Secondary Care Trusts Research Articles

Identifying where hospital and community trusts are managing general practices in England: a service mapping study.

Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of 'vertical integration' is happening are lacking, making it difficult to evaluate its impact. To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements. This service mapping study comprises review, collation, synthesis, and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021. Desk-based collection, including hand-searching, of secondary care organisations' statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts. It was possible to construct a database of all instances of trusts running general practices in England as of 31 March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework. We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and whether that is an NHS trust, another public body, or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration.

Improving the understanding and management of back pain in older adults: the BOOST research programme including RCT and OPAL cohort

Improving the understanding and management of back pain in older adults: the BOOST research programme including RCT and OPAL cohort

Faecal Immunochemical Testing to Detect Colorectal Cancer in Symptomatic Patients: A Diagnostic Accuracy Study.

(1) Background: NHS England recommended faecal immunochemical testing (FIT) for symptomatic patients in June 2020 to rationalise limited diagnostic services during COVID-19. (2) Aim: to investigate the diagnostic performance of FIT, analysing the proportion of FIT-negative colorectal cancers (CRC) missed in symptomatic patients and how this risk could be mitigated. (3) Design and Setting: a retrospective study of biochemistry and cancer databases involving patients referred from primary healthcare with suspected CRC to a single secondary care trust in North East London. (4) Methods: a retrospective cohort diagnostic accuracy study was undertaken to determine the performance of FIT for detecting CRC at 10 µgHb/g. (5) Results: between January and December 2020, 7653 patients provided a stool sample for FIT analysis; 1679 (22%) samples were excluded due to inadequate or incorrect specimens; 48% of suspected CRC referrals completed FIT before evaluation; 86 FIT tested patients were diagnosed with histologically proven CRC. At 10 µgHb/g, FIT performance was comparable with the existing literature with a sensitivity of 0.8140 (95% CI 0.7189-0.8821), a specificity of 0.7704 (95% CI 0.7595-0.7809), a positive predictive value (PPV) of 0.04923 (95% CI 0.03915-0.06174), a negative predictive value (NPV) of 0.9965 (95% CI 0.9943-0.9978), and a likelihood ratio (LR) of 3.545; 16 patients with CRC had an FIT of ≤10 µgHb/g (18.6% 95% CI 11.0-28.4%). (6) Conclusions: this study raises concerns about compliance with FIT testing and the incidence of FIT-negative CRC at the NICE recommended threshold and how this risk can be mitigated without colonic imaging. Whilst FIT may have facilitated prioritisation during COVID-19, we must be cautious about using FIT alone to determine which patients are referred to secondary care or receive further investigation.

BT09 Clinical performance of an artificial intelligence-based medical device deployed within an urgent suspected skin cancer pathway

Abstract A secondary care trust received over 2800 urgent suspected skin cancer referrals (USCRs) in 2021, 50% more than in 2016 (www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times), < 1 in 10 of which resulted in diagnosis of skin cancer (www.cancerdata.nhs.uk/cwt_conversion_and_detection). Judicious implementation of artificial intelligence (AI) may improve referral accuracy. We conducted a prospective, postdeployment, single-centre clinical performance review of a UK Conformity Assessed Class IIa-approved, AI-based, skin lesion analysis medical device intended for use in the screening, triage and assessment of skin lesions suspicious for skin cancer (AIaMD). The AIaMD is deployed at the trust as a decision-support tool following USCR from primary care, with a second read of all cases by a consultant dermatologist. Patients assessed by the two most recent versions of AIaMD from October 2021 to October 2022 were eligible for inclusion. Outcomes were confirmed from histology reports for cancerous lesions and histology reports or Consultant teledermatology assessment for noncancerous lesions. The AIaMD assessed 1363 lesions with outcomes confirmed, including 51 melanomas, 64 squamous cell carcinomas (SCCs), 96 basal cell carcinomas, 8 rare skin cancers and 244 premalignancies. The AIaMD referral sensitivity for melanoma, all skin cancer and premalignancy was 100% (n = 51/51), 99.5% (n = 218/219) and 96.3% (n = 235/244), respectively. The AIaMD benign lesion specificity was 55.9% (n = 434/777). The negative predictive value (how often AIaMD labelled lesions as premalignant/benign and correctly ruled out cancer) was 99.8% (n = 539/540). The conversion rate (the percentage of lesions classified as high risk by AIaMD that resulted in a diagnosis of melanoma or SCC) was 13.8% (n = 122/886), while the USCR conversion in the local clinical commissioning group was 9.9% in 2020–2021. The service discharged 9.4% (n = 239/2551) of patients during this time without using trust dermatologist capacity, with the potential to have discharged 18.3% (n = 467/2551) without a second read. This postmarket service evaluation reported the clinical outcomes of an AI device used for assessment of skin lesions. The pathway was sensitive, identifying 218 of 219 skin cancers, and specific, correctly identifying over half of benign lesions. Moreover, AIaMD was able to improve the conversion rate of USCRs. The integration of AIaMD into skin cancer diagnostic pathways could significantly improve the accuracy of USCRs. Conflicts of interest: these were commercial deployments of the AI, and three of the authors are employed by the AI provider.

A first census of skin cancer specialist nurses across UK secondary care trusts

BackgroundSkin cancer specialist nurses (SCSNs) support patients and work alongside healthcare professionals throughout the care pathway. Skin cancer management is rapidly evolving, with increasing and more complex treatment options now available, so the need for patient support is growing. While SCSNs are a major source of that support, the provision of SCSN resource across the UK has never previously been assessed. We therefore undertook a first SCSN census on 1st June 2021.MethodsAn electronic survey was disseminated to UK hospital trusts and registered skin cancer healthcare professionals. Responses were identifiable only by the respective trust name.Results112 responses from 87 different secondary care trusts were received; 92% of trusts reporting having at least 1 established SCSN post. Average SCSN staffing per trust was 2.4 (range 0–7) whole time equivalents, managing an average caseload of 83 (range 6–400) patients per week. SCSN workload had increased in 82% hospitals in the previous year and 30% of trusts reported being under-resourced. Most SCSN time was spent managing melanoma (as opposed to non-melanoma skin cancer) patients linked to surgical services. Regional variations existed, particularly associated with provision of lymphoedema services, nurse prescribing skills and patient access to clinical trials. The COVID-19 pandemic was associated with a marked increase in SCSN-led telemedicine clinics, but loss of training and education opportunities.ConclusionsSCSNs based in secondary care hospitals play a major role supporting both clinicians and patients throughout the care pathway. This first UK census confirmed that SCSN workload is increasing and in one third of hospital trusts, the work was reported to outstrip the staffing available to manage the volume of work. Regional variations in SCSN resource, workload and job role, as well as availability of certain skin cancer services were identified, providing valuable information to healthcare commissioners concerned with service improvement.

National statutory reporting: not even ticking the boxes? The quality of ‘Learning from Deaths’ reporting in quality accounts within the NHS in England 2017–2020

IntroductionRegulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary...

Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020

IntroductionThe imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched...

A cohort study of duplicate faecal immunochemical testing in patients at risk of colorectal cancer from North-West England

ObjectivesWe sought to investigate if duplicate faecal immunochemical testing (FIT) sampling improves the negative and positive predictive value of patients thought to be at risk of colorectal cancer (CRC). Specifically,...

Socioeconomic deprivation, age and language are barriers to accessing personal health records: a cross-sectional study of a large hospital-based personal health record system

ObjectivesTo investigate barriers to accessing a hospital-based personal health record (PHR) system.DesignRetrospective cross-sectional study.SettingThis study was conducted in a large secondary and tertiary acute care trust in Birmingham, UK.ParticipantsData were...

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

ObjectivesTo review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths.IntroductionPotentially preventable deaths occur...

Recommendations for improving follow-up care for patients with mesothelioma: a qualitative study comprising documentary analysis, interviews and consultation meetings

ObjectivesThe study aim was to explore experiences of patients with pleural mesothelioma of follow-up care in three National Health Service (NHS) Trusts to develop recommendations for practice.DesignThe study design was...

Determinants of lost theatre capacity.

Secondary care Trusts nationwide are continuing to fail the 18-week referral to treatment (RTT) target despite several initiatives to improve theatre efficiency (2018 NHS England review). A limitation of wasted theatre productivity is required to alleviate pressures on waiting lists. Productivity, which is a measure of treatment time as a proportion of available/allocated time, takes into consideration variations in operator performance, early (non-funded) theatre starts, and over-run, and its analysis enables the determination of theatre downtime and lost theatre capacity. We monitored productivity over a 12-week period and performed downtime analysis as reported in the NHS Improvement national audit (NHSI). Results showed a marked but predictable variation in productivity connected to turnaround and session list scheduling. Productivity and booking efficiency correlated uniformly (Pearson's r=0.82). Theatre downtime was analysed with respect to three components defined in the NHSI national audit: late starts, early finish, and turnaround. We found that lost theatre time was predominantly due to early finishes; late starts were infrequent. Transport time correlated unfavourably with productivity (Pearson's r=-0.29, p=0.037) and over-run (r=0.44), and prolonged transport times were shorter when surgery was performed in a dedicated day surgery unit. Calculating the mean transport times for lists with high compared with low productivity helped us set a benchmark for patient transport times for future audit.

P101 ‘Best Foot Forward Workshops’: a novel supported self-management approach for foot health

Abstract Background Rheumatic foot health challenges can be multiple and wide-ranging, leading to reduced mobility or quality of life. However, the provision of foot health services is disparate. There is a need to innovate new approaches to personalised foot health care outside of traditional clinical models of service delivery. A new healthcare model was co-designed by patients, academics and clinicians from secondary and primary care Trusts, to support self-management. Part of this model included the development of ‘best foot forward’ workshops. There is a need to: minimise the impact of the demonstrated gap between what service users need or want and what services are providing; reduce waiting times; empower self-management; improve MDT availability for those in need; reduce the number of appointments needed to get resolution; reduce service costs; maintain patient satisfaction. Methods The team co-designed a series of foot health workshops, at 8-week intervals. The novel workshop design extended beyond a traditional patient education session and consisted of: 1. an education session about anatomy and physiology for the lower limb, 2. social networking time, 3. a themed education session, 4. opportunity for group discussion, 5. opportunity for individual question and answer with a health professional, 6. Access to direct request for follow-up appointment. Electronic invitations were sent to all patients registered within a single rheumatology department enrolled on the electronic notification system. Posters advertising the workshops were displayed in waiting areas. After three workshops data regarding patient attendance, satisfaction, and health service use up to four weeks after the workshop was collected. Results Nineteen, 22 and 30 patients attended the workshops respectively. Seven people attended multiple workshops. All patients reported having an unmet foot health need and would have otherwise sought a clinical appointment. Allowing for session preparation time (approx. 3 hours per session) 20 hours of clinical time was saved; the clinical waiting list was reduced by 12 sessions (6 weeks). Three patients (4%) requested one follow-up clinical appointment immediately after the workshop. No patients requested additional appointments in the four weeks after each workshop; enabling patient led review saved 71 further appointments. Patients reported content, venue and satisfactions scores of 9.6, 8.7 and 9.6/10 respectively. Conclusion Further research is needed to confirm that patients’ needs are being fully met, in addition to enabling supported self-management and improving clinical outcomes. There is potential for these workshops to be co-ordinated and facilitated by expert patient partners. The role of group interaction as a therapeutic mechanism to aid supported self-management is worthy of further study. Best foot forward workshops could represent a viable supported self-management alternative to traditional clinical models for people with rheumatic conditions. Disclosures S. Connett None. C. Beevor None. S. Ward None. E. Wong None. L. Cherry None.

Implementation and Evaluation of a Standardized Non-Vitamin K Oral Anticoagulant (NOAC) Patient Safety Alert Card Across the Northern Region of England.

Many patients are prescribed anticoagulants. Newer non–vitamin K oral anticoagulants, NOACs, were launched in 2008 and are increasingly commonly used. However, they may still be unfamiliar to patients and health care professionals. It is mandated by the National Patient Safety Agency and European Society of Cardiology to provide written safety information for patients receiving anticoagulants. We developed a standard patient alert card with the support of the North of England Strategic Clinical network (NESCN) to clearly provide key safety information for patients and health care professionals. This is the only card in the United Kingdom that is used over such a wide geographical area. We recognized that this would avoid duplication of work devising a similar card across all the sites in primary and secondary care. Given that staff and patients commonly move about the region it would also lead to better ease of recognition. The NESCN card was developed with input from all the key stakeholders, including cardiology, stroke, hematology, acute medicine, primary care, and patient groups. It was launched in 2015 across the Northern region, which includes over 3 million people. It was distributed to general practitioners (GPs), primary and secondary care pharmacists. Electronic and face-to-face education was carried out alongside to pharmacists, GPs, and hospital physicians. We gathered patient and clinical staff feedback regarding the card and found the alert card was widely embedded within practice across the region and patient feedback was good. The evaluation shows a simple and inexpensive intervention delivered with no formal funding can address this patient safety concern. We have engaged with Clinical Commissioning Groups and secondary care trusts in the region to ensure the legacy of the project. In response to requests from other regions and organizations, the card has been widely shared and implemented across many areas of the United Kingdom.

GPs must push back against work dumped on them by hospitals, says BMA

GPs should push back on inappropriate work given to them by hospitals, the BMA has said. The BMA has published guidance for GPs on how to transfer unnecessary work back to secondary care managers.1 The organisation said that the 2017/18 NHS standard contract for secondary care trusts, which came into force …

G238 A Local Guideline Improves Care for Children with Neutropenia

AimsNeutropenia is clinically significant due to its association with serious and potentially fatal infection. The National Institute of Clinical Excellence (NICE) recently published guidelines for the management of neutropenic sepsis....

Learning the lessons from banding appeals: evidence based guidance for running junior doctor rotas.

Designing and running robust junior doctor rotas is a challenging task and much previous advice has been based on consensus or anecdote. This paper aims to discern the most frequently occurring problems with trainee working patterns and produce evidence-based guidance for implementing and running contract-compliant rotas. A total of 35 secondary care trusts in North West England were invited to supply information on pay banding appeals requested under the New Deal junior doctor contract. Of these, 15 (43 per cent) participated with data from 35 appeals between 2004 and 2012. A thematic analysis was undertaken to discern the commonly occurring causes of contractual breaches. A total of 83 per cent (n = 29/35) of appeals were based on data showing the rota to be non-compliant with the contract (band 3), with the remainder being compliant with the contract but not in keeping with the pay banding currently assigned. Inability to take adequate natural breaks was the most frequently cited cause of rota non-compliance. Where underlying reasons were given for breaches of hours/rest limits they clustered around 20 themes, the top four being poor or absent dialogue between HR and doctors, excessive workload, inappropriately timed ward rounds, and inadequate or non-existent bleep policies. This is the first analysis of banding appeals under the UK junior doctor contract. The findings show that problems with rotas cluster around specific themes. The authors provide recommendations to target these so as to avoid financially detrimental contract breaches and trainee dissatisfaction.

A re-audit of paediatric blood transfusions within a secondary care trust

<h3>Aim</h3> Paediatric blood transfusions have a significantly greater incidence of adverse outcomes in comparison with adults. In 2005, following a baseline audit, (presented at the RCPCH Annual Conference) we designed a local proforma incorporating the British Committee for Standards in Haematology (BCSH) guidelines on paediatric blood transfusion. Following an audit of this in 2007, education on blood transfusions was implemented. In 2010 the National Comparative Audit of the use of Red Cells in Neonates and Children made multiple new recommendations for safe paediatric blood transfusion. This is a re-audit comparing current practice with guidelines and the recommendations of the National Comparative Audit with the aim of improving the quality of care delivered to children receiving blood transfusion. <h3>Method</h3> A retrospective case notes audit was conducted on all general paediatric patients who received a packed red cell transfusion during a one year period (11/08/2010 to 11/08/2011). The local proforma for each transfusion was analysed. <h3>Results</h3> There were 52 blood transfusions (15 patients) within the time period, however 41 were available for analysis. 98% utilised the Trust proforma versus 91.5% in 2007. The salient results are represented in tabular and graphical form (table 1 and figure 1). <h3>Conclusions</h3> Safe transfusion practice with recording of observations on all patients was demonstrated. We have demonstrated improvement over six years, although there is still room for development in order to adhere to the National Comparative Audit recommendations and the 2004 BCSH guidelines. We have been closely monitoring transfusion practice for six years and there have been no adverse events. Having completed the audit cycle we are committed to vigilantly improving practice within this high risk area.

S7 Annual trends in asthma emergency attendance, hospital admission and readmission

Introduction and ObjectivesRecent government initiatives rooting care of chronic conditions in primary care settings with particular emphasis on reducing hospital use require on-going collection of high-quality data. However, in most...

Anti-theory in action? Planning for pandemics, triage and ICU or: how not to bite a bullet

Anti-theory is a multi-faceted critique of moral theory which, it appears, is undergoing something of reassessment. In a recent paper Hämäläinen discusses the relevance of an anti-theoretical perspective for the activity of applied ethics. This paper explores her view of anti-theory. In particular I examine its relevance for understanding the formal guidance on pandemic flu planning issues by the Department of Health (DoH) in the UK and some subsequent discussions around triage and reverse triage decisions which may be considered by both Primary and Secondary Care Trusts (PCTs and SCTs) (On the division between Primary and Secondary Care Trusts in the UK National Health Service see: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx [Accessed August 2010]). in setting their own policies and which may face clinicians in the eventuality of a pandemic. Following Hämäläinen in contrasting reflective equilibrium with her anti-theory inspired suggestion of an instrumental approach to moral theory in practice I demonstrate how this understanding complements the diversity of our intuitive moral judgements. Consequentially I suggest that this anti-theoretical instrumental approach is in greater accord with the conditions under which such policy planning and decision making is, or will be, made. Furthermore, on the grounds of keeping open the ethical dimensions of medical practice in conditions of uncertainty, i.e. during a pandemic, I suggest that the anti-theoretical instrumental perspective is, ethically, the preferable approach to producing such policies and guidelines.