Service Evaluation of the Encompass Community Hub Operating Centres (CHOCS), Report: June 2018

This report details the findings of a service evaluation of the Vanguard Encompass MCP (MultiSpecialty Community Provider) in East Kent. Encompass was awarded Vanguard status in 2015, through the first wave of Vanguards prompted by NHS England’s ‘Five Year Forward View’ strategy. The evaluation was conducted from March 2017 to April 2018 by the Centre for Health Service Studies in partnership with Encompass, who provided and analysed the metric data. The operational model developed and implemented by Encompass is Community Hub Operating Centres (CHOCs). CHOCs are holistic community based models of integrated service delivery aiming to improve user experience of co-ordinated care and self-management at home; contribute to a reduction in A&E demand and onward admission in the short term; and reduce pressure on acute services and long term care home placements in the longer term. Five CHOCs were initiated after an initial pilot period in 2016, which consist of clusters of GP practices serving a total practice population of 180,784 patients. The evaluation focused on the CHOCs, and the evaluation questions were informed by the NHSE local evaluation document (NHS 2015): ? What impact are the CHOCs having on user outcomes and experience? ? What are the components of the care model delivery (or ‘active/successful ingredients’) that are really making a difference? ? What are the influencing contextual factors and how have they affected implementation and outcomes? ? What changes to the use of resources and activity in the local health system have taken place and to what costs? ? What could be improved, replicated and sustained

Understanding Public Priorities and Perceptions of the Use of Linked Healthcare Data in South East England

The counties of Kent, Surrey and Sussex (KSS) in South East England are creating anonymized, linked databases of healthcare records for audit, service planning and research for the first time. We consulted with 79 citizens from KSS in 5 deliberative focus groups, asking about perceived benefits and concerns regarding these new data assets. Participants hoped the linked datasets could be used for joining up care and information, improving efficiency, and improving healthcare provision, but were concerned about missing and inaccurate data, data breaches and hacking, use of data by profit-making organisations, and stigma and discrimination. Findings will be used to underpin governance and engagement strategies for integrated datasets in KSS

Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study

Background: Growing prevalence of atrial fibrillation (AF) in the ageing population, and its associated life-changing health and resource implications, have led to a need to improve its early detection. Primary care is an ideal place to screen for AF, however this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care, makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice-based clinical pharmacists to screen the over 65s for AF, using digital technology and pulse palpation during the influenza vaccination season. Methods and Findings: Screening was conducted over two influenza vaccination seasons, 2017-2018 and 2018-2019 in four GP practices in Kent, UK. Pharmacists were trained by a cardiologist to pulse palpate, record and interpret a single-lead ECG (SLECG). Eligible persons aged ≥65 years, attending an influenza vaccination clinic were offered a free heart rhythm check. 604 participants were screened (median age 73 years, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); older; have an increased BMI and have a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, previous Stroke, Age 65-74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% [95% CI: 56.4-91.0] and 92.2% [89.7-94.3], respectively. This rose to 88.5% (69.9-97.6) and 97.2% [95.5-98.4] with a SLECG. At follow-up, four participants (0.7%) were diagnosed with new AF and 3 (0.5%) were initiated on anticoagulation. Screening with SLECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SLECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort. Conclusions: This study demonstrates that AF screening performed by GP practice-based pharmacists was feasible, economically viable and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using a SLECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing the adoption of national screening programmes

Delivering clinical studies of exercise in the COVID-19 pandemic: challenges and adaptations using a feasibility trial of isometric exercise to treat hypertension as an exemplar.

The COVID-19 pandemic has significantly impacted on the delivery of clinical trials in the UK, posing complicated organisational challenges and requiring adaptations, especially to exercise intervention studies based in the community. We aim to identify the challenges of public involvement, recruitment, consent, follow-up, intervention and the healthcare professional delivery aspects of a feasibility study of exercise in hypertensive primary care patients during the COVID-19 pandemic. While these challenges elicited many reactive changes which were specific to, and only relevant in the context of 'lockdown' requirements, some of the protocol developments that came about during this unprecedented period have great potential to inform more permanent practices for carrying out this type of research. To this end, we detail the necessary adaptations to many elements of the feasibility study and critically reflect on our approach to redesigning and amending this ongoing project in order to maintain its viability to date. Some of the more major protocol adaptations, such as moving the study to remote means wherever possible, had further unforeseen and undesirable outcomes (eg, additional appointments) with regards to extra resources required to deliver the study. However, other changes improved the efficiency of the study, such as the remote informed consent and the direct advertising with prescreening survey. The adaptations to the study have clear links to the UK Plan for the future of research delivery. It is intended that this specific documentation and critical evaluation will help those planning or delivering similar studies to do so in a more resource efficient and effective way. In conclusion, it is essential to reflect and respond with protocol changes in the current climate in order to deliver clinical research successfully, as in the case of this particular study. [Abstract copyright: © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.

Feasibility study to assess the delivery of a novel isometric exercise intervention for people with stage 1 hypertension in the NHS: protocol for the IsoFIT-BP study including amendments to mitigate the risk of COVID-19.

BackgroundHypertension  (HTN) affects approximately 25% of the UK population and is a leading cause of mortality. Associated annual health care costs run into billions. National treatment guidance includes initial lifestyle advice, followed by anti-hypertensive medication if blood pressure (BP) remains high. However, adoption and adherence to recommended exercise guidelines, dietary advice and anti-hypertensive medication is poor. Four short bouts of isometric exercise (IE) performed 3 days per week (d/wk) at home elicits clinically significant reductions in BP in those with normal to high-normal BP. This study will determine the feasibility of delivering personalised IE to patients with stage 1 hypertension for whom lifestyle changes would be recommended before medication within NHS primary care.MethodsThis is a randomised controlled feasibility study. Participants were 18+ years, with stage 1 hypertension, not on anti-hypertensive medication and without significant medical contraindications. Trial arms will be standard lifestyle advice (control) or isometric wall squat exercise and standard lifestyle advice. Primary outcomes include the feasibility of healthcare professionals to deliver isometric exercise prescriptions in a primary care NHS setting and estimation of the variance of change in systolic BP. Secondary outcomes include accuracy of protocol delivery, execution of and adherence to protocol, recruitment rate, attrition, perception of intervention viability, cost, participant experience and accuracy of home BP. The study will last 18 months. Sample size of 100 participants (50 per arm) allows for 20% attrition and 6.5% incomplete data, based upon 74 (37 each arm) participants (two-sided 95% confidence interval, width of 1.33 and standard deviation of 4) completing 4 weeks. Ethical approval IRAS ID is 274676.DiscussionBefore the efficacy of this novel intervention to treat stage 1 hypertension can be investigated in any large randomised controlled trial, it is necessary to ascertain if it can be delivered and carried out in a NHS primary care setting. Findings could support IE viability as a prophylactic/alternative treatment option.Trial registrationISRCTN13472393 , registered 18 August 2020

Pharmacists detecting atrial fibrillation (PDAF) in primary care during the influenza vaccination season: a multi-site, cross sectional feasibility pilot study

Reducing AF-related stroke risk is both clinically and economically important, with AF-related illness costing the NHS over £2 billion per annum. Despite this, there is no national screening programme for AF. Growing medical consensus backed by public health policy, agrees that there is an unmet need to improve diagnosis and that primary care is an appropriate setting. This model is likely to be convenient for patients and cost effective, but with the current shortage of GPs and nurses, and increasing GP workloads, it is unlikely to succeed. Huge investment by NHS England to introduce new work role models to GP practices, could mean, by 2021, that over 34 million patients will have access to the expertise of a clinical pharmacist, making clinical pharmacists a viable option for such screening initiatives. AIM: To determine whether clinical pharmacists based within GP practices, were able to accurately and effectively screen and diagnose patients for AF, using pulse palpation and a single-lead ECG device (AliveCor Kardia Mobile®) during the influenza vaccination season

Family carer experiences of hospice care at home: qualitative findings from a mixed methods realist evaluation

This document is the Accepted Manuscript version of a published work that appeared in final form in [Palliative Medicine]. To access the final edited and published work see https://doi.org/10.1177/02692163231206027Background: Hospice-at-home aims to enable patients approaching end-of-life to die at home and support their carers. A wide range of different service models exists but synthesised evidence on how best to support family carers to provide sustainable end-of -life care at home is limited. Aim: To explore what works best to promote family carers’ experiences of hospice-at-home. Design: Realist evaluation with mixed methods. This paper focuses on qualitative interviews with carers (to gain their perspective and as proxy for patients) and service providers from twelve case study sites in England. Interviews were coded and programme theories were refined by the research team including two public members. Setting/participants: Interviews with carers (involved daily) of patients admitted to hospice-at-home services (n=58) and hospice-at-home staff (n=78). Results: Post bereavement, 76.4% of carers thought that they had received as much help and support as they needed and most carers (75.8%) rated the help and support as excellent or outstanding. Of six final programme theories capturing key factors relevant to providing optimum services, those directly relevant to carer experiences were: integration and co-ordination of services; knowledge, skills and ethos of hospice staff; volunteer roles; support directed at the patient–carer dyad. Conclusions: Carers in hospice-at-home services identified care to be of a higher quality than generic community services. Hospice staff were perceived as having ‘time to care’, communicated well and were comfortable with dying and death. Hands-on care was particularly valued in the period close to death