Response to the article by Mitchell, P., Nightingale, J., and Reeves, P. (2019). Competence to capability: An integrated career framework for sonographers. Radiography

We would like to congratulate Mitchell, Nightingale and Reeves for their article on ‘Competence to capability: An integrated career framework for sonographers’ for providing a suggested framework for skills escalation for sonographers.1 This is particularly relevant to the current work being undertaken by Health Education England (HEE) to attempt to address the sonographer shortages in England2 and challenges faced by the introduction of a wider range of entry points to ultrasound practice

Integrating the teaching, learning and assessment of communication with children within the qualifying social work curriculum

Qualifying social work education must provide students with a variety of experiential, personalized, participatory, didactic and critically reflective learning opportunities across both the taught curriculum and in practice placements if deep learning of the capabilities needed for effective communication with children and young people is to be ensured. At present, programmes in England are not consistent in the curriculum structures, content and pedagogical approaches they are employing to teach and assess this topic. This paper discusses first how current proposals for the reform of qualifying education in England do not address the ambiguities and discretion in regulatory guidance, which have meant that the place and relevance of this topic within the curriculum remain uncertain and contested. It then draws on a model of the sequencing of students' learning and development in qualifying training, developed through the author's recent empirical research, to present an integrated and coherent approach to the teaching, learning and assessment of this topic. It is proposed that this strategy will enable students to develop the generic, ‘child-focused’ and ‘applied child-specialist’ capabilities they need for the ‘knowing’, ‘being’ and ‘doing’ of effective communication with children

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care : an interrupted time–series analysis

Aim To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. Design Interrupted time–series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006–31 March 2008); (2) during the implementation of financial incentives (1 April 2008–31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015–31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. Setting England. Participants Newly registered patients (16+) in 500 primary care practices for 2006–16 (n = 4 278 723). Measurements The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher‐risk drinking; and (3) were reported as having received brief advice on alcohol consumption. Findings There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21–3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87–14.23) per 1000 patients screening positive for higher‐risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen‐positive rates of 29.96 (95% CI = 19.56–40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51–2.77) per 1000. Screen‐positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30–28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26–0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97–24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28–1.12) per 1000 per month. Conclusions Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme

Effective dementia education and training for the health and social care workforce: A systematic review of the literature

Ensuring an informed and effective dementia workforce is of international concern, however there remains limited understanding of how this can be achieved. This systematic review aimed to identify factors associated with effective dementia educational programmes. Critical Interpretive Synthesis underpinned by Kirkpatrick’s return on investment model for evaluation of education was applied. One hundred and fifty-two papers of variable quality were included in the review. Common features of more efficacious educational programmes included the need for educational programmes to: be relevant to participants’ role and experience; involve active face-to-face participation; underpin practice-based learning with theory; be delivered by an experienced facilitator; have a total duration of at least eight hours with individual sessions of 90 minutes or more; support application of learning in practice; and provide a structured tool or practice guideline to underpin care practice. Further robust research is required to develop the evidence base; however, the findings of this review have relevance for all working in workforce education

Can Healthcare Assistant Training (CHAT) improve the relational care of older people? A developmental and feasibility study of a complex intervention

Background: Older people account for an increasing proportion of those receiving NHS acute care. The quality of healthcare delivered to older people has come under increased scrutiny. Healthcare assistants (HCAs) provide much of the direct care of older people in hospital. Patients’ experience of care tends to be based on the relational aspects of that care including dignity, empathy and emotional support. Objective(s): We aimed to: understand the relational care training needs of HCAs caring for older people; design a relational care training intervention for HCAs; and assess the feasibility of a cluster-randomised controlled trial to test the new intervention against HCA training as usual. Design: (1) Telephone survey of all NHS hospital Trusts in England to assess current HCA training provision; (2) focus groups of older people and carers and (3) semi-structured interviews with HCAs and other care staff to establish training needs and inform intervention development; (4) feasibility cluster-randomised controlled trial. Setting: (1) All acute NHS hospital Trusts in England; (2,3,4) Three acute NHS hospital Trusts in England and the populations they serve. Participants: (1) 113 of 161 (70.2%) Trusts took part in the telephone survey; (2) 29 older people or carer participants of three focus groups; (3) 30 HCA and 24 ‘other staff’ interviewees; (4) 12 wards (four per Trust); 112 HCAs; 92 patients during the pre-randomisation period and 67 patients during the post-randomisation period. Interventions: For the feasibility trial a training intervention (Older People’s Shoes) for HCAs developed as part of the study was compared with HCA training as usual. Main outcome measures: Patient level outcomes were the experience of emotional care and quality of life during their hospital stay as measured by the Patient Evaluation of Emotional Care during Hospitalisation (PEECH) and the European Quality of Life (EQ-5D) questionnaires. HCA outcomes were empathy measured by the Toronto Empathy Questionnaire (TEQ) and attitudes towards older people measured by the Age Group Evaluation and Description (AGED) Inventory. Ward level outcomes were the quality of HCA/patient interaction measured by the Quality of Interaction Scale (QUIS). Results: (1) A third of Trust telephone survey participants reported HCA training content that we considered to be ‘relational care’. Training for HCAs is variable across Trusts and focused on new recruits. The biggest challenge for HCA training is getting HCAs released from ward duties. (2) Older people and carers are aware of the pressures ward staff are under but good relationships with care staff determines whether the experience of hospital is positive. (3) HCAs have training needs related to ‘difficult conversations’ with patients and relatives; they have particular preferences for learning styles that are not always reflected in available training. (4) In the feasibility trial 187 of the 192 planned ward observation sessions were completed; response to HCA questionnaires at baseline, eight and 12 weeks post-randomisation was 64.2%, 46.4% and 35.7% respectively; 57.2% of eligible patients returned completed questionnaires. Limitations: This was an intervention development and feasibility study so no conclusions can be drawn about the effectiveness of the intervention. Conclusions: The intervention had high acceptability among nurse trainers and HCA learners. Viability of a definitive trial is conditional on overcoming specific methodological (patient recruitment processes) and contextual (involvement of wider ward team) challenges. Future work: Methods to ease the burden of questionnaire completion without compromising ethics or methodological rigour need to be explored. Study registration: ISRCTN1038579

Transforming Community Health Services for Children and Young People who are Ill : A quasi-experimental evaluation

Background: Children’s community nursing (CCN) services support children with acute, chronic, complex and end-of-life care needs in the community. Objectives: This research examined the impact of introducing and expanding CCN services on quality, acute care and costs. Methods: A longitudinal, mixed-methods, case study design in three parts. The case studies were in five localities introducing or expanding services. Part 1: an interrupted time series (ITS) analysis of Hospital Episode Statistics on acute hospital admission for common childhood illness, and bed-days and length of stay for all conditions, including a subset for complex conditions. The ITS used between 60 and 84 time points (monthly data) depending on the case site. Part 2: a cost–consequence analysis using activity data from CCN services and resource-use data from a subset of families (n = 32). Part 3: in-depth interviews with 31 parents of children with complex conditions using services in the case sites and a process evaluation of service change with 41 NHS commissioners, managers and practitioners, using longitudinal in-depth interviews, focus groups and documentary data. Findings: Part 1: the ITS analysis showed a mixed pattern of impact on acute activity, with the greatest reductions in areas that had rates above the national average before CCN services were introduced and significant reductions in some teams in acute activity for children with complex conditions. Some models of CCN appear to have more potential for impact than others. Part 2: the cost–consequence analysis covered only part of the CCN teams’ activity. It showed some potential savings from reduced admissions and bed-days, but none that was greater than the total cost of the services. Part 3: three localities implemented services as planned, one achieved partial service change and one was not able to achieve any service change. Organisational stability, finance, medical stakeholder support, competition, integration with primary care and visibility influenced the planning and implementation of new and expanded CCN services. Feeling supported to manage their ill child at home was a key outcome of using services for parents. Various service features contributed to this and were important in different ways at different times. Other outcomes included being able to avoid hospital care, enabling the child to stay in school, and getting respite. Although parents judged that care was of high quality when teams enabled them to feel supported, reassured and secure in managing their ill child at home, this did not depend on a constant level of contact from teams. Limitations: Delays in service reconfigurations required adaptation of research activity across sites. Use of administrative data, such as Hospital Episode Statistics, for research purposes is technically difficult and imposed some limitations on both the ITS and the cost–consequence analyses. Conclusions: Large, generic CCN teams that integrate acute admission avoidance for all children with support for children with complex conditions and highly targeted teams for children with complex conditions offer the possibility of supporting children more appropriately at home while also making some difference to acute activity. This possibility remains to be tested further. Future work: Further work should refine the evidence on outcomes of services by looking at outcomes in promising models, value for money and measuring quality-based outcomes. Funding: The National Institute for Health Research Health Services and Delivery Research Programme

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

Background: Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations. Aims: (1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study. Methods: Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions. Results: There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five ‘top-priority’ interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation. Limitations: No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups. Future work: To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities

Pathways to permanence in England and Norway: A critical analysis of documents and data

The English language term ‘permanence’ is increasingly used in high income countries as a ‘short-hand’ translation for a complex set of aims around providing stability and family membership for children who need child welfare services and out-of-home care. From a scrutiny of legislative provisions, court judgments, government documents and a public opinion survey on child placement options, the paper draws out similarities and differences in understandings of the place of ‘permanence’ within the child welfare discourse in Norway and England. The main differences are that in England the components of permanence are explicitly set out in legislation, statutory guidance and advisory documents whilst in Norway the terms ‘stability’ and ‘continuity’ are used in a more limited number of policy documents in the context of a wide array of services available for children and families. The paper then draws on these sources, and on administrative data on children in care, to tease out possible explanations for the similarities and differences identified. We hypothesise that both long-standing policies and recent changes can be explained by differences in public and political understandings of child welfare and the balance between universal services and those targeted on parents and children identified as vulnerable and in need of specialist services

Self-care support for children and adolescents with long-term conditions : the REfOCUS evidence synthesis

Background: Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems. Objectives: To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people. Design: Systematic review with meta-analysis. Population: Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression). Intervention: Self-care support in health, social care, educational or community settings. Comparator: Usual care. Outcomes: Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs. Design: Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs. Data sources: MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015. Methods: We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity). Results: Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings. Limitations: Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded. Conclusions: Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs. Future work: Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs. Study registration: This study is registered as PROSPERO CRD42014015452. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England - 1: Methods and women׳s overall ratings of care

Objective: To describe and compare women’s choices and experiences of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. Design: Telephone surveys undertaken in late pregnancy and about six weeks after birth in two separate time periods, Phase 1 before the birth centre opened and Phase 2 after it had opened. Setting: Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010. Participants: 620 women who were resident in Tower Hamlets and who satisfied the Barts and the London NHS Trust’s eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. Measurements and findings: Women who satisfied the criteria for birth centre care and who booked antenatally for care at the birth centre were significantly more likely to rate their care as good or very good overall than corresponding women who also satisfied these criteria but booked initially at the hospital. Women who started labour care in spontaneous labour at the birth centre were significantly more likely to be cared for by a midwife they had already met, have one to one care in labour and have the same midwife with them throughout their labour. They were also significantly more likely to report that the staff were kind and understanding, that they were treated with respect and dignity and that their privacy was respected. Key conclusions and implications for practice: This survey in an inner city area showed that women who chose the freestanding midwifery unit care had positive experiences to report. Taken together with the findings of the Birthplace Programme, It adds further weight to the evidence in support of freestanding midwifery unit care for women without obstetric complications