Cinderella Services in the NHS Internal Market:Does Contracting Make a Difference?

This paper examines the impact of the NHS internal market reforms on an aspect of equity in the British system that features little in recent policy commentary: the allocation of resources between acute services for the entire population and nonacute services for the elderly, the mentally ill, and the disabled (the so-called Cinderella services). The authors\u27 research on health planning and contracting in the NHS in Wales suggests that patterns of services have remained largely unchanged, and that pressures in the reformed system, such as the Patient\u27s Charter initiative, prevent any major reallocation of resources away from the acute sector. Given the ineffectiveness of the contract mechanism in changing funding patterns, the authors consider whether the wider NHS reforms have nevertheless extended the legal remedies available to patients from the Cinderella groups faced with inadequate services. Recent cases suggest that, while the courts are reassessing the principles applied in reviewing administrative action affecting the allocation of health care resources, it is patients requiring acute care who are most likely to benefit. The authors conclude that, in terms of progress towards a more equitable distribution of resources between sectors, the NHS internal market is not a good model for other nations to emulate

Ventromedial Frontal Lobe Damage Disrupts Value Maximization in Humans

Recent work in neuroeconomics has shown that regions in orbitofrontal and medial prefrontal cortex encode the subjective value of different options during choice. However, these electrophysiological and neuroimaging studies cannot demonstrate whether such signals are necessary for value-maximizing choices. Here we used a paradigm developed in experimental economics to empirically measure and quantify violations of utility theory in humans with damage to the ventromedial frontal lobe (VMF). We show that people with such damage are more likely to make choices that violate the generalized axiom of revealed preference, which is the one necessary and sufficient condition for choices to be consistent with value maximization. These results demonstrate that the VMF plays a critical role in value-maximizing choice

Evidence on the use of Birthrate Plus® to guide safe staffing in maternity services - A systematic scoping review

Background Birthrate Plus® is a widely used tool that informs decisions about the number of midwifery staff needed to provide safe and high quality care in maternity services. Evidence about the effectiveness, validity, reliability, and feasibility of tools such as this is needed. Objective To identify, describe and analyse the available evidence supporting the use of Birthrate Plus. Methods We searched PubMed, Medline, CINAHL, Google Scholar, Scopus, Academic Search, British Library Ethos, Directory of Open Access Journals and Science Direct. Studies were eligible if they reported empirical data relevant to the validity, reliability, or useability of Birthrate Plus or if they measured the impact on staffing levels, outcomes, costs or provided a comparison with other methods. Results 23 sources of evidence were identified and reviewed. We found no prospective intervention studies on the use of Birthrate Plus to demonstrate outcomes for mothers, babies or staff wellbeing. Nor did we find studies comparing the tool to other methods or addressing resource use. Most of the evidence was descriptive, focussing on the use of the tool or the results of Birthrate Plus assessments. There is some evidence of the reliability of application of categories within the tool, the ability of the tool to detect variation in demand and to highlight staff shortages. Conclusions In terms of traditional hierarchies of evidence, the evidence for Birthrate Plus is weak. There is a need for more independent research or simulation using real world data to understand how the tool performs in the current context of midwifery practice

Severely Photosensitive Psoriasis: A Phenotypically Defined Patient Subset

A subset of patients with chronic plaque psoriasis exhibits severely photosensitive psoriasis (PP) with a pronounced seasonal pattern, but the pathomechanism is not understood. We performed two related studies; first, a detailed clinical characterization of PP, and second, a controlled investigation exploring the underlying pathomechanisms through the assessment of disease onset after photoprovocation. Patients with PP (n=20) showed striking female predominance (19F:1M), very low mean age of psoriasis onset (11 years, range 2–24), family history of psoriasis (13/20), a strong HLA–Cw*0602 association (16/17), and a rapid abnormal clinical response to broadband UVA, comprising erythema±scaling plaques (17/20). Subsequently, patients with PP (n=10), non-PP (n=9), and healthy volunteers (n=11) were challenged with low-dose broadband UVA on 3 consecutive days, and serial biopsies were taken after 6hours to 7 days and from unchallenged skin. Histological changes consistent with early psoriasis occurred in 4 of 10 PP patients, but in neither of the control groups, with significant dermal infiltration by neutrophils, CD4+, CD8+, and CD45RO+ cells at 24h, accompanied by acanthosis. Thus, a phenotypically distinct subset of psoriasis has been characterized. In contrast with earlier assumptions, UV can provoke psoriasiform features rapidly de novo; a role for memory effector T cells is supported in the early phase

Future Care: A Training Needs Analysis of the Out of Hospital Workforce across Thames Valley

This report considers a variety of topics to explore how a group of different workforces need to alter to provide more integrated care in the community, out of hospitals

Effectiveness of nurse‐led group CBT for hot flushes and night sweats in women with breast cancer: results of the MENOS4 randomised controlled trial

Objective Troublesome hot flushes and night sweats (HFNS) are experienced by many women after treatment for breast cancer, impacting significantly on sleep and quality of life. Cognitive behavioural therapy (CBT) is known to be effective for the alleviation of HFNS. However, it is not known if it can effectively be delivered by specialist nurses. We investigated whether group CBT delivered by breast care nurses (BCNs) can reduce the impact of HFNS.MethodsWe recruited women with primary breast cancer following primary treatment with seven or more HFNS/week (including 4/10 or above on the HFNS problem rating scale), from six UK hospitals to an open, randomised, phase 3 effectiveness trial. Participants were randomised to Group CBT or usual care (UC). The primary endpoint was HFNS problem rating at 26 weeks post randomisation. Secondary outcomes included sleep, depression, anxiety and quality of life. ResultsBetween 2017-2018, 130 participants were recruited (CBT:63, control:67). We found a 46% (6.9 to 3.7) reduction in the mean HFNS problem rating score from randomisation to 26 weeks in the CBT arm and a 15% (6.5 to 5.5) reduction in the UC arm (adjusted mean difference -1.96, CI -3.68 to -0.23, p=0.039). Secondary outcomes, including frequency of HFNS, sleep, anxiety and depression all improved significantly.ConclusionOur results suggest that specialist nurses can be trained to deliver CBT effectively to alleviate troublesome menopausal hot flushes in women following breast cancer in the NHS setting

Longitudinal qualitative study of living with neurogenic claudication

Objectives: Neurogenic claudication (NC) causes pain and reduced mobility, particularly in older people, and can negatively affect mental and social well-being, so limiting successful ageing. This qualitative study explored how people with NC changed over 12 months. Design: A longitudinal qualitative study using semi-structured interviews. Setting: Participants were recruited from a UK clinical trial of a physiotherapy intervention for NC. Participants: Interviews were undertaken at baseline, 1 month after receiving any intervention and at 12 months. We analysed 30 sets of three interviews. Results: Interview data were summarised for each time point into biopsychosocial domains: pain, mobility and activities of daily living, psychological impact, and social and recreational participation. Through comparative analysis we explored participant trajectories over time. Progressive improvement in at least one domain was experienced by 13 participants, but there was variability in trajectories with early improvements that remained the same, transient changes and no change also commonly observed. Eleven participants described co-present improvement trajectories in all domains. Three participants described co-present improvement in all domains except participation; one had never stopped their participation and two had unattainable expectations. Five participants described co-present improvement in one domain and deterioration in another and 14 participants described co-present no change in one domain and change in another. There was evidence of interaction between domains; for example, improved mobility led to improved participation and for some participants, specific factors influenced change. Of the 15 participants who experienced improved participation, 10 reported improvements in all other domains and five participants did not; for two, pain did not prevent participation, one used a walking aid and two had a positive psychological outlook. Conclusion: The daily lived experiences of older adults with NC are variable and include interaction between biopsychosocial domains. Therapist understanding of these trajectories and their interactions may help to provide personalised therapy. Trial Registration Number: ISRCTN1269867

A Qualitative Study Exploring Facilitators for Improved Health Behaviors and Health Behavior Programs: Mental Health Service Users’ Perspectives

Objective. Mental health service users experience high rates of cardiometabolic disorders and have a 20–25% shorter life expectancy than the general population from such disorders. Clinician-led health behavior programs have shown moderate improvements, for mental health service users, in managing aspects of cardiometabolic disorders. This study sought to potentially enhance health initiatives by exploring (1) facilitators that help mental health service users engage in better health behaviors and (2) the types of health programs mental health service users want to develop. Methods. A qualitative study utilizing focus groups was conducted with 37 mental health service users attending a psychosocial rehabilitation center, in Northern British Columbia, Canada. Results. Four major facilitator themes were identified: (1) factors of empowerment, self-value, and personal growth; (2) the need for social support; (3) pragmatic aspects of motivation and planning; and (4) access. Participants believed that engaging with programs of physical activity, nutrition, creativity, and illness support would motivate them to live more healthily. Conclusions and Implications for Practice. Being able to contribute to health behavior programs, feeling valued and able to experience personal growth are vital factors to engage mental health service users in health programs. Clinicians and health care policy makers need to account for these considerations to improve success of health improvement initiatives for this population

Is the abundance of Faecalibacterium prausnitzii relevant to Crohn's disease?

Reports that bacteria within the Firmicutes phylum, especially the species Faecalibacterium prausnitzii, are less abundant in Crohn’s disease (CD) patients and supernatants from cultures of this bacterium are anti-inflammatory prompted the investigation of the possible correlations between the abundance of F.prausnitzii and the response to treatment in patients with gut diseases and healthy controls. In a randomized, double-blind trial, faeces were collected from healthy volunteers, and from patients with active CD, ulcerative colitis (UC) and irritable bowel syndrome before and after treatment. The levels of F. prausnitzii DNA in faecal suspensions were determined by PCR. Treatment by an elemental diet was effective, resulting in decreases in both the Harvey and Bradshaw index (P<0.001) and the concentrations of serum C-reactive protein (P<0.05). The total levels of F. prausnitzii in faecal samples from CD patients at presentation were lower than those in the other groups both before and after the treatment. There was no correlation between F. prausnitzii abundance and the severity of CD before treatment. Clinical improvement unexpectedly correlated with a significant decrease in the abundance of F. prausnitzii, especially the A2-165 subgroup (P<0.05). Our data suggest that a paucity of F. prausnitzii in the gastrointestinal microbial communities is likely to be a minor aetiological factor in CD: recovery following elemental diet is attributed to lower levels of gut flora