Geographical variation in certification rates of blindness and sight impairment in England, 2008-2009

To examine and interpret the variation in the incidence of blindness and sight impairment in England by PCT, as reported by the Certificate of Vision Impairment (CVI). Design: Analysis of national certification data. Setting: All Primary Care Trusts, England. Participants: 23 773 CVI certifications issued from 2008 to 2009. Main Outcome measures: Crude and Age standardised rates of CVI data for blindness and sight loss by PCT. Methods: The crude and age standardised CVI rates per 100 000 were calculated with Spearman's rank correlation used to assess whether there was any evidence of association between CVI rates with Index of Multiple Deprivation (IMD) and the Programme Spend for Vision. Results: There was high-level variation, almost 11-fold (coefficient of variation 38%) in standardised CVI blindness and sight impairment annual certification rates across PCTs. The mean rate was 43.7 and the SD 16.7. We found little evidence of an association between the rate of blindness and sight impairment with either the IMD or Programme Spend on Vision. Conclusions: The wide geographical variation we found raises questions about the quality of the data and whether there is genuine unmet need for prevention of sight loss. It is a concern for public health practitioners who will be interpreting these data locally and nationally as the CVI data will form the basis of the public health indicator ‘preventable sight loss’. Poor-quality data and inadequate interpretation will only create confusion if not addressed adequately from the outset. There is an urgent need to address the shortcomings of the current data collection system and to educate all public health practitioners

Proposal of a learning health system to transform the National Health System of Spain

This article identifies the main challenges of the National Health Service of Spain and proposes its transformation into a Learning Health System. For this purpose, the main indicators and reports published by the Spanish Ministries of Health and Finance, Organization for Economic Co-operation and Development (OECD) and World Health Organization (WHO) were reviewed. The Learning Health System proposal is based on some sections of an unpublished report, written by two of the authors under request of the Ministry of Health of Spain on Big Data for the National Health System. The main challenges identified are the rising old age dependency ratio; health expenditure pressures and the likely increase of out-of-pocket expenditure; drug expenditures, both retail and consumed in hospitals; waiting lists for surgery; potentially preventable hospital admissions; and the use of electronic health record (EHR) data to fulfil national health information and research objectives. To improve its efficacy, efficiency, and quality, the National Health Service of Spain should be transformed into a Learning Health System. Information and communication technologies (IT) enablers are a fundamental tool to address the complexity and vastness of health data as well as the urgency that clinical and management decisions require. Big Data solutions are a perfect match for that problem in health systems

Section 47 : The compulsory removal of old people from their homes

The objective of the research presented in the thesis was to review the use of the powers of compulsory removal contained in Section 47 of the National Assistance Act of 1948. These powers do not require the person to be mentally ill, as the Mental Health Act does. All that is required is that he or she is either suffering from "grave chronic disease" or is "aged, infirm, or physically incapacitated", and that they are living in insanitary conditions. Such persons can be removed by a community physician acting for the local authority if "they are not devoting to themselves or receiving from other persons proper care and attention" provided that he applies to a magistrate or a court. The Department of Health no longer collects information about the use of Section 47 so it was necessary to write to all the responsible community physicians in England. From the 90 per cent response, the frequency of use of these powers was calculated. In most cases elderly people in crisis were removed. Most of them went to hospitals rather than to old people's homes. There is a considerable variation in the frequency with which the powers are used and 25 per cent of the community physicians did not use them at all during the four years under consideration, which were 1974-78. The possible reasons for this are analysed and the effects of compulsory removal on the elderly people are discussed. Two disturbing themes emerged from the research. First, there is considerable evidence to suggest that the powers are not used often enough; that many elderly people are coerced, deceived, or "persuaded" from their homes without Section 47 powers of compulsory removal being invoked. There are many admissions which can in no way be considered to be voluntary admissions although they are not covered by Mental Health Act or Section 47 orders. The implications for professional training and practice are outlined and the need for greater legal protection for elderly people is considered. The second disturbing theme is that the manner in which the Act has been drafted and is currently interpreted defines the "need" only in terms of personal incapacity. Criteria are laid down with respect to the degree of the person's disability but nothing is said about the degree of community support he should be entitled to expect before he is deemed to need institutional care. Where the need is for treatment which can only be obtained in hospital, for example operative repair of a fractured neck of femur, such definition is unnecessary. However, where the person's requirement is for more care of the type he could receive in his own home if more resources were available, such a definition of "need" evades the basic issue of resource shortage. The implications of this particular definition of need for professionals who meet elderly people and for those who plan services are discussed, using examples from other areas of health care, for example, renal transplantation. The research summarised in the thesis had two broad aims. One was to determine whether the law was still relevant or whether it should be repealed and the conclusion reached is that it should not be repealed. It is argued that the existence of these powers of compulsory removal is, paradoxically, a means of safeguarding liberty, although their use does infringe the liberty of those individuals who are compulsorily removed. If it were repealed those who would at present be removed using Section 47 would not all be left in liberty at home; many would be coerced, persuaded, drugged, or deceived into an institution without any legal control over the professionals and without any means of appeal. The second of these more general aims was to analyse paternalistic attitudes towards old people. This relates closely to the former am because the law, as a whole, is more than a collection of legal instruments. It is an expression of certain attitudes and values and a reflection of certain beliefs, and the function of a law is as important as the manner in which it is used. The methods used in studying this aspect of the subject were drawn from the closely related methodologies of history and anthropology. It is this aspect of the thesis which is, in my opinion, the most significant for the practice of medicine and other professions because it is an appreciation of the attitudes towards old people which prevail in society which is of fundamental importance in understanding public pressure on professionals and the manner in which professionals themselves analyse, classify and attempt to solve the problems of elderly people

Evidence-based primary health care and local research: a necessary but problematic partnership

Background: Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project. Aims and methods of study:The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre. Development of the study: Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge. Learning from the study: Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address

Healthcare organizational performance: why changing the culture really matters

An organization may be considered as having three components: a structure, systems and culture. Culture is the most difficult part of the organization to affect. After all, culture has the key role in impacting and improving rganizational performance. The leadership of an organization and its key operations are paramount in shaping the culture. Leadership and organizational culture are inextricably intertwined. They are two sides of the same coin. Culture is a medium through which leadership travels and impacts organizational erformance. If leaders are to fulfil the challenges of the 21st century, they must first understand the dynamics of culture and their role as sculptors through behavioural and cognitive ways

Visualising value for money in public health interventions

Background: The Socio-Technical Allocation of Resources (STAR) has been developed for value for money analysis of health services through stakeholder workshops. This paper reports on its application for prioritisation of interventions within public health programmes. Methods: The STAR tool was used by identifying costs and service activity for interventions within commissioned public health programmes, with benefits estimated from the literature on economic evaluations in terms of costs per Quality-Adjusted Life Years (QALYs); consensus on how these QALY values applied to local services was obtained with local commissioners. Results: Local cost-effectiveness estimates could be made for some interventions. Methodological issues arose from gaps in the evidence base for other interventions, inability to closely match some performance monitoring data with interventions, and disparate time horizons of published QALY data. Practical adjustment for these issues included using population prevalences and utility states where intervention specific evidence was lacking, and subdivision of large contracts into specific intervention costs using staffing ratios. The STAR approach proved useful in informing commissioning decisions and understanding the relative value of local public health interventions Conclusions:. Further work is needed to improve robustness of the process and develop a visualisation tool for use by public health department

Better value primary care is needed now more than ever

Healthcare systems globally are facing multiple challenges, with ageing populations, increasing chronic disease, rising multimorbidity, and innovative treatments and technologies all leading to rising costs. With finite resources, and an increasing recognition of the potential harms to patients of overdiagnosis and overtreatment, it is essential that resources are used optimally. We explore how the value based healthcare framework can help decisions about how to allocate resources, and the importance of good evidence not only for patient treatment but for the organisation of health service

It’s a long shot, but it just might work! Perspectives on the future of medicine

Abstract What does the future of medicine hold? We asked six researchers to share their most ambitious and optimistic views of the future, grounded in the present but looking out a decade or more from now to consider what’s possible. They paint a picture of a connected and data-driven world in which patient value, patient feedback, and patient empowerment shape a continually learning system that ensures each patient’s experience contributes to the improved outcome of every patient like them, whether it be through clinical trials, data from consumer devices, hacking their medical devices, or defining value in thoughtful new ways

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety : assessor-blind pilot comparison

Background: There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors’ subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy. Aim: We therefore studied the effects on patient's safety and doctors’ work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota. Methods: Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors. Results: Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0–60.0) vs. 52.4 (11.2) (30.0–77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota. Conclusions: Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety