Evaluating changes to emergency and urgent healthcare in England

The work presented here is for the degree of PhD by publication. I have selected seven papers for consideration, published in high quality academic journals between 2002 and 2011. I am the lead author on four papers and joint author on three. These papers derive from projects undertaken during my fifteen year research career at the School for Health and Related Research (ScHARR), University of Sheffield. Whilst the services I evaluated varied in scope, my research forms a coherent body of work informing the evidence base on policy driven initiatives implemented within emergency and urgent care. I have contributed to the evidence base around three key aspects of evaluation: acceptability (patient, carer, and workforce), effectiveness, and equity with respect to three of the most significant recent changes within emergency and urgent healthcare in England: telephone delivered healthcare, new roles within the workforce and, extended access and patient choice. Specifically, I have identified: • Telephone delivered healthcare did not significantly change demand for services: patient reported data suggested that NHS Direct was ineffective in reducing demand for other health services across the whole system of emergency and urgent care. • Inequity in the use of new telephone triage services: those from poorer socioeconomic groups or with communication difficulties were less likely to have used NHS Direct than other groups. • Problems with acceptability within a newly established workforce: although the majority of NHS Direct nurses were satisfied with this new way of working, a minority of staff found the work to be monotonous, posing a challenge to the retention of staff. • Clinical effectiveness of new roles within the workforce: a community based service utilising paramedics with extended skills demonstrated that paramedics can be trained to safely assess and treat older people with minor conditions which in turn led to a reduction in the need for attendance at an emergency department. • Patient and carer acceptability of new roles within the workforce: whilst minor acute health episodes do impact on patients and carers, initiatives such as utilising paramedics with extended skills in the community have a positive impact on the lives of these groups. Indeed, both groups reported high levels of satisfaction, and carers reported needing to provide less input with physical caring activities as a result of this new role being implemented. • Where patients choose to seek care and their satisfaction with this care during an emergency and urgent care episode: the majority of patients use multiple services on their care pathway, a daytime GP as their access point to emergency and urgent care, and are satisfied with their overall care during an episode. My work has demonstrated both the strengths and limitations of the policy related initiatives which I have evaluated. In particular my evidence regarding NHS Direct indicated some limitations regarding this telephone based service. Policymakers must take note of this given their plans for the national roll out of the non-emergency healthcare telephone service ‘NHS 111’, and if the telephone is considered as the medium for a single point of access to emergency and urgent care in the future. In contrast, the evidence that I have provided regarding paramedics with extended skills was overwhelmingly positive. Policymakers should support, and commissioners should explore, this model of service delivery when considering how to utilise emergency care practitioners within a locality. As policymakers continue to move forward with a vision for integrated emergency and urgent care healthcare attention must be directed towards the potential impact this has on users of the emergency and urgent care system

Visualizing Mississippi Histories: Two Short Films

Raisin\u27 Cotton / Emma Knowles Lytle (1941), introduction by Andy HarperHomeplace / Michael Ford (1975

A Meta-Analysis and Quality Review of Mathematics Interventions Conducted in Informal Learning Environments with Caregivers and Children

The purposes of this study included conducting a meta-analysis and reviewing the study reporting quality of math interventions implemented in informal learning environments (e.g., the home) by children’s caregivers. This meta-analysis included 25 preschool to third-grade math interventions with 83 effect sizes that yielded a statistically significant summary effect (g = 0.26, 95% CI [0.07, 0.45) on children’s math achievement. Significant moderators of the treatment effect included the intensity of caregiver training and type of outcome measure. There were larger average effects for interventions with caregiver training that included follow-up support and for outcomes that were comprehensive early numeracy measures. Studies met 58.0% of reporting quality indicators, and analyses revealed that quality of reporting has improved in recent years. The results of this study offer several recommendations for researchers and practitioners, particularly given the growing evidence base of math interventions conducted in informal learning environments

The BASES expert statement in safeguarding in the sport sciences.

Within the context of sport and exercise science, safeguarding concerns a professional obligation to protect all parties (for example the client, athlete and/or self) from maltreatment or harm (Mountjoy et al., 2016). Safeguarding should embrace relational (others), individual (self) and organisational (culture) considerations. The understanding of physical, emotional and social well-being and freedom from discrimination are the focus of safeguarding education. In this expert statement we provide information in three key areas: 1) a brief summary of the research themes and findings surrounding maltreatment in sport; 2) a discussion of safeguarding within the sport and exercise profession and finally; 3) recommendations for sport and exercise scientists on matters of safeguarding

Automated Ex Situ Assays of Amyloid Formation on a Microfluidic Platform.

Increasingly prevalent neurodegenerative diseases are associated with the formation of nanoscale amyloid aggregates from normally soluble peptides and proteins. A widely used strategy for following the aggregation process and defining its kinetics involves the use of extrinsic dyes that undergo a spectral shift when bound to β-sheet-rich aggregates. An attractive route to carry out such studies is to perform ex situ assays, where the dye molecules are not present in the reaction mixture, but instead are only introduced into aliquots taken from the reaction at regular time intervals to avoid the possibility that the dye molecules interfere with the aggregation process. However, such ex situ measurements are time-consuming to perform, require large sample volumes, and do not provide for real-time observation of aggregation phenomena. To overcome these limitations, here we have designed and fabricated microfluidic devices that offer continuous and automated real-time ex situ tracking of the protein aggregation process. This device allows us to improve the time resolution of ex situ aggregation assays relative to conventional assays by more than one order of magnitude. The availability of an automated system for tracking the progress of protein aggregation reactions without the presence of marker molecules in the reaction mixtures opens up the possibility of routine noninvasive study of protein aggregation phenomena.Financial support from the Frances and Augustus Newman Foundation, the BBSRC, the EPSRC, the ERC and the Swiss National Science Foundation is gratefully acknowledged.This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.bpj.2015.11.352

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Objective The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis. Methods We have conducted a rapid framework-based evidence synthesis approach. Five separate reviews were conducted linked to themes in the NHS England review. A general and five theme specific database searches were conducted for the years 1995-2014. Relevant systematic reviews and additional primary research papers were included with narrative assessment of evidence quality was conducted for each review. Results The review was completed in six months. In total 45 systematic reviews and 102 primary research studies have been included across all 5 reviews. The key findings for each reviews were 1) Demand - there is little empirical evidence to explain increases in demand for urgent care, 2) Telephone triage - Overall, these services provide , appropriate and safe decision making with high patient satisfaction but required clinical skill mix and effectiveness in a system is unclear , 3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital. 4)ED – The evidence on co-location of GP services with ED indicates there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed. 5) There is no empirical evidence to support the design and development of urgent care networks. Limitations Although there is a large body of evidence on relevant interventions much of it is weak with only very small numbers of randomised controlled trials identified. Evidence is dominated by single site studies many of which were uncontrolled. Conclusions The evidence gaps of most relevance to the delivery of services are 1) more detailed understanding and mapping of the characteristics of demand to inform service planning, 2) assessment of the current state of urgent care network development and evaluation of effectiveness of different models, and 3) Expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning