Bridgewater Community Healthcare NHS Foundation Trust

ObjectiveTo explore the challenges experienced by people with intellectual disability, their carers and health and social care professionals when using and managing medication.DesignA synthesis of qualitative research using meta-ethnography.Data sourceWe searched seven databases: MEDLINE, Embase, CINAHL, Science, Social Science and Conference Proceedings Citation Indices (Web of Science), Cochrane Library, PsycINFO and Proquest Dissertations and Theses from inception to September 2022 (updated in July 2023).Eligibility criteria for selecting studiesWe included studies exploring the challenges and perceptions of people with intellectual disability, their carers and health and social care professionals regarding medication management and use.ResultsWe reviewed 7593 abstracts and 475 full texts, resulting in 45 included papers. Four major themes were identified: (1) Medication-related issues, (2) navigating autonomy and relationships, (3) knowledge and training needs and (4) inequalities in the healthcare system. We formulated a conceptual framework centred around people with intellectual disability and described the interconnectedness between them, their carers and health and social care professionals in the process of managing and using medication. We identified challenges that could be associated with the person, the medication and/or the context, along with a lack of understanding of these challenges and a lack of capability or resources to tackle them. We developed an overarching concept of ‘collective collaboration’ as a potential solution to prevent or mitigate problems related to medication use in people with intellectual disability.ConclusionsThe effective management of medication for people with intellectual disability requires a collaborative and holistic approach. By fostering person-centred care and shared decision-making, providing educational and practical support, and nurturing strong relationships between all partners involved to form a collective collaboration surrounding people with intellectual disability, improved medication adherence and optimised therapeutic outcomes can be achieved.PROSPERO registration numberCRD42022362903.

IntroductionNational (OHID) data indicates that healthy life expectancy across Warrington significantly lags behind overall life expectancy. A recent survey by Warrington Borough Council found a decrease in the number of adults reporting good health, with a marked decline among more deprived populations. Warrington has a higher median age than England, and projections indicate a 50% increase in the over-65 population within two decades. To mitigate escalating demand and to arrest health crises before they emerge, early proactive engagement is required. Oakwood, a community in east Warrington, ranks in the top 20% of the most deprived regions in the UK.Aims and objectives of the research project or activityOakwood contends with profound healthcare deficits, largely attributable to adverse social determinants of health. Challenges include underutilisation of healthcare resources, educational deficits, unemployment, housing issues, and insufficient social support, culminating in a broad spectrum of unmet healthcare needs. As underscored by the Marmot report, these inequalities are avoidable and unfair and require innovative approaches to tackle them.To better serve the Oakwood area, Bridgewater Community Healthcare Foundation Trust initiated a pioneering Community Health and Wellbeing Worker (CHWW) service. This initiative, developed in collaboration with local providers and the National Association of Primary Care (NAPC), employs proactive, universal and ongoing community outreach, to help residents access the support they need. Improvements in these areas are often difficult to measure, so the project aimed to put specific process and wellbeing measures around the project.Method or approachThe Trust drew together in-house expertise and community partners to establish a service following the CHWW model, an example of evidence-based practice adopted from the Brazilian primary care Family Health Strategy and championed by the NPAC. In the model, each CHWW works in a patch of around 150 households, providing monthly visits on an ongoing basis. This enables CHWWs to proactively identify need and help residents access help before issues escalate. Their role is based on trust and local knowledge, with the CHWWs recruited locally to maximise cultural competency. It is a universal and holistic service, open to all ages, that seeks to develop a culture of preventive health and wellbeing and community enablement. As a novel approach, the service challenged established practice and demanded innovative thinking. The project’s leadership has been instrumental in navigating systemic barriers to establishing the service and seeking to reduce health disparities.FindingsIn one year of service (up to December 2022), five CHWWs have proactively engaged with Oakwood’s households to understand residents’ health and social care needs and help them to access support in the community. Of 642 households offered the service, 37% have taken up the offer. The CHWWs have had 688 unique community engagements, identifying 125 previously unmet healthcare and making 161 referrals to community services. Combining public and population health approaches, the CHWWs have promoted vaccination, screening, health checks, and wellbeing services; they have identified, escalated and helped to resolve multiple situations involving isolation, inadequate housing and safeguarding issues.Measuring impact:An evidence-based wellbeing metric, used across CHWW services, assesses an individual’s skill and confidence in managing their health and wellbeing. The service has seen a cumulative 21-point increase in the wellbeing scores among the engaged cohort. Each incremental point on the wellbeing scale corresponds to an annual healthcare cost saving of £540 across primary and secondary care.Key messagesThe CHWW service demonstrates a way of addressing social determinants, demonstrating that local, community-driven interventions can significantly influence overall healthcare outcomes. It demonstrates a scalable strategy to proactively mitigating health disparities and promoting equitable healthcare access. It serves as a standard for how a collaborative, leadership-driven approach can yield substantive improvements in healthcare access and outcomes.Financial sustainability is an ongoing priority, addressed by organisational leaders to develop partnerships aligned with community needs. Initial efforts have established a framework for engagement, with the aim of continuing collaborations for future funding stability.Communicating the service’s objectives to some of our local partners posed challenges. Nonetheless, Bridgewater’s medical leadership has been essential in maintaining and advancing these collaborations.

Sleep disorders are very common among children and young people (CYP) with neurodevelopmental, emotional, behavioural and intellectual disorders (NDEBID). NDEBID include several conditions such as Attention Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral palsy (CP), Epilepsy and Learning (Intellectual) disorders. Extant literature have reported up to 80% of CYP with NDEBID experiencing different types of chronic insomnia, compared to 3–36% of their otherwise normally developing counterparts. Sleep disorders among CYP with NDEBID have severe negative consequences on the affected individuals and their families. Chronic sleep deprivation causes behavioural, memory and attention problems, mood disorders, impaired cognitive development, learning abilities, and school performances. It also significantly increases the stress level and impact the wellbeing of other family members and impair family cohesion. Sleep disorders therefore further aggravate both internalising and externalising behaviours, emotional wellbeing and daily functioning of CYP with NDEBID. This chapter provides a brief summary of the various important aspects of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various behavioural, non-pharmacological management strategies and pharmacotherapy. Practical tips for clinicians are outlined in an easy-to read flow chart, including sections on assessment, investigations, care plan formulation and follow-up.

BackgroundThe UK Department of Health has produced guidance on the statutory health assessment required for identifying and managing their health needs. It is well known that Children and young people (CYP) under public care are at increased risk of both mental and physical health needs compared to those living within their birth families. There are many factors known to influence the high vulnerabilities of looked after CYP to high levels of morbidities. There is a high rate of previous experience of adverse traumatic events including neglect and abuse, family deprivation, poverty, disharmony and disruption, parental vulnerability to drugs, alcohol abuse and mental health disorder, as well as genetic predisposition and subsequent instability experienced while in public care.ObjectivesWe aimed to identify and itemise the range of adverse or traumatic childhood experiences among the LACYP, with the intention of informing better targeted preventive measures from all stakeholders involved in their care.MethodsThe healthcare records of all the CYP who were referred for the statutory Initial health assessment (IHA) between Apr 2019 and Mar2020, under the care of the Halton Local Authority were reviewed retrospectively. The audit was carried out as part of the Clinical Governance strategy and no ethical approval was required.ResultsData was available for a total of 82 LAC aged between 6 months and 19 years (averaged 8 yrs), with 51 Males/31 Females. One patient failed to attend the clinic. All the LAC had at least one or more identifiable adverse risk factors. A total of 21 socio-emotional risk factors recorded, classified into categories:Parental (94%) such as abuse in childhood, alcohol and substance abuse, mental health problems, and Learning Difficulties;Family-related insults (80%) such as parental neglect and exposure to domestic violence;Prenatal insults (62%) such as intra-uterine exposure to stress, tobacco, drugs and alcohol;Child-related factors (40%) such as physical, emotional or sex abuse, incomplete immunization and poor school attendance.Each LACYP was exposed to an average of 5 risk factors including parental (2.5), family (1), child-related (1) and Intrauterine (0.5).ConclusionsThis audit confirms that CYP in public care have significantly higher risks of exposure to adverse traumatic experiences compared with the normal childhood population. Socio-economic deprivation and attachment difficulties in LACYP are known to significantly contribute to their development including impaired speech, language and communication (SLC) skills, which often remain largely undetected in 60% to 80% of cases.It emphasises the need for comprehensive assessment and provision of early integrated care for LAC of all ages, working across a wide range of setting and involving multi-agency collaborations between the schools, social care, healthcare and the voluntary sectors.It is recommended that every LACYP should be offered comprehensive multidisciplinary assessments to help identify the impact of biological, psychological and social factors on their individuality.

Management of laryngopharyngeal reflux (LPR) typically comprises alginates and proton pump inhibitors (PPIs) alone or in combination, yet evidence to support any particular treatment regimen is lacking. We sought to evaluate the efficacy of Gaviscon® Advance alone versus co-prescription with a PPI in treating LPR. One hundred consecutive LPR patients with a reflux symptom index (RSI) score > 10 attending our joint voice clinic (JVC) were studied prospectively. All were treated with Gaviscon® Advance four times daily. If patients had been started on a PPI prior to their JVC attendance, this was optimised to a twice-daily dosing regimen and continued. RSI scores were recorded at first attendance and 3months post-treatment via postal questionnaire. Scores were analysed using t tests and Levene's test for equality of variances. Follow-up RSI scores were returned by 72 patients, 39 of whom were treated with Gaviscon® Advance only (group A) and 33 with Gaviscon® Advance + PPI (group B). Mean pre-treatment RSI scores were similar between groups [group A: 19.2, 95% confidence interval (CI) ± 2.4; group B: 21.3, 95% CI ± 3.2 (p = 0.65)]. No significant differences were observed with respect to 3-month post-treatment RSI scores [group A: 9.9, 95% CI ± 2.8; group B: 12.6, 95% CI ± 4.2 (p = 0.82)] and change in RSI scores [group A: 9.3, 95% CI ± 3.0; group B: 8.7, 95% CI ± 2.9 [p = 0.75]). Gaviscon® Advance alone is effective in treating symptoms of LPR, while co-prescription with a high-dose PPI offers no additional benefit.

To provide national consensus on the range of conditions community practitioner nurse prescribers manage and for which it is considered important that they can prescribe. Around 35,000 community practitioner nurse prescribers in the United Kingdom are able to prescribe from a limited formulary. Although prescribing is a key role for these nurses, there has been a decline in the numbers of community practitioner nurse prescribers who prescribe. It is evident that changing patterns of client and service delivery, changes the role of community nurses and the conditions they manage, however, little is known about the conditions community practitioner nurse prescribers manage. A modified Delphi approach comprising three on-line surveys delivered to a national Expert Panelof 89 qualified community practitioner prescribers. Data collection took place between January-March 2017. Panelists reached a consensus, with consistent high levels of agreement reached, on nineteen conditions for which it is believed community practitioner nurse prescribers should be able to prescribe. Conditions identified by school nurses (N=12) and health visitors (N=7) were mainly acutely focused, whereas those identified by district nurses (N=9) and community staff nurses (N=6) included both long-term and acute conditions. Given the high degree of consensus, this list of conditions should influence any decisions about the items community and public health nurses should be able to prescribe. The findings should also influence the education and training of these nurses.

BackgroundSocio-economic factors are known to influence the prevalence of chronic childhood disabling conditions including emotional and behavioural disorders. Referrals of school-age children for assessment of difficult or challenging behaviour constitute a major case load of neurodevelopmental paediatricians (designated as community paediatricians in the UK).AimsWe aimed to evaluate the characteristics of school-age children screened for ADHD following referral for behaviour problems to the local community paediatric unit of a large healthcare NHS Foundation Trust in the North West of England over an 18-month period. We compared the characteristics of children diagnosed with ADHD with those not diagnosed following standard comprehensive assessments.ResultsA total of 61 children were assessed for possible ADHD using the Swanson, Nolan, and Pelham –IV Questionnaire (SNAP-IV) (26-item freely available resource online at myadhd.com) between April 2014 and Sept 2015. The characteristics of children fulfilling the clinical criteria for a diagnosis of ADHD was compared with those who were not diagnosed. Using the residential postcodes,the socio-economic status of each child was determined using the Index of Multiple Deprivation (IMD) 2010 scores and ranking order out of all the 34378 LSOAs in England. The ranked LSOAs were analysed as groups of 5 (Quintiles), groups of ten (Deciles). Spearman’s rank correlation coefficient was used to determine the relationship between the prevalence of ADHD in different socioeconomic groups. Table 1 displays the main characteristics of the two groups (ADHD and non-ADHD) compared with the whole group of children. G607(P) Table 1Displays the main characteristics of the two groups (ADHD and non-ADHD) compared with the whole group of childrenConclusionThere was no statistically significant difference between the distribution of the socio-economic deprivation of both groups. The highest prevalence for the ADHD and non-ADHD children was highest in the most deprived areas.These findings have important clinical implications for identifying individuals at highest risk of developing ADHD and other challenging behaviours, and in planning effective management strategies.

There are several types of childhood behavioral disorders. The most common disruptive behavior disorders include ODD, CD and ADHD. Socio-economic factors are known to influence the prevalence of chronic childhood disabling conditions including emotional and behavioral disorders. Assessment of school-age children for difficult or challenging behavior constitutes a major case load of neurodevelopmental pediatricians (mainly designated as community pediatricians) and child/adolescent psychiatrists in the UK. We aimed to evaluate the influence of the socio-economic status among school-age children on the distribution and types of behavioral disorders, including ADHD, in a local district Community Pediatric unit of a large healthcare NHS Foundation Trust in the North West of England. The record of all the patients who were seen in any outpatient clinic over a 22-month period between Jan 2014 and Oct 2015 were retrospectively analyzed. Information was collected on the range of clinical presentation and socioeconomic characteristics. The socio-economic status of each child was determined using the latest published Index of Multiple Deprivation (IMD) 2015. A total of 201 school-age children were referred (9 monthly), corresponding to an average of 31% of total monthly caseload. The proportion of patients living in the most deprived deciles and quintiles was 39% and 70% respectively. The prevalence in the most deprived decile (11.6/1000) was 193 times that of the most affluent area. History of family and social adversities was common among the patients including separated parents (24%), fostered / adopted (11%) and previous exposure to abuse, domestic violence or neglect (9%). Socioeconomic deprivation is significantly associated with the prevalence of behavior problems in children living in the North-West of England. Poverty-related chronic stressors are hypothesized to cumulatively compromise parental psychology and ultimately childhood behavioral and mental health outcomes. Tackling the problem requires integrated multidisciplinary and multi-agency approach.