on the organ donor register than the public. This increased awareness and support was found across minority ethnic and religious groups. Those working in a transplanting centre were most aware and supportive and those working in the ambulance service were most likely to ‘opt-in’ following the change in legislation.ConclusionsNHS staff in England were well informed about the change in organ donation legislation and levels of support were high. NHS staff were six times more likely than the public to have a conversation with their family about their organ donation choices. The size and ethnic diversity of the NHS workforce offers an opportunity to enable and support NHS staff to be advocates for organ donation and raise awareness of the change in legislation amongst their communities.

Very rapid insight generation to support UK health and care systems: An AHSN approach.

COVID-19 challenges are well documented. Academic Health Science Networks (AHSNs) are a key partner to NHS and care organizations. In response to managing COVID-19 challenges, Wessex AHSN offered rapid insight generation and rapid evaluation to local NHS and care systems to capture learning during this period. This novel "Rapid Insight" approach involved one-off online deliberative events with stakeholders to generate insights linked to specific, priority areas of interest, followed by rapid analysis and dissemination of the findings. Key objectives were to enable system leaders to build their adaptive leadership capability and learn from the experience of COVID-19 to inform recovery planning and system support. Rapid Insight (RI) gathered together health and care professionals into a tightly managed, virtual forum to share system intelligence. Focused questions asked about the systems' response to the pandemic, what changes to continue and sustain, or discontinue. Participants responded simultaneously to each question using the virtual chat function. Immediate thematic analysis of the chat conducted in 48-72 h by paired analysts for each question strengthened analytical integrity. Mind maps, the key output, provided easily assimilated information and showed linkages between themes. Telephone or virtual interviews of key informants (health and care professionals and patients) and routinely collected data were synthesized into short reports alongside several RI events. However, insufficient time limited the opportunities to engage diverse participants (e.g., mental health users). Data from RI can scope the problem and immediate system needs, to stimulate questions for future evaluative work. RI facilitated a shared endeavor to discover "clues in the system" by including diverse opinions and experience across NHS and care organizations. Although these rapid virtual events saved on travel time, digital exclusion might constrain participation for some stakeholders which needs other ways to ensure inclusion. Successful rapid engagement required Wessex AHSN's existing system relationships to champion RI and facilitate participant recruitment. RI events "opened the door" to conversations between up to 150 multi-professional clinicians to share their collective response to COVID-19. This paper focuses on the RI approach with a case example and its further development.

Job satisfaction among NHS and private orthotists: a cross-sectional comparative study

Background/Aims The orthotic profession is facing a national staff shortage, which has been compounded by high attrition rates. Overall, 70% of NHS orthotic services in the UK are subcontracted out to private companies, but there has been little investigation of how this has affected job satisfaction and intention to remain in the profession among orthotists. This study evaluated and compared job satisfaction among orthotists employed by the NHS and private organisations. Methods A mixed-methods, cross-sectional comparative study was conducted. A total of 123 orthotists (36 employed by the NHS, 82 employed privately) completed an online questionnaire comprising 32 questions regarding their working conditions and job satisfaction, with a combination of free-text and 5-point Likert scale formats. Quantitative analysis was performed using the Statistical Package for Social Sciences (version 24), with P≤0.05 indicating significance. Results Over a third (37.4%, n=46) of respondents indicated that they would leave the orthotic profession if they could. The strongest predicting variable for intent to leave was how well staff felt that they were treated by their employer. Respondents consistently reported that their working environments were poor, but this was worse for those who were privately employed. Overall job satisfaction was low in both groups. Conclusions The orthotic profession may be facing a staff retention crisis. Employers should focus on improving working environments and ensuring that staff feel appreciated. Further research is required to investigate the impact of these issues on patient care.

Healthcare Services for Undocumented Migrants: Organisation and Costs from the Italian NHS Perspective.

Based on the principle of health equity, the Italian National Health Service is known worldwide for being a universalistic system that guarantees healthcare services for all its population, among which there are undocumented migrants. A commitment for their health needs is further motivated by their lower utilisation rates of healthcare services, which becomes even more crucial when considering chronic conditions such as diabetes that require adherence and continuity of care. However, the need for more official data has resulted in little research documenting these healthcare usage patterns. For this reason, our objective has been to deepen, from the Italian NHS perspective, the quantity, costs, type, preventability and organisation of healthcare services directed to undocumented migrants. We used official healthcare data from the Lombardy Region, which enable the identification of people receiving the STP code (undocumented migrants) and of people with foreign citizenship (documented migrants). After quantifying the average annual amount and expenditure for healthcare services grouped by Italian citizens, documented migrants and undocumented migrants for all clinical conditions (quantity and costs), we performed three primary investigations where we enlightened differences between the three mentioned groups focusing on the diagnosis of diabetes: (i) mapping the types of healthcare services used and their characteristics (type); (ii) quantifying the impact of preventable hospital admissions (preventability); (iii) examining the healthcare patterns linking pharmaceutical prescriptions with hospital accesses (organisation). Our results reveal significant differences among the three groups, such as more urgent hospital admissions, more preventable complications, and a higher recurrence in terms of access and costs to hospital services rather than pharmaceutical prescriptions for undocumented migrants. These findings can represent the leverage to raise awareness toward the emerging challenges of the migrant health burden.

Using Programme Theory to evaluate Lean interventions in healthcare

Lean in healthcare has continued to attract practitioner and research interest over the past two decades yet lacks evidence of sustained application. This longitudinal case study examines Lean healthcare interventions through the lens of Programme Theory, to provide an understanding of the design and implementation of a Lean programme. Through a qualitative single case study of an NHS organisation implementing Lean, content analysis of 70 reports from a 6-year period was undertaken and supported by interview data from 12 respondents involved in Lean initiatives. Through Programme Theory, we identify contextual moderators, internal and external, informing the design and development of Lean efforts. The key to successful and sustained Lean efforts is staff acceptance of the Programme Theory for delivering and maintaining outcomes. This has been identified as a key social determinant for Lean sustainability. Results from the research provide practical implications for designing a programme that accommodates resource challenges while incorporating multiple contextual drivers. The case study highlights an organisation’s Lean journey and the best practices that evolved; however, further longitudinal investigations are required to validate the findings.

RealTalk evidence-based communication training resources: development of conversation analysis-based materials to support training in end-of-life-related health and social care conversations

Training to enhance healthcare practitioners’ capabilities in engaging people in sensitive and end-of life-related conversations is in demand. However, evaluations have either not measured, or found very limited impact on actual practice and patient experience. Training effectiveness is improved when it is based on in-depth evidence, reflects the complexity of real-life interactions, and instils principles adaptable to everyday practice. A relatively new source of in-depth evidence and practice-relevant insights on healthcare interactions is conversation analytic research, a form of observational analysis of real-life interactions. However, conversation analytic research findings have largely been disseminated by and for scientists, rather than clinicians and trainers. We used conversation analytic evidence to develop resources for use by healthcare trainers. The aim was to increase training’s evidence-base and authenticity. We further aimed to develop resources applicable to working with learners ranging from novices to advanced practitioners.Methods: Using an intervention development approach, we created online video-clips and supplementary written materials for professionals who deliver training, supervision, and support in healthcare communication for staff and students. The materials were reviewed by an advisory group comprising clinicians, lay consultees, educators, and researchers, and piloted by trainers in UK universities, NHS organisations and independent hospices. We refined materials based on their feedback.Results: The resulting ‘RealTalk’ resources focus on practices for communicating with patients and their companions about end-of-life and prognosis. Two core training modules were developed, each comprising several patient case studies featuring video-clips from real-life healthcare consultations. The clips featured practices that patients and experienced practitioners use in approaching end-of-life matters. The case studies also included evidence-based descriptions of observable practices and the principles underlying these, alongside transcripts and case synopses.Conclusions: RealTalk training resources aim to facilitate evidence-based, experiential and reflective learning, focusing on communication challenges, practices and principles for end-of-life-related interactions. The resources are designed for use by trainers for delivering all levels of training, from introductory to advanced, in both formal and informal training settings. Our development process may serve as a blueprint for the production of future evidence-based training resources based on conversation analytic research.

A qualitative exploration of digital medicines information usage: Insights from an evaluation of the BNF

Objectives: To explore the driving and resisting forces to the use of digital medicines information in the context of the British National Formulary (BNF) and British National Formulary for Children (BNFc). Methods: Qualitative semi-structured interviews were carried out with 25 doctors, pharmacists and nurses. Data were analysed via thematic analysis. Results: Key drivers identified included organisations making digital use of BNF/BNFc easier through measures such as electronic prescribing systems, compatible handheld devices and training/induction sessions for staff. The COVID-19 pandemic had expedited the shift to digital BNF/BNFc usage in some settings. A strong driver of digital usage was the desire by staff to use the most up-to-date information. Reduced access to print copies was a common initial driver of digital usage, whilst ease of searching and speed of access often acted to consolidate digital usage. Important resisting forces included lack of supporting organisational digital infrastructure and an onus on individuals to obtain access to digital platforms, particularly through personal smartphones. Poor prior experience of earlier digital BNF/BNFc platforms had also prevented participants from using them again. Conclusions: More driving than resisting forces were identified and, in most settings, a transition to digital BNF/BNFc usage is underway, which has been expedited by the COVID-19 pandemic. However, this is not happening uniformly across the NHS and there continue to be strong resisting forces to digital BNF/BNFc usage, particularly at organisational level. Public interest summary: The British National Formulary (BNF) and British National Formulary for Children (BNFc) provide information about all medicines prescribed in the UK. They are available as a book, a website and an app. As healthcare information becomes increasingly digital, it is important to understand how this is used by healthcare staff and we spoke to doctors, nurses and pharmacists about how they use the BNF/BNFc. We found that staff are increasingly using the digital BNF/BNFc and that the COVID-19 pandemic has speeded up this transition. Staff are likely to use the digital BNF/BNFc where their organisation makes it easy to do so, such as through access to IT equipment and electronic prescribing systems. However, many NHS organisations lack the facilities for widespread digital usage and staff are not routinely trained in using digital resources. Future efforts should focus on the digital technology itself, and on upskilling healthcare staff to use it.

Daily testing of contacts of SARS-CoV-2 infected cases as an alternative to quarantine for key workers in Liverpool: A prospective cohort study.

SummaryBackgroundCovid-19 test-to-release from quarantine policies affect many lives. The SMART Release pilot was the foundation of these policies and an element of the world's largest population cohort study of community-wide, SARS-CoV-2 rapid antigen testing. The objective of the study was to evaluate daily lateral flow testing (LFT) as an alternative to 10-14 days quarantine for key worker contacts of known Covid-19 (or SARS-CoV-2 infection) cases.MethodsProspective cohort study incorporating quantitative and qualitative research methods to consider how serial LFT compares with PCR testing to detect SARS-CoV-2 infections and to understand experiences/compliance with testing and the viability of this quarantine harm-reduction strategy. Participants were residents of the Liverpool area who were key workers at participating fire, police, NHS and local government organisations in Liverpool, and who were identified as close contacts of cases between December 2020 and August 2021. Thematic qualitative analysis was used to evaluate stakeholder meetings.FindingsCompliance with the daily testing regime was good across the three main organisations in this study with 96·9%, 93·7% and 92·8% compliance for Merseyside Police, Merseyside Fire & Rescue Service and Alder Hey Children's Hospital respectively. Out of 1657 participants, 34 positive Covid-19 cases were identified and 3 undetected by the daily LFT regime. A total of 8291 workdays would have been lost to self-isolation but were prevented due to negative daily tests. Organisations reported that daily contact testing proved useful, flexible and well-tolerated initiative to sustain key worker services.InterpretationCompliance with daily testing among key workers was high, helping sustain service continuity during periods of very high risk of staffing shortage. Services reported that the pilot was a “lifeline” and its successful delivery in Liverpool has been replicated elsewhere.FundingThis report is independent research commissioned by DHSC and part funded by DHSC and NIHR. Further funding was received from Liverpool City Council, the EPSRC and MRC.

Trusts are missing the mark on accessible information

NHS organisations must do more to ensure that people with learning disabilities can access healthcare information and support

Moving From Peripheral Project to Integrated Governance: Developing System Sustainability in Excellence Reporting

AimsThere has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.MethodsWe developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.ResultsStaff were initially excited, reports submitted, feedback good, then a plateau and slump.Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.By July 2021 we saw 10 reports per week in the Specialist Directorate.By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.ConclusionWe recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.

Women with Lived Experience in the Perinatal Period: What do they want from Their Doctors?

IntroductionBest practice requires the treating physician to understand the needs and hopes of his/her patient, particularly in relation to pregnancy and childbirth preferences. This is even more necessary for women with Severe Mental Illness (SMI) because of the complicated decisions they face balancing the need to continue medication in pregnancy to prevent relapse against any possible harm to the foetus. Objectives: To explore what women themselves view as most important when discussing pregnancy and childbirth with psychiatrists and what barriers there are to a) having a meaningful conversation and b) achieving optimum outcomes. Qualitative methods were used to analyse the data from in-depth interviews with 21 women, recruited from a South London NHS organisation (76%) and the UK’s national bipolar charity (24%). The views of 25 health professionals, including 19 psychiatrists, were also collected and analysed. Results: Many themes emerged but principally women wanted: information, continuity of care, better training for health professionals, to co-produce a detailed care plan, access to a Mother and Baby Unit, peer support and more research on medications in pregnancy. Conclusions: This study highlighted the importance of understanding women’s needs and fears and giving them the necessary information to make the difficult decisions that face them. Such understanding is likely to lead to more positive therapeutic relationships and better long-term outcomes.DisclosureNo significant relationships.

‘Do I have to say I’m gay?’: Using a video booth for public visibility and impact

Using data generated from a ‘video booth’, this paper explores how LGBT+ identifying individuals and allies navigate public visibility in front of a video camera. The video booth was set up in eight different NHS organisations in the UK to enable users to record short messages (30 s maximum) about their working life and/or experiences of LGBT+ employee networks, using a self-operated tablet system. The workplace context had an impact on how people represented themselves in front of the camera with prioritisation of professional identities and positive work-self. LGBT+ visibility was further masked by the inclusion of allies. We also discuss ethics and privacy issues related to using video booth methodology and signal how this methodology can best be used for future research purposes.

Improving health inequalities and wellbeing through the development of NHS Anchor Institutions – the Advancing Quality Alliance (aqua) using a ‘living laboratory’ approach to understand and facilitate learning into how NHS organisations engage, learn and

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Research as part of the advanced clinical practitioner role

British Journal of NursingVol. 31, No. 7 Advanced Clinical PracticeResearch as part of the advanced clinical practitioner roleCatherine Fielding, Jennifer Riley, Clare Sutherland, Karen Swift, Adam GordonCatherine FieldingE-mail Address: [email protected]Clinical Academic Trainee Advanced Clinical Practitioner and Health Education England (HEE) and National Institute for Health Research (NIHR) Integrated Clinical Academic (ICA) Clinical Doctoral Research Fellow, University Hospitals of Derby and Burton NHS Foundation Trust, DerbySearch for more papers by this author, Jennifer RileyAssociate Director for Advanced Practice, University Hospitals of Derby and Burton NHS Foundation Trust, DerbySearch for more papers by this author, Clare SutherlandAssociate Director for Advanced Practice, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, Associate Dean Interprofessional Learning, Health Education England East Midlands and Senior Professional Advisor ACP, Health Education England National TeamSearch for more papers by this author, Karen SwiftACP Teaching Fellow, University Hospitals of Derby and Burton NHS Foundation Trust, DerbySearch for more papers by this author, Adam GordonConsultant Geriatrician, University Hospitals of Derby and Burton NHS Foundation Trust, and Professor of the Care of Older People, University of NottinghamSearch for more papers by this authorCatherine Fielding; Jennifer Riley; Clare Sutherland; Karen Swift; Adam GordonPublished Online:11 Apr 2022https://doi.org/10.12968/bjon.2022.31.7.372AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Baltruks D., Callaghan P; Council of Deans of Health. 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An audit to determine how teratogenic risks of carbimazole are considered for patients of child-bearing potential in an acute hospital setting

Abstract Introduction Carbimazole is associated with an increased risk of congenital malformations when used in pregnancy. In 2019, the Medicines and Healthcare products Regulatory Agency (MHRA) strengthened its advice on risk minimisation (1). The valproate national campaign raised awareness of risks amongst healthcare professionals and the public (2). However, within our organisation it was perceived that awareness of teratogenic effects of carbimazole was potentially less well-known. Aim The aim was to determine if teratogenic risks associated with carbimazole were considered in patients of child-bearing potential. Objectives were to measure the percentage of patients that had a documented: acknowledgement of risk (audit standard 70%); pregnancy or contraception status (audit standard 80%); record of provision of patient information (audit standard 70%) and make recommendations to improve practice. Methods An audit approach was used with standards derived from national guidance (1). The setting was an acute NHS organisation comprising two main sites. The prescribing, health record (HR) and pharmacy dispensing systems were electronic. A cluster sample of female patients aged ≤45 years that had carbimazole dispensed between November 2018 and November 2019 were included. A data collection tool was developed and piloted prior to use. A trainee pharmacist reviewed patient HRs and extracted details of prescription, risk conversations, contraception and pregnancy status onto the data collection tool. Patients without a consultation record were excluded. No patient or staff identifiable data were recorded. Data were collated using Microsoft Excel and analysed descriptively. Results Seventy-nine of 81 patients aged 11-45 years were included; two patients were excluded because their consultation records were unavailable. Of 79 patients, 35 (44%) had either pregnancy status, contraception, teratogenic risk consideration or discussion documented. For 44 (56%) patients, there was no documented acknowledgement of risk. Twenty-nine (36%) patients had their pregnancy or contraception status documented. For six pregnant patients, provision of advice was unclear. Only fifteen (19%) had specific documentation about risk consideration and six of documented risk conversations with patients. There was no evidence pharmacists had checked risk considerations made by prescribing clinicians or actively provided information to patients. Conclusion Findings suggest that consideration of teratogenic risk of carbimazole is inconsistent. Where pregnancy and contraception status were documented in the absence of further information, it was unclear if patients were informed of risks or involved in treatment discussions. Findings have limited generalisability due to the small sample. Although HR were thoroughly reviewed, findings were based on documentation that was potentially incomplete or not representative of detailed discussions during patient consultations. Further research should use methods to explore clinician and patient awareness of teratogenic risk of carbimazole and patient involvement in their treatment decisions. Recommendations are to: upskill pharmacists so they more actively provide risk information; better utilise electronic prescribing to mandate inclusion of contraception status and facilitate standardised risk consideration. National bodies should implement formal risk minimisation strategies for all teratogenic drugs. References (1) Medicines and Healthcare products Regulatory Agency. Carbimazole: increased risk of congenital malformations strengthened advice on contraception [internet]. London: MHRA; 2019 [cited February 2019]. Available from: https://www.gov.uk/drug-safety-update/carbimazole-increased-risk-of-congenital-malformations-strengthened-advice-on-contraception (2) NHS England and NHS Improvement. Patient Safety Alert Resources to support the safety of girls and women who are being treated with valproate [internet]. London: NHSEI; 2017 [updated 2019 December 6]. Available from https://www.england.nhs.uk/wp-content/uploads/2019/12/Patient_Safety_Alert_-_Resources_to_support_safe_use_of_valproate.pdf

Health Technology Adoption in Liver Disease: Innovative Use of Data Science Solutions for Early Disease Detection.

Chronic liver disease (CLD) is an ignored epidemic. Premature mortality is considerable and in the United Kingdom (UK) liver disease is in the top three for inequitable healthcare alongside heart and respiratory disease. Fifty percentage of patients with CLD are first diagnosed with cirrhosis after an emergency presentation translating to poorer patient outcomes. Traditional models of care have been based in secondary care when the need is at community level. Investigating patients for disease based on their risk factors at a population level in the community will identify its presence early when there is potential reversibility. Innovation is needed in three broad areas to improve clinical care in this area: better access to diagnostics within the community, integrating diagnostics across primary and secondary care and utilizing digital healthcare to enhance patient care. In this article, we describe how the Integrated Diagnostics for Early Detection of Liver Disease (ID-LIVER) project, funded by UK Research and Innovation, is developing solutions in Greater Manchester to approach the issue of diagnosis of liver disease at a population level. The ambition is to build on innovative pathways previously established in Nottingham by bringing together NHS organizations, academic partners and commercial organizations. The motivation is to co-create and implement a commercial solution that integrates multimodal diagnostics via cutting edge data science to drive growth and disrupt the currently inadequate model. The ambitious vision is for this to be widely adopted for early diagnosis and stratification of liver disease at a population level within the NHS.

Nurses' and midwives' experiences and views about responding to out of work emergencies: A constructivist grounded theory study.

To explore nurses' and midwives' experiences, views, perceptions and impact on their responses to out of work emergencies where first aid may be required. A constructivist grounded theory study was conducted between 2012 and 2019. In-depth, semi-structured interviews were undertaken with 16 nurses and midwives. Participants were recruited via a participant referral process with registered nurses and midwives being accessed from three NHS organizations. Data were analysed and coded using constant comparative analysis with the support of Nvivo 10software leading to the construction of a substantive grounded theory. A core enduring in vivo theme, 'The Right Thing to Do', emerged as a central conceptual reality constructed via three key in vivo themes; 'Something I've Heard', 'Am I Covered?' and 'Just Who I Am', each with several sub-themes. A pervading anxiety about responding at off-duty situations requiring first aid was persistently evident across these themes. The study showed a strong sense of moral agency among nurses and midwives, despite a powerful underlying feeling of anxiety surrounding broader issues of urban myth, protection and personal and professional identity. The substantive theory emerged as 'doing "The Right Thing" in a climate of anxiety'. The study illuminates an area that has previously been the subject of anecdotal debate. The substantive theory, 'doing "The Right Thing" in a climate of anxiety' illustrates the issues and tensions that exist surrounding the off-duty response. Implications and recommendations for practice and education focus on the fostering of knowledge and understanding of professional identity, position in law and scope of practice, together with potential future research directions. This work provides the first in-depth qualitative study contributing a significant new perspective both nationally and globally.