The proposal for a third medical school in New Zealand: A community-engaged graduate entry medical program

New Zealand has a maldistributed workforce that is heavily dependent on recruiting international medical graduates. Shortages are particularly apparent in high needs communities and in general scope specialties in provincial regions. The University of Waikato in partnership with the Waikato District Health Board has proposed a third medical school for New Zealand which will concentrate on addressing the workforce needs of disadvantaged rural and provincial communities. The proposed program is a community engaged, graduate entry medical course

Te Ira Tangata: A Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Maori who present to hospital after self harm

<p>Abstract</p> <p>Background</p> <p>Maori, the indigenous people of New Zealand, who present to hospital after intentionally harming themselves, do so at a higher rate than non-Maori. There have been no previous treatment trials in Maori who self harm and previous reviews of interventions in other populations have been inconclusive as existing trials have been under powered and done on unrepresentative populations. These reviews have however indicated that problem solving therapy and sending regular postcards after the self harm attempt may be an effective treatment. There is also a small literature on sense of belonging in self harm and the importance of culture. This protocol describes a pragmatic trial of a package of measures which include problem solving therapy, postcards, patient support, cultural assessment, improved access to primary care and a risk management strategy in Maori who present to hospital after self harm using a novel design.</p> <p>Methods</p> <p>We propose to use a double consent Zelen design where participants are randomised prior to giving consent to enrol a representative cohort of patients. The main outcome will be the number of Maori scoring below nine on the Beck Hopelessness Scale. Secondary outcomes will be hospital repetition at one year; self reported self harm; anxiety; depression; quality of life; social function; and hospital use at three months and one year.</p> <p>Discussion</p> <p>A strength of the study is that it is a pragmatic trial which aims to recruit Maori using a Maori clinical team and protocol. It does not exclude people if English is not their first language. A potential limitation is the analysis of the results which is complex and may underestimate any effect if a large number of people refuse their consent in the group randomised to problem solving therapy as they will effectively cross over to the treatment as usual group. This study is the first randomised control trial to explicitly use cultural assessment and management.</p> <p>Trial registration</p> <p>Australia and New Zealand Clinical Trials Register (ANZCTR): <a href="http://www.anzctr.org.au/ACTRN12609000952246.aspx">ACTRN12609000952246</a></p

From positive screen to engagement in treatment: A preliminary study of the impact of a new model of care for prisoners with serious mental illness

Background: The high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources. Method: The PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care. Results: The number of prisoners in the study in the year before the PMOC (n = 19,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = −7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment. Conclusions: The PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison

Imprisonment following discharge from mental health units: A developing trend in New Zealand

IntroductionContemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years.MethodsA quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health.ResultsRisk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission.DiscussionWe concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND: Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein. OBJECTIVES: To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials. SEARCH METHODS: We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019. SELECTION CRITERIA: Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment. MAIN RESULTS: We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes. AUTHORS' CONCLUSIONS: The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events

A Review of the Psychiatric Care Provided to Patients who Subsequently Offended

Background: An examination (audit) of the files of patients who had received any mental health services in the year prior to an alleged offence may inform our understanding of the relationship between mental health and crime. More helpfully, it may provide information to facilitate a reduction in the rate of such tragic eventsMethod: The records of all patients assessed by the Midland Regional Forensic Psychiatric service in the 26 months from January 2010 were screened. The 222 who received a diagnosis of a non-organic psychosis and who were recorded as having offended within one year of a previous psychiatric service attendance formed the cohort. The data extracted from their clinical files, relating primarily to that pre-offence psychiatric contact, included legal, clinical and contextual information.Results: Analysis examined the characteristics of this forensic population and most particularly, of their pre-offending service contact. This identified clinical practice and delivery issues which could reduce the rate of conversion of psychiatric patients to “forensic†status.Conclusions: The results inform issues of effectiveness of adult service delivery with particular consideration of the intensity of clinical contact, antipsychotic drug choice and adherence and the use of assertive treatment

A review of the psychiatric care provided to service users who subsequently offended

Background:&nbsp;An examination (audit) of the files of patients who had received any mental health services in the year prior to an alleged offence may inform our understanding of the relationship between mental health and crime. More helpfully, it may provide information to facilitate a reduction in the rate of such tragic events Method:&nbsp;The records of all patients assessed by the Midland Regional Forensic Psychiatric service in the 26 months from January 2010 were screened. The 222 who received a diagnosis of a non-organic psychosis and who were recorded as having offended within one year of a previous psychiatric service attendance formed the cohort. The data extracted from their clinical files, relating primarily to that pre-offence psychiatric contact, included legal, clinical and contextual information. Results:&nbsp;Analysis examined the characteristics of this forensic population and most particularly, of their pre-offending service contact. This identified clinical practice and delivery issues which could reduce the rate of conversion of psychiatric patients to “forensic” status. Conclusions: The results inform issues of effectiveness of adult service delivery with particular consideration of the intensity of clinical contact, antipsychotic drug choice and adherence and the use of assertive treatment

From positive screen to engagement in treatment: a preliminary study of the impact of a new model of care for prisoners with serious mental illness

Abstract Background The high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources. Method The PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care. Results The number of prisoners in the study in the year before the PMOC (n = 19,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = −7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment. Conclusions The PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison

Flood Resilience Community Pathfinder evaluation: final evaluation report

The Flood Resilience Community Pathfinder scheme was intended to enable and stimulate communities at significant or greater risk1 of flooding to work with key partners to develop innovative local solutions that: - Enhance flood risk management and awareness in ways which quantifiably improve the community’s overall resilience to flooding. - Demonstrably improve the community’s financial resilience in relation to flooding. - Deliver sustained improvements which have the potential to be applied in other areas. Defra launched the scheme in December 2012, with the announcement that up to £5 million was being made available to fund up to 20 innovative projects between 2013 and 2015. It was open to all local authorities in England. There were 45 applications with projects2 submitted by 13 local authorities from across England receiving funding. The scheme was evaluated by Collingwood Environmental Planning (CEP) and a consortium of expert project partners. Evaluating policy interventions such as the Flood Resilience Community Pathfinder scheme generates valuable information and helps understand which actions work and are effective. The purpose of the evaluation was to report on the progress made by the individual pathfinder projects, on the results and impacts of the scheme as a whole and to provide evidence to ensure that lessons can be learnt from the pathfinder scheme. A mixed methods approach using qualitative and quantitative social research techniques was used to collect, synthesise and analyse evidence for the evaluation at the baseline, interim (Year 1) and end of project (Year 2) stages. The evaluation drew on and incorporated a number of data sources (collected at the community and household levels) to provide information about the impacts and outcomes generated by the pathfinder projects as well as on implementation and process. The pathfinder project teams were asked to collect some of the data for the evaluation themselves, including: information for the baseline community indicators and changes at the end of the project; and household level information collected via household surveys at baseline and the end of the project. Triangulation of survey data with qualitative data sources has helped to address the problem of the variability of some of the data collected locally. Discussions of what the pathfinders did and their outcomes in the five different areas of community resilience are based on robust qualitative evidence and analysis which gives confidence in the evaluation