United Kingdom Healthcare System Research Articles

Assessing the barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service within the NHS in England: a systematic literature review

IntroductionThe United Kingdom (UK) government's healthcare policy in the early 1990s paved the way adoption of the skills mix development and implementation of diagnostic radiographers' X-ray reporting service. Current clinical practice within the public UK healthcare system reflects the same pressures of increased demand in patient imaging and limited capacity of the reporting workforce (radiographers and radiologists) as in the 1990s. This study aimed to identify, define and assess the longitudinal macro, meso, and micro barriers and enablers to the implementation of the diagnostic radiographer musculoskeletal X-ray reporting service in the National Healthcare System (NHS) in England.MethodsMultiple independent databases were searched, including PubMed, Ovid MEDLINE; Embase; CINAHL, and Google Scholar, as well as journal databases (Scopus, Wiley), healthcare databases (NHS Evidence Database; Cochrane Library) and grey literature databases (OpenGrey, GreyNet International, and the British Library EthOS depository) and recorded in a PRISMA flow chart. A combination of keywords, Boolean logic, truncation, parentheses and wildcards with inclusion/exclusion criteria and a time frame of 1995–2022 was applied. The literature was assessed against Joanna Briggs Institute's critical appraisal checklists. With meta-aggregation to synthesize each paper, and coded using NVivo, with context grouped into macro, meso, and micro-level sources and categorised into subgroups of enablers and barriers.ResultsThe wide and diverse range of data (n = 241 papers) identified barriers and enablers of implementation, which were categorised into measures of macro, meso, and micro levels, and thematic categories of context, culture, environment, and leadership.ConclusionThe literature since 1995 has reframed the debates on implementation of the radiographer reporting role and has been instrumental in shaping clinical practice. There has been clear influence upon both meso (professional body) and macro-level (governmental/health service) policies and guidance, that have shaped change at micro-level NHS Trust organisations. There is evidence of a shift in culturally intrenched legacy perspectives within and between different meso-level professional bodies around skills mix acceptance and role boundaries. This has helped shape capacity building of the reporting workforce. All of which have contributed to conceptual understandings of the skills mix workforce within modern radiology services.

An online questionnaire exploring how recruiting organisations support international nurses and midwives undertake the OSCE and gain UK professional registration.

BACKGROUND There is an active strategy to recruit international nurses and midwives to help manage vacancy gaps in the United Kingdom's healthcare system. International recruits need to pass a two-stage test of competence in order to gain required professional registration with the Nursing and Midwifery Council: a Computer Based Test followed by an Objective Structured Clinical Exam. There is little evidence detailing how recruiting organisations prepare new recruits for these tests, and no set standards govern the support provision deemed necessary. AIMS AND OBJECTIVES To gather and analyse feedback from recruiting organisations on the preparation offered to international nurses and midwives on arrival in the United Kingdom, prior to undertaking an Objective Structured Clinical Exam (OSCE) in order to gain Nursing and Midwifery Council professional registration. DESIGN AND METHODS An online cross-sectional questionnaire was developed, using themes taken from a systematic literature search. This questionnaire was completed by 17 organisations involved in the recruitment of international nurses and/or midwives to the UK. The data was analysed using thematic analysis. This research was quality assessed using the STROBE observational research checklist. RESULTS Four main themes emerged from thematic analysis of the qualitative data: SAME IDEAS DIFFERENT PRACTICE; PASSING THE OSCE; INDIVIDUALISED SUPPORT; SUPPORT NETWORKS. The limited response rate inhibited inferential analysis of the quantitative data. Descriptive analysis showed higher median reported OSCE pass rates when recruiters were grouped by shared characteristics (e.g., those offering less clinical practice). CONCLUSION Differences in how organisations prepare and support international nurses and midwives to undertake the OSCE suggest standardised approaches could benefit new recruits. These standardised approaches should be based on shared practice and scientific evidence. Broader assistance transitioning to working and living in the UK should also be addressed. This could be in the form of specific preceptorship programs following success of the OSCE. IMPACT STATEMENT Addressing an evidence gap, this research suggests recruits may benefit from standardised support around working and living in the UK.

The Clinical Exercise Physiologist Revolution is Happening Now

The Clinical Exercise Physiologist revolution for professional recognition in the United Kingdom (UK) turned a corner recently. On December 14, 2021, the British Association of Sport and Exercise Sciences (BASES) and Clinical Exercise Physiology United Kingdom (CEP-UK) announced a partnership with a stated purpose of promoting the role of clinical exercise physiologists to manage those with chronic and complex medical health conditions who are being treated within the UK healthcare system (1). Worldwide recognition by other allied health professionals and patients has been lacking for those who are trained as a clinical exercise physiologist.I have written about this in previous issues of this journal. Currently, Australia has arguably advanced the most in both professional and public recognition, as well as integrating clinical exercise physiologists (known Down Under as Accredited Exercise Physiologists) into the healthcare system (2). In Australia these healthcare professionals are recognized by their nationalized healthcare system, which has allowed them to provide services and independently charge for these services. Additionally, and similar to physical therapy clinics in the United States, privately owned exercise physiology clinics in Australia cater to the exercise physiology needs of those with various chronic diseases who are under the care of their physician. Much of the services provided are partially covered by Medicare Australia or private health insurers.The stated aim of the UK initiative is to “establish and promote the role of Clinical Exercise Physiologists as part of the treatment and management of chronic and complex health conditions within the UK health care system” (1). So, it seems this is a similar goal to what the Australians have developed. This announcement states that clinical exercise physiologists in the United Kingdom are eligible to receive professional registration with the Registration Council for Clinical Physiologists (RCCP). Those who apply for registration and meet the qualifications will be conferred the title of Clinical Exercise Physiologist, if accepted. The registration is designed to ensure that those conferred as a Clinical Exercise Physiologist “are appropriately trained, meet standards of proficiency, have indemnity insurance, are committed to continued professional development, and are deemed ‘fit to practice'” (1).It is exciting to see countries recognize the knowledge and abilities of those who are adequately trained clinical exercise physiologists. Efforts such as this in the United Kingdom are the beginnings of carving out a niche for clinical exercise physiologists. Importantly, recognition and acceptance as a partner in multidisciplinary health care teams appears to be a key strategy. Various efforts continue to evolve in the United States (3). And in addition to the countries already mentioned in this article, both New Zealand (4) and Canada (5) recognize clinical exercise physiologists as an important part of their national approach to treating and preventing many chronic diseases. The momentum of the clinical exercise movement is palpable around the world. As part of this process, we need to continue to provide high-quality evidence of the importance of providing clinical exercise services to patients as delivered by clinical exercise physiologists. Solid research is the best ammunition to make the case for clinical exercise physiologists. The Journal of Clinical Exercise Physiology stands ready and eager to support the publication of this type of original research, reviews, and expert commentary. The time is now!

PDB24 An EARLY Cost-Utility MODEL of Mrna-Based Therapies Compared with Standard of Care in EARLY-Onset Propionic Acidaemia in the United Kingdom

Propionic acidaemia (PA) is a rare metabolic disease with high mortality rates and severe chronic sequelae in children surviving the initial onset of the disease. Current standard of care (SOC) includes low-protein diet, pharmacologic therapy and, potentially, liver transplantation. Also, innovative intracellular mRNA-based therapies are currently being trialled. The objective of this study was to build an early cost-utility model to identify key variables impacting the cost-utility of mRNA-based therapies versus SOC (diet or diet/transplant) in early-onset PA in the United Kingdom (UK). A Markov model simulating a hypothetical cohort of newborn PA patients was developed from the UK healthcare system perspective. Efficacy and cost inputs were obtained from the literature, British National Formulary and NHS Reference Costs. Quality-adjusted life years (QALYs) and costs were estimated for each treatment arm over a lifetime horizon, with a discount rate of 3.5% for both. One- and two-way sensitivity analyses were conducted to identify key model drivers, such as those with largest impact on the incremental cost-effectiveness ratio (ICER). When comparing mRNA-based therapies versus patients receiving diet only, the variables with the largest impact on ICER were patient weight, the annual cost of mRNA-based therapy, cost of medical foods, cost of L-carnitine and improvement in utility following mRNA-based therapy in that order. Results were similar when comparing mRNA-based therapies with the diet/transplant arm. Despite the current lack of a strong evidence base, this model can be used to estimate value-based prices of mRNA-based therapies in PA and guide the design of evidence generation activities.

PDB40 An EARLY Cost-Utility MODEL of Mrna-Based Therapies Compared with Standard of Care in EARLY-Onset Methylmalonic Acidaemia in the United Kingdom

Methylmalonic acidaemia (MMA) is a rare metabolic disease with high mortality rates and severe chronic sequelae in children surviving the initial disease onset. Current standard of care (SOC) includes low-protein diet, pharmacologic therapy and, potentially, liver transplantation or combined liver-kidney transplantation. Also, innovative intracellular mRNA-based therapies are currently being trialled that could offer novel systemic treatment. The objective of this study was to build an early cost-utility model to identify key variables impacting the cost-utility of mRNA-based therapies versus SOC in early-onset MMA in the United Kingdom (UK). A Markov model simulating a hypothetical cohort of newborn MMA patients was developed from the UK healthcare system perspective. Efficacy and cost inputs were obtained from the literature, British National Formulary and NHS Reference Costs. Quality-adjusted life years (QALYs) and costs were estimated for each treatment arm over a lifetime horizon, with a discount rate of 3.5% for both. One- and two-way sensitivity analyses were conducted to identify key model drivers, such as those with largest impact on the incremental cost-effectiveness ratio (ICER). When comparing mRNA-based therapies with diet-based management, the variables with the largest impact on the ICER were the annual cost of mRNA-based therapy, improvement in utility following mRNA-based therapy, patient weight, cost of medical foods and cost of L-carnitine in that order. Results were similar when comparing mRNA-based therapies with the diet/transplant arm. Despite the current lack of a strong evidence base, this model can be used to estimate value-based prices of mRNA-based therapies in MMA and guide the design of evidence generation activities.

Communicating antimicrobial resistance and stewardship in the national press: Lessons from sepsis awareness campaigns

1The Review on AMR was an expert panel commissioned by the UK Government in 2014 tasked with analysing the economic and social impacts of AMR and proposing solutions to these. 2NICE is a UK non-departmental public body that sponsored by but separate from the Department of Health that produces evidence-based guidance for health practitioners. 3NHS England is a non-departmental public body sponsored by the Department of Health that oversees planning and delivery of health services in England. 4Note that circulation of the News of the World ceased in July 2011; the Sun on Sunday was launched by the same newsgroup in 2012, but is unavailable on the Nexis database.

Cost-effectiveness of percutaneous patent foramen ovale closure as secondary stroke prevention

Objective: Compared to medical therapy alone, percutaneous closure of patent foramen ovale (PFO) further reduces risk of recurrent ischemic strokes in carefully selected young to middle-aged patients with a recent cryptogenic ischemic stroke. The objective of this study was to evaluate the cost-effectiveness of this therapy in the context of the United Kingdom (UK) healthcare system.Methods: A Markov cohort model consisting of four health states (Stable after index stroke, Post-Minor Recurrent Stroke, Post-Moderate Recurrent Stroke, and Death) was developed to simulate the economic outcomes of device-based PFO closure compared to medical therapy. Recurrent stroke event rates were extracted from a randomized clinical trial (RESPECT) with a median of 5.9-year follow-up. Health utilities and costs were obtained from published sources. One-way and probabilistic sensitivity analyses (PSA) were performed to assess robustness. The model was discounted at 3.5% and reported in 2016 Pounds Sterling.Results: Compared with medical therapy alone and using a willingness-to-pay (WTP) threshold of £20,000, PFO closure reached cost-effectiveness at 4.2 years. Cost-effectiveness ratios (ICERs) at 4, 10, and 20 years were ₤20,951, ₤6,887, and ₤2,158, respectively. PFO closure was cost-effective for 89% of PSA iterations at year 10. Sensitivity analyses showed that the model was robust.Conclusions: Considering the UK healthcare system perspective, percutaneous PFO closure in cryptogenic ischemic stroke patients is a cost-effective stroke prevention strategy compared to medical therapy alone. Its cost-effectiveness was driven by substantial reduction in recurrent strokes and patients’ improved health-related quality-of-life.

Using Patient Flow Information to Determine Risk of Hospital Presentation: Protocol for a Proof-of-Concept Study.

BackgroundEvery day, patients are admitted to the hospital with conditions that could have been effectively managed in the primary care sector. These admissions are expensive and in many cases are possible to avoid if early intervention occurs. General practitioners are in the best position to identify those at risk of imminent hospital presentation and admission; however, it is not always possible for all the factors to be considered. A lack of shared information contributes significantly to the challenge of understanding a patient’s full medical history. Some health care systems around the world use algorithms to analyze patient data in order to predict events such as emergency presentation; however, those responsible for the design and use of such systems readily admit that the algorithms can only be used to assess the populations used to design the algorithm in the first place. The United Kingdom health care system has contributed data toward algorithm development, which is possible through the unified health care system in place there. The lack of unified patient records in Australia has made building an algorithm for local use a significant challenge.ObjectiveOur objective is to use linked patient records to track patient flow through primary and secondary health care in order to develop a tool that can be applied in real time at the general practice level. This algorithm will allow the generation of reports for general practitioners that indicate the relative risk of patients presenting to an emergency department.MethodsA previously designed tool was used to deidentify the general practice and hospital records of approximately 100,000 patients. Records were pooled for patients who had attended emergency departments within the Eastern Health Network of hospitals and general practices within the Eastern Health Network catchment. The next phase will involve development of a model using a predictive analytic machine learning algorithm. The model will be developed iteratively, testing the combination of variables that will provide the best predictive model.ResultsRecords of approximately 97,000 patients who have attended both a general practice and an emergency department have been identified within the database. These records are currently being used to develop the predictive model.ConclusionsRecords from general practice and emergency department visits have been identified and pooled for development of the algorithm. The next phase in the project will see validation and live testing of the algorithm in a practice setting. The algorithm will underpin a clinical decision support tool for general practitioners which will be tested for face validity in this initial study into its efficacy.

A Comparison of Integration Models for Professionals With Different Skills in Healthcare

Integration between hospital and territory has to be faced as a critical aspect in modern health systems. The evolving of health care demand in Western countries leads the debate on health care system to focus on how to meet the needs of chronic diseases. Creating gatekeeper models for admission to health care facilities presumes a high level of integration between a wide variety of professions that interact in patients’ therapy processes. This paper analyzes two models of integration of professionals with different skills: Clinical commissioning groups (CCGs) in United Kingdom health care system and Case della Salute (CdS) in Italian regional health care system of Emilia Romagna. The analysis of the two models highlights critical situations, strong points, and success critical factors in the two models. In particular, the analysis will highlight how the two systems faced the necessity to integrate the different category of professionals that, during the care process of a chronic patient, have to integrate in order to guarantee the continuity of the care process and the most effective response for the patient. This study highlights the methodologies used to share competences and knowledge on which the building of a system with high professional integration is based.

ANALYZING THE UNITED KINGDOM HEALTHCARE SYSTEM: LENSING ON CANCER MANAGEMENT IN ENGLAND

United Kingdom (UK) healthcare system is quite successful for achieving the goals of good health outcomes, risk protection, and public satisfaction. Based on the Commonwealth Fund study in 2014, UK healthcare system ranks first regarding quality, access, efficiency, equity, and healthy lives among 11 developed nations with even a fair cost. However, when it comes to cancer outcomes, UK lags behind many developed countries. Cancer survival is a good example of an area in which both health outcomes and public satisfaction, key determinants of quality, are strikingly lacking. Therefore, this paper, to analyze and formulate reforms to address deficient quality in the English health system, will look at the particular example of cancer survival rates. The key factors leading to deficient outcomes in cancer survival are delays in diagnosis and access to appropriate care. Policy recommendations to improve cancer survival rates are to timely screening and early diagnostic opportunities within the primary care system, utilize available treatment capacity and quick approval and workforce training for utilization of new treatments and drugs, and continue prioritizing cancer care coordination and integration through improved referral services, and increase provider decision support

Cost-effectiveness of Out-of-Hospital Continuous Positive Airway Pressure for Acute Respiratory Failure

Study objectiveWe determine the cost-effectiveness of out-of-hospital continuous positive airway pressure (CPAP) compared with standard care for adults presenting to emergency medical services with acute respiratory failure.MethodsWe developed an economic model using a United Kingdom health care system perspective to compare the costs and health outcomes of out-of-hospital CPAP to standard care (inhospital noninvasive ventilation) when applied to a hypothetical cohort of patients with acute respiratory failure. The model assigned each patient a probability of intubation or death, depending on the patient’s characteristics and whether he or she had out-of-hospital CPAP or standard care. The patients who survived accrued lifetime quality-adjusted life-years (QALYs) and health care costs according to their age and sex. Costs were accrued through intervention and hospital treatment costs, which depended on patient outcomes. All results were converted into US dollars, using the Organisation for Economic Co-operation and Development purchasing power parities rates.ResultsOut-of-hospital CPAP was more effective than standard care but was also more expensive, with an incremental cost-effectiveness ratio of £20,514 per QALY ($29,720/QALY) and a 49.5% probability of being cost-effective at the £20,000 per QALY ($29,000/QALY) threshold. The probability of out-of-hospital CPAP’s being cost-effective at the £20,000 per QALY ($29,000/QALY) threshold depended on the incidence of eligible patients and varied from 35.4% when a low estimate of incidence was used to 93.8% with a high estimate. Variation in the incidence of eligible patients also had a marked influence on the expected value of sample information for a future randomized trial.ConclusionThe cost-effectiveness of out-of-hospital CPAP is uncertain. The incidence of patients eligible for out-of-hospital CPAP appears to be the key determinant of cost-effectiveness.

Cost-effectiveness of zoledronic acid vs clodronic acid for newly-diagnosed multiple myeloma from the United Kingdom healthcare system perspective

Objective:In the Medical Research Council Myeloma IX Study (MMIX), zoledronic acid (ZOL) 4 mg 3–4/week reduced the incidence of skeletal-related events (SREs), increased progression free survival (PFS), and prolonged overall survival (OS), compared with clodronic acid (CLO) 1600 mg daily, in 1970 patients with newly-diagnosed multiple myeloma (MM).Methods:An economic model was used to project PFS, OS, the incidence of SREs and adverse events and expected lifetime healthcare costs for patients with newly-diagnosed MM who are alternatively assumed to receive ZOL or CLO. The incremental cost-effectiveness ratio [ICER] of ZOL vs CLO was calculated as the ratio of the difference in cost to the difference in quality-adjusted life years (QALYs). Model inputs were based on results of MMIX and published sources.Results:Compared with CLO, treatment with ZOL increases QALYs by 0.30 at an additional cost of £1653, yielding an ICER of £5443 per QALY gained. If the threshold ICER is £20,000 per QALY, the estimated probability that ZOL is cost-effective is 90%.Limitations:The main limitation of this study is the lack of data on the effects of zoledronic acid on survival beyond the end of follow-up in the MMIX trial. However, cost-effectiveness was favourable even under the highly conservative scenario in which the timeframe of the model was limited to 5 years.Conclusions:Compared with clodronic acid, zoledronic acid represents a cost-effective treatment alternative in patients with multiple myeloma.

A change in UK epistaxis management

Ear nose and throat oral and maxillofacial surgery service provision is undergoing major changes within the United Kingdom Healthcare System (NHS) with devolution of many treatments to primary care. Epistaxis, active bleeding from the nose, is a common ear nose and throat/oral and maxillofacial surgery emergency, and can be severe or even fatal. The causes can be from local or systemic illnesses. We aimed to apply a revised clinical protocol to epistaxis patients presenting to an Accident and Emergency (A&E) department of a District General Hospital (DGH) and to compare the results to the routine management protocol in same hospital. Sixty consecutive patients suffering epistaxis of local origin in an Accident and Emergency department in a District General Hospital were included in this study which was conducted over a 7-month-period (September-March). A revised management protocol was developed using nasal tampons (Netcel Polyvinyl alcohol sponge) and a proforma was created for the A&E department. Retrospective recorded data of all cases who presented with epistaxis of local origin to the A&E department in the same DGH in the past 4 years, (September-March), were analysed. Data collected included: patient's demographics, cause of epistaxis, management plan, admission, in-patient stay and complications. Previously, all patients requiring nasal packing were admitted. Over the previous 4-year-period (September-March) a mean of 28 patients were admitted per month, with a mean duration of in-patient stay of 2.7 days. In the patients' group treated under the revised protocol, the total number of admissions was significantly reduced, by 73%, (P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (P < 0.0001), the admitted patients had a mean length of stay of 2.5 days. This revised management protocol saved 201 bed days per annum. After careful assessment and provided that nasal packing properly performed and advice sheet is given and understood, we believe it is safe to manage patients with routine epistaxis at home. This is a change to the current standard UK management. We discuss the case for and against the adoption of this policy by the main healthcare components (primary and secondary) of the NHS. We present an economic argument.

Who wants to know if their care is rationed? Views of citizens and service informants.

To explore the views of citizens and service informants about whether they would want to know about any rationing of their own health care. In-depth interviews using a semistructured schedule. Data were analysed using the methods of constant comparison. Citizens and service informants. Issues around health care rationing were explored within the context of the United Kingdom health care system. The views of citizens and service informants were very similar in terms of whether they, personally, wanted to know about any rationing of their own care, with the vast majority wanting to be given this information. Informants were also similar in terms of their reasons for wanting to know about rationing: to be given a 'good explanation' to enable them to judge whether the decision made had been correct; and to enable them to change the decision if necessary, either through protest or payment. Many informants suggested that they would indeed be likely to react either by challenging the decision or by paying for care. The findings suggest that policies to be open with people about the rationing of care would be welcomed, but also indicate that if protest follows such openness, it may be difficult for the health service to cope with greater explicitness. Further research is needed among patient groups actually facing this situation.

Developing a culture of quality within the United Kingdom healthcare system

It is established that there are three levels of quality, technical, generic and systemic with systemic being the preferred goal for Salford Royal Hospitals NHS Trust (SRHT). In an effort to achieve their goal SRHT embarked on using the EFQM Excellence Model to provide one overarching framework for all their quality initiatives. The article explains SRHT’s approach to implementation and integration in addition to providing a flavour of the outcomes observed from the journey so far. In essence, many benefits were realised, some aspired to, some unexpected and all worthwhile and welcomed. However, even after seven years the organisation still does not have full deployment, which confirms that efforts to assure excellence need to be relentless if there is to be a sustainable culture change that puts quality at the heart of day‐to‐day decision making.

Pricing, insurance and the National Health Service.

Since the birth of the National Health Service in 1948 there have been periodic discussions of the potential role of pricing and insurance in the United Kingdom health care system. This article is concerned with discussing the problems inherent in these mechanisms and it advocates more careful articulation of the cost and benefits of such policies. The first section gives a description of some quite recent proposals to extend the role of the pricing and insurance mechanisms which have been made by the British Medical Association and the McKinsey consultancy company. The second section uses economic analysis to show that both the pricing and the insurance mechanisms have inherent problems which may vitiate their efficiency in many western health care markets. The third section is concerned with the mechanisms by which the efficiency of the health care system can be improved, and radical experimentation is advocated. Without radical experimentation and the implementation of suitable incentive systems, inefficiency and inequality will continue in the National Health Service.