North West London Research Articles

Clinical characteristics and comorbidities associated with testosterone prescribing in men.

Testosterone replacement therapy (TRT) is recommended for the treatment of symptomatic hypogonadism in men. Data on prescription behaviours are, however, limited and conflicting. The objective of this study was to investigate clinical characteristics associated with the likelihood of being prescribed TRT by general practitioners (GP) in North-West London (NWL). Retrospective cohort study using Discover database of GP-registered patients in NWL between 2015 and 2019. We identified 20,299 men aged ≥18 years with serum total testosterone measurement (TT) and without prior TRT prescription records. We determined whether TRT was subsequently commenced, while analysing clinical characteristics related to hypogonadism. Of all men having TT measurement, 19,583 (96.4%) were not commenced on TRT (Group A) and 716 (3.5%) men were commenced on TRT (Group B). Men prescribed TRT (Group B) had higher mean age, body mass index (BMI) and higher risks of hypertension, depression type 2 diabetes and ischaemic heart disease; conversely, men in Group B had lower mean pretreatment TT and were less likely to have prostate cancer. Four-hundred and thirty-six men (24.3%) with TT < 8 nmol/L and symptoms of low libido were not prescribed TRT. Our study highlights several factors which may influence the decisions made by clinicians when initiating TRT in primary care. Clearer guidance for clinicians may help to improve the consistency of treatment of men with hypogonadism.

How is patient activation related to healthcare service utilisation? Evidence from electronic patient records in England

BackgroundThere is increasing awareness of the importance of patient activation (knowledge, skills, and confidence for managing one’s health and health care) among clinicians and policy makers, with emerging evidence showing higher levels of patient activation are associated with better health outcomes and experiences of health care. This study aimed to examine the association between patient activation and a wide range of specific types of healthcare service utilisation in England, including GP and non-GP primary care, elective and emergency hospital admissions, outpatient visits, and attendances at the Accident and Emergency department.MethodsData were derived from linked electronic patient records collected by primary and secondary healthcare providers in North West London between January 2016 and November 2019. Our analyses focused on adults (18+) with a valid Patient Activation Measure (PAM). After excluding patients with missing data, we had an analytical sample of 15,877 patients. Data were analysed using negative binomial regression and logistic regression models depending on the outcome variable.ResultsPatients had a mean activation score of 55.1 and a standard deviation (SD) of 17.7 (range: 0–100). They had an average of 5.4 GP visits (SD = 8.0), 26.8 non-GP visits (SD = 23.4) and 6.0 outpatient attendances (SD = 7.9) within a one-year follow-up. About 24.7% patients had at least one elective admission, 24.2% had one or more emergency admissions, and 42.3% had one or more A&E attendance within the follow-up. After accounting for a number of demographic and health factors, we found a linear (or proximately linear) association between patient activation and the number of GP visits, emergency admissions and A&E attendance, but a non-linear relationship between patient activation and the number of non-GP visits, the number of outpatient attendance and elective inpatient admission.ConclusionsThis study has provided strong empirical evidence from England linking patient activation with healthcare service utilisation. It suggests the value of supporting patient activation as a potential pathway to ease the burden of healthcare system.

Community–academic partnerships addressing local health inequalities during COVID-19: a qualitative evaluation

BackgroundDuring the COVID-19 pandemic, inequalities among communities were amplified and local organisations had reductions in resources. In response, seven community organisations, an academic primary care and public health department, and 25 medical students partnered to co-create tailored projects to address community-defined goals. We aimed to explore community perspectives from such a partnership approach. MethodsWe did a qualitative realist evaluation to explore what works, why, and for whom regarding the community–academic partnerships. Data were gathered through ten semistructured interviews and one focus group. Themes were constructed from iterative deductive and inductive coding conducted in NVivo 10. These themes were used to continually test and refine propositions co-created with the community partners that hypothesised key components of successful partnerships that could provide a useful response during a pandemic. FindingsBetween June 9 and Aug 20, 2020, we gathered data from 12 community partners (nine women and three men). The community–academic partnerships led to co-creation of tangible outputs that responded to challenges facing communities experiencing poor health outcomes pre-pandemic. Enablers of effective partnerships included developing faculty–community relationships, articulating common goals tailored around local priorities, recognition of community value, and adopting a flexible, collaborative process throughout. Short timelines and long quality assurance processes were perceived as barriers. Longstanding inequalities impeded the ability of outputs to address needs for certain communities. For example, a video about COVID-19 was produced in multiple languages but not translated into Somali quickly enough, despite the absence of appropriate communications for this community. The medical students were perceived by community partners to add capacity and technical expertise. An example output was a co-produced resource pack for low-income, single parent families, accompanied by a public health campaign encouraging participation in healthy, creative activities. InterpretationThe findings highlighted the enablers and barriers to successful community–academic partnerships that achieved their goals, as defined by the community. Community-academic partnerships have the potential to offer increased capacity for community interventions as a response to the COVID-19 pandemic through student involvement. FundingWest London Health Partnership funded two of the projects mentioned in the Abstract. This abstract presents independent work commissioned by the National Institute for Health Research (NIHR) under the Applied Health Research programme for North West London. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

Providing gastrointestinal nurse education during the pandemic.

Jennifer Burch, Head of Gastrointestinal Nurse Education, St Mark's Hospital, London North West University Healthcare NHS Trust (jburch1@nhs.net), was runner-up in the Gastrointestinal/Inflammatory Bowel Disease Nurse of the Year category of the British Journal of Nursing Awards 2021.

P09 Uncommon cause of back pain

P09 Uncommon cause of back pain

Assessing COVID-19 Vaccine Uptake and Effectiveness Through the North West London Vaccination Program: Retrospective Cohort Study.

BackgroundOn March 11, 2020, the World Health Organization declared SARS-CoV-2, causing COVID-19, as a pandemic. The UK mass vaccination program commenced on December 8, 2020, vaccinating groups of the population deemed to be most vulnerable to severe COVID-19 infection.ObjectiveThis study aims to assess the early vaccine administration coverage and outcome data across an integrated care system in North West London, leveraging a unique population-level care data set. Vaccine effectiveness of a single dose of the Oxford/AstraZeneca and Pfizer/BioNTech vaccines were compared.MethodsA retrospective cohort study identified 2,183,939 individuals eligible for COVID-19 vaccination between December 8, 2020, and February 24, 2021, within a primary, secondary, and community care integrated care data set. These data were used to assess vaccination hesitancy across ethnicity, gender, and socioeconomic deprivation measures (Pearson product-moment correlations); investigate COVID-19 transmission related to vaccination hubs; and assess the early effectiveness of COVID-19 vaccination (after a single dose) using time-to-event analyses with multivariable Cox regression analysis to investigate if vaccination independently predicted positive SARS-CoV-2 in those vaccinated compared to those unvaccinated.ResultsIn this study, 5.88% (24,332/413,919) of individuals declined and did not receive a vaccination. Black or Black British individuals had the highest rate of declining a vaccine at 16.14% (4337/26,870). There was a strong negative association between socioeconomic deprivation and rate of declining vaccination (r=–0.94; P=.002) with 13.5% (1980/14,571) of individuals declining vaccination in the most deprived areas compared to 0.98% (869/9609) in the least. In the first 6 days after vaccination, 344 of 389,587 (0.09%) individuals tested positive for SARS-CoV-2. The rate increased to 0.13% (525/389,243) between days 7 and 13, before then gradually falling week on week. At 28 days post vaccination, there was a 74% (hazard ratio 0.26, 95% CI 0.19-0.35) and 78% (hazard ratio 0.22, 95% CI 0.18-0.27) reduction in risk of testing positive for SARS-CoV-2 for individuals that received the Oxford/AstraZeneca and Pfizer/BioNTech vaccines, respectively, when compared with unvaccinated individuals. A very low proportion of hospital admissions were seen in vaccinated individuals who tested positive for SARS-CoV-2 (288/389,587, 0.07% of all patients vaccinated) providing evidence for vaccination effectiveness after a single dose.ConclusionsThere was no definitive evidence to suggest COVID-19 was transmitted as a result of vaccination hubs during the vaccine administration rollout in North West London, and the risk of contracting COVID-19 or becoming hospitalized after vaccination has been demonstrated to be low in the vaccinated population. This study provides further evidence that a single dose of either the Pfizer/BioNTech vaccine or the Oxford/AstraZeneca vaccine is effective at reducing the risk of testing positive for COVID-19 up to 60 days across all age groups, ethnic groups, and risk categories in an urban UK population.

Detecting signs of deterioration in young patients with serious mental illness: a systematic review

BackgroundSerious mental illnesses (SMI) such as schizophrenia and bipolar disorder first develop between ages 14 and 25. Once diagnosed, young peoples’ health can deteriorate, and it is therefore vital to detect this early to prevent severe outcomes including hospitalisations and deaths by suicide. The main study aim is to describe and discuss observational studies that examine signs of deterioration in young patients with SMI.MethodsA systematic review guided by the published protocol was conducted. Cumulative Index to Nursing and allied Health Literature (CINAHL), MEDLINE, Embase, PsycINFO, Health Management Information Consortium (HMIC) and Web of Science were searched against pre-defined criteria until 1 March 2021. Observational studies were extracted according to design, country, participant, indicator, outcome and main finding categories. Quality was assessed independently using the Newcastle Ottawa Scale (NOS).ResultsOf the 15,788 publications identified, 5 studies were included and subjected to narrative synthesis. Two indicators of mental health deterioration were identified: cognitive functioning (decline, worsening and poor school/academic performance) and expressed emotion status. Indicators revealed mixed views on predicting deterioration. Worsening cognitive functioning and expressed emotion status significantly predicted medication non-adherence and relapse respectively. However, a decline in cognitive functioning (poor academic performance) was not found to significantly correlate to deaths by suicide. Study quality was mostly poor and associations between indicators and varied outcomes were weak. The heterogeneous nature of the data made comparisons difficult and did not allow for further statistical analysis.ConclusionTo our knowledge, this is the first review of observational studies to identify indicators of deterioration in young patients with SMI. Worsening cognitive functioning and expressed emotion status could indicate non-adherence and relapse in young patients with SMI but larger sample sizes in good quality studies are needed. The dearth of observational studies means further research is required to ascertain other indicators of deterioration before serious outcomes occur.FundingThis work was supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre via an NIHR programme grant. The authors are also grateful for support from the NIHR under the Applied Health Research programme for North West London and the NIHR Imperial Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Trial registrationThis systematic review has been registered on PROSPERO (registration number: CRD42017075755).

Correction: Aflibercept for treatment-naïve diabetic macula oedema in a multi-ethnic population: Real-world outcomes from North West London

[This corrects the article DOI: 10.1371/journal.pone.0246626.].

The effect of mode of delivery and duration of labour on subsequent pregnancy outcomes: a retrospective cohort study.

To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy. Retrospective analysis of prospectively collected data. 15 Maternity units in North West London (1988-2000). 30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. Compared with vaginal birth, an emergency CS in the first-term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy. An emergency caesarean section in the first-term pregnancy affects the duration and outcome of the next pregnancy.

P–344 Clarifying tubo-ovarian abscess management: a risk score for predicting antibiotic failure

Abstract Study question Can antibiotic treatment failure of tubo-ovarian abscesses (TOA) be predicted based on clinical features at the time of diagnosis? Summary answer We propose a risk score including patient temperature, c-reactive protein and TOA size that could predict which patients are likely to fail parental antibiotic treatment. What is known already Current guidance is that the first line management of non-ruptured TOA is with parental antibiotics. However, it is reported that treatment failure rate is 20–30%. Alternative treatment modalities include radiological drainage or laparoscopic/open surgery. In patients who require intervention, outcomes, such as morbidity, length of hospital stay and fertility, are improved when this is performed early rather than later in their hospital admission. However, our current guidance is scant with regards to the decision making for interventional TOA management. Study design, size, duration This is a multicentre retrospective cohort study over 81 months (01/01/13- 30/09/19) identifying 214 consecutive patients admitted to hospitals in North-West London with diagnosed TOA. Participants/materials, setting, methods: Demographics, medical history, presenting symptoms, laboratory results, radiological findings, treatments administered, hospital length of stay and follow up data was collected. The patients were chronologically split with the first 150 being used for the development of our risk score. Univariate and bivariate analyses were employed to ascertain statistically significant variables in the failure of parental antibiotic. The remaining 64 patients were used for risk score validation. Main results and the role of chance Statistically significant variables were: temperature at admission (median= 37.1 °C vs 38.2 °C, p = 0.0001), C-reactive protein (CRP) at admission (151mg/L vs 243mg/L, p = 0.0001) and size of TOA (6.0cm vs 8.0cm, p = 0.0001). Those requiring intervention, stayed in hospital twice as long as those who did not (4 days vs 8 days, p &amp;lt; 0.001). A scoring system was formulated using the statistically significant variables. A score of ≥ 4 was associated with requiring radiological/surgical intervention (p &amp;lt; 0.001), with sensitivity 69% and specificity 88% (AUC 0.859) when tested on the validation cohort. Limitations, reasons for caution Being a retrospective study, which puts the data at risk of information and selection bias. Although there are merits to a multi-centre study, variation in patient management will invariably cause data heterogeneity. Wider implications of the findings: TOA patients may have their hospital management tailored early according to the postulated tool, alleviating uncertainty in their treatment as well as possibly reducing morbidity and length of hospital stay. Trial registration number Not applicable

Impact of social restrictions during the COVID-19 pandemic on the physical activity levels of adults aged 50–92 years: a baseline survey of the CHARIOT COVID-19 Rapid Response prospective cohort study

ObjectivesPhysical inactivity is more common in older adults, is associated with social isolation and loneliness and contributes to increased morbidity and mortality. We examined the effect of social restrictions to...

PRINCIPLE: a community-based COVID-19 platform trial

PRINCIPLE: a community-based COVID-19 platform trial

Counseling of Patients with Severe Psychiatric Conditions and Referral to Smoking Cessations Programs

Background: Cigarette smoking and Nicotine dependence are highly prevalent in patients with severe and chronic mental illness. Psychiatric patients consume more cigarettes than general population. Smokers with chronic mental illness can quit smoking with appropriate intervention by smoking cessations programs. These patients can benefit from pharmacotherapy, but consideration should be given for possible interaction with patients’ psychiatric medications. Tobacco use and dependence need to be formally documents on electronic medical records and be offered a referral to smoking cessations programs.&#x0D; Method: All patients in a community rehabilitation service ward in Northwest London were interviewed to identify the type, quantity, and duration of their tobacco. Their electronic clinical records were reviewed to confirm their age, ICD 10 Primary Diagnosis, ICD10 Tobacco dependence diagnosis, medications they take, record of ECG tests and presence of cardiopulmonary problems. Then their records were checked if they were given advice regarding their smoking habit, desire to quit smoking and agreement to be referred to a smoking cessation program.&#x0D; Results and Discussion: Half of the total number of patients in the community psychiatric rehabilitation were cigarette smokers. Majority of the smokers had history of polysubstance abuse. Recording of current smoking status were not regularly update. Patients who had recorded status of being a smoker were all referred to a smoking cessation program and majority had counseling by the healthcare professionals in their unit. Attending the smoking cessation program in those patients have as good outcomes as general population.&#x0D; Conclusions: A substantial number of patients in psychiatric rehabilitation units smoke cigarettes. If their smoking status is accurately documented, they would be referred to a formal smoking cessation program.

The Effect of 24/7, Digital-First, NHS Primary Care on Acute Hospital Spending: Retrospective Observational Analysis.

BackgroundDigital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective.ObjectiveThe aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending.MethodsA retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or “weight” the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20.ResultsThe NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20.ConclusionsPatients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis

ObjectivesReminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study...

Supporting treatment and appropriate medication in paediatrics (STAMP):A Brent Child and Adolescent Mental Health Service audit for the LD pathway

• STAMP stands for ‘Supporting Treatment and Appropriate Medication in Paediatrics.’ STAMP aims to make sure (1) psychological intervention is considered before medication; (2) medication is given only when needed and reviewed regularly; (3) medication is given for the right reason in children and young people.• The Learning Disability pathway within the Child and Adolescent Mental Health Service (CAMHS) in Brent (North-West London) conducted an audit to see how the team were performing to meet STAMP’s aims.• For children and young people taking medication, the results showed that there was not a big difference (a ‘statistical difference’) between (1) those receiving psychological intervention and those who do not; (2) those receiving medication reviews and those who do not; and (3) those who had their medication justified and those who do not. This means that the service is currently not meeting STAMP’s aims in the best way it can.• The service has suggested some ways to help them achieve STAMP’s aims and plans to re-audit in 18 months.

Audit of delays in the diversion of mentally disordered defendants under the Mental Health Act 1983/2007 at a liaison and diversion service in North West London

AimsTo ascertain the length of time defendants wait for a Mental Health Act assessment (MHAA) and where necessary, how long they are waiting for a hospital bed.BackgroundThe Liaison and Diversion Service in North West London (the Service) is provided by Central North West London Foundation NHS Trust (CNWL), Barnet Enfield Haringey (BEH) and Together to Willesden Magistrates Court in North West London.One of the core activities of the Service is diverting individuals from the criminal justice system to hospital under the Mental Health Act (MHA).The Code of Practice allows for a period of 14 days between the medical recommendation and conveyance to hospital. Defendants needing admission under MHA are remanded to custody if a bed is not available. This prevents them from receiving the assessment and care they need. We consider that all defendants found to be liable to detention under the MHA should be admitted to a hospital bed on the same day.MethodData were collected between October 2018 and February 2019. All patients referred for a MHAA were included. The time a MHAA was requested, took place as well as how long the defendant waited for a bed was noted.ResultA total of 42 MHAA were requested. 25 individuals were detained under Section 2 of the MHA 1983.The time between referral for a MHAA and the MHAA taking place was obtained in 25 of the 42 referrals. The range of times between a referral being made and the assessment taking placed varied between 1.5 hours and 22 hours. Two defendants were remanded overnight in prison as the MHAA could not take place on the same day as the referral.In the 25 cases where an application for detention under Section 2 of the MHA was made, beds were not available on the same day in 7 cases. In 4 cases defendants required remand in prison custody due to beds not being available.ConclusionThere were some limitations to this audit as data were not available for all 42 individuals referred for a MHAA.Individuals referred for MHAA by the Service had both medical recommendations completed within 5 days and those who required admission to hospital were admitted within 14 days of the recommendations being completed.Whilst these standards are being met, individuals referred for MHAA and those requiring admission to hospital are still facing remand to custody.

Applying ethical dimensions in clinical dilemmas

AimsCentral and North West London's Clinical Ethics Committee (CEC) offers a non-judgmental space to discuss ethical concerns and challenges and provide ethical guidance. This project aims to publicise these ethical dilemmas and guidance to inform decision making trust-wide.BackgroundA Clinical Ethics Committee (CEC) encompasses a diverse range of figures, from psychiatrists and general practitioners to members of the clergy and experts by experience. The CEC in Central and North West London have been meeting regularly since 2003 to provide ethical assistance to a wide range of medical, surgical and psychiatric teams. Complex ethical cases are presented by the treating team, allowing a subsequent discussion of the ethical theories and frameworks within the case with the committee members. This synthesis of information can then assist the treating team in the shaping of ethical based solutions to their dilemmas.The committee wished to encourage ethical based clinical thinking within the trust and enable others to learn from the valuable insights already provided by the CEC over the years.MethodCase notes, recorded from the last 17 years of meetings of the Clinical Ethics Committee were reviewed. 98 cases were identified between 2003-2019. The contemporaneous case reports were then anonymised and indexed into one easy to use file. This file was published on the local intranet and publicised to staff.ResultThe cases were compiled into a PDF document which is available for all staff members within the trust on the intranet. This resource is open to all clinical staff, and serves the dual purpose of encouraging ethical-based thinking and also promoting the ethics committee to those who might be in need of assistance.ConclusionClinical decisions can be complex and nuanced, often complicated by multiple viewpoints and ways of thinking. The database demonstrates the use of ethical dimensions by the ethics committee to inform decision making in a series of varied clinical and management dilemmas. The project required careful consideration around preservation of confidentiality as well as overcoming the logistical barriers of trust-wide dissemination. The result is a document that will allow ethical based decision-making to be embedded into everyday practice.

Prevalence, associated factors and prevention of burnout in psychiatry trainees in Central and North West London NHS Foundation Trust

AimsTo assess burnout, resilience, professional quality of life and coping mechanisms in Central and North West London psychiatry traineesObjectivesTo determine Key factors associated with stress and burnout in workplace Effects of burnout on patient care and doctors Coping mechanisms used by traineesBackgroundBurnout is a well established condition that has been recently reported to affect a third of doctors. Psychiatrists in particular represents a high risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work related stress.MethodThe study comprised of a cross sectional questionnaire survey which included measure of stress (General Health Questionnaire), burnout (Maslach Burnout Inventory), and satisfaction with medicine as a career and personality (Big Five). During October to December 2019, core trainee and specialty trainee doctors in CNWL were asked to complete an online survey via emails.ResultWe collected data from 50 CNWL psychiatry trainees. The sample consisted of 20 females (40%) and 30 males (60%). Ages varied from 26–58 years old, with a median age of 28. Core trainees (CT1–3) were recorded as 72% and specialty trainees at 28%.Of those who responded, around half of the trainees (52%) experienced high levels of stress outside of work in their personal life. The most common causes that trainees felt makes psychiatry a stressful profession were violence and fear of violence, limited resources, dealing with confrontational patients, inability to affect systemic change and increasing culture of blame. Around half of respondents (54%) felt that they have experienced burnout but only 26% of respondents knew where to go to find resources to help cope with burnout. Physical exercise and speaking to colleagues were the most common coping mechanisms used by trainees to deal with stress.Free text responses on what can be improved in workplace to enhance a positive experience of work included improving multidisciplinary interactions, easily accessible resources and increasing staffing levels. 74% of respondents felt they continued to care about what happens to patients regardless of working conditions.ConclusionHalf of CNWL trainee doctors who responded have experienced burnout. Some factors associated with stress and burnout in doctors are unique to psychiatry profession. Free text responses were useful in identifying areas for improvement in work places and useful coping mechanisms, which can be used to inform prevention and implement interventions to tackle burnout.

North West London New Model of Care Project (NMOC) – improving inpatient mental health care for children and young people

AimsSpecialised inpatient mental health services for children and young people are commissioned and managed by NHS England (NHSE) and provided by NHS as well as independent sector. The access to beds has been managed nationally with young people admitted far from home. There were capacity issues identified in London. To address these concerns, NHSE invited organisations to work in partnership to co-design and establish new models of care. This is one of the first of such projects, set up to manage the budget for children and young people's beds on behalf of NHSE and change the way of managing and monitoring admissions.Our aims:To reduce length of inpatient stayTo enable admission of young people as close to home as possibleTo improve resource efficiency, capacity and capability of managing young people in crisis in the community.MethodA number of changes were introduced, including engagement of community and inpatient clinical staff, repatriation to units closer to home and introduction of CRAFT meetings (early review meetings in inpatient units to enable timely and effective discharge planning and support back to local services). The implementation has been closely monitored by the project manager and clinical group, which included representatives from all organisations involved.ResultAfter four years, young people are admitted to hospitals closer to home and the length of inpatient stay has decreased by 18%. The number of admissions has decreased by 28%. Out of area occupied beds days have been decreased by 66%.Significant recurrent budget savings have been achieved. Over the past three years, these savings have been reinvested in developing crisis community support and more specialist community services within CNWL and West London Trust.ConclusionThere have been considerable benefits of multiple organisations working in partnership to improve patients care. The success of the project has created further opportunities for the development of services which provide safe and effective alternatives to admission (such as crisis services, home treatment teams and specialized community services). In summary, this collaborative model has improved the quality of care and experience for young people and reduced the need for psychiatric admission.