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PubMed2001

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999.

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument 'controlled' by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.

England↗
PubMed2026

Open Dialogue versus treatment as usual for adults presenting in crisis to mental health services in England (the ODDESSI Trial): a multisite cluster-randomised trial.

BACKGROUND: Open Dialogue is a person-centred, transdiagnostic model of mental health care that emphasises continuity, therapeutic relationships, and collaboration with the service user's social network. Open Dialogue is a service-wide approach to care involving network meetings with the service user, members of their social network, and usually two practitioners who support the network throughout the duration of care. In this cluster-randomised trial, we aimed to evaluate the clinical effectiveness of Open Dialogue versus treatment as usual for adults presenting in crisis to community mental health services in England. METHODS: This multicentre, parallel two-arm, cluster-randomised, controlled superiority trial was conducted in mental health services in five National Health Service trusts in London and the South of England. Clusters were defined at the level of primary care practices within service catchment areas. Participants were adults aged 18 years or older presenting in crisis to mental health services and registered with a practice within trial clusters. Randomisation was done at the cluster level (1:1), stratified by catchment area, and balanced on average general practice (GP) list size and Index of Multiple Deprivation (2015). The chief investigator, senior statistician, and assessors of the primary outcome were masked in the study. Participants either received Open Dialogue or treatment as usual, which refers to the functional team model currently implemented throughout English mental health services. The primary outcome was time (days) to first relapse following initial recovery from the index crisis censored at the end of the 2-year follow-up period. Participant-reported secondary outcomes were EuroQol Visual Analogue Scale, Social Provisions Scale, Lubben Social Network Scale, Questionnaire about the Process of Recovery, and the Client Satisfaction Questionnaire, measured at five timepoints over 2 years, and clinical measures were extracted from electronic health records. People with relevant lived experience were involved in the design and execution of the study. Fidelity to the model of care in Open Dialogue and treatment as usual, and adherence to the delivery of Open Dialogue, were measured prior to each site starting participant recruitment, then every 6 months thereafter until the final participant follow-up in that site. The trial was retrospectively registered (ISRCTN52653325) and is complete. FINDINGS: 185 general practices associated with six mental health Trusts across England were identified for screening. 105 practices were excluded, and 80 were included in cluster formation, forming 32 clusters that were randomly assigned (16 to treatment as usual and 16 to the Open Dialogue intervention). One mental health trust (two clusters) withdrew, resulting in five mental health trusts (30 clusters) participating in the trial. Between June 25, 2019, and Dec 9, 2021, 494 participants (266 [54%] female gender, 221 [45%] male gender, 341 [69%] White British) with a mean age of 38·1 years (SD 13·4) provided consent for study inclusion (223 in the treatment as usual group and 271 in the Open Dialogue group). Of these, 174 (78%) in the treatment as usual group and 225 (83%) in the Open Dialogue group recovered and had data enabling relapse determination; there was no significant difference between groups on the primary outcome of time to relapse following initial recovery (marginal hazard ratio 0·95 [95% CI 0·67-1·32]). For secondary outcomes, Open Dialogue was associated with significantly lower probabilities of psychiatric inpatient admission and re-referral to crisis care or secondary mental health services, and with improvements in self-rated recovery, health-related quality of life, and satisfaction with services. There were no significant differences in social network quality or size. There were 386 serious adverse events (281 in the treatment as usual group and 105 in the Open Dialogue group); 376 (97%) were deemed to be unrelated to the intervention. INTERPRETATION: Open Dialogue did not reduce time to first relapse compared with treatment as usual, the primary outcome, but it reduced acute inpatient bed use, improved service user reported outcomes and experience, and there were no significant safety concerns. Further investigation is required to determine whether Open Dialogue can enhance the effectiveness and acceptability of crisis care and continuing care in community mental health services. FUNDING: National Institute for Health Research.

Humans↗
PubMed1990

Trends in perinatal mortality attributed to congenital malformations in England and Wales during 1974-81: a study of the variations among regional health authority areas.

Analysis of perinatal mortality attributed to congenital malformations in England and Wales, using data from birth and death registration over the years 1974-81 showed significant declines in England and Wales as a whole and in the individual Regional Health Authority (RHA) areas. A greater decrease in death rate from congenital malformations, particularly central nervous system malformations, was seen among stillbirths than among early neonatal deaths. There were marked regional differences in perinatal mortality due to central nervous system malformations over the period but not in cardiovascular system malformations or in other malformations. The highest mortality rates due to central nervous system malformations occurred in the North, North-West, West and South-West of England and in Wales, and the lowest rates in the South and South-East. The larger percentage reductions in the mortality rates were found in most of the regions which had had the highest rates. Possible explanations for the decline in regional rates are suggested.

Cause of Death↗
PubMed1976

Studies of experimental rhinovirus type 2 infections in polar isolation and in England.

After five months of total isolation a wintering party of seventeen British Antarctic Survey (BAS) personnel was inoculated under double blind concitions with placebo, or rhinovirus type 2 which had been propagated in tissue culture. The clinical and virological responses of these subjects were compared with those of volunteers in England who received a similar dose of the same strain. The virus used was apparently partly attenuated for man; at the dosage used its effects in England were similar to a smaller dose of an unattenuated strain, but in the Antarctic it caused relatively severe infections. Both the symptoms and the laboratory evidence of virus infection appeared to be more pronounced in the BAS subjects than in the volunteers in England who received the same challenge. In the former group the infection readily spread to those who were originally given placebo. In the BAS subjects serum antibody titres were well maintained during the isolation period but a significant fall in nasal immunoglobulin concentration was recorded during the 5 months of isolation after the virus challenge. Possible mechanisms for the increased sensitivity to rhinovirus of subjects who have been totally isolated in a small closed community are discussed.

Adult↗
PubMed2002

Suicide preceded by murder: the epidemiology of homicide-suicide in England and Wales 1988-92.

BACKGROUND: We describe for the first time the epidemiology of homicide-suicide incidents for England and Wales. Previous descriptions have been of incidents in London (1946-62) and Yorkshire and Humberside (1975-1992). METHODS: Death certificates were obtained for all who died in homicide-suicide incidents in England and Wales (1988-1992) that were reported by the police to the Home Office. Incidents were included in the analysis if the interval between death or fatal injury of victim and suspect was 3 or fewer days. RESULTS: Three hundred and twenty-seven people died in 144 incidents (180 victims and 147 suspects). Eighty per cent of incidents had one victim and one suspect. Three incidents were also suicide pacts between two suspects killing their children. Eighty-eight per cent of incidents exclusively involved members of the same family, 9 % acquaintances or strangers, and 3 % both family and acquaintances or strangers. Seventy-five per cent of victims were female, 85% of suspects male. The victims of male suspects were predominantly their womenfolk, past and present, and their children, and of female suspects their young children. Car exhaust and firearms accounted for 40% of victim and 50% of suspect deaths. Of all homicides during 1988-1992, 3 % of male, 11% of female and 19% of child deaths occurred in homicide-suicide incidents. Similarly, of all suicides, 0.8% of male and 0.4% of female deaths occurred in homicide-suicide incidents. CONCLUSIONS: Homicide-suicide in England and Wales is mostly 'a family matter', men of predominantly lower social class killing their kin, and pre-menopausal mothers their young children, before they kill themselves. A few men kill strangers during a crime and then themselves.

Adolescent↗
PubMed2005

Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey.

BACKGROUND: Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England. METHOD: We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16-74 years, living in private households in England. RESULTS: Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups. CONCLUSIONS: Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

Adolescent↗
PubMed2004

Influences upon the diffusion of thrombolysis for acute myocardial infarction in England: case study.

OBJECTIVES: To investigate the factors that influenced the adoption and diffusion of thrombolysis in acute myocardial infarction in England and to verify usage data from 1981 to 2001. METHODS: Survey of cardiologists in England using a pre-prepared time line of historical events and a plot of thrombolysis diffusion since 1981. The cardiologists were divided into three groups that were provided with (i) the time line only, (ii) the diffusion curve only, and (iii) the time line and the diffusion curve. RESULTS: The GISSI and ISIS-2 clinical trials were perceived to have had a significant influence upon the initial diffusion of thrombolysis in England occurring over the 3 years after launch. Other positive influences included the initial listing in the national formulary, the change to administration in emergency departments, the rise in evidence-based medicine, and production of national guidance. CONCLUSIONS: Although it is apparent that the overall influences on adoption and diffusion of thrombolysis were multiple; clinical trials, service developments, and national guidelines all were judged to have played a part. The GISSI and ISIS-2 clinical trials were confirmed as the major influence on initial adoption.

Attitude of Health Personnel↗
PubMed2001

Emerging trends in the epidemiology of invasive mycoses in England and Wales (1990-9).

Invasive fungal infections are becoming an increasing public health problem owing to the growth in numbers of susceptible individuals. Despite this, the profile of mycoses remains low and there is no surveillance system specific to fungal infections currently existing in England and Wales. We analysed laboratory reports of deep-seated mycoses made to the Communicable Disease Surveillance Centre between 1990 and 1999 from England and Wales. A substantial rise in candidosis was seen during this period (6.76-13.70 reports per million population/year), particularly in the older age groups. Rates of cryptococcosis in males fluctuated over the decade but fell overall (1.05-0.66 per million population/year), whereas rates of female cases gradually rose up until 1998 (0.04-0.41 per million population/year). Reports of Pneumocystis carinii in men reduced substantially between 1990 and 1999 (2.77-0.42 per million population/year) but showed little change in women. Reports of aspergillosis fluctuated up until 1996, after which reports of male and female cases rose substantially (from 0.08 for both in 1996 to 1.92 and 1.69 per million population/year in 1999 for males and females respectively), largely accounted for by changes in reporting practice from one laboratory. Rates of invasive mycoses were generally higher in males than females, with overall male-to-female rate ratios of 1.32 (95% CI 1.25-1.40) for candidosis, 1.30 (95% CI 1.05-1.60) for aspergillosis, 3.99 (95% CI 2.93-5.53) for cryptococcosis and 4.36 (95% CI 3.47-5.53) for Pneumocystis carinii. The higher male than female rates of reports is likely to be a partial reflection of HIV epidemiology in England and Wales, although this does not fully explain the ratio in infants and older age groups. Lack of information on underlying predisposition prevents further identification of risk groups affected. Whilst substantial under-reporting of Pneumocystis carinii and Cryptococcus species was apparent, considerable numbers of superficial mycoses were misreported indicating a need for clarification of reporting guidelines. Efforts to enhance comprehensive laboratory reporting should be undertaken to maximize the utility of this approach for surveillance of deep-seated fungal infections.

Adolescent↗
PubMed2005

The changing epidemiology of cryptosporidiosis in North West England.

Between 1996 and 2000, rates of cryptosporidiosis in North West England were significantly higher than overall in England and Wales, particularly during the first half of each year. In addition, during the second quarter of each year in this period, up to 40% of all cases recorded in England and Wales were from the North West Region. In 2001, cryptosporidiosis dramatically decreased throughout the United Kingdom and the springtime excess of cases formerly seen in the North West was no longer apparent. This changed epidemiology was due to a decline in cases of Cryptosporidium parvum (formerly genotype 2), associated with zoonotic transmission. Although the initial loss of a spring peak of infection corresponded with the outbreak of foot-and-mouth disease throughout the United Kingdom, its continued absence relates to major structural changes in the North West public water supply. This study highlights the far-reaching public health benefit of local working relationships in addressing re-occurring disease issues.

Adolescent↗
PubMed1999

The prevalence of hepatitis B infection in adults in England and Wales.

Cost effectiveness analyses of alternative hepatitis B vaccination programmes in England and Wales require a robust estimate of the lifetime risk of carriage. To this end, we report the prevalence of infection in 3781 anonymized individuals aged 15-44 years whose sera were submitted in 1996 to 16 microbiology laboratories in England and Wales. One hundred and forty-six individuals (3.9%) were confirmed as anti HBc positive, including 14 chronic carriers (0.37%). The prevalence of infection and carriage was higher in samples collected in London and increased with age. No increased risk of infection was seen in sera from genito-urinary (GUM) clinics. Only 15 sera positive for hepatitis B were also positive for hepatitis C. Our results confirm the low prevalence of hepatitis B in England and Wales, are consistent with previous estimates of carriage and suggest that many infections were acquired while resident outside the UK. Future prevalence studies should determine the country of birth and other risk factors for each individual in order to confirm these findings.

Adolescent↗
PubMedDate not supplied

Acute inpatient psychiatry in England: an old problem and a new priority.

With the development of community care, the number of National Health Service psychiatric beds in England has been reduced to between one-fifth and one-quarter of those provided in the mid-1950s. Psychiatric bed numbers are close to the irreducible minimum if they have not already reached it. The problems facing today's acute psychiatric admission wards include: poor design, maintenance and ambience; a lack of therapeutic and leisure activities for patients leading to inactivity and boredom; frequent incidents of aggression and low-level violence and problems with staffing. It is suggested that there are a number of underlying causes: First, there has been failure to plan inpatient services, or to define their role, as attention has focused on new developments in community care. Second, the reduction in bed numbers has led to a change in the casemix of inpatients with a concentration on admission wards of a more challenging group of patients. Third, admission ward environments are permeable to the adverse effects of local street life, including drug taking. After years of neglect, acute inpatient psychiatric services in England are now high on the UK Government agenda. The paper lists a number of national initiatives designed to improve their quality and safety. A recent review of qualitative research suggests that acute psychiatric wards in other countries face similar problems to those reported in England. It is suggested that there might be a need for joint action which might take the form either of international research about acute inpatient care or the development of international standards and a common quality improvement system.

Acute Disease↗
PubMed2006

Meal patterns and cooking practices in Southern France and Central England.

OBJECTIVE: To evaluate whether meal patterns and cooking practices in Central England and Mediterranean France conform to popular stereotypes, eating together as a household, preparation of meals, food purchasing patterns, cooking practices and eating out were investigated. DESIGN: Cross-sectional studies conducted simultaneously in April 2001 using self-administered postal questionnaires. SETTING: England (Nottingham, East Midlands) and France (Montpellier, Languedoc-Roussillon). SUBJECTS: A stratified random sample of 1000 males and 1000 females aged 18-65 years was generated from the electoral roll in each country. The final sample comprised 826 subjects in England (58% males, 42% females; mean age 44 years) and 766 subjects in France (42% males, 58% females; mean age 42 years). Analyses were conducted on samples standardised for sociodemographic differences. RESULTS: The French cooked from raw ingredients most often (P<0.001), ate together as a household more regularly (P<0.001) and were most likely to follow a regular meal pattern of three meals a day. On the other hand, the English relied more on ready-prepared (P<0.001) and take-away (P<0.001) meals, as well as on energy-dense snack foods such as crisps (P<0.001). Females in both countries reported having most responsibility for preparing meals. CONCLUSIONS: Some of the study's findings confirm popular stereotypes of French and English food cultures, as the importance of the convivial aspects of eating, as well as more traditional practices such as cooking meals from basic ingredients, structured mealtimes and less between-meal snacking, remain more prominent within the French population. This may contribute to the differences in prevalence of obesity seen between the two countries.

Adolescent↗
PubMed2006

Modeling the probability of arsenic in groundwater in New England as a tool for exposure assessment.

We developed a process-based model to predict the probability of arsenic exceeding 5 microg/L in drinking water wells in New England bedrock aquifers. The model is being used for exposure assessment in an epidemiologic study of bladder cancer. One important study hypothesis that may explain increased bladder cancer risk is elevated concentrations of inorganic arsenic in drinking water. In eastern New England, 20-30% of private wells exceed the arsenic drinking water standard of 10 micrograms per liter. Our predictive model significantly improves the understanding of factors associated with arsenic contamination in New England. Specific rock types, high arsenic concentrations in stream sediments, geochemical factors related to areas of Pleistocene marine inundation and proximity to intrusive granitic plutons, and hydrologic and landscape variables relating to groundwater residence time increase the probability of arsenic occurrence in groundwater. Previous studies suggest that arsenic in bedrock groundwater may be partly from past arsenical pesticide use. Variables representing historic agricultural inputs do not improve the model, indicating that this source does not significantly contribute to current arsenic concentrations. Due to the complexity of the fractured bedrock aquifers in the region, well depth and related variables also are not significant predictors.

Arsenic↗
PubMed2001

Mental health service provision in England.

OBJECTIVE: To describe mental health service provision for adults of working age in England. METHOD: Services in an inner London area are described so as to illustrate current patterns of service organization in England. National trends are then discussed. RESULTS: Despite relatively low public expenditure, substantial progress has been made in deinstitutionalization and development of comprehensive community-based services. Persisting difficulties include high staff turnover, a minority of patients. who do not engage with community services, user and carer dissatisfaction with emergency services, and social exclusion because of stigma. Recent government policy advocates resolving some of these problems using new service models such as assertive outreach and crisis teams. CONCLUSION: Closure of the large asylums has largely been accomplished. England is now entering a new phase in community service development, with a range of innovative developments aimed at resolving problems still encountered after the initial phases of integrated community service development.

Adult↗
PubMed1972

A comparison between England and Wales and Sweden in the incidence and mortality of malignant skin tumours.

Although the population lives in a higher latitude, the incidence of and death rate from skin cancer is approximately the same in Sweden as it is in England and Wales. The proportion of malignant melanoma is higher in the Swedish deaths and the death rate from malignant melanoma is higher in Sweden than in England and Wales.The ratios of male to female cases and deaths from malignant melanoma are higher in Sweden than in England and Wales.These differences do not appear likely to be due to differences in the statistical or medical care systems, and suggest important genetic and occupational effects.Total skin cancer rates and rates summarizing all ages may be poor indicators of the real variations between populations in the epidemiology of malignant skin tumours.

Adult↗
PubMed1981

Recent trends in mortality from prostate cancer in male populations of Australia and England and Wales.

Mortality rates from cancer of the prostate in successive periods from 1908 to 1978 in Australia, and 1911 to 1977 in England and Wales, have been examined for trends with time and birth cohort. Age-specific rates and a proportional hazards model, designed to isolate the effect of birth cohort from those of calendar year and age, were used in the analysis. During the period of study, age-standardized mortality rose more than 5-fold in Australian men compared to just over 3-fold in men in England and Wales. In both countries the increases occurred almost entirely before 1960, with relative stability in age-standardized rates since then. The trends in mortality with year of birth were similar in the two sets of data. The risk of death from prostate cancer increased with successive birth cohorts to reach a peak in men born around 1865-1880 in Australia and men born around 1876-1896 in England and Wales. Males born later experienced a continuing reduction in rates, with the exception of age groups between 50 and 69 in which a further increase has appeared, starting with cohorts born after 1910. On the basis of current knowledge of the aetiology of prostate cancer, possible relationships between changes in sexual practices and prostate-cancer risk in successive generations have been explored. It is suggested that lowered sexual activity during the Great Depression may account for the recent cohort-based increases in mortality in middle-aged men.

Adult↗
PubMed1991

Ovarian germ cell malignancies in England: epidemiological parallels with testicular cancer.

The epidemiology of germ cell cancer of the ovary has been little investigated. We studied ovarian germ cell cancers incident 1971-84 in England, using data from the England and Wales national cancer register. The age distribution showed a sharp peak at ages 15-19, to which both teratomas and dysgerminomas contributed equally, and a secondary, much wider peak, at ages 65-69, mainly due to teratomas. For teratomas there were diverging secular trends by age: incidence has been increasing at ages 0-44 (P around 0.05) and decreasing at ages over 44 (P less than 0.01). Birth cohort analysis showed an increase in risk at ages 0-44 for more recent generations of women. There were no changes over time for dysgerminomas. There was no clear geographic pattern of distribution across the regions of England. The early age peak, and the increase in incidence of ovarian germ cell cancers at young ages but decrease at older ages, resembles testicular cancer epidemiology. Interestingly, discrepancies and similarities in the age distribution of these tumours between the sexes parallel lifetime profiles of gonadotropin levels in each sex.

Adolescent↗
PubMed1995

Problems with registration of cutaneous malignant melanoma in England.

The aim of the study was to assess the completeness and accuracy of cancer registration for cutaneous malignant melanoma. The study was conducted in seven health districts in England and one health board in Scotland from 1987 to 1989 with a total resident population of 3.6 million. Records from pigmented lesion clinics and pathology laboratories collected during the Cancer Research Campaign's health education programme to promote the early detection of melanoma were matched with cancer registrations from a total of five regional cancer registries. In England 74% out of a total of 642 cases of invasive malignant melanomas (ICD 172) and 44% out of a total of 155 in situ melanomas (ICD 232) had been registered compared with 96% and 100% respectively in Scotland. A significantly higher proportion of late-stage cases was found among registered than among non-registered cases in England (P < 0.001). In all registries the majority of superficial spreading in situ melanomas were miscoded as invasive cases. The annual incidence of invasive malignant melanoma in the English study areas was found to be seven per 100,000 in men and 11 per 100,000 in women, similar to that reported in Scotland. The registries are best at recording thick or late-stage melanomas. As the skin cancer target for Health of the Nation depends on monitoring trends in the incidence of malignant melanoma, future improved ascertainment of cases and changes in the type of cases being registered must be taken into account.

England↗