NHS Region Research Articles

Support for primary care prescribing for adult ADHD in England: national survey.

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support. This study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement. Cross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care. Three interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software. Data from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region - for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%). Elements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps.

Where next for type B aortic dissection?

In April 2021 the acute aortic dissection toolkit was launched by NHS England.1 It was designed to improve the care of patients with acute aortic dissection (AD) by raising awareness of the condition and introduced seven key principles of management including better governance, 24/7 rotas and specialist care. Each NHS region in England was encouraged to form an AD group, benchmark their current service against the toolkit principles and then try to improve their management of these patients by addressing deficiencies. The toolkit provided tools for self-assessment together with protocols to improve deficiencies by sharing best practice. A regular series of regional meetings has been held with clinicians and managers to advise and help progress – engagement with the process and feedback has been good. National key performance indicators are being developed to monitor the overall effect of the toolkit. Although the toolkit applies to all dissections, there is inevitably a bias towards management of type A dissections because many need urgent cardiac surgical repair. So where next and what about type B dissections?

Equity of Access to Proton Beam Therapy in England: A National NHS analysis

Policies to improve population health have often focused on equitable access to health services. While new technologies have an enormous potential in improving health outcomes, they may not always be equally accessible across diverse geographical areas and socio-economic backgrounds. Between 2008 and 2018, 1352 patients with eligible indications for Proton Beam Therapy (PBT) were treated overseas within the NHS Proton Overseas Programme (POP) and 947 patients have been treated at the Christie since the National NHS PBT service started in December 2018. The 8 most common PBT cancer indications cover more than 80% of the referrals and referral rates depend on several factors. Aim of this study is to evaluate equity of access to PBT throughout the country and how this has changed since the national PBT service inception. Incidence data were available for 7/8 of the most common PBT cancer indications. These data were provided by the National Disease Registration Service (NDRS) by diagnosis, age group and by the 7 NHS regions in England. The incidence data referred to the time period 2013-2019. The first national NHS PBT center started accepting referrals in October 2018, therefore this time period was split in pre-NHS PBT (1/1/13-30/9/18) and post-NHS PBT (1/10/18-31/12/19). Demographics and clinical characteristics of patients referred for PBT were extracted from the national NHS PBT registry for matching clinical diagnoses and time period. The ratio between the referred (observed) and newly diagnosed (expected) patients is the Proton Utilization Proportion (PUP), which tracks the proportion of eligible patients using the technology. For the 7 common PBT indications examined, the total number of newly diagnosed patients was 2134 in the pre-NHS PBT period and 461 in the post-NHS PBT period. The (accepted) referrals were 587 and 300 in the pre-and post-NHS PBT period, respectively. An increase in the PUP between the pre-NHS PBT and the post-NHS PBT is noted for any diagnostic category, age group and NHS region. The most noticeable increase is noticed for Medulloblastoma, which became a commissioned indication for PBT only in 2016.The PUP in England increased post-NHS PBT by 137% overall. Of note, post-NHS PBT, 99% of the patients aged 0-15 with these 7 common indications for PBT were referred and treated with PBT. Promoting equality of access to cutting-edge radiotherapy technologies is at the heart of NHS England's values. Throughout the development of the policies and processes related to PBT access in the UK, the NHS has given regard to the need to reduce geographical variation which may contribute to health inequalities. The PUP has increased since the opening of a National PBT service in England, which uses a central web-based Proton Referral Pathway managed by a National Proton Office. Further analysis will follow to examine whether socio-economic or geographical barriers exist within each region.

How Safety Culture Surveys Influence the Quality and Safety of Healthcare Organisations.

Objectives Safety culture surveys have been widely used in healthcare for more than two decades predominantly as a tool for measuring the level of safety culture (as defined as the beliefs and attitudes that staff express about how their organisation ought to work and how it does in fact work).However, there is the potential for the survey process itself to influence the safety culture and working practices in departments and organisations.The objective of this study was to identify the mechanism by which these changes might occur. Design, setting and participants Mixed methods combining qualitative semi-structured interviews and quantitative scores from patient safety surveys. This evaluation was conducted across general practice, community and acute hospitals in two NHS regions in England; South West and Greater Manchester. The study was undertaken between 2015 and 2018during the implementation of a series of Patient Safety Collaboratives. Safety, Communication, Operational Reliability, and Engagement (SCORE) surveys were administered in 15 units, followed by a staff debriefing and a second SCORE survey. Semi-structured interviews were conducted with clinicians (n=61). Results from the first and second surveys were compared in order to test for differences in responses. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed. Analysis and results Results from the first and second surveys were compared using chi-squared and Fisher's exact tests. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed. There was little change in responses between the first and second SCORE surveys.Within general practicethere was some improvement in responses in three survey domains; however, these differences were not conclusive. The qualitative interview data demonstrated a beneficial effect on safety culture. Staff stated that the survey debriefings created a new safe space where problems could be discussed and improvement plans created. Conclusions Safety culture surveys can improve safety culture within departments if they are followed by a process that includes debriefing the staff and working with them to develop improvement plans.

Trends, variation, and clinical characteristics of recipients of antiviral drugs and neutralising monoclonal antibodies for covid-19 in community settings: retrospective, descriptive cohort study of 23.4 million people in OpenSAFELY

ObjectiveTo ascertain patient eligibility status and describe coverage of antiviral drugs and neutralising monoclonal antibodies (nMAB) as treatment for covid-19 in community settings in England.DesignRetrospective, descriptive cohort study, approved by...

Mixed-methods implementation study of a virtual culturally tailored diabetes self-management programme for African and Caribbean communities (HEAL-D) in south London and its scaling up across NHS regions in England: study protocol

IntroductionThe National Health Service Insight Prioritisation Programme was established to accelerate the implementation and evaluation of innovation that supports post-pandemic working. Supporting this, the Academic Health Science Network and National...

Adherence to the paediatric immunisation schedule in England

Both adequate coverage and adherence to paediatric immunisation schedules are required for optimal protection against vaccine preventable diseases. We studied the timeliness of routine paediatric vaccinations according to the NHS’s immunisation schedule and potential factors of schedule adherence. Immunisation data was obtained from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC). We collected vaccine types, doses, and dates for all routine paediatric vaccines between 2008 and 2018: DTaP/IPV/Hib/HepB, DTaP/IPV/Hib, DTaP/IPV, dTaP/IPV, Td/IPV, MMR, PCV, MenB, MenC, MenACWY, Hib/MenC, RV, HPV. Adherence to the immunisation schedule was calculated for each vaccine and dose. Differences in adherence between genders, NHS regions, and IMD quintiles were analysed. Our study included 6′257′828 vaccinations in 1′005′827 children. Seventy-five percent of first doses were administered within one (for vaccines scheduled in the first year of life) or two months (for vaccines scheduled later in life) following the recommended age, 19% too late and 6% too early. About half of the subsequent doses were given timely. The time between first and second doses was too short for 36% of vaccinations while 13% of second doses were administered too long after the first dose. Third doses were administered timely for 45%, too short for 37%, and too long for 18% of vaccinations. Differences in immunisation schedule adherence between girls and boys were negligible, except for HPV, and differences between the four main NHS regions were small. Overall, immunisation schedule adherence improved slightly with decreasing deprivation according to the Index of Multiple Deprivation. Efforts are required to improve the timeliness of paediatric vaccinations and to assure adequate protection against vaccine preventable diseases. We propose developing a compound measure combining coverage and adherence to provide a better indication of the protection against vaccine preventable diseases in a community.

Co-administration of routine paediatric vaccines in England often deviates from the immunisation schedule

Vaccine co-administration can facilitate the introduction of new vaccines in immunisation schedules and improve coverage. We analysed real life data to quantify the extent of routine paediatric vaccine co-administrations as recommended and as never recommended in the immunisation schedule in England, and assessed factors for recommended and never recommended vaccine co-administrations.Immunisation data for all scheduled routine paediatric vaccines between 2008 and 2018 was obtained from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC).We included 6′257′828 doses administered to 1′005′827 children. Twenty-one percent of vaccines were given separately, 79% were co-administered. Sixty-four percent of vaccines scheduled for co-administration were co-administered as recommended while 15% were administered separately. Among all vaccine co-administrations, 75% happened as recommended in the schedule, 4% were never recommended, while 21% deviated from the schedule. Vaccine co-administration according to the schedule varied greatly between vaccines. Forty-eight percent of English children received at least one of their vaccine co-administrations not as recommended in the immunisation schedule, with 19% of children receiving none of their co-administered vaccines as recommended. Late administration of one or more vaccines increased the odds for deviated co-administrations (OR 1.60) and strongly increased the odds for never recommended co-administrations (OR 5.34). Differences between genders, NHS regions, and IMD quintiles were statistically significant but small.Suboptimal co-administration rates for routine paediatric vaccines are a missed opportunity and should be optimised by concerted public health action.

Implementing the PIE (Person, Interaction and Environment) programme to improve person-centred care for people with dementia admitted to hospital wards: a qualitative evaluation

Background: In the UK, improving person-centred care for people with dementia in hospitals is a policy priority. The PIE (Person, Interaction, Environment) programme comprises cycles of observation of care by staff, identification of areas for improvement and plans for practice change and evaluation. Aim: To describe and evaluate PIE implementation in three UK NHS regions. Methods: A qualitative design was adopted at 10 case study sites (wards), selected on the basis of readiness for change criteria. Following a training workshop, PIE cycles were introduced into each ward. Data collection comprised observation, interviews, documentary analysis and an events log. Normalisation process theory provided a guiding framework for analysis. Results: PIE was fully adopted in two study wards over 18 months, which resulted in sustained practice change and increased awareness of person-centredness. Partial implementation of PIE took place in a further two wards but progress stalled before significant action. The remaining six wards did not implement the programme. Factors influencing the likelihood of implementation were: relevance of PIE; collective team involvement; fit with strategic priorities; adequate resourcing; effective clinical leadership; good facilitation; and organisational stability. Conclusion: PIE has the potential to help staff improve person-centred care for people with dementia admitted to hospital wards. However, the evidence provided by this article is limited to 10 wards, of which only two fully implemented the programme. Implications for practice: A programme for improving person-centred care for people with dementia in acute hospital wards requires sustained commitment from the ward and the wider organisation Successful practice change depends on multiple factors, including effective clinical leadership and good facilitation Contextual factors at various levels of an organisation need to be considered Use of the PIE tool has the potential to enable staff to focus on person-centred care for older people with dementia in acute settings

Supporting Urgent Dental Care as the New Normal

Across healthcare systems stringent measures have been introduced to prevent the sustained transmission of COVID-19. With the ease of lockdown the provision of all routine, non-urgent dental care will continue to be affected in England for some time. The provision of urgent dental care (UDC) via a robust and safe service has been constructed across every NHS region. In the South West, phone triaging has been an integral part of UDC centres operating procedure. Phone triaging will be required for some time. This proforma will be a valuable resource, especially for primary care practices as they move to re-opening. CPD/Clinical Relevance: The clinical relevance is to share the effective use of a standardized telephone triage form supported by NHS England and NHS Improvement – South West (NHSE/I SW).

The UK hibernated pandemic influenza research portfolio: triggered for COVID-19

The UK hibernated pandemic influenza research portfolio: triggered for COVID-19

Baby-box schemes in England: parent and practitioner experiences, and recommendations

BackgroundProgrammes offering carboard baby boxes to parents in England began in some NHS Trusts in 2016. This study aimed to examine the strengths and weaknesses of English baby-box schemes as experienced by healthcare providers and parents.MethodsAn independent mixed-methods evaluation was conducted via telephone interviews and online surveys with healthcare providers and parents in all 7/9 NHS regions of England where baby-box schemes were established 2016–2019. Participants responded to requests circulated electronically by NHS Research & Design Departments, and infant health organisations in England. The objectives were to identify how parents and healthcare providers understood and experienced baby-box schemes implemented in England to date, and to produce recommendations for organisations considering involvement in future schemes.ResultsBaby-box schemes changed over time, and were complex to run and monitor. Both parents and practitioners were misinformed about their purpose and origins. Partnerships with a commercial box-provider reduced the investment needed to run a baby-box scheme, and offered potential benefits to staff regarding engagement with families via online education and face-to-face contact around handover of boxes, but carried unforeseen costs. Of particular concern was the box-provider’s access to parent personal details being promoted by NHS staff and parents’ lack of awareness; the hidden costs incurred by NHS facilities of running a box-scheme; and the costs incurred by parents in accessing their ‘free’ box. Sixteen recommendations are proposed for healthcare providers and organisations considering commercial - health-provider baby-box partnerships in future.ConclusionsMany assumptions exist about the origins and purpose of baby-boxes; this misinformation needs correcting, especially as it relates to infant death reduction and safe infant sleep. Baby-box schemes take multiple forms from those motivated by social welfare to those motivated by commercial profit. The English experience of partnership schemes between healthcare facilities and commercial box-providers reveals some success stories, along with multiple points of ambiguity, unanticipated difficulty, and concerns for infant safety.

Guided self-help for depression in autistic adults: the ADEPT feasibility RCT.

Co-occurring depression frequently occurs in autism. Evidence-based psychological interventions have been successfully adapted to treat co-occurring anxiety, but there is little evidence about the usefulness of adapted cognitive-behavioural therapy for depression. To the authors' knowledge, to date there have been no randomised trials investigating the usefulness of low-intensity cognitive-behavioural therapy for depression in autism. The objectives of the study were to (1) develop a low-intensity psychological intervention for depression adapted for autism, (2) assess the feasibility and patient and therapist acceptability of the intervention, (3) estimate the rates of recruitment and retention for a full-scale randomised controlled trial and (4) identify an appropriate measure of depression to be used in a full-scale randomised controlled trial. The study comprised a randomised controlled trial (n = 70) with a nested qualitative evaluation (n = 21). Seventy eligible and consenting participants were randomly allocated to guided self-help or to treatment as usual. Adult autism services in two NHS regions. Adults with a diagnosis of autism spectrum disorder with depression, that is, a Patient Health Questionnaire-9 items score of ≥ 10. People who had attended more than six sessions of cognitive-behavioural therapy in the previous 6 months were excluded. The low-intensity intervention (guided self-help) comprised materials for nine individual sessions, based on behavioural activation adapted for autism, facilitated by therapist guides (coaches) who were graduate-level psychologists who attended training and regular supervision. Treatment as usual was standard NHS care for depression. Outcomes were measured 10, 16 and 24 weeks post randomisation using self-report and interview measures of depression, anxiety, obsessive-compulsive symptoms, social function and quality of life, and a health-care and service use questionnaire. As this was a feasibility study also designed to identify the most appropriate measure of depression, it was not possible to specify the primary outcome measure or outcome point a priori. The aims of the study were met in full. The guided self-help intervention was feasible and well received by participants and coaches. The majority of allocated participants attended the intervention in full. The most practical outcome point was determined to be 16 weeks. There were differential rates of attrition across the treatment groups: 86% of the guided self-help group remained in the study at 24 weeks, compared with 54% of treatment as usual group. The qualitative study suggested that guided self-help had enhanced credibility with participants at the point of randomisation. Inter-rater reliability of the interview measure of depression was less than adequate, limiting the conclusions that can be drawn from the prespecified sensitivity to change analyses. The intervention was feasible and well received. Although this feasibility study was not a fully powered trial, it provided some evidence that the guided self-help intervention was effective in reducing depressive symptoms. A full-scale clinical effectiveness and cost-effectiveness trial of the intervention is warranted. Improvements to the intervention materials as a result of qualitative interviews. Stakeholder consultation to consider future trial design, consider strategies to improve retention in a treatment as usual arm and select a self-report measure of depression to serve as the primary outcome measure. Current Controlled Trials ISRCTN54650760. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 68. See the NIHR Journals Library website for further project information. This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

National Diabetes Audits inform best practice for diabetes foot care and hospital inpatients

National Diabetes Audits inform best practice for diabetes foot care and hospital inpatients

Planning and Providing Acute Stroke Care in England: The Effect of Planning Footprint Size.

Background: Guidelines in England recommend that hyperacute stroke units (HASUs) should have a minimum of 600 confirmed stroke admissions per year in order to sustain expert consultant-led services, and that travel time for patients should ideally be 30 min or less. Currently, 61% of stroke patients attend a unit with at least 600 admissions per year and 56% attend such a unit and have a travel time of no more than 30 min.Objective: We have sought to understand how varying the planning and provision footprint in England affects access to care whilst achieving the recommended admission numbers for hyper-acute stroke care. We have compared two different planning footprints to national-level planning: planning using five NHS Regions in England, and planning using 44 Sustainability and Transformation Partnerships (STPs) in England.Methods: Computer modeling and optimization using a multi-objective genetic algorithm.Results: The number of stroke admissions between STPs varies by seven-fold, while the number of stroke admissions between NHS Regions varies by 2.5-fold. In order to meet stroke admission guidelines (600/year) for all units the maximum possible proportion of patients within 30 min would be 82, 78, and 72% with no boundaries to planning/provision, NHS Region boundaries, and STP boundaries (in these scenarios patients cannot move outside of their own STP or NHS Region). If STP or NHS Region boundaries are removed for provision of service (after planning is performed at these local levels), travel time is improved, but number of admissions to individual hospitals become significantly changed, especially at STP planning level where admission numbers per unit changed by an average of 204 (19%), and not all units maintained 600 admissions after removal of boundaries.Conclusion: Planning and providing services at STP level could lead to sub-optimal service provision compared with using larger and more consistently populated planning areas.

Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice.

BackgroundHypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database.Methods and findingWe carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4–18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1–25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5–38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8–47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion.ConclusionsSubstantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.

Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice.

The Scottish Patient Safety Programme - Pharmacy in Primary Care collaborative is a quality improvement initiative adopting the Institute of Healthcare Improvement Breakthrough Series collaborative approach. The programme developed and piloted High Risk Medicine (HRM) Care Bundles (CB), focused on warfarin and non-steroidal anti-inflammatories (NSAIDs), within 27 community pharmacies over 4 NHS Regions. Each CB involves clinical assessment and patient education, although the CB content varies between regions. To support national implementation, this study aims to understand how the pilot pharmacies integrated the HRM CBs into routine practice to inform the development of a generic HRM CB process map. Regional process maps were developed in 4 pharmacies through simulation of the CB process, staff interviews and documentation of resources. Commonalities were collated to develop a process map for each HRM, which were used to explore variation at a national event. A single, generic process map was developed which underwent validation by case study testing. The findings allowed development of a generic process map applicable to warfarin and NSAID CB implementation. Five steps were identified as required for successful CB delivery: patient identification; clinical assessment; pharmacy CB prompt; CB delivery; and documentation. The generic HRM CB process map encompasses the staff and patients' journey and the CB's integration into routine community pharmacy practice. Pharmacist involvement was required only for clinical assessment, indicating suitability for whole-team involvement. Understanding CB integration into routine practice has positive implications for successful implementation. The generic process map can be used to develop targeted resources, and/or be disseminated to facilitate CB delivery and foster whole team involvement. Similar methods could be utilised within other settings, to allow those developing novel services to distil the key processes and consider their integration within routine workflows to effect maximal, efficient implementation and benefit to patient care.

20 - Impact of introducing spinal pain pathway in an NHS region (Northern Ireland)

20 - Impact of introducing spinal pain pathway in an NHS region (Northern Ireland)

Clinical Indications and Outcome of Biotinidase Deficiency Screening among Children and Youths in a Scottish NHS Region Between 2014 and 2016

Clinical Indications and Outcome of Biotinidase Deficiency Screening among Children and Youths in a Scottish NHS Region Between 2014 and 2016

Variation in Direct Access to Tests to Investigate Cancer: A Survey of English General Practitioners.

BackgroundThe 2015 NICE guidelines for suspected cancer recommend that English General Practitioners have direct access to diagnostic tests to investigate symptoms of cancer that do not meet the criteria for urgent referral. We aimed to identify the proportion of GPs in England with direct access to these tests.MethodsWe recruited 533 English GPs through a national clinical research network to complete an online survey about direct access to laboratory, radiology, and endoscopy tests in the three months leading up to the release of the 2015 NICE guidance. If they had direct access to a diagnostic test, GPs were asked about the time necessary to arrange a test and receive a report. Results are reported by NHS sub-region and, adjusting for sampling, for England as a whole.ResultsAlmost all GPs reported direct access to x-ray and laboratory investigations except faecal occult blood testing (54%, 95% CI 49–59%) and urine protein electrophoresis (89%, 95% CI 84–92%). Fewer GPs had direct access to CT scans (54%, 95% CI 49–59%) or endoscopy (colonoscopy 32%, 95% CI 28–37%; gastroscopy 72%, 95% CI 67–77%). There was significant variation in direct access between NHS regions for the majority of imaging tests—for example, from 20 to 85% to MRI. Apart from x-ray, very few GPs (1–22%) could access radiology and endoscopy within the timescales recommended by NICE. The modal request to test time was 2–4 weeks for routine radiology and 4–6 weeks for routine endoscopy with results taking another 1–2 weeks.ConclusionAt the time that the 2015 NICE guideline was released, local investment was required to not only provide direct access but also reduce the interval between request and test and speed up reporting. Further research using our data as a benchmark is now required to identify whether local improvements in direct access have been achieved in response to the NICE targets. If alternative approaches to test access are to be proposed they must be piloted comprehensively and underpinned by robust effectiveness data.