Evaluation of NHS Direct ‘‘referral’’ to community pharmacists

OBJECTIVES: To evaluate a pilot scheme of referrals from a nurse-led telephone helpline (NHS Direct) to community pharmacists. METHODS: A multi-method approach, including analysis of routine data from NHS Direct, postal surveys of NHS Direct callers, analysis of anonymised transcripts of calls, a postal survey of callers referred to pharmacists, and face-to-face interviews with NHS Direct nurses. SETTING: Essex, Barking and Havering. KEY FINDINGS: During the first three months of the pilot scheme, 6% (1,995/31,674) of NHS Direct calls triaged by nurses were logged as referred to pharmacists. This built on an existing foundation of informal referral to pharmacists of 4%. There was no measurable change in callers’ views of the helpfulness of advice, enablement, or caller satisfaction associated with the scheme. Conditions sent to pharmacists included skin rash, cough, sore throat, stomach pain, and vomiting and/or diarrhoea. 86% (54/63) of callers referred to pharmacists during the scheme felt the referral was very or quite appropriate and 75% (48/64) attempted to contact a pharmacist. In general, those who did so found the experience a positive one: 65% (31/48) spoke to the pharmacist, and 80% (28/35) of people expressing an opinion were satisfied with the advice offered, but the lack of privacy in the pharmacy was of some concern. Although routine data indicated high usage of the scheme, nurse referral of callers to pharmacists declined over time. Their initial enthusiasm diminished due to concerns about the appropriateness of guidelines, their lack of understanding of the rationale behind some referrals, and the lack of feedback about the appropriateness of their referrals. CONCLUSIONS: The evaluation of the pilot scheme has generated a range of recommendations for the wider national roll-out of the scheme, including revision of the guidelines and review of NHS Direct nurse training for referral to pharmacy. NHS Direct and pharmacists should consider how to strengthen the system of pharmacist feedback to NHS Direct

Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys

Background Unscheduled care is defined here as when someone seeks treatment or advice for a health problem without arranging to do so more than a day in advance. Recent health policy initiatives in England have focused on introducing new services such as NHS Direct and walk in centres into the unscheduled care system. This study used population surveys to explore the effect of these new services on the use of traditional providers of unscheduled care, and to improve understanding of help seeking behaviour within the system of unscheduled care. Methods Cross-sectional population postal surveys were undertaken annually over the five year period 1998 to 2002 in two geographical areas in England. Each year questionnaires were sent to 5000 members of the general population in each area. Results The response rate was 69% (33,602/48,883). Over the five year period 16% (5223/33602) 95%CI (15.9 to 16.1) of respondents had an unscheduled episode in the previous four weeks and this remained stable over time (p = 0.170). There was an increased use of telephone help lines over the five years, reflecting the change in service provision (p = 0.008). However, there was no change in use of traditional services over this time period. Respondents were most likely to seek help from general practitioners (GPs), family and friends, and pharmacists, used by 9.0%, 7.2% and 6.3% respectively of the 5815 respondents in 2002. Most episodes involved contact with a single service only: 7.0% (2363/33,602) of the population had one contact and 2% (662/33602) had three or more contacts per episode. GPs were the most frequent point of first contact with services. Conclusion Introducing new services to the provision of unscheduled care did not affect the use of traditional services. A large majority of the population continued to turn to their GP for unscheduled health care

Impact of NHS Direct on demand for immediate care: observational study

OBJECTIVES: To quantify the impact of NHS Direct on the use of accident and emergency, ambulance, and general practitioner cooperative services. DESIGN: Observational study of trends in use of NHS Direct and other immediate care services over 24 months spanning introduction of NHS Direct. Setting Three areas in England in first wave of introduction of NHS Direct, and six nearby general practitioner cooperatives as controls. SUBJECTS: All contacts with these immediate care services. MAIN OUTCOME MEASURES: Changes in trends in use after introduction of NHS Direct. Results NHS Direct received about 68 500 calls from a population of 1.3 million in its first year of operation, of which 72% were out of hours and 22% about a child aged under 5 years. Changes in trends in use of accident and emergency departments and ambulance services after introduction of NHS Direct were small and non­significant. Changes in trends in use of general practitioner cooperatives were also small but significant, from an increase of 2.0% a month before introduction of NHS Direct to - 0.8% afterwards (relative change - 2.9% (95% confidence interval - 4.2% to - 1.5%)). This reduction in trend was significant both for calls handled by telephone advice alone and for those resulting in direct contact with a doctor. In contrast, the six control cooperatives showed no evidence of change in trend; an increase of 0.8% a month before NHS Direct and 0.9% after (relative change 0.1% ( - 0.9% to 1.1%)). CONCLUSION: In its first year NHS Direct did not reduce the pressure on NHS immediate care services, although it may have restrained increasing demand on one important part—general practitioners' out of hours services

Derivation of the time dependent Gross-Pitaevskii equation without positivity condition on the interaction

Using a new method it is possible to derive mean field equations from the microscopic $N$ body Schr\"odinger evolution of interacting particles without using BBGKY hierarchies. In this paper we wish to analyze scalings which lead to the Gross-Pitaevskii equation which is usually derived assuming positivity of the interaction. The new method for dealing with mean field limits presented in [6] allows us to relax this condition. The price we have to pay for this relaxation is however that we have to restrict the scaling behavior to $\beta<1/3$ and that we have to assume fast convergence of the reduced one particle marginal density matrix of the initial wave function $\mu^{\Psi_0}$ to a pure state $|\phi_0><\phi_0|$

NHS Direct: consistency of triage outcomes

OBJECTIVES: To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct. METHODS: 119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System. RESULTS: The overall level of agreement between the nurses using the four systems was “fair” rather than “moderate” or “good” (k=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services. CONCLUSIONS: There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved

Probing quasiparticle excitations in a hybrid single electron transistor

We investigate the behavior of quasiparticles in a hybrid electron turnstile with the aim of improving its performance as a metrological current source. The device is used to directly probe the density of quasiparticles and monitor their relaxation into normal metal traps. We compare different trap geometries and reach quasiparticle densities below 3um^-3 for pumping frequencies of 20 MHz. Our data show that quasiparticles are excited both by the device operation itself and by the electromagnetic environment of the sample. Our observations can be modelled on a quantitative level with a sequential tunneling model and a simple diffusion equation

On the Scale of the Nonlinear Effect in a Crack Problem

When crack problems are analyzed on the basis of nonlinear theories, such as finite elasticity or deformation theory of plasticity, it is inevitable that nonlinear effects will predominate near a crack-tip, even if the loads are small. The most favorable circumstance in this regard occurs when the loads are so small that the zone of significant nonlinearity lies within the region of validity of the near-tip approximation to the global solution of the associated linearized crack problem. This situation - called small-scale yielding for crack problems in plasticity - permits simplifications in analysis which are often decisive; see, e.g., Knowles (1977) and Rice (1968). Insofar as we know, there are no analytical estimates available of the level of load below which nonlinear effects are guaranteed to be small-scale in the above sense. Indeed, even a precise version of the question seems to be lacking. In the present note we formulate and answer such a question for an especially cooperative crack problem; that corresponding to finite anti-plane shear of an infinite medium containing a crack of finite length for an elastic material of Neo-Hookean type. The associated boundary value problem is a linear one for Laplace's equation and thus can be solved globally. Nevertheless, there is a significant nonlinear effect of Kelvin type in the stress field. We give a condition under which this nonlinear response occurs on a small scale near the crack tips

Active heat exchange system development for latent heat thermal energy storage

Active heat exchange concepts for use with thermal energy storage systems in the temperature range of 250 C to 350 C, using the heat of fusion of molten salts for storing thermal energy are described. Salt mixtures that freeze and melt in appropriate ranges are identified and are evaluated for physico-chemical, economic, corrosive and safety characteristics. Eight active heat exchange concepts for heat transfer during solidification are conceived and conceptually designed for use with selected storage media. The concepts are analyzed for their scalability, maintenance, safety, technological development and costs. A model for estimating and scaling storage system costs is developed and is used for economic evaluation of salt mixtures and heat exchange concepts for a large scale application. The importance of comparing salts and heat exchange concepts on a total system cost basis, rather than the component cost basis alone, is pointed out. The heat exchange concepts were sized and compared for 6.5 MPa/281 C steam conditions and a 1000 MW(t) heat rate for six hours. A cost sensitivity analysis for other design conditions is also carried out

Statistical analysis of activation and reaction energies with quasi-variational coupled-cluster theory

The performance of quasi-variational coupled-cluster (QV) theory applied to the calculation of activation and reaction energies has been investigated. A statistical analysis of results obtained for six different sets of reactions has been carried out, and the results have been compared to those from standard single-reference methods. In general, the QV methods lead to increased activation energies and larger absolute reaction energies compared to those obtained with traditional coupled-cluster theory

Acceptability of NHS 111 the telephone service for urgent health care: cross sectional postal survey of users' views

Background. In 2010, a new telephone service, NHS 111, was piloted to improve access to urgent care in England. A unique feature is the use of non-clinical call takers who triage calls with computerized decision support and have access to clinical advisors when necessary. Aim. To explore users’ acceptability of NHS 111. Design. Cross-sectional postal survey. Setting. Four pilot sites in England. Method. A postal survey of recent users of NHS 111. Results. The response rate was 41% (1769/4265), with 49% offering written comments (872/1769). Sixty-ive percent indicated the advice given had been very helpful and 28% quite helpful. The majority of respondents (86%) indicated that they fully complied with advice. Seventy-three percent was very satisied and 19% quite satisied with the service overall. Users were less satisied with the relevance of questions asked, and the accuracy and appropriateness of advice given, than with other aspects of the service. Users who were autorouted to NHS 111 from services such as GP out-of-hours services were less satisied than direct callers. Conclusion. In pilot services in the irst year of operation, NHS 111 appeared to be acceptable to the majority of users. Acceptability could be improved by reassessing the necessity of triage questions used and auditing the accuracy and appropriateness of advice given. User acceptability should be viewed in the context of indings from the wider evaluation, which identiied that the NHS 111 pilot services did not improve access to urgent care and indeed increased the use of emergency ambulance services