Integrated out-of-hours care arrangements in England: observational study of progress towards single call access via NHS Direct and impact on the wider health system

Objectives: To assess the extent of service integration achieved within general practice cooperatives and NHS Direct sites participating in the Department of Health’s national “Exemplar Programme” for single call access to out-of-hours care via NHS Direct. To assess the impact of integrated out-of-hours care arrangements upon general practice cooperatives and the wider health system (use of emergency departments, 999 ambulance services, and minor injuries units). Design: Observational before and after study of demand, activity, and trends in the use of other health services. Setting: Thirty four English general practice cooperatives with NHS Direct partners (“exemplars”) of which four acted as “case exemplars”. Also 10 control cooperatives for comparison. Main Outcome Measures: Extent of integration achieved (defined as the proportion of hours and the proportion of general practice patients covered by integrated arrangements), patterns of general practice cooperative demand and activity and trends in use of the wider health system in the first year. Results: Of 31 distinct exemplars 21 (68%) integrated all out-of-hours call management by March 2004. Nine (29%) established single call access for all patients. In the only case exemplar where direct comparison was possible, cooperative nurse telephone triage before integration completed a higher proportion of calls with telephone advice than did NHS Direct afterwards (39% v 30%; p<0.0001). The proportion of calls completed by NHS Direct telephone advice at other sites was lower. There is evidence for transfer of demand from case exemplars to 999 ambulance services. A downturn in overall demand for care seen in two case exemplars was also seen in control sites. Conclusion: The new model of out-of-hours care was implemented in a variety of settings across England by new partnerships between general practice cooperatives and NHS Direct. Single call access was not widely implemented and most patients needed to make at least two telephone calls to contact the service. In the first year, integration may have produced some reduction in total demand, but this may have been accompanied by shifts from one part of the local health system to another. NHS Direct demonstrated capability in handling calls but may not currently have sufficient capacity to support national implementation

Development and initial application of δ18Op to understand phosphorus cycling in river, lake and groundwater ecosystems.

Variation in the stable isotope composition of oxygen within dissolved phosphate (δ18Op) represents a novel and potentially powerful environmental tracer. In freshwater, marine and terrestrial ecosystems, δ18Op can act as an inherent label for the sources of phosphorus and the extent to which phosphorus from different sources is metabolised. This paper focuses on the methodological development and initial application of δ18Op across a range of freshwater ecosystems. Initially, we report modifications to the analytical protocol for δ18Op that are designed to minimise incorporation of contaminant oxygen in the final silver phosphate precipitate prior to pyrolysis. This is critical given the range of possible sources of contaminant oxygen within freshwater matrices. Subsequently, we consider the potential utility of δ18Op through application of the technique within a range of freshwater ecosystems in England, UK. Firstly, we characterise δ18Op in river water and effluents from Sewage Treatment Works (STW), and examine the opportunity to use the 18Op of STW effluents to trace the entry and downstream fate of phosphorus from these point sources in rivers. Secondly, we analyse δ18Op to gain insights into variations in the sources and biological cycling of phosphorus in a seasonally stratified lake ecosystem. Thirdly, we characterise δ18Op in shallow and deep groundwater samples, considering whether δ18Op might provide evidence for variation in source and extent of metabolism for phosphorus in groundwater ecosystems. Taken together, these data extend the catalogue of δ18Op in freshwater ecosystems, and further the scope of δ18Op as a tool to better understand phosphorus biogeochemistry

Psychology students’ perception of and engagement with feedback as a function of year of study

Undergraduate students’ perception of feedback and level of engagement with the feedback they receive have gained increasing attention in the educational literature recently to identify areas which require educators’ attention. However, research in this area has generally been based on limited self-selecting samples, and has not considered how students’ relationship with feedback may alter depending on their year of study. To address this, a survey measuring students’ views and practices regarding feedback was completed at a higher education institution by 447 first-, second- and third-year psychology students, representing 77% of the cohort. Findings revealed that third years responded more negatively in both areas than their first- and second-year counterparts, whose ratings on these aspects themselves were far from optimal. These findings highlight the need for early interventions to improve students’ perception of and engagement with feedback in the earlier years, and to prevent the recorded deterioration later on in the degree course

A multi-stable isotope framework to understand eutrophication in aquatic ecosystems

Eutrophication is a globally significant challenge facing aquatic ecosystems, associated with human induced enrichment of these ecosystems with nitrogen (N) and phosphorus (P). However, the limited availability of inherent labels for P and N has constrained understanding of the triggers for eutrophication in natural ecosystems and appropriate targeting of management responses. This paper proposes and evaluates a new multi-stable isotope framework that offers inherent labels to track biogeochemical reactions governing both P and N in natural ecosystems. The framework couples highly novel analysis of the oxygen isotope composition of phosphate (δ18OPO4) with dual isotope analysis of oxygen and N within nitrate (δ15NNO3, δ18ONO3) and with stable N isotope analysis in ammonium (δ15NNH4). The River Beult in England is used as an exemplar system for initial evaluation of this framework. Our data demonstrate the potential to use stable isotope labels to track the input and downstream fate of nutrients from point sources, on the basis of isotopic differentiation for both P and N between river water and waste water treatment work effluent (mean difference = +1.7‰ for δ18OPO4; +15.5‰ for δ15NNH4 (under high flow); +7.3‰ for δ18ONO3 and +4.4‰ for δ15NNO3). Stable isotope data reveal nutrient inputs to the river upstream of the waste water treatment works that are consistent with partially denitrified sewage or livestock sources of nitrate (δ15NNO3 range = +11.5 to +13.1‰) and with agricultural sources of phosphate (δ18OPO4 range = +16.6 to +19.0‰). The importance of abiotic and metabolic processes for the in-river fate of N and P are also explored through the stable isotope framework. Microbial uptake of ammonium to meet metabolic demand for N is suggested by substantial enrichment of δ15NNH4 (by 10.2‰ over a 100 m reach) under summer low flow conditions. Whilst the concentration of both nitrate and phosphate decreased substantially along the same reach, the stable isotope composition of these ions did not vary significantly, indicating that concentration changes are likely driven by abiotic processes of dilution or sorption. The in-river stable isotope composition and the concentration of P and N were also largely constant downstream of the waste water treatment works, indicating that effluent-derived nutrients were not strongly coupled to metabolism along this in-river transect. Combined with in-situ and laboratory hydrochemical data, we believe that a multi-stable isotope framework represents a powerful approach for understanding and managing eutrophication in natural aquatic ecosystems

Making good?: A study of how senior penal policy makers narrate policy reversal

This paper provides insights into the predominant styles of political reasoning in England and Wales that inform penal policy reform. It does so in relation to a particular development that constitutes a dramatic, perhaps even unique, wholesale reversal of a previously introduced market-based criminal justice delivery model. This is the ‘unification’ of probation services in England and Wales, which unwound the consequential privatization reforms introduced less than a decade earlier. This paper draws on in-depth interviews with senior policy makers to present a narrative reconstruction of the unification of probation services in England and Wales. Analogies with desistance literature are drawn upon in order to encapsulate the tensions posed for policy makers as they sought to enact this penal policy reform

A necessary but painful journey: Experiences of unification in a probation service region

In this article, we present some initial findings from the first year of a longitudinal study of the experiences of unification by staff in one Probation Service region. Their reaction to unification is explored as well as their hopes and fears regarding the newly unified service. Despite working in what was often presented as an unsettled and fractured environment marked by on-going staff shortages – whilst at the same time having to respond to the impact of the COVID-19 pandemic – amongst most participants there remained a high level of loyalty to the probation profession (or the idea of probation). However, while many expressed optimism regarding the longer-term prospects for the unified organisation, this was also overlaid with concerns about how unification would play out in the short to medium term. Their enduring sense of commitment and loyalty to their role was also being tested by what some saw as overbearing pressure to manage risk, coupled with the fear of being exposed if people whom they supervised committed a Serious Further Offence

Making Good?: A Study of How Senior Penal Policy Makers Narrate Policy Reversal

This paper provides insights into the predominant styles of political reasoning in England and Wales that inform penal policy reform. It does so in relation to a particular development that constitutes a dramatic, perhaps even unique, wholesale reversal of a previously introduced market-based criminal justice delivery model. This is the ‘unification’ of probation services in England and Wales, which unwound the consequential privatization reforms introduced less than a decade earlier. This paper draws on in-depth interviews with senior policy makers to present a narrative reconstruction of the unification of probation services in England and Wales. Analogies with desistance literature are drawn upon in order to encapsulate the tensions posed for policy makers as they sought to enact this penal policy reform

The ‘ins and outs’ of colonoscopy at Wits Donald Gordon Medical Centre, South Africa: A practice audit of the outpatient endoscopy unit

Background. In South Africa, there are no national guidelines for the conduct or quality assessment of colonoscopy, the gold standard for investigation and diagnosis of bowel pathology.Objectives. To describe the clinical profile of patients and evaluate the practice of colonoscopy using procedural quality indicators at the Wits Donald Gordon Medical Centre (WDGMC) outpatient endoscopy unit (OEU).Methods. We conducted a prospective, clinical practice audit of colonoscopies performed on adults (≥18 years of age). A total of 1 643 patients were included in the study and variables that were collected enabled the assessment of adequacy of bowel preparation, length of withdrawal time and calculation of caecal intubation rate (CIR), polyp detection rate (PDR) and adenoma detection rate (ADR). We stratified PDR and ADR by sex, age, population group, withdrawal time and bowel preparation. CIR, PDR and ADR estimates were compared between patient groups by the χ2 test; Fisher’s exact test was used for 2 × 2 tables. A p-value &lt;0.05 was used. Benchmark recommendations by the American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force on Colorectal Cancer (CRC) were used in this audit to assess individual endoscopist performance and that of the endoscopy unit as a whole.Results. The mean age of patients was 55.7 (standard deviation (SD) 14.4; range 18 - 91) years, ~60% were female, and the majority (75.5%) were white. Of the outpatients, 77.6% had adequate bowel preparation (ASGE/ACG benchmark ≥85%). The CIR was 97.0% overall, and screening colonoscopy was 96.3% (ASGE/ACG benchmark ≥90% overall and ≥95% for screening colonoscopies). The median withdrawal time for negative-result screening colonoscopies was 5.7 minutes (interquartile range (IQR) 4.2 - 9.3; range 1.1 - 20.6) (ASGE/ACG benchmark ≥ 6minutes), and PDR and ADR were 27.6% and 15.6%, respectively (ASGE/ACG benchmark ADR ≥25%). We demonstrated a 23.7% increase in PDR and 14.1% increase in ADR between scopes that had mean withdrawal times of ≥6 minutes and &lt;6 minutes, respectively. Although the number of black Africans in the study was relatively small, our results showed that they have similar ADRs and PDRs to the white population group, contradicting popular belief.Conclusions. The WDGMC OEU performed reasonably well against the international guidelines, despite some inadequacy in bowel preparation and lower than recommended median withdrawal times on negative-result colonoscopy. Annual auditing of clinical practice and availability of these data in the public domain will become standard of care, making this audit a baseline for longitudinal observation, assessing the impact of interventions, and contributing to the development of local guidelines