How do Healthcare Workers 'Do' Guidelines? Exploring How Policy Decisions Impacted UK Healthcare Workers During the First Phase of the COVID-19 Pandemic

We describe how COVID-19-related policy decisions and guidelines impacted healthcare workers (HCWs) during the UK's first COVID-19 pandemic phase. Guidelines in healthcare aim to streamline processes, improve quality and manage risk. However, we argue that during this time the guidelines we studied often fell short of these goals in practice. We analysed 74 remote interviews with 14 UK HCWs over 6 months (February-August 2020). Reframing guidelines through Mol's lens of 'enactment', we reveal embodied, relational and material impacts that some guidelines had for HCWs. Beyond guideline 'adherence', we show that enacting guidelines is an ongoing, complex process of negotiating and balancing multilevel tensions. Overall, guidelines: (1) were inconsistently communicated; (2) did not sufficiently accommodate contextual considerations; and (3) were at times in tension with HCWs' values. Healthcare policymakers should produce more agile, acceptable guidelines that frontline HCWs can enact in ways which make sense and are effective in their contexts.

Experiences and concerns of health workers throughout the first year of the COVID-19 pandemic in the UK: A longitudinal qualitative interview study

OBJECTIVE

To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK.

METHODS

Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis.

RESULTS

We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion.

CONCLUSIONS

Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.

Evaluating social and spatial inequalities of large scale rapid lateral flow SARS-CoV-2 antigen testing in COVID-19 management: An observational study of Liverpool, UK (November 2020 to January 2021)

BACKGROUND

Large-scale asymptomatic testing of communities in Liverpool (UK) for SARS-CoV-2 was used as a public health tool for containing COVID-19. The aim of the study is to explore social and spatial inequalities in uptake and case-detection of rapid lateral flow SARS-CoV-2 antigen tests (LFTs) offered to people without symptoms of COVID-19.

METHODS

Linked pseudonymised records for asymptomatic residents in Liverpool who received a LFT for COVID-19 between 6th November 2020 to 31st January 2021 were accessed using the Combined Intelligence for Population Health Action resource. Bayesian Hierarchical Poisson Besag, York, and Mollié models were used to estimate ecological associations for uptake and positivity of testing.

FINDINGS

214 525 residents (43%) received a LFT identifying 5192 individuals as positive cases of COVID-19 (1.3% of tests were positive). Uptake was highest in November when there was military assistance. High uptake was observed again in the week preceding Christmas and was sustained into a national lockdown. Overall uptake were lower among males (e.g. 40% uptake over the whole period), Black Asian and other Minority Ethnic groups (e.g. 27% uptake for 'Mixed' ethnicity) and in the most deprived areas (e.g. 32% uptake in most deprived areas). These population groups were also more likely to have received positive tests for COVID-19. Models demonstrated that uptake and repeat testing were lower in areas of higher deprivation, areas located further from test sites and areas containing populations less confident in the using Internet technologies. Positive tests were spatially clustered in deprived areas.

INTERPRETATION

Large-scale voluntary asymptomatic community testing saw social, ethnic, digital and spatial inequalities in uptake. COVID-19 testing and support to isolate need to be more accessible to the vulnerable communities most impacted by the pandemic, including non-digital means of access.

FUNDING

Department of Health and Social Care (UK) and Economic and Social Research Council.

Perspectives on COVID-19 testing policies and practices: a qualitative study with scientific advisors and NHS health care workers in England

BACKGROUND

As COVID-19 death rates have risen and health-care systems have experienced increased demand, national testing strategies have come under scrutiny. Utilising qualitative interview data from a larger COVID-19 study, this paper provides insights into influences on and the enactment of national COVID-19 testing strategies for health care workers (HCWs) in English NHS settings during wave one of the COVID-19 pandemic (March-August 2020). Through the findings we aim to inform learning about COVID-19 testing policies and practices; and to inform future pandemic diagnostic preparedness.

METHODS

A remote qualitative, semi-structured longitudinal interview method was employed with a purposive snowball sample of senior scientific advisors to the UK Government on COVID-19, and HCWs employed in NHS primary and secondary health care settings in England. Twenty-four interviews from 13 participants were selected from the larger project dataset using a key term search, as not all of the transcripts contained references to testing. Framework analysis was informed by the non-adoption, abandonment, scale-up, spread, and sustainability of patient-facing health and care technologies implementation framework (NASSS) and by normalisation process theory (NPT).

RESULTS

Our account highlights tensions between the communication and implementation of national testing developments; scientific advisor and HCW perceptions about infectiousness; and uncertainties about the responsibility for testing and its implications at the local level.

CONCLUSIONS

Consideration must be given to the implications of mass NHS staff testing, including the accuracy of information communicated to HCWs; how HCWs interpret, manage, and act on testing guidance; and the influence these have on health care organisations and services.

From "Honeymoon Period" to "Stable Marriage": The Rise of Management Consultants in British Health Policymaking

Since the creation of the National Health Service in 1948, different groups of experts have competed to inform the development of British health policy. This article analyzes the long-term rise of one of these groups-management consultants. The scale and regularity of their engagement has increased considerably over time, strikingly in recent years, and the functions fulfilled by consultants have become ever more diverse. At important moments they were often seen by policymakers-particularly when there was understood to be a lack of internal expertise-as possessors and imparters of important knowledge. Firms and individuals worked consciously to integrate themselves into emerging health policy networks. But there has often been relatively little consideration of their real suitability for work in the health field. Many debates around the use of external consultants today-accountability, value for money, dependency-were foreshadowed during earlier periods, with implications for current policymakers.

Understanding the policy dynamics of COVID-19 in the UK: Early findings from interviews with policy makers and health care professionals

The UK government response to COVID-19 has been heavily criticised. We report witnesses’ perceptions of what has shaped UK policies and how these policies have been received by healthcare workers. Such studies are usually affected by hindsight. Here we deploy a novel prospective approach to capture real-time information.

We are historians, social scientists and biomedical researchers who study how societies cope with infectious disease. In February 2020 we began regular semi-structured calls with prominent members of policy communities, and health care professionals, to elicit their roles in, and reactions to, the pandemic response.

We report witnesses’ perceptions that personal protective equipment (PPE) stocks were too small, early warnings have not led to sufficiently rapid policy decisions, and a lack of transparency is sapping public trust. Significant successes include research mobilisation. The early experiences and reactions of our witnesses suggest important issues for investigation, notably a perception of delay in decision making.

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UK coronavirus response delayed after the alarm was raised.

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Politicians abdicated responsibility by their early ‘follow the science’ rhetoric.

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Science advice to policy making needs people who bridge the two worlds.

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Centralised responses wasted valuable local public health skills.

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Pandemic response needs to move faster than the infectious disease.

The social underpinnings of mental distress in the time of COVID-19 - time for urgent action

We argue that predictions of a ‘tsunami’ of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health.  Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services.  However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations.  Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care.  Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater.

Taking the long view: the development of the Well-being of Future Generations (Wales) Act

BACKGROUND

The Well-being of Future Generations (Wales) Act, 2015 (WFG Act), aims to change the ways of working in Wales to be sustainable for the future. Goals within the WFG Act include 'a healthier Wales', 'a more equal Wales' and 'a more prosperous Wales'. Reviewing key factors that led to Wales enacting this ground-breaking legislation is worthwhile for other legislatures around the world that may wish to create policy for future generations. We suggest that the drive of individual politicians, events at the time and recent history were the most critical issues in developing a more nuanced piece of legislation - the WFG Act.

METHODS

Ten interviews were conducted with those involved in the development of the WFG Act. Relevant documents were identified through systematic literature reviews and discussion with interviewees. Initial outcomes were tested against policy analysis frameworks, and Kingdon's Multiple Stream Analysis was selected.

RESULTS

Key 'policy entrepreneurs' were found to be important, along with growing evidence of the problems of climate change and recommendations for sustainable development in Wales. The importance of context and capitalising on global and local events by policy actors was significant. A supportive environment, including the third sector, community groups, cross-party backing, committed civil servants and a change of ministers helped with momentum.

DISCUSSION

Policy-makers did not work directly with historians on developing the WFG Act. However, recent history was included with collaboration of the Wales Audit Office, who had evaluated the Welsh Government's implementation of the duty to promote sustainable development. Sustainable, future-generation policies of other nations were also used to help shape the WFG Act. Kingdon's Multiple Stream Analysis is a useful theory to interpret the timing and impact of this policy change.

CONCLUSIONS

The problem of climate change, suitable policy solutions, political support, timing and, most importantly, policy entrepreneurs were all significant in the development of the WFG Act. Due to multiple factors, policy-makers in Wales have legislated for the long term, placing sustainability and the well-being of present and future generations at the heart of public services and government.

'All the stars were aligned'? The origins of England's National Institute for Health Research

BACKGROUND

In 2006, the research and development (R&D) activity of England's national healthcare system, the National Health Service, was reformed. A National Institute for Health Research (NIHR) was established within the Department of Health, the first body to manage this activity as an integrated system, unlocking significant increases in government funding. This article investigates how the NIHR came to be set up, and why it took the form it did. Our goal was a better understanding of 'how we got here'.

METHODS

We conducted oral history interviews with 38 key witnesses, held a witness seminar, and examined published and unpublished documents.

RESULTS

We conclude that the most important forces shaping the origin of NIHR were the growing impact of evidence-based medicine on service policies, the growth of New Public Management ways of thinking, economic policies favouring investment in health R&D and buoyant public funding for healthcare. We note the strong two-way interaction between the health research system and the healthcare system - while beneficial for the use of research, challenges for healthcare (such as stop-go funding) could also produce challenges for health research.

CONCLUSIONS

Understanding how and why England came to have a centralised health service research system alongside a long-established funder of biomedical research (the Medical Research Council) helps us interpret the significance of the English health research experience for other countries and helps English policy-makers better understand their present options. Learning lessons from the features of the English health research system calls for an understanding of the processes which shaped it. Firstly, the publicly funded, nationally organised character of healthcare promoted government interest in evidence-based medicine, made research prioritisation simpler and helped promote the implementation of findings. Secondly, the essential role of leadership by a group who valued research for its health impact ensured that new management methods (such as metrics and competitive tendering) were harnessed to patient benefit, rather than as an end in themselves. A policy window of government willingness to invest in R&D for wider economic goals and buoyant funding of the health system were also effectively exploited.

Roma populations and health inequalities: a new perspective

Purpose

The purpose of this paper is to explore the emergence of "Roma health and wellbeing" as a focus of attention in European research and in policy and the possible detrimental consequences of action founded on a generic representation of "Roma health."

Design/methodology/approach

Based on discussions with and research conducted by scholars who work directly with Roma communities across European regions from a wide range of academic disciplines it suggests how future research might inform: a more nuanced understanding of the causes of poor health and wellbeing among diverse Roma populations and; actions that may have greater potential to improve the health and wellbeing among these populations.

Findings

In summary, the authors promote three types of research: first critical analyses that unpick the implications of current and past representations of "Roma" and "Roma health." Second, applied participatory research that meaningfully involves people from specific self-defined Roma populations to identify important issues for their health and wellbeing. Third, learning about processes that might impact on the health and wellbeing of Roma populations from research with other populations in similarly excluded situations.

Originality/value

The authors provide a multidisciplinary perspective to inform research that does not perpetuate further alienation and prejudice, but promotes urgent action to redress the social and health injustices experienced by diverse Roma populations across Europe.

McKinsey and the 'Tripartite Monster': The Role of Management Consultants in the 1974 NHS Reorganisation

The first major reorganisation of the National Health Service took place in 1974, twenty-six years after the service had been established. It has long been perceived as a failure. This article draws on archival records and a witness seminar held in November 2016 to provide a more nuanced assessment of the 1974 reorganisation and understand more fully why it took the form that it did. In particular it identifies the reorganisation as an important moment in the ongoing story of management consultants engaging with health policymakers, and explores the role of McKinsey and Co. in detail for the first time. Key explanatory factors for their involvement are identified, including the perceived lack of expertise and manpower inside the civil service and the NHS, and perceptions of their impact and effectiveness are discussed. Many debates about the use of management consultants today were directly foreshadowed during the early 1970s. Alongside this, the role of other groups of policy actors, including civil servants, politicians and medical professionals, are established and the extent to which British health policymakers have had to work within existing cultural, political, legislative and practical constraints when trying to initiate change is demonstrated. The fact that many of the 'mistakes' that were made have been repeated in the course of subsequent reforms, speaks to the poor institutional memory of Whitehall, and the Department of Health and Social Care in particular. In the run up to 1974 management consultants could make only a limited contribution to an imperfect compromise.

History Matters: The Critical Contribution of Historical Analysis to Contemporary Health Policy and Health Care

History is popular with health policymakers, if the regularity with which they invoke historical anecdotes to support policy change is used as an indicator. Yet the ways in which they ‘use’ history vary enormously, as does its impact. This paper explores, from the perspective of a UK academic historian, the development of ‘applied’ history in health policy. It draws on personal experience of different types and levels of engagement with policymakers, and highlights mechanisms through which this dialogue and partnership can be made more efficient, effective, and intellectually rewarding for all involved.

Quantifying life: Understanding the history of Quality-Adjusted Life-Years (QALYs)

Quality-Adjusted Life-Years (QALYs) are central to healthcare decision-making in Britain and abroad, yet their history is poorly understood. In this paper, we argue that a more in-depth and political history of the QALY is needed to allow a critical evaluation of its current dominance. Exploiting rich data from archives and 44 semi-structured interviews conducted between 2015 and 2018, we employ Multiple Streams Analysis to construct a complex and dynamic picture of how the idea of QALYs emerged and was adopted within UK health policy. Through its historical and political approach, the paper illuminates the relative roles in the policy-making process of experts (especially economists) and politicians as 'entrepreneurs' in the development of new ideas; how these were influenced by negotiation within established and emerging institutional structures; and the role of serendipity and crisis.

Space, place and (waiting) time: reflections on health policy and politics

Health systems have repeatedly addressed concerns about efficiency and equity by employing trans-national comparisons to draw out the strengths and weaknesses of specific policy initiatives. This paper demonstrates the potential for explicit historical analysis of waiting times for hospital treatment to add value to spatial comparative methodologies. Waiting times and the size of the lists of waiting patients have become key operational indicators. In the United Kingdom, as National Health Service (NHS) financial pressures intensified from the 1970s, waiting times have become a topic for regular public and political debate. Various explanations for waiting times include the following: hospital consultants manipulate NHS waiting lists to maintain their private practice; there is under-investment in the NHS; and available (and adequate) resources are being used inefficiently. Other countries have also experienced ongoing tensions between the public and private delivery of universal health care in which national and trans-national comparisons of waiting times have been regularly used. The paper discusses the development of key UK policies, and provides a limited Canadian comparative perspective, to explore wider issues, including whether 'waiting crises' were consciously used by policymakers, especially those brought into government to implement new economic and managerial strategies, to diminish the autonomy and authority of the medical professional in the hospital environment.

Physical activity and osteoarthritis: a consensus study to harmonise self-reporting methods of physical activity across international cohorts

Physical activity (PA) is increasingly recognised as an important factor within studies of osteoarthritis (OA). However, subjective methods used to assess PA are highly variable and have not been developed for use within studies of OA, which creates difficulties when comparing and interpreting PA data in OA research. The aim of this study was, therefore, to gain expert agreement on the appropriate methods to harmonise PA data among existing population cohorts to enable the investigation of the association of PA and OA. The definition of PA in an OA context and methods of harmonization were established via an international expert consensus meeting and modified Delphi exercise using a geographically diverse committee selected on the basis of individual expertise in physical activity, exercise medicine, and OA. Agreement was met for all aims of study: (1) The use of Metabolic Equivalent of Task (MET) minutes per week (MET-min/week) as a method for harmonising PA variables among cohorts; (2) The determination of methods for treating missing components of MET-min/week calculation; a value will be produced from comparable activities within a representative cohort; (3) Exclusion of the domain of occupation from total MET-min/week; (4) The need for a specific measure of joint loading of an activity in addition to intensity and time, in studies of diseases, such as OA. This study has developed a systematic method to classify and harmonise PA in existing OA cohorts. It also provides minimum requirements for future studies intending to include subjective PA measures.

The effect of vitamin D supplementation on knee osteoarthritis, the VIDEO study: a randomised controlled trial

OBJECTIVE

Epidemiological data suggest low serum 25-hydroxyvitamin D₃ (25-OH-D₃) levels are associated with radiological progression of knee osteoarthritis (OA). This study aimed to assess whether vitamin D supplementation can slow the rate of progression.

METHOD

A 3-year, double-blind, randomised, placebo-controlled trial of 474 patients aged over 50 with radiographically evident knee OA comparing 800 IU cholecalciferol daily with placebo. Primary outcome was difference in rate of medial joint space narrowing (JSN). Secondary outcomes included lateral JSN, Kellgren & Lawrence grade, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, function, stiffness and the Get up and Go test.

RESULTS

Vitamin D supplementation increased 25-OH-D₃ from an average of 20.7 (standard deviation (SD) 8.9) μg/L to 30.4 (SD 7.7) μg/L, compared to 20.7 (SD 8.1) μg/L and 20.3 (SD 8.1) μg/L in the placebo group. There was no significant difference in the rate of JSN over 3 years in the medial compartment of the index knee between the treatment group (average -0.01 mm/year) and placebo group (-0.08 mm/year), average difference 0.08 mm/year (95% confidence interval (CI) [-0.14-0.29], P = 0.49). No significant interaction was found between baseline vitamin D levels and treatment effect. There were no significant differences for any of the secondary outcome measures.

CONCLUSION

Vitamin D supplementation did not slow the rate of JSN or lead to reduced pain, stiffness or functional loss over a 3-year period. On the basis of these findings we consider that vitamin D supplementation has no role in the management of knee OA.

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

Background

Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals.

Objectives

To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes.

Design

A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care.

Setting

Eleven acute hospitals in a region of England.

Participants

Qualitative study – 43 health professionals working in fracture prevention services in secondary care.

Interventions

Changes made to secondary fracture prevention services at each hospital between 2003 and 2012.

Main outcome measures

The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture.

Data sources

Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13,n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013,n = 11,243).

Results

Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician.

Conclusion

In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered.

Future work

Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.

Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study

Objectives: to evaluate orthogeriatric and nurse-led fracture liaison service (FLS) models of post-hip fracture care in terms of impact on mortality (30 days and 1 year) and second hip fracture (2 years).

Setting: Hospital Episode Statistics database linked to Office for National Statistics mortality records for 11 acute hospitals in a region of England.

Population: patients aged over 60 years admitted for a primary hip fracture from 2003 to 2013.

Methods: each hospital was analysed separately and acted as its own control in a before–after time-series design in which the appointment of an orthogeriatrician or set-up/expansion of an FLS was evaluated. Multivariable Cox regression (mortality) and competing risk survival models (second hip fracture) were used. Fixed effects meta-analysis was used to pool estimates of impact for interventions of the same type.

Results: of 33,152 primary hip fracture patients, 1,288 sustained a second hip fracture within 2 years (age and sex standardised proportion of 4.2%). 3,033 primary hip fracture patients died within 30 days and 9,662 died within 1 year (age and sex standardised proportion of 9.5% and 29.8%, respectively). The estimated impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) = 0.73 (95% CI: 0.65–0.82) and HR = 0.81 (CI: 0.75–0.87), respectively. Following an FLS, these associations were as follows: HR = 0.80 (95% CI: 0.71–0.91) and HR = 0.84 (0.77–0.93). There was no significant impact on time to second hip fracture.

Conclusions: the introduction and/or expansion of orthogeriatric and FLS models of post-hip fracture care has a beneficial effect on subsequent mortality. No evidence for a reduction in second hip fracture rate was found.

Describing variation in the delivery of secondary fracture prevention after hip fracture: an overview of 11 hospitals within one regional area in England

SUMMARY

There is variation in how services to prevent second fractures after hip fracture are organised. We explored this in more detail at 11 hospitals. Results showed that there was unwarranted variation across a number of aspects of care. This information can be used to inform service delivery in the future.

INTRODUCTION

Hip fractures are usually the result of low impact falls and underlying osteoporosis. Since the risk of further fractures in osteoporotic patients can be reduced by between 20 and 70 % with bone protection therapy, the NHS is under an obligation to provide effective fracture prevention services for hip fracture patients to reduce risk of further fractures. Evidence suggests there is variation in service organisation. The objective of the study was to explore this variation in more detail by looking at the services provided in one region in England.

METHODS

A questionnaire was designed which included questions around staffing, models of care and how the four components of fracture prevention (case finding, osteoporosis assessment, treatment initiation and adherence (monitoring) were undertaken. We also examined falls prevention services. Clinicians involved in the delivery of osteoporosis services at 11 hospitals in one region in England completed the questionnaire.

RESULTS

The service overview showed significant variation in service organisation across all aspects of care examined. All sites provided some form of case finding and assessment. However, interesting differences arose when we examined how these components were structured. Eight sites generally initiated treatment in an inpatient setting, two in outpatients and one in primary care. Monitoring was undertaken by secondary care at seven sites and the remainder conducted by GPs.

CONCLUSIONS

The variability in service provision was not explained by local variations in care need. Further work is now needed to establish how the variability in service provision affects key patient, clinical and health economic outcomes.

Efficient and clean photoreduction of CO(2) to CO by enzyme-modified TiO(2) nanoparticles using visible light

A hybrid enzyme-nanoparticle system is described for achieving clean reduction of CO(2) to CO using visible light as the energy source. An aqueous dispersion of TiO(2) nanoparticles modified by attachment of carbon monoxide dehydrogenase (CODH) and a Ru photosensitizer produces CO at a rate of 250 mumol of CO (g of TiO(2))(-1) h(-1) when illuminated with visible light at pH 6 and 20 degrees C.

Developing history of medicine in the University of Liverpool medical curriculum 1995-2005

CONTEXT

The University of Liverpool has always been innovative in its approach to medical education. The medical faculty's decision to switch to a full problem-based learning (PBL) medical curriculum from September 1996 represented an opportune moment for history of medicine to put a foot in the curricular door.

DISCUSSION

The history of medicine component was launched with an initial team of 3 staff members, although some 16 people have been involved in its development and delivery over the 10 years since it began. This paper is an attempt to construct and discuss the history of the course over the past decade, examining both the proactive and reactive aspects of its evolution, and how it has been perceived by students, the university and staff who have taught on it.

Profit is a dirty word: the development of the public baths and wash-houses in Britain 1847-1915

Researh on sanitary reform in nineteenth-century Britain has focused mainly on the introduction of large-sanitary infrastructure, especially waterworks and sewage systems. Other sanitary measures such as the provision of public baths and wash-houses have been ignored, or discussed in the limited context of working-class responses to middle-class sanitarianism. Yet by 1915 public baths and wash-houses were to be found in nearly every British town and city. A detailed analysis of these 'enterprises' can provide a useful way of understanding the changing priorities of public health professionals and urban authorities as well as the changing attitudes of the working classes. Connections between personal cleanliness and disease evolved during the century, particularly after the formation of germ theory in the 1880s. This paper demonstrates how the introduction of public baths and wash-houses in Liverpool, Belfast, and Glasgow was initially a direct response to sanitary reform campaigns. It also shows that the explicit public health ideology of these developments was constantly compromised by implicit concerns about municipal finance and the potential profit that such enterprises could generate. This city-based analysis shows that this conflict hindered the full sanitary benefit which these schemes potentially offered.

Integrated-optic array illuminator: a new design for guided-wave optical interconnections

An integrated array illuminator can be used not only as an opticalpower distributor for an array of guided-wave optic devices but also asa key element for guided-wave optical interconnections. We presenta new design for an integrated-optic array illuminator with focusingwaveguide diffractive doublet arrays. This integrated arrayilluminator allows independent optimizations of efficient and uniformoptical power distribution and focusing performance. Furthermore, the device can be fabricated with all-optical lithographic technologyand hence has the advantages of mass production with lowcost.

Radiation characteristics of waveguide diffractive doublets

The radiation characteristics of waveguide diffractive doublets consisting of double gratings located on two surfaces of waveguide cladding film are modeled based on a singular perturbation method. We determine the conditions under which the presence of the upper grating does not affect the radiation characteristics of the waveguide diffractive doublet as a whole. This allows independent performance of the upper grating, which may be replaced by a general diffractive optical element, and of the lower grating as a waveguide grating coupler. The results obtained provide an alternative method for determining the thickness of cladding film in the waveguide diffractive doublets for guided-wave manipulation.

Integrated waveguide diffractive doublet for guided-wave manipulation

An integrated waveguide diffractive doublet consisting of a uniform grating coupler and a diffractive optical element is proposed. Design of this waveguide diffractive doublet for guided-wave manipulation is described in detail. Experimental results for a fabricated waveguide diffractive doublet are also presented to demonstrate the device principles. It was found that this waveguide diffractive doublet can enhance device functionality while remaining simple and compact and having a planar structure. Furthermore, this device can be fabricated by use of all-optical lithography.

Focusing waveguide grating coupler using a diffractive doublet

A novel focusing waveguide grating coupler comprising an integrated uniform grating coupler and binary-phase-only diffractive lens is proposed, designed, and fabricated. Experimental results are also presented to demonstrate the device performance. This device is in direct competition with single-element focusing grating couplers defined by direct-write electron-beam lithography and its structure is attractive because the fabrication procedure is better suited for mass production.

Gagging public health doctors

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