NIHR Central Commissioning Facility

BackgroundPeople living with severe mental illness (SMI) face significant health inequalities, including in palliative care. Advance Care Planning (ACP) is widely recommended by palliative care experts and could reduce inequalities. However, implementing ACP with this group is challenging. Electronic Palliative Care Coordination Systems such as Coordinate my Care (CMC) have been introduced to support documentation and sharing of ACP records with relevant healthcare providers. This study explores the use of CMC amongst those with SMI and aims to describe how those with a primary diagnosis of SMI who have used CMC for ACP, and makes recommendations for future research and policy.MethodA retrospective observational cohort analysis was completed of CMC records created 01/01/2010–31/09/2021 where the service user had a primary diagnosis of SMI, with no exclusions based on comorbidities. Descriptive statistics were used to report on characteristics including: age, diagnosis, individual prognosis and resuscitation status. Thematic analysis was used to report on the content of patients’ statements of preference.Results1826 records were identified. Of this sample most (60.1%) had capacity to make treatment decisions, 47.8% were aged under 70, 86.7% were given a prognosis of ‘years’ and most (63.1%) remained for full cardio-pulmonary resuscitation in the event of cardio-pulmonary arrest. Records with completed statements of preferences (20.3%) contained information about preferences for physical and mental health treatment care as well as information about patient presentation and capacity, although most were brief and lacked expression of patient voice.DiscussionCompared to usual CMC users, the cohort of interest are relatively able, younger people using CMC to make long-term plans for active physical and mental health treatment. ADM is a service user-driven process, and so it was expected that authentic patient voice would be expressed within statements of preference, however this was mostly not achieved.ConclusionsThis digital tool is being used by people with SMI but to plan for more than palliative care. This cohort and supporting professionals have used CMC to plan for longer term physical and mental healthcare. Future research and policy should focus on development of tailored digital tools for people with SMI to plan for palliative, physical and mental healthcare and support expression of patient voice.

Unprecedented extra demands on healthcare staff during the covid-19 pandemic have made it more difficult than ever for professionals to keep up to date with research. This time of major upheaval has underlined the need for health and social care to be the best and most efficient possible. To ensure that changes represent progress, they need to be based on sound research. With this in mind, The BMJ is restarting its partnership with the National Institute for Health Research (NIHR). The NIHR is one of the UK’s largest funders of health and care research. It is funded …

The studyFord J, Thomas F, Byng R, McCabe R. Asking about self-harm and suicide in primary care: moral and practical dimensions. Patient Educ Couns 2020;104:4.To read the full NIHR Alert go to: https://evidence.nihr.ac.uk/alert/open-questions-improve-gp-conversations-self-harm/

BackgroundPublic involvement in research is an established part of the research process in the UK, however there remain questions about what good public involvement in research looks and feels like. Until now public involvement practitioners, researchers and members of the public have looked for answers in examples shared across networks, published case studies, guidance and research articles. Pulling these strands together, the UK Standards for Public Involvement provides six statements (standards) about public involvement in research. They were produced by a partnership of organisations from Scotland, Northern Ireland, Wales and England with contributions from involvement practitioners, public partners, researchers and research funders.Main bodyEach standard has reflective questions, which are designed to encourage standard users to use approaches and behaviours that improve involvement, over time. The standards are designed to be used as a practical tool, and reflect the agreed hallmarks of good public involvement in research for example, flexibility in approaches used, shared learning, and mutual respect.The standards development process is described from the initial idea and scoping, via the appraisal of existing standard sets and integration of values and principles in public involvement in research. The collaborative writing process of and consultation on the draft standard set is described, together with what changed as a result of feedback. The initiation of a year-long testing programme with forty participating research organisations, the experiential feedback and the resulting changes to the standards is summarised.ConclusionThis commentary paper describes, in some detail, a process to develop a set of six standards for public involvement in research in the UK. Producing a complex, national public involvement initiative is not without its challenges, and in supplementary material partnership members reflect on and share their experiences of standards development. The next phase of integration and implementation is explored with concluding comments from those that tested and helped improve the standards.

Variations in emergency care quality for alcohol-related liver disease (ARLD) have been highlighted. To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality. Retrospective observational cohort study using hospital administrative data spanning a 1-year period before (2014/2015) and 3years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index ("first") emergency admissions for ARLD (n=3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk-adjusted odds of death. In 2014/2015, three of seven hospitals had an SMR above the upper control limit ("outliers"). Adjusted odds of death for patients admitted to outlier hospitals was higher than non-outliers (OR 2.13, 95% CI 1.32-3.44, P=0.002). Following the QI programme there was a step-wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non-outliers at baseline, but improved after intervention. There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co-ordinated efforts to drive adoption of evidence-based practice can save lives.

BackgroundNational guidelines for sexually transmitted infections (STIs) in primary care exists but their management is uncertain.AimTo assess the management of STIs against national standards in primary care.Design & settingA questionnaire based study in London and Brighton. The survey was conducted in 2015 following reorganisation of sexual health services in England.MethodQuestionnaires were sent to GPs in London and Brighton about testing for STIs, treatment for gonorrhoea, specialist advice, and referral services.ResultsOf 119 GPs who responded, most expressed confidence in treating chlamydia (n = 105/119, 88%), trichomonas (n = 81/119, 68%), and herpes (n = 82/119, 69%) but not gonorrhoea (n = 32/119, 27%). Most referred cases of syphilis (n = 92/119, 77%) and genital warts (83/119, 70%) to genito-urinary medicine (GUM) as per guidance. Most GPs tested for gonorrhoea on patient request (n = 95/119, 80%), in tandem with chlamydia screening (n = 89/119, 75%), because of high risk status (n = 85/119, 71%) and genital symptoms (n = 108/119, 91%). Some GPs (n = 22/119, 18%) sampled urine for culture, 53/119 (45%) provided high vaginal swabs (HVS), and 28/119 (24%) provided self-taken vulvovaginal swabs (STVVS) for culture. These samples are not appropriate for gonococcal culture and not processed in the laboratory. Urethral swabs for men and endocervical swabs (ECS) are recommended for gonococcus culture. Over half (n = 60/102, 59%) of GPs did not treat gonorrhoea but some prescribed cefixime, ciprofloxacin, or azithromycin. Eighty-seven per cent (n = 104/119) sought advice from GUM, and 83/103 (81%) referred gonorrhoea nucleic acid amplification test (NAAT)-positive patients.ConclusionThere is scope for improvement of STIs management in primary care to ensure that patients are optimally investigated, treated, and referred.

A case study was conducted in 2016 to evaluate the effectiveness of an innovation to enable people with "complex" care requirements to be discharged from hospital to an appropriate service for their care, without using the NHS England Continuing Health Care (CHC) assessment. The setting was a rural district general hospital in England, where the quality outcomes and cost-effectiveness of the CHC assessment being conducted in hospital were giving cause for concern. The NHS CHC Framework advocates conducting these assessments in the community where a more accurate indication of long-term care can be determined. The "5Q Care Test" was collaboratively developed with health and social care partners, care providers, and CHC interest groups, including users of the services. It was implemented as a tool to support moving the CHC assessment into the community, as it enabled practitioners to swiftly determine patients' appropriate initial care pathway out of hospital. A full economic impact analysis was conducted 7months after the tool was introduced. The results showed significant improvement in the quality and cost-effectiveness of the "5Q Care Test," with a reduction in the hospital length of stay, which is known to be associated with improved outcomes for patients and financial savings.