Using group therapy to support eating disordered mothers with their children: the relevance for primary care

Eating disorders are a crippling and disabling condition. If they become chronic, the emotional, physical and social effects are substantial. The death rate is the highest of all psychiatric illnesses so the need to find prevention strategies is urgent. This research project has three aims, primary prevention of an eating disorder for the child, helping the mother recover and developing a protocol for a group to be used in primary care. Children of mothers with an eating disorder, are a proven ‘at risk’ group, because children model and internalize their experiences. This project was carried out in a community setting, targeting mothers with an eating disorder who had children under the age of 13. It was argued that if these mothers can be encouraged to change the dysfunctional behaviour they may be passing on to their children, an attempt can be made to break the cycle. This qualitative research pilot project utilized semi-structured interviews before and after 11 weeks of group therapy, with three- and six-month follow-ups. Although the sample was small, the results showed that a group allowed these mothers a safe space for reflection, enabling them to become aware of their behaviour. As a result the mothers implemented changes in response to their children's needs, encouraging healthier development. The pilot was a precursor for a larger study to be carried out and developed within the primary care network

What role can local and national supportive services play in supporting independent and healthy living in individuals 65 and over?

Executive summary The UK population is ageing rapidly and the extent of comorbidities will continue to increase. This greater demand for support and care will need to be met within an environment of continued economic restraint. One policy response to mitigate such demand has been the reinvigorated focus on prevention and early intervention in health, social and third sector care. Prevention is broadly defined to include a wide range of services that promote independence; prevent or delay the deterioration of health and well-being resulting from ageing, illness or disability; and delay the need for more costly and intensive services. In exploring the existing evidence base around effective and cost-effective preventative services, our typology of prevention includes the accepted discourse of primary, second and tertiary prevention, while placing those ‘upstream’ well-being interventions at the core of any prevention strategy. Well-being preventative services across the continuum • In mitigating social isolation and loneliness, there is relatively good evidence that befriending interventions, social prescribing services, group activities and volunteer schemes can reduce loneliness and depressive symptomology, improve physical health, and result in differences in mortality. • A range of exercise provision is able to improve balance, cognition, well-being, mobility, core strength and cardio-metabolic health, and reduce fall or fracture risk, depressive symptomology and cognitive decline. Physical activity can be supported through community-based interventions (e.g. walking for health groups, peer-supported exercise programmes), resulting in improved health-related quality of life and reductions in the use of secondary health care. • Information, advice and signposting are seen as fundamental by individuals, as well as their families or carers, who need (or in the future may need), care and support to maintain independence. However, few studies concentrate on what works for older people, or whether timely and appropriate advice is able to maintain independence or improve quality of life. There is emerging evidence that care navigators (CNs) can provide effective practical and social support to older people, ensuring timely signposting to interventions and acting as a ‘link’ between community and statutory services. • There is a range of low-level practical interventions that can support older people to remain at home, e.g. minor housing repairs, assisted gardening and shopping. While the link between such services and the use of higher-intensity provision is little discussed in the literature, a timely and trusted response can improve quality of life and reduce service use. Gardening has been shown to improve physical strength, fitness and cognitive ability and to reduce depression and anxiety. Primary, secondary and tertiary prevention Available primary and secondary preventative services (e.g. health screening, vaccinations, care management, day services, reablement) should be delivered holistically, i.e. ‘making every contact count’. • Two national population health screening programmes – breast and bowel screening – demonstrate efficacy. In contrast, the level of uptake of the NHS Health Check has been lower than expected. While older people are more likely to attend, older individuals most likely to benefit (e.g. smokers, minority ethnic groups and those living in more deprived areas) seem less keen to engage. • Day services for older people are a contested area, often perceived as part of the ‘one-size-fits-all’ welfarist agenda. Where the evidence is available, day services improve social care and quality of life for users and carers, reduce social isolation, may delay institutionalisation for people with dementia, and provide a sense of purpose for the individual, but are unlikely to reduce health service use. • Care management, essential in supporting the individual to ‘age in place’, can reduce hospital admissions, lengths of stay and Accident and Emergency (A&E) attendances, although outcomes are dependent on the structure and processes adopted. Improved outcomes can be achieved by delivering well-being services alongside statutory provision. • While reablement improves independence, health-related quality of life and service use, there are continuing process difficulties in appropriately involving or transferring older people to further service provision. • In exploring tertiary prevention (minimising disability and deterioration from established diseases), the evidence base remains fragmented, with little clarity on the processes, structures or outcomes of, for example, rapid response teams (RRTs) or ambulatory emergency care (AEC) units. Fragmented evidence base? There is a wide range of available and effective well-being preventative services that can support older people to live independent and healthy lives. However, there are still gaps in the evidence base. Few evaluations explore whether reported changes in quality of life, service use, morbidity or mortality are maintained long term, with even fewer reporting cost-effectiveness. There is also little evidence that identifies the types of package of early interventions that should be provided, when these need to be offered, and to whom they would make the most difference. The evidence is non-existent on the structures and processes of effective preventative pathways. The future role of services to 2030 If appropriate management of future pressures on the health and social care environment is to be delivered, the system needs to be rebalanced toward well-being interventions, and primary, secondary and tertiary prevention. However, the budget for such care is continually under threat. There is an urgent need to apply a single health and social care budget, incorporating housing and transport and delivered through a single commissioning point. Perhaps the main challenge in reorienting provision toward preventative care is that there first needs to be an accepted clarity from all partners across the health and social care environment as to what is being prevented – unnecessary hospital admissions or morbidity (ill health). The rhetoric of prevention needs to be embedded into service provision with appropriate care strategies, processes and structures able to support the promotion of well-being and health, rather than the management of disease

Development of a Patient Reported Experience Measure (PREM) for use in the ambulance service

Background NHS health policy emphasises the crucial role of patient experience as a core component of high quality care, alongside effectiveness and safety. Patient Reported Experience Measures (PREMs) measure patients’ experiences with their healthcare. They are increasingly being seen as valuable for assessing patient outcomes and differences in quality between health care providers. Previous patient surveys to assess ambulance service care have not been implemented routinely or in a standardised way. This research forms part of a doctoral study to develop a PREM for use in UK ambulance services. Methods The study comprised three subsections: 1. A secondary analysis of interview data exploring patients’ experiences of their prehospital care. 2. Development of questionnaire items based on those themes emerging from the secondary analysis. 3. Semi-structured interviews with service users that explore their opinions of the questionnaire items and whether the PREM includes all aspects of the ambulance service experience that should be encompassed. Results The secondary data analysis revealed specific ‘processes of importance’ to service users accessing ambulance care i.e. ‘timeliness’ and parallel ‘experiential components of care’ i.e. ‘reassurance’ that either enhanced or reduced the perception that the ‘processes of care’ were undertaken to a high standard. The key themes formed the foundation for generating the 53 item questionnaire. The interview stage is on-going and the data obtained are being used to amend the questionnaire items. Conclusions The construction of the PREM has incorporated the views of patients that the measure is ultimately designed for, and conforms to the concept of patient-centred care—the theoretical foundation of the research. Once completed, the PREM will enable ambulance trusts to measure differences in patient experiences, between and within organisations. This can result in positive changes to patient experience through the introduction of feedback, training and education to prehospital clinicians

Differences in delivery of prehospital ambulance care comparing non-white versus white patients with suspected cardiac chest pain: cross-sectional study

Introduction Quality implies equitable care irrespective of ethnicity. There have been few previous studies investigating quality of prehospital cardiac care by ethnicity. We aimed to investigate whether prehospital care for suspected cardiac pain varied by ethnicity. Methods We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with chest pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data (ethnicity, age, sex, deprivation), clinical measurements (blood pressure, respiratory rate, pain assessment, temperature, blood glucose, oxygen saturation), drugs (aspirin, nitroglycerin, Entonox, morphine) and outcomes such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-white with white patients. Results There were 7046 patients with suspected cardiac chest pain, with 4825 who had ethnicity recorded including 4661 (96.6%) white, 164 (3.4%) non-white (2221 patients had missing data for ethnicity). Non-white patients were similar in sex (p=0.63) and socioeconomic group (p=0.07) but significantly younger in age (p<0.001) than white patients. After correcting for age, sex, socioeconomic status and whether transported to hospital, non-white patients were similar to white patients in recording of blood pressure, pain score or electrocardiogram but significantly more likely to have temperature (77.4 vs.69.8%), blood glucose (78.7 vs. 69.4%), and oxygen saturation (85.4 vs. 80.7%) recorded. There were no differences in aspirin, nitroglycerin, Entonox or morphine treatment but non-white patients were less likely than white patients to be transported to hospital (93.3 vs. 94.4, p=0.02). Conclusion We found differences in prehospital ambulance care for non-white compared with white patients with cardiac pain that could be due to recording bias, varying clinical condition or provider management. Further analysis should involve larger and more complete datasets to explore ethnic differences in greater detail

National evaluation of Partnerships for Older People Projects

Executive Summary The Partnership for Older People Projects (POPP) were funded by the Department of Health to develop services for older people, aimed at promoting their health, well-being and independence and preventing or delaying their need for higher intensity or institutional care. The evaluation found that a wide range of projects resulted in improved quality of life for participants and considerable savings, as well as better local working relationships. • Twenty-nine local authorities were involved as pilot sites, working with health and voluntary sector partners to develop services, with funding of £60m • Those projects developed ranged from low level services, such as lunch-clubs, to more formal preventive initiatives, such as hospital discharge and rapid response services • Over a quarter of a million people (264,637) used one or more of these services • The reduction in hospital emergency bed days resulted in considerable savings, to the extent that for every extra £1 spent on the POPP services, there has been approximately a £1.20 additional benefit in savings on emergency bed days. This is the headline estimate drawn from a statistically valid range of £0.80 to £1.60 saving on emergency bed days for every extra £1 spent on the projects. • Overnight hospital stays were seemingly reduced by 47% and use of Accident & Emergency departments by 29%. Reductions were also seen in physiotherapy/occupational therapy and clinic or outpatient appointments with a total cost reduction of £2,166 per person • A practical example of what works is pro-active case coordination services, where visits to A&E departments fell by 60%, hospital overnight stays were reduced by 48%, phone calls to GPs fell by 28%, visits to practice nurses reduced by 25% and GP appointments reduced by 10% • Efficiency gains in health service use appear to have been achieved without any adverse impact on the use of social care resources • The overwhelming majority of the POPP projects have been sustained, with only 3% being closed – either because they did not deliver the intended outcomes or because local strategic priorities had changed • PCTs have contributed to the sustainability of the POPP projects within all 29 pilot sites. Moreover, within almost half of the sites, one or more of the projects are being entirely sustained through PCT funding – a total of 20% of POPP projects. There are a further 14% of projects for which PCTs are providing at least half of the necessary ongoing funding • POPP services appear to have improved users’ quality of life, varying with the nature of individual projects; those providing services to individuals with complex needs were particularly successful, but low-level preventive projects also had an impact • All local projects involved older people in their design and management, although to varying degrees, including as members of steering or programme boards, in staff recruitment panels, as volunteers or in the evaluation • Improved relationships with health agencies and the voluntary sector in the locality were generally reported as a result of partnership working, although there were some difficulties securing the involvement of GP

Modified Early Warning Scores (MEWS) to support ambulance clinicians’ decisions to transport or treat at home

Introduction Modified Early Warning Scores (MEWS), calculated from patients’ vital signs, are used in hospital to identify patients who may benefit from admission or intensive care: higher MEWS indicates greater clinical risk. We aimed to evaluate MEWS to support paramedics’ decisions to transport patients to hospital or treat and leave them at home. Methods We used an interrupted time series design. We trained 19 volunteer paramedics to use MEWS to support decisions to transport or treat and leave at home. We used linear regression to evaluate differences in weekly transportation rates (percentage of patients attended and transported to hospital) and revisit rates (percentage of patients attended, treated at home and subsequently revisited within 7 days), comparing trends in rates 17 weeks prior (pre-MEWS) and 17 weeks post implementation of MEWS. Auto-calculated scores retrospectively applied to all data provided pre-MEWS and were compared with paramedic calculated scores post-MEWS. Results Of the 4140 patients attended, 2208 were excluded owing to missing values (n=1897), recording errors (n=21) or excluded clinical complaints (n=290). From the remaining data (n=1932) there were no significant differences in transportation rates (pre=55±6%; post=63±11%) by catering for the existing increasing trends where the confidence intervals of the regression slopes overlap (pre=0.15; 95%CI -0.51 to 0.80 vs. post=0.54; -0.58 to 1.65). Similarly, there were no significant difference in revisit rates (pre=4±4%; post=2±4%) catering for the similar trends (pre=-0.13; -0.53 to 0.27 vs. post=0.08; -0.33 to 0.49). Paramedic scores were incorrect 39% of the time (n=622). Conclusion MEWS had a minimal effect on transportation or revisit rates. Scores were frequently not calculated or recorded, or incorrectly calculated. Opportunities for ongoing training, clinical support and feedback were limited. A larger study, ensuring adequate ongoing support, is recommended before implementing MEWS on a wider scale

Investigating the potential role of ICT to support older people with multi-morbidity to navigate the care network

Tools are available to help people navigate when they are not quite sure where they should be going (e.g. GPS). In the care system there is (as yet) no available map to guide patients, users or carers to particular health and care services. This poster displays the mixed method research protocol in which we will investigate the potential role of ICT to support older people with multi morbidities to navigate through the care system. Three distinct work streams are set up to explore and analyse the current literature, patients’ perspective about their care network and patients’ experience about problems in their care system. A fourth work stream will bring these analyses together to generate design requirements for engineers in order to prototype an electronic tool. This will support patients to appropriately and successfully navigate through health and social care services

Evaluation of the personal health budget pilot programme

1. The personal health budget initiative is a key aspect of personalisation across health care services in England. Its aim is to improve patient outcomes, by placing patients at the centre of decisions about their care. Giving people greater choice and control, with patients working alongside health service professionals to develop and execute a care plan, given a known budget, is intended to encourage more responsiveness of the health and care system. 2. The personal health budget programme was launched by the Department of Health in 2009 after the publication of the 2008 Next Stage Review. An independent evaluation was commissioned alongside the pilot programme with the aim of identifying whether personal health budgets ensured better health and care outcomes when compared to conventional service delivery and, if so, the best way for personal health budgets to be implemented

A systematic scoping review of care navigation for older people with multimorbidity

Introduction: The health and social care environment is being transformed by the needs of the aging population, higher levels of multimorbidity, and shifts in the care landscape, such as specialisation, ‘privatisation’ and fragmentation. Health and social care systems were not designed to appropriately support individuals with multimorbidities; primarily evolving to cater for single diseases and acute events. Nevertheless, there is now an urgent need to redesign existing structures and care delivery to address the needs of the population, ensuring individuals can access the right care at the right time and in the right place. If patients or users are unable to adequately navigate health, social and third sector care, there is likely to be an increase in expenditure through use of non-appropriate services and a reduction in patient satisfaction and well-being. Multimorbidity requires patients to seek care from different clinicians and professionals, within and beyond primary care. However, little is known about how these patients interact with the complex health and social care systems, and particularly how this impacts on effective care navigation. This study aimed to scope the literature on how older people (aged 55 years and over) with multimorbidities effectively navigate the care system. Methods: A scoping review was conducted to address the research question: ‘What information is available in the literature regarding care system navigation in the setting of older people with multimorbidity?’. A detailed search strategy was developed, including the following inclusion criteria: literature published between 2003-2014 in English, Dutch, French or German, holding the key terms of navigat* AND multi*morbid*. Papers were initially selected based on title from five electronic databases together with a review of ten grey literature sources. The selection was further refined through abstract reading. The final selection of full text papers was analysed through the use of a data extraction tool. Results: In total 3,171 papers were found. After title and abstract reading, 367 papers were extracted. These were subject to more in-depth abstract and full text reading, which resulted in a final selection of 46 papers. These papers were reviewed in depth and analysed. Only 12 papers addressed the research question, suggesting that limited literature is available on the experience of older people with multimorbidities navigating the care system. Overall, the studies demonstrated that patients perceived they were expected to find their own way, learning from experience, rather than being able to rely on a particular service or system that could support them to navigate their different care needs. The scoping review further revealed the necessity of providing patients with practical, information and social support to help them navigate the system. Where care navigation programs were in place across primary and secondary care, demonstrable benefits were shown for patients with single diseases (e.g. cancer, chronic lung disease). In contrast, although promising results were seen for those patients with multimorbidities there was a lack of implementation. Conclusion: Older people with multiple morbidities face a daunting task navigating the care system. In order to maximise health and wellbeing, increase patient empowerment and satisfaction, and limit inappropriate costs due to inappropriate navigation better systems are needed to support people to navigate the care system. Although there is clarity as to the type and extent of support patients perceive they need, there is little evidence around the most effective method of delivering such support

Ethnicity and prehospital emergency care provided by ambulance services

Prehospital ambulance care is becoming more important as an increasingly complex health system seeks to prevent avoidable admissions to hospital. Inequalities in prehospital care for ethnic minority groups are underpinned by problems of cultural awareness in professionals; language and communication difficulties; and a limited understanding of how the healthcare system operates for some minority groups. These inequalities in the face of increasing diversity have elicited a range of legislative and policy responses promoting equality. Ambulance services can also employ a number of practical measures to improve prehospital care for minority ethnic patients, including the collection of patient ethnicity data; targeted interventions; improved cultural competency; and better interpreting services. Challenges in delivering these strategies still exist and providers should strive to embed and improve measures to meet the needs of diverse communities