Elderly need to take responsibility for their own long-term health

My Post (6)Elderly people are not doing enough to protect their long-term health and it is having a knock on effect on the NHS. A recent survey found almost a quarter of people aged 65 and over do no strengthening activities at all, and only 9% do them once a week (Chartered Society of Physiotherapy, 2017).

Along with 150 minutes of moderate aerobic activity, national activity guidelines recommend adults over 65 do strength training at least two times a week (NHS Choices, 2015). Working all the major muscles on a regular basis has the benefit of improving daily movement, maintaining strong bones and regulating blood pressure. It is also known to reduce the risk of falls.

Falls cost the NHS more than £2.3 billion a year, not to mention the human cost of pain, injury, and loss of confidence (National Institute for Health and Care Excellence, 2013). It has regularly been highlighted that physiotherapists can greatly reduce the number of falls in the elderly if utilised properly. This is done by a multifactorial assessment of those who may be at risk, followed by a multifactorial intervention to improve strength and balance. As many as 160 000 falls could be prevented if everyone 65 and over at risk of falling was referred to physiotherapy. This would save the NHS £250 million a year (Chartered Society of Physiotherapy, 2014).

While these figures are substantial and illustrate how physiotherapists play a key role in the pathway of care, a simpler solution would be to increase the amount of education in the community in the benefits of strengthening activities. If people were encouraged more and realised how including strengthening activities as part of their weekly routine would affect them, it would reduce the number of people requiring medical attention for falls and take the pressure off health care professionals. The public should be taking responsibility for their own health, yet evidently they are not.

Many adults are put off by the idea of traditional strength training and squirm at the thought of hitting the gym to lift weights. However, this is by no means the only way to gain strength. Recent evidence highlights the benefit of both recreational and non-recreational activities in improving overall health (Lear et al, 2017). Recreational activities that can help to improve strength include yoga, dancing or even heavy gardening. If time is a concern, non-recreational activities such as carrying heavy shopping or doing the housework offer a practical way to build strength. By being mindful of these sorts of activities, the national recommended target can easily be reached.

People need to be inspired to meet these targets, but that is no easy task. However, more can and must be done. The Chartered Society of Physiotherapy’s poll found that advice from a GP or physiotherapist would be effective in encouraging people to meet national guidelines so this needs to be pushed. Additionally, more information is needed, both online and in the community. The public must take responsibility for their own health, but to do that they need to be properly educated.

References

Chartered Society of Physiotherapy. Cost of falls [Internet]. London: CSP; 2014 Sep 2 [cited 2017 Oct 11]. Available from: http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/cost-falls

Chartered Society of Physiotherapy. Too many people letting muscle waste as they age, physiotherapists warn [Internet]. London: CSP; 2017 Sep 29 [cited 2017 Oct 11]. Available from http://www.csp.org.uk/press-releases/2017/09/28/too-many-peopleletting-muscle-waste-they-age-physiotherapists-warn

Lear SA, Hu W, Rangarajan S. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study. Lancet. 2017;pii:S0140-6736(17)31634-3. http://dx.doi.org/10.1016/S0140-6736(17)31634-3

National Institute for Health and Care Excellence. Falls in older people: assessing risk and prevention (CG 161). London: NICE; 2013

NHS Choices. Physical activity guidelines for older adults [Internet]. London: NHS Choices; 2015 July 11 [cited 2017 Oc 12]. Available from http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-older-adults.aspx

Taken from International Journal of Therapy and Rehabilitation, published November 2017.

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Is now the winter of our discontent? Exploring seasonal pressure on the NHS

My Post (1)Around this time every year, the media is strewn with forewarnings of how winter will put undue strain on the NHS. In a system already struggling to cope, there are concerns that the seasonal pressure pushes services to breaking point. The NHS’s ability to handle yearly increases in demand has led the British Red Cross to go as far as to call it a ‘humanitarian crisis’ (Campbell et al, 2017).

This article will consider the causes of winter pressure on NHS services and how they differ to those experienced throughout the rest of the year. It will explore whether the warnings are genuine or mere hyperbole, and look at some of the ways the NHS attempts to combat these pressures.

Causes of winter pressures

The leading cause of winter pressure is difficult to pinpoint, and can vary from year to year. However, there are a number of recurring contributing factors. While most health problems are not caused by extremes of cold, the weather indelibly has an effect on the number of patients attending accident and emergency (A&E) departments.

Cold weather increases the risk of heart attacks, strokes, respiratory illnesses, flu, falls and other diseases (NHS England, 2013; Public Health England, 2017). Vulnerable people— such as the very young, elderly and those with pre-existing conditions— are those predominantly affected by changes in the weather (National Institute for Health and Care Excellence (NICE), 2015). The effect of winter on the NHS becomes apparent in early December. Performance in A&Es is measured through their ability to meet a 4-hour waiting target. One of the core standards of the NHS Constitution states that a minimum of 95% of patients attending A&E departments in England must be seen, treated and then admitted or discharged in under 4 hours (NHS England, 2015). Breaches of the 4-hour waiting standard result in trusts having to pay penalties (House of Commons Health Committee, 2016).

A&E attendances
Annual attendances at A&E departments have increased. The number of people arriving at major (type 1) A&E departments has seen a 7% rise from 2010 to 2015—from an average of 36 731 attendances per day in August 2010, to 39 220 in August 2015 (Fisher and Dorning, 2016).

Consequently, only 87.9% of patients in type 1 departments were admitted, transferred or discharged within 4 hours in 2015–16 (House of Commons Health Committee, 2016). This is clearly far below the expected standard. The Royal College of Emergency Medicine (2016a) has estimated that the increased attendance over the past 5 years is equivalent to the workload of 10 additional medium sized emergency departments.

Contrary to expectation, the highest number of A&E attendances does not take place in winter. Instead, there is an observable ‘dip’ in visits to A&E around December and January (Fisher and Dornin, 2016). The highest overall attendances are actually in the summer months. The important factor affecting winter pressure is the number of patients subsequently admitted to hospital. The highest proportion of the patient population in summer is under 60 years of age. By contrast, in the winter, it tends to consist of those over 60 years. This spike in the number of more vulnerable, elderly patients is significant because they tend to stay longer in A&E, and are more likely to be readmitted to hospital (Fisher and Dornin, 2016).

Hospital admissions
Like attendances, hospital admissions have also increased. Similarly, they have seen a 7% rise from 13 723 in August 2010 to 14 666 in August 2015 (Fisher and Dornin, 2016). There is a notable ‘peak’ of admissions during the middle of winter (Fisher and Dornin, 2016).

The difference between the proportion of patients admitted is 27.9% in winter, compared with 25.8% in the summer months (Department of Health (DH) et al, 2017).

‘Congestive hospital failure’
The rise in hospital admissions has caused a subsequent decrease in the number of available hospital beds, with the percentage of beds occupied peaking in winter (Fisher and Dornin, 2016). Due to the number of beds available for admission of acutely ill and injured patients continuing to fall over the past 5 years, the UK now has the lowest number of beds per capita in Europe, and England has the lowest number within the UK (Royal College of Emergency Medicine, 2016a). The consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11, to 91.2% in 2015–16 (Royal College of Emergency Medicine, 2016b).

A lack of available beds reduces flow through A&Es as it slows the accommodation of new attendances (Royal College of Emergency Medicine, 2016a). This in turn affects the ability of ambulance services to off-load patients—an issue known as ‘congestive hospital failure’ (NHS England, 2013).

Another factor influencing occupancy rates is delayed transfer of care, which leaves systems less resilient to operational pressures. Unnecessary delay in discharging patients who no longer need to be in hospital led to 1.15 million bed days being lost in acute hospitals during 2015 (National Audit Office, 2016).

Combatting pressures

To help combat winter pressures, the NHS conducts strategic planning each year. For the 2017/18 winter, formal planning began at its earliest time yet in July (Philip, 2017). Local plans were submitted in September covering resilience arrangements from the start of December up to Easter 2018.

As part of this preparation, Public Health England (2017) publishes a Cold Weather Plan every year to help protect the population against harm from cold weather. A mixture of past experience and forward-planning will help build future resilience. Below are some of the key methods of combatting pressure.

Best use of ambulance services
An expansion of the ‘hear and treat’ and ‘see and treat’ services provided by ambulance services can help alleviate demand on A&E departments. ‘Hear and treat’ services refer to 999 calls that are successfully completed without dispatching an ambulance vehicle response. Examples of this include over-the-phone advice, instructions for self-care, or referral to other urgent services (Urgent and Emergency Care Review Programme Team, 2015).

‘See and treat’ services refer to a model of care where a patient is clinically assessed at scene, before being provided with immediate treatment and subsequent discharge and/or referral (Urgent and Emergency Care Review Programme Team, 2015). By avoiding taking patients unnecessarily to A&E, they can be referred to more appropriate services that better fit the patient’s needs, or further support can be provided at home or in a community setting. ‘Hear and treat’ and ‘see and treat’ services now cover 3.5 million people (NHS England, 2017b).

This winter will see the full rollout of phase two of the Ambulance Response Programme, with the introduction of new call standards that accurately reflect the type and urgency of care needed by patients (Quaile, 2017). Along with the new dispatch on disposition system, giving call handlers more time to triage 999 calls, it is hoped that many patients can avoid being taken unnecessarily to A&Es.

Boosting flu vaccinations
Flu outbreaks within health services can be crippling and are a genuine concern each winter. Last year, 49% of NHS staff were vaccinated against the influenza virus and, this year, the number of vaccinated staff has been raised to 63% (NHS England, 2017b).

Additionally, free flu jabs will be provided to hundreds of thousands of care-home staff at a cost of up to £10 million; and numbers of vaccinations for young children and vulnerable people will be increased (NHS England, 2017a). Being vaccinated is the best way to prevent the spread of flu infection and reduce avoidable deaths. As it is possible to have flu without showing any symptoms, health professionals could find themselves working with flu but not realising it. It is essential they are vaccinated to avoid spreading the illness to vulnerable people.

Increasing funding
The spring budget announced an additional £100 million to support improvements in emergency departments through the implementation of a primary-care streaming model (Philip, 2017). Here, patients are streamed away from highly pressured emergency departments, to co-located GP-led primary care services, for conditions more suited to assessment and treatment in primary care (NHS Improvement, 2017).

Achieving ‘good’ patient flow
According to Monitor (2015), improving patient flow through hospital departments other than A&E is ‘the most important systemic means’ of avoiding sharp declines in A&E performance during winter. Health systems that have better patient flow are much better at coping with external pressures than those who don’t (NHS Improvement, 2017). Within ambulance services, good patient flow is seen as the handing over of a patient to an emergency department within 15 minutes of arriving (NHS Improvement, 2017).

My Post (2)Encouraging self-care
Further promotion of self-care is essential to reducing demand on health services. Giving people the confidence and information to look after themselves can help prevent ill health and reduce pressure (British Medical Association, 2016). However, for this to work, support needs to be easily accessible.

Improving housing conditions
Housing conditions for vulnerable people play an important part in the number of excess winter deaths and illnesses. In the coldest 10% of homes, the death rate rises approximately 2.8% for every degree Celsius drop in the outside temperature (NICE, 2015).

In England, there is a relatively sharp increase in the risk of death when outdoor temperatures fall to around 6°C (NICE, 2015). Improving heating and insulation for vulnerable people is therefore highly important for reducing avoidable illness or death.

Addressing growing GP demand
General practice is on the brink of crisis as a result of inadequate resourcing, an insufficient workforce, and an unsustainable workload (British Medical Association, 2016). The number of GP consultations in England rose from 303 million in 2008/9 to 361 million in 2013/14 (Royal College of General Practitioners, 2015). However, despite this 19% increase in demand, there has been no change in resourcing and staffing, putting undue strain on GP services (British Medical Association, 2016).

Increased funding in social care
Social care has been struck by considerable funding cuts in recent years, creating a knock-on effect on the number of people receiving services.

There were 500 000 fewer people who accessed social care in 2013/14 compared to 2008/9 (Franklin, 2015). This is despite an increasing ageing population, where the number of over-85s will double over the next two decades. It is also anticipated that adults with a learning disability will increase by at least a third (Local Government Association, 2016).

The cut of £5 billion in local authority social care budgets over the last 5 years has placed significant pressure on services (Local Government Association, 2016). Delays in arranging community nursing or social care has a considerable impact on delayed transfers, with 60% of trusts believing the increase in delayed transfers of care is owing to reductions in social care capacity (Monitor, 2015).

Conclusion
This article has sought to explain the reasons behind additional pressures on health services brought on by the winter season. While attendances at A&E are lower during the winter, the number of hospital admissions of vulnerable patient groups rises, largely because of seasonal illnesses such as flu and norovirus. This causes a reduction in the number of beds available and reduced patient flow within hospitals.

To combat these pressures, longer term investments are needed to address the insufficient workforce, lack of social care, and demand on primary care services. Although there has been additional investment in vaccination against flu; primary-care streaming; and resilience funding for ambulance services for this winter; it is unclear what impact—if any—this will have on health services.

References

British Medical Association. Beating the effects of winter pressures: Briefing paper. 2016; London: BMA

Campbell D, Morris S, Marsh S. NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns [Internet]. London: The Guardian; 2017. [cited 2017 Oct 23]. Available from http://tinyurl.com/y73vemzg

Department of Health, NHS England, NHS Improvement. Written evidence submitted by the Department of Health, NHS England and NHS Improvement (WIP0035) [Internet]. 2017. [cited 2017 Oct 23]. Available from http:// tinyurl.com/y7vlmu5r

Fisher E, Dorning H. Winter pressures: what’s going on behind the scenes? London: Quality Watch; 2016

Franklin B. The end of formal adult social care: A provocation by the ILC-UK. 2015; London: ILC-UK

House of Commons Health Committee. Winter pressure in accident and emergency departments: Third Report of Session 2016–17. 2016; London: The Stationery Office

Local Government Association. Adult social care funding: 2016 state of the nation report. 2016; London: LGC

Monitor. A&E delays: why did patients wait longer last winter? [Internet]. 2015. [cited 2017 Oct 23]. Available from http://tinyurl.com/ ofw2uv3

National Audit Office. Discharging older patients from hospital [Internet]. 2016. [cited 2017 Oct 23]. Available from http://tinyurl.com/hnyuy2p

National Institute for Health and Care Excellence. Excess winter deaths and illness and the health risks associated with cold homes. Clinical Guideline 6. 2015; London: NICE

NHS England. NHS leaders unveil action to boost flu vaccination and manage winter pressures. [Internet]. 2017a. [cited 2017 Oct 21]. Available from http://tinyurl.com/ycp5k8er

NHS England. The Handbook to the NHS Constitution. 2015; London: The Stationery Office

NHS England. Understanding Winter Pressures in A&E Departments [Internet]. 2013. [cited 2017 Oct 21]. Available from http://tinyurl.com/ yblaeduc

NHS England. Urgent and emergency care [Internet]. 2017b. [cited 2017 Oct 21]. Available from http://tinyurl.com/y9dctbsp

NHS Improvement. National priorities for acute hospitals 2017. Good practice guide: Focus on improving patient flow [Internet]. 2017. [cited 2017 Oct 23]. Available from http://tinyurl. com/y7t6mfam

Philip P. Letter to all CCGs and providers regarding planning for winter 2017/18, and other operational priorities [Internet]. 2017. [cited 2017 Oct 22]. Available from http:// tinyurl.com/y82kelxe

Public Health England. The Cold Weather Plan for England: Protecting health and reducing harm from cold weather. 2017; London: The Stationery Office

Quaile A. What’s next for England’s ambulance services? J Paramed Pract. 2017;9(10): 443-444

Royal College of Emergency Medicine. Why does winter in A&E get worse every year? 2016a; London: The Royal College of Emergency Medicine

Royal College of Emergency Medicine. Written evidence submitted on behalf of the Royal College of Emergency Medicine (WIP009) [Internet]. 2016b. [cited 2017 Oct 23].Available from http://tinyurl.com/y8naucxs

Royal College of General Practitioners. Patient safety implications of general practice workload. 2015; London: RCGP

Urgent and Emergency Care Review Programme Team. Transforming urgent and emergency care services in England: Clinical models for ambulance services. 2015; Leeds: NHS England

Taken from Journal of Paramedic Practice, published November 2017.

Experts call on NICE to review TAVI guidelines for aortic stenosis

Adobe Spark (5)Leading experts have urged the National Institute for Health and Care Excellence (NICE) to review its guidelines on the use of transcatheter aortic valve implantation (TAVI) for aortic stenosis to include intermediate-risk patients.

Speaking at a plenary session of the PCR–London Valves conference, experts delivered a focused summary of the new European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on valvular heart disease (Baumgartner et al, 2017). This included details of how the guidelines have been updated to lower the threshold for intervention with TAVI to patients at intermediate-risk of surgery. Previous guidance stipulated that TAVI should only be considered for those patients with symptomatic aortic stenosis at high risk of surgery (Vahanian et al, 2017).

Dr Helmut Baumgartner, chair of the taskforce for the European Guidelines, has said the new recommendations mark a profound change to the 2012 guidelines. This is largely owing to the number of randomised controlled trials comparing surgical and transcatheter treatments in the last 5 years. These have looked at intermediate- and low-risk patients treat-ed, not just elderly high-risk patients (Leon et al, 2016). He said:

‘There is much controversy right now over who should undergo surgery and who should undergo per-cutaneous valve implantation, and this is an area in which we have profound changes in what we recommend and have consequently dedicated a large part of the guide-lines to the choice of intervention in symptomatic aortic stenosis.

‘We are now recommending that surgical valve replacement remains the first line of therapy in low-risk patients, and low risk should not only be defined by risk scores, because these have several limitations, but by the lack of frailty and other specific risks for surgery not included in risk scores such as porcelain aorta or sequelae of chest radiation. There are numerous issues that need to be considered before we speak of low-risk patients.’

How NICE guidelines differ

An updated version of NICE’s Interventional Procedures Guidelines (IPG), which considers whether procedures are safe and work well enough for wider use in the NHS, was published a month before the ESC/EACTS guidelines (NICE, 2017). At first glance, it appears not to have revised the indication for TAVI beyond the high-risk patient population, unlike the European guidelines. According to a press advisory from Edwards Lifesciences (2017), NICE said additional trials are needed before TAVI could be considered in patients at inter-mediate risk for surgery:

‘Based on current data, TAVI is recommended in patients with severe symptomatic aortic stenosis who are, according to the heart team considered unsuitable for conventional surgery because of severe comorbidities.

Should NICE guidelines change?

Approximately 1.5 million people in the UK over 65 years suffer from heart valve disease with aortic stenosis (d’Arcy et al, 2016). This represents 2–7% of those over 65 years (Spaccarotella et al, 2011) and 13% of those over 75 years (Nkomo et al, 2006). For many cardiologists, it is believed that expanding the use of TAVI would enable more patients in the UK to have access to the minimally-invasive therapy, rather than have to undergo open-heart surgery.

According to Dr Bernard Prendergast, Consultant Cardiologist at Guy’s and St Thomas Hospital and Course Director/Board Member of PCR London Valves, recent evidence increasingly supports the use of TAVI for intermediate-risk patients. Speaking at the PCR–London Valves conference, he said:

‘There is growing evidence in favour of the use of TAVI for the treatment of intermediate-risk patients with severe symptomatic aortic stenosis. This expanded indication in the ESC/EACTS guidelines paves the way for more patients to receive a true alter-native to open-heart surgery.’

As a result, Prendergast emphasised why NICE should update their guidelines to be in line with the rest of Europe:

‘We are calling for NICE to review their recent IPG in light of these new ESC guidelines in order to address current inequalities in treatment across the UK, and between the UK and most of Europe.’

There is concern that the NICE guidelines leave UK patients at a disadvantage in the treatment of aortic stenosis com-pared with the rest of Europe. Currently, the UK performs far fewer aortic valve implantations than Germany, France, Norway and Sweden.

Clearing up misconceptions

It was hoped in light of the new ESC/EACTS guidelines that this disadvantage would change. However, when NICE was asked if they will be looking into revising their guidelines to recommend TAVI for aortic stenosis for intermediate-risk patients for the writing of this article, they clarified that their guidelines have actually already been extended beyond the high-risk population.

In response to the expert calls for revision and the critical comments quoted in this article, a spokesperson from NICE requested a correction, stating:

‘The new guidance gives standard arrangements for TAVI and does not any longer differentiate between different risk groups. The decision as to which patients are suitable is left to risk assessment by clinicians and the MDT [multidisciplinary team].’

References

Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–2791.

d’Arcy JL, Coffey S, Loudon MA et al. Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: The OxVALVE Population Cohort Study. Eur Heart J. 2016;37(47):3515-3522.

Edwards Lifesciences Ltd. Leading Experts Call for Adoption of New ESC/EACTS Guidelines on the Management of Valvular Heart Disease to include Intermediate-Risk Patients in National Protocols [Press Advisory]. Berkshire: Edwards Lifesciences Ltd.

Leon MB, Smith CR, Mack MJ et al. Transcatheter or surgical aortic-valve replacement in intermediate risk patients. N Engl J Med. 2016;374(17):1609-20.

National Institute for Health and Care Excellence. Transcatheter aortic valve implantation for aortic stenosis. Interventional procedures guidance [IPG586]. London: NICE; 2017.

Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart disease: a population-based study. Lancet. 2006;368:1005-11.

Spaccarotella C, Mongiardo A, Indolfi C. Pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation. Circ J. 2011;75(1):11-19.

Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451-96.

Taken from British Journal of Cardiac Nursing, published October 2017.

More advanced paramedics needed if A&E pressure is to be eased

Adobe Spark (1)The NHS must introduce more advanced paramedics if emergency departments are to meet growing patient demand. The NHS is reaching a crisis point—annual rises in emergency admissions and insufficient resources mean patients aren’t receiving the necessary levels of care. Traditionally, care provided by paramedics has focused on the immediate assessment and management of potentially life-threatening emergencies. This is then followed by transfer to an appropriate receiving unit. However, increasingly, evidence suggests that patients who present to ambulance services with lower acuity presentations could alleviate the need for hospital admission by undergoing assessment and management in the community.

This is highlighted in new draft guidance published by NICE (2017), which should fall on welcome ears to ambulance services. It recommends that the NHS provides more advanced paramedic practitioners (APPs), who have extended training in assessing and treating people with medical emergencies, to relieve pressure on emergency departments.

Evaluating the evidence

In order to make these recommendations, the guideline committee investigated whether enhancing the competencies of paramedics resulted in a reduction in hospital admissions and demand for emergency department services. When considering clinical evidence, three studies were included in the review. Two studies, which came from the same cluster-randomised controlled trial, looked at a paramedic practitioner service in the UK, which gave enhanced training to paramedics.

The first study comprised 3018 people and evaluated the benefits of paramedic practitioners who have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community (Mason et al. 2007). The evidence suggested that enhanced competencies of paramedics may provide benefit for reducing the number of hospital admissions (0–28 days), emergency department attendance (0–28 days), and patient and/or carer satisfaction. There was no effect on mortality.

The second study comprised 2025 people and evaluated the safety of clinical decisions made by paramedic practitioners of older patients contacting the emergency medical services with a minor injury or illness (Mason et al. 2008). Of the 3018 patients recruited into the randomised-controlled trial, 993 were admitted to the hospital at the index episode, which explains why they were excluded from the analysis in this study. The evidence suggested that there was no effect of paramedics’ enhanced competencies on unplanned emergency department attendance.

The final study was a non-randomised (quasi-experimental) study of emergency care practitioners who worked as single responders to ambulance service 999 calls, compared with standard paramedic or technician ambulance responding to ambulance service 999 calls. The study comprised 1107 people and aimed to evaluate the impact of emergency care practitioners on patient pathways and care indifferent emergency care settings.
(Mason et al. 2012). The evidence suggested that enhanced competencies of paramedics may provide a benefit from reduced numbers of patients referred to hospital (emergency department or direct admission to a hospital ward), and increased number referred to primary care.

Additionally, one cost-utility analysis was assessed to consider the economic implications of providing additional advanced paramedics within ambulance services, and found that the paramedic practitioner scheme was cost-effective compared with the standard 999 service (Dixon et al. 2009). This study was assessed as partially applicable with minor limitations.

Points for concern

There are a number of considerations when looking at the evidence in question that could be cause for concern. While evidence exists, it is minimal, with only one randomised-controlled trial and one non-randomised study evaluated by NICE. Though results from the studies are positive, it would be difficult to generalise them beyond the services assessed. Additionally, the quality of evidence is generally of a low GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The randomised-controlled trial evidence has a moderate-to-low GRADE rating overall, mainly owing to risk of bias and imprecision (NICE 2017). The non-randomised study, although it had large effect sizes, has a very low GRADE rating as a result of high risk of bias and indirectness of the outcomes to the protocol (NICE 2017). The economic evidence was considered high-quality but only partially applicable because the costs were quite dated. Some social care costs were also included, which means that the perspective is not strictly NHS and personal social services (NICE 2017).

There are notable concerns over the definition of an APP, as there is a national lack of consensus over paramedic roles and scope of practice. This was a contributing factor to why independent prescribing by APPs was not recommended by the CHM and MHRA (Allied Health Professions Medicines Project Team 2016).

The need for unanimity across all ambulance services is a concern the College of Paramedics emphasised inits response to the guidance:

‘There has previously been insufficient attention given to career development and career opportunities and there is currently significant variation across the ambulance services in the definitions, titles, education, and training of specialist and advanced paramedics. To ensure consistency of education, training and qualification, the UK ambulance services would need to adopt the frameworks developed by the College of Paramedics, which provide detailed guidance on education, competencies, and career development’ (College of Paramedics 2017).

The College of Paramedics has a clear definition of the APP role in terms of competencies and education:

‘Advanced paramedics are experienced autonomous paramedics who have undertaken further study and skill acquisition to enable them to be able to deliver a more appropriate level of assessment and indeed care to patients in the community and access many more referral pathways.’

It is essential that this becomes the accepted definition across the NHS, and the private health sector. This will ensure that all advanced paramedics are clinically competent and that patient safety is not at risk. More advanced paramedic practitioners with extended training could alleviate current pressures on A&E services.

From guidance to practice

Consulting on the guidance closed on 14 August, with an expected publication of 20 December. If the guidance is to be put into practice, the most important step is to introduce additional funding for NHS ambulance services to educate their clinicians through advanced practice programmes. NHS England and clinical commissioning groups would then have to provide funding to deliver specialist and advanced paramedics as part of the core workforce. Additionally, regulation is essential to ensure clinical competency and patient safety.

There is no denying that acute and emergency care is a challenge for all health services. This is largely owing to the fact that as populations age, costs rise, and technological developments extend the limits of health care. However, providing acute and medical care in the community can reduce the need for hospital admissions.

The introduction of more advanced paramedics will meet the increasing and changing needs of patients who access 999 emergency ambulance services. Having a higher proportion of emergency patients assessed and treated in the community will cause a reduction in the number of attendances at emergency departments.

References

Allied Health Professions Medicines Project Team. 2016. Summary of the responses to the public consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom. Leeds: NHS England.

College of Paramedics. 2017. College of Paramedics respond to NICE Consultation [Internet]. Bridgwater: College of Paramedics; [cited 2017 29 August]. Available from https://www.collegeofparamedics.co.uk/news/college-of-paramedics-responds-tonice-consultation.

Dixon S, Mason S, Knowles E. 2009. Is it cost effective to introduce paramedic practitioners for older people to the ambulance service? Results of a cluster randomised controlled trial. Emerg Med J. 26(6):446-51. http://doi.org/ 10.1136/emj.2008.061424.

Mason S, Knowles E, Colwell B et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. BMJ. 335(7626):919. http://doi.org/10.1136/bmj.39343.649097.55

Mason S, Knowles E, Freeman J, Snooks H. 2008. Safety of paramedics with extended skills. Acad Emerg Med. 15(7):607–12. http://doi.org/10.1111/j.1553-2712.2008.00156.x.

Mason S, O’Keeffe C, Knowles E. 2012. A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial). Emerg MedJ. 29(1):47-53. http://doi.org/10.1136/emj.2010.103572.

National Institute for Health and CareExcellence. 2017. Emergency and acute medical care in over 16s: service delivery and organisation: Draft guidance consultation [GID-CGWAVE0734] [Internet]. London: NICE; [cited 2017 29 August]. Available from https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0734/consultation/html-content.

Taken from Journal of Paramedic Practice, published 8 September 2017.

Royal Pharmaceutical Society updates prescribing competency framework

Adobe Spark (1)The Royal Pharmaceutical Society (RPS, 2016) has published an update to the Competency Framework for all Prescribers to ensure health professionals prescribe safely and effectively.

Originally published in 2012, the framework was developed to offer a common set of competencies for prescribing, regardless of professional background. As a result, it is relevant to all prescribers, including doctors, pharmacists, nurses, dentists, physiotherapists, optometrists, radiographers, podiatrists and dietitians. However, the framework should be contextualised to reflect different areas of practice and levels of expertise.

Ash Soni, President of the RPS, said:

‘Both the number of medicines prescribed and the complexity of medicine regimens are increasing. The challenges associated with prescribing the right medicines and supporting patients to use them effectively should not be underestimated.

‘There’s lots of evidence to show that much needs to be done to improve the way we prescribe and support patients in effective medicines use. This guide will be invaluable and I’m delighted the RPS has coordinated the update.’

The initial framework was published by the National Prescribing Centre and the National Institute for Health and Care Excellence (NICE). For the update, the RPS was approached by NICE and Health Education England to carry out the work on behalf of all prescribing professions. Additionally, the RPS was asked to ensure the framework had UK-wide applicability.

A project steering group of prescribers across all professions and patients updated the framework. This involved a 6-week consultation of the draft policy, where hundreds of organisations and individuals responded.

The framework has been endorsed by the UK’s Chief Pharmaceutical Officers—Keith Ridge, Rose Marie Parr, Andrew Evans and Mark Timoney—who said:

‘The single competency framework provides a means for all prescribers to become equipped to support patients to achieve the best outcomes from their medicines.

‘This update will ensure individuals can continue to benefit from access to resources which help them continually improve their practice and work more effectively.

‘We commend the updated framework and encourage prescribers, professional bodies, education providers and regulators to use it to support their role in delivering safe and effective care.’

How the competencies are separated

The framework comprises 10 competencies split into two areas: the consultation and prescribing governance. Within each of these competency areas, statements describe the activity or outcomes that prescribers should be able to demonstrate.

The consultation

The first competency concerns assessing the patient. It promotes taking an appropriate medical, social and medication history, before undertaking an appropriate clinical assessment.

The second competency involves the prescriber considering the options for the patient. This includes both non-pharmacological and pharmacological approaches to treatment, and weighing up the risks and benefits to the patient of taking medicine.

The third competency is about reaching a shared decision with the patient/carer, so the patient/carer can make informed choices and agree on a plan that respects the patient’s preferences.

The fourth competency is the prescribing itself. The framework states the medicine should be prescribed only with ‘adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and unwanted effects.’ Where appropriate, medicines should be prescribed within relevant frameworks, such as local formularies or care pathways.

The fifth competency concerns providing information to the patient/carer about their medicines. This includes what the medicine is for, how to use it, possible unwanted effects and how to report them, and expected duration of treatment.

The sixth and final competency in the area of consultation is monitoring and reviewing. Here the prescriber should establish and maintain a plan for reviewing the patient’s treatment. The effectiveness of treatment and potential unwanted effects should be monitored.

Prescribing governance

The seventh competency, and first under the area of prescribing governance, concerns prescribing safely. It highlights that the prescriber should prescribe within their own scope of practice and recognise the limits of their own knowledge and skill.

The eighth competency comprises prescribing professionally, and ensuring the prescriber maintains confidence and competence to prescribe. This includes accepting personal responsibility for prescribing and understanding the legal and ethical implications.

The ninth competency focuses on improving prescribing practice through reflection. It also stresses the importance of acting on feedback and discussion.

The tenth and final competency involves prescribing as part of a multidisciplinary team to ensure continuity of care across care settings. Part of this concerns establishing relationships with other professionals based on understanding, trust and respect.

Putting the framework into practice

The framework can be used for a variety of reasons by prescribers to help them improve their performance and work more effectively. The following examples are highlighted in the framework:

  • To inform the design and delivery of education programmes; for example, through validation of educational sessions (including rationale for need) and as a framework to structure learning and assessment
  • To help health professionals prepare to prescribe and provide the basis for ongoing education and development programmes, continuous professional development and revalidation processes. For example, use as a framework for a portfolio to demonstrate competency in prescribing
  • To help prescribers identify strengths and areas for development through self-assessment, appraisal and as a way of structuring feedback from colleagues
  • To inform the development of education curricula and relevant accreditation of prescribing programmes for all prescribing professions
  • To provide professional organisations or specialist groups with a basis for the development of levels of prescribing competency; for example, from recently qualified prescriber through to advanced prescriber
  • To stimulate discussions around prescribing competencies and multidisciplinary skill mix at an organisational level
  • To inform organisational recruitment processes to help frame questions and benchmark candidates’prescribing experience
  • To inform the development of organisational systems and processes that support safe effective prescribing; for example, local clinical governance frameworks.

The RPS is liaising with the professional bodies and organisations of the other prescribing professions to encourage uptake of the framework, which will be reviewed again in July 2020.

References

Royal Pharmaceutical Society (2016) A Competency Framework for all Prescribers. http://www.rpharms.com/support-pdfs/prescribing-competencyframework.pdf (accessed 1 August 2016)

Taken from Nurse Prescribing, published 12 August 2016.

Dental Nursing News February 2016

DN News FebPatients test positive for Hepatitis C

dental nurse who spoke out about hygiene conditions at a dentist’s surgeries in Ayrshire—sparking an HIV scare for 5600 patients—was told by the practice manager: ‘no one has caught anything yet,’ a disciplinary hearing has heard.

The nurse, who remains anonymous and is identified only as ‘Dental Nurse One’, contacted the NHS Ayrshire and Arran health board on 16 September 2013, after she was told of the routine reuse of equipment in an area known for high drug dependency.

Dentist Alan Morrison is accused at a General Dental Council Committee of failing to sterilise instruments between treating patients and reusing dirty gloves at his clinics in Cumnock and Drongan.

An investigation was launched into the dentist’s practices after the nurse blew the whistle, sacrificing her new job. At a hearing in London, the nurse recalled how she was offered a job on the spot, but was told by the practice manager, Lorraine Kelly, of procedures that put patients at risk.

‘She then told me that, “We would do things a bit differently here”…She proceeded to tell me that the practices reuse gloves and matrix bands and did not sterilise aspirators.’

The nurse said that she was shocked at Mrs Kelly’s remarks but that the manager replied in a ‘flippant manner’ that ‘no one’s caught anything yet.’ The whistleblower went on to say: ‘Both practices are in areas of high levels of drug use and therefore are likely to have contact with patients with blood-borne viruses. Although Mr Morrison was not present in this conversation, it was obvious he was aware of procedures and practices as owner of the practices and a practising dentist.’

Many patients underwent testing as a result of being sent a letter. No patients had contracted HIV, however four adult patients tested positive for Hepatitis C. Of these, three had evidence of chronic infection and one showed signs of a previous infection.

It emerged at a health board meeting that two of the patients had received dental treatment on the same day.

However, it could not be established whether the infection was picked up from the practice or from outside their dental treatment.

Mr Morrison has admitted falsifying invoices for medical supplies handed to NHS investigators, which showed phoney purchases of single-use equipment, including matrix bands, but denies the rest of the allegations.

Morrison and Kelly are accused of failing to adhere to infection control guidelines and of being dishonest during the health investigation.

NHS England guide to unscheduled care

NHS England has published a quick guide to unscheduled dental care to help provide practical tips for dental providers and commissioners, and relieve pressure on frontline services.

Within the guide, dental health professionals are advised to ensure accessibility of services by keeping their NHS Choices profile and Directory of Services profile up to date, and ensuring their answerphone provides correct details for signposting to 111 for urgent dental care.

To relieve winter pressures on services, it is recommended that patients are encouraged to seek oral care early. Winter campaign materials should be used to promote oral health and seek early advice for oral symptoms, social media and practice websites should be used to provide information about oral health and access to services, and patients should be advised about taking good care of their own oral health.

The guide goes on to say that self-care advice and management of pain is essential during times when dental treatment services are not available. The dental case mix should be managed by suitably trained dental care professionals (DCPs), who should have the capability to book treatment slots directly with dental providers. Where DCPs cannot provide advice, it is recommended that there should be a mechanism for them to refer to a pharmacist or seek additional clinical advice.

The effective triage of patients with dental problems is also emphasised within the guide. It is noted there are a number of options for triage that could be used and the configuration will depend on local requirements, such as the Dental Nurse Triage service that is being procured in London. This service will receive patient information via NHS 111; return calls and carry out a clinical telephone triage using established dental algorithms; and provide information, reassurance and advice to callers and allocate patients to same day, next day treatment slots or signpost to an NHS dental service.

The service will be delivered by trained and experienced dental care professionals, and is planned to operate between 6pm and 8am during the week. It is also planned to operate 24 hours during weekends and bank holidays. The service will have a phased implementation from 1 April 2016 and align with NHS providers in London.

BDA suspends strike action

The British Dental Association (BDA) suspended industrial action planned for 26–28 January in support of the British Medical Association (BMA), as it seeks to rekindle talks to resolve the differences over the proposed new contract for hospital juniors in England.

The BDA has been following the BMA’s lead in disputing the proposed contract, and supporting hospital junior dentist members to ensure a safe and fair junior contract is put in place. BDA junior hospital dentists took action on 12 January, protesting against the erosion of patient safety and the potential impact on dentists’ working lives.

An announcement from the BDA on the proposed contract, said: ‘We feel it removes vital safeguards for both dentists and their patients. We want to ensure dentists are protected from being required to work excessive hours in a week. We oppose the plans for the extension of standard time from the current 7am to 7pm, Monday to Friday to 7am to 10pm, Monday to Saturday, as we don’t feel this values dentists’ time appropriately.

‘We also object to the proposals on pay progression, which may mean some dentists are discouraged from entering specialist training, due to the plans to increase pay only when a trainee moves to the next stage of training and responsibility. We feel this particularly disadvantages those with families, because of the financial worries of taking time out of training for maternity leave or to work part time. It will also discourage those already in training from undertaking research or retraining in a preferred specialty, to the long-term detriment of the NHS.’

Further action for a full withdrawal of labour is still planned for Wednesday 10 February 2016.

Sound bites

Parliament calls for ‘complete overhaul’ of the General Dental Council (GDC). Members of the House of Commons debated the Section 60 Order which, if laid, will allow the GDC to introduce case examiners into its fitness to practise (FTP) process. This followed a debate in the House of Lords on the same subject, during which Shadow Health Minister Lord Hunt repeatedly called for resignations within the GDC.While the debates in both Houses were held to discuss these changes to the Dentists Act 1984, the main focus of the discussions was the performance, and the fitness to regulate, of the GDC. Shadow Health Minister Justin Madders raised the need for a ‘complete overhaul’ of the GDC, calling it the most expensive and least efficient of the health regulators, and noting the lack of confidence the profession has in the GDC.

The National Institute for Health and Care Excellence (NICE) has published new guidelines on oral health promotion in general dental practice, placing a focus on giving patients the ability to make an informed decision about their care. The guidelines cover how general dental practice teams can give advice about oral hygiene, the use of fluoride, as well as how areas such as diet, smoking, smokeless tobacco and alcohol intake affect oral health in order to help patients make informed decisions about their own care and encourage preventive treatments. Dr Ben Atkins, a dentist and Trustee of the British Dental Health Foundation, was a member of the committee for the NICE guidelines. Dr Atkins said: ‘These guidelines outline a patient-centred approach to ensure patients who are using the services are actively involved in discussions and able to make informed decisions about their care.’

Taken from Dental Nursing, published 29 January 2016.

DN_Feb_2016_News_DPS

NICE issues new draft guidelines on heart attack treatment

The National Institute for Health and Care Excellence (NICE) is updating its guidance on the care of people who have survived heart attacks, including new advice on the secondary prevention of myocardial infarctions.

The draft guideline, which was published on June 13 for public consultation, contains a number of important new recommendations aimed at improving the care given to hundreds of thousands of people in England and Wales who have survived heart attacks.

The guidelines were first issued in 2007 and recommended that patients took part in cardiac rehabilitation programmes to increase the chances of a healthy recovery, but because the uptake of these courses was low, the new guidelines call for interventions to ensure more patients benefit from the programmes.

Among the new recommendations issued by the organisation include a focus on the use of interventional procedures such as using stents rather than drugs as a means of widening blocked or narrowed coronary arteries.

Another notable revision to the guidelines is its removal of the advice that patients eat oily fish, or take omega-3 fatty acid capsules or omega-3 fatty acid supplemented foods in the hope of preventing further heart attacks.

It is felt that the impact these foods would have had on preventing heart attacks would be minimal when compared to new treatments that are now available.

Instead, the guidelines call for a more Mediterranean style diet. Some of the products this would encompass, include more bread, fruit, vegetables and fish, and less meat, while replacing butter and cheese with products based on plant oils.

The draft guidelines also includes recommendations on the use of drugs following a heart attack that reflect new findings on treatments to prevent blood clots (antithrombotic therapy) and on the use of drugs to reduce blood pressure and control heart rhythm and rate such as angiotensin-converting enzyme (ACE) inhibitors and beta-blockers.

Professor Mark Baker, director of the centre for clinical practice at NICE, said: ‘Healthcare professionals should ensure that a programmed of education and activity to help people recover from a heart attack and lead their lives as normally as possible, is designed to motivate people to attend and complete it.’

Taken from Journal of Paramedic Practice, published 25 June 2013.